An Atlas of Lingual Lesions, Part 1
Alexander K. C. Leung, MD
Clinical Professor of Pediatrics, University of Calgary; Pediatric Consultant, Alberta Children’s Hospital, Calgary, Alberta, Canada
Benjamin Barankin, MD
Dermatologist, Medical Director, and Founder, Toronto Dermatology Centre, Toronto, Ontario, Canada
Kin Fon Leong, MD
Pediatric Dermatologist, Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
Helen Tam-Tham, PhD
Medical Student, University of Calgary, Calgary, Alberta, Canada
Leung AKC, Barankin B, Leong KF, Tam-Tham H. An atlas of lingual lesions, part 1. Consultant. 2019;59(5):146-148, 151.
EDITOR’S NOTE: This article is part 1 of a 5-part series of Photo Essays describing and differentiating conditions affecting the tongue and related structures in the oral cavity. Parts 2, 3, 4, and 5 are published in subsequent issues of Consultant.
A strawberry tongue is most commonly caused by group A β-hemolytic streptococcal pharyngitis, which leads to hypertrophy of the papillae.1,2 The prominent papillae are initially covered by a white coating, giving the appearance of a white strawberry tongue (Figure 1).3 The white coating is usually lost in 1 to 2 days, giving rise to a red strawberry tongue (Figure 2).3 Other features of group A β-hemolytic streptococcal pharyngitis include fever, beefy red pharynx, enlarged and erythematous tonsils with or without exudates, enlarged tender anterior cervical lymph nodes, and sometimes, palatal petechiae, and a scarlatiniform rash.1
Group A β-hemolytic streptococcal pharyngitis may lead to local suppurative complications such as peritonsillar abscess, suppurative cervical lymphadenitis, cellulitis, and retropharyngeal abscess.1 Rarely, group A β-hemolytic streptococcal pharyngitis may result in bacteremia, necrotizing fasciitis, and streptococcal toxic shock-like syndrome.2 Nonsuppurative complications can include acute glomerulonephritis, rheumatic fever, reactive arthritis-synovitis, and pediatric autoimmune neuropsychiatric disorder.1
Strawberry tongue is a notable feature of Kawasaki disease.4 Kawasaki disease is an acute vasculitis, a systemic disease that mostly involves coronary arteries and typically occurs in children younger than 5 years of age.4 The diagnosis of classic or typical Kawasaki disease is based on clinical criteria established by the American Heart Association.5 These criteria include fever for at least 5 days (the first calendar day of the established fever is illness day 1) and 4 or more of the 5 primary clinical features without plausible alternative explanations: oral mucosal changes (strawberry tongue, erythematous, fissured cracked lips, diffuse erythema of the oral pharynx); bilateral bulbar conjunctival injection without exudate; polymorphous rash (diffuse maculopapular, urticarial, erythroderma, erythema multiforme-like, not vesicular or bullous); changes in the extremities (erythema and indurated edema of the hands and feet, sharp demarcation at the ankles and wrists, periungual desquamation); and cervical lymphadenopathy (unilateral, >1.5 cm in diameter, nonfluctuant).5 In the presence of 4 or more major features, mainly when redness and swelling of the hands and feet are present, the diagnosis can be made with only 4 days of fever.5 Patients who have a fever for 5 or more days and only 3 major clinical features can also receive a classic Kawasaki disease diagnosis when coronary artery disease is detected by 2-dimensional echocardiography or coronary angiography.5
Rarely, strawberry tongue can be caused by yellow fever and Yersinia pseudotuberculosis.3
- Leung AKC, Kellner JD. Group A β-hemolytic streptococcal pharyngitis in children. Adv Ther. 2004;21(5):277-287.
- Leung TNH, Hon KL, Leung AKC. Group A Streptococcus disease in Hong Kong children: an overview. Hong Kong Med J. 2018;24(6):593-601.
- Adya KA, Inamadar AC, Palit A. The strawberry tongue: what, how and where? Indian J Dermatol Venereol Leprol. 2018;84(4):500-505.
- Yuan K, Park JK, Qubti MA, Haque UJ. Recurrent Kawasaki disease with strawberry tongue and skin desquamation in a young adult. J Clin Rheumatol. 2012;18(2):96-98.
- McCrindle BW, Rowley AH, Newburger JW, et al; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Council on Epidemiology and Prevention. Diagnosis, treatment, and long-term management of Kawasaki disease: a scientific statement for health professionals from the American Heart Association. Circulation. 2017;135(17):e927-e999.