Dermatology

Median Rhomboid Glossitis (posterior midline atrophic candidiasis, central papillary atrophy of the tongue, posterior lingual papillary atrophy)

Median Rhomboid Glossitis (posterior midline atrophic candidiasis, central papillary atrophy of the tongue, posterior lingual papillary atrophy)

Are You Confident of the Diagnosis?

What you should be alert for in the history

Most patients with median rhomboid glossitis are asymptomatic, but some complain of a burning sensation that is exacerbated by acidic or spicy foods.

Characteristic findings on physical examination

Clinically there is a rhomboid-shaped, well-defined, erythematous plaque in the central tongue due to localized atrophy of the filiform papillae. Median rhomboid glossitis is a clinical diagnosis, therefore no investigations are required. Anti-yeast medications are commonly used, when treatment is desired. If the patient's fear of oral cancer is heightened, a biopsy can be done.

Expected results of diagnostic studies

Histologically one expects to find an atrophic epithelium with a dense chronic inflammatory infiltrate. Some consider this a localized variant of erythematous thrush, in which case a swab for fungal culture taken from the plaque may be informative. Any culture results need to be interpreted knowing 50% of the population has commensal oral candida.

Diagnosis confirmation

The differential diagnosis includes lingual thyroid, granular cell tumor, tertiary gummatous syphilis, and deep fungal infection.

Who is at Risk for Developing this Disease?

The male:female ratio = 3:1, Cases have been reported in children and adults. Prevalence variation with age has not been reported.

What is the Cause of the Disease?

Etiology

The etiology of median rhomboid glossitis is unknown. It is most often hypothesized to be a congenital anomaly or a chronic, localized candida infection.

Pathophysiology

The filiform papillae anterior to the cicumvate papillae are almost exclusively involved.

Systemic Implications and Complications

None

Treatment Options

Median rhomboid glossitis is a benign condition so no treatment is necessary. If patients are symptomatic and/or desire treatment, topical anti-yeast treatments, such as nystatin suspension or clotrimazole troches, can be tried for a 2-week period. Oral fluconazole for a 2-week period would be reasonable as well (200 mg daily x 1 day followed by 100mg daily x 13 days).

If the patient responds to treatment but relapses, maintenance therapies can be considered. It may be necessary to address risk factors for reinfection such as sleeping in dentures as well. Patients should avoid sleeping with thier dentures in place.

Optimal Therapeutic Approach for this Disease

No treatment is necessary. If patients are symptomatic and/or desire treatment, topical anti-yeat treatments such as nystatin suspension or clotrimazole troches can be tried for a 2-week period. Oral fluconazole for a 2-week period would be reasonable as well (200 mg daily x 1 day followed by 100 mg daily x 13 days).

If the patient responds to treatment but relapses, maintenance therapies can be considered. It may be necessary to address risk factors for reinfection such as sleeping in dentures as well.

Patient Management

Due to the benign nature of this condition, no patient follow-up is required.

Unusual Clinical Scenarios to Consider in Patient Management

Although the presence of median rhomboid glossitis is not pathognomonic for immunosuppression, HIV patients, and particularly pediatric HIV patients, are known to have high rates of oral candidiasis, including erythematous thrush and median rhomboid glossitis.

What is the Evidence?

Byrd, JA, Bruce, AJ, Rogers, RS. "Glossitis and other tongue disorders". Dermatol Clin. vol. 21. 2003. pp. 123-34.

(Review of wide range of tongue diseases.)

Barasch, A, Safford, MM, Catalanotto, FA, Fine, DH, Katz, RV. "Oral soft tissue manifestations in HIV-positive vs. HIV-negative children from an inner city population: a two-year observational study". Pediatr Dent. vol. 22. 2000. pp. 215-20.

(Reviews the oral findings in HIV as well as HIV-negative children.)
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