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September 2001

Pathological Case of the Month

Arch Pediatr Adolesc Med. 2001;155(9):1065-1066. doi:10.1001/archpedi.155.9.1065

Diagnosis and Discussion: Pyogenic Granuloma of the Tongue

Figure 1. A 2 × 1-cm mass on the midline of the tongue.

Figure 2. Endothelial proliferation with formation of vascular spaces. Note the lymphocytic infiltration of the lesion (hematoxylin-eosin, original magnification ×40).

First described in humans by Poncet and Dor,1 pyogenic granuloma is relatively common and accounts for 1.85% to 7% of all biopsy findings from oral cavity lesions.2,3 Females are slightly more affected than males,2-6 and the age at presentation ranges from 18 months to 93 years. Our patient, at age 6 weeks, is the youngest reported case to our knowledge.

The pathogenesis of this benign lesion is not well understood. Trauma is felt to be the most common initiating event but is not always present in the history.4 The occasional presence of microorganisms has led to speculation of an infectious cause. This has not been proven. There is a higher incidence of pyogenic granuloma in women during pregnancy, and this is felt to be caused by the raised levels of progesterone and estrogen; the tumor usually regresses postparturition.7,8 The underlying problem seems to be an exaggerated tissue response and vascular proliferation secondary to local irritation.

The most common symptom of oral cavity pyogenic granuloma is the presence of a mass. The tumor may grow rapidly in size and then remain stable for indefinite periods of time.4,6 The most common sites within the oral cavity according to several large series2,4,6 are gingiva (61%), lip (14%), tongue (9%), and buccal mucosa (7%). Pain, aside from the local mass effect, may or may not be present. The tumors are often vascular and can bleed either spontaneously or in response to trauma. Adjacent bone resorption may occur.6-9

On gross examination, the tumor appears as an elevated, often lobulated and ulcerated mass that could be either sessile (as in our case; Figure 1) or pedunculated.4 Some4,6 feel that younger tumors are soft in consistency, progressing to a rubbery texture on maturation. The color may range from pink to bright red to purple or brown.

An extreme endothelial proliferation with formation of vascular spaces is histopathologically visible (Figure 2); renaming this lesion to lobular capillary hemangioma has been proposed.10 The tumor is covered by a thin epithelium that is usually ulcerated.2,4 There is often a lymphocytic infiltration; bacteria may be present, especially if ulcerated.

The only curative treatment is conservative local excision. Recurrence rates after excision range from 0% to 16%.2,3,5 Because the pyogenic granuloma of pregnancy often regresses postparturition, they need not be excised unless symptomatic.7,8,11 After complete excision, our patient has been symptom- and disease-free for a follow-up period of 1 year.

Accepted for publication August 15, 2000.

Reprints: Gary D. Josephson, MD, Division of Pediatric Otolaryngology–Head and Neck Surgery, Nemours Children's Clinic, 807 Nira St, Jacksonville, FL 32225 (e-mail: gjosephs@nemours.org).

References
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3.
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Kerr  DA Granuloma pyogenicum.  Oral Surg. 1951;4158- 176Google ScholarCrossref
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Leyden  JJMaster  GH Oral cavity pyogenic granuloma.  Arch Dermatol. 1973;108226- 228Google ScholarCrossref
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Manus  DASherbert  DJackson  IT Management considerations for the granuloma of pregnancy.  Plast Reconstr Surg. 1995;951045- 1050Google ScholarCrossref
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Goodman-Topper  EDBimstein  E Pyogenic granuloma as a cause of bone loss in a twelve-year-old child: report of case.  J Dent Child. 1994;6165- 67Google Scholar
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Mills  SECooper  PHFechner  RE Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma.  Am J Surg Pathol. 1980;4471- 479Google ScholarCrossref
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Goette  DKCarpenter  WM Pyogenic granuloma of the oral cavity.  South Med J. 1977;701358- 1360Google ScholarCrossref
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