Case presentation

A 79-year-old man reported to the department of oral medicine for a routine dental checkup. The patient's medical history revealed he was not a diabetic, hypertensive, or associated with any other comorbidities. History revealed he had a habit of chewing smokeless tobacco, one packet per day, for the past 15 years. There was no past surgical history for his tongue. There was no history of any associated burning sensation on his tongue. Extraoral examination revealed no pruritic skin lesions. Clinical examination revealed a non-homogeneous white leathery plaque of size measuring 3.5 cm x 3 cm, resembling a mosaic or marble-like appearance on the left lateral dorsum near the tip of the tongue. The right lateral dorsum and lateral borders of the anterior one-third of the tongue were smooth and devoid of papilla intermingled with discrete areas of white plaque and grayish pigmentation. A cleft was observed on the tip of the tongue, resulting in a bifid tongue (Figure 1).

Figure 1: Intraoral examination revealed a non-homogeneous white plaque measuring about 3.5 cm x 3 cm on the left lateral dorsum of the tongue (yellow arrow) and a cleft at the tip of the tongue (red arrow)

There was no restriction in tongue movements. On palpation, it was non-scrapable and non-tender. Based on the above history and clinical findings, a provisional diagnosis of non-homogeneous leukoplakia on the dorsum of the bifid tongue was made. The staging of leukoplakia in our case was L2 PX [1]. Because the size of the leukoplakia was 3.5 cm in our case, and it was designated L2 and PX, dysplasia was not specified. The differential diagnosis was chronic hyperplastic candidiasis, proliferative verrucous leukoplakia, and iron-deficiency anemia. His serum laboratory investigation revealed a hemoglobin percentage of 14.2 g/dL (normal range = 14-17 g/dL). Hence, depapillation of the tongue due to iron-deficiency anemia was ruled out. The patient was followed up after a month, and the white lesion on the left dorsum of the tongue persisted without any associated clinical symptoms such as a burning sensation (Figure 2).

Figure 2: Follow-up after a month revealed a white non-homogeneous plaque on the left dorsum of the tongue (yellow arrow) with no reduction in size of the lesion

Limitations

The patient was completely asymptomatic, with no burning sensation. Hence, he did not consent to the biopsy despite explaining the risk of malignant transformation.

Clinical significance

This case reports a rare, unique occurrence of dorsal tongue leukoplakia and bifid tongue in a 79-year-old man, not reported in any previous literature.