We describe a 40-year-old lady who presents with a painful white tongue on exposure to the cold. The differential diagnosis and investigations are outlined with a discussion about this unusual presentation of a common problem.LEARNING POINTS • Raynaud's can affect areas of the body besides the digits.• Lingual Raynaud's should be considered in patients with transient tongue pain.• Alternative diagnoses should be sought if ulceration or permanent symptoms develop. KEYWORDS Raynaud's, tongue CASE DESCRIPTION A 40-year-old woman presented with intermittent, 20 minute episodes of sequential painful white and blue tongue discoloration upon exposure to the cold. The peripheral rim of her tongue was relatively spared and on re-warming, the tongue became bright red associated with a burning sensation. The episodes caused moderately severe discomfort with dysarthria and stiffness at the back of the tongue as well as hypersalivation. The patient had a past history of vitamin B12 deficiency and was a smoker. There was no concurrent digital vasospasm of fingers or toes, lips or nipples. She did not have a past medical history of any connective tissue disease. Physical examination was normal but the tongue colour change is shown in Figure 1. Laboratory testing was negative for anti-nuclear antibody and rheumatoid factor. Other blood investigations demonstrated no abnormalities in biochemistry, haematology, ESR or clotting profile.

Introduction Ingestion of foreign bodies are not uncommon, however enterohepatic migration of fish bones causing liver abscesses remains a rare phenomenon. Case Report We present the case of a 58-year-old female admitted with 11 days history of fever, rigors, shortness of breath and malaise associated with vomiting and diarrhoea. Her COVID-19 rapid antigen test was negative. She was tender in the left lower quadrant of her abdomen and inflammatory markers were markedly high so initial differential diagnosis included colitis and diverticulitis. Contrast Computed Tomography of the abdomen and pelvis showed an 8.1cm irregular hepatic lesion initially thought to be a multi-loculated abscess, malignancy or complex cyst. She was started on broad-spectrum antibiotics, escalated to Intensive Care Unit (ICU) and discussed at the hepato-biliary multi-disciplinary team (MDT) where magnetic resonance images demonstrated a perforated duodenum from a 2.5cm fish bone penetrating from the duodenal wall into the liver parenchyma causing a necrotic abscess. She underwent percutaneous drainage of the hepatic abscess. Endoscopic retrieval was then attempted; however, the fish bone was not visualised. Definitive management followed with laparoscopic removal of the fish bone and primary duodenal repair. Discussion Identification of the cause of the abscess during MDT discussion enabled prompt source control which was key in managing intra-abdominal sepsis – radiological drainage in the first instance prevented secondary peritonitis from a potentially ruptured abscess and enabled the patient to be de-escalated from ICU. Previous literature suggests endoscopic retrieval however, laparoscopic surgery remains safer for managing complications following removal of sharp foreign bodies.

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