Generalized Gingival Hyperplasia and Rectorrhagia in a 13-Year-Old Boy

Abstract

Question: A 13-year-old boy of Arab origin was referred to the Department of Periodontology with a chief complaint of generalized bleeding gums for 3 years, which had an impact on his daily quality of life. The young patient did not report any particular symptoms other than a chronic fatigue that hampered his sport activities. The patient's mother mentioned 2 episodes of perianal abscess that were surgically drained at the age of 6 months and 1 year and few episodes of rectorrhagia during childhood. She also noticed a year ago, swollen lips and mouth breathing. The patient's body mass index is 21.5 kg/m 2. The extraoral examination showed an asymmetric macrocheilia and mouth breathing (Figure A). Periodontal examination highlighted a generalized gingival hyperplasia mainly in the vestibular area extending beyond the mucogingival junction and covering a part of the clinical tooth crown (Figures B, C). The gingiva presented a granulomatous aspect associated with a dentomaxillary discrepancy. The plaque index and bleeding on probing index (estimating gingival inflammation) were 42% and 48%, respectively. Previous sessions of scaling were performed once a year by a general dentist, without any observable impact on the gingival aspect. Blood samples and gingival biopsies were taken. Normocytic nonregenerative anemia was diagnosed associated with an iron deficiency. Gingival biopsies revealed the presence of a parakeratinized epithelium with hyperplastic areas. The inflammatory infiltrate was rich in plasma cells, noncaseating granulomas, and epithelioid cells (Figure D). The patient was then referred to the Pediatric Pulmonology and Gastroenterology Departments for further workup. Esophagogastroduodenoscopy and colonoscopy were performed with biopsy at the level of the esophagus, stomach, duodenum and colon, showing several inflammatory areas associated with numerous ulcerations. What is the most likely diagnosis? Look on page 2032 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.