Pyogenic Granuloma Presenting As a Congenital Epulis

ARTICLE Pyogenic Granuloma Presenting as a Congenital Epulis

Lindia J. Willies-Jacobo, MD; Hart Isaacs, Jr, MD; Martin T. Stein, MD

Objective: To describe a clinical approach to the dif- was determined to be a pyogenic granuloma. Careful ferential diagnosis of oral lesions in neonates. attention to alternative diagnoses led to the correct eti- ology. Design: Case report. Conclusions: Primary care pediatricians encounter neo- Setting: Academic ambulatory care center. natal oral lesions infrequently. The most common oral lesions in the newborn period are Epstein pearls and Bohn Participants: Male infant. nodules. This case illustrates the importance of formu- lating a more extensive differential diagnosis on discov- Results: A gingival mass in a male infant appeared ery of a neonatal oral mass. clinically consistent with a congenital epulis. Follow- ing excision and histologic examination, the diagnosis Arch Pediatr Adolesc Med. 2000;154:603-605

HE ORAL examination is an born visit on the third day of life, the le- essential part of the rou- sion had evolved into a 2ϫ2-cm yellow tine physical examination mass. The mass changed over the course of the newborn. When a of 1 week, leaving a residual, flat, yellow mass is found in the oral lesion. Over the next week, the lesion grew, Tcavity, it is important to formulate a dif- becoming fluctuant, fleshy, and pedun- ferential diagnosis since this will help guide culated (Figure 1). The diagnosis at this further evaluation of the condition and time was a mucocele, and he was referred management of the patient. Most of the in- to a pediatric dentist for further evalua- formation regarding oral lesions in the tion. At this visit he was thought to have newborn is found in the dental, surgical, a Bohn nodule (a firm, yellow white mu- and pathology literature, but very little ex- cous gland cyst) vs an Epstein pearl (a ists in the pediatric literature. This case re- keratin-filled cystic lesion lined with strati- port describes a male infant with a gingi- fied squamous epithelium). val mass presenting clinically as a At age 5 weeks, the infant was evalu- congenital epulis of the newborn; how- ated by a maxillofacial surgeon. A diag- ever, histologically it proved to be a pyo- nosis of congenital epulis of the newborn genic granuloma. was made and a period of observation was recommended. The infant continued PATIENT REPORT to breastfeed well with normal growth parameters, and he had no respiratory A 2.7-kg 364-g male infant was born af- difficulty. At 71⁄2 months of age, because ter uncomplicated normal spontaneous of interference with teething, the mass From the Division of Primary vaginal delivery to a 34-year-old gravida was excised under general anesthesia. Care Pediatrics, Department of 2 para 2 Vietnamese woman. On physical The specimen consisted of a 1ϫ0.8ϫ0.5- Pediatrics (Drs Willies-Jacobo examination performed shortly after de- cm, irregularly shaped, lobulated mass and Stein), University of livery, he was found to have a 1- to 2-mm with a smooth and glistening surface. California San Diego Medical Center, and Department of whitish cystic lesion over the right ante- Microscopic examination revealed polyp- Pathology (Dr Issacs), rior maxillary alveolar ridge. The preg- oid nodules covered by acanthotic, non- University of California San nancy had been uncomplicated. The in- keratinized stratified squamous epithe- Diego School of Medicine and fant’s Apgar scores were 9 and 9 at 1 and lium and edematous fibrous connective Children’s Hospital, San Diego. 5 minutes, respectively. At his routine new- tissue containing prominent blood ves-

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, JUNE 2000 WWW.ARCHPEDIATRICS.COM 603

©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Figure 1. A lesion found in the patient at routine newborn visit grew and 1 Figure 2. Microscopic examination of excised mass when patient was age week later became fluctuant, fleshy, and pedunculated as seen here and was 71⁄2 months. Epithelial collarette formation was present. The lesion was diagnosed as a mucocele. histologically most consistent with a pyogenic granuloma (hematoxylin-eosin, original magnificationϫ100).

Masses of the Oral Cavity

Mass Location Description Management Epstein pearl Gingiva or palate Whitish keratin-filled cystic lesion lined Spontaneous resolution with stratified epithelium Bohn nodule Roof of mouth near midline Small white yellow nodules Ͻ3mmin Spontaneous resolution diameter arising as retention cysts in mucous glands Viral enanthem Soft palate, gingiva, oropharynx Vesicular lesions Spontaneous resolution Congenital epulis (granular cell Maxillary and/or mandibular alveolar Firm, pedunculated mass with a Conservative: removal if interferes tumor) ridge smooth or lobulated surface, several with feeding, teething, or millimeters to 9 cm in diameter respiration Reparative giant cell granuloma Gingiva, adjacent bone Firm, well-circumscribed red brown Surgical excision nodule with a pedunculated base (0.5-1.5 cm); multinucleated giant cells, fibroblasts Natal teeth Mandibular incisor area Often in pairs Conservative: extract if poor crown formation or mobile Pyogenic granuloma* Gingiva Red, polypoid nodule with epithelial Surgical excision collarette, proliferating capillaries and fibroblasts; prone to bleed with manipulation Hemangioma Gingiva; may have associated Red nodule; lobules of proliferating Spontaneous resolution; excise if cutaneous hemangioma(s) capillaries; no collarette complications Teratoma Palate Tissues derived from all 3 germ layers; Surgical excision tumor may or may not contain body parts Gingival cyst Maxillary or mandibular alveolar Grayish white cystic enlargement of the Spontaneous resolution ridge enamel organ presenting as a nodule Ranula (mucocele) Minor salivary glands Sublingual retention cyst lined by Surgical excision if spontaneous mucous-secreting cells resolution does not occur Melanotic neuroectodermal tumor Maxillary alveolar ridge Smooth surfaced, bluish black nodule; Complete surgical excision of infancy small neuroblastic cells and larger pigmented melanocytic cells

*The currently preferred histologic term is lobular capillary hemangioma.

sels. Epithelial collarette formation was present ticularly the gingiva, and umbilicus are common sites.1-3 (Figure 2). Although this lesion clinically appeared to It is usually painless, develops rapidly, and may range be an epulis, it was histologically most consistent with a in size from a few millimeters to a few centimeters. The pyogenic granuloma. current thinking is that this lesion represents a benign neoplasm, a form of capillary hemangioma, rather than 2 COMMENT a reactive infectious or traumatic process. Pyogenic granu- loma has a diagnostic, lobular arrangement of capillar- Pyogenic granuloma, or the currently preferred histo- ies at its base. The lobules are composed of discrete clus- logic term lobular capillary hemangioma, occurs during ters of endothelial cells, and the lumina vary from infancy, typically as a single polypoid nodule that bleeds indistinct to prominent. The surface of the lesion may easily on palpation. The face, lip, and oral cavity, par- undergo secondary, nonspecific changes that include stro-

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, JUNE 2000 WWW.ARCHPEDIATRICS.COM 604

©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 mal edema, capillary dilation, inflammation, and a granu- Most oral masses encountered in the neonatal pe- lation tissue reaction.2 The presence of an epithelial col- riod, including teratomas, are benign except for the mela- larette, which was present in our patient (Figure 2), notic neuroectodermal tumor, which occasionally rep- distinguishes the pyogenic granuloma from a capillary resents a malignant process.4,5 Although hemangiomas, hemangioma.2,3 Management consists of complete sur- including pyogenic granuloma, are the principal benign gical excision.1,4 If not completely excised, the lesion even- conditions of the oral mucosa in children, the most com- tually scleroses. mon oral lesions in the newborn period are Epstein pearls Hemangiomas are the most common soft tissue and Bohn nodules. This case illustrates the importance masses found in the newborn, occurring in approxi- of a complete oral examination at the initial newborn visit mately 2% of neonates and 10% of infants. In a retro- as well as at subsequent office visits. spective review by Sato et al,5 hemangiomas were found to be the most common pediatric benign tumors of the Accepted for publication November 16, 1999. oral mucosa. They may appear singly or as multiple Corresponding author: Lindia J. Willies-Jacobo, MD, lesions, as in infantile hemangiomatosis. Some may Division of Primary Care Pediatrics, Department of Pedi- regress spontaneously; however, others may require atrics, University of California San Diego Medical Center, removal by cryosurgery, sclerosing agents, or laser. 200 W Arbor Dr, No. 8464, San Diego, CA 92103-8464. Other oral cavity conditions to consider in the dif- ferential diagnosis are Epsteins pearls, Bohn nodules, vi- REFERENCES ral enanthems, granular cell tumors, natal teeth, hem- angiomas, reparative giant cell granulomas, teratomas, 1. Mueller BU, Mulliken JB. The infant with a vascular tumor. Semin Perinatol. 1999; gingival cysts, ranulas, and melanotic neuroectodermal 23:332-340. tumor of infancy (Table). Trying to make a definitive 2. Mills SE, Cooper PH, Fechner RE: Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma: a study of 73 cases from the oral and nasal mu- diagnosis can present a challenge to the primary care pe- cous membranes. Am J Surg Pathol. 1980;4:470-479. diatrician as it did in this case. Although the mass ap- 3. Isaacs H Jr.Tumors of the Fetus and Newborn. Vol 35. Philadelphia, Pa: WB Saun- ders Co; 1997. peared clinically to be a congenital epulis (granular cell 4. Dilley DC, Siegel MA, Budnick S. Diagnosing and treating common oral patholo- tumor), the absence of the characteristic large cells with gies. Pediatr Clin North Am.1991;38:1227-1264. granular cytoplasms6 essentially ruled out this entity. The 5. Sato M, Tanaka N, Sato T, Amagasa T. Oral and maxillofacial tumours in chil- dren: a review. Br J Oral Maxillofac Surg. 1997;35:92-95. histologic findings are most consistent with an old pyo- 6. Kershisnik M, Batsakis JG, MacKay B. Pathology consultation: granular cell tu- genic granuloma. mors. Ann Otol Rhinol Laryngol. 1994;103:416-419.

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, JUNE 2000 WWW.ARCHPEDIATRICS.COM 605

©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021