|LETTER TO EDITOR
|Year : 2011 | Volume
| Issue : 1 | Page : 104
Chronic ulcer: Common problem uncommon diagnosis
Monika Gupta1, Rajeev Sen2, Virendra Singh2
1 Department of Haematology, AIIMS, New Delhi, India
2 Department of Pathology and Oral and Maxillofacial Surgery, PGIMS, Rohtak, India
|Date of Web Publication||10-Oct-2011|
Department of Haematology, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gupta M, Sen R, Singh V. Chronic ulcer: Common problem uncommon diagnosis. Natl J Maxillofac Surg 2011;2:104
Chronic indurated ulcer of oral cavity is always a diagnostic dilemma for the clinician as well as for the pathologist due to varying etiology. Sometimes, common presentation of pain, swelling and reddening of gingiva is difficult to diagnose and treat. Ulcer can be because of canker sores, herpes virus, oral cancer, oral lichen planus and oral thrush. However, sometimes oral ulcer, when nonhealing and investigated meticulously, can be the presentation of a rare systemic disease.
A female patient with longstanding oral ulcer, pain, gingival swelling was such a challenge. Additional findings were a bluish patch over extensor surface of left little finger, a hard tender swelling over left submandibular region. Gingiva was fragile, inflamed with granular and necrotic degenerative changes over maxillary anterior vestibule with mobility of associated teeth.
Investigations revealed microcytic hypochromic RBCs with normal cell count, raised erythrocyte sedimentation rate, uric acid, blood urea and decreased albumin:globulin ratio. On ultrasonography, left side submandibular lymph nodes were enlarged with necrotic changes in submandibular gland. Histopathologic examination from gingiva revealed suppurative inflammation of mucosal and submucosal tissue with few foci revealing fibrinous deposit embedding histiocytes, occasional foreign body giant cells and few clusters of epithelioid cells. Occasional clusters of small blood vessels also showed necrotic inflammation. There was no evidence of fungus or malignancy. Biopsy from the lesion over little finger showed marked acute and chronic inflammatory infiltrate in subepithelial tissue with evidence of neovascularization and vessels showing fibrinoid vasculitis.
Based on histopathologic report, vasculitic syndromes affecting medium- and small-sized vessels were considered. Further evaluation revealed cavitatory lesions in lungs, raised c-ANCA and normal p-ANCA, which led to an impression of Wegener granulomatosis (WG).
WG is a chronic, relapsing necrotizing vasculitis of small- to medium-sized vessels and capillaries, with a variable course. The oral lesions of WG occur as focal or generalized enlargement of gingiva associated with loss of alveolar bone with tooth mobility. Atypical oral ulceration, facial pain and enlargement of salivary glands may also be present. Diagnosis is made from high degree of suspicion with combination of clinical, biochemical, radiological and microscopic findings.
So, timely recognition of vascular involvement by histopathologic examination can help in work up, early diagnosis and treatment of the not so common diseases.