History

Fact Explanation
Swollen tongue The term glossitis refers to a condition of the tongue in which it's swollen and change in colour with smooth surface of the tongue. There are many causes for this condition such as Allergic reactions to oral care products, foods, or medicine, Sjogren syndrome, infection from bacteria, yeast or viruses (including oral herpes), injury (such as from burns, rough teeth, or bad-fitting dentures), skin conditions that affect the mouth, irritants such as tobacco, alcohol, hot foods, spices, or other irritants, hormonal factors, familial and due to various vitamin deficiencies. [1] [2] [3] [4] [5]
Difficulty with chewing, swallowing, or speaking [1] [2] Because of the swollen and sore tongue there could be difficulties in chewing, swallowing and speaking. [1] [2]
Sore and tender tongue [1] [2] [3] This is mainly seen in glossitis associated with nutritional deficiencies There are inflammatory changes char acterized by bright red plaques which may then evolve into the atrophic form, noted as atrophy of the lingual papillae, affecting more than 50% of the tongue’s surface. A burning sensation of the mouth is reported. [1] [2]
Colour change in the tongue [1] [2] This is mainly seen in glossitis associated with nutritional deficiencies There are inflammatory changes char acterized by bright red plaques in vitamin B 12 deficiency and pale tongue in iron deficiency. [1] [2]
Difficulty in speaking and other features of blocked airway [1] [2] Swollen tongue can cause respiratory difficulties and block the air way. [1] [2]
Dry mouth [6] Sometimes there could be symptoms of underlying disease such as Sjogren's syndrome and patient may complain of dry mouth. [6]
Fatigue, Weakness, Shortness of breath on exertion [1] [2] [4] When the underlying disorder is nutritional deficiency such as iron or vitamin B12 deficiency, there could be anemic symptoms due to low hemoglobin level in the circulation. [1] [2] [4]
References
  1. REAMY BV, DERBY R, BUNT CW. Common tongue conditions in primary care. Am Fam Physician [online] 2010 Mar 1, 81(5):627-34 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20187599
  2. STOOPLER E. T., KUPERSTEIN A. S.. Glossitis secondary to vitamin B12 deficiency anemia. Canadian Medical Association Journal [online] December, 185(12):E582-E582 [viewed 09 August 2014] Available from: doi:10.1503/cmaj.120970
  3. GOSWAMI M, VERMA A, VERMA M. Benign migratory glossitis with fissured tongue. J Indian Soc Pedod Prev Dent [online] 2012 December [viewed 09 August 2014] Available from: doi:10.4103/0970-4388.100008
  4. ERRIU MATTEO, CANARGIU FERNANDO, ORRù GERMANO, GARAU VALENTINO, MONTALDO CATERINA. Idiopathic atrophic glossitis as the only clinical sign for celiac disease diagnosis: a case report. Array [online] 2012 December [viewed 09 August 2014] Available from: doi:10.1186/1752-1947-6-185
  5. PATHAK ASHA, PANDEY ACHYUT, MISHRA ATUL, MISHRA ARUN. Cefuroxime axetil induced glossitis: a case report. Int J Basic Clin Pharmacol [online] 2014 December [viewed 09 August 2014] Available from: doi:10.5455/2319-2003.ijbcp20140809
  6. PRICE E. J.. Dry eyes and mouth syndrome--a subgroup of patients presenting with sicca symptoms. [online] 2002 April, 41(4):416-422 [viewed 10 August 2014] Available from: doi:10.1093/rheumatology/41.4.416

Examination

Fact Explanation
Red , tender and swollen tongue [1] [2] inflammatory changes characterized by bright red plaques which then evolve into the atrophic form, noted as atrophy of the lingual papillae, affecting more than 50% of the tongue’s surface is seen commonly with nutritional deficiencies. [1] [2]
Smooth surface of the tongue [1] [2] Smooth tongue because of the smooth, glossy appearance with a red or pink background and seen in atrophic glossitis. The smooth quality is caused by the atrophy of filiform papillae. Atrophic glossitis is primarily a manifestation of underlying conditions such as nutritional deficiencies of iron, folic acid, vitamin B12, riboflavin, and niacin [1] [2]
Map-like appearance to the surface of the tongue [3] [4] This is seen in Geographic tongue or benign migratory glossitis. The exact cause of geographic tongue is unknown but attributed to lack of vitamin B. It also may be due to irritation from hot or spicy foods, or alcohol. The change in pattern on the surface of the tongue occurs when there is a loss papillae, on the tongue. These areas look flat as a result. [3] [4]
Fissuring of the tongue [3] [4] There could be development of deep grooves due to physiologic deepening of normal tongue fissures. These occur commonly with aging and require no treatment, unless trapping of food and bacteria leads to inflammation of the fissures. Fissured tongue has been associated with Down syndrome, acromegaly, psoriasis, and Sjögren syndrome. [3] [4] [8]
Angular stomatitis [7] These symptom of fissuring of corners of the mouth are mainly seen associated with nutritional deficiency of Vitamin B12 and also iron. [7]
Pallor [5] [6] Pallor develops with anemia secondary to iron and vitamin B12 deficiency. [5] [6]
References
  1. STOOPLER E. T., KUPERSTEIN A. S.. Glossitis secondary to vitamin B12 deficiency anemia. Canadian Medical Association Journal [online] December, 185(12):E582-E582 [viewed 10 August 2014] Available from: doi:10.1503/cmaj.120970
  2. ERRIU MATTEO, CANARGIU FERNANDO, ORRù GERMANO, GARAU VALENTINO, MONTALDO CATERINA. Idiopathic atrophic glossitis as the only clinical sign for celiac disease diagnosis: a case report. Array [online] 2012 December [viewed 10 August 2014] Available from: doi:10.1186/1752-1947-6-185
  3. GOSWAMI M, VERMA A, VERMA M. Benign migratory glossitis with fissured tongue. J Indian Soc Pedod Prev Dent [online] 2012 December [viewed 10 August 2014] Available from: doi:10.4103/0970-4388.100008
  4. REAMY BV, DERBY R, BUNT CW. Common tongue conditions in primary care. Am Fam Physician [online] 2010 Mar 1, 81(5):627-34 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20187599
  5. KALANTRI ASHWINI, KARAMBELKAR MANDAR, JOSHI RAJNISH, KALANTRI SHRIPRAKASH, JAJOO ULHAS, MALAGA GERMAN. Accuracy and Reliability of Pallor for Detecting Anaemia: A Hospital-Based Diagnostic Accuracy Study. PLoS ONE [online] 2010 January [viewed 10 August 2014] Available from: doi:10.1371/journal.pone.0008545
  6. SHETH TN, BARTSSC, CHOUDHRY NK, BOWES M, DETSKY AS. The Relation of Conjunctival Pallor to the Presence of Anemia J Gen Intern Med [online] 1997 Feb, 12(2):102-106 [viewed 10 August 2014] Available from: doi:10.1046/j.1525-1497.1997.00014.x
  7. EARNSHAW R, SMITH DC. Angular Stomatitis and Dentures Br Med J [online] 1954 Jul 24, 2(4881):242-243 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2079386
  8. PRICE E. J.. Dry eyes and mouth syndrome--a subgroup of patients presenting with sicca symptoms. [online] 2002 April, 41(4):416-422 [viewed 10 August 2014] Available from: doi:10.1093/rheumatology/41.4.416

Differential Diagnoses

Fact Explanation
Allergic reactions [1] Allergic reactions to certain medications, food, and other potential irritants can aggravate the papillae and the muscle tissues of the tongue and cause glossitis. Potential irritants include toothpastes and certain types of medications that treat hypertension and antibiotics [1]
Infections [2] Systemic infections such as oral herpes simplex, a virus that causes blisters, may contribute to swelling and pain in the tongue as well as local infections of Candida too can cause glossitis. [2]
Iron deficiency anemia [2] [6] Low iron and consequent low hemoglobin level in blood can trigger glossitis. Iron helps to regulate cell growth by helping the body make red blood cells. Red blood cells carry oxygen to your organs, tissues, and muscles. Low iron in the blood may result in low levels of myoglobin, a protein in red blood cells that is important for muscle health, including the tongue’s muscle tissue. [2] [6]
Vitamin B complex deficiencies [2] [3] Vitamin B complex deficiencies, particularly vitamin B 12, folic acid, riboflavin, niacin can cause beefy red sore tongue. [2] [3]
Sjogren's syndrome [4] Dry mouth caused by Sjogren's syndrome due lack of saliva is also another differential diagnosis. [4]
Trauma [2] Injuries can affect the condition of your tongue. Inflammation may come from dental appliances placed on the teeth or from cuts and burns on the tongue. [2]
Amyloidosis [2] [7] Amyloidosis is another systemic disease which affects the tongue and cause atrophic glossitis. [2] [7]
Celiac disease [2] [5] Celiac disease (CD) is a disorder linked to an autoimmune intolerance to gliadin, a protein contained in gluten. The main target of this intolerance is the mucosa of the small intestine with development of histological lesions characterized by villous atrophy, crypt hyperplasia, damage to the surface epithelium, and an increased number of activated lymphocytes and other inflammatory cells infiltrating the lamina propria. Idiopathic atrophic glossitis may be the only clinical sign observed sometimes. [2] [5]
Protein-calorie malnutrition [2] [8] This can lead to a form of atrophic glossitis. [2] [8]
References
  1. PATHAK ASHA, PANDEY ACHYUT, MISHRA ATUL, MISHRA ARUN. Cefuroxime axetil induced glossitis: a case report. Int J Basic Clin Pharmacol [online] 2014 December [viewed 10 August 2014] Available from: doi:10.5455/2319-2003.ijbcp20140809
  2. REAMY BV, DERBY R, BUNT CW. Common tongue conditions in primary care. Am Fam Physician [online] 2010 Mar 1, 81(5):627-34 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20187599
  3. STOOPLER E. T., KUPERSTEIN A. S.. Glossitis secondary to vitamin B12 deficiency anemia. Canadian Medical Association Journal [online] December, 185(12):E582-E582 [viewed 10 August 2014] Available from: doi:10.1503/cmaj.120970
  4. PRICE E. J.. Dry eyes and mouth syndrome--a subgroup of patients presenting with sicca symptoms. [online] 2002 April, 41(4):416-422 [viewed 10 August 2014] Available from: doi:10.1093/rheumatology/41.4.416
  5. ERRIU MATTEO, CANARGIU FERNANDO, ORRù GERMANO, GARAU VALENTINO, MONTALDO CATERINA. Idiopathic atrophic glossitis as the only clinical sign for celiac disease diagnosis: a case report. Array [online] 2012 December [viewed 10 August 2014] Available from: doi:10.1186/1752-1947-6-185
  6. NOVACEK GOTTFRIED. . Orphanet J Rare Dis [online] 2006 December [viewed 10 August 2014] Available from: doi:10.1186/1750-1172-1-36
  7. SUBRAMANIAN K, SIVAPRAKASH , HARRIS M, RAJI V. A rare presentation of primary (AL) amyloidosis. Ann Indian Acad Neurol [online] 2006 December [viewed 10 August 2014] Available from: doi:10.4103/0972-2327.27661
  8. SHEETAL APARNA. Malnutrition and its Oral Outcome – A Review. JCDR [online] 2013 December [viewed 10 August 2014] Available from: doi:10.7860/JCDR/2012/5104.2702

Investigations - for Diagnosis

Fact Explanation
Full blood count [1] [2] To evaluate the hemoglobin status as anemia due to various nutritional deficiencies can cause glossitis. Red cell indices can also point towards the diagnosis with low mean corpuscular volume (MCV), Mean corpuscular hemoglobin (MCH), will be low in iron deficiency anemia but high MCV is seen in vitamin B12 deficiency anemia. Furthermore changes in the white cell count can also direct towards infections. Also low white cell count and platelet count is observed in vitamin B12 deficiency. [1] [2]
Serum iron studies [1] Iron deficiency anemia is a recognized cause for glossitis and serum iron studies including, serum ferritin, total iron binding capacity (TIBC), Serum iron can be done. TIBC will be high but others will be low. [1]
Serum vitamin B 12 level [2] Vitamin B12 deficiency can also cause glossitis and low serum vitamin B 12 will be shown [2]
Serum folate/ Red cell folate level [2] [3] [4] In folic acid deficiency, serum folate will be low, but in the presence of vitamin B12 deficiency, this will be normal. Therefore most reliable investigation is red cell folate which is invariably low in both deficiencies. [2] [3] [4]
Blood picture [2] [3] [4] In the presence of vitamin B12 deficiency, macrocytosis is seen which are oval with hypersegmented neutrophils sometimes with leukopenia and thrombocytopenia. In iron deficiency anemia, microcytic anemia is seen. [2] [3] [4]
Bone marrow aspiration [3] [4] This is carried out in anemia, and in vitamin B12 deficiency anemia, hypercellular bone marrow with megaloblasts with giant and abnormal metamyelocytes are seen. [3] [4]
Serum unconjugated bilirubin [5] These levels are high because marrow cell breakdown is high [5]
Serum hydroxy Butyrate [5] These levels are high because marrow cell breakdown is high [5]
Serum lactate dehydrogenase level (LDH) [5] These levels are high because marrow cell breakdown is high [5]
Serum creatinine, Blood urea nitrogen level [6] Renal function tests will give abnormal results when the cause is Amyloidosis and renal amyloidosis is common. [6]
Urine analysis [6] Urine full report may show proteinuria in the presence of renal amyloidosis. [6]
Antibody test for Celiac disease [7] Anti-endomysial antibody levels can be done in a patient with suspected Celiac disease. [7]
Rhematoid factor, Anti nuclear antibody level [8] These levels are commonly high in Sjogren's syndrome. [8]
Schirmer test [8] This test is done when Sjogren's syndrome is suspected in which a bent piece of filter paper is placed into the lower conjunctiva and left there for five minutes. A definitive positive result can be considered if the paper is wet less than 5 mm after five minutes. In normal people the paper will be wet to 15 mm or beyond after five minutes, [8]
References
  1. LOGAN E C M. Investigation and management of iron deficiency anaemia in general practice: a cluster randomised controlled trial of a simple management prompt. [online] 2002 September, 78(923):533-537 [viewed 10 August 2014] Available from: doi:10.1136/pmj.78.923.533
  2. JAIN . Megaloblastic Anaemia Presenting as Pyrexia: An Interesting Case Report. J Hematol [online] 2012 December [viewed 10 August 2014] Available from: doi:10.4021/jh40e
  3. ASLINIA F., MAZZA J. J., YALE S. H.. Megaloblastic Anemia and Other Causes of Macrocytosis. Clinical Medicine & Research [online] 2006 September, 4(3):236-241 [viewed 10 August 2014] Available from: doi:10.3121/cmr.4.3.236
  4. SOBCZYńSKA-MALEFORA AGATA, HARRINGTON DOMINIC J., VOONG KIERAN, SHEARER MARTIN J.. Plasma and Red Cell Reference Intervals of 5-Methyltetrahydrofolate of Healthy Adults in Whom Biochemical Functional Deficiencies of Folate and Vitamin B12 Had Been Excluded. Advances in Hematology [online] 2014 December, 2014:1-7 [viewed 10 August 2014] Available from: doi:10.1155/2014/465623
  5. ACHARYA UTKARSH, GAU JEN-TZER, HORVATH WILLIAM, VENTURA PAOLO, HSUEH CHUNG-TSEN, CARLSEN WAYNE. Hemolysis and hyperhomocysteinemia caused by cobalamin deficiency: three case reports and review of the literature. Array [online] 2008 December [viewed 10 August 2014] Available from: doi:10.1186/1756-8722-1-26
  6. ROSENZWEIG MICHAEL, LANDAU HEATHER. Light chain (AL) amyloidosis: update on diagnosis and management. Array [online] 2011 December [viewed 10 August 2014] Available from: doi:10.1186/1756-8722-4-47
  7. KAGNOFF MARTIN F.. Celiac disease: pathogenesis of a model immunogenetic disease. J. Clin. Invest. [online] 2007 January, 117(1):41-49 [viewed 10 August 2014] Available from: doi:10.1172/JCI30253
  8. DöRNER THOMAS. Challenges in understanding Sjögren's syndrome - improved insights into the pathogenesis generate hope for innovative therapies?. Array [online] 2011 December [viewed 10 August 2014] Available from: doi:10.1186/ar3425

Investigations - Followup

Fact Explanation
Full blood count [1] [2] Patient can be followed up with periodical hemoglobin level to see the efficacy of treatment with iron, vitamin B12, folate. [1]
Serum iron studies [1] This levels can be done to assess the efficacy of treatment with nutritional supplements.
Serum Vitamin B 12 level [2] [3] This levels can be done to assess the efficacy of treatment with nutritional supplements. [2] [3]
Serum Red cell folate [2] [3] [4] This levels can be done to assess the efficacy of treatment with nutritional supplements. [2] [3] [4]
Reticulocyte count [5] [6] With treatment, reticulocytosis should be seen within 3-5 days with a peaking in 4-10 days. [5] [6]
Serum LDH [5] [6] Elevated lactate dehydrogenase (LDH) and rapid fall of indirect bilirubin levels is seen. Prolonged elevated LDH level indicates failure of the therapy, or possible development of iron deficiency, or even an error in diagnosis. [5] [6]
Serum unconjugated bilirubin [5] [6] This level should also fall rapidly with treatment. [5] [6]
Serum potassium level [6] With treatment for severe cobalamin or folate deficiency, serum potassium level may fall rapidly and can result in sudden death. Hence potassium levels should be monitored carefully. Supplementation of potassium may be needed especially if older patients on diuretics. [6]
References
  1. LOGAN E C M. Investigation and management of iron deficiency anaemia in general practice: a cluster randomised controlled trial of a simple management prompt. [online] 2002 September, 78(923):533-537 [viewed 10 August 2014] Available from: doi:10.1136/pmj.78.923.533
  2. JAIN . Megaloblastic Anaemia Presenting as Pyrexia: An Interesting Case Report. J Hematol [online] 2012 December [viewed 10 August 2014] Available from: doi:10.4021/jh40e
  3. ASLINIA F., MAZZA J. J., YALE S. H.. Megaloblastic Anemia and Other Causes of Macrocytosis. Clinical Medicine & Research [online] 2006 September, 4(3):236-241 [viewed 10 August 2014] Available from: doi:10.3121/cmr.4.3.236
  4. SOBCZYńSKA-MALEFORA AGATA, HARRINGTON DOMINIC J., VOONG KIERAN, SHEARER MARTIN J.. Plasma and Red Cell Reference Intervals of 5-Methyltetrahydrofolate of Healthy Adults in Whom Biochemical Functional Deficiencies of Folate and Vitamin B12 Had Been Excluded. Advances in Hematology [online] 2014 December, 2014:1-7 [viewed 10 August 2014] Available from: doi:10.1155/2014/465623
  5. NYHOLM E. Oral vitamin B12 can change our practice. [online] 2003 April, 79(930):218-219 [viewed 10 August 2014] Available from: doi:10.1136/pmj.79.930.218
  6. CARMEL R.. How I treat cobalamin (vitamin B12) deficiency. Blood [online] December, 112(6):2214-2221 [viewed 10 August 2014] Available from: doi:10.1182/blood-2008-03-040253

Investigations - Screening/Staging

Fact Explanation
Rhematoid factor, Anti nuclear antibody level [1] These antibody levels are needed to screen for Sjogren's syndrome as these are commonly elevated. [1]
Anti-endomysial antibody levels [2] Anti-endomysial antibody levels can be done in a patient with suspected Celiac disease. [2]
References
  1. DöRNER THOMAS. Challenges in understanding Sjögren's syndrome - improved insights into the pathogenesis generate hope for innovative therapies?. Array [online] 2011 December [viewed 10 August 2014] Available from: doi:10.1186/ar3425
  2. SILVESTER J., DUERKSEN D.. Celiac disease. Canadian Medical Association Journal [online] December, 185(1):60-60 [viewed 10 August 2014] Available from: doi:10.1503/cmaj.111646

Management - General Measures

Fact Explanation
Patient education [1] [2] [3] Patient education plays an important role to educate on good oral care such as brushing teeth thoroughly at least twice a day and floss at least once a day, to avoid irritants (such as hot or spicy foods, alcohol, and tobacco) to ease discomfort. Patient should also educated on importance of healthy diet. [1] [2] [3]
Diet [1] [2] [3] Diet changes are needed and patient should be instructed to eat iron rich food, vitamin B containing food to combat nutritional deficiencies. [1] [2] [3]
Anti inflammatory agents [5] Corticosteroids such as prednisone may be given to reduce the inflammation of glossitis and for mild cases, topical applications such as a prednisone mouth rinse may be recommended [5]
Management of acute airway obstruction [4] When a patient presents with acute airway obstruction due to swollen tongue, urgent measures are needed to secure the airway. [4]
References
  1. REAMY BV, DERBY R, BUNT CW. Common tongue conditions in primary care. Am Fam Physician [online] 2010 Mar 1, 81(5):627-34 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20187599
  2. ALLEN L. H. How common is vitamin B-12 deficiency?. American Journal of Clinical Nutrition [online] 2009 January, 89(2):693S-696S [viewed 10 August 2014] Available from: doi:10.3945/​ajcn.2008.26947A
  3. O’LEARY FIONA, SAMMAN SAMIR. Vitamin B12 in Health and Disease. Nutrients [online] 2010 March, 2(3):299-316 [viewed 10 August 2014] Available from: doi:10.3390/nu2030299
  4. HASANI ANTIGONA, THAQI HAJDIN, AZIZI SHEFKI. Management of child with acute airway obstruction: a case report. Array [online] 2009 December [viewed 10 August 2014] Available from: doi:10.1186/1757-1626-2-7517
  5. GOSWAMI M, VERMA A, VERMA M. Benign migratory glossitis with fissured tongue. J Indian Soc Pedod Prev Dent [online] 2012 December [viewed 10 August 2014] Available from: doi:10.4103/0970-4388.100008

Management - Specific Treatments

Fact Explanation
Antibiotics [1] Antibiotics or other medicines to treat infections such as antifungals for candidiasis, and antivirals for herpes simplex is important [1]
Vitamin B 12 therapy [2] [4] [5] Intramuscular Cobalamin (1000 µg) a day is given for 2 weeks, followed by a weekly dose until the hematocrit value becomes normal, and then monthly for rest of the life. Oral cobalamin (1000-2000 µg) also can be administered as an alternative method. [2] [4] [5]
Folate therapy [2] [3] Folate (3-5 mg) is administered orally or comparable doses can be administered parenterally and Fortification of foods and folic acid supplements have been recommended. [2] [3]
Iron therapy [6] Oral administration of ferrous iron salts is commonly carried out in iron deficiency anemia. ferrous sulphate is commonly used. Parenteral iron therapy is reserved for patients those who are either unable to absorb oral iron or shows no response to oral iron. [6]
Treatment of Sjogren's syndrome [7] When the underlying disease is Sjogren's syndrome, mainly supportive therapy is given and consists of artificial tears, Saliva substitutes for dry mouth and medications such as pilocarpine, Hydroxychloroquine [7]
Gluten free diet for celiac disease [8] As there is no cure for celiac disease, the only treatment is a gluten-free diet. [8]
References
  1. KAUFMAN H E, VARNELL E D, CENTIFANTO-FITZGERALD Y M, DE CLERCQ E, KISSLING G E. Oral antiviral drugs in experimental herpes simplex keratitis.. Antimicrobial Agents and Chemotherapy [online] 1983 December, 24(6):888-891 [viewed 10 August 2014] Available from: doi:10.1128/AAC.24.6.888
  2. JAIN . Megaloblastic Anaemia Presenting as Pyrexia: An Interesting Case Report. J Hematol [online] 2012 December [viewed 10 August 2014] Available from: doi:10.4021/jh40e
  3. ASLINIA F., MAZZA J. J., YALE S. H.. Megaloblastic Anemia and Other Causes of Macrocytosis. Clinical Medicine & Research [online] 2006 September, 4(3):236-241 [viewed 10 August 2014] Available from: doi:10.3121/cmr.4.3.236
  4. NYHOLM E. Oral vitamin B12 can change our practice. [online] 2003 April, 79(930):218-219 [viewed 10 August 2014] Available from: doi:10.1136/pmj.79.930.218
  5. CARMEL R.. How I treat cobalamin (vitamin B12) deficiency. Blood [online] December, 112(6):2214-2221 [viewed 10 August 2014] Available from: doi:10.1182/blood-2008-03-040253
  6. MILLER J. L.. Iron Deficiency Anemia: A Common and Curable Disease. Cold Spring Harbor Perspectives in Medicine [online] December, 3(7):a011866-a011866 [viewed 10 August 2014] Available from: doi:10.1101/cshperspect.a011866
  7. DöRNER THOMAS. Challenges in understanding Sjögren's syndrome - improved insights into the pathogenesis generate hope for innovative therapies?. Array [online] 2011 December [viewed 10 August 2014] Available from: doi:10.1186/ar3425
  8. SILVESTER J., DUERKSEN D.. Celiac disease. Canadian Medical Association Journal [online] December, 185(1):60-60 [viewed 10 August 2014] Available from: doi:10.1503/cmaj.111646