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

[Autoimmunity and oral cavity, where are we in 2023?]

Autoimmune diseases (AIDs) remain an enigma to the current understanding of immune system functioning. Identifying their etiologies remains a major challenge, despite growing knowledge. The oral cavity has a very special place in regard to AIDs. The oral mucosa, the most exposed body's natural barrier to pathogens, plays a role in both education of the immune system and the organism's daily protection. On the one hand, systemic disturbance of the immune system can impact the oral sphere with early signs which are useful diagnostic tools. On the other hand, the current research efforts on interactions between microbiota and the immune system allow an update of the old hypothesis involving an initial infection to trigger autoimmunity. Dysbiosis of our microbiota, especially in the oral sphere, could lead to a breakdown in tolerance mechanisms. Immune tolerance has to maintain the integrity of the organism but also cohabitation with commensal microbiota. The relationship between periodontitis, a chronic infectious disease, and rheumatoid arthritis, one of the most common systemic autoimmune disorders, illustrates the possible relationship between chronic infections and the etiopathogenesis of autoimmunity. Indeed, its association with oral pathogens involved in periodontal damage raises questions about a possible infectious etiology of rheumatoid arthritis (RA) which would place the management of periodontitis not only as mandatory RA's support therapy but also as a prophylactic gesture to prevent autoimmunity.

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.

A 39-Year-Old Woman With Hemoptysis, Polydipsia, and Polyuria

CASE PRESENTATION

A 39-year-old previously healthy woman presented to the hospital with a nonproductive cough, small-volume hemoptysis, and exertional dyspnea. In addition, she reported a 4-week history of progressive left-sided headache, retro-orbital pain, left ear conductive hearing loss, fever, chills, anorexia, and a 10-lb weight loss. She had no prior sick contacts or history of respiratory tract infections. She did not take any chronic medications or supplements. The patient was a lifelong nonsmoker. She worked as a field consultant in Northern Manitoba communities. While in the hospital, she developed new symptoms of "unquenchable thirst," polydipsia, and polyuria.

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.

From strawberry gingivitis to palatal perforation: The clinicopathological spectrum of oral mucosal lesions in granulomatosis with polyangiitis

BACKGROUND

Reports of oral manifestations of granulomatosis with polyangiitis (GPA) usually refer to single-case reports; "strawberry gingivitis" has been increasingly reported.

OBJECTIVE

To study the clinicopathological findings of four patients in which the diagnosis of GPA was suspected from the observation of their oral lesions and compare these to existent data.

METHODS

Retrospective study of a case series.

RESULTS

One patient presented typical "strawberry gingivitis" with localized disease and negative ANCA results. Two patients presented rapidly growing oral ulcers associated with systemic compromise and high ANCA levels. One patient presented with a chronic granulomatous lesion that leaded to palatal perforation.

CONCLUSION

Oral manifestations of GPA may vary from rapidly evolving lesions in acutely ill patients to chronic and locally destructive lesions in slowing developing disease. These differences are also evident in the histopathological findings.

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.

Granulomatosis with polyangiitis: potentially lethal gingival lesions presenting to the dentist

Gingival pathology is a daily presentation, however a small number of systemic conditions can manifest similar to a common gingival condition and have fatal results. Dentist referred 56-year-old woman to Oral and Maxillofacial Surgery department with a 2-week medical history of gingival bleeding not responding to local measures. Biopsy showed eosinophilic infiltrate and vasculitis, and blood tests showed positive markers including cytoplasmic antineutrophil cytoplasmatic antibodies. Granulomatosis with polyangiitis is a rare disease affecting the respiratory tract, blood vessels and kidneys. Oral lesions are rarely the primary presenting feature. When left untreated, most cases are fatal within a year of diagnosis. The diagnosis can only be made when certain criteria are found, including granular oral lesions exhibiting an eosinophilic inflammatory infiltrate on biopsy. With 5% of cases showing intraoral lesions as the primary feature, it is essential that dentists have the knowledge of this rare disease to refer and not to treat as a common gingival condition.

Role of gingival manifestation in diagnosis of granulomatosis with polyangiitis (Wegener's granulomatosis)

Purpose

This report describes a case of granulomatosis with polyangiitis (GPA) in which the gingival manifestation was crucial in both making an early diagnosis and possibly in deciding the approach to treatment.

Methods

A 57-year-old sailor presented to the Department of Dentistry at Ulsan University Hospital complaining of gingival swelling since approximately 2 months. He had orofacial granulomatous lesions and the specific gingival manifestation of strawberry gingivitis.

Results

The diagnosis of GPA was made on the basis of clinical symptoms and signs, and confirmed by the presence of the anti-neutrophil cytoplasmic antibody and a positive biopsy. The patient was admitted to the hospital and subsequently placed on a disease-modifying therapy regimen that included methotrexate and prednisone.

Conclusions

Identification of the gingival manifestation of the disease permitted an early diagnosis and prompt therapy in a disease in which time is a crucial factor. Because of its rapid progression and potentially fatal outcome, an early diagnosis of GPA is important. Therefore, dentists should be aware of the oral signs and symptoms of such systemic diseases.

Proposed Clinico-Pathological Classification for Oral Exophytic Lesions

Oral exophytic lesions often have proven to be diagnostically challenging due to the varied clinical presentation. The exophytic growth of the oral lesions is due to the type of pathology and histological changes. Careful clinical interpretation with a better histological understanding of exophytic lesions may ease the diagnosis from the differential diagnosis panel. The purpose of proposing classification system is to categorize the exophytic lesions of interest under specific clinical and/or histological explanation; and this will eventually lead to better understanding of the pathological condition that is described. To the best of our knowledge, there is no such classification system available for oral exophytic lesions and hence proposal of classification system is attempted in this study. Further, proposing a new classification system is not just to influence the academic contribution, but also to assist at greatest extent for diagnosis during clinical practice.

Gingival hyperplasia being the first sign of Wegener's granulomatosis

Wegener's granulomatosis (GW) is a multisystemic granulomatous vasculitis that predominantly affects the airways and the kidneys, but may affect any organ. Otorhinolaryngological manifestations may be gingival swelling, oral ulcer or septal perforations that can cause saddle nose deformities, rhinitis, sinusitis and hearing loss. We report a case of WG that was first diagnosed on oral gingival mucosa. A 54-year old woman was referred to a specialized dentist because of consistent irritative buccal gingival hyperplasia that did not react to conservative and microbial treatment. The lesion was biopsied and the diagnosis was suggestive for WG. Patient was further referred to the Unit of Rheumatology and the diagnose of WG was confirmed and treated. This case emphasizes the importance to recognize the oral manifestation of WG to get proper medication as soon as possible and avoid serious systemic tissue damage.

Wegener's granulomatosis: a review of clinical features and an update in diagnosis and treatment

Wegener's granulomatosis (WG) is an idiopathic, systemic inflammatory disease characterized by necrotizing granulomatous inflammation and pauci-immune small-vessel vasculitis of upper and lower respiratory tract and kidneys. The condition affects both genders equally, although some inconsistent gender differences have been observed. The aetiology of WG remains unknown although a number of exogenous factors have been suggested to be of aetiological relevance. Most clinical characteristics of this disease are non-specific, making clinical diagnosis challenging. Histopathological examination of lesional and peritoneal tissue is not pathognomonic, but is an essential investigation to confirm the presence of disease and exclude other disorders. At present, despite the increasingly wide range of potential therapies, cyclophosphamide plus corticosteroids remain the most recognized and effective means of inducing and sustaining remission of WG.