|Year : 2021 | Volume
| Issue : 4 | Page : 480-483
An ambiguous clinical presentation of a gingival plasma cell granuloma – A case report
Areeba Shahid, Priya Singh, Neeta Misra, Deepak Umapathy
Department of Oral Medicine and Radiology, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||15-Apr-2021|
|Date of Decision||28-Sep-2021|
|Date of Acceptance||09-Oct-2021|
|Date of Web Publication||27-Dec-2021|
Dr. Areeba Shahid
Flat no. C-1, Tuba Palace,15, Madan Mohan Malviya Marg, Lucknow, 226001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Plasma cell granuloma (PCG) is a rare localized benign proliferation of polyclonal mature plasma cells. The etiopathogenesis of the PCG remains inexplicit. Although it primarily occurs in the lungs, intraoral variants, involving the gingiva, tongue, buccal mucosa, have been reported too. Here we report a case of a 19-year-old female patient with mandibular anterior gingival exophytic growth that gave an impression of pyogenic granuloma clinically. The overgrown tissue was excised and histological examination revealed inflammatory cell infiltrate containing sheets of plasma cells. This case highlights the presence of a PCG having a periodontal origin. As intraoral occurrences of PCG are uncommon, such observations should be well documented and added to the existing literature. Advanced investigations such as immunohistochemistry can be done, which rule out the possibility of any malignancy, as seen in cases of plasmacytoma that mimic PCG (no malignant potential).
Keywords: Gingiva, oral cavity, plasma cell granuloma, plasma cell, pyogenic granuloma
|How to cite this article:|
Shahid A, Singh P, Misra N, Umapathy D. An ambiguous clinical presentation of a gingival plasma cell granuloma – A case report. J Indian Acad Oral Med Radiol 2021;33:480-3
|How to cite this URL:|
Shahid A, Singh P, Misra N, Umapathy D. An ambiguous clinical presentation of a gingival plasma cell granuloma – A case report. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2022 May 21];33:480-3. Available from: https://www.jiaomr.in/text.asp?2021/33/4/480/333882
| Introduction|| |
Plasma cell granuloma (PCG) is an atypical benign reactive pseudotumor, described in 1973 by Bahadori and Liebow. Reactive lesions are associated with chronic allergen exposure. PCG is characterized by the proliferation of inflammatory cells, with predominant polyclonal plasma cells, in a fibrovascular background. Anatomically, it is most commonly seen in the lungs. In the head and neck region, the orbit is the most common site followed by paranasal sinuses, tonsil, thyroid, larynx, salivary glands, lips, temporal bone, skull base, and facial nerve. Intraorally, it occurs on the gingiva, tongue, buccal mucosa, and palate.,, The literature reveals gingival PCG to be a rare entity although case reports documenting such lesions have been reported (the exact number is indeterminable). Intraoral PCG occurs in a wide age range of 19 months to 63 years, with a slight female predilection. The etiopathogenesis is ambiguous and recurrence is undetermined. Clinically, PCG presents as a nodular, polypoidal mass with a smooth surface, producing no significant systemic manifestations. The lesion primarily is asymptomatic unless secondarily ulcerated due to trauma, eliciting pain. The recommended treatment is simple resection, along with treatment of underlying inciting agents such as periodontitis and foreign body. This case presentation is of a gingival PCG.
| Case Report|| |
A 19-year-old female patient reported a chief complaint of gum swelling in the lower front region of the jaw since 7 to 8 months. The history of the present illness revealed the swelling to be initially small in size but gradually increased over the past few months. The patient was completely asymptomatic, observed bleeding while brushing teeth and sometimes on touch. The medical history was non-contributory.
Intraoral examination revealed a solitary sessile growth on the buccal and lingual marginal and attached gingiva with respect to 41, 42, and partial 43. The growth was well-demarcated, irregularly shaped, smooth, measuring approximately 2 cm × 1.5 cm in diameter. The growth was bright reddish pink with no active bleeding [Figure 1]. The mandibular anterior gingiva was soft and edematous with calculus deposits. Mobility was absent in respect to 41, 42, and 43. On palpation, the inspection findings were confirmed. The growth was firm, fixed to underlying structures, non-tender, non-fluctuant, and non-compressible. Bleeding was elicited on palpation.
|Figure 1: Intraoral clinical presentation of the lesion on the day of the visit. (a) Front view. (b) Bird-eye view|
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A provisional diagnosis of pyogenic granuloma was made for the localized nodular lesion, with chronic inflammatory gingival enlargement with respect to the mandibular gingiva. Fibrous epulis, peripheral giant cell granuloma, and peripheral ossifying fibroma were considered in the differential diagnosis.
On radiographic examination, orthopantomography (OPG) revealed no bone resorption or bony expansion with respect to 41, 42, and 43 [Figure 2]. The patient was advised surgical excision. Before the surgery, the patient was advised hematology (complete hemogram), immunology, and serology (HIV I and II, HbsAg), and COVID-19 (real-time-polymerase chain reaction [RT-PCR]) investigations. The blood parameters were in the normal range, and the patient tested negative in all the advised tests.
|Figure 2: Orthopantomogram reveals no significant bony alterations in relation to the mandibular anteriors|
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Surgical and therapeutic intervention
The lesion was excised under local anesthesia along with an extraction of 41. A betadine-soaked gauze pack was placed at the surgical site. The excised soft tissue specimen was preserved in formalin solution (10%) and sent for histopathological examination.
Following post-surgery medications were prescribed to the patient:
- Antacid: Tab pantoprazole (40 mg), once-daily, empty stomach in the morning
- Antibiotic: Cap amoxicillin (500 mg) + clavulanic acid (125 mg), twice daily for 5 days, 30 min after meals
- Analgesic: Tab diclofenac sodium (50 mg), twice daily for 3 to 5 days
- Probiotics capsule (250 mg), once daily for 10 days, preferably at night after meals
The histopathological report revealed a polypoidal lesion covered by thickened non-keratinizing stratified squamous epithelium [Figure 3]. Sub-epithelium contained fibrovascular connective tissue comprising numerous plasma cells in sheets and lobules (A) and a few lymphocytes, neutrophils, and eosinophils (B). No mitoses or necrosis was observed. Clinical and microscopic findings were correlated to make a final diagnosis of gingival PCG.
|Figure 3: Microphotographs of the excised tissue section stained with hematoxylin and eosin. (A) Micrograph at 4× (scanner view) magnification, showing: (a) Thickened non – keratinizing stratified squamous epithelium, (b) and (c) Fibrovascular connective tissue comprising of numerous plasma cells in sheets and lobules. (B) Low microscopy (40×) showing: (d) Plasma cells in a lobule, (e) Plasma cells in sheets, (f) Few lymphocytes, neutrophils, and eosinophils are also seen|
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Follow-up and outcome
After a month, the patient visited for her first follow-up. She was asymptomatic and the lesion showed no recurrence [Figure 4]. However, the persistence of enlarged and edematous mandibular anterior gingiva indicated complete oral prophylaxis. She was also advised to use chlorhexidine gluconate (0.2%) as mouth rinses twice daily. The patient was recalled after 1 month again for her second follow-up; however, she did not turn up for the same. Therefore, a telephonic conversation was established in which she informed of no lesion recurrence or any associated discomfort. The outcome revealed a good prognosis. The patient was instructed to contact if needed.
|Figure 4: Postoperative site at the end of 1 month, with no recurrence, was observed|
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The timeline for the case is tabulated in [Table 1].
| Discussion|| |
PCG is an uncommon, post-inflammatory reactive tumor formed by the aggregation of mature plasma cells. It may arise due to periodontal tissue irritation or idiopathic antigenic signaling. Plasma cell infiltrates have been found on the periodontal tissues, buccal mucosa, palate, lips, tongue, and other orofacial surfaces. This lesion probably represents the oral counterpart of the cutaneous angioplasmocellular hyperplasia. The generalized presentation has been reported by Ketkar and Kaarthikeyan. However, no cutaneous involvement was noted in this patient. Alike this case, gingival PCG can occur at any age, with a slight female predilection. Maxillary and mandibular gingiva are equally involved. In 1968, Bhaskar et al. reported the first case of a gingival PCG. Multiple gingival lesions have also been reported, as by Lu et al. In this patient, the age suggested it to be a reactive lesion (possibly traumatic brushing), similar to the lesion reported by Bhagawati et al. Contrastingly, Kim et al. reported cyclosporine-induced gingival PCG. No such medication history was positive in this patient.
Clinically, a PCG can mimic an aggressive lesion. Radiographically, few reported lesions have shown alveolar bone destruction with infiltrative margins resembling a malignant tumor. No bony alterations were observed in this case. Histological evaluation revealed vascular stroma and abundant inflammatory cells with prominent plasma cell infiltration, characterized by eccentrically placed “cartwheel nucleus,” usually surrounded by connective tissue septae. No cytologic abnormalities are present. The present case showed a predominance of plasma cell infiltrates in the connective tissue stroma. Because the tissue excised was a part of boggy gingiva, the impression of histologically indistinguishable plasma cell gingivitis, is possible.
Gingival PCG can resemble pyogenic granuloma, peripheral giant cell granuloma, epulis, and fibroma; however, instead of a plasma cell infiltration, these entities have a rich or vascular stroma. Histologically, PCG mimics plasmacytoma (soft tissue neoplasm of plasma cells). [Table 2] highlights the differentiating features of plasma cell dominant pathologies. In this case, plasmacytoma was therefore ruled out. Advanced immunohistochemistry determines the lesion clonality; the kappa to lambda light chain ratio was 2:1 in a reactive lesion, whereas it may be greater than 10:1 or 1:10 in malignancy. Our patient was unwilling and unmotivated for further investigations (urine analysis and immunohistochemistry) which was a limitation. Similar exophytic growths were reported by Namboodiripad et al. Kanteti et al. Acevedo and Buhler, Bhaskar et al. Peacock et al., and Rathnakara et al. Most of them were diagnosed as pyogenic granuloma similar to this case. In contrast, besides histopathological examination, their patients underwent immunohistochemistry, which confirmed the diagnosis of PCG.
Surgical excision is best indicated. Treatment options for non-resectable or neoplastic PCG lesions include cryotherapy, radiotherapy, and/or steroid therapy. Plasma cell gingivitis management includes oral prophylaxis, topical steroids for symptomatic lesions, followed by gingivectomy or laser therapy. The prognosis of PCG is good as no evidence of recurrence is reported. The strength in our case was a successful curative excision, followed by an uneventful healing period with no sign of recurrence.
| Conclusion|| |
Awareness of distinctive morphologic features of an extramedullary PCG is important to prevent misdiagnosis. Intraoral PCG is a rare entity mimicking other oral chronic inflammatory gingival lesions such as epulis, pyogenic granuloma, peripheral fibroma, peripheral giant cell granuloma, and plasmacytoma (neoplastic variant). Such lesions share similar gross features and bleed on provocation. This adds to the diagnostic dilemma; however, despite the similarities, their prevalence differs with age, site, duration, and histological features. Successful treatment involves the complete removal of the lesion and the irritants with proper follow-up. This case report fortifies the existence of a gingival PCG, emphasizing the importance of proper diagnostic evaluation of such lesions.
Declaration of patient consent
The patient's consent was obtained for clinical images and information to be reported in the journal.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]