Carrie L. Gick, BA,a Ginat W. Mirowski, DMD, MD,a,b John S. Kennedy, MD,c
A 73-year-old white male with a 6-month history of glossodynia, unresponsive to clotrimazole troches,cevimeline, triamcinolone dental paste, paroxetine, and lorazepam presented to the dermatology clinic forconsultation. Work-up revealed no oral abnormalities and no underlying systemic disorder. He deniedsymptoms consistent with a psychiatric disorder. A detailed free amnestic assessment by a board certifiedGeriatric Psychiatrist (John S. Kennedy, MD) found that the patient was oppressed by the pain. He did notmeet the criteria for major depression nor did he have any anxiety disorder or delusions. Because of thepresence of dysphoria and anticipatory anxiety secondary to glossodynia, the patient was started onolanzapine. Improvement of pain symptoms were noted within 3 days with full resolution of symptoms at1- and 3-month follow-ups. Dysphoria and anticipatory anxiety remitted fully upon pain relief. (J Am AcadDermatol 2004;51:463-5.)
unresponsive to clotrimazole troches, cevimeline,
A 73-year-old white male presented with a
triamcinolone dental paste, paroxetine, and lora-
6-month history of ‘‘painful burning tongue and
zepam. He denied tobacco, alcohol, or other drug
bitter taste’’ following acute trauma from eating
hot soup. The patient also complained of thick
On physical examination, the patient appeared
saliva, cotton mouth, and a red tender tongue with
physically well. Oral mucosa and conjunctiva were
eating. The tenderness and taste perversion re-
pink and moist. The tongue appeared normal both
sulted in a 20-pound weight loss. The patient
before and after eating. The mandible was edentu-
denied cancer phobia. Past medical history was
lous with a lower complete denture and the maxilla
significant for non-Hodgkin’s lymphoma treated
was partially edentulous without a partial denture.
with chemotherapy 5 years previously and no
There was no angular cheilitis or lymphadenopathy.
evidence of recurrence. He noted that during
He was dysphoric and had anticipatory anxiety just
chemotherapy he had experienced similar tongue
prior to eating each morning. He did not report
symptoms for a brief period, but they had remitted
symptoms consistent with a depression syndrome.
following completion of treatment. He reported no
He expressed a wish not to continue living in his
personal or family history of psychiatric disorder.
current state, but denied any active plans of suicide.
His only medication prior to symptom onset was
A detailed free amnestic assessment by a board
terazosin, which he had taken for 5 years. He was
certified Geriatric Psychiatrist (J. S. K.) found thatthe patient was oppressed by the pain. The patientdid not meet the criteria for major depression. He did
From the Departments of Dermatologya and Psychiatry and
not have any anxiety disorder and he had no de-
Medicine,c Indiana University School of Medicine, Indiana
University School of Dentistry,b and Lilly Research Laboratories,
A review of the patient’s prior laboratory evalua-
tion revealed normal blood counts, serum chemistry
profile, and erythrocyte sedimentation rate. Vitamin
Conflicts of interest: Frank P. Bymaster, MS, PhD is currently
employed in the research laboratory of Eli Lilly and Company.
B12 and folate levels were normal. Oral culture was
John S. Kennedy, MD was employed by Eli Lilly and Company
obtained and was negative for fungus.
from 1997-2002, but is now employed by Indiana University
A diagnosis of idiopathic glossodynia was
School of Medicine. The other two authors are unaffiliated with
rendered. The patient was started on olanzapine
Eli Lilly and Company and contacted Frank Bymaster, MS, PhD
(Zyprexa, Eli Lilly and Company, Indianapolis,
after the patient was seen in follow-up.
Reprint requests: Ginat W. Mirowski, DMD, MD, Department of
Ind) 5 mg once daily. He noted improvement of
Dermatology, Indiana University School of Medicine, 550 N.
symptoms within 3 days. His taste perception nor-
University Blvd, Suite 3240, Indianapolis, IN 46202. E-mail:
malized, burning sensation was eliminated, and
appetite improved. His mood was euthymic without
evidence of anxiety. He remained free of symptoms
ª 2004 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2004.02.016
onset of glossodynia and remitted fully upon pain
glossodynia and their associated etiologies
Treatment of secondary glossodynia is aimed at
correcting the underlying condition. Reassuring that
the pain is not related to neoplasia is appropriate in
patients with cancerophobia. Topical antifungals are
controversial treatments in cases of normal exams
and cultures. Topical steroids and viscous lidocaine
have been cited as therapy for glossodynia, but often
The mainstay of treatment for primary glossodynia
has been benzodiazepines and tricyclic antidepres-sants. Low-dose clonazepam was successful in re-ducing symptoms of burning mouth syndrome in67% of 30 patients.Chlordiazepoxide is another
long-acting benzodiazepine that has been successful
Glossodynia (burning mouth syndrome, glos-
in the treatment of glossodynia.Low-dose tricyclic
salgia, stomatodynia, glossopyrosis, glossitis) is
antidepressants such as amitriptyline and doxepin
defined as a spontaneous syndrome of burning
have been effective in treating glossodynia, neurop-
sensation, discomfort, pain, irritation, or rawness of
athy, fibromyalgia, and other chronic pain con-
the tongue, lips, or oral cavity often without organic
cause.In a cohort of 70 patients with glossodynia,
This case is noteworthy because the patient was
80% were female with a mean age of 59 years.The
refractory to benzodiazepine and antidepressant
reported prevalence of glossodynia is between 0.7%
therapy. The patient responded to a medication
currently indicated only for psychosis in schizophre-
There are no diagnostic criteria for glossodynia.
nia and acute mania in bipolar disorder. This is the
Patients often complain of pain, tenderness, or
first reported case in the literature of olanzapine
burning with symptoms often worsening throughout
successfully relieving the symptoms of glossodynia.
the day. Patients may also complain of dysgeusia
Recent case reports demonstrate the potential suc-
(altered taste) or xerostomia (dry mouth). In a pro-
cess of olanzapine in treating patients with other pain
spective study of 96 patients, dysgeusia was detected
in 44.8% of patients with glossodynia, approximately
The mechanism responsible for this effect of
half of which did not present with a complaint of
olanzapine is unknown. Olanzapine is a potent
dysgeusia.Xerostomia has been reported in more
antagonist at a number of neuronal receptors in-
than 20% of patients with glossodynia.On exam-
cluding dopamine and serotonin receptors and
ination, the tongue appears normal, with erythema,
produces antipsychotic effects with reduced risk of
edema, or atrophy present in rare cases.
The work-up for glossodynia should be guided by
that the efficacy of olanzapine in treating glossodynia
clinical suspicion and may include: detailed patient
is due, in part, to its blockade of a subset of these
history, complete blood count, serum iron, serum
serotonin receptors. Olanzapine may exhibit anxio-
B12 and folate levels, mucosal culture, serum tests
lytic, antipsychotic, and gastrointestinal anti-motility
¨gren’s syndrome antibodies (SS-A, SS-B),
properties secondary to other serotonin receptor
glycosylated hemoglobin, patch testing, and biopsy
(if exam is abnormal).Further consultation may be
or involvement of alpha2-adrenoreceptorsby
helpful. In the case presented above, no underlying
olanzapine may be partially responsible for the pain
systemic conditions, nutritional deficiencies, adverse
relief observed in our patient. Possible side-effects
drug reactions, or oral disorders were detected
of olanzapine include weight gain, which may be
to explain the etiology of the patient’s continued
substantial in a small subset of patients. Minimal
anticholinergic side effects may be observed in
orders, particularly those with depressive or anxiety
geriatric patients.Olanzapine, a newer anti-
symptoms, have been reported in 30%-72% of
psychotic and dopamine modifier, may induce or un-
patients with glossodynia.However, in the case
cover extrapyramidal syndromes such as parkinson-
of our patient, symptoms of dysphoria and anxiety
ism, akathisia, tardive dyskinesia, and neuroleptic
were felt to be secondary to oppression associated
malignant syndrome. The risk of the atypical anti-
with pain since these symptoms developed after the
cardiotoxicity is much lower than has been reported
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AIR POLLUTION IN DENSE, LOW-INCOME SETTLEMENTS IN SOUTH AFRICA A Friedl1, D Holm2, J John3, G Kornelius4,C J Pauw5, R Oosthuizen6 and A S van Niekerk7 Abstract This research is carried out on behalf of the Royal Danish Embassy as partof the Urban Environmental Management Programme in cooperation with theSouth African Department of Environmental Affairs and Tourism. In the callfor proposa
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