Traumatic Ulcerative Granuloma with Stromal Eosinophilia

A 41-year-old man presented with an 8-year history of recurrent mouth ulcers, previously treated with unrecalled antibiotics and vitamins but with no relief. Examination showed a 2.0 x 1.0 cm hard, immovable ulcer at the right lateral tongue. On further interview, a history of repeated biting trauma on the site of the lesion was elicited. The clinical impression was a non-healing tongue ulcer. Incision biopsy of the lesion was performed and the specimen sent for histopathologic evaluation. The specimen consisted of three, cream-tan, irregularly-shaped soft tissues measuring up to 0.9 cm in widest diameter. The cut sections of the tissues showed a tan-pink to cream-white soft cut surface. Microscopic examination showed a squamous epithelium-lined tissue with a dense polymorphic infiltrate of inflammatory cells rich in neutrophils, eosinophils, plasma cells and large atypical mononuclear cells, and accompanying granulation tissue formation. (Figure 1 and 2) Immunohistochemical studies showed CD20 expression of B-cells in the lymphoid follicles, with CD3 and CD5 highlighting the surrounding T-cells. The plasma cells are staining for both kappa and lambda, with kappa-lambda ratio of 3:1. The Ki-67 showed a high proliferation index within the reactive germinal centers, and scattered low proliferative activity within the interfollicular areas. (Figure 3) Given the morphologic and immunohistochemical profile of the lesion, we diagnosed it as traumatic ulcerative granuloma with stromal eosinophilia. Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is considered a rare lesion of the oral mucosa. First described in 1881 by Riga then defined histologically in 1890 by Fede,1,2 it has since been called by a variety of terms including traumatic ulcerative granuloma, ulcerative eosinophilic granuloma, and Riga-Fede disease in infants and neonates. The term TUGSE was first coined by Elzay in 1983 to delineate it from more aggressive conditions such as eosinophilic granuloma, eosinophilic fasciitis and carcinoma with stromal eosinophilia.3 It is a benign, chronic, self-limiting lesion of the oral mucosa.1,2 TUGSE typically manifests as an isolated ulcer with elevated margins or an indurated submucosal mass, most commonly affecting the dorsal or lateral surfaces of the tongue but can be found in other locations in the oral mucosa such as the lip, palate, and gingiva. 2,4 The lesions can also be multifocal and recurrent, and can persist from several weeks to