Tongue swelling may be associated with COVID-19

Patients who experience swelling of the tongue and mouth may be infected with the novel coronavirus, according to a letter to the editor published on March 9 in the British Journal of Oral and Maxillofacial Surgery.

The patients discussed in the article had no other dental-related problems, the authors noted.

"These cases may represent a rare manifestation of COVID-19 which should be borne in mind in patients presenting with edema of the tongue or floor of mouth, especially in the absence of a clear source," wrote the group, led by Dr. David McGoldrick from the oral and maxillofacial surgery department at Queen Elizabeth Hospital in Birmingham, U.K.

Evidence has shown that a variety of oral manifestations, including ulcers and geographic tongue (also being called "COVID tongue"), may be linked to infection with SARS-CoV-2. Indeed, a dentist may have recently diagnosed asymptomatic cases of infection from routine dental exams of two teenagers who had good oral hygiene but bleeding gums and multiple oral lesions.

Based on such findings, it's thought that tongue and mouth swelling may also be linked to the novel coronavirus, and McGoldrick and colleagues described two potential cases from the U.K.

A 53-year-old man

In the first case, a 53-year-old man went to the hospital after experiencing tongue and floor-of-mouth swelling for one day. He had no history of trauma, dental pain, or salivary symptoms, and he had no known symptoms of COVID-19.

A computed tomography (CT) scan showed the man had neck and mouth edema, which clinicians suspected may have been caused by Ludwig angina, a rare bacterial infection that often occurs after a tooth abscess. The patient was transferred to the hospital's department of oral and maxillofacial surgery for evaluation. The man had soft bilateral neck swelling and an edematous, raised floor of mouth, but clinicians could not find a dental source of infection, the authors wrote.

The man was admitted to the hospital for steroid therapy. A subsequent polymerase chain reaction test confirmed infection with the novel coronavirus. The patient improved, and he was discharged after one day, McGoldrick and colleagues wrote.

A 22-year-old man

The second case involved a patient who presented to the hospital with a day of tongue pain and swelling. He was found to have moderate tongue swelling and mild voice changes. An endoscopic exam of the nose showed swelling of the man's nasal mucosa and tongue base. A CT scan confirmed the patient had generalized tongue swelling, specifically at its base, as well as lung changes consistent with COVID-19.

While clinicians were waiting for the imaging results, the patient became uncooperative and discharged himself from the hospital. He left before a confirmatory COVID-19 test could be performed.

No dental or other maxillofacial cause was identified in either case, the authors noted. The rare COVID-19 presentation may be due to the tongue's epithelial cells having a high concentration of angiotensin-converting enzyme 2 receptors. Organs with these receptors may be more vulnerable to an inflammatory response, they wrote.

"Although correlation does not imply causation, we feel both of these cases may represent a rare presentation of COVID-19," McGoldrick and colleagues concluded.