Multiple myeloma presenting as gingival hyperplasia
A 58-year-old male patient was referred to our department because of the generalized enlargement of gingiva. The enlargement was first noted by the patient 6 months prior to the referral, and progressed steadily since then. Patient also complained of weakness, fatigue and anorexia. The intraoral examination revealed soft, granular, friable, non-tender, and red/magenta enlargement that bled spontaneously. The growth was painless in nature. Purulent discharge from some areas of the enlargement was also noted. The enlargements were present on both buccal and lingual/palatal sides []. On physical examination, Grade III mobility was observed in 16, 17, 18, 36, 37. General examination showed signs of pallor and poor nourishment. The medical history of the patient included epilepsy for which he took prescribed medication with no occurrence of seizure for last 10 years. Based on clinical presentation, a provisional diagnosis of inflammatory gingival enlargement, plasma cell gingivitis or Wegener's granulomatosis was made. Routine blood investigations were done along with HIV and Hepatitis B and sputum examination to rule out any leukemic infiltration and enlargement associated with tuberculosis. Orthopantomography was advised, which revealed severe bone loss in 16, 17, 18 and 36, 37 regions. Oral hygiene status of the patient was good. After Phase I therapy and consultation with the physician, gingivectomy was performed in anterior mandibular region and excised tissue was sent for histopathological examination. Periodontal dressing was given after performing gingivectomy. The patient was followed up every week [] but after 1 month the clinical examination revealed recurrence of enlargement in the anterior mandibular region []. The histopathology report revealed a lining of stratified squamous epithelium with foci of ulceration. The subepithelial zone showed infiltration by sheets of plasma cells mainly mature with few being less differentiated []. Binucleate and multinucleate plasma cells were also noted []. Presence of rounded cytoplasmic inclusion bodies was identified in many of these cells. Based on these findings, serum protein electrophoresis and urine analysis for Bence-Jones proteins was carried out. Serum protein electrophoresis revealed monoclonal increase in immunoglobulin G levels. No Bence-Jones proteins were detected in urine. Subsequently, patient was advised to undergo cranial and pelvic radiography [Figures and ]. The radiographs revealed small punched out osteolytic lesions in the cranium and pelvic region. The patient was referred to an oncologist for systemic screening. Bone marrow aspiration was done, which showed a marginal prominence of plasma cells. The biochemistry revealed high values of alkaline phosphatase and lowered albumin/globulin ratio. Bone marrow biopsy also revealed a patchy prominence of plasma cells. The patient was diagnosed as a case of multiple myeloma and chemotherapy was started with thalidomide. The patient reported for follow-up after 1 month. The gingiva appeared normal after the start of chemotherapy [].