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CASE REPORTS

Base of tongue varices associated with portalhypertension

P Jassar, M Jaramillo, D A Nunez

AbstractA symptomatic case of tongue basevarices in a patient with portal hyper-tension secondary to liver cirrhosis ispresented. There are no previously docu-mented cases in the world literature.Oesophageal varices may not be the onlysource of expectorated blood in a patientwith portal hypertension.(Postgrad Med J2000;76:576577)

Keywords: portal hypertension; lingual; tongue; vari-cose vein

Case report

An 82 year old women with known portalhypertension secondary to cirrhosis of the liverwas referred to the otolaryngology outpatientdepartment with a two month history of dailyhaemoptysis and bloodstained pharyngeal se-cretions; this occurred mostly on early morningcoughing. There was no history of weight loss,dysphagia, dysphonia, or throat pain. She hadalready been investigated for a pulmonarycause of the haemoptysis and none was found.In keeping with her history, liver function testsand the prothrombin time were abnormal. Shealso had a history of well controlled essentialhypertension. Chest radiography showedcardiomegaly, but the jugular venous pressurewas not raised and there was no other clinicalmanifestation of heart failure.

Indirect laryngoscopy revealed varicose ves-sels in the tongue base, mainly on the left side(see fig 1). These appeared friable and one arearevealed a propensity to bleed on examination.The rest of the ear, nose, and throat examina-tion was normal.

After perioperative cover with fresh frozenplasma, vitamin K, and tranexamic acid she

underwent ablation of the varicosities using a15 watt continuous carbon dioxide laser undergeneral anaesthesia (see fig 2). She had anuneventful recovery and has remained symp-tom free.

AnatomyThe dorsal lingual veins drain the tongue basethrough two or more tributaries. These courseinferiorly, join together and form the lingualvein, which accompanies the lingual artery.These vessels pass between genioglossus and

hyoglossus and the vein empties into the inter-nal jugular vein just above the level of thegreater cornu of the hyoid bone.1

PORTOSYSTEMIC ANASTOMOSIS

Because the portal system has no valves, portalhypertension results in shunting of bloodthrough anastomotic communications with thesystemic venous system. Recognised connec-tions are2:

(1) Lower oesophageal veinsthe branchesof the left gastric vein anastomose profuselywith the azygous and hemiazygous veins.Increased shunting results in oesophagealvarices within the mucosa of the lower third ofthe oesophagus.

(2) Periumbilical veinsveins contained inthe falciform ligament anastomose with supe-rior and inferior epigastric veins of the anteriorabdominal wall. Excessive dilatation of theseveins are evident as caput medusa.

(3) Haemorrhoidsthe superior rectal veinanastomoses with the middle rectal vein whichdrains into the internal iliac vein. In additionthe middle rectal veins anastomose with theinferior rectal veins which drain into the inter-nal pudendal vein. Increased shunting resultsin internal and external haemorrhoids.

Figure 1 Tongue base varices. Figure 2 Tongue base varices after laser ablation.

Postgrad Med J2000;76:576577576

Department of

Otolaryngology,Aberdeen Royal

Infirmary, UK

P JassarM JaramilloD A Nunez

Correspondence to:Mr D A Nunez, Departmentof Otolaryngology, Ward 45,Aberdeen Royal Infirmary,Aberdeen AB25 2ZN, UK(email:Dnunez1ORL@aol.com)

Submitted 28 October 1999Accepted 10 February 2000

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(4) Veins of Retziusthe veins of a second-ary retroperitoneal structure may anastomosewith the veins of the dorsal body wall, formingveins of Retzius.

Thus, there is no recognised anastomosisbetween lingual venous drainage and the portalcirculation.

Discussion

A varicosity is a condition indicating an

enlarged and tortuous vein. Previously de-scribed lingual varices referred to sublingualvarices on the ventral surface of the tongue orfloor of mouth. These were ascribed to the useof dentures, and vitamin C deficiency in anelderly population.3

Burket associated the occurrence of lingualvarices with cardiorespiratory disease,4 how-ever this assumption was shown to be unsub-stantiated in a double blind study byKleinman.5

This represents the first reported case ofdorsal tongue base varices in a patient withportal hypertension. We propose three expla-

nations for this association. Firstly that thevarices represent a spontaneous entity unre-lated to systemic disease. Secondly, they are a

manifestation of cardiopulmonary disease, anassociation endorsed by the known anatomicconnection, but improbable given that therewas no other clinical evidence of heart failuresuch as a raised jugular venous pressure.Lastly,that there is an, as yet, unrecognised anasto-motic connection between lingual venousdrainage and the portal circulation.

Tongue base varices should be considered incases of blood expectoration and portal hyper-tension.

1 Gray H. Grays anatomy.15th Ed. New York: Bounty Books,1978: 598.

2 April EW. Anatomy. 2nd Ed. National Medical Series.Baltimore: Williams and Wilkins, 1990: 22930.

3 Colby RA, Kerr DA, Robinson HBG. Colour atlas of oralpathology. 2nd Ed. Philadelphia: JB Lippincott, 1961: 125.

4 Burket LW. Oral medicine. 4th Ed. Philadelphia: JB Lippin-cott, 1961: 146.

5 Kleinman HZ. Lingual varicosities. Oral Surgery, Oral Medi-cine, Oral Pathology1967;23:5468.

Cefuroxime induced lymphomatoidhypersensitivity reaction

S A M Saeed, M Bazza, M Zaman, K S Ryatt

Abstract

An 84 year old women developed ery-

thematous blotchy erythema and purpu-

ric rashes over the lower limbs three daysafter being started on intravenous cefuro-

xime for acute diverticulitis. A skin biopsy

specimen showed a mixed infiltrate of

lymphoid cells and eosinophils; many of

the lymphocytes were large, pleomorphic,

and showeda raised mitotic rate. Immuno-

histochemistry showed the infiltrate to be

T cell rich, with all the large cells being

CD30 positive. Typical mycosis fungoides

cells, marked epidermotropism, and Pau-

triers abscesses were not seen. The rash

disappeared 10 days after cessation of

cefuroxime and the patient remained

asymptomatic 15 months later. This ap-

parent cutaneous T cell lymphoma-likereaction is best described as lymphoma-

toid vascular reaction. The drug induced

immune response with an atypical cutane-

ous lymphoid infiltrate mimics a cutane-

ous pseudolymphoma.(Postgrad Med J2000;76:577579)

Keywords: cefuroxime; atypical cutaneous lymphoma-

toid infiltrate; cutaneous T cell lymphoma

Case report

An 84 year old women, with established diver-ticula disease, presented as an emergency with

a short history of fever, acute abdominal pain,and diarrhoea. On examination she was foundto be toxic, febrile, dehydrated, with a tachycar-

dia of 110/min and blood pressure 80/40 mmHg. The left iliac fossa was tender. Haemo-globin, full biochemistr y profile,including serum amylase, chest radiography,plain abdominal radiography, and an abdomi-nal ultrasound scan were normal. Her whitecell count was raised at 20.4 109/l withmarked neutrophilia at 14.2 109/l.

A provisional clinical diagnosis of acute diver-ticulitis with septic shock was made and she wasstarted on intravenous (IV) fluids, IV metroni-dazole 500 mg eight hourly, and IV cefuroxime750 mg three times a day in a sequentialmanner. Three days later and after five doses ofIV cefuroxime, purpuric and erythematous

macular rashes developed over the lower limbs.Cefuroxime was considered to be responsibleand was discontinued; metronidazole was con-tinued for another week.The rashes were treatedwith flucinolone acetonide 0.00625% cream.Further investigations at this stage showed nor-mal immunoglobulins, antinuclear factor, an-tineutrophilic cytoplasmic antibodies, and au-toantibody profile. A haematoxylin and eosinstained section of representative skin biopsyshowed a mixed dermal infiltrate of lymphoidcells and eosinophils, marked red blood cellextravasation indicative of ongoing small vesseldamage, minimal focal vacuolar interface

Cefuroxime induced lymphomatoid hypersensitivity reaction 577

Manor Hospital,

Walsall, UK:

Department of Elderly

Care

S A M SaeedM Zaman

Department of

Dermatology

M BazzaK S Ryatt

Correspondence to:Dr M Bazza, Department ofDermatology, Walsall ManorHospital, Walsall, WestMidlands WS2 9 PS, UK

Submitted 21 April 1999Accepted 7 December 1999

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