Traumatic Ulcerative Granuloma with Stromal Eosinophilia

So-called eosinophilic ulcers are chronic but self-limiting lesions of a traumatic or reactive nature in which there is an intense inflammatory infiltration with a prominent eosinophilic component [45]. Despite their designation, about a third of these lesions do not undergo ulceration. Eosinophilic ulcers are seen most commonly in children and young adults and are frequently painless. In infants, particularly, the condition has been called Riga-Fede disease [46]. Although these ulcers can be seen anywhere in the oral mucosa, including the gingiva, they are most common on the tongue and buccal mucosa. About a third of patients have a history of trauma, particularly a crush injury of the lingual muscle due to biting [43]. The lesions are usually single and can be several centimetres in diameter. If left, most heal spontaneously within 2 months, and this may be accelerated by in-cisional biopsy. Although recurrence tends to be uncommon, in one report 6 out of 15 cases were recurrent or multiple [43]. On the basis of the clinical and immunocytochemical features it has been suggested that eosinophilic ulcers might be the oral equivalent of primary cutaneous CD30-positive lymphoprolifer-ative disorders [54].

Microscopically, these lesions can be mistaken for malignancy. There is non-specific ulceration with underlying inflamed granulation tissue (Fig. 3.6). There is an associated dense inflammatory infiltrate that extends deeply into the underlying muscle. The infiltrate consists of lymphocytes and plasma cells, macrophages, polymorphonuclear leukocytes and mast cells. Eosino-phils are particularly numerous and they may form mi-croabscesses. Macrophages are frequently conspicuous and can form sheets of cells with poorly demarcated cytoplasm, but large, vesicular nuclei with prominent nu-cleoli and a high mitotic frequency. These macrophages, together with damaged muscle cells showing sarcolem-mal nuclear degeneration and regeneration, can give the erroneous impression of a lymphoma. In addition, the prominent eosinophilic component can lead to a mistaken diagnosis of Langerhans cell histiocytosis. This erroneous diagnosis is particularly likely in lesions involving the gingiva, where there may be associated resorption of the underlying bone. Appropriate immuno-cytochemical characterisation should avoid this confusion.

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