Eosinophilic ulcer of the oral mucosa

The role of eosinophils in the differential diagnosis of inflammatory skin diseases

Eosinophils are known to be present in inflammatory skin diseases, but their diagnostic utility is not well established. Upon review of the published status of lesional eosinophils, several categories were identified. 1) Lesional eosinophils highly characteristic such that, in their absence, the pathologist may question the diagnosis. These include arthropod bite reactions and scabies, urticarial dermatitis, and other eosinophilic dermatoses. 2) Lesional eosinophils rare or absent, such that, in their presence, the pathologist may question the diagnosis. These include pityriasis lichenoides, graft versus host disease, and connective tissue disorders. 3) Lesional eosinophils variable and, while in some cases expected, are not required for diagnosis. These include drug reactions, atopic dermatitis and allergic contact dermatitis. 4) Lesional eosinophils variable and not expected but may be seen to a limited extent. These include lichen planus and psoriasis.

Eosinophilic ulcer of the oral mucosa: An update on clinicopathologic features, pathogenesis, and management

Eosinophilic ulcer of the oral mucosa is a benign, reactive, self-limited lesion. Its pathogenesis is unclear, and it clinically manifests as a punched-out ulcer with surrounding indurated border, raising suspicion for a possible malignancy. On histology, an acute and chronic dense inflammatory infiltrate can be appreciated, which can extend to the deep underlying tissue (including skeletal muscle). Eosinophils are especially conspicuous on hematoxylin and eosin staining and might play an important role in the development of the ulcer. Removal of possible triggers followed by monitoring and possible biopsy are among the initial recommendations. Most lesions heal spontaneously without the need for intervention. This review aims at assisting dermatologists to easily recognize this entity, avoiding unnecessary interventions and apprehension.

Eosinophilic ulcer mimicking malignancy of the lower lip: A case report

Eosinophilic ulcer (EU) is a rare self-limiting chronic benign lesion of the oral mucosa. It is an uncommon and benign disease, which may leading to diagnostic difficulties. Biopsy is recommended to rule out any malignant etiology.

Recurrent Oral Eosinophilic Ulcers of the Oral Mucosa. A Case Report

Objective:

This article describes a case of an Oral Eosinophilic Ulcer (OEU) in an otherwise healthy 31-year-old white woman.

Introduction:

The importance of reporting this case was the presence of recurrent episodes with lesions appearing in different areas of the oral mucosa, a type of manifestation not commonly associated with this disease. A typical manifestation of OEU occurs as a single ulceration that goes into healing after an incisional biopsy, a procedure usually required for a proper diagnosis of the disease. In spite of trauma being suggested as the main culprit of OEU, the exact pathogenesis mechanism of this disease remains controversial.

Case report:

The pattern of the present case contradicts the usually common course of the disease, as the patient had experienced many recurrent episodes for almost 2.5 years, with the recurrences occurring even after biopsies performed during some of the relapses. Differential diagnosis included recurrent aphthous stomatitis, recurrent intra-oral herpes, autoimmune disease, Crohn’s disease and malignancy.

Conclusion:

Fortunately, the patient has been free of any recurrences for 1.5 years since the last biopsy was taken at the time she came to our clinic seeking treatment.

Eosinophilic ulcer of the tongue--Case report

Eosinophilic ulcer of the oral mucosa is a rare, self-limiting, chronic and benign lesion of unknown pathogenesis that affects the oral mucosa. We present the case of a 65 year-old Caucasian female with a fivemonth history of a painful ulcer on the lateral side of her tongue. The ulcer was not adhered to the underlying structures and there was no evidence of regional lymph node involvement. Laboratory examinations and X-rays revealed no abnormalities. Topical treatments had been performed without any improvement. Histopathological examination showed an ulcerated surface and mixed inflammatory infiltrate with several eosinophils extending into the mucosa and submucosa. No cellular atypia was observed. Based on the patient-s history and mucosal biopsy, a final diagnosis of eosinophilic ulcer of the oral mucosa was made.

Traumatic ulcerative granuloma with stromal eosinophilia - Mystery of pathogenesis revisited

Oral ulcers are a common symptom in clinical practice. Among various causative factors, different types of ulcers in oral cavity exist. Among this, traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) appears to be quite neglected by the clinicians due to the limited knowledge and awareness. On reviewing with a detailed approach to titles and abstracts of articles eliminating duplicates, 40 relevant articles were considered. Randomized studies, review articles, case reports and abstracts were included while conference papers and posters were excluded. Of importance, TUGSE cases been reported only to a minimal extent in the literature. Lack of its awareness tends to lead clinicians to a misconception of cancer. Thus, this particular lesion needs to be differentiated from other malignant lesions to provide a proper mode of treatment. The present article reviews various aspects of the TUGSE with emphasis on the clinical manifestation, pathogenesis, histological, and immunohistochemical study. This study provides the clinician contemporaries, a humble expansion to their knowledge of the disease, based on the searched literature, enabling a more comprehensive management of this rare occurrence.

The spectrum of primary mucosal CD30-positive T-cell lymphoproliferative disorders of the head and neck

OBJECTIVE

To retrospectively investigate the clinicopathologic spectrum of primary mucosal CD30-positive T-cell lymphoproliferative disorders (PTCLDs) of the head and neck.

STUDY DESIGN

Archives of PTCLDs primarily arising in head and neck mucosa were reviewed. Immunostaining of CD20, CD3, CD4, CD8, CD30, CD56, anaplastic lymphoma kinase (ALK), epithelial membrane antigen (EMA), cytotoxic molecules (TIA-1, granzyme B, or perforin), and Ki67; in situ hybridization for Epstein-Barr virus; and T-cell receptor gene rearrangement analysis were performed.

RESULTS

Fourteen cases of primary mucosal anaplastic large cell lymphoma (M-ALCL) were identified, and no lymphomatoid papulosis (LyP) cases were found. All cases demonstrated atypical mononuclear neoplastic cells with diverse histology and cytomorphology. The typical immunophenotype of neoplastic cells was CD3-positive, CD4-positive, CD8-negative, CD30-positive, ALK-negative, and cytotoxic molecules-positive. Infiltration of inflammatory cells was common. All cases presented an indolent course, regardless of therapy.

CONCLUSIONS

PTCLDs of the head and neck provisionally included M-ALCL alone.

Mucosal CD30-positive T-cell lymphoproliferations of the head and neck show a clinicopathologic spectrum similar to cutaneous CD30-positive T-cell lymphoproliferative disorders

CD30-positive T-cell lymphoproliferative disorders are classified as cutaneous (primary cutaneous anaplastic large cell lymphoma and lymphomatoid papulosis) or systemic. As extent of disease dictates prognosis and treatment, patients with skin involvement need clinical staging to determine whether systemic lymphoma also is present. Similar processes may involve mucosal sites of the head and neck, constituting a spectrum that includes both neoplasms and reactive conditions (eg, traumatic ulcerative granuloma with stromal eosinophilia). However, no standard classification exists for mucosal CD30-positive T-cell lymphoproliferations. To improve our understanding of these processes, we identified 15 such patients and examined clinical presentation, treatment and outcome, morphology, phenotype using immunohistochemistry, and genetics using gene rearrangement studies and fluorescence in situ hybridization. The 15 patients (11 M, 4 F; mean age, 57 years) had disease involving the oral cavity/lip/tongue (9), orbit/conjunctiva (3) or nasal cavity/sinuses (3). Of 14 patients with staging data, 7 had mucosal disease only; 2 had mucocutaneous disease; and 5 had systemic anaplastic large cell lymphoma. Patients with mucosal or mucocutaneous disease only had a favorable prognosis and none developed systemic spread (follow-up, 4-93 months). Three of five patients with systemic disease died of lymphoma after 1-48 months. Morphologic and phenotypic features were similar regardless of extent of disease. One anaplastic lymphoma kinase-positive case was associated with systemic disease. Two cases had rearrangements of the DUSP22-IRF4 locus on chromosome 6p25.3, seen most frequently in primary cutaneous anaplastic large cell lymphoma. Our findings suggest mucosal CD30-positive T-cell lymphoproliferations share features with cutaneous CD30-positive T-cell lymphoproliferative disorders, and require clinical staging for stratification into primary and secondary types. Primary cases have clinicopathologic features closer to primary cutaneous disease than to systemic anaplastic large cell lymphoma, including indolent clinical behavior. Understanding the spectrum of mucosal CD30-positive T-cell lymphoproliferations is important to avoid possible overtreatment resulting from a diagnosis of overt T-cell lymphoma.

T-cell receptor gene rearrangement and CD30 immunoreactivity in traumatic ulcerative granuloma with stromal eosinophilia of the oral cavity

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is an ulcerative lesion of the oral mucosa with unknown pathogenesis. A few recent case reports have demonstrated molecular evidence of T-cell clonality in TUGSE and CD30 immunoreactivity in the large atypical mononuclear cells, raising the possibility that a TUGSE subset may represent the oral counterpart of primary cutaneous CD30+ T-cell lymphoproliferative disorders. We examined the immunoreactivity for CD30 and T-cell receptor (TCR) gamma gene rearrangement in 37 TUGSE cases. Clonal TCR gene rearrangements were demonstrated in 7 (24%) of 29 cases with amplifiable DNA, and the morphologic features and CD30 immunoreactivity of these cases did not differ from those with polyclonal TCR gene rearrangements. Clinical follow-up was available for 5 of 7 TUGSE cases with clonal TCR gene rearrangement for an average period of 1.75 years after the initial biopsy or excision, and there was no evidence of local recurrence or development of systemic T-cell lymphoproliferative disorder. Without morphologic and/or clinical evidence of lymphoma, T-cell clonality and/or CD30 positivity in these lesions is not indicative of malignancy and should be interpreted with caution.

Localized eosinophilic (Langerhans' cell) granuloma of the lower lip. A lesion that may cause diagnostic error

Eosinophilic (Langerhans' cell) granuloma is most common in children and is unusual in the elderly. A cutaneous lesion as the sole manifestation of adult Langerhans' cell histiocytosis is rare. We report an 81-year-old man who presented with a noduloulcerative lesion on the lower lip. A punch biopsy suggested a lymphoepithelioma-like carcinoma. In the absence of immunohistochemistry, the large pale cells with atypical lobular nuclei and patent nucleoli, with an overlying ulceration, were interpreted as carcinoma cells. Definitive diagnosis was established after complete resection of the lesion aided with the use of immunohistochemistry. The proliferating cells were S100, CD1a and CD207 (langerin) positive and cytokeratin, epithelial membrane antigen, CD15, CD30, melan A and carcinoembryonic antigen negative. To our knowledge, eosinophilic (Langerhans' cell) granuloma of the lip has not been described. The case constituted a diagnostic challenge because of its unusual clinical presentation and its histopathological similarity to certain other benign and malignant entities. Because there was no other organ involved, the patient was treated with complete surgical excision without recurrence or other organ involvement in the 4-month follow-up period. Labial eosinophilic (Langerhans' cell) granuloma should be considered in the histological differential diagnosis in cases with atypical polymorphous infiltrates including large pale cells.

Inorganic chemistry of defensive peroxidases in the human oral cavity

The innate host response system is comprised of various mechanisms for orchestrating host response to microbial infection of the oral cavity. The heterogeneity of the oral cavity and the associated microenvironments that are produced give rise to different chemistries that affect the innate defense system. One focus of this review is on how these spatial differences influence the two major defensive peroxidases of the oral cavity, salivary peroxidase (SPO) and myeloperoxidase (MPO). With hydrogen peroxide (H(2)O(2)) as an oxidant, the defensive peroxidases use inorganic ions to produce antimicrobials that are generally more effective than H(2)O(2) itself. The concentrations of the inorganic substrates are different in saliva vs. gingival crevicular fluid (GCF). Thus, in the supragingival regime, SPO and MPO work in unison for the exclusive production of hypothiocyanite (OSCN(-), a reactive inorganic species), which constantly bathes nascent plaques. In contrast, MPO is introduced to the GCF during inflammatory response, and in that environment it is capable of producing hypochlorite (OCl(-)), a chemically more powerful oxidant that is implicated in host tissue damage. A second focus of this review is on inter-person variation that may contribute to different peroxidase function. Many of these differences are attributed to dietary or smoking practices that alter the concentrations of relevant inorganic species in the oral cavity (e.g.: fluoride, F(-); cyanide, CN(-); cyanate, OCN(-); thiocyanate, SCN(-); and nitrate, NO(3)(-)). Because of the complexity of the host and microflora biology and the associated chemistry, it is difficult to establish the significance of the human peroxidase systems during the pathogenesis of oral diseases. The problem is particularly complex with respect to the gingival sulcus and periodontal pockets (where the very different defensive stratagems of GCF and saliva co-mingle). Despite this complexity, intriguing in vitro and in vivo studies are reviewed here that reveal the interplay between peroxidase function and associated inorganic chemistry.

Eosinophilic ulcer of the tongue

A 76-year-old woman presented with a 1-month history of a rapidly expanding painful ulcerated nodule on her tongue following tooth extraction. Triamcinolone acetonide ointment was applied twice daily for 1 month without any benefit. The histopathology of the excision specimen was consistent with an eosinophilic ulcer of the oral mucosa. There has been no recurrence 12 months later.

Traumatic ulcerative granuloma with stromal eosinophilia: a reactive lesion of the oral mucosa

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a benign lesion of the oral mucosa of an unclear pathogenesis. We analyzed the profile of the inflammatory infiltrate in 12 cases of TUGSE by using immunohistochemical analysis and polymerase chain reaction-based repertoire analysis to detect T- and B-cell receptor gene rearrangements. The inflammatory infiltrate consisted in most cases of B and T lymphocytes, macrophages, abundant eosinophils, and large atypical cells. In 5 cases, CD30+ cells were found. Spectratyping analysis displayed a polyclonal rearrangement of the T-cell receptor g gene in 6 cases and oligoclonality in 5 cases. Monoclonality was observed in 1 case that also fulfilled histologic criteria for lymphoma. Healing was uneventful in all cases, including the one suspected of being lymphoma, with no recurrences in more than 2 years'follow-up. TUGSE can be regarded reactive. Some cases, however, may harbor a dominant clonal T-cell population; in these cases, long-term follow-up is mandatory.

Eosinophilic ulcer of the oral mucosa: another histological simulator of CD30+ lymphoproliferative disorders

Eosinophilic ulcer of the oral mucosa (EUOM), also known as traumatic ulcerative granuloma with stromal eosinophilia or Riga-Fede disease, is an uncommon benign self-limited lesion poorly described in the dermatological literature. It probably includes a spectrum of related disorders presenting as an ulcer with elevated indurated borders affecting the tongue, oral mucosa or lip. Histopathological findings are characteristic and consist of eosinophil-rich mixed infiltrates accompanied by a population of large mononuclear cells whose origins have been a matter of debate. Immunohistochemical studies of these cells have suggested a myofibroblastic or histiocytic origin. We present a 93-year-old woman with two episodes of self-healing ulcers on the upper lip and on the lingual mucosa, respectively. Histopathological findings on both biopsies were consistent with EUOM and showed the presence of large atypical CD30+ lymphocytes. Some recent reports have also shown positivity for the CD30 antigen, raising the possibility that a subset of EUOM could be included within the spectrum of CD30+ lymphoproliferative disorders. This finding most likely suggests that EUOM can represent another histological simulator of CD30+ lymphoproliferative disorders.

Bi-lateral eosinophilic ulcers in an infant treated with propolis

BACKGROUND

Propolis is a natural substance, produced by the honey bee, containing amino acids, flavanoids, terpenes and cinnamic acid. It has long been used in folk-medicine for topical inflammatory conditions including ulcerative lesions of different aetiologies.

METHODS

A 13-month-old female infant developed bilateral eosinophilic ulcers of the mouth, becoming the youngest patient in the literature so far reported to have done so. Following a protracted 4-month course, during which time the lesions remained unchanged despite various treatments, the ulcers were treated locally with a lanolin-based propolis ointment.

RESULTS

Application of the propolis ointment was associated with the rapid resolution of the ulcers within 3 weeks and they did not subsequently recur.

CONCLUSIONS

Although inevitably circumstantial, the abrupt healing of this child's chronic eosinophilic ulcers suggests that, in the light of its previously known therapeutic associations, propolis deserves further evaluation in the treatment of this condition, and perhaps in other forms of oral ulceration as well.

Tumorlike eosinophilic granuloma of the skin

In 1952, Kuske reported on a patient with a peculiar tumor on the dorsum of the right hand; histological analysis revealed a dense dermal infiltrate with numerous eosinophils. Not aware of any similar case report in the literature, he coined the descriptive term "tumor-like eosinophilic granuloma of the skin." In 1995, a 55-year-old white man with cancer of the prostate presented with a 4-month history of two reddish-brown, solid skin tumors on his left forearm and on the right side of his abdomen, respectively. Histologic examination revealed a dense, superficial and deep, tumorlike dermal inflammatory infiltrate consisting mainly of eosinophils as well as neutrophils and in part epithelioid, in part foamy histiocytes. Flame figures were absent. Immunohistochemical analysis was negative for S-100 protein, whereas sporadic cells in the infiltrate were CD1a positive and many mononuclear-histiocytic cells reacted with MAC 387. Stains as well as cultures for bacteria, mycobacteria, and fungi were negative. The descriptive diagnosis of tumorlike eosinophilic granuloma of the skin was made. Seven weeks after prostatectomy, both tumors resolved spontaneously and so far has not recurred. In our opinion, this is the second report of Kuske's tumorlike eosinophilic granuloma of the skin. Perhaps tumorlike eosinophilic granuloma of the skin, eosinophilic ulcer of the mucosa, and transient eosinophilic nodulomatosis should be considered a mucocutaneous reaction pattern as is seen in cats. In humans, hypersensitivity reactions or atopy could emerge as an etiological link.

Traumatic eosinophilic granuloma of the oral mucosa: a CD30+(Ki-1) lymphoproliferative disorder?

Traumatic eosinophilic granuloma of the oral mucosa, also known as eosinophilic ulcer, is considered to be a reactive lesion of unknown aetiology. It usually presents as a tongue ulcer and injury has been considered to play a role in its cause. We present a 72-year-old man who had suffered multiple episodes of recurrent eosinophilic ulcers of the oral mucosa which underwent self-healing. Biopsy specimens (including fresh tissue) were studied with a combination of histology, electron microscopy and immunohistochemistry. A dense cell infiltrate composed of eosinophilis, lymphocytes and large mononuclear cells was constantly shown. Immunostains showed that the infiltrate was mainly composed of CD3+,CD4+,CD8-T-cells and CD1a + dendritic cells. Approximately 70% of the T-cells expressed CD30 (Ki-1) antigen. On the basis of the clinical behaviour, histology and antigenic features, it seems reasonable to suggest that traumatic eosinophilic granuloma of the oral mucosa may represent the oral countpart of primary cutaneous CD30 (Ki-1)-positive lymphoproliferative disorders. This group of cutaneous lymphomas are indeed characterised by non-aggressive clinical behaviour (sequential evolution in ulceration, necrosis and self-regression) and expression of CD30 antigen by the infiltrating large T-cells.