Management of polyostotic eosinophilic granuloma
A 51-year-old female referred to our department with the complaint of pain and swelling in the left mandibular region since two years. During systemic history, patient revealed low back pain, hypertension and diabetic mellitus Type 2 since 10-11 years. She underwent surgery of the maxillary sinus region which as per her previous records was treated with FESS (functional endoscopic sinus surgery), left conchaplasty with widening of maxillary sinus. The biopsied tissue of the ophthalmic and maxillary region showed inflammatory cells and was not suggestive of any malignancy. During course of time patient underwent root canal treatments of mandibular molars, premolars and incisors for her dental pain. However, the pain did not subside and patient referred to our department. On examination pain was mild, dull, and localized in nature. The family history of the patient was not contributory. Physical examination showed facial asymmetry attributable to diffuse swelling of the left mandibular region. Mouth opening and sensation over the distribution of the left inferior alveolar nerve was normal. Intraorally, the alveolar ridge posterior to the right first molar was covered with intact, normal-appearing mucosa. No teeth showed mobility or pain on percussion. There was no cervical or axillary lymphadenopathy. A two-year-old panoramic radiograph [] showed an ill-defined osteolytic lesion in the left posterior mandibular body, with involvement of the apices of both the first molar and the second molar and in the anterior part of the mandible involving the incisors and premolars of the left side of the mandible. However, a recent panoramic radiograph showed massive increase of erosion in the posterior and anterior part of the mandible [].\nBecause the clinical and radiographic findings led to suspicion of a malignancy, surgical intervention with biopsy of the lesion was planned and performed. The specimen, which was friable and resembled granulation tissue, showed a proliferation of histiocytic cells and an infiltration of eosinophils and neutrophils on microscopic examination. Soft-tissue fragments permeated by hematopoietic cells and predominantly mononuclear cells with clefted nuclei and granular cytoplasm were seen admixed with eosinophils, neutrophils and lymphocytes []. Immunohistochemical staining showed that the histiocytic cells were positive for the CD 68, CD1a, S-100 protein [Figures –], and Myeloperoxidaes were positive in the surrounding granulocytes. The CD 45 was also positive in lymphocytes [].\nThese features were consistent with a diagnosis of eosinophilic granuloma. To evaluate the possibility of systemic histiocytosis X, a radiographic skeletal survey and a visceral ultrasound was performed. These examinations detected no other lesions except a few changes in sacroiliac joint. The results of laboratory tests, consisting of blood and serum biochemical studies, were within normal ranges except there was a significant increase in ESR observed. A chest radiograph did not show any significant abnormality. Consequently, the mandibular lesion was diagnosed as eosinophilic granuloma. After three weeks of surgery the mandibular swelling decreased rapidly, and there was marked improvement in the facial asymmetry. Patient reported again after one year to us with a pain in the right mandibular posterior region. Computed tomography (CT) scans showed a destructive bony lesion extending from the mesial side of the right first premolar to the distal side of the second premolar []. A separate well-defined new radiolucent lesion was observed distal to the left mandibular first molar [].\nSecond surgery with curettage of the lesion was done along with biweekly intralesional 40 mg injections of methylprednisolone in the posterior lesion for the next eight weeks. The patient was also given systemic steroid Defcort 6 mg (Deflazacortil, Mehius India) per day for 30 days in a tapering manner along with surgical curettage. The patient was evaluated after every six months for the next two years. Patient was free of symptoms and signs and her radiographs revealed healed lesions in the anterior and posterior part of the mandible [].