Introduction
A granulomatous disease is a chronic form of inflammation that results in collagen damage and the formation of a ring-like unfiltered red lesion known as granuloma annulare. The formation of granuloma in various parts of the body characterizes it and is a reaction to infection, inflammation of a foreign body, and irritants from granulomas. The clumping of white blood cells helps protect the body by reducing the infection and preventing further damage.
The treatment for granulomatous lesions depends on the underlying cause of the formation. Granuloma formation is a normal part of the body's immune functioning, which fights the threat of damage to the body. It is part of the body's innate immune response, which acts as the first line of defense for the body's protection. Granuloma formation occurs as a continuous T-cell response to the pathogens. Persistent chronic inflammation may lead to the death of the organ tissues.
What Is Granulomatous Lesion?
The granulomatous lesion is a chronic inflammatory response to a granulomatous disease characterized by granuloma formation. It is characterized by microscopic granuloma formation with the prominent proliferation of granulation cells. The granulomatous inflammation of the body is ubiquitous in pathogenesis and clinically manifested as infective allergic neoplastic autoimmune and toxic diseases.
What Is the Classification of Granulomatous Lesions?
Granulomatous lesions have been classified according to their etiology-
1. Infection:
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Bacterial infections like tuberculosis, leprosy, actinomycosis, anthrax, and brucellosis.
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Fungal infections like histoplasmosis, blastomycosis, aspergillosis, and candidiasis.
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Spirochetal infection like syphilis.
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Parasitic infections like leishmaniasis, myiasis, and toxoplasmosis.
2. Traumatic Granulomatous Lesion:
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Pyogenic Granuloma.
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Reparative Granuloma.
3. Foreign Body Etiology:
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Foreign body reactions.
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Cholesterol Granuloma.
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Cocaine-induced midline granuloma.
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Gout.
4. Neoplastic:
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Benign fibrous histiocytoma.
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Eosinophilic Granuloma.
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Necrotizing sialo metaplasia.
5. Autoimmune Origin or Diseases:
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Wegner's granulomatosis.
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Systemic Lupus Erythematosus.
6. Developmental:
- Melkerson Rosenthal Syndrome.
7. Unknown Etiology:
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Crohn's disease.
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Sarcoidosis.
What Is Pathophysiology of Granulomatous Lesion?
Granuloma is usually of two types; one is immune granuloma, and the other type is foreign body granuloma. If the foreign material in the body is too large for the macrophages to engulf, it results in foreign body reactions. It attempts to eliminate the foreign bodies without evoking the immune response.
The epithelioid macrophages are activated, transformed, and organized to form granuloma. Immune-mediated granuloma formation is a delayed type of cell-mediated hypersensitive reaction in the body. Immune-mediated granuloma formation occurs as a response to mycobacterial and fungal infections.
There is an initial exposure to nondegradable antigen, a protein derived from infective microorganisms. There is a differentiation of T cells and secretion of various cytokines that helps macrophages reach the site of antigen. The macrophages are transformed into epitheloid cells and organized to form granuloma.
What Are the Granulomatous Lesions of the Oral Cavity?
Following are the granulomatous lesion of the oral cavity:
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Tuberculosis- Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis. It is classified as pulmonary and extrapulmonary type. Lungs are the most commonly involved organ; however, it also involves the ear, larynx, nasopharynx, oral cavity, esophagus, and spine. In the oral cavity, it manifests as a chronic, painless ulcer seen in the palate and lateral border of the tongue. The lesions commonly appear on the tongue, lip, and palate with an enlarged lymph node. The lesion may be nodular, granular, or rarely firm. Tuberculosis osteomyelitis is also reported in jaws and appears radiolucent in X-rays.
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Leprosy - It is a chronic granulomatous disease involving the peripheral nerve and skin surface. It is also known as Hansen disease. The mycobacterium leprae causes it. The organism infecting the peripheral nerve causes numbness, weakness, hypopigmented skin, painful neuritis, and loss of sensation in hands and feet. In the oral cavity, papules, plaque, and nodules are seen as eroded ulceration involving the tongue, buccal mucosa, and palate. Endonasal inflammatory changes are noted with alveolar destruction. Inflammation of the nasal cavity, palatal perforation, and oronasal communication can be seen in severe cases. The dental pulp may also be affected, leading to pulp necrosis.
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Syphilis - It is caused by treponema palladium, which penetrates the mucosal surface and causes abrasion on the skin surface. It is classified as primary, secondary, and tertiary types. It is present as solitary ulcers in the oral cavity with indurated margin. The palate, lip, and tongue are the most common site of occurrence. The painless mucosal patch is seen on the palate, pharynx, and tongue.
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Blastomycosis- Blastomycosis is caused by the dimorphic (having two different forms) fungus Blastomyces dermatitis. It is found most commonly on the soil and decaying matter. It presents as ulceration and exophytic mucosal lesion. Oral manifestations include ulceration of the palate and large and deep lesions leading to erosion of underlying bone.
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Wegner Granulomatosis- It is a systemic autoimmune granulomatous lesion characterized by the triad of necrotizing glomerulonephritis, systemic vasculitis, and necrotizing granulomatous inflammation. It commonly affects the upper and lower respiratory tract. It clinically manifests in the oral cavity as hyperplastic granular and friable gingiva, also known as strawberry gingivitis, in addition to the presentation of multiple petechiae on the gingiva's buccal surface, which is most commonly affected. Periodontal bone loss can also occur, leading to the mobility of teeth. Moreover, necrosis and ulceration of the palate can also be seen.
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Crohn's Disease - It is a chronic immunological inflammatory disease. There is a presence of diffuse nodular swelling seen in the oral cavity. The lesion present in the oral cavity appears as a cobblestone appearance. In addition, there is the presence of linear ulceration and fibroepithelial hyperplasia. In addition, granulomatous gingivitis, aphthous ulcers, and angular cheilitis are present.
Conclusion
Granulomatous disease is the body's unique inflammatory response in a unique form against infections and foreign bodies. Granuloma formation can occur as infectious or noninfectious. Extensive clinical laboratory and microscopic evaluation are essential for identifying granulomatous lesions, as it is always a diagnostic dilemma for physicians. The diagnosis of granulomatous lesions is complicated due to the clinical appearance of the lesion and the wide variety of etiology. Proper diagnosis with early identification of signs and symptoms is essential for proper treatment and a good prognosis of chronic granulomatous lesions.
