A Letter

Lobular Capillary Haemangioma: A Case Report  

Abhishek Singh Nayyar1 , Lakshmana N.2 , Debasis Sahu3 , Karteek E.4
1 Department of Oral Medicine and Radiology, Saraswati Dhanwantari Dental College and Hospital and Post-Graduate Research Institute, Parbhani, Maharashtra, India
2 Department of Oral Medicine and Radiology, Sri Sai Dental College and Hospital, Srikakulam, Andhra Pradesh, India
3 Department of Oral and Maxillofacial Surgery, Sri Sai Dental College and Hospital, Srikakulam, Andhra Pradesh, India
4 Department of Pedodontics, Sri Sai Dental College and Hospital, Srikakulam, Andhra Pradesh, India
Author    Correspondence author
International Journal of Clinical Case Reports, 2016, Vol. 6, No. 27   doi: 10.5376/ijccr.2016.06.0027
Received: 09 Aug., 2016    Accepted: 11 Oct., 2016    Published: 13 Oct., 2016
© 2016 BioPublisher Publishing Platform
This is an open access article published under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Preferred citation for this article:

Nayyar A.S., Lakshmana N., Debasis S., and Karteek E., 2016, Lobular Capillary Haemangioma: A Case Report, International Journal of Clinical Case Reports, 6(27):1-3 (doi: 10.5376/ijccr.2016.06.0027)

Abstract

Pyogenic granuloma is vascular growth occurring on skin and mucous membrane. The term pyogenic granuloma is actually said to be a misnomer as it is neither associated with pus nor it represents granuloma histologically. Oral pyogenic granuloma commonly occurs on gingiva but can, also, be seen in relation to lips, palate, tongue and buccal mucosa. This case report presents a case of lobular capillary haemangioma variant of pyogenic granuloma occurring interdentally in relation to palatal aspect of maxillary right second premolar and first molar.

Keywords
Lobular capillary haemangioma; Pyogenic granuloma

Introduction

Pyogenic granuloma is a vascular growth occurring on skin and mucous membrane. The term pyogenic granuloma is a misnomer as it is neither associated with pus nor it represents granuloma histologically (Shafer WG, Hine MK, and Levy BM, 1983). Oral pyogenic granuloma commonly occurs on gingiva but can also occur on lips, palate, tongue and buccal mucosa. Extra-orally, fingers and toes are commonly affected areas (Marks K, 2003). Clinically, pyogenic granuloma occurs as a painless, soft mass, smooth or, lobulated, sessile or, pedunculated with the color varying from pink to reddish purple and with a tendency to bleed spontaneously or, after minute provocations in the form of physical trauma. Pyogenic granuloma was first described by Poncet and Dor in 1897 (Graham RM, 1996; Bjork K, et al., 1996). The term pyogenic granuloma or, granuloma pyogenicum was coined by Hertzell (Hertzell MB, 1904). Other names for pyogenic granuloma include pregnancy tumor, Crocker and Hertzell’s disease, granuloma gravidrum, vascular epulis and epulisgranulomatosa. Epulisgranulomatosa is a specific variant of pyogenic granuloma consisting of hyperplastic growth of granulation tissue arising in the healing extraction sockets as a response to bony sequestra in the socket (Neville BW, Damm DD, Allen CM, and Bouquot JE, 2002). Based on histological features, two variants of pyogenic granuloma are known: lobular capillary hemangioma (LCH) and non- lobular capillary hemangioma (non-LCH) variants (Epivatianos A, et al., 2005). In this case report, we are reporting a case of lobular capillary hemangioma variant of pyogenic granuloma that is relatively rare in its occurrence.

 

Case Report

A 30 year old female patient (Figure 1) reported with a chief complaint of swelling on gum in upper right back jaw region. It was small in size when the patient first noticed it but went on increasing to the present size over a span of one month. Intra-oral clinical examination revealed a 1.5X0.9X0.6cms, ovoid, reddish brown, pedunculated, homogenous growth on the palatal aspect of maxillary right second premolar and first molar interdentally (Figure 2). It was non-tender on palpation and bleeding was minimal. The margins were smooth and firm in consistency. Intra-oral hard tissue examination revealed significant amount of calculus and plaque which might be the etiologic factor in this case reported. Also, the patient gave history of using toothpick to remove food particles stuck in that particular region which may have caused injury to the tissues in this region responsible for the growth. Based on the said history and clinical features, a provisional diagnosis of pyogenic granuloma was arrived-at while peripheral giant cell granuloma was considered to be the first differential. Excisional biopsy was carried-out followed by flap surgery and extraction of 17 was done which was grade III mobile. Suturing was done using 3-0 black silk suture (Figure 3). The excised specimen was sent for histopathological analysis. Histopathologically, H and E stained section revealed a hyperparakeratotic, stratified squamous epithelium which was discontinuous, proliferative, with multiple connective tissue entrapments, and with basal cell hyperplasia in some areas. Underlying connective tissue stroma was fibro-cellular in nature with moderate chronic inflammatory cell infiltration, chiefly, composed of lymphocytes. Several endothelial-lined blood vessels, some of them, were dilated and with extravasated RBCs, were seen. Numerous areas showed endothelial cell proliferation (Figure 4). All these features were consistent with the diagnosis of lobular capillary hemangioma variant of pyogenic granuloma that is relatively rare in its occurrence.

 

 

Figure 1 Profile photograph of the patient

 

 

Figure 2 An ovoid, reddish brown growth on the palatal aspect of maxillary right second premolar and first molar interdentally

 

Discussion

Pyogenic granuloma can occur at any age although it is more commonly seen during the 2nd and 3rd decades of life with no specific racial predilection. It, however, is said to have a definite female predilection with a female to male ratio for occurrence of 2:1. It was originally thought to be caused by pyogenic microorganisms including Bartonella quintana, Bartonella henselaea and Human Herpes Virus type 8 which were, also, said to have a role in the frequent recurrence of the lesion seen, however, there is no confirming evidence regarding the same (Janier M, 1999). A pre-existing vascular lesion, chronic irritation to the soft tissues by proximal overhangs of the restorations, fractured restorations and grossly damaged tooth structures, food impaction, chronic periodontitis, hormonal changes during pregnancy, drugs-like cyclosporine, indinavir sulphate, isotretinoin, oral contraceptive pills are all considered to be the important pre-disposing, if not, etiologic factors for the lesion. Iatrogenic factors like Guided Tissue Regeneration (GTR) using Decalcified Freeze-Dried, Bone Allografts (DFDBAs) with expanded poly-tetra-fluoro-ethylene membranes, have, also, been seen to lead to the occurrence of pyogenic granulomas (Fowler EB, et al., 1996). Factors-like inducible nitric oxide synthase, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (b-FGF), connective tissue growth factors, involved in angiogenesis, are considered responsible for the rapid growth of pyogenic granulomas seen in few cases (Hamid Jafarzadeh, et al., 2006). Pyogenic granulomas are, also, reported to occur after bone marrow transplants (Kanda Y, 2000). The important differential diagnoses of pyogenic granulomas include peripheral giant cell granulomas, peripheral ossifying fibromas, peripheral odontogenic tumors, and Kaposi’s sarcoma, and non-Hodgkin’s lymphomas, to add in the end (Wood NK, and Goaz PW, 1997). Treatment of pyogenic granulomas involves surgical excision along with the removal of the underlying etiologic factors, if recognizable, with maintenance of a good oral hygiene and avoidance of trauma to the soft tissues in that area, as it is considered to be, principally, a reactive tumor in nature (Shafer WG, Hine MK, and Levy BM, 1983). New modalities like cryosurgery, excision by Nd: Yag laser, injection of absolute alcohol, ethanol or, corticosteroids, sodium tetradecyl sulphate sclerotherapy, can, also, be used. Topical application of timolol gel has, also, been found to be effective in few cases without side effect as reported in few studies (Hamid Jafarzadeh, et al., 2006). With surgical excision of pyogenic granulomas, a recurrence rate, as high as 15%, has been reported. This high recurrence rate observed might be, attributed to incomplete excision or, failure to remove the underlying etiologic factors of the lesion or, re-injury to the area. Sometimes, recurrence manifests as Warner-Wilson Jones syndrome, where multiple satellite nodules, surrounding the original lesion, are seen (Reichart PA, and Philipsen HP, 2000). Also, the recurrence rate of gingival lesions reported is higher than the lesions from other oral mucosal sites (Sapp JP, Eversole LR, and Wyoscki GP, 1997).

 

 

Figure 3  Suturing done with 3-0 black silk suture post-excision and flap surgery with extraction of 17

 

 

Figure 4 H and E stained section revealing a hyperparakeratotic, stratified squamous epithelium with multiple connective tissue entrapments and with basal cell hyperplasia

 

Conclusion

Pyogenic granuloma is a common lesion occurring in oral cavity which frequently occurs on the buccal aspect of attached gingival tissues. In this case, we came across a highly vascular variant of pyogenic granuloma, named on histopathological background, as lobular capillary hemangioma that is relatively rare in occurrence. Also, the lesion was seen as a growth in relation to the palatal aspect of the gingiva. The treatment included surgical excision of the lesion with flap surgery after a thorough debridement in the affected region. No recurrence was reported when the patient was followed-up after 1-year of excision, despite being suspected with recurrence, being a purely vascular lesion.

 

References

Shafer WG, Hine MK, Levy BM. A Textbook of Oral Pathology. 4th ed., WB Saunders, Philadelphia: 1983; pg.no.s.359-360.

 

Marks K. Roxburgh's Common Skin Diseases. 17th ed., Arnold, London: 2003; pg.no.197.

 

Graham RM. Pyogenic granuloma: An unusual presentation. Dental Update 1996;26:2401.

 

Bjork K, Hoede N, Korting GW, Burgdorf WHC, Young SK. Diseases of the Oral Mucosa and the lips. WB Saunders, Philadelphia: 1996; pg.no.s.229-230.

 

Hertzell MB. Granuloma pyogenicum. J Cutan Dis Syph 1904;22:520-525.

 

Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Surgery.2nd ed., Philadelphia, Saunders: 2002; pg.no.s.447-449.

 

Epivatianos A, Antoniades D, Zaraboukas T, Zairi E, Poulopoulos A, Kiziridou A, et al.. Pyogenic granuloma of the oral cavity: Comparative study of its clinico-pathological and immune-histochemical features. Pathol Int 2005;55:391-397. 

http://dx.doi.org/10.1111/j.1440-1827.2005.01843.xPMid:15982213

 

Janier M. Infection and angiomatous cutaneous lesions. J Mal Vasc 1999;24:135-138. PMid:10399647

 

Fowler EB, Cuenin MF, Thompson SH, Kudryk VL, Billman MA.Pyogenic granuloma associated with guided tissue regeneration: A case report. J Periodontol 1996;67:1011-1015.

http://dx.doi.org/10.1902/jop.1996.67.10.1011PMid:8910841

 

Hamid Jafarzadeh, Majid Sanatkhani, NooshinMohtasham. Oral pyogenic granuloma: A review. Journal of Oral Science 2006;48:167-175.

http://dx.doi.org/10.2334/josnusd.48.167PMid:17220613

 

Kanda Y, Arai C, Chizuka A, Suguro M, Hamaki T, Yamamoto R, et al.. Pyogenic granuloma of the tongue early after allogeneic bone marrow transplantation for multiple myeloma. Leuk Lymphoma 2000;37:445-449. 

 

Wood NK, Goaz PW. Differential Diagnosis of Oral and Maxillofacial Lesions. 5th ed., Mosby, Missouri: 1997; pg.no.s.549-550.

 

Reichart PA, Philipsen HP. Color Atlas of Dental Medicine Oral Pathology. Stuttgart, Thieme: 2000; pg.no.s.167-175.

 

Sapp JP, Eversole LR, Wyoscki GP. Contemporary Oral and Maxillofacial Pathology. 2nd ed., Mosby, Missouri: 1997; pg.no.s.318-322.

 

International Journal of Clinical Case Reports
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