Sir, a 39-year-old Caucasian gentleman of Polish origin presented to our department with a non-healing ulcer of the tongue of three months' duration. The area was minimally tender and had not seen significant change in size after the initial growth. His past medical history was significant for 'self-diagnosed' anxiety for which he used diazepam obtained from his friends. He smoked 20-30 cigarettes along with cannabis and consumed 1 litre of vodka every day. He denied any recent foreign travel, fevers or night sweats. He had lost approximately 5 kg of weight in the past three months which he related to not eating well due to a busy job.

On examination, he had no obvious palpable cervical lymphadenopathy. A 3 x 2 cm large indurated ulcer with rolled borders was noted on the right posterolateral aspect of the tongue suspicious for malignancy (Fig. 1). An urgent biopsy revealed ulceration and necrotising granulomatous inflammation with no evidence of dysplasia or malignancy. Magnetic resonance imaging demonstrated a 1 cm diameter enhancing lesion on the right lateral tongue with additional multiple necrotic nodes of ipsilateral level II/III region and contralateral level II region. Computed tomography imaging of the chest showed extensive 'tree in bud' nodularity with calcified granulomas and parenchymal fibrosis (Fig. 2). The patient was referred to the respiratory team for further investigations and management. During the investigative period, the patient developed a productive cough along with dyspnoea. Sputum examination confirmed the diagnosis of tuberculosis (TB).

Fig. 1
figure 1

Large indurated ulcer right posterolateral tongue

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Fig. 2
figure 2

CT imaging showing 'tree in bud' nodularity

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The patient was isolated and treated initially with quadruple therapy (rifampicin/ethambutol/isoniazid/pyrizinamide) with pyridoxine for two months. On review after three months, there was symptomatic improvement and satisfactory healing of the tuberculous ulcer.

It is estimated that 10% of cases of extra-pulmonary TB are found in the head and neck region and 10% of those cases present in the oral cavity.1,2 Early differentiation together with prompt multidisciplinary management prevents spread of this deadly disease.