Pyogenic Granuloma or Haemangioma- A Diagnostic Dilemma in a 13-year-old Female
Correspondence Address :
Dr. Shweta Singh,
Associate Professor, Department of Oral and Maxillofacial Pathology, Saraswati Dental College and Hospital, Faizabad Road, Lucknow-226028, Uttar Pradesh, India.
E-mail: dr.shwettaa@gmail.com
Pyogenic granulomas and haemangiomas are well-known benign lesions of the oral cavity. Although pyogenic granulomas are known to have a gingival preference, while capillary haemangiomas are more commonly found on the lips, cheeks, tongue, and palate. There are several lesions in the oral cavity that resemble haemangiomas microscopically. Pyogenic granuloma is one of these lesions, characterised by the proliferation of endothelial cells, and is often indistinguishable from true haemangiomas microscopically. The clinical diagnosis of such a rare phenomenon can be quite difficult, as they can sometimes resemble more serious lesions, such as malignancies. Hereby, the authors present a case report of capillary haemangioma in the maxillary left posterior region of the jaw in a 13-year-old female, which was clinically diagnosed as pyogenic granuloma. The patient presented with a painless swelling, and no significant findings were observed on radiographic examination. The present case report aimed to resolve the dilemma in the diagnosis of vascular tumours and malformations, and to assess their histological, biological behaviour, and clinical presentation.
Benign tumour, Oral haemangioma, Vascular lesions
A 13-year-old female patient complained primarily of a painless swelling in the left posterior maxillary region for five years. The swelling started at the size of a peanut and slowly grew to a large size, which was associated with bleeding while brushing and eating.
On clinical examination, the growth was pedunculated, showing a lobular pattern intraorally, completely occupying the left palatal region. The lesion measured about 4.5×3 cm in diameter, extending anteroposteriorly from 24-27 and mesiodistally from the free gingival margin to the midline of the palate, extending 1 cm towards the right side of the palate. The surface of the growth was smooth with small red to pink dots known as petechiae. On palpation, the swelling was non tender and soft to firm. Bleeding on palpation was present, and the swelling was non pulsatile in nature. Grade-I mobility was also observed on 24,25,26,27. Radiographic findings were insignificant (Table/Fig 1)a,b.
Based on clinical observations, a provisional diagnosis of pyogenic granuloma was given. Complete excision of the lesion was performed under local anaesthesia with compression/pressure pack to reduce bleeding. The specimen was preserved and sent in 10% neutral buffered formalin for histopathological examination.
On histopathological examination, the Haematoxylin and Eosin (H&E) stained section revealed the presence of superficially ulcerated stratified squamous epithelium underlying a fibrovascular and inflamed connective tissue stroma. A large number of young proliferating congested blood capillaries of different shapes and sizes, lined by a single layer of flattened endothelial cells, were observed. Central areas also showed the presence of elongated endothelial-lined feeder blood vessels. A mixed inflammatory infiltrate, chiefly composed of lymphocytes and plasma cells, was also observed (Table/Fig 2)a-d. Based on histopathological examination, the final diagnosis of “Capillary Haemangioma” was made.
After complete surgical excision, the patient was recalled for routine follow-up examinations to check the status of healing and recurrence. After one month, the lesion had completely healed, and no signs of recurrence had been recorded (Table/Fig 3)a-d.
Haemangiomas are regarded as benign proliferative lesions of vascular tissue that may appear at birth or develop later in life, manifesting within the first month of life (1). Haemangiomas can be defined as a heterogeneous group of clinically benign vascular lesions with similar histological features (2). Haemangiomas are one of the most prevalent benign vasoformative tumours of early childhood and generally appear as a period of rapid proliferation followed by gradual regression, usually within the first month of life (3),(4),(5). There are no malignant changes in cell proliferation (6),(7).
The clinical presentation of capillary haemangiomas can be either sessile or pedunculated. They present as soft, smooth, or irregular swellings that appear bulbous in outline. The colour may vary from reddish to purple, and there may be blanching on applying pressure. Haemangiomas located on the palate can be classified as capillary type (8),(9). Haemangiomas are rare in the oral cavity; the gingiva, lips, buccal mucosa, and tongue are the most common intraoral sites, while the maxilla, mandible, and nasal bone are rarely affected (3),(10).
Haemangiomas and pyogenic granulomas of the hard palate may mimic each other clinically as well as histopathologically, making them a diagnostic enigma (3). The present case is of high significance, 2as there are currently very few literature available diagnosing capillary haemangioma due to its association with the hard palate, which is very rare in young women.
Haemangiomas can mimic other types of lesions, such as vascular malformations and pyogenic granulomas, clinically, radiographically, and histologically (Table/Fig 4) (9),(11),(12),(13),(14). Vascular malformations are present at birth and continue to grow with the child, whereas haemangiomas are lesions that develop later in life and are usually not present at birth. The hallmark of vascular malformations is proportional growth throughout an individual’s life (1). Histopathologically, haemangiomas consist of many small capillaries lined by a layer of endothelial cells. The connective tissue stroma of variable densities can be observed (15). Sometimes, haemangiomas may show similarities to young granulation tissue, and notable endothelial cell proliferation may appear indistinguishable from a few cases of pyogenic granuloma (16).
Vascular malformations are localised or diffuse errors of embryonic development. Vascular anomalies are currently classified based on a system developed in 1982 by Mulliken and Glowacki, which takes into account the histology, biological behaviour, and clinical presentation of these entities (9). On the other hand, pyogenic granuloma is a proliferative vascular lesion frequently confused with haemangioma, as observed in the present case. In the oral cavity, pyogenic granulomas are typically found on the gingiva, with interdental papillae being the most common site in 70% of cases. Based on histological findings, Pyogenic Granuloma can be categorised into two types: Lobular Capillary Haemangioma (LCH) type and non LCH type. LCH is characterised by the proliferation of blood vessels organised into lobular aggregates, even when the appearance of the lesion shows no specific changes or oedema, capillary dilation, or inflammatory reaction of granulation tissue (15).
Such unusual manifestations can be quite confusing and can lead to inaccurate diagnoses of other lesions, such as peripheral giant cell granuloma, Epulis granuloma, squamous cell carcinoma, Kaposi’s sarcoma, etc., (11),(16).
In the present case, a provisional diagnosis of pyogenic granuloma was made based on the clinical presentation. The diagnosis of capillary haemangioma was confirmed based on histopathological examination. It is advisable to perform a biopsy of all clinically diagnosed cases of pyogenic granulomas and capillary haemangiomas to rule out more serious conditions like carcinoma and sarcomas (11). Radiographs should be taken to rule out any bony destruction suggestive of malignancy, central haemangiomas, or to identify foreign bodies (16).
Oral haemangiomas are rare benign tumours typically diagnosed in children, and the majority of these lesions will involute over time. Intraoral capillary haemangioma is an uncommon pathological entity that must be included in the differential diagnosis of benign oral tumours. This entity may be confused with pyogenic granuloma and requires careful evaluation to make a final diagnosis. Simple surgical excision of capillary haemangioma may result in bleeding during and after surgery and should, therefore, be performed with caution. Regular follow-up appointments should be maintained for monitoring.
DOI: 10.7860/JCDR/2024/66353.18904
Date of Submission: Jul 03, 2023
Date of Peer Review: Aug 25, 2023
Date of Acceptance: Oct 11, 2023
Date of Publishing: Jan 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 08, 2023
• Manual Googling: Sep 15, 2023
• iThenticate Software: Oct 07, 2023 (3%)
ETYMOLOGY: Author Origin
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