The differential diagnosis of tongue swelling

Abstract

A 44-year-old-man was found lying lifeless on the kitchen floor in his apartment. The emergency medical doctor who attended certified his death immediately. He hypothesized that death was caused by an anaphylactic reaction as a result of ingesting strawberries as their stems were found in the kitchen sink, and the man’s tongue showed remarkable swelling. When the man was found, his underpants and trousers were wet with urine (urinary incontinence). Relatives reported, however, that the man was not allergic to any foods or medications. Except for hypertension under medical treatment, he had no notable clinical medical history, including psychotic disorders and epilepsy. In addition, he did not bite his nails. At medico-legal autopsy the most significant finding was a remarkably swollen tongue (Fig. 1). Several fresh lacerations corresponding to bite marks were found on both sides of the tongue. Horizontal sectioning of the tongue revealed massive intramuscular hemorrhage throughout the first half of the tongue, corresponding to the bilateral bite marks (Fig. 2). Trauma to the face and head that might have caused the tongue injuries was excluded by careful dissection. Interestingly, fresh semicircular lacerations of the nail (Fig. 3) and the opposite finger pulp, probably indicating a pair of bite marks, were also observed on the right thumb. The pharyngeal space was not obstructed by the swollen tongue. Laryngeal or epiglottic mucosa was not edematous and no mucus plugging was observed in the bronchi. The oral cavity was filled with bloody fluid, which leaked out when the position of the body was altered during autopsy. The stomach contained 180 ml of fluid with ‘‘coffee-grounds’’, oxidized blood. There was no source of bleeding in the esophagus or the stomach. No blood aspiration was observed in the airways. The brain showed edematous swelling (weight 1,420 g), but no herniation. There were no remarkable pathological findings including organic diseases and post-traumatic lesions. Neuropathological examination of the brain revealed mild hypoxic changes in the hippocampus that was represented by eosinophilic necrosis of single neurons. The urinary bladder was almost empty. Apart from a fatty liver, no other gross pathological findings were noted. Toxicological analysis was negative.