Lingua Plicata: A Precursor of Pemphigus Vegetans

Abstract

A 45-year-old female presented to the Dermatology outpatient department with complaints of painful oral erosions on the lips and a burning sensation on the tongue for two weeks. Oral cavity examination showed a tongue with multiple fissures (resembling sulci) with a few erosions on the lips. Regarding the erosions on the lips, cheilitis and nutritional deficiencies were considered. She was treated conservatively with multivitamin supplements, topical analgesics, and emollients. Complete dermatological examination was normal, and she was kept under regular monthly follow-up. Four months after the onset of oral lesions, she presented with raw areas over the trunk, bilateral upper and lower limbs, raised lesions over the bilateral axillae, and gluteal region [Table/Fig-1a]. On examination, vegetative plaques with oozing and crusting were present over the bilateral axillae and gluteal region. Multiple erosions were present on the trunk, groin, bilateral upper and lower limbs. The classical oral presentation of a fissured tongue [Table/Fig-1b] with cutaneous erosions and vegetative plaques pointed towards a provisional diagnosis of pemphigus vegetans with drug reaction and other bullous dermatoses like pemphigus vulgaris, pemphigus foliaceous, bullous pemphigoid, and paraneoplastic pemphigus as differentials. A skin biopsy was done and sent for histopathological examination, which showed suprabasal clefts containing abundant eosinophils and acantholytic cells [Table/Fig-1c]. Based on the clinical findings of vegetative plaques and cerebriform tongue (Premalatha’s Sign) [1], along with the histopathological findings, the diagnosis of pemphigus vegetans was confirmed.

Keywords

• cerebriform tongue
• fissured tongue
• oral mucosal lesions