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Special Feature |

Pathological Case of the Month FREE

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Section Editor: Enid Gilbert-barness, MD

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Arch Pediatr Adolesc Med. 2001;155(9):1065-1066. doi:10.1001/archpedi.155.9.1065.
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DIAGNOSIS AND DISCUSSION: PYOGENIC GRANULOMA OF THE TONGUE

Figure 1. A 2 × 1-cm mass on the midline of the tongue.

Figure 2. Endothelial proliferation with formation of vascular spaces. Note the lymphocytic infiltration of the lesion (hematoxylin-eosin, original magnification ×40).

First described in humans by Poncet and Dor,1 pyogenic granuloma is relatively common and accounts for 1.85% to 7% of all biopsy findings from oral cavity lesions.2,3 Females are slightly more affected than males,26 and the age at presentation ranges from 18 months to 93 years. Our patient, at age 6 weeks, is the youngest reported case to our knowledge.

The pathogenesis of this benign lesion is not well understood. Trauma is felt to be the most common initiating event but is not always present in the history.4 The occasional presence of microorganisms has led to speculation of an infectious cause. This has not been proven. There is a higher incidence of pyogenic granuloma in women during pregnancy, and this is felt to be caused by the raised levels of progesterone and estrogen; the tumor usually regresses postparturition.7,8 The underlying problem seems to be an exaggerated tissue response and vascular proliferation secondary to local irritation.

The most common symptom of oral cavity pyogenic granuloma is the presence of a mass. The tumor may grow rapidly in size and then remain stable for indefinite periods of time.4,6 The most common sites within the oral cavity according to several large series2,4,6 are gingiva (61%), lip (14%), tongue (9%), and buccal mucosa (7%). Pain, aside from the local mass effect, may or may not be present. The tumors are often vascular and can bleed either spontaneously or in response to trauma. Adjacent bone resorption may occur.69

On gross examination, the tumor appears as an elevated, often lobulated and ulcerated mass that could be either sessile (as in our case; Figure 1) or pedunculated.4 Some4,6 feel that younger tumors are soft in consistency, progressing to a rubbery texture on maturation. The color may range from pink to bright red to purple or brown.

An extreme endothelial proliferation with formation of vascular spaces is histopathologically visible (Figure 2); renaming this lesion to lobular capillary hemangioma has been proposed.10 The tumor is covered by a thin epithelium that is usually ulcerated.2,4 There is often a lymphocytic infiltration; bacteria may be present, especially if ulcerated.

The only curative treatment is conservative local excision. Recurrence rates after excision range from 0% to 16%.2,3,5 Because the pyogenic granuloma of pregnancy often regresses postparturition, they need not be excised unless symptomatic.7,8,11 After complete excision, our patient has been symptom- and disease-free for a follow-up period of 1 year.

Accepted for publication August 15, 2000.

Reprints: Gary D. Josephson, MD, Division of Pediatric Otolaryngology–Head and Neck Surgery, Nemours Children's Clinic, 807 Nira St, Jacksonville, FL 32225 (e-mail: gjosephs@nemours.org).

Poncet  ADor  L Botryomycose humaine. Rev Chir Orthop. 1897;18996
Bhaskar  SNJacoway  JR Pyogenic granuloma-clinical features, incidence, histology and result of treatment: report of 242 cases. J Oral Surg. 1966;24391- 398
Lawoyin  JOArotiba  JTDosumu  OO Oral pyogenic granuloma: a review of 38 cases from Ibadan, Nigeria. Br J Oral Maxillofac Surg. 1997;35185- 189
Link to Article
Kerr  DA Granuloma pyogenicum. Oral Surg. 1951;4158- 176
Link to Article
Leyden  JJMaster  GH Oral cavity pyogenic granuloma. Arch Dermatol. 1973;108226- 228
Link to Article
Angelopoulos  AP Pyogenic granuloma of the oral cavity: statistical analysis of its clinical features. J Oral Surg. 1971;29840- 847
Sills  ESZegarelli  DJHoschander  MMStrider  WE Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med. 1996;41467- 470
Manus  DASherbert  DJackson  IT Management considerations for the granuloma of pregnancy. Plast Reconstr Surg. 1995;951045- 1050
Link to Article
Goodman-Topper  EDBimstein  E Pyogenic granuloma as a cause of bone loss in a twelve-year-old child: report of case. J Dent Child. 1994;6165- 67
Mills  SECooper  PHFechner  RE Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma. Am J Surg Pathol. 1980;4471- 479
Link to Article
Goette  DKCarpenter  WM Pyogenic granuloma of the oral cavity. South Med J. 1977;701358- 1360
Link to Article

Tables

References

Poncet  ADor  L Botryomycose humaine. Rev Chir Orthop. 1897;18996
Bhaskar  SNJacoway  JR Pyogenic granuloma-clinical features, incidence, histology and result of treatment: report of 242 cases. J Oral Surg. 1966;24391- 398
Lawoyin  JOArotiba  JTDosumu  OO Oral pyogenic granuloma: a review of 38 cases from Ibadan, Nigeria. Br J Oral Maxillofac Surg. 1997;35185- 189
Link to Article
Kerr  DA Granuloma pyogenicum. Oral Surg. 1951;4158- 176
Link to Article
Leyden  JJMaster  GH Oral cavity pyogenic granuloma. Arch Dermatol. 1973;108226- 228
Link to Article
Angelopoulos  AP Pyogenic granuloma of the oral cavity: statistical analysis of its clinical features. J Oral Surg. 1971;29840- 847
Sills  ESZegarelli  DJHoschander  MMStrider  WE Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med. 1996;41467- 470
Manus  DASherbert  DJackson  IT Management considerations for the granuloma of pregnancy. Plast Reconstr Surg. 1995;951045- 1050
Link to Article
Goodman-Topper  EDBimstein  E Pyogenic granuloma as a cause of bone loss in a twelve-year-old child: report of case. J Dent Child. 1994;6165- 67
Mills  SECooper  PHFechner  RE Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma. Am J Surg Pathol. 1980;4471- 479
Link to Article
Goette  DKCarpenter  WM Pyogenic granuloma of the oral cavity. South Med J. 1977;701358- 1360
Link to Article

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