?
The Answer :
C . Traumatic ulcerative granuloma with stromal eosinophilia
DISCUSSION
Option A . Squamous cell carcinoma ( SCC ) is a reasonable differential diagnosis for a non-healing ulcer of the lateral border of the tongue , which is one of the commonest site for squamous cell carcinoma in the oral cavity . SCC is estimated to constitute approximately 94 percent of all oral malignancies . 6 Clinically , SCC of the tongue typically presents as a painless , indurated ulcer with rolled borders , which has been present for several months . With time , SCCs might achieve sizes considerably larger than TUGSEs . Most of the patients who develop a SCC are usually over the age of 50 years and common risk factors are tobacco and alcohol use . Due to the clinical presentation and persistent nature of the lesion , an incisional biopsy for histopathologic examination is usually warranted in order to achieve a correct diagnosis and for appropriate treatment .
Option B . Major aphthous ulcers are large aphthae which measure greater than 1 cm in diameter , whereas ulcers associated with the far more common minor variant measure less than 1 cm . The number of ulcers varies from 1 to 10 and , although multiple lesions are more common , some afflicted individuals could present with a solitary lesion . 5 Major aphthae take from 2 to 6 weeks to heal and may be perceived as persistent or non-healing by a clinician . Scarring at the site of healed ulcers is not uncommon . While the lesions have a predilection for non-keratinized tissue , they can affect any oral mucosal surface . Clinically , major aphthous ulcers are associated with considerable pain . Generally , aphthae respond well to treatment with corticosteroids . 5 Histopathologic examination of the lesion shows features of a non-specific ulcer which lacks eosinophils in the ulcer bed and deep stroma .
Option C . Traumatic ulcerative granuloma with stromal eosinophilia ( TUGSE ) is a chronic benign ulcerative lesion of the oral mucosa . TUGSE was first identified by Richard Elzay in 1983 , when he described 41 cases . 1 Various synonyms have been used for TUGSE , such as traumatic ulcer , oral traumatic granuloma , eosinophilic ulcer , eosinophilic granuloma of the soft tissue , or ulcerative eosinophilic granuloma . 2-4 The tongue is the typical site for TUGSE , but various oral mucosal surfaces can be involved , such as labial , buccal , vestibular , and alveolar mucosae . 5 Trauma is the implicated etiology for this lesion because of the incidence at sites that are subjected to chronic insult . Clinically , TUGSE presents as a painless , persistent ulcer with indurated borders , commonly found on the lateral border of the tongue , making it difficult to clinically differentiate this lesion from a squamous cell carcinoma . Given that the lateral border of the tongue is a high risk site for oral cancer , it is important that persistent ulcers in this location be adequately evaluated and biopsied when necessary . Histologically , TUGSE differs from other ulcers due to the presence of eosinophils within the underlying stroma . TUGSE is treated by conservative excision or with an incisional biopsy , since incising the lesion can induce healing . 5 Since this lesion can mimic a malignancy , it is important to biopsy a non-healing ulcer when no source of chronic irritation can be identified , particularly for persistent ulcers found at high risk sites . Due to the benign nature of this lesion , it is also important to achieve a correct diagnosis to avoid overtreatment .
Option D . Histoplasmosis is a respiratory fungal infection caused by Histoplasma capsulatum , an organism found in soil contaminated with bird droppings . 7 , 8 Infection occurs mainly through inhalation of airborne organisms . In the oral cavity , histoplasmosis usually presents as a chronic ulcer in patients with disseminated disease . It occurs predominantly in immunocomprised patients . 9 , 10 The most commonly affected intraoral sites for histoplasmosis are the tongue , buccal mucosa , and palate . Clinically , patients typically present with other systemic symptoms of disseminated disease , such as weight loss , dysphagia , chronic cough , and fever . 11 Patients tend to do well with the use of a systemic antifungal like amphotericin B . 11 Histopathologic examination of the lesion shows numerous histiocytes with formation of granulomas . The organisms can usually be identified within giant cells or with the aid of special stains .
CONCLUSION
In conclusion , TUGSEs are benign , reactive lesions which present as persistent oral ulcers , with a predilection for the lateral border of the tongue . Sources of chronic trauma or irritation , such as a nearby sharp broken tooth cusp should be identified if present to avoid overtreatment of this benign condition . However , TUGSE can clinically mimic a malignancy ( squamous cell carcinoma ) and other worrisome conditions ( disseminated deep fungal infections or tuberculosis ). Therefore , if no readily apparent source of irritation can be identified , the lesion should be biopsied to avoid underdiagnosis of a potentially life-threatening condition .
REFERENCES
1 . Elzay RP . Traumatic ulcerative granuloma with stromal eosinophilia ( Riga-Fede ’ s disease and traumatic eosinophilic granuloma ). Oral Surg Oral Med Oral Pathol 1983 ; 55 ( 5 ): 497-506 .
2 . Regezi JA , Zarbo RJ , Daniels TE , Greenspan JS . Oral traumatic granuloma . Characterization of the cellular infiltrate . Oral Surg Oral Med Oral Pathol 1993 ; 75 ( 6 ): 723-7 .
3 . Movassaghi K , Goodman ML , Keith D . Ulcerative eosinophilic granuloma : a report of five new cases . Br J Oral Maxillofac Surg 1996 ; 34 ( 1 ): 115-7 .
4 . el-Mofty SK , Swanson PE , Wick MR , Miller AS . Eosinophilic ulcer of the oral mucosa . Report of 38 new cases with immunohistochemical observations . Oral Surg Oral Med Oral Pathol 1993 ; 75 ( 6 ): 716-22 .
5 . Neville BW . Oral and maxillofacial pathology . 3rd ed . St . Louis , Mo .: Saunders / Elsevier ; 2009 . 6 . Barnes L . Surgical pathology of the head and neck . New York : Informa healthcare ; 2009 .
7 . Lamps LW , Molina CP , West AB , Haggitt RC , Scott MA . The pathologic spectrum of gastrointestinal and hepatic histoplasmosis . Am J Clin Pathol 2000 ; 113 ( 1 ): 64-72 .
8 . Valle AC , Moreira LC , Almeida-Paes R , et al . Chronic disseminated histoplasmosis with lesions restricted to the mouth : case report . Rev Inst Med Trop Sao Paulo 2006 ; 48 ( 2 ): 113-6 .
9 . Wheat LJ . Diagnosis and management of histoplasmosis . Eur J Clin Microbiol Infect Dis 1989 ; 8 ( 5 ): 480-90 .
10 . Goodwin RA , Jr ., Shapiro JL , Thurman GH , Thurman SS , Des Prez RM . Disseminated histoplasmosis : clinical and pathologic correlations . Medicine ( Baltimore ) 1980 ; 59 ( 1 ): 1-33 .
11 . Antonello VS , Zaltron VF , Vial M , Oliveira FM , Severo LC . Oropharyngeal histoplasmosis : report of eleven cases and review of the literature . Rev Soc Bras Med Trop 2011 ; 44 ( 1 ): 26-9 .
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