Eosinophilic ulcer (atypical or traumatic eosinophilic granuloma)

What is Eosinophilic ulcer: Eosinophilic ulcer of the oral mucosa is an uncommon benign
ulcer seen in middle-aged to elderly adults that appears suddenly in the mouth or on the lips, is
usually painful, and heals over a few weeks. It may represent a nonspecific reaction pattern to
trauma.

Eosinophils are a type of inflammatory cell with a characteristic appearance under the microscope.

Eosinophilic ulcer of the oral mucosa is also known as traumatic ulcerative granuloma with stromal
eosinophilia, oral traumatic granuloma, traumatic granuloma of the tongue or eosinophilic ulcer of the
tongue. It is possibly the adult version of Riga-Fede disease.

Clinical picture:

Age and Sex: Eosinophilic ulcer of the oral mucosa affects adults, with a peak in the sixth and
seventh decades of life (50-80 years old). There is a slight female predominance reported.

Causes: The cause of eosinophilic ulcer of the oral mucosa is unknown. Trauma is a reported trigger in
39%. The ulcer usually occurs on sites where trauma from teeth is common and it is seen in the age
group most likely to have damaged teeth and dentures that may cause trauma. However, most simple
traumatic ulcers in the mouth do not show the characteristic clinical and histological features of
eosinophilic ulcer. Therefore it has been suggested that trauma may allow as-yet-unidentified
infections, toxins or foreign proteins to enter and trigger the characteristic inflammatory reaction in
susceptible people. Another theory is that is represents a CD30+ lymphoproliferative disorder (a type
of lymphoma).

The typical clinical features of eosinophilic ulcer of the oral mucosa include:

Rapid growth

Painful in most but not all cases

Solitary multiple or recurrent lesions are reported but are uncommon

Size range from a few mm to several cm

Base white or yellow film which can be wiped off

Edge raised and firm

Surrounding redness

The most commonly affected site is the tongue, usually the sides or the top.

Other reported locations (in decreasing order) are:

Inside of cheeks

Between the gum and cheek (mucobuccal fold)

Lips (usually the lower lip)

Gums
 Palate

Floor of the mouth

Behind the molar teeth

The patient is generally well, but eating and drinking may be limited by pain. Enlarged lymph glands in
the neck may be felt in rare cases.

Eosinophilic ulcer of the oral cavity usually heals by itself within 3 to 10 weeks, but can persist up to
one year. Recurrences have rarely been reported.

Histology: The histology is characteristic: There is typically a dense aggregation of eosinophils and
cells which resemble histiocytes beneath the ulcerated surface. The histiocytes lack the
ultrastructural features and surface markers of Langerhans cells but are occasionally
pleomorphic.
Ulcerated mucosal surface

Poorly developed granulomas

Mixed inflammatory infiltrate extending deep into muscle and salivary glands

Numerous eosinophils showing degranulation

Large atypical CD30+ T-cells occasional, scattered, can be monoclonal

Increased numbers of mast cells

Degeneration and loss of muscle fibres

DIFFERENTIAL DIAGNOSIS
Clinically, both traumatic and atypical histiocytic granulomas appear identical to
squamous cell carcinoma or specific granulomatous inflammatory ulcerations,
Langerhans cell histocytosis. Biopsy is therefore essential to determining the
diagnosis.

TREATMENT
Once an incisional biopsy has been procured and the diagnosis is established, no
further treatment is required. The lesions resolve in 4 to 5 weeks.
Figure 1A 47-year-old African American woman with an eosinophilic ulcer on the lateral
surface of the tongue. The anterior border of the lesion is raised. Courtesy of Dr Paul D.
Freedman.
Figure 2Raised, indurated, nonhealing ulcer on the lateral surface of the tongue. The lesion
was related to an adjacent fractured tooth. Courtesy of Dr Paul D. Freedman.
Figure 3Low-power view showing an ulcerated surface epithelium with a dense cellular
inflammatory infiltrate underlying the mucosal surface (original magnification X40).
Courtesy of Dr Paul D. Freedman.
Figure 4Cellular infiltrate composed mainly of large mononuclear cells, including
histiocytes and submucosal dendrocytes, eosinophils, and scattered T lymphocytes
(original magnification X400). Courtesy of Dr Paul D. Freedman.
Figure 5 Inflammatory infiltrate extending through and between muscle bundles (original
magnification X400). Courtesy of Dr Paul D. Freedman.