Traumatic ulcerative granuloma with stromal eosinophilia - clinical case report, literature review, and differential diagnosis

Background

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a rare self-limiting condition of the oral mucosa. The lesion manifests as an isolated ulcer that can be either asymptomatic or associated with mild to severe pain, and in most cases, it affects the tongue. TUGSE lesions may mimic malignancy such as squamous cell carcinoma, CD30 positive lymphoproliferative disorder, or infectious diseases such as primary syphilis, tuberculosis, or Epstein-Barr virus mucocutaneous ulcer. Histologically dominating cells are lymphocytes, histiocytes, and eosinophils.

Case presentation

We describe a TUGSE case of a patient with a solitary ulcer on the lower left retromolar buccal plane. Upon presentation, the patient reported a swelling on the buccal mucosa of the left lower jaw since 1 year with rapid growth over the last days and mild pain while chewing. The diameter of the intraoral lesion on the lower left retromolar buccal plane was approximately 4 × 3 cm; the lesion presented as indurated base with a central superficial ulceration of 2 × 1 cm, indicative for a malignant process. Histologically, the ulceration showed an expanding, infiltrative, and vaguely granulomatous morphology, involving the superficial mucosa and the fatty tissue, and extended between the deep striated muscle fibers. The lesion was rich in lymphocytes, histiocytes, and eosionophils intermingled with activated T-blasts without phenotypic abnormalities. TUGSE was then diagnosed based on the phenotype (especially the lacking expression of CD30, the retained T-cell phenotype, and the absence of Epstein-Barr virus), the clinical presentation, and the morphology. Twenty-six months after diagnosis, no recurrence of the ulceration was seen.

Conclusions

As TUGSE may mimic malignancy or infectious diseases, biopsy is mandatory and should be combined with thorough clinical examination. A screening for infectious diseases (mainly syphilis, Epstein-Barr virus, and HIV infections) must be performed routinely. In most cases, the lesions resolve spontaneously, obviating the need of further actions other than clinical follow-up. The pathogenesis of TUGSE lesions is still under debate, although local traumatic events and a locotypic immune response have been suggested to be major contributing factors.

Ulcerative eosinophilic granuloma: a report of five new cases

Five new cases of ulcerative eosinophilic granuloma were diagnosed at the Massachusetts General Hospital between 1982 and 1993. In all cases the site was the tongue. They were unifocal, did not recur, and had a benign course. This report illustrates their benign nature despite the occasional aggressive presentation, and outlines possible aetiology.

Eosinophilic ulcer of the oral mucosa

BACKGROUND

The eosinophilic ulcer is a rare lesion of the oral mucosa that has been infrequently described in the literature.

OBJECTIVE

We attempted to characterize the history, demographics, clinical features, histologic features, pathogenesis, and treatment of the eosinophilic ulcer.

METHODS

We observed three new cases of eosinophilic ulcer and reviewed the English-language literature.

RESULTS

Eosinophilic ulcer occurs in any age group, without sex preference. The most common site in the oral cavity is the tongue, and the average size at diagnosis is 1.6 cm2. These lesions are often ulcerated, may be tender, and are sometimes multiple. The histologic features are characteristic but likely represent a spectrum of related disorders. Most eosinophilic ulcers will resolve spontaneously within a month. Recurrences are uncommon (< 15%).

CONCLUSION

The eosinophilic ulcer is a benign, self-limited, reactive process of the oral mucosa of unknown origin. Its histologic features are characteristic but may be confused with atypical histiocytic granuloma and angiolymphoid hyperplasia with eosinophilia or, more importantly, lymphoma. This condition most likely represents a spectrum of related disorders with overlapping clinical and histologic features. After the diagnosis has been histologically confirmed, conservative management is suggested.

Periodontal manifestations of adult onset of histiocytosis X

Histiocytosis X, a reticuloendothelial disorder, includes the three clinical syndromes: Letterer-Siwe and Hand-Schuller-Christian diseases and eosinophilic granuloma of the bone. Twenty-eight cases of adult onset of histiocytosis X involving the head and neck region were found in the literature during the past 20 years; 15 cases were confined to this area, out of which 13 involved jaw bones. Characteristic signs and symptoms of periodontal disease were observed in 22 out of 28 cases (79%) with the lower molar area as a predominant site. A case report of a non-osseous chronic disseminated histiocytosis X with periodontal involvement is presented. The importance of histiocytosis X, as an entity that should be kept in mind as a differential diagnosis of a process where destructive periodontitis is involved, is discussed.

Atypical histiocytic granuloma with eosinophilia

Atypical histiocytic granuloma in the oral mucosa has recently been described as a benign non-neoplastic ulcero-proliferative lesion of histiocytic origin with eosinophilia. The disease is confined to the oral mucosa where the lesion is solitary. These lesions, which heal spontaneously, are not associated with systemic disease or dissemination. This report deals with such a case, and it stresses the benign nature of the lesion despite the worrying clinical and microscopic appearance. The morphological diagnosis was substantiated by the use of a series of immunohistochemical reactions.

Multiple linear ulcers on the dorsum of the tongue in a patient with Waldenstrom's macroglobulinemia

An unusual clinical presentation of an eosinophilic ulcer of the tongue has been described. This lesion is seen most often in the fourth to sixth decades of life and has been shown to have a strong predilection for males. The etiology is unknown although trauma has been implicated by several investigators. Because of the clinical resemblance of eosinophilic ulcer to carcinoma, biopsy examination is recommended. After the diagnosis is made, conservative management is most appropriate.

Eosinophilic angiocentric fibrosis of the upper respiratory tract: a mucosal variant of granuloma faciale? A report of three cases

Three patients with an unusual stenosing lesion affecting the upper respiratory tract are described. The lesion involved the mucosa of the nasal septum and lateral nasal wall in two cases and the mucosa of the sub-glottic region of the larynx in one. The lesion leads to thickening of the sub-mucosal connective tissues by an usual pathological process. It begins as a focal peri-vascular sub-epithelial exudate of eosinophils accompanied by collections of plasma cells and lymphocytes without fibrinoid necrosis. These foci progress to form extensive areas of peri-vascular fibrosis showing a characteristic angiocentric whorling with an 'onion-skin' pattern. This process leads to thickening and matting of the mucosa which becomes adherent to the underlying structures. As fibrosis progresses, the lympho-plasmacytic component regresses but the eosinophils remain. The fibrosis does not resolve and the consequent stenosis requires surgical relief. No other site appears to be affected by this process, but one case was associated with granuloma faciale. The cause is unknown. We have given the term 'eosinophilic angiocentric fibrosis of the upper respiratory tract' to this condition to encompass its cardinal features.

Eosinophilic ulcer of the oral mucosa

Two additional cases of eosinophilic ulcer of the oral mucosa are presented. Both patients were treated with corticosteroids, with favorable results. A review of the literature provided useful information on the clinical characteristics, histologic features, method of treatment, and benign course of the lesions.

Eosinophilic ulcers of the tongue

A case of eosinophilic ulcer of the tongue is presented. Although the entity is rarely described, the distinctive histopathologic pattern featuring the remarkable presence of eosinophils in the superficial corium and in between muscle bundles, together with the benign clinical course, make a diagnosis possible.

Traumatic ulcerative granuloma with stromal eosinophilia (Riga-Fede's disease and traumatic eosinophilic granuloma)

A review of the English literature revealed ten lesions classified as Riga-Fede's disease and nineteen lesions classified as traumatic eosinophilic granuloma. These two entities have the same histologic features and are often associated with a history of trauma. These are benign, reactive, nonosseous lesions that occur either in infancy or later in life. It is suggested that they be considered as one entity. To delineate them from more aggressive lesions, such as the eosinophilic granuloma of histiocytosis X, the author suggests the term traumatic ulcerative granuloma with stromal eosinophilia. Forty-one previously unreported cases are described. Histologic examination revealed the presence of mast cells in addition to eosinophils. A pathogenesis for traumatic ulcerative granuloma with stromal eosinophilia, based on the hypothesis that mast cells release an eosinophilic chemotactic factor and that eosinophils may act as cytotoxic agents, is suggested.

Traumatic granuloma of the tongue

The traumatic granuloma is a rare, reactive lesion that occurs primarily in the tongue of males. It can mimic other diseases, including malignancy, both clinically and histologically. It is, therefore, a lesion with which clinicians and pathologist should be familiar.