Photo Quiz

Enlarging Nodule on the Tongue


Am Fam Physician. 2019 Sep 15;100(6):367-368.

A 51-year-old man presented with a nodule on his tongue that had been growing slowly for three years. The nodule had become painful and interfered with his speech and oral intake. He did not recall any injury or trauma to his mouth. The lesion had never bled, ruptured, or ulcerated. His medical history was significant for current tobacco use, chronic hepatitis C, and past intravenous drug use.

Physical examination revealed an 8-mm, well-circumscribed, smooth, pink, firm nodule on the dorsal aspect of the tongue (Figure 1). A punch biopsy showed squamous proliferation with papillary surface projections and virally altered cells.

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Based on the patient's history, physical examination, and biopsy findings, which one of the following is the most likely diagnosis?

A. Condyloma acuminatum.

B. Irritation fibroma.

C. Oral squamous papilloma.

D. Pyogenic granuloma.

E. Squamous cell carcinoma.


The answer is A: condyloma acuminatum, a highly contagious skin lesion caused by infection with human papillomavirus (HPV) type 2, 6, 11, 16, or 18.1 Although condyloma acuminatum is usually caused by low-risk HPV types, infection with the high-risk types 16 and 18 has been linked with anogenital, head, and neck cancers.2 Condyloma acuminatum typically occurs in the anogenital region but can involve the oral cavity via oral-genital contact or autoinoculation.3 Oral condyloma acuminatum is usually asymptomatic and can appear as single or multiple pedunculated, smooth, or dome-shaped papules or plaques.1 Histopathologic features include broad hyperplastic papillary projections with cells demonstrating viral changes, such as koilocytosis, parakeratosis, and increased nuclear atypia.4 Condyloma acuminatum is treated with surgical excision or cauterization.1

Irritation fibromas are caused by chronic irritation of the oral mucosa and appear along the bite line as a single smooth, do

Address correspondence to Mohenish Daughtry, DO, FAAFP, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Swan RH, McDaniel RK, Dreiman BB, et al. Condyloma acuminatum involving the oral mucosa. Oral Surg Oral Med Oral Pathol. 1981;51(5):503–508....

2. Chaturvedi AK, Engels EA, Anderson WF, et al. Incidence trends for human papillomavirus-related and -unrelated oral squamous cell carcinomas in the United States. J Clin Oncol. 2008;26(4):612–619.

3. Syrjänen S. Oral manifestations of human papillomavirus infections. Eur J Oral Sci. 2018;126(suppl 1):49–66.

4. Kumar V, Robbins SL. Robbins Basic Pathology. Elsevier; 2017.

5. Reamy BV, Derby R, Bunt CW. Common tongue conditions in primary care. Am Fam Physician. 2010;81(5):627–634. Accessed August 1, 2019.

6. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci. 2006;48(4):167–175.

7. Kalavrezos N, Scully C. Mouth cancer for clinicians part 6: potentially malignant disorders. 2015;42(9):866–877.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

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