Strawberry gingivitis: A diagnostic feature of gingival Wegener's granulomatosis!
A 54-year-old male patient was referred to the Government Dental College, Trivandrum, South India in December 2010, with soreness of gingiva and malaise. Clinical examination revealed painful and erythematous generalized gingival enlargement involving the entire maxillary gingiva and focal areas of involvement in the mandibular gingiva, with the appearance simulating “ripe strawberry” []. The gingiva was very friable and easily bled on touch. There was grade III mobility of maxillary anterior teeth that had spontaneously exfoliated on the subsequent visit. The remaining teeth had grade I mobility. The oral hygiene status was poor and all teeth were stained with tobacco stain. The patient was a chronic smoker and alcoholic, but quit the habits 1 year back. Panoramic radiograph revealed generalized bone loss, which was more pronounced in the maxillary anterior region. Examination of specific organ systems revealed that the patient had prostatic hypertrophy with slight elevation of prostate-specific antigen. He was on medication (Tamsulosin + Finasteride) for prostatic hypertrophy, but the serum creatinine level was normal. The patient was not on any other drugs except those mentioned above. There was no history of dyspnea, fever, night sweat or allergy to any substance. Evaluation of serum cytoplasmic antineutrophilic cytoplasmic antibody (cANCA) was done, and it was within normal limits. Peripheral blood smear showed neutrophilia and leuckocytosis. Further, the patient was referred to the Department of Internal Medicine for systemic evaluation, but reports were inconclusive.\nMicroscopic evaluation of biopsy from the gingival tissue showed parakeratinised stratified squamous epithelium with pseudoepitheliomatous hyperplasia and intraepithelial abscess, as well as abscess penetrating into the surface of the epithelium. Connective tissue stroma was densely collagenous with dense diffuse infiltration of neutrophils, plasma cells and few macrophages, particularly around the blood vessels, with dilatation and thickening of blood vessels. At one end of the section, some multinucleate giant cells were also seen [].\nHistopathological differential diagnoses of tuberculosis, deep fungal infection and WG were made. Special staining by Grocott-Gomori methenamine-silver nitrate [] and PAS [] were done, which were negative for fungal organisms. Mantoux test was done, which was negative and thus tuberculosis was ruled out.\nBy the above-mentioned clinical features, lab investigations and histopathological examination with special stains, we arrived at the diagnosis of WG limited to the upper aerodigestive tract. The patient has been started on Prednisolone 20 mg/day on divided and tapering dose for 1 week with morning doses of 10 mg after proper systemic evaluation in the Department of Periodontology. To give symptomatic relief, local steroid as well astringing agents was also advised. The patient felt symptomatically better after 1 week of follow-up. After that, the dose of Prednisolone was tapered to 10 mg/day in dividing doses with 5 mg of morning dose; unfortunately, the patient did not turn up for the follow-up.