139 Burning Mouth Syndrome After Hemicolectomy and Hyperalimentation

Abstract

Study Objective

Burning mouth syndrome (BMS) is characterized by a burning sensation in the tongue or other oral sites [Grushka 2002]. Vitamin B complex deficiencies have been associated with BMS, including B1 (thiamine) [Lamey 1988]. Replacement with thiamine and other B vitamins was noted to cause relief of BMS in 34 of 150 patients [Lamey 1988]. BMS secondary to vitamin deficiencies have been discussed; however, hemicolectomy and hyperalimentation associated thiamine deficiency inducing chronic BMS has not heretofore been described.

Methods

Case Study: A 63 year old female presents with a two year history of BMS pain, two weeks following a hemicolectomy from terminal ileum to transverse colon and five days of hyperalimentation. She describes it as a burning pain, 8/10 in severity, localized to both lips, anterior tongue, and middle tongue. It is aggravated with eating and drinking, increasing to 10/10 on the pain scale. Alleviation of pain is seen when ice, Blistex, or lidocaine-mouthwash is used, decreasing the pain to 4/10. Diurnal variation was noted, wherein the pain is exacerbated later in the evening.

Results

Abnormalities in neurological examination: Motor Examination: abductor pollicis brevis 4/5 bilaterally. Drift testing with bilateral cerebellar spooning and bilateral abductor digiti minimi signs. Cerebellar Examination: rapid alternating movements are decreased in the left upper extremity. Reflex Examination: Deep Tendon Reflexes: Brachioradialis: 3+ bilaterally. Biceps: 3+ bilaterally. Triceps: 3+ bilaterally. Ankle Jerk: 2+ bilaterally with delayed return. Hoffman reflex: positive bilaterally. Serum Thiamine level: 66 nmol/L (normal 70-180 nmol/L).

Conclusion

Although, BMS can be seen with thiamine deficiency [Lamey 1988], it has yet to be described status-post hemicolectomy and hyperalimentation. Thiamine is absorbed systemically in the upper jejunum, as well as in duodenum and ileum in conjunction with folate [Friedamann 1948]. Thiamine deficiency is associated with Wernicke-Korsakoff Syndrome and Wet/Dry Beri-Beri; however, these abnormalities are associated with a significant decrease of serum vitamin B1 [Martin 2004]. Even with near normal levels of thiamine, her BMS pain may be a prodromal syndrome which may act as a biological marker of dietary vitamin deficiency.

BMS is highly prevalent in postmenopausal women, wherein trigeminal nerve sensitivity may amplify and worsen pain, given a decrease in estrogen and progesterone [Martin 2007], indirectly influencing her BMS pain. Salivary output and composition can alter due to a drop in estrogen and progesterone as well, allowing baseline reduction of proprioceptive input on the tongue. Ergo, acting through Melzack and Wall’s Gate Control Theory of Pain to disinhibit small C-fibers, it may be perceived as burning pain [Melzack 1965]. Given this case, in those who undergo abdominal surgery or hyperalimentation, query regarding BMS symptoms is warranted.

Funding Acknowledgements

Smell and Taste Treatment Research Foundation