Oral lichenoid granulomatous stomatitis

a rare case report

Abstract

Introduction: The presence of granulomatous inflammation associated with lymphocytic infiltrate in the oral mucosa is rare, restricting diagnostic possibilities. Oral Lichenoid Granulomatous Stomatite (EGL Oral) is an unusual condition, clinically characterized by white-acinzented striae and, histologically, by the association of lichenoid and granulomatous inflammation.
Its etiology is not fully clarified, and may be related to autoimmune, infectious diseases, reactions to foreign bodies and the use of medications that induce lichenoid reactions. Clinically, it is more prevalent in women over 50 years of age, manifesting as erythroleukoplasic or erythroplastic lesions, frequently accompanied by pain, burning and functional discomfort.
Histologically, hyperkeratose, damage to the basal layer, lympho-histiocytic infiltrate in some and varying degrees of granulomatous inflammation were observed. An immunohistochemical analysis shows markers such as CD68, CD3, CD4 and CD20. The differential diagnosis includes Lichen planus, Plasmocytic mucosite, Erythema multiforme, Systemic lupus erythematosus and Candidiasis, being essential to perform incisional biopsy associated with histopathological and immunohistochemical examinations.
The treatment is based mainly on the use of topical corticosteroids, with clinical accompaniment. This study aims to report a case of Oral EGL and review its main clinical and diagnostic aspects. Case Description: Male patient, 36 years old, brown, presented at the Clínica de Stomatologia da Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM) with complaints of painful lesions in the oral cavity for approximately 40 days. In the history of the case, the story of seeking medical attention was that Nystatin, Acyclovir and Azithromycin were prescribed for five days, without the best time in the box. The medical history is not contributory to the association of comorbidities or pre-existing conditions. The laboratory tests (blood count, blood glucose, FAN, VDRL, FTA-ABS and tests for hepatitis B and C) are presented within two normal patterns. During the intraoral examination, plaques and yellowish-sbranchial, diffuse and irregular striae were observed, involving the labial mucosa, gingivae, jugal mucosa, dorsum and belly of the tongue, as well as erosive areas in the gingiva bilaterally. Given the diagnostic hypotheses of Lichen planus, Plasmocytic mucosite and Erythema multiforme, an incisional biopsy was performed. After a week, proceed to remove the suture and forams prescribed with betamethasone 0.1% twice a day, while awaiting the result of the histopathological examination.
A histopathological analysis revealed a fragment of mucosa covered by hyperkeratinized and hyperplastic stratified squamous epithelium, with lichenoid lympho-histiocytic inflammatory infiltrate and discrete areas of degeneration of the basal layer. In depth, lymphohistiocytic infiltrate was observed forming perivascular aggregates. The immunohistochemical markers evidence a significant population of macrophages (CD68+, CD163+), T lymphocytes (CD3+, CD4+, CD8+, FOXP3+) and B lymphocytes (CD20+), as well as dendritic cells (CD1a+, CD207+, CD209+, Fator XIIIa+). As stains with periodic acid Schiff, Grocott and Ziehl-Neelsen negative forams. Results: Diante desses achados, estabeleceu-se or diagnosis of oral EGL. She was kept under prescription of Betamethasone 0.1% for 15 days. After 20 days, the patient reports the absence of sleep and reduced injuries. The accompaniment was maintained and, after two months, complete regress of the lesions was observed, with an appearance of normality in the entire oral mucosa. The patient remained in accompaniment for two years, without presenting a recurrence. Conclusion: This case reinforces the rarity and diagnostic challenge of Oral Lichenoid Granulomatous Stomatite, highlighting the importance of histopathological and immunohistochemical analysis for the differential diagnosis. The answer in favor of treatment with topical corticosteroids and the absence of recurrence is evidenced by a good prognosis when there is an adequate approach and careful clinical accompaniment. Keywords: Granulomatous. Lesões Lichenóides. Doenças da Oral Mucosa. Granulomatous Inflammation. Histiocytic Lichenoid Stomatite.