A 78-year-old woman with bilateral tongue necrosis.

A 78-year-old woman presented to the emergency department complaining of a sore tongue. Her medical history included essential hypertension managed with atenolol, 100 mg/d, and enalapril, 5 mg/d, osteoporosis managed with calcium and vitamin D (with no past bisphosphonate treatment), and gastroesophageal reflux disease managed with omeprazole, 20 mg/d. Seventeen years before admission, she had suffered from ovarian carcinoma that was treated by chemotherapy and oophorectomy without therapeutic irradiation. She had no known hypersensitivities or drug allergies. The patient reported pain of the right head, neck, face, and shoulder (ranked 8 on a 0 to 10 visual analog scale, with “10” the most painful), especially while eating. She also reported fatigue, and visual blurring that had developed 2 months before, weight loss over the preceding 8 weeks (from 67 to 60 kg; a 10.4% reduction), and tongue pain of 4-weeks’ duration, which she rated as 10 on a 10-point scale. Ten days before presentation at the emergency room, she had undergone a complete blood count (CBC) and computed tomography (CT) of the head to rule out any underlying systemic conditions and space-occupying lesions. CBC and CT results at that time were normal, except for a mild anemia (hemoglo-