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Eosinophilic Ulcer Clinical Presentation

  • Author: Faizan Alawi, DDS; Chief Editor: William D James, MD  more...
 
Updated: Sep 22, 2014
 

History

The most common complaint is that of an asymptomatic or mildly tender, solitary, nonhealing ulcer of variable duration. The lesion may be present for as short as 1 week or 12 months or longer. Patients with early ulcers often report pain and severe discomfort. Patients may have a history of trauma to the affected area. Depending on the location of the ulcer, other signs and symptoms may include dysphagia, odynophagia, dysphonia, and dyspnea. Occasionally, patients may present with a history of recent weight loss.

Infants with Riga-Fede disease often experience discomfort while breastfeeding, and they may fail to thrive in the postnatal period.

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Physical

Clinical appearance

Eosinophilic ulcer typically presents as an irregular, solitary ulcer with a fibrinous membrane on the surface. A zone of erythema surrounds the ulcer. The margins of the lesion are often raised and usually indurated. Purulence may be noted emanating from the ulcer.

Eosinophilic ulcers may be a few millimeters to as large as 7-8 cm in greatest dimension.

In rare reports, multiple synchronous or metachronous lesions have been identified.

Occasional ulcers may be macular, whereas others may present as nonspecific erythroplakic or leukoplakic lesions.

In rare cases, an eosinophilic ulcer may present as an elevated, smooth mass that is free of ulceration; however, biopsy reveals the underlying, characteristic, invasive cellular proliferation. In some of these cases, the overlying epithelium may have regenerated without resolution of the underlying inflammation.

Mucosal sites

Any mucosal surface can be affected; however, the tongue is the most common location, accounting for 60% of reported cases.[6] The lateral and dorsal surfaces are usually affected because these are the areas most often traumatized.

Lesions on the ventral surface of the tongue more commonly are observed in infants because of contact with the adjacent mandibular incisors during breastfeeding.

The dorsal surface of the tongue may also be affected in infants because of irritation associated with maxillary incisors. The buccal mucosa and mucobuccal fold are also particularly susceptible to ulceration; lesions in these locations account for 24% of reported cases.

Eosinophilic ulcers have also been reported (in decreasing order of frequency) on the lips, gingiva, palate, floor of the mouth, and retromolar area.

In extremely rare cases, cervical lymphadenopathy is reported.

See the images below.

A 47-year-old African American woman with an eosin A 47-year-old African American woman with an eosinophilic ulcer on the lateral surface of the tongue. The anterior border of the lesion is raised. Courtesy of Dr Paul D. Freedman.
Raised, indurated, nonhealing ulcer on the lateral Raised, indurated, nonhealing ulcer on the lateral surface of the tongue. The lesion was related to an adjacent fractured tooth. Courtesy of Dr Paul D. Freedman.
Ulcer on the ventrolateral surface of the tongue. Ulcer on the ventrolateral surface of the tongue. The differential diagnosis should include squamous cell carcinoma or an infectious etiology. Courtesy of Dr Paul D. Freedman.
Lesion on the lateral surface of the tongue. Court Lesion on the lateral surface of the tongue. Courtesy of Dr Paul D. Freedman.
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Causes

Common causes of oral trauma include the following:

  • Self-inflicted injury in which the patient accidentally or deliberately traumatizes the mucosa
  • Injury due to sharp-edged teeth or food
  • Injury due to neonatal or natal teeth (Riga-Fede disease)
  • Toothbrush abrasion
  • Injury due to ill-fitting dentures
  • Injury due to orthodontic or occlusal appliances
  • Iatrogenic injuries (eg, those that occur during dental procedures, such as anesthetic necrosis that occurs during intubation for surgery)
  • Injuries due to accidents

Certain patients may be inherently predisposed to the development of eosinophilic ulcers, although this factor remains controversial.

The role of drug reactions, if any, is unclear.

Medical conditions or therapeutic regimens that predispose an individual to immune suppression may also delay healing.

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Contributor Information and Disclosures
Author

Faizan Alawi, DDS Associate Professor, Department of Pathology, Penn Dental Medicine, University of Pennsylvania School of Dental Medicine; Associate Professor, Department of Dermatology, Section of Dermatopathology, Hospital of the University of Pennsylvania

Faizan Alawi, DDS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, International Association for Dental Research

Disclosure: Nothing to disclose.

Coauthor(s)

Paul D Freedman, DDS Director of Oral Pathology, New York Hospital Medical Center of Queens; Chief, Division of Oral Pathology and Oral Medicine, New York Presbyterian Hospital; Associate Professor of Surgery, Weill Cornell Medical College

Paul D Freedman, DDS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, American Dental Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Donald Belsito, MD Professor of Clinical Dermatology, Department of Dermatology, Columbia University Medical Center

Donald Belsito, MD is a member of the following medical societies: New York County Medical Society, Noah Worcester Dermatological Society, Phi Beta Kappa, American Contact Dermatitis Society, Dermatology Foundation, Dermatologic Society of Greater New York, Alpha Omega Alpha, American Academy of Dermatology

Disclosure: Nothing to disclose.

References
  1. Segura S, Pujol RM. Eosinophilic ulcer of the oral mucosa: a distinct entity or a non-specific reactive pattern?. Oral Dis. 2008 May. 14(4):287-95. [Medline].

  2. Elzay RP. Traumatic ulcerative granuloma with stromal eosinophilia (Riga-Fede's disease and traumatic eosinophilic granuloma). Oral Surg Oral Med Oral Pathol. 1983 May. 55(5):497-506. [Medline].

  3. Bhaskar SN, Lilly GE. Traumatic granuloma of the tongue (human and experimental). Oral Surg Oral Med Oral Pathol. 1964 Aug. 18:206-18. [Medline].

  4. Elovic AE, Gallagher GT, Kabani S, Galli SJ, Weller PF, Wong DT. Lack of TGF-alpha and TGF-beta 1 synthesis by human eosinophils in chronic oral ulcers. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996 Jun. 81(6):672-81. [Medline].

  5. Gerbig AW, Zala L, Hunziker T. Tumorlike eosinophilic granuloma of the skin. Am J Dermatopathol. 2000 Feb. 22(1):75-8. [Medline].

  6. Chawla O, Burke GA, MacBean AD. The eosinophilic ulcer revisited. Dent Update. 2007 Jan-Feb. 34(1):56-7. [Medline].

  7. Rosenberg A, Biesma DH, Sie-Go DM, Slootweg PJ. Primary extranodal CD3O-positive T-cell non-Hodgkins lymphoma of the oral mucosa. Report of two cases. Int J Oral Maxillofac Surg. 1996 Feb. 25(1):57-9. [Medline].

  8. Eleni G, Panagiotis S, Andreas K, Georgia A. Traumatic ulcerative granuloma with stromal eosinophilia: a lesion with alarming histopathologic presentation and benign clinical course. Am J Dermatopathol. 2011 Apr. 33(2):192-4. [Medline].

  9. Abdel-Naser MB, Tsatsou F, Hippe S, Knolle J, Anagnostopoulos I, Stein H, et al. Oral eosinophilic ulcer, an Epstein-Barr virus-associated CD30+ lymphoproliferation?. Dermatology. 2011. 222(2):113-8. [Medline].

  10. Misterska M, Dmochowski M, Szulczynska-Gabor J, Walkowiak H, Bowszyc-Dmochowska M, Kaczmarek J, et al. Eosinophilic ulcer of the oral mucosa: report of a child with CD30-negative cells in an infiltration on the lower lip. Med Sci Monit. 2010 Aug. 16(8):CS95-9. [Medline].

  11. Pilolli GP, Lucchese A, Scivetti M, Maiorano E, Favia G. Traumatic ulcerative granuloma with stromal eosinophilia of the oral mucosa: histological and immunohistochemical analysis of three cases. Minerva Stomatol. 2007 Jan-Feb. 56(1-2):73-9. [Medline].

  12. Neville BW, Damm DD, Allen CM. Oral and Maxillofacial Pathology. 1st ed. Philadelphia, Pa: WB Saunders; 1995. 213-22.

 
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A 47-year-old African American woman with an eosinophilic ulcer on the lateral surface of the tongue. The anterior border of the lesion is raised. Courtesy of Dr Paul D. Freedman.
Raised, indurated, nonhealing ulcer on the lateral surface of the tongue. The lesion was related to an adjacent fractured tooth. Courtesy of Dr Paul D. Freedman.
Ulcer on the ventrolateral surface of the tongue. The differential diagnosis should include squamous cell carcinoma or an infectious etiology. Courtesy of Dr Paul D. Freedman.
Lesion on the lateral surface of the tongue. Courtesy of Dr Paul D. Freedman.
Low-power view showing an ulcerated surface epithelium with a dense cellular inflammatory infiltrate underlying the mucosal surface (original magnification X40). Courtesy of Dr Paul D. Freedman.
Cellular infiltrate composed mainly of large mononuclear cells, including histiocytes and submucosal dendrocytes, eosinophils, and scattered T lymphocytes (original magnification X400). Courtesy of Dr Paul D. Freedman.
Inflammatory infiltrate extending through and between muscle bundles (original magnification X400). Courtesy of Dr Paul D. Freedman.
 
 
 
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