Indian Journal of Dental ResearchIndian Journal of Dental ResearchIndian Journal of Dental Research
HOME | ABOUT US | EDITORIAL BOARD | AHEAD OF PRINT | CURRENT ISSUE | ARCHIVES | INSTRUCTIONS | SUBSCRIBE | ADVERTISE | CONTACT
Indian Journal of Dental Research   Login   |  Users online:

Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size         

 


 
CASE REPORT Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 1  |  Page : 74-77
Histochemical and polarization microscopic study of two cases of vegetable/pulse granuloma


1 Dept of Oral Pathology, SJM Dental College and Hospital, PB Road, Chitradurga, Karnataka, India
2 KSR Institute of Dental Sciences and Research, KSR Kalvi Nagar, Tiruchengode, Tamil Nadu - 637 209, India
3 Narayana Dental College, Nellore, Andhra Pradesh, India

Click here for correspondence address and email

Date of Submission22-Jan-2007
Date of Decision28-Jul-2007
Date of Acceptance01-Aug-2007
 

   Abstract 

Vegetable granuloma (VG) or pulse granuloma (PG) results from the implantation of food particles of plant or vegetable origin. It is usually seen in the periapical or in the sulcus areas. These lesions have been described as a distinct entity and classified into central and peripheral lesions according to the location. Central lesions are asymptomatic, whereas peripheral lesions present as painless sub-mucosal swellings. Many authors have postulated that food particles in VG or PG get implanted and are rapidly digested, and sometimes partly get altered by host responses. The cellulose part of plant foods being indigestible persists in the form of hyaline material, whereas the starch matter gets digested. This cellulose moiety invokes chronic granulomatous response.

Keywords: Ameloblastoma, foreign body granuloma, giant cells, hyaline ring granuloma, pulse granuloma, vegetable granuloma

How to cite this article:
Manjunatha B S, Kumar G S, Raghunath V. Histochemical and polarization microscopic study of two cases of vegetable/pulse granuloma. Indian J Dent Res 2008;19:74-7

How to cite this URL:
Manjunatha B S, Kumar G S, Raghunath V. Histochemical and polarization microscopic study of two cases of vegetable/pulse granuloma. Indian J Dent Res [serial online] 2008 [cited 2023 May 31];19:74-7. Available from: https://www.ijdr.in/text.asp?2008/19/1/74/38937

   Case Reports Top


Case-1

A 65-year-old man habituated to smoking and tobacco chewing reported to our hospital with a painful swelling on the right cheek region and inability to open the mouth for 3 months. The patient gave no history of any allergic illness or any allergy to medications. He had not undergone any dental treatment in the past.

Intraoral examination revealed an ulcero-proliferative lesion of about 3 × 3 cm with a raised and indurated border in the right retro-molar region extending on to the adjacent gingival and buccal mucosa [Figure - 1]. The submandibular lymph nodes were enlarged. The clinical features were suggestive of squamous cell carcinoma. No radiographic changes were observed in the underlying bone.

An incisional biopsy was taken from the anterior part of the lesion, and the histopathological diagnosis was that of a 'non-specific granuloma with foreign body reaction'. A second incisional biopsy from an adjacent site with more depth was advised to rule out the possibility of squamous cell carcinoma.

Microscopically, the second tissue showed a diffuse granuloma densely infiltrated with both acute and chronic inflammatory cells and eosinophils, along with intersecting areas of fibrosis. A pale, eosinophilic, hyalinised area resembling starch cells associated with a variety of inflammatory cells was observed in one of the sections [Figure - 2]. The granuloma extended into the submucosa, to involve large islands of muscles, causing degeneration of muscle fibers [Figure - 3]. Some muscle cells with prominent central nuclei and scattered multinucleated giant cells of foreign body type were also observed [Figure - 4],[Figure - 5]. An ulcerated oral epithelium was seen overlying the granuloma. A final diagnosis of vegetable granuloma associated with eosinophils was made based on the finding of homogenous, pale, eosinophilic, hyalinised vegetable matter along with infiltration of eosinophils deep into the muscles.

Case-2

A 38-year-old female patient presented with a painful swelling on the right lower side of the face. The swelling was extending from the angle of mandible to the parasymphysis region antero-posteriorly and from ala-tragal line to 2 cm inferior to lower part of the angle of the mandible. On palpation, the swelling was bony hard and tender with radiating pain to the right ear. Past dental history revealed similar lesion, which had occurred in the same area about 11 years back and had been operated without any ensuing complications.

Intraoral examination revealed a large lesion in right posterior mandible with expansion of both buccal and lingual cortices with perforation in 48 regions. Mouth opening was restricted and teeth from 44 to 48 were missing. Radiographically, a multilocular radiolucent lesion extending from the right ramus of the mandible to the left molar area, causing root resorption from 43 to 35 was observed [Figure - 6]. The lesion was provisionally diagnosed as Ameloblastoma, which was later confirmed by the histopathologic features of excised lesion.

Microscopically, the excised mass showed follicles of ameloblastoma, varying in size and shape with many undergoing cystic degeneration and squamous metaplasia. Interestingly, one of the sections showed a homogenous, pale, eosinophilic, ellipsoid area containing individual starch cells, many of which were degenerating, but the discrete double-layered refractile hyaline membranes encasing them were prominent with surrounding granulomatous reaction [Figure - 7]. In another smaller area, a collection of oval or round homogenous brown-colored granules suggestive of vegetable matter appeared with few multinucleated giant cells surrounding it.

Histochemical staining

Various histochemical staining procedures such as PAS [Figure - 8] with and without diastase, van Gieson [Figure - 9], von Kossa, Gram's, Giemsa, AFB, Congo red and Perl's Prussian blue were done for both cases. The staining reactions and results are shown in [Table - 1].

Polarization microscopic findings

When the vegetable matter was examined under polarized light, it appeared as birefringent refractile particles [Figure - 10] and was similar to that in a previous report. [1] The encasing cellulose membranes appeared light and the starch contained in it appeared dark. The surrounding collagen showed very weak birefringence representing immature collagen fibers.

Other routine investigations, such as erythrocyte sedimentation rate (ESR), total RBC count, total and differential WBC count, platelet count, Hb% and specific investigations for bacterial and fungal infections, Wegener's granulomatosis, sarcoidosis, allergic granulomatosis, Crohn's disease, oral tuberculosis and Melkerson-Rosenthal syndrome, were done as in case-1 to rule out both local and systemic oro-facial granulomatosis.


   Discussion Top


Pulse granuloma (PG) is a controversial lesion with regard to its etiopathogenesis and nomenclature. It has been described in the literature under a variety of names, [1] since its inception in 1971. The recent term for this lesion is hyaline ring granuloma, which is reported to occur in inflammatory and developmental odontogenic cysts. [2]

Chou et al. have described these lesions as a distinct entity and classified them into central and peripheral according to the location. The etiopathogenesis for VG has been explained based on two concepts, i.e., exogenous and endogenous concepts. The concept of exogenous origin for these lesions is based on the suggestion of implantation of food particles of plant origin, through extraction sockets, deep periodontal pockets, unfilled root canals and grossly decayed teeth. [1] Animal experiments have lent evidence to this concept. [3] Talacko and Radden [3] have suggested that implanted food particles in VG or PG get rapidly digested and also get altered by host responses. The cellulose part of plant foods being indigestible persists in the form of hyaline material, whereas the starch matter gets digested. This cellulose moiety invokes chronic granulomatous response.

The endogenous origin is attributed to localized degenerative changes in the walls of blood vessels, [4] degraded collagen or fibrosed extravasated serum proteins [1] for these lesions. Some investigators [5] have considered the lesion to be caused by Torulopsis glabrata infection, a yeast-like fungus similar to the candida species, which was ruled out.

The diagnosis of PG is made only in the presence of starch granules, with cellulose envelopes that appear as hyaline rings. Variation in the number of hyaline structures accounts for the discrepancy between reported cases and reviewed cases of PG. [6]

The pale, eosinophilic, hyalinised areas identified in the H and E stained sections stained positive for PAS with and without diastase, thus confirming the cellulose content [Figure - 8]. van Gieson was positive in the peripheral portion of the vegetable matter, and it represented the peripheral condensation of collagen [Figure - 9] in both the cases. Both the hyalinised areas and the homogenous brown-colored granules were negative for von Kossa stain, implying that these were not calcified structures.

Thus, the hyalinised structures in our cases were positive for both PAS and van Gieson, which supports the hypothesis of McMillan et al . [4] Cellulose derived from the implanted plant food material accounts for PAS positivity, and the peripheral collagen condensation exhibits positivity to van Gieson.

In all the cases reported, the first case had a clinical presentation of an ulcero-proliferative growth in the retro-molar area, mimicking a carcinoma. The histopathological features consisted of a granulomatous reaction of foreign body type and showed a variety of inflammatory cells associated with occasional 'hyaline rings'. An interesting feature was the finding of eosinophils admixed with lymphocytes in the ulcerated areas and in the deeper regions between the muscles. Some muscle cells with prominent central nuclei resembling the ganglion cells [Figure - 4] were also observed. This was confirmed by PTAH stain for muscle fibers (results in [Table - 1]).

Wegener's granulomatosis was ruled out based on normal C reactive protein, ESR, and negative antineutrophil cytoplasmic antibody tests. As the lesion was not seen in the midline, midline lethal granuloma too was eliminated from the list. Considering Crohn's disease, many blood investigations such as ESR, total platelet and RBC counts, and hemoglobin levels were performed. The values of all these were within normal limits, and there was no complaint of persistent lip swelling or cobble stone appearance of oral mucosa.

The differential count of all types of WBC was also normal, ruling out the possibility of allergic oral granulomatosis. The patient also gave no history of facial paralysis, edema of his face, and lip swelling. This resulted in excluding Melkerson-Rosenthal syndrome.

Finally, sarcoidosis was thought of, and later calcium level in both serum and urine was investigated. The results were within normal limits.

In this case, since there was no history of trauma or surgery, the implantation of the pulses into the submucosa could have been through the ulcerated epithelium.

Thus, all investigative procedures and histopathologic examination, the site, and the appearance of the lesion pointed to the final diagnosis of VG.

The second case presented as a recurrent multilocular radiolucent lesion in the right posterior mandible, which was diagnosed as ameloblastoma. Histologically, the excised specimen showed many ameloblastoma follicles with few large, pale, eosinophilic, hyalinised area lined by double layered cellulose-like material and a collection of homogenous round to oval, brown granules surrounded by few multinucleated giant cells.

In contrast to the first case, the second case, which had a history of being operated for a similar lesion, was elicited, and perforated cortical plates near the 48 region were observed. These could have helped in the entry of vegetable matter.

Clinically, most of the PGs follow an indolent course, and many have been reported as chronic periostitis. [7] Histopathologically, these constitute a classical foreign body granuloma with or without hyaline structures. [1],[4],[6] The diagnosis remains largely on microscopic features and is rarely diagnosed clinically. [2] Hyaline rings, if present in few numbers, can go undetected if extensive sampling is not done.

PG has been reported in association with many odontogenic cysts [2],[8] and in chronic periostitis. [5]

The presence of inflammatory infiltrate with abundance of eosinophils, extending from the ulcerated areas and involving the muscles as observed in the first case, is consistent with the diagnosis of 'eosinophilic ulcer'. Eosinophilic ulcer is a self-limiting benign, ulcerative condition of oral mucosa without a definitive etiology. It is seen commonly on the tongue, buccal mucosa, and lip and was considered a distinct clinical entity by Shapiro and Juhlin. [9] The clinical suspicion of squamous cell carcinoma was, however, ruled out by microscopic examination of two biopsies and extensive sampling. Various factors such as psychological, physical, and socio-economical impact on patient in case-1 can be prevented or minimized if adequate measures are taken in establishing the diagnosis. In such cases, microscopic examination with adequate tissue sampling and serial sections may be helpful. Therefore, PG may be included in the differential diagnosis of ulcero-proliferative lesions.

In case-2, these PG or foreign body reaction may hinder postoperative healing and prognosis or final outcome.

Thus, our cases showed the presence of PG in association with eosinophils and with ameloblastoma, and this kind of association appears to be unnoticed and unreported previously.


   Acknowledgements Top


The authors wish to thank Dr. Ravikala Rao, Professor of Pathology, SDM College of Medical Sciences and Hospital, Dharwad, India, for her valuable opinion in case-1. Authors also thank the Principal and the Management of SJM Dental College and Hospital, Chitradurga, for all the support given in publishing this article.

 
   References Top

1.Chou L, Ficarra G, Hansen LS. Hyaline ring granuloma: A distinct oral entity. Oral Surg Oral Med Oral Pathol 1990;70:318-24.  Back to cited text no. 1  [PUBMED]  
2.Keskin A, Duran S, Alkan A, Gunhan O. Hyaline ring granuloma in inflammatory odontogenic cysts: Report of two cases. J Oral Maxillofac Surg 2000;58:115-8.  Back to cited text no. 2    
3.Talacko AA, Radden BG. The pathogenesis of oral pulse granuloma: An animal model. J Oral Pathol 1988a;17:99-105.  Back to cited text no. 3  [PUBMED]  
4.McMillan MD, Kardos TB, Edwards JL, Thornburn DN, Adams DB, Palmer DK. Giant cell hyaline angiopathy or pulse granuloma. Oral Surg Oral Med Oral Pathol 1981;52:178-86.  Back to cited text no. 4    
5.Hase MP, Radden BG, Reade PC. Torulopsis glabrata infection in the oral cavity. J Oral Pathol 1976;5:8-16.  Back to cited text no. 5  [PUBMED]  
6.Talacko AA, Radden BG. Oral pulse granuloma: Clinical and histopathological features. Int J Oral Maxillofac Surg 1988b;17:343-4.  Back to cited text no. 6  [PUBMED]  
7.Lewars PH. Chronic periostitis in the mandible underneath artificial dentures. Br J Oral Surg 1971;8:264-9.  Back to cited text no. 7  [PUBMED]  
8.Chen SY, Fantasia JE, Miller AS. Hyaline bodies in the connective tissue wall of odontogenic cysts. J Oral Pathol 1981;10:147-57.  Back to cited text no. 8  [PUBMED]  
9.Matthys BM, Somach SC. A crusted lip nodule in a 50 year old man. Arch Dermatol 2001;137:815-20.  Back to cited text no. 9    

Top
Correspondence Address:
B S Manjunatha
Dept of Oral Pathology, SJM Dental College and Hospital, PB Road, Chitradurga, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.38937

Rights and Permissions


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10]
 
 
    Tables

  [Table - 1]

This article has been cited by
1 Unusual case of hyaline ring granuloma associated with pericoronitis: Case report and review of literature
Anish Gupta, Ami Rawal
IP Indian Journal of Anatomy and Surgery of Head, Neck and Brain. 2022; 8(2): 77
[Pubmed] | [DOI]
2 Comparative evaluation of vegetable matter involved lesions with oral parasitic infections in the oral cavity
Tiago Novaes Pinheiro, Milena Gomes Melo Leite, Cristiane Cantiga da Silva, Cleber Nunes Alexandre, Lioney Nobre Cabral, Hannah Marcelle Paulain Carvalho, Daniel Frota de Souza, Jéssica Lourdes de Aguiar Gonçalves, Thales Edecherly Nasserala de Souza, Nara Deise de Souza Melo, Luciano Tavares Ângelo Cintra, Beatriz Terumi Barreto Kanehira, Gustavo Cavalcanti de Albuquerque
Microscopy Research and Technique. 2021;
[Pubmed] | [DOI]
3 Hyaline ring granuloma of the mouth—A foreign-body reaction that dentists should be aware of
Talita de Carvalho Kimura, Mailon Cury Carneiro, Yuri Fernando Sampaio Coelho, Suzana Cantanhede Orsini Machado Sousa, Vanessa Cristina Veltrini
Oral Diseases. 2021; 27(3): 391
[Pubmed] | [DOI]
4 Insights into the Pathogenesis and Clinicopathological Spectrum of Oral Vegetable Granuloma. Case Series with Literature Review
Shankargouda Patil, Roopa S. Rao, A. Thirumal Raj, Pavithra Venkataswamy, Vanishree Haragannavar, Shwetha Nambiar, Dominic Augustine, Sowmya Samudrala Venkatesiah, Sachin Sarode, Gargi Sarode
Clinics and Practice. 2017; 7(4): 150
[Pubmed] | [DOI]
5 Disseminated hyaline ring granuloma in the omentum of a dog
Izabella Dolka,Anna Gruk-Jurka,Piotr Jurka,Beata Dolka,Joanna Bonecka
Acta Veterinaria Scandinavica. 2017; 59(1)
[Pubmed] | [DOI]
6 Disseminated hyaline ring granuloma in the omentum of a dog
Izabella Dolka,Anna Gruk-Jurka,Piotr Jurka,Beata Dolka,Joanna Bonecka
Acta Veterinaria Scandinavica. 2017; 59(1)
[Pubmed] | [DOI]
7 Mandibular Osteolytic Lesion Associated with Exuberant Hyaline Ring Granuloma Reaction
Luciana Yamamoto Almeida, Paulo Alceu Kiemle Trindade, Alexander Tadeu Sverzut, Cassio Edvard Sverzut, Alexandre Elias Trivellato, Christiano Oliveira-Santos, Jorge Esquiche León
Medical Principles and Practice. 2016; 25(4): 391
[Pubmed] | [DOI]
8 Granulomatous Diseases Affecting Jaws
Baddam Venkat Ramana Reddy,Kiran K. Kuruba,Samatha Yalamanchili,Mel Mupparapu
Dental Clinics of North America. 2016; 60(1): 195
[Pubmed] | [DOI]
9 Granulomatous Diseases Affecting Jaws
Baddam Venkat Ramana Reddy,Kiran K. Kuruba,Samatha Yalamanchili,Mel Mupparapu
Dental Clinics of North America. 2016; 60(1): 195
[Pubmed] | [DOI]
10 Hyaline ring granuloma of vegetable: Report of two cases with histochemical and immunohistochemical study
Francisco Jadson Lima,Maria Luiza Diniz de Sousa Lopes,Márcia Cristina da Costa Miguel,Éricka Janine Dantas da Silveira
Pathology - Research and Practice. 2015; 211(12): 1020
[Pubmed] | [DOI]
11 Hyaline ring granuloma of vegetable: Report of two cases with histochemical and immunohistochemical study
Francisco Jadson Lima,Maria Luiza Diniz de Sousa Lopes,Márcia Cristina da Costa Miguel,Éricka Janine Dantas da Silveira
Pathology - Research and Practice. 2015; 211(12): 1020
[Pubmed] | [DOI]
12 Oral pulse granuloma- a rare entity
Madalli, V. and Basavaraddi, S. and Horatti, P. and Naikmasur, V.
Iranian Journal of Pathology. 2013; 8(4): 281-282
[Pubmed]
13 Pulse granuloma involving Meckelæs diverticulum: A case report and literature review
Karp, J.K. and Davis, A. and Read, P.J. and Mashayekh, A. and Bombonati, A. and Palazzo, F.
Pathologica. 2013; 105(2): 59-61
[Pubmed]
14 Pulse granuloma, unusual localization: Appendix
Şimşek, G.G. and Buluş, H. and Güreşçi, S.
Turkish Journal of Gastroenterology. 2012; 23(4): 417-418
[Pubmed]



 

Top
 
 
  Search
 
 
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


    Abstract
    Case Reports
    Discussion
    Acknowledgements
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed8604    
    Printed511    
    Emailed2    
    PDF Downloaded523    
    Comments [Add]    
    Cited by others 14    

Recommend this journal