Pyogenic Granuloma in 45-year-old with type 2 diabetes
A 45-year-old female patient with type 2 diabetes presented to the plastic surgery clinic after experiencing a painless upper-lip lesion for 6 weeks. The lesion had grown dramatically in size over the past three weeks and bled when lightly touched. The patient was not expecting a child. The lesion was discovered to be an erythematous, spherical, smooth, pedunculated mass on physical examination (Panel A). It was friable but not soft to the touch. An excisional biopsy specimen was histopathologically examined and revealed proliferating vasculature, fibroblasts, many inflammatory cells, and surface ulceration, all of which were consistent with pyogenic granuloma (Panel B).
Pyogenic granulomas, also known as lobular capillary hemangiomas, are benign, fast growing vascular tumours that can appear on the lips, gingiva, and fingers. Contrary to what the name implies, these lesions are not linked with pus or granulomatous tissue. Bleeding is a common symptom and is frequently the presenting symptom. Typically, lesions are removed to treat bleeding, ulceration, or cosmetic appearance. The lesion had not recurred during a 4-month follow-up appointment.
Pyogenic granuloma, also known as granuloma pyogenicum, is a benign vascular tumour that develops in tissues such as the skin and mucous membranes. It is more precisely known as a lobular capillary hemangioma. The lesion appears as a single, crimson, pedunculated papule that is extremely friable. It can also manifest as a sessile plaque, which is less common. Similarly, has rapid exophytic development and a frequently ulcerated surface. It is frequently found on cutaneous or mucosal surfaces. Typically seen in the oral cavity among the latter. Moreover, the tumour may develop at different locations in the gastrointestinal tract on rare occasions. This activity introduces the interprofessional team to this entity and assists them in recognising, evaluating, and managing it.
Pyogenic granuloma – a benign vascular tumour
Pyogenic granuloma (PG), also known as granuloma pyogenicum, is a benign vascular tumour that develops in tissues such as the skin and mucous membranes. The medical word for this condition is lobular capillary hemangioma. Previously, pyogenic granulomas were assumed to be an excessive granulomatous reaction to an infectious or pyogenic stimulus, giving rise to terminology like ‘pyogenic granuloma’ and ‘granuloma pyogenicum.’ However, the term pyogenic granuloma is a misnomer that may cause some misunderstanding at first.
The lesion appears as a pedunculated papule that is extremely friable, solitary and red. It can also manifest as a sessile plaque, which is less common. It has rapid exophytic development and a frequently ulcerated surface. It is frequently found on cutaneous or mucosal surfaces. It is most typically seen in the oral cavity among the latter. It may develop at different locations in the gastrointestinal tract on rare occasions.
When the lesion is present in the intraoral mucosa during pregnancy, particularly on the gingiva, it is known as granuloma gravidarum, granuloma of pregnancy, or epulis gravidarum, and it usually occurs in the second or third trimester. There is one case report in the literature of a patient developing many disseminated lesions while on oral contraceptive pill therapy, and one report of lesions developing following a renal transplant.
Aetiology
Several factors contribute in the etiopathogenesis of pyogenic granuloma, but the precise cause is unknown. Studies on distinct angiogenic factors and signal transduction pathways have failed to indicate a single mechanism in the lesion’s aetiology. The proposed processes emphasise the relevance of shocks that cause an imbalance of pro-angiogenic and anti-angiogenic factors, resulting in a fast expansion of neovascular, friable, and lobulated capillaries. Although reactive granulation tissue from minor trauma may be a factor, studies show that only up to 7% of these lesions are directly related to a history of trauma. Infections and preexisting vascular abnormalities are two more possible risk factors.
Hormonal variables appear to have a role in this lesion’s pregnancy-associated phenotype. Women have a later peak incidence, often during reproductive years. Critics of this notion point to a lack of vaginal mucosal lesions, as well as a minor preference for cutaneous lesions in men. It is hypothesised that oestrogens and other sex hormones, particularly during pregnancy, enhance inflammatory reactions in gingival tissue. More research is needed to identify their exact relevance in the aetiology of the tumour.
Certain lobular capillary hemangioma variations have also been linked to pharmaceutical use. Multiple periungual pyogenic granulomas are connected with pharmaceuticals the most frequently (studies show up to 30% of them are associated with medications) and are also associated with other chronic dermatoses such as atopic dermatitis and psoriasis.
Prognosis
These lesions do not have a cancerous potential. However, because they may not retreat on their own and may bleed, ulcerate, or be cosmetically disfiguring, they may require treatment. Oral pyogenic granulomas in pregnant women normally resolve after giving birth.
Partial resection via shave excision or curettage may result in future recurrence; thus, total primary excision is advised. Complete surgical excision is required for recurrence.
Source: NEJM
