9 September 2009 – Case of the Week #156
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Thanks to Dr. Juan José Segura Fonseca, Laboratorio de Patología Diagnóstica, S.A., San José, Costa Rica, for contributing this case and much of the discussion. To contribute a Case of the Week, email NatPernick@Hotmail.com with the clinical history, your diagnosis and diagnostic, high quality microscopic images in JPG, GIF or TIFF format (send as attachments, we will shrink if necessary). Please include any other images (gross, immunostains, etc.) that may be helpful or interesting. We will write the discussion (unless you want to), list you as the contributor, and send you $35 (US dollars) by check or PayPal for your time after we send out the case. Please only send cases with high quality images and a diagnosis that is somewhat unusual (or a case with unusual features).
Case of the Week #156
Clinical History
A 50-year-old man with a history of heavy cigar smoking presented with severe inflammation, marked hyperemia and swelling of the free and attached gingival in the maxillary and mandibular arches. Heavy plaque accumulation was present around the teeth, and the gingiva bled easily when touched. Small biopsies were taken.
Clinical image:
Micro images:
Immunostains:
Kappa light chain Lambda light chain
What is your diagnosis?
Diagnosis:
Plasma cell gingivitis
Discussion:
Microscopically, there was a dense infiltration of mature plasma cells beneath the squamous epithelium, separated by thick collagen bundles. A pronounced lichenoid reaction was seen in the overlying squamous epithelium. The plasma cells were polyclonal based on cytoplasmic staining for both kappa and lambda light chains.
Plasma cell gingivitis, first reported in 1960 as plasmocytosis circumorificialis (Dtsh Zahnorzd 1960;15:601), is a rare inflammatory condition of uncertain etiology. It is characterized by a diffuse and intense infiltration of mature plasma cells in the subepithelial gingiva. Causes include an allergic reaction to chewing gum (J Periodontol 1971;42:709, Oral Surg Oral Med Oral Pathol 1992;73:690), mint (J Periodontol 1984;55:235), red chili, black pepper and cardamom (CDS Rev 1995;88:22), toothpaste, including herbal brands (Br Dent J 1990;168:115, J Contempt Dent Pract 2007;8:60) and khat (Catha edulis, a plant that is chewed in Africa and the Arabian peninsula) (Br Dent J 2002;192:311). Though plasma cell gingivitis seems to be a well-established entity, its classification as a distinct condition has recently been questioned (SADJ 2008;63:394).
The clinical differential diagnosis includes more serious conditions that affect the gingiva, such as leukemic infiltrates, multiple myeloma, solitary plasmacytoma (forms a mass, clonal) and Walden-Strom macroglobulinaemia. Chronic hyperplastic gingivitis usually has thick collagen fibers and granulation tissue, and lacks an intense plasma cell infiltrate. Dermatologic diseases that involve the gingiva include discoid lupus erythematosus, lichen planus and pemphigus.
Treatment includes removal of the offending substance.
This case was also reviewed by an oral and maxillofacial pathologist, who noted that for his specialty (certified by the American Board of Oral and Maxillofacial Pathology), this case represents non-specific gingival inflammatory hyperplasia, although the possibility that there could be a drug-related component (phenytoin, Ca-channel blocker, cyclosporin) would also be a consideration. Clinically, the gingival tissues would be much more erythematous in plasma cell gingivitis than in the present case, and the plasma cell infiltrate would be much more diffuse, essentially mimicking extramedullary plasmacytoma.
Additional references: Cutis 2002;69:41
Nat Pernick, M.D., President,
and Kara Hamilton, M.S., Assistant Medical Editor
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