Pyogenic granuloma of the tongue early after allogeneic bone marrow transplantation for multiple myeloma

Unusual clinical presentation, microscopy and immunohistochemistry of oral pyogenic granuloma in a paediatric patient

An unusual clinical presentation of any pathology prompts a diagnostic dilemma, which further brings challenges in treatment planning. Pyogenic granuloma (microscopically lobular capillary haemangioma) is a benign vascular tumour that commonly involves the skin and mucous membranes and usually manifests as a solitary papule with a friable pedunculated base. Rapid exophytic growth and an ulcerated surface with bleeding on provocation are characteristic, with a gingival predominance for the site. This case report aims to elaborate on an unusual clinical presentation of oral pyogenic granuloma in a middle-childhood female patient. The clinical and radiographic characteristics of the lesion were unremarkable to the diagnosis but rather mimicked other intraoral lesions. It is histopathology that could solve the puzzle with the microscopic and immunohistochemical findings that rendered the final diagnosis of lobular capillary haemangioma.

Pyogenic Granuloma in a One-Year-Old Child: A Rare Entity

Pyogenic granuloma (PG) is a benign vascular neoplasm seen in the first and second decades of life, and it has a female predilection. It presents as a small reddish exophytic lesion, gingiva being the most common site. This article describes an unusual presentation of PG in a one-year-old female child and highlights the importance of its early diagnosis and management to avoid discomfort and distress in these patients. The diagnosis was verified by histological examination, which revealed significant markers such as endothelial growth, vascular abundance, and chronic inflammatory cell infiltration. The chosen treatment protocol was surgical excision, which led to a successful outcome with no symptoms of recurrence, as confirmed by thorough follow-up examinations.

Pyogenic granuloma of the epiglottis: a common lesion in a rare site

Pyogenic granulomas are benign vascular lesions occurring on skin and mucous membranes, most commonly in the oral cavity.A case report of a woman in her 80s who presented with one episode of haemoptysis, secondary to an atypical epiglottic lesion is discussed. The patient denied associated symptoms, such as dyspnoea, dysphasia or recent weight loss. Flexible nasendoscopy and CT scan confirmed a highly vascular pedunculated mass on the left laryngeal surface of the epiglottis. The lesion was completely excised and there was no sign of recurrence after a 12-month follow-up.This case report represents the fourth documented case of a pyogenic granuloma arising from the epiglottis, resulting in haemoptysis. While rare, there is a significant risk of airway compromise from haemorrhage, which is refractory to pressure and may be difficult to control at this site. Surgery is required to completely excise the lesion and prevent recurrence.

A case series of medication-related fibrovascular hyperplasia following hematopoietic stem cell transplantation for Fanconi anemia

Systemic medications categorized as diphenylhydantoin, calcineurin inhibitor and calcium channel blocker may have effects on the oral cavity by modifying the inflammatory and immune response and causing undesired tissue proliferative reactions. Calcineurin inhibitors are medications commonly used for long periods in patients undergoing allogeneic hematopoietic stem cell transplant (HSCT) and solid organ transplantation. Medication-related fibrovascular hyperplasia (MRFH) is an extra gingival hyperplastic nodular growth associated with medications use. This study reports five cases of pediatric patients (6 to 12-years-old) diagnosed with Fanconi anemia (FA) after HSCT who presented similar oral mucosal lesions associated with the use of cyclosporine, phenobarbital and amlodipine. After excision of the lesions, histopathological analysis described them as pyogenic granuloma (PG). As the aetiology of the lesions manifested by the patients was associated with the use of medications, the final diagnosis was MRFH. Despite the clinical and histopathological similarity between PG and MRFH, it is fundamental to know the aetiological agent for achieving definitive diagnosis and correct management. Considering the etiologic agent (medication) and histopathological findings, it is suggested that the most appropriate term for this manifestation should be "medication-related fibrovascular hyperplasia". The correct nomenclature related to extra gingival hyperplastic lesions identified in patients on medications with potential to induce hyperplastic reactions should be adopted to facilitate scientific communication and improve the treatment.

Medication-related fibrovascular hyperplasia lesion in tongue: Case report

OBJECTIVE

The objective of this study is to report the case of a patient who underwent hematopoietic stem cell transplantation for Hodgkin's lymphoma treatment and developed multiple tongue lesions during recovery.

METHODS AND RESULTS

This is the case report of a patient who developed ulcerated lesions with areas of depapillation on the border and dorsum of the tongue. The ulcer evolved to a reddish fibrous hyperplastic nodule, similar to adjacent mucosa. The patient was using a series of medications, such as antifungals, antibiotics, antivirals, corticosteroids, and analgesics in addition to immunosuppression with cyclosporine. Considering the medical history of the patient, a biopsy was performed. Histopathological analyses describe hyperplasia, granulation tissue, vascular proliferation, and intense inflammatory infiltrate, and the diagnosis was of medication-related fibrovascular hyperplasia (MRFH).

CONCLUSION

Patients in use of cyclosporine are at risk to develop oral lesions, such as MRFH. The correct diagnosis is important, so the adequate treatment and follow-up are instituted even considering the immunosuppression protocol.

Oral Pyogenic Granuloma After Bone Marrow Transplant in the Pediatric/Adolescent Population: Report of 5 Cases

Pyogenic granuloma (PG) is a benign, neoplastic, soft tissue growth of granulation and fibrous tissue that may rarely occur in the mouth of patients after hematopoietic cell transplant (HCT). This case series describes 5 pediatric/adolescent patients who developed oral PG after HCT for acute lymphoblastic leukemia, Fanconi anemia, nodular sclerosis Hodgkin's lymphoma, or junctional epidermolysis bullosa. The underlying mechanism for the appearance of oral PG after HCT is unknown, but it is suggested that calcineurin inhibitors used for graft versus host disease (GVHD) may play a role, as all patients were on cyclosporine A or tacrolimus at the time of development of oral PG. Three of the patients were being treated for chronic GVHD, and 1 other treated for acute GVHD. Overall, this report illustrates that PG should be considered in the differential diagnoses when encountering oral lesions in pediatric/adolescent patients after undergoing HCT, especially in the context of chronic GVHD and calcineurin inhibitors use.

Orofacial diseases in solid organ and hematopoietic stem cell transplant recipients

OBJECTIVE

Solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients are at risk of several diseases, principally attributable to immunosuppression. This global overview of SOT/HSCT-associated orofacial diseases is aimed at providing a practical instrument for the oral healthcare management of SOT/HSCT recipients.

METHODS

Literature search was made through MEDLINE. The associations between orofacial diseases and SOT/HSCT were assessed using observational studies and case series and were classified into 'association', 'no association', and 'unclear association'.

RESULTS

Lip/oral cancers, drug-induced gingival overgrowth (DIGO), infections, including hairy leukoplakia and, less frequently, post-transplantation lymphoproliferative disorders (PTLDs) and oral lichenoid lesions of graft-versus-host disease (GVHD), were associated with SOT. Lip/oral cancers, GVHD, mucositis, DIGO, infections and, less frequently, PTLDs were associated with HSCT. Associations of orofacial granulomatosis-like lesions and oral mucosa-associated lymphoid tissue-type lymphoma with SOT, and of pyogenic granuloma and hairy leukoplakia with HSCT were unclear. Periodontal disease and dental caries were not associated with SOT/HSCT. For none of the local treatments was there a strong evidence of effectiveness.

CONCLUSIONS

Solid organ transplant/HSCT recipients are at risk of orofacial diseases. Adequate management of these patients alleviates local symptoms responsible for impaired eating, helps prevent systemic and lethal complications, and helps where dental healthcare has been neglected.

Gingival enlargements and localized gingival overgrowths

Gingival enlargements are a common clinical finding and most represent a reactive hyperplasia as a direct result of plaque related inflammatory gingival disease. These generally respond to conservative tissue management and attention to plaque control. However, a small group are distinct from these and whilst they also represent a reactive tissue response, this occurs at the level of the superficial fibres of the periodontal ligament. These epulides grow from under the free gingival margin and not as a result of a primary inflammatory gingival enlargement. This distinct aetiopathogenesis separates this group of lesions both in terms of their specific clinical presentation and behaviour and their propensity for recurrence if managed inadequately.

Immunosuppression-related fibroproliferative polyps: a substantial subset of acquired pediatric mucocutaneous polyps

A distinct group of fibroproliferative polyps of the tongue arising in immunosuppressed children and often associated with chromosomal breakpoints at chromosomes 9p34 or 22q11 was recently described. Based on this finding, we reviewed fibroepithelial polyps arising in nonlingual sites in the pediatric population to investigate a possible relationship with immunosuppression. We identified 8 fibroepithelial polyps arising in 6 immunosuppressed patients (4 males and 2 females, median age 17 years) in a wide range of mucocutaneous sites. Histologic features were identical to the common fibroepithelial polyp, or skin tag, with a variably collagenous fibrovascular core covered by unremarkable squamous epithelium. No viral cytopathic changes were identified in any case. Although cytogenetic studies were not performed on any of the biopsy material, 1 patient had a constitutional deletion of chromosome 22q11. We suggest that there may be a relationship between these polyps and the previously described tongue lesions and that immunosuppression may be an important factor in their pathogenesis.

Immunosuppression-related fibroproliferative polyps of the tongue

Polypoid tongue lesions arising after bone marrow transplantation have been described. Their etiopathogenesis has been unclear, as has their relationship to similar lesions arising in other settings of chronic immunodeficiency. We identified 12 polypoid lesions (from 8 immunosuppressed patients aged 6 months to 13 years) among all tongue lesions biopsied over the course of 13 years at our institution. Clinical history, histologic and ultrastructural features, special stains (Gram, Grocott methenamine silver, acid-fast bacilli, CD34, actin, desmin, human herpesvirus-8), in situ hybridization for Epstein-Barr virus, and cytogenetic features were studied. Immunocompromise was from bone marrow transplantation for severe combined immunodeficiency (n = 1) and acute lymphoblastic leukemia (n = 3), hypogammaglobulinemia (n = 2), 22q11 deletion syndrome (n = 1), and asthma therapy (n = 1). Histologic examination revealed fibrous stromal cores with squamous epithelial covering and various degrees of ulceration and accompanying inflammation and granulation tissue. In 2 patients lesions were multiple in number. Fibroblasts were variably positive for smooth muscle actin and desmin and negative for CD34. Special stains, immunohistochemistry, in situ hybridization, and ultrastructural examination identified no organisms except occasional surface bacteria. The tongue lesion from 1 patient with Down's syndrome showed t(2;9)(p11;q34)+21 (translocation not seen in peripheral blood). Another patient had constitutional del 22q11. All transplant patients had Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL) (translocations involving 9q34 and 22q11). Patients with congenital immunosuppression had polyps arise at significantly younger ages than did patients with acquired immunosuppression. Immunosuppression-related lingual polyps are a fibroproliferative process occurring in patients with bone marrow transplantation and other immune-deficient conditions. Our findings indicate that these polyps are driven by both immunosuppression and chromosomal rearrangement.

Oral pyogenic granuloma: a review

Pyogenic granuloma is one of the inflammatory hyperplasias seen in the oral cavity. This term is a misnomer because the lesion is unrelated to infection and in reality arises in response to various stimuli such as low-grade local irritation, traumatic injury or hormonal factors. It predominantly occurs in the second decade of life in young females, possibly because of the vascular effects of female hormones. Clinically, oral pyogenic granuloma is a smooth or lobulated exophytic lesion manifesting as small, red erythematous papules on a pedunculated or sometimes sessile base, which is usually hemorrhagic. The surface ranges from pink to red to purple, depending on the age of the lesion. Although excisional surgery is the treatment of choice for it, some other treatment protocols such as the use of Nd:YAG laser, flash lamp pulsed dye laser, cryosurgery, intralesional injection of ethanol or corticosteroid and sodium tetradecyl sulfate sclerotherapy have been proposed. Because of the high frequency of pyogenic granuloma in the oral cavity, especially during pregnancy, and necessity for proper diagnosis and treatment, a complete review of published information and investigations about this lesion, in addition to knowledge about new approaches for its treatment is presented.

Rare case of pyogenic granuloma of the tongue in an 8-week-old infant

We present a case of a large pyogenic granuloma of the tongue causing swallowing difficulties in an 8-week-old infant. In the literature, we found no case reports of pyogenic granuloma in such a young infant. It is a quickly growing, hypertrophic inflammatory change consisting of exceptionally richly vascularized granular tissue. The granuloma was located in the central part of the tongue and appeared dark pink in color. It was an easily bleeding pedunculated tumor measuring 3 x 2.5 cm. The etiology of the tumor is unknown; it can arise in sites of previous injury, chronic irritation and infection. The course of the disease is benign and painless, though it can be recurrent. No recurrence was found in the control examination after 3 years.