A 49-year-old male veteran with a history of overseas deployment to Iraq presented 7 years after his most recent deployment. He reported a several-month history of an enlarging painful ulcer in the center of his tongue, with dysphagia, odynophagia, and a 9-kg weight loss. His medical history was remarkable for scattered nonnecrotizing liver granulomas that had been diagnosed from a liver biopsy 5 years earlier as well as for elevated liver enzyme levels (alanine transaminase, 127 IU/L; aspartate transaminase, 89 IU/L; and alkaline phosphatase, 474 IU/L [to convert liver enzyme values to microkatals per liter, multiply by 0.0167]), splenomegaly, and chronic thrombocytopenia.
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