Wegener's granulomatosis presenting as oral lesions: a case report

Challenges in Differential Diagnosis of Diffuse Gingival Enlargement: Report of Two Representative Cases and Literature Review

Background/Objectives: The etiology of diffuse gingival enlargement is multifactorial, and the definitive diagnosis may be challenging. To highlight the nuances of the differential diagnosis, we present two cases of generalized gingival overgrowth and discuss the diagnostic dilemmas. Case description: In the first case, an 82-year-old male with a medical history of hypertension and prostatitis had a chief complaint of symptomatic oral lesions of a 20-day duration, accompanied by fever and loss of appetite. The clinical examination revealed diffusely enlarged, hemorrhagic, and focally ulcerative upper and lower gingiva, ecchymoses on the buccal mucosa, as well as bilateral cervical lymphadenitis. The histopathologic and immunohistochemical findings combined with the hematologic examination led to a final diagnosis of acute myeloid leukemia, and the patient was referred to a specialized hematology/oncology unit for further management. The second case was a 74-year-old female with a medical history of breast cancer (successfully managed in the past), type II diabetes mellitus, and cardiovascular disease, taking various medications. An intraoral examination revealed diffusely enlarged, erythematous, and hemorrhagic upper and lower gingiva. An incisional biopsy showed hyperplastic granulation and fibrous connective tissue with a predominantly chronic inflammatory infiltrate. Considering the patient's medical history and current medications, the clinical and microscopic findings were in support of the diagnosis of drug-induced gingival overgrowth associated with calcium channel blocker (amlodipine), partially controlled diabetes serving as an additional predisposing factor. Gingivectomy and periodontal scaling, along with substitution of the offending medication, were curative, and better diabetic control was recommended. Conclusions: Diffuse gingival overgrowth may be caused by a variety of diverse conditions, ranging from an exuberant response to local factors, potentially exacerbated by hormonal influences (e.g., puberty or pregnancy), to drug side effects to genetic, systemic, or even neoplastic diseases. A careful evaluation of the medical and drug history and clinicopathologic correlation is essential for accurate diagnosis and appropriate management.

A Rare Presentation of Wegener's Granulomatosis in ENT

Wegener's granulomatosis or Granulomatosis with polyangiitis is a rare multisystem autoimmune vasculitis disease which may become life threatening due to the various system involvement. Granular hyperplastic gingivitis, the so called "strawberry gingivitis" is a rare manifestation of this disease, yet pathognomic when present. Early diagnosis and treatment is very important.

Oral granulomatosis with polyangiitis a systematic review

OBJECTIVE

Granulomatosis with polyangiitis is an unusual multisystemic inflammatory disease, with vasculitis of small- and medium-sized vessels, with a predilection for upper lower airways and kidneys. The etiology remains unknown although it may originate from different stimuli, in genetically susceptible patients.

MATERIALS AND METHODS

A detailed database search was performed. The variables were demographics, localization, histopathological findings, antineutrophil cytoplasmic autoantibody, cytoplasmic (c-ANCA) tests, treatment, and follow-up.

RESULTS

Fifty-two cases were identified; the mean age was 49.6 years, with a range from 6 to 87 years. It was most frequently seen in females (57.7%). The most common race was white (59.6%). The most frequent location was in the maxillary gingiva (28.8%), followed by both the upper and lower gingiva (19.2%). The most common clinical presentation was "strawberry gingivitis" (61.5%). The main symptom was pain, in 50%. Regarding the c-ANCA test, it was positive in 71.2% of cases. The most common therapy was prednisone and cyclophosphamide, utilized in 51.9%. The average follow-up was 23.6 months, and 88.5% of patients were still alive at follow-up.

CONCLUSION

The diagnosis initially was difficult to establish, an early diagnosis and treatment are mandatory. If untreated the disease can be associated with morbidity and mortality. For the oral clinician, this disease needs to be addressed in the differential diagnosis of oral lesions.

Oral Microbiota Profile in Patients with Anti-Neutrophil Cytoplasmic Antibody–Associated Vasculitis

Microbiota has been associated with autoimmune diseases, with nasal Staphylococcus aureus being implicated in the pathogenesis of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). Little is known about the role of oral microbiota in AAV. In this study, levels of IgG antibodies to 53 oral bacterial species/subspecies were screened using immunoblotting in plasma/serum in pre-symptomatic AAV-individuals (n = 85), matched controls, and established AAV-patients (n = 78). Saliva microbiota from acute-AAV and controls was sequenced from 16s rDNA amplicons. Information on dental status was extracted from a national register. IgG levels against oral bacteria were lower in established AAV versus pre-AAV and controls. Specifically, pre-AAV samples had, compared to controls, a higher abundance of periodontitis-associated species paralleling more signs of periodontitis in established AAV-patients than controls. Saliva microbiota in acute-AAV showed higher within-sample diversity but fewer detectable amplicon-sequence variants and taxa in their core microbiota than controls. Acute-AAV was not associated with increased abundance of periodontal bacteria but species in, e.g., Arthrospira, Staphylococcus, Lactobacillus, and Scardovia. In conclusion, the IgG profiles against oral bacteria differed between pre-AAV, established AAV, and controls, and microbiota profiles between acute AAV and controls. The IgG shift from a pre-symptomatic stage to established disease cooccurred with treatment of immunosuppression and/or antibiotics.

Granulomatous diseases: Oral manifestations and recommendations

Granulomatous diseases may present with oral manifestations that are detectable by dental care providers. In certain cases, oral manifestations may precede systemic signs and symptoms. Dentists managing patients with these conditions may modify the dental treatment plan and possibly retain the support of other health professionals. This review gives an update on granulomatous diseases that can be faced by the dental practitioner.

Strawberry gingivitis - First sign of Wegener's granulomatosis

Wegener's Granulomatosis (WG) is an immunologically mediated rare multisystem disease characterized by necrotizing granulomatous inflammation affecting the upper and lower respiratory tracts, disseminated vasculitis and glomerulonephritis. WG oral lesions are reported to occur in 6%–13% of patients; they were an initial presenting feature in only 2% of cases. A case of strawberry gingivitis as the first sign of WG presented with erythematous and painful localized gingival enlargement affecting the maxillary anterior region of jaw in a 17-year-old boy is reported here. Correlation of histopathology with routine hematoxylin and eosin and special stains such as Grocott-Gomori's methenamine-silver nitrate and periodic acid–Schiff, peripheral blood smear, chest radiographs, Mantoux test and clinical presentation were established in diagnosing this rare entity. By the above-mentioned procedures, we arrived at the diagnosis of WG. The aim of reporting this case was to emphasize that, the dental surgeon often being the first person to examine the oral cavity, should be familiar with the typical appearance of gingiva as “strawberry gingivitis,” its clinical course, diagnostic parameters and adequate management of WG.

Gingival Swelling as the Initial Manifestation of Granulomatosis with Polyangiitis

We describe a case of granulomatosis with polyangiitis (GPA; formerly named Wegener granulomatosis) that presented initially as florid areas of gingival swelling. The patient also had upper respiratory symptoms that included sinus congestion and cough of recent onset. Clinical-pathologic correlation aided the interpretation of non-specific biopsy findings and immediate referral to an appropriate medical specialist. Treatment was rendered at an early stage of disease with a good response to date. Review of the literature indicates that gingival swelling, often with the characteristic appearance of "strawberry gingivitis" may represent the initial sign of disease in 2% of patients with GPA. Biopsy of gingival lesions often shows a non-specific histologic appearance that should be interpreted in the context of the clinical appearance and pertinent medical history. The clinical investigations that lead to definitive diagnosis and treatment are presented to facilitate the management of this uncommon but potentially fatal condition.

Oral manifestations of granulomatosis with polyangiitis - Clinical and radiological assessment

Background/purpose

Granulomatosis with polyangiitis (GPA) is a type of primary systemic vasculitis associated with the presence of anti-neutrophil cytoplasmic antibodies (ANCA). GPA mainly affects medium and small vessels and may manifest in different organs, most commonly upper respiratory tract. Oral lesions occur in 6–13% of GPA patients and might be the first symptom observed by the patient. This study presents the evaluation of orofacial manifestations of patients with GPA.

Materials and methods

Prospective study was conducted between June 2014 and November 2017 in Department of Allergy and Immunology at University Hospital in Krakow. Patients diagnosed with GPA, after medical assessment, were examined including precise dental inspection, bacterial and fungal flora of oral cavity evaluation and Cone Beam Computed Tomography (CBCT) imaging.

Results

Nine patients were enrolled in the study. Characteristic for GPA strawberry gingivitis was observed in one patient. Bone destruction and inflammatory lesions in paranasal sinuses was confirmed by CBCT in 55.6% of patients. Fungal infection was revealed in 66.7% of patients.

Conclusion

These findings oblige dentists to consult patient with laryngologist or internal medicine physician to establish further diagnostic approach, because early diagnosis of GPA is crucial for implementing appropriate treatment and preventing chronic organ damage.

Wegener's Granulomatosis: Strawberry Gums of the Oral Cavity

Wegener's Granulomatosis is a rare and potentially life-threatening vasculitic disease of unknown origin. The diagnosis of Wegener's Granulomatosis is made on the basis of clinical presentation, positivity for serum c-ANCA and histologic examination of the lesions. This report details a case of limited Wegener's Granulomatosis with hyperplastic gingivitis lesions presenting as an initial manifestation of Wegener's Granulomatosis. The resemblance of the affected gums to over-ripe strawberries is pathognomonic of this condition and is thus highlighted. Because of the rarity of Wegener's Granulomatosis presenting initially in the oral cavity, clinicians should be alerted to the characteristic appearance of “strawberry gingivitis”.

Pediatric Wegener's granulomatosis with oral ulcers and progressive periodontitis: a case report

Wegener's granulomatosis (WG) is a rare multisystem disorder. Although it can occur at any age, it is rarely observed in children. Oral manifestations, which are present in fewer than 10% of patients, include oral ulceration, nonhealing extraction sockets, and the most common oral lesion, hyperplastic gingivitis, which is known as "strawberry gingivitis." We report the unusual case of a 6-year-old boy with WG who presented with atypical oral manifestations, including severe progressive periodontitis accompanied by oral ulcers, before the development of systemic symptoms. Although WG is rare, this case emphasizes the importance of considering the diagnosis in those who present with progressive and atypical oral disease, as prompt treatment of the systemic illness can significantly improve outcome.

Strawberry gingivitis as the first presenting sign of Wegener's granulomatosis: report of a case

Wegener's granulomatosis is a rare multi-system disease characterized by the classic triad of necrotizing granulomas affecting the upper and lower respiratory tracts, disseminated vasculitis and glomerulonephritis. Oral lesions as a presenting feature are only encountered in 2% of these cases. Hyperplastic gingival lesions or strawberry gingivitis, is a characteristic sign of Wegener's granulomatosis. The latter consists of reddish-purple exophytic gingival swellings with petechial haemorrhages thus resembling strawberries. Recognition of this feature is of utmost importance for timely diagnosis and definitive management of this potentially fatal disease. A case of strawberry gingivitis as the first presenting sign of Wegener's granulomatosis affecting a 50-year-old Malay male is reported here. The differential diagnosis of red lesions that may present in the gingiva is discussed.

Recurrence of Wegener's granulomatosis with de novo intraoral presentation treated successfully with rituximab

We describe a unique case of a recurrence of Wegener's granulomatosis (WG) that presented with oral pain involving a left maxillary molar, which thereafter led to an extraction. Oral lesions with a classical appearance of strawberry gingivitis developed following the extraction. The primary disease did not have any oral manifestations. Both the primary disease and recurrence responded to rituximab, a monoclonal B-cell depleting antibody. Rituximab is emerging as a drug with significant potential to improve treatment of primary and, as described in this case, recurrent WG.

Lingual infarction in Wegener's Granulomatosis: a case report and review of the literature

Wegener's granulomatosis (WG) is a multi-system disease, characterised by the triad of necrotising granulomata affecting the upper and lower respiratory tracts, disseminated vasculitis and glomerulonephritis. Oral lesions are associated with up to 50% of cases, although are rare as a presenting feature. The most common oral lesions associated with WG are ulceration and strawberry gingivitis. We review the literature regarding oral manifestations of WG and present a case of lingual infarction, an extremely rare oral lesion associated with WG, in a severe, rapidly progressive and ultimately fatal form of the disease.

Oral ulceration: an unusual manifestation of Churg-Strauss syndrome

Churg-Strauss Syndrome (CSS) is a relatively rare entity characterized by asthma, transient pulmonary infiltrates, eosinophilia and systemic vasculitis. Oral ulceration is a possible clinical manifestation of some systemic vasculitides, such as Wegener's granulomatosis (WG) or giant cell arteritis, but has never been reported with Churg-Strauss syndrome. We report the first observation of a palatine ulceration in a 15-year-old girl with Churg-Strauss syndrome.

Oral manifestations of Wegener's granulomatosis: a report of three cases and a literature review

BACKGROUND

Hyperplastic granular gingivitis or "strawberry gingivitis" is a rare manifestation of Wegener's granulomatosis (WG), but it is nearly pathognomonic for this multisystem autoimmune vasculitis. The dentist may be the first health care professional to see patients with symptoms and findings of this condition. Early diagnosis and treatment is the most important factor in the management of this potentially fatal disease.

METHODS

The authors present three case reports that demonstrate the disease spectrum and conducted a literature review focused on current understanding of this disease.

RESULTS

The first patient had only the classic gingival manifestations of the disease. The second patient had simultaneous typical gingival lesions, as well as dermatologic findings. The third patient had an atypical oral presentation of aphthous ulcers and erythematous gingiva, as well as respiratory and genital involvement. Reaching a definitive diagnosis sometimes is challenging owing to the subtle onset of the disease and variable clinical and laboratory findings.

CONCLUSION AND CLINICAL IMPLICATIONS

Clinicians should be familiar with the broad variety of oral and systemic components of WG, as well as strategies to facilitate prompt disease recognition and to provide continued oral health care to these medically complex patients.

[Foudroyant course of a therapy resistent Wegener's granulomatosis with negative c-ANCA]

BACKGROUND

Wegener's Granulomatosis is a rare systemic disease characterized by the triad of necrotizing granulomas of blood vessels, upper respiratory tract, and kidneys. Diagnosis depends on clinical symptoms (ACR-criteria), detection of serum circulating antineutrophil cytoplasmic antibodies (c-ANCA) and bioptical histopathology.

CASE-REPORT

A 34-year-old patient presented with intraoral ulcerating, necrotizing inflammations of the palate and the gingiva. Chest radiograph (nodules, infiltrates), urin analysis (red blood cell casts) being inconspicuous Wegener's granulomatosis was diagnosed by histopathology of an intraoral incisional biopsy. Conventional therapy with corticosteroids and cyclophosphamide relapsed while the disease was taking a progressive course (pulmonary infiltrates, necrotizing vasculitides all over the common integument). The patient died of cardiac decompensation three months after diagnosis. c-ANCAs were not present at any time of disease.

CONCLUSIONS

1. Symptoms of the head and neck are manifest in up to 95% of Wegener's granulomatosis. So knowledge of the disease is important for dentists and oral and maxillofacial surgeons in spite of its low prevalence. 2. c-ANCA-titers do not reflect disease activity. Negative c-ANCAs do not exclude Wegener's granulomatosis. 3. Wegener's granulomatosis can take a progressive, therapy resistent course.

Wegener's granulomatosis: The current understanding

Wegener's granulomatosis (WG) is a rare systemic disease characterized by necrotizing granulomatous inflammation of the upper and lower respiratory tract, glomerulonephritis and vasculitis. It occurs as a limited form or generalized form and usually presents with nonspecific symptoms in its early stages, making the diagnosis of this disease more elusive. Strawberry gingivitis is the most common oral manifestation and is characteristic. Prompt recognition of this early manifestation is of utmost importance for the institution of early treatment, thereby avoiding serious complications. The present paper selectively reviews the literature regarding the current status of WG with respect to diagnosis, laboratory features, and treatment.

Oral manifestations of systemic disease

Most systemic diseases can affect the oral cavity. Some oral changes are nonspecific, whereas others directly lead to the diagnosis of a particular disorder. A systems approach is used here to catalog these oral changes. In some instances it is difficult to separate the oral manifestations of pharmacotherapy for a particular disease from that entity. The oral manifestations of pharmacotherapy are presented for selected disease processes. This article introduces the most common oral manifestations of systemic disease.

Oral lesions as the first clinical sign of microscopic polyangiitis: a case report

Microscopic polyangiitis (MPA) is defined as a systemic necrotizing vasculitis that clinically and histologically affects small-sized vessels without granulomata. The main clinical feature of MPA is renal involvement characterized by rapidly progressing glomerulonephritis. We report a case of oral lesions, initially thought to be associated with Wegener's granulomatosis, as the first sign of MPA in an otherwise healthy man. To our knowledge, this is the first published case of MPA-associated oral lesions.