Multifocal Eosinophilic Granuloma of Jaws and Skull with Classical and Unusual Radiographic/Imaging Findings

Abstract

A 37-year-old male patient reported with a chief complaint of loosening of teeth in lower front teeth region since three years. Patient gave a history of trauma to the left skull and left mandibular body region five years back in a road traffic accident. Following the trauma patient did not observe any changes related to his medical and dental health. Patient underwent extraction of teeth no #36,37 due to mobility four months back. The rest of the missing teeth i.e., teeth no #25,26,35,43,45,46 got exfoliated a year back. Patient's past medical history was non-contributory. Extraoral examination revealed no abnormality. Intraoral examination revealed flattening of mandibular left and right posterior alveolar ridges with unhealed sockets in mandibular left posterior region. The gingiva and other mucosal areas did not exhibit any abnormalities. The mucosa covering the residual ridges of mandible appeared as if it was ulcerated due to unhealed sockets in the missing teeth in mandibular left posterior region [Table/ Fig-1a]. On palpating the lingual aspect of mandibular left posterior region a bony hard swelling was appreciable, which corresponded to the periosteal reaction in the occlusal radiograph. The residual ridge of mandibular right posterior region appeared to be flattened. However, the mucosa covering the same appeared normal [ Table/ Eosinophilic granuloma is basically a disorder of reticuloendothelial system and is one of the variants of langerhans cell histiocytosis. Multifocal eosinophilic granuloma affecting jaws and skull is relatively a rare disorder. We hereby report a case of multifocal eosinophilic granuloma involving mandible, maxilla and several skull bones. The present case has mixture of classical floating teeth appearance and an unusual radiographic/imaging finding of periosteal remodeling, which is rarely seen in adult patients of eosinophilic granuloma and pseudo-multilocular appearance in anterior mandibular region in coronal sections and moth-eaten appearance of skull was appreciated in axial slices of Computed Tomography (CT).[

Diagnosis and management of eosinophilic granuloma of the jaw: a case report

“…Radiographically, the lesions present as radiolucent areas accompanied by a perforating aspect without cortical margin, and become more evident when the alveolar cortical bone is destroyed. Extensive involvement of the alveolar bone may result in the appearance of teeth "floating in the air" [1,6,8]. In these cases teeth may be observed with the presence of mobility and deep periodontal pockets, mucosa with ulcerative or proliferative lesions, with erythema and severe tendency to bleeding on probing [7].…”

“…The therapeutic options for the treatment of EG are surgical removal by means of curettage, radiotherapy in low doses, chemotherapy, intralesional injection of steroids for reduction in size of the lesion followed by curettage, and depending on the case, there are reports of spontaneous resolution of the lesion [3,7,8]. Moreover, for confirmation of the diagnosis, incisional biopsy and histopathological analysis [6] are necessary, because from the clinical characteristics of the lesion, it may present differential diagnosis from other pathologies, such as osteomyelitis, carcinoma, sarcoma, lymphoma, Paget's disease, multiple myeloma and Papillon-Lefèvre Syndrome [3,6,8].…”