Traumatic ulcerative granuloma with stromal eosinophilia - Mystery of pathogenesis revisited

An Unusual Clinical Presentation of Traumatic Ulcerative Granuloma With Stromal Eosinophilia

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a reactive and chronic ulcerative lesion that is most frequently found on the tongue. It appears as a large yellowish ulcer with elevated margins and central induration. TUGSEs exhibit a characteristic pattern of regression often spontaneously, following incisional biopsy, or after removal of the potential traumatic trigger. Herein, we present an unusual case of a TUGSE on the anterior maxillary gingiva of a 70-year-old male that regressed following incisional biopsy. Histopathologic evaluation revealed fragments of squamous mucosa and submucosal tissue with large atypical cells mixed with small lymphocytes, abundant eosinophils, and focal clusters of plasma cells. Immunohistochemistry was performed and the large, atypical cells were positive for CD3, CD4, CD5, and CD30 and negative for CD1a, CD8, CD20, CD56, CD117, ALK1, Langerin, and EBER ISH. To our knowledge, this is the first case of TUGSE reported in the anterior maxilla.

Traumatic ulcerative granuloma with stromal eosinophilia mimicking a squamous cell carcinoma

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a rare lesion of a traumatic-reactive nature of the oral mucosa that can clinically mimic an oral carcinoma. A 59-year-old male patient presented painful ulceration with indurated margins on the base of the tongue, extending to the floor of the mouth. The use of ill-fitting denture hurting the mucosa of the region was reported by the patient. The evolution time was 45 days. The presumptive diagnoses were oral squamous cell carcinoma and chronic ulcer. An incisional biopsy revealed an ulceration associated with an eosinophil-rich inflammatory infiltrate and a bed of proliferating histiocyte-like cells in either diffuse or fasciculate arrangement. There was diffuse immunopositivity for CD3, but focal for CD68 and α-SMA, and negativity for CD30. The final diagnosis was TUGSE. The use of the ill-fitting dental prosthesis was suspended and the lesion had complete spontaneous remission three weeks later. TUGSE is an uncommon traumatic self-limiting lesion that must be included in the differential diagnosis of ulcerative lesions resembling oral cancer. The correlation of clinical and histopathological findings is pivotal for a proper diagnosis, avoiding unnecessary aggressive surgical approaches. Key words:Oral ulcer, eosinophilia, immunohistochemical, differential diagnosis.

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE): a rare presentation and case report

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a rare, benign, and self-limiting ulcerative lesion, with the tongue being the most common site of occurrence and traumatic inflictions being the common etiology. Case report: A 45-year-old female reported to the dental operatory with a complaint of pain on the left side of her tongue for the past 8 months. Her history revealed that a small ulcer had gradually grown to be 2 cm x 1.5 cm on presentation. She indicated that the ulcer often interfered with her maxillary left canine while occluding. She also gave a history of a tobacco chewing habit for 15 years which she stopped 6 years ago. Clinically she had a single erythematous ulcer with irregular borders and raised margins. The client was treated with surgical excision of the lesion. The excised lesion was confirmed histologically to have eosinophil rich cells and was diagnosed as TUGSE. Conclusion: TUGSE should be recognized and not neglected as it closely resembles malignancies of the oral cavity. It also has a good prognosis and heals rapidly after the surgical excision or on its own with time, which may range from a few weeks to a year.

Traumatic ulcerative granuloma with stromal eosinophilia: A puzzle

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is an ulcerative condition of the oral mucosa amid a chronic course and delayed healing. It is a reactive lesion that usually affects the tongue. TUGSE is a rare mucosal lesion to aid as an ulcer or an indurated submucosal mass and might cause diagnostic problems as it mimics a traumatic or neoplastic ulcer. However, chronic irritation from traumatic agents is well thought out to be a major initiating aspect. Histopathologically, it is categorized by an eosinophilic inflammatory infiltrate penetrating into the underlying muscle. It is significant to make out this mucosal lesion as it mimics malignant ulcers; the condition tends to resolve on its own. Thus, attentiveness of this entity is imperative to emphasize the accurate diagnosis of indurated ulcerated lesions and convey suitable and effective treatment. The present case highlights the clinical aspects, etiopathogenesis and histopathology of this unusual lesion.

EXPRESSION OF MATRIX METALLOPROTEINASE-9 IN ORAL SQUAMOUS CELL CARCINOMA AND ORAL PSEUDOEPITHELIOMATOUS HYPERPLASIA

Background: Oral pseudoepitheliomatous hyperplasia (PEH) appears histologically similar to oral squamous cell carcinoma (OSCC) in small oral biopsies, thus posing diagnostic dilemma. The objective of this study was to compare the expression of matrix metalloproteinase-9 (MMP-9) in differential diagnosis of OSSC and oral PEH. Materials & Methods: This comparative cross-sectional study was conducted in the Department of Histopathology, Armed Forces Institute of Pathology (AFIP), Rawalpindi, Pakistan from January 2013 to March 2016. It included sixty archival cases, 30 each of OSCC and PEH. Paraffin embedded blocks were prepared, hematoxylin and eosin stained sections taken and immunostained with MMP-9. The expression of MMP-9 was evaluated in OSCC and PEH. Results: The OSCC group included 16 (53.33%) men and 14 (46.67%) women, whereas PEH group included 18 (60%) men and 12 (40%) women. The mean age of OSCC group was 60.1±17.3 and that of PEH group was 52.7±16.6. In OSCC group, site of lesion was buccal mucosa in 12 (40%), gingiva 10 (33.33%), tongue 7 (23.33%) and floor of mouth 1 (3.34%) case. In PEH group, site of lesion was buccal mucosa in 12 (40%), tongue 11 (36.66%), gingiva 6 (20%) and palate 1 (3.34%) case. The expression of MMP-9 was positive in all the 30 cases of OSCC and negative in all 30 cases of PEH. Conclusion: Compared to pseudoepitheliomatous hyperplasia (PEH), MMP-9 revealed a higher expression in oral squamous cell carcinoma (OSCC). This finding has become mainstream strategy in distinguishing OSCC from PEH in oral mucosal biopsies in cases difficult to diagnose.