KNOW THE FIELD
|Year : 2020 | Volume
| Issue : 1 | Page : 148-151
Pink bodies with halo
Sushruth Nayak1, Asha Karadwal1, Amit Aggarwal2, Prachi Nayak1
1 Department of Oral Pathology, MM College of Dental Sciences and Research, Mullana (Deemed to be University), Ambala, Haryana, India
2 Department of Oral Medicine and Radiology, MM College of Dental Sciences and Research, Mullana (Deemed to be University), Ambala, Haryana, India
|Date of Submission||11-Mar-2020|
|Date of Acceptance||04-Apr-2020|
|Date of Web Publication||08-May-2020|
D/O Sh Jaipal, #984 Sector 17 Huda, Jagadhri - 135 003, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The presence of eosinophilic Toto bodies in oral lesions could be found in a variety of situations and sometime may present a challenge to the pathologist. We present three case reports where the oral biopsy was taken from the gingival region of a 30-year-old female, a 32-year-old male patient and another from the buccal mucosa of a 67-year-old male patient. Histopathologically, the three cases were finally diagnosed as pyogenic granuloma and moderately differentiated squamous cell carcinoma with the presence of clusters of Toto bodies in the upper spinous layer of stratified squamous epithelium.
Keywords: Eosinophilic bodies, pyogenic granuloma, Toto bodies
|How to cite this article:|
Nayak S, Karadwal A, Aggarwal A, Nayak P. Pink bodies with halo. J Oral Maxillofac Pathol 2020;24:148-51
| Introduction|| |
Toto bodies are the eosinophilic bodies located in the superficial spinous cell layer of stratified squamous epithelium. These are homogenous eosinophilic bodies, are round-to-oval shaped with a peripheral halo appearance and generally vary in size. These are mostly seen in reactive or inflammatory lesions. These are also known as mucopolysaccharide keratin dystrophy.
Till now, these bodies were commonly seen in inflammatory gingival and other oral mucosal lesions such as irritational fibroma, pyogenic granuloma, peripheral giant cell granuloma and gingivitis. The present reported cases are of pyogenic granuloma and moderately differentiated squamous cell carcinoma showing the presence of Toto bodies in clusters in the upper spinous cell layer.
| Case Report|| |
Oral biopsies were taken, one from the gingival region with respect to 33–35 having smooth surface and reddish pink in color and nontender from a 30-year-old female patient [Figure 1]a, and another biopsy was taken from a 32-year-old male patient, where the lesion was soft to firm in consistency, was light pink in color and surrounding the attrited right incisor tooth region [Figure 1]b. The third biopsy was taken from a 62-year-old male patient [Figure 1]c with respect to the left buccal mucosa in relation to the maxillary and mandibular molar tooth region having both white and erythematous ulcerative areas, which was tender on palpation.
|Figure 1: Intraoral clinical images a and b, showing pyogenic granuloma of gingiva involving the lower right mandibular region. Image c showing squamous cell carcinoma of the left buccal mucosa|
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On incisional biopsy, the first soft-tissue specimen was measuring about 1 cm × 1.2 cm, was soft to firm in consistency, was creamish in color, had an irregular surface and margin and was roughly oval in shape [Figure 2]a. The second gross specimen was measuring about 1 cm × 1 cm, was soft to firm in consistency and was cream to brown in color with an irregular surface [Figure 2]b. The third soft-tissue specimen was measuring about 1.2 cm × 1 cm, was cream to dark brown in color with an irregular surface and had rolled-out margin [Figure 2]c.
|Figure 2: Incisional biopsy photographs a and b, gross specimen of pyogenic granuloma measuring about 1×1.2 cm, 1×1 cm. (c) gross specimen of squamous cell carcinoma measuring about 1.2×1 cm with soft to firm consistency along with irregular surface and margin|
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Histopathologically, the first [Figure 3]a and second cases [Figure 3]b revealed the presence of parakeratinized stratified squamous epithelium overlying the connective tissue components and clusters of eosinophilic Toto bodies in the upper spinous cell layer. The underlying connective tissue of both the cases [Figure 4]a and [Figure 4]b showed the presence of haphazardly arranged collagen fiber bundles, numerous large endothelial lined blood capillaries with red blood cells and mild-to-moderate chronic inflammatory cell infiltrates. The third case [Figure 5] showed the presence of nonkeratinized stratified squamous epithelium showing areas of eosinophilic Toto bodies. The epithelium was hyperplastic in nature and had superficially confined Toto bodies with few focal areas showing a break in the continuity of the basement membrane (shown with black arrow). The subepithelial connective tissue was composed of severe inflammatory cell response mainly composed of lymphocytes and plasma cells [Figure 6]. Deeper connective tissue was composed of moderately differentiated epithelial cell population arranged in the form of sheets and cords. Dysplastic epithelial cells within the connective tissue showed features of dysplasia such as nuclear and cellular pleomorphism (black arrow) and nuclear hyperchromatism (arrowhead) [Figure 7].
|Figure 3: a and b, H&E stained pictures showing parakeratinized stratified squamous epithelium overlying the connective tissue components and clusters of eosinophilic toto bodies in the upper spinous cell layer (10×)|
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|Figure 4: a and b, underlying connective tissue shows the presence of haphazardly arranged collagen fibers bundles, numerous large endothelial lined blood capillaries with RBC'S and mild to moderate chronic inflammatory cell infiltrate (4×)|
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|Figure 5: H&E picture showing the presence of nonkeratinized stratified squamous epithelium showing areas of eosinophilic Toto bodies (10×)|
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|Figure 6: H&E- stained picture showing hyperplastic epithelium and superficially confined To to bodies with few focal areas showing a break in the continuity of the basement membrane (black arrow). Subepithelial connective tissue is composed of severe inflammatory cell response mainly composed of lymphocytes and plasma cells (4×)|
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|Figure 7: H&E- stained picture showing that the deeper connective tissue is composed of moderately differentiated epithelial cell population arranged in the form of sheets and cords and presenting dysplastic epithelial cells with nuclear and cellular pleomorphism (black arrow) and nuclear hyperchromatism (arrowhead) (20×)|
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On analyzing the histopathology, which correlated with the clinical diagnosis, the first two cases were diagnosed as lobular capillary hemangioma and the last case was diagnosed as moderately differentiated squamous cell carcinoma.
| Discussion|| |
Toto bodies are located extracellularly in the dilated intercellular spaces of degenerative epithelial cells. The incidence and severity of the presence of Toto bodies are related to the intensity of the inflammatory reaction in the underlying tissue. The inflammatory reaction was observed in our diagnosed present cases with the presence of round eosinophilic Toto bodies in the superficial spinous cell layer. The highest percent of cases with Toto bodies are seen in pyogenic granuloma, followed by other inflammatory hyperplastic gingivitis. In our present cases also, we found two cases of pyogenic granuloma showing Toto bodies, followed by moderately differentiated squamous cell carcinoma. Various histochemical and ultrastructural studies have been done to answer toto bodies possibility of origin, but its actual etiology has still not been clearly mentioned. Various diverse possibilities of its origin have been explained by different authors as follows:
According to Toto, these bodies show positive staining for periodic acid–Schiff (PAS), Alcian blue and other metachromatic stains, which stain mucopolysaccharides and are homogeneous dystrophic complexes of acid and neutral mucopolysaccharides with keratin. Hence, he labeled them as mucopolysaccharide keratin dystrophy.
Buchner et al. suggested two possibilities of its origin. One is blood plasma infiltrate, i.e., as the intensity of inflammatory reaction increases, which might represent a filtrate from the blood vessels similar to the inflammatory exudates. Another possibility is that histochemically, these bodies show the presence of –SH and –SS groups similar to keratin. Therefore, they suggested the term keratin-like material for these Toto bodies.
Chen suggested that ultrastructurally, these bodies are located extracellularly in superficial cells of inflamed oral mucosa, which are weakened by the degenerative changes and become compressible. The plasma membrane of superficial cells is thickened and becomes less permeable to macromolecules. Thus, there would be no outpouring of keratin-like material, i.e., tonofilaments or keratohyalin granules into the extracellular spaces. Therefore, he suggested that these bodies are formed by the combination of glycoprotein and mucopolysaccharides of normal intercellular substance and exudates of the plasma fluid, which are accumulated in the dilated intercellular spaces of superficial degenerating cells.
Padala et al. evaluated the staining characteristics of Toto bodies to establish their origin and to identify their significance in lesions. They investigated Toto bodies in the epithelium of pyogenic granuloma, fibroma and leukoplakia after hematoxylin and eosin staining. Sections were stained with Alcian blue, PAS and Ayoub–Shklar stains to evaluate staining intensity and distribution. More of the Toto bodies were found in pyogenic granuloma than in fibroma and leukoplakia, similar to our present cases. PAS and Alcian blue staining exhibited mild intensity and did not establish the origin of Toto bodies. High staining intensity and diffuse distribution of stain were observed with Ayoub–Shklar staining, which indicated that Toto bodies originate from keratin.
| Conclusion|| |
The uniqueness of these three cases is that we observed the presence of homogenous eosinophilic Toto bodies, which were round to oval shaped with a peripheral halo appearance and varying in size in the superficial spinous cell layer of the stratified squamous epithelium as discussed in the introduction. Till now, no case report has been published regarding Toto bodies, which are seen rarely histopathologically in inflammatory lesions. As such, there is less documentation about Toto bodies. However, we came across these beautiful Toto bodies while reporting histopathology slides and thought to put some light on them. Rarely, the presence of Toto bodies could be of diagnostic importance in reactive or inflammatory process.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
“Guidance in the proper direction is necessity for any form of success in life.”
I express my sincere thanks to Dr. Sushruth Nayak, Professor, Head of the D epartment, Department of Oral and Maxillofacial Pathology, MMCDSR, Mullana, Ambala, for his constant inspiration, assiduous guidance rendered during the case and words of wisdom. I owe my deep gratitude to Dr. Amit Aggarwal, Dr. Prachi Nayak and Dr. Kush Pathak for their concrete assistance, intellectual support and unseen sacrifices. I also want to thank The Almighty as He not only guided my directions, but also overruled my mistakes. He gave me wisdom to understand and grow in better ways.
Financial support and sponsorship
Conflict of interest
There are no conflicts of interest.
| References|| |
Toto PD. Mucopolysaccharide keratin dystrophy of the oral epithelium. Oral Surg Oral Med Oral Pathol 1966;22:47-8.
Buchner A, Mlineck A, Calderon S. Eosinophilic bodies in the epithelium of oral inflammatory hyperplastic lesions. Histopathologic and histochemical study. Oral Surg Oral Med Oral Pathol 1976;41:378-84.
Chen SY. Ultrastructure of eosinophilic bodies in the degenerative surface epithelium of chronic hyperplastic oral lesions. Oral Surg Oral Med Oral Pathol 1977;43:256-66.
Padala SS, Kiresur MA, Ananthaneni A, Guduru VS, Puneeth HK, Bhavana B. Comparison of staining characteristic of Toto bodies. Biotech Histochem 2018;93:336-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]