1 Banerjee A, et al. BMJ Case Rep 2021;14:e245097. doi:10.1136/bcr-2021-245097 Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE): a rare self-healing oral mucosal lesion Abhishek Banerjee, 1 Satya Ranjan Misra, 2 Vivek Kumar, 1 Neeta Mohanty 3 Images in… To cite: Banerjee A, Misra SR, Kumar V, et al. BMJ Case Rep 2021;14:e245097. doi:10.1136/bcr-2021- 245097 1 Oral & Maxillofacial Pathology, Awadh Dental College and Hospital, Jamshedpur, Jharkhand, India 2 Oral Medicine & Maxillofacial Radiology, Institute of Dental Sciences, Siksha ’O’ Anusandhan Deemed to be University, Bhubaneswar, India 3 Oral & Maxillofacial Pathology & Microbiology, Institute of Dental Sciences, Siksha O Anusandhan Deemed to be University, Bhubaneswar, Odisha, India Correspondence to Professor Neeta Mohanty; neetamohanty@soa.ac.in Accepted 6 August 2021 © BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ. DESCRIPTION Oral ulceration is a common report encountered by the oral physician, and a solitary ulcer of long duration especially when it is asymptomatic and occurs in middle aged and elderly patients is always under suspicion for oral squamous cell carcinoma. 1 Chronic trauma of the oral mucosa (CTOM) due to repeated mechanical irritation from an intraoral injury agent has been debated as an oral potentially malignant disorder contributing to oral carcino- genesis and needs to be evaluated ruling out other associated contributing factors like tissue abuse habits and oral hygiene. 2 Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is an uncommon self-limiting oral mucosal lesion. It presents as a single ulcer which may be asymptom- atic or associated with pain with the dorsum or the tip of the tongue being the most common site. The importance of this rare lesion lies in the fact that it is often misdiagnosed as oral carcinoma or specific infections like tuberculosis, primary syphilis or Epstein-Barr virus ulcer. Biopsy is mandatory and exhibits typical histological findings diffuse poly- morphic inflammatory infiltrate, predominately consisting of histiocytes, activated and predomi- nantly T-lymphocytes, and of eosinophils with the lesion extending deep into the submucosa, deeper muscle fibres and even the salivary glands. 3 Eosino- phils are known to regulate local inflammatory and immune responses; hence, their presence is asso- ciated with inflammation and infection and their abundance in this lesion indicates an associated inflammatory component. The aetiopathogenesis of TUGSE is debatable but a localised traumatic cause is a significant predisposing factor as seen in this case, though it may be absent in half of the cases. 4 These lesions show a male gender predilec- tion with an age range of 41–60 years. The lesions generally heal following biopsy. TUGSE is entirely a histologic entity and is incidentally diagnosed when lesions associated with CTOM are biopsied suspecting malignancy. A 35-year-old woman presented with an ulcer in the right buccal mucosa which had been present for about 7 months. History revealed the ulcer had been associated with pain and did not increase in size over time. The patients’ medical history was unremarkable. On clinical examination, a single irregular ulcer measuring 1 cm×1.5 cm in size was seen on the right buccal mucosa in relation to carious maxillary molars 17, 16. The floor of the ulcer was erythematous and the borders irregular and whitish in colour. The indentation of the tooth cusp of maxillary molar was apparent on the ulcer surface (figure 1). On palpation, the base appeared Figure 1 A solitary, irregular ulcer on the right buccal mucosa in relation to carious maxillary molars having an erythematous foor and irregular hyperkeratotic white borders with indentation of the tooth cusp of maxillary molar on the ulcer surface. Figure 2 H&E-stained section showing (A) infltrative lesion with dense granulomatous reaction in the stroma (original magnifcation 5×) and (B) infltration of the chronic infammation at the level of deeper connective tissue extending into the musculature (original magnifcation 10×). At higher magnifcation, presence of (C) tissue macrophages along with budding vascular channels and lymphocytes and (D) pool of eosinophils along with other components of chronic infammation are seen (original magnifcation 40×). on February 19, 2022 by guest. Protected by copyright. http://casereports.bmj.com/ BMJ Case Rep: first published as 10.1136/bcr-2021-245097 on 13 August 2021. Downloaded from