Oral Pyogenic Granuloma After Bone Marrow Transplant in the Pediatric/Adolescent Population: Report of 5 Cases

Abstract

Pyogenic granuloma (PG) is a benign, neoplastic, soft tissue growth of granulation and fibrous tissue that may rarely occur in the mouth of patients after hematopoietic cell transplant (HCT). This case series describes 5 pediatric/adolescent patients who developed oral PG after HCT for acute lymphoblastic leukemia, Fanconi anemia, nodular sclerosis Hodgkin's lymphoma, or junctional epidermolysis bullosa. The underlying mechanism for the appearance of oral PG after HCT is unknown, but it is suggested that calcineurin inhibitors used for graft versus host disease (GVHD) may play a role, as all patients were on cyclosporine A or tacrolimus at the time of development of oral PG. Three of the patients were being treated for chronic GVHD, and 1 other treated for acute GVHD. Overall, this report illustrates that PG should be considered in the differential diagnoses when encountering oral lesions in pediatric/adolescent patients after undergoing HCT, especially in the context of chronic GVHD and calcineurin inhibitors use.

Medication‐related fibrovascular hyperplasia lesion in tongue: Case report

“…There are studies in the literature reporting the appearance of lesions similar to the present case in patients after HSCT or after solid organ transplantation who underwent immunosuppression with calcineurin inhibitor drugs 9‐13 . Although they associate the lesions occurrence to the drug, they refer to them as PGs 11,12,17,18 . The establishment of a specific nomenclature for these drug‐induced lesions can help the understanding of this clinical entity and therefore improve management guidelines in the literature.…”

“…Drugs classified as calcineurin inhibitors are known to have potential for hyperplastic tissue growth, such as well‐known and documented gingival hyperplasia 6‐8 . Thus, as suggested in previous studies, 9 the histological features similar to PG (Figure 2), associated with the clinical history of cyclosporine immunosuppression, 9‐13 should be classified as medication‐related fibrovascular hyperplasia (MRFH). Overall, PG has unique lesions, while MRFH can have multiple lesions and relapses.…”

“…Similar cases have been reported in patients after HSCT, where the authors associate the appearance of these lesions with oral manifestations of GVHD. It is believed that lichenoid or ulcerated lesions of oral GVHD could be the initial etiological factor for mucosal trauma 12,19 . After stabilization of the active disease, the body would initiate a healing process, thus, modified by the use of calcineurin inhibitors, presenting inflammatory hyperplastic responses as MRFH.…”

“…Confirmation of MRFH, in which the etiological agent is medicated, 9‐13 is important for adequate management. Surgical excision is the treatment of choice, as well as oral hygiene guidelines or removal of the associated etiological agent.…”

Clinical practice guidelines: Oral health care for children and adults living with epidermolysis bullosa

“…A rare case of pyogenic granuloma on the tongue was reported in young child with severe JEB that had undergone allogenic hematopoietic cell transplant. Both granulomas were successfully excised with no recurrence 62 …”