Year : 2005 | Volume
: 9 | Issue : 1 | Page : 30--33
Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE)
B Sivapathasundharam, S Lavanya
Department of Oral Pathology and Microbiology, Meenakshi Ammal Dental College and Hospital, Chennai - 600 095, India
Department of Oral and Maxillo Facial Pathology, Meenakshi Ammal Dental College and Hospital, Chennai 600 095
Oral traumatic ulcerations are reactive lesions that are characterized by an intense mononuclear inflammatory infiltrate (usually eosinophils) that may mimic neoplasia. These granulomas are chronic but self limiting lesions of oral mucus membrane, usually of tongue. Though traumatic ulcerations are common, they are not frequently reported. Here we present a case report of traumatic ulcerative granuloma with stromal eosinophilia of tongue with a brief review of literature.
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Sivapathasundharam B, Lavanya S. Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE).J Oral Maxillofac Pathol 2005;9:30-33
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Sivapathasundharam B, Lavanya S. Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE). J Oral Maxillofac Pathol [serial online] 2005 [cited 2020 May 26 ];9:30-33
Available from: http://www.jomfp.in/text.asp?2005/9/1/30/39058
Traumatic ulcerative granuloma is a chronic, self limiting reactive lesion of oral mucous membrane, usually of tongue. Clinically, it mimics oral squamous cell carcinoma and microscopically, lymphoid neoplasm or Langerhans's cell disease.
Injuries of oral mucosa may be acute or chronic and arc caused by various physical, chemical; thermal, and electrical factors. Trauma to the oral mucosa results in surface ulcerations, which usually heal within days but may remain for extended periods of time in sonic instances.
A histopathologically unique type of chronic traumatic ulceration of oral mucosa is eosinophilic ulceration and we herewith present such a case for its rarity.
A 40-year-old female patient reported with the chief complaint of painful ulcer since one month on the postero-lateral border of the tongue. The ulcer was small in size initially and slowly increased to the present size in one month. She gave history of extraction of 26, 36, and 37 due to decay. Patient was a known diabetic, hypertensive, and was under medication for the same. Personal history was not relevant.
On clinical examination, an oval shaped reddish ulcer measuring about 2 x 1 sq, cm and with raised borders was seen on the postero lateral border of the tongue in relation to 36, 37 region. On palpation, it was tender and the base was slightly indurated.
With the above clinical findings, the lesion was diagnosed as squamous cell carcinoma of the tongue. An incisional biopsy was done and sent for histopathological examination.
On microscopic examination, it showed a fibro-purulent membrane and hyperplastic epithelium with intra cellular edema. The inflammatory infiltrate consisted of neutrophils, lymphocytes, eosinophils, mast cells, and plasma cells. Sheets of histiocytes were seen below the epithelium. Numerous blood capillaries were also seen. There was no evidence of any malignancy.
With the above clinical and histological findings, the case was diagnosed as traumatic ulcerative granumloma with stromal eosinophilia (TUGSE).
Eosinophilic ulcerations are common but not frequently reported. These lesions are almost ulcerated but some have been described as submucosal masses. The cause is unknown but a traumatic background has been suggested. Trauma may he due to missing or malposed teeth, partial denture, and more commonly erupting teeth during nursing. This lesion can occur in all age groups, that is, from one week to 92 years of age (mean age is 44 yrs). Male predilection is seen (male: female ratio is 1.6: 1).The most common sites are antero-ventral and dorsal surfaces of the tongue. The other sites include gingiva, palate, and mucobuccal fold. Individual lesions appear as areas of erythrema surrounding central areas of removable yellow fibrinopurulent membrane. The lesion develops a rolled while border of hyperkeratosis immediately adjacent to the area of ulceration.
Similar type of lesion seen in infants is called Riga-fede's disease, commonly Occurring in age between one week and one year. All the lesions are usually associated with history of trauma in conjunction with erupting primary teeth or associated with natal or neonatal teeth, commonly seen on the anterioventral and dorsal surfaces of the tongue and sublingual surface. Ventral lesions are usually associated with adjacent mandibular incisors and dorsal lesions arc associated with adjacent maxillary incisors.
Histologically, it shows granulation tissue in the ulcer bed that supports mixed inflammatory cell infiltrate of lymphocytes, histiocytes, neutrophils, and occasionally plasma cells. Inflammatory infiltrate extend into the deeper structures and exhibits sheets of lymphocytes and histiocytes inter mixed with eosinophils. Vascular connective tissue deep to the ulceration may become hyper plastic and cause the adjacent surface raising.
The suggested pathogenesis of' this lesion is ulceration resulting from some form of trauma, which permits the ingress of microorganisms, toxins, or foreign protein into the connective tissue. These substances in the predisposed persons induce a severe inflammatory response resulting from an exaggerated mast cell-eosinophil reaction similar to that noticed in the pathogenesis of bronchial asthma. The mast cells degranulate, resulting in the release of mediators, which cause inflammation and also attract eosinophils by release of eosinophil chemotactic factor of anaphylaxis. Eosinophils then release aryl sulfates arid histamines, which inhibit slow reacting substance of anaphylaxis and histamine (harmful mediators). Eosinophils further suppress basophils and mast cell degranulation and inhibit the release of other mediators of inflammation by mast cells. Eosinophils also produce major basic protein which causes tissue destruction. Thus, eosinophils are associated with cellular destruction.
A moderate population of mast cells are observed in normal tongue, inflamed tongue, gingivitis, inflammatory fibrous hyperplasia, non specific ulcers, epithelial hyperplasia, and normal/inflamed salivary gland. Presence of eosinophils in tissue is seen in numerous conditions such as insect bites, parasitic, allergic reactions, granuloma facial, angiolymphoid hyperplasia with eosinophilic lymphoid granuloma, eosinophilic fascitis, eosinophilic granuloma, and histiocytosis X.
Treatment and Prognosis
The treatment part includes the removal of traumatic agents. The lesion may regress after the incisional or excisional biopsy. In Riga-fede's disease, removal of the offending teeth heals the lesion. Prognosis of TUGSE is good.
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