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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 11  |  Issue : 4  |  Page : 212-215

Oral pyogenic granuloma: An unusual presentation in tongue – Case report and comprehensive review


1 PG Student, Department of Oral Pathology &Microbiology, SRM Dental College, SRMIST, Chennai, India
2 CRRI, Department of Oral Pathology &Microbiology, SRM Dental College, SRMIST, Chennai, India
3 Senior Lecturer, Department of Oral Pathology &Microbiology, SRM Dental College, SRMIST, Chennai, India

Date of Submission16-Nov-2020
Date of Acceptance19-Nov-2020
Date of Web Publication05-Feb-2021

Correspondence Address:
Dr. V Vasanthi
Department of Oral Pathology and Microbiology, SRM Dental College, SRMIST, Ramapuram, Chennai - 600 089, Tamil Nadu
India
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DOI: 10.4103/srmjrds.srmjrds_116_20

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  Abstract 

Pyogenic granuloma (PG) is a reactive, hyperplastic lesion of the skin and mucosa in response to chronic irritation. It clinically presents as sessile or pedunculated growth, most commonly in the gingiva. The clinical and histopathological spectrum of PG depends on the phase of the lesion. Healing lesions are pinkish white compared to reddish lesions in the established phase. Long-standing lesions show features of fibrosis and calcification. We report a case of PG extra gingival in location, on the left lateral surface of tongue in a 45-year-old male with an insight into etiopathogenesis, clinical presentation, histopathological, molecular, and immunohistochemical features. Novel concept of isolation of stem cells from pathological tissues such as PG might help future research in regenerative dentistry.

Keywords: Pyogenic granuloma, regenerative dentistry, stem cell, tongue


How to cite this article:
Deena P, Sivakumar C, Jawahar D, Boobalan P, Mohanadhass B, Vasanthi V. Oral pyogenic granuloma: An unusual presentation in tongue – Case report and comprehensive review. SRM J Res Dent Sci 2020;11:212-5

How to cite this URL:
Deena P, Sivakumar C, Jawahar D, Boobalan P, Mohanadhass B, Vasanthi V. Oral pyogenic granuloma: An unusual presentation in tongue – Case report and comprehensive review. SRM J Res Dent Sci [serial online] 2020 [cited 2021 Feb 26];11:212-5. Available from: https://www.srmjrds.in/text.asp?2020/11/4/212/308779


  Introduction Top


The first case of pyogenic granuloma (PG) was described by Poncet and Dor in 1897. Hartzell coined the term PG in 1904. The term is believed to be a misnomer as the lesion is neither related to pus formation nor resembles a granuloma histologically.[1],[2],[3] The histological presentation was described by Angelopoulos as “hemangiomatous granuloma.” Granuloma pyogenicum, botryomycoma, human botryomycosis, pseudobotryomycosis, fibroangioma, benign pedunculated granuloma, lobular hemangioma, eruption hemangioma, pregnancy tumor, Crocker and Hartzell's disease, and granuloma telangiectacticum are few of the eponyms of the lesion. Lobular capillary hemangioma (LCH) and the non-LCH are the two forms of the lesion.[4],[5],[6]

Here, we present a case of PG in a 45-year-old male on the left lateral aspect of the tongue. Etiopathogenesis, clinical presentation, histopathological, molecular, immunohistochemical, and recent concept of expression stem cell markers in tissue of PG are being discussed.


  Case Report Top


A 45-year-old male reported to our department with the complaint of difficulty in feeding due to the growth on the left lateral side of the tongue. The patient gave a history that he noticed the growth 5 months ago, which gradually increased in size to attain the present form. The patient also gave a history of bleeding from the growth at times. Intraoral examination revealed a reddish, lobular, pedunculated growth of 7 mm × 4 mm in size over the left lateral aspect of the anterior two-thirds of the tongue in relation to 34.35 [Figure 1]. The growth was soft-firm, nontender and did not bleed on palpation. Lymph nodes were not palpable. The lesion was provisionally diagnosed as PG. Oral squamous cell carcinoma was also considered owing to the site of the lesion and associated tooth. Irritational fibroma, fibroepithelial polyp, and peripheral giant cell granuloma were considered in the differential diagnosis. The lesion was excised under local anesthesia. Macroscopically, the specimen was brownish in color, firm in consistency, and measured 7 mm × 5 mm in size [Figure 2]. Histopathology revealed parakeratinized stratified squamous epithelium showing hyperplasia and atrophy. The underlying connective tissue showed proliferating endothelial cells, numerous capillaries of various sizes engorged with red blood cells, and mild-to-moderate inflammatory cell infiltrate [Figure 3]. The histopathological features were suggestive of PG. Postoperative follow-up was found to be uneventful.
Figure 1: Intraoral photograph of exophytic lesion on the lateral tongue

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Figure 2: Macroscopic image of the biopsied specimen

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Figure 3: Photomicrograph showing hyperplastic epithelium, proliferating endothelial cells, budding capillaries, and inflammatory infiltrate

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  Discussion Top


PG is a nonneoplastic, reactive, inflammatory, hyperplastic lesion of skin or mucosa in response to chronic irritation. Chronic irritation from dental plaque, calculus, or overhanging restorations activates the host defense mechanism to elicit inflammatory response through chemokines. Expression of intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 promotes adhesion and migration of the inflammatory cells.[7] Vascular endothelial growth factor (VEGF) induces angiogenesis and results in exuberant mass of tissue. Mast cells also contribute to the neoangiogenesis through potent mediators such as heparin, histamine, tryptase, interleukin-8, tumor necrosis factor-alpha, basic fibroblast growth factor (bFGF), and VEGF.[8],[9] Female hormones are also reported to synergistically increase the production of bFGF and VEGF.[10] Long-standing cases of PG exhibit a desmoplastic response characterized by transformation of fibroblast to myofibroblast phenotype.[5]

PG is most commonly reported in females in the age group of 20–59 years. Gingiva is the most common site, followed by tongue, hard palate, buccal mucosa, lip, and floor of the mouth. It clinically presents as nontender, sessile, or pedunculated mass of few millimeter to centimeters in size. The color depends on the clinical course and vascularity. Early lesions resemble normal mucosa, established lesions are reddish to purplish, and healing lesions are pinkish to white.[11],[12],[13] Clinically, LCH is usually sessile and non-LCH is usually pedunculated.[14]

Histologically, three phases have been reported, namely, the cellular, capillary/vascular, and involutionary phase. The early cellular phase exhibits a cellular stroma with little lumen. The vascular phase shows dilated, capillaries engorged with red blood cells and proliferating endothelial cells. The involutionary phase shows fibrosis inducing reparative action.[2],[15],[16],[17]

Histologically, based on the vascularity and proliferation, subforms of PG include LCH and non-LCH. LCH type presents with lobular aggregates of proliferating blood vessels and non-LCH type resembles granulation tissue with vascular proliferation. The lobular type has small luminal diameter compared to non-LCH type. The perivascular mesenchymal cells of LCH type are positive for α-smooth-muscle actin (α-SMA) whereas of non-LCH type are negative for α-SMA. Considering all the above facts, Epivatianos et al. reported that there might be different evolutionary pathways for both types of PG.[1],[6],[14],[18]

On a molecular level, reactive nature and vascular growth in PG are reported to be driven by FLT4, a tyrosine kinase receptor, and the nitric oxide pathway.[19]

Immunohistochemically, PG was reported to show positive expression of bFGF, VEGF, anti-CD3, Tie-2, factor VIII-related antigen, anti-alpha SMA antibodies, angiopoietin-1, angiopoietin-2, ephrinB2, and ephrinB4. The expression of VEGF is found to decrease during the course of the lesion as the budding capillaries mature and form well-organized vessels. The decreased expression of VEGF in established lesions may also be attributed due to the expression of angiogenesis inhibitors, namely, TSP-1 and angiostatin.[20],[21],[22],[23]

Recent studies revealed that stem cells can be isolated from pathological tissue such as PG. PG has properties of stemness as it is positive for embryonic stem cell markers such as pSTAT3, OCT4, SOX2, and NANOG.[24],[25] Dehghani Nazhvani et al. reported osteogenic and adipogenic differentiation from single cell cultures of PG.[24] Blackwell et al. reported that expression of embryonic stem cell markers by endothelial cells of microvessels suggested primitive origin and by the interstitial cells represented downstream derivative of primitive endothelium.[25] Dehghani Nazhvani et al. reported the expression of STRO-1+cells, a mesenchymal stem cell marker in PG.[26] Novel insights into research may be implicated into the histopathological and immunohistochemical aspects of PG to prove the biology of stemness.

Being a reactive lesion, surgical excision is the mode of treatment. Proper oral hygiene measures and withdrawal of the source of irritation are recommended as a preventive measure.


  Conclusion Top


The histopathological spectrum of Pyogenic granuloma depends on the phase of the lesion. Long-standing lesions may possess feature of fibrous lesions. Stem cells can also be isolated from pathological lesions such as PG. Being the most commonly reported reactive oral lesion, expression of stem cell markers in PG might contribute to tissue regeneration in dentistry.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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