JICDRO is a UGC approved journal (Journal no. 63927)

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CASE REPORT
Year : 2014  |  Volume : 6  |  Issue : 1  |  Page : 55-58

Oral plasma cell granuloma: A case report of an ambiguous lesion


1 Department of Oral and Maxillofacial Pathology and Microbiology, Luxmi Bai Institute of Dental Sciences and Hospital, Patiala, Punjab, India
2 Department of Oral and Maxillofacial Surgery, Guru Nanak Dev Dental College and Research Institute, Sunam, Punjab, India
3 Department of Periodontology, Luxmi Bai Institute of Dental Sciences and Hospital, Patiala, Punjab, India

Date of Web Publication18-Aug-2014

Correspondence Address:
Manveen Kaur Jawanda
H. No. 9, Doctor's Colony, Bhadson Road, Patiala - 147 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-0754.139108

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   Abstract 

Plasma cell granuloma (PCG) is a rare reactive tumor such as proliferation composed chiefly of plasmacytic infiltrate. Both clinically and histopathologically, it may be misinterpreted as various pathological entities thus necessitating the complete evaluation of patient and proper histopathological and immunohistochemical analysis of the tissue to rule out other lesions with poor prognosis. Here, we present a case of PCG of gingiva in a female patient masquerading as pyogenic granuloma clinically and plasma cell neoplasms histopathologically.

Keywords: Plasma cell gingivitis, plasma cell granuloma, plasma cell neoplasms, solitary plasmacytoma


How to cite this article:
Jawanda MK, Narula R, Nirola A, Gupta S, Gupta P. Oral plasma cell granuloma: A case report of an ambiguous lesion. J Int Clin Dent Res Organ 2014;6:55-8

How to cite this URL:
Jawanda MK, Narula R, Nirola A, Gupta S, Gupta P. Oral plasma cell granuloma: A case report of an ambiguous lesion. J Int Clin Dent Res Organ [serial online] 2014 [cited 2020 Jul 8];6:55-8. Available from: http://www.jicdro.org/text.asp?2014/6/1/55/139108


   Introduction Top


Plasma cell granuloma (PCG) is a rare, nonneoplastic lesion consisting of a proliferation of inflammatory cells predominantly plasma cells in a fibrovascular background. [1] It was first described in 1973 by Bahadori and Liebow. [2] PCG primarily occurs in lungs, but nearly all other organs may be involved, including the head and neck region. Rarely seen in the oral cavity, the lesions are usually single, seen primarily on gingiva, followed by tongue, lips, buccal mucosa, and palate. [3] PCG of gingiva can be easily mistaken clinically as peripheral giant cell granuloma, pyogenic granuloma or fibrous gingival epulis, thus necessitating the histopathological examination to confirm the diagnosis. However, microscopically, it may masquerade as various plasma cell neoplasms. [3],[4] Thus, for accurate diagnosis, it is essential to correlate the clinical, radiological, histopathological, and immunohistochemical findings. The present case report describes a rarely reported case of PCG on the gingiva mimicking clinically as pyogenic granuloma and plasma cell neoplasms microscopically.


   Case report Top


A 50-year-old female presented with a painless mass in the right maxillary anterior gingival area since 2 years. Patient had undergone extraction of right maxillary canine 2.5 years back because of grade III mobility, without any complications. On intraoral examination, a well-defined solitary growth of size 1.5 cm × 1 cm was observed in the right maxillary canine region. The growth was oval in shape with reddish smooth surface and bleed on touching. Complete hemogram showed all blood counts to be within normal limits. Based on the clinical findings, differential diagnosis of pyogenic granuloma, peripheral giant cell granuloma, fibrous epulis, and fibroma were considered. An excisional biopsy [Figure 1] was performed under local anesthesia and a bony crater like defect was seen on the labial alveolar bone after soft tissue removal. Histopathological examination of resected specimen revealed the lesional soft tissue covered by hyperplastic parakeratinized stratified squamous epithelium which appeared thinned out and ulcerated at few places. The fibrocellular connective tissue showed mixed inflammatory cell infiltrate composed of abundant plasma cells with typical eccentrically placed hyperchromatic, cartwheel nucleus, arranged in sheets and islands along with few lymphocytes [Figure 2]. Numerous blood vessels are also observed. No cytologic abnormalities and mitotic figures are observed. The lesion was diagnosed as PCG and the patient was advised kappa and lambda light chain immunohistochemical analysis to rule out the possibility of extramedullary plasmacytoma. Immunohistochemical analysis revealed the strong expression for kappa light chain [Figure 3] whereas weak expression for lambda light chain [Figure 4] and thus demonstrating the polytypic and benign nature of the condition. Thus, on the basis of clinical, histopathological, and immunohistochemical analysis, the diagnosis of PCG was confirmed.
Figure 1: Gross photograph showing a nodular mass

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Figure 2: (a) Low power photomicrograph of the biopsy specimen which reveals normal epithelium and foci of plasma cells separated by connective tissue septa (H and E, ×10). (b) High power photomicrograph of the biopsy specimen which reveals morphologically normal plasma cells without atypia (H and E, ×40)

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Figure 3: (a) Immunohistochemical photomicrograph showing Kappa light chain immunoreactivity present in the cytoplasm of the plasma cells (×10). (b) High power photomicrograph of the same (×40)

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Figure 4: (a) Immunohistochemical photomicrograph showing Lambda light chain immunoreactivity present in the cytoplasm of the plasma cells (×10). (b) High power photomicrograph of the same (×40)

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   Discussion Top


Plasma cell granuloma is rare, reactive lesions, usually pulmonary in locations, which are found even more infrequently intraoral. WHO describes PCG as an intermediate (rarely metastasizing) fibroblastic/myofibroblastic tumors composed of myofibroblastic spindle cells accompanied by an inflammatory infiltrate of plasma cells, lymphocytes, and eosinophils. [5]

The origin of development of PCG is unclear, although some speculate either an altered antigen antibody reaction [6] or an alteration of blood flow imposing congestive vasodilation (angioplasmacellular hyperplasia). [7] In situ hybridization studies have revealed the presence of the Epstein-Barr virus in a large number of these lesions suggesting a possible important role of virus in the etiopathogenesis of these tumors. [8] PCG is thought to result from inflammation following minor trauma or surgery [9],[10] and our patient gave a history of extraction of right maxillary canine 2.5 years back. Hence, in our patient PCG may be due to postinflammatory reactive process.

Clinically, gingival PCG presents as a mass, which is nodular, polypoidal lesions with a smooth surface and is well circumscribed. It does not produce significant systemic symptoms. [11] In the present case, growth was oval in shape with reddish smooth surface and bleed on touching. Had it not been for a detailed histopathological and immunohistochemical examination conducted in our case, it could have been mistaken for pyogenic granuloma, peripheral giant cell granuloma or a fibrous gingival epulis.

Plasma cell granuloma is microscopically characterized by a vascular stroma with reactive inflammatory cells, including plasma cells predominantly and usually surrounded by connective tissue septa. No cytologic abnormalities are usually present. Russell bodies, which are intra-cytoplasmic eosinophilic hyaline droplets, may also be seen. [12] In our case, microscopic examination of superficial sections revealed mixed chronic inflammatory infiltrate with predominant plasma cells in connective tissue stroma underlying the epithelium but deeper sections of the tissue showed the presence of dense subepithelial cellular infiltrate composed of plasma cells arranged in sheets and islands along with few lymphocytes separated by thick fibrous connective tissue septa.

Plasma cell granuloma is a diagnosis of exclusion, distinguished primarily on the histological finding of a marked submucosal plasma cell infiltrate. [13] Histopathologically, it is important to differentiate various plasma cell lesions such as PCG, plasma cell gingivitis, and extramedullary plasmacytoma (a possible precursors of multiple myeloma) [14] [Table 1]. Therefore, it is important to do excisional biopsy to distinguish PCG from other pathological entities that are cause for great concern because of their potential morbidity or mortality and thus, histopathological analysis remains the gold standard for achieving the diagnosis of PCG. [15]
Table 1: Differential diagnosis of PCG

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Extramedullary plasmacytoma presents as a soft tissue plasma cell mass outside of bone. Differentiation between reactive PCG and extramedullary plasmacytoma is based on whether lesion is polyclonal or monoclonal. Immunohistochemistry determines the clonality of the lesion, where, in a reactive lesion, the kappa: Lambda light chain ratio is 2:1. When this ratio is greater than 10:1 or 1:10, reactive disease is usually excluded and is suggestive of a neoplastic lesion. [16] In our case, a slightly strong expression for kappa light chain, whereas weak expression for lambda light chain demonstrates the polytypic and inflammatory nature of the condition.

Some consider PCG to be a subtype of plasma cell gingivitis. [16] Plasma cell gingivitis is a polyclonal lesion of gingival tissue that is usually not a localized nodular lesion, as seen in PCG but presents as generalized edematous and erythematous elevations. [17] In the present case single, localized nodular mass was present. Plasma cell gingivitis is considered as an allergic hypersensitivity reaction to various flavoring agents used in chewing gums and dentifrices. [18] But in our case, there was no identifiable inciting agent.

Plasma cell granuloma is usually treated by simple excision and removal of underlying inciting agent. [1] In our case, complete surgical excision of the lesion was done. The postoperative course was uneventful. One year of follow-up has not shown any evidence of recurrence.

With respect to prognosis, PCG seems to be a generally benign, nonrecurring condition; nevertheless, local aggressiveness, and recurrences may complicate the outcome of the disease. [2]

Thus, this article laid an emphasis on submission of every tissue excised for microscopic examination regardless of their clinical impression so that proper and accurate diagnosis can be made. Furthermore, it will help in documentation of rare lesions and in understanding the etiology and nature of the lesion. PCG is a rare pathology, and its etiopathogenesis is still controversial, so documentation of cases of PCG will help in understanding its etiology and nature.


   Conclusion Top


Plasma cell granuloma is a rare benign lesion but its exact etiology, behavior and prognosis is still controversial. Attributing to the fact that it can masquerade as various pathological entity, it is difficult to establish the exact diagnosis alone on the basis of clinical or histopathological examination. Therefore, it is necessary to perform complete lab investigations differentially to diagnose it from other lesions that have a poor prognosis and to avoid unnecessarily extensive and potentially destructive surgery.

 
   References Top

1.Buccoliero AM, Caldarella A, Santucci M, Ammannati F, Mennonna P, Taddei A, et al. Plasma cell granuloma - An enigmatic lesion: Description of an extensive intracranial case and review of the literature. Arch Pathol Lab Med 2003;127:e220-3.  Back to cited text no. 1
    
2.Bahadori M, Liebow AA. Plasma cell granulomas of the lung. Cancer 1973;31:191-208.  Back to cited text no. 2
    
3.Phadnaik MB, Attar N. Gingival plasma cell granuloma. Indian J Dent Res 2010;21:460-2.  Back to cited text no. 3
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4.Jeyaraj P, Naresh N, Malik A, Sahoo NK, Dutta V. A rare case of gingival plasma cell granuloma of the gingiva masquerading as a gingival epulis. Int J Dis Disord 2013;1:016-9.  Back to cited text no. 4
    
5.Fletcher CD, Unni KK, Mertens F, editors. World Health Organization Classification of Tumours. Pathology and Genetics of Tumours of Soft Tissue and Bone. Lyon: IARC Press; 2002.  Back to cited text no. 5
    
6.Dehner LP. The enigmatic inflammatory pseudotumours : t0 he current state of our understanding, or misunderstanding. J Pathol 2000;192:277-9.  Back to cited text no. 6
    
7.Ide F, Shimoyama T, Horie N. Plasma cell granuloma of the oral mucosa with angiokeratomatous features : a0 possible analogue of cutaneous angioplasmocellular hyperplasia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:204-7.  Back to cited text no. 7
    
8.Fukunaga A, Yoshida K, Otani M, Ogawa Y, Horiguchi T, Ishihara M, et al. Plasma cell granuloma extending from the extracranial to the intracranial space associated with Epstein-Barr virus infection. Neurol Med Chir (Tokyo) 1998;38:292-6.  Back to cited text no. 8
    
9.Maves CK, Johnson JF, Bove K, Malott RL. Gastric inflammatory pseudotumor in children. Radiology 1989;173:381-3.  Back to cited text no. 9
    
10.Sanders BM, West KW, Gingalewski C, Engum S, Davis M, Grosfeld JL. Inflammatory pseudotumor of the alimentary tract : c0 linical and surgical experience. J Pediatr Surg 2001;36:169-73.  Back to cited text no. 10
    
11.Fang JC, Dym H. Myofibroblastic tumor of the oral cavity. A rare clinical entity. N Y State Dent J 2004;70:28-30.  Back to cited text no. 11
    
12.Ronald B, Kuppersmith MD. Extramedullary Plasmacytoma of the Head and Neck. Houston, TX : G0 rand Rounds Archive, Baylor College of Medicine; 1996.  Back to cited text no. 12
    
13.Anila Namboodripad PC, Jaganath M, Sunitha B, Sumathi A. Plasma cell granuloma in the oral cavity. Oral Surg 2008;1:206-12.  Back to cited text no. 13
    
14.Pandav AB, Gosavi AV, Lanjewar DN, Jagadale RV. Gingival plasma cell granuloma. Dent Res J (Isfahan) 2012;9:816-20.  Back to cited text no. 14
    
15.Renfrow JJ, Mitchell JW, Goodman M, Mellen LA, Wilson JA, Mott RT, et al. Relapsing intracranial plasma cell granuloma : A0 case report. Oncol Lett 2014;7:531-3.  Back to cited text no. 15
    
16.Peacock ME, Hokett SD, Hellstein JW, Herold RW, Matzenbacher SA, Scales DK, et al. Gingival plasma cell granuloma. J Periodontol 2001;72:1287-90.  Back to cited text no. 16
    
17.Karthikeyan BV, Pradeep AR. Plasma cell granuloma of gingiva. Indian J Dent Res 2004;15:114-6.  Back to cited text no. 17
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18.Silverman S Jr, Lozada F. An epilogue to plasma-cell gingivostomatitis (allergic gingivostamtitis). Oral Surg Oral Med Oral Pathol 1977;43:211-7.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]


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