Traumatic ulcerative granuloma with stromal eosinophilia — clinical case report, literature review, and differential diagnosis
Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a rare self-limiting condition of the oral mucosa. The lesion manifests as an isolated ulcer that can be either asymptomatic or associated with mild to severe pain, and in most cases, it affects the tongue. TUGSE lesions may mimic malignancy such as squamous cell carcinoma, CD30 positive lymphoproliferative disorder, or infectious diseases such as primary syphilis, tuberculosis, or Epstein-Barr virus mucocutaneous ulcer. Histologically dominating cells are lymphocytes, histiocytes, and eosinophils.
We describe a TUGSE case of a patient with a solitary ulcer on the lower left retromolar buccal plane. Upon presentation, the patient reported a swelling on the buccal mucosa of the left lower jaw since 1 year with rapid growth over the last days and mild pain while chewing. The diameter of the intraoral lesion on the lower left retromolar buccal plane was approximately 4 × 3 cm; the lesion presented as indurated base with a central superficial ulceration of 2 × 1 cm, indicative for a malignant process. Histologically, the ulceration showed an expanding, infiltrative, and vaguely granulomatous morphology, involving the superficial mucosa and the fatty tissue, and extended between the deep striated muscle fibers. The lesion was rich in lymphocytes, histiocytes, and eosionophils intermingled with activated T-blasts without phenotypic abnormalities. TUGSE was then diagnosed based on the phenotype (especially the lacking expression of CD30, the retained T-cell phenotype, and the absence of Epstein-Barr virus), the clinical presentation, and the morphology. Twenty-six months after diagnosis, no recurrence of the ulceration was seen.
As TUGSE may mimic malignancy or infectious diseases, biopsy is mandatory and should be combined with thorough clinical examination. A screening for infectious diseases (mainly syphilis, Epstein-Barr virus, and HIV infections) must be performed routinely. In most cases, the lesions resolve spontaneously, obviating the need of further actions other than clinical follow-up. The pathogenesis of TUGSE lesions is still under debate, although local traumatic events and a locotypic immune response have been suggested to be major contributing factors.
KeywordsTraumatic ulcerative granuloma with stromal eosinophilia TUGSE TUGSE lesions Riga-Fede disease
Human immunodeficiency virus
Polymerase chain reaction
Squamous cell carcinoma
Traumatic eosinophilic granuloma
Transforming growth factor
Traumatic ulcerative granuloma with stromal eosinophilia
Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a rare, benign, and self-limiting lesion of the oral mucosa. The pathogenesis remains uncertain. Although trauma seems to affect the development of TUGSE, the majority of cases present without evident trauma [1, 2, 3]. The tongue is the most commonly affected location, although other areas may also be involved, including the buccal and vestibular mucosa, palatal mucosa, retromolar area, gingiva, and the floor of the mouth . There are two age peaks of incidence in TUGSE. The incidence of TUGSE peaks during the first 2 years of life, primarily in connection with teething, and between the fifth and seventh decade [4, 5, 6]. Men and women are nearly equally affected, with a minor female predominance [1, 2].
Clinically, TUGSE often manifests as an ulcer with elevated and indurated margins as well as a yellowish fibrinous base. As it grows fast, it is often assumed to represent a malignant process, such as a squamous cell carcinoma (SCC), a CD30 positive lymphoproliferative disorder (LPD), or an infectious disease, such as primary syphilis, tuberculosis, or Epstein-Barr virus (EBV)-associated mucocutaneous ulcer . TUGSE can either present asymptomatically or are associated with mild to severe pain [4, 5]. The definitive diagnosis should be established by combined histological and clinical results. Histologically, the ulcerative lesion is characterized by a vaguely granulomatous, sometimes jigsaw-like appearance with a diffuse polymorphic inflammatory infiltrate of histiocytes, predominantly activated T-lymphocytes, and eosinophils, and it often extends into the submucosa, deeper muscle fibers, and salivary glands [2, 3, 5]. The lesion usually regresses spontaneously or after removal of possible triggers for microtrauma (e.g., artificial denture), within weeks to months. In a few cases, the healing process may take up to 1 year [3, 4]. Elovic reported that a delayed healing of oral TUGSE lesions can be associated with the lack of significant synthesis of transforming growth factor (TGF)-α and TGF-β by eosinophils infiltrating the lesions .
Here, we aim to report a case of TUGSE located on the lower left retromolar buccal plane, to review clinical and histopathological features, and to point out some differential diagnoses and clinical work-up of this entity.
TUGSE was first clinically described by Riga in 1881 and called the Riga-Disease. In 1890, Fede  was the first to histologically describe the lesion based on samples of two infants aged 8 and 10 months. In infants, the eosinophilic ulcer is thus referred to as Riga-Fede disease. The lesions are usually located sublingually or on the ventral side of the anterior tongue and are provoked by trauma from natal or neonatal teeth or newly erupted primary teeth [8, 9]. The first reports about those ulcerations localized on the oral mucosa were published between the 1950s and 1960s. The first case describing an analogous lesion in adults was published in 1956 by Popoff . A few years later, Shapiro and Juhlin described this lesion as a separate independent entity . Different terms have been used in the literature to describe this phenomenon ever since. It was called traumatic granuloma of the tongue , traumatic eosinophilic granuloma (TEG) , eosinophilic ulcer of the oral mucosa , eosinophilic ulcer of the tongue , and in 1983, Elzay named the disease traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) . Finally, Elzay proposed to include Riga-Fede disease as well as TEG into one entity (since they share obvious clinical and histological characteristics), and to use the term TUGSE .
We detail the case of a 48-year-old man, never-smoker and non-drinker, who was referred to the Clinic of Oral and Craniomaxillofacial Surgery at the University Hospital Basel, Switzerland, by his dentist, for further evaluation of a solitary ulcer on the lower left retromolar buccal plane. The patient reported swelling of the left cheek since 5 days, mild pain while chewing, and a swelling on the buccal mucosa related to the left lower jaw since about 1 year. Fever, night sweat, and weight loss were denied. Due to his obsessive-compulsive disorder, the patient has been under psychiatric medication treatment in the past (Deroxat®, paroxetine, selective serotonin reuptake inhibitor (SSRI)), but at the point of consultation, he did not take any medication. The patient reported on his allergy to penicillin, with erythematous rash episodes in the past. The data set includes the medical record of our TUGSE case including the corresponding photo material. No risk for third parties existed. Informed consent was obtained from the patient for case description and photo material.
Differential Diagnosis of TUGSE
Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE)
Squamous cell carcinoma (SCC)
CD30 positive lymphoprolipherative disorder (LPD)
Lues (syn. Syphilis)
Epstein-Barr virus (EBV) mucocutaneous ulcer
Location in the oral cavity
Tongue, buccal and vestibular mucosa, palatal mucosa, retromolar area, gingiva, floor of the mouth
Bottom of the oral cavity, lateral side and tip of the tongue, lower lip, retromolar area
Rarely in the oral cavity, often recurring lesions
Lips, tongue, pharynx
Non-keratinizing epithelial surfaces in the mouth (labial and buccal mucosa, soft palate, lower side of the tongue); in patients with Severe aphthous stomatitis, the keratinized mucosa can also be affected
Unknown, causal connection with repeated trauma
Causal connection with chronic tobacco and alcohol consumption and poor oral hygiene
Typically in patients with an impaired immune system
Most commonly spread through unprotected (oral) sexual intercourse or congenital infection
Associated with immunosuppression
Stress, trauma, hormonal fluctuations, allergic reaction (certain foods, drinks, toothpastes and mouth rinses)
Two peaks of life incidence: one during the first two years of life and another between the 5th and 7th decade
Most commonly after the 5th decade of life (men more frequently affected than women)
Elderly (> 75 years)
Most commonly between the 3rd and the 4th decade of life (men more frequently affected than women)
Primarily elderly (> 75 y), any age
Any age but the frequency increases later in life
Ulcer with elevated and indurated margins and yellowish fibrinous base
Endophytic growth, nodose and shallow ulcer with elevated margins, often covered by a non-strippable reddish, whitish or mixed focus growing infiltrative and destructive
Nodules or ulceration, indolent clinical behavior, primary cutaneous manifestation possible
Stage I (primary syphilis): after an incubation period of 2–3 weeks, the papule at the portal of entry converts into a indolent and superficial ulcers with indurated margins (also called primary chancre) multifocal, aphthous enanthema
Sharply circumscribed indolent ulceration
Nonspecific shallow round or oval painful ulcer, covered by a grayish-white fibrin pseudomembrane with a sharply defined erythematous border
Granulomatous tissue with a dense, diffuse, polymorphic, inflammatory infiltrate predominately of eosinophils and histiocytes, often extending into the submucosa, deeper muscle fibers and salivary glands
Epithelial differentiated structures with cornification (hyperkeratosis, parakeratosis, horn beads and multiple dyskeratotic keratinocytes) and peritumoral inflammatory reaction composed of a mixed cellular infiltrate, which is rich in plasma cells
Infiltrate of atypical lymphoid cells admixed with eosinophils involving the oral epithelium and the deep soft tissues
Significant plasmacytosis, plasmacell phlebitis, vague granulomas, detectable spirochetes (Warthin-Starry, immunohistochemistry)
Polymorphous infiltrate with inflammatory cells and atypical large B-cells blasts often with Hodgkin/Reed-Sternberg (HRS) cell-like morphology, sharply demarcated towards deeper structures (assessible only on excisional biopsies)
Nonspecific ulcer, inflammatory cells, predominately T-cells, with high local levels of TNF-α
Mixture of phenotypically regular T-lymphocytes, occasionally CD30+
CK5/6+, CK19+, p63+, p40+
MUM1p+, MYC+, CD30+ T-cells with antigenic loss of T-cell markers
Detection of Treponema pallidum by the following tests: TPPA test (Treponema pallidum particle agglutination assay test), FTA-ABS test (fluorescent treponemal antibody absorption test)
EBER+ (EBV encoded small nuclear RNA), CD30+
In the majority of the cases, the lesions heal spontaneously . Except for the incisional biopsy for definitive diagnosis, only regular observation is required because the resolution of the lesions may take weeks up to several months, and in few cases up to 1 year [3, 4]. Application of topical corticosteroids, like triamcinolone acetonide ointment, had no additional benefit. Recurrence has been reported in some cases . Because the integrative diagnosis of TUSGE is mostly based on exclusion of other, particularly malignant disorders, clinical follow-up should be performed in all cases, even after the lesions are completely removed.
In our case, the histologically dominant cells in the infiltrate were smaller lymphocytes, histiocytes, and eosionophils continuously streaked by T-lblasts. Degranulating eosinophils and toxic products or cytotoxic T-cells cause the typical mucosal degeneration of TUGSE lesions . Interestingly, Elovic et al.  found that the expression of TGF-α or TGF-β1 in the eosinophils of TUGSE lesions was significantly decreased compared to the eosinophils in normal wounds. They suggested that the typical delayed healing in TUGSE lesions is associated with the lack of synthesis of TGF by eosinophils.
The immunohistochemical characteristic of TUGSE has been a matter of debate due to the unidentified origin of the large, atypical mononuclear cells. Authors have suggested their origin in macrophages (CD68 positive cells) [3, 13], dendritic cells (factor XIIIa positive cells) , and myofibroblasts (vimentin positive cells) . Yet these large, atypical mononuclear cells (often CD30 positive) most likely originate from T-lymphocytes, as they often express T-cell markers or/and cytotoxic markers, and often display clonal T-cell receptor gene rearrangements, as in our case. They might play a role in the reparative phase of the lesion. In 1997, Ficarra et al.  for the first time described a case of TEG, in which CD30-positive cells in an ulcerated lesion could be evidenced. Subsequently, other reports revealed CD30-positive eosinophilic ulcers. CD30-positive large atypical cells can be observed in TUGSE lesions in a scattered or clustered manner [3, 5]. Therefore, these lesions were considered the oral counterpart of the spectrum of primary cutaneous CD30-positive LPDs by some authors. CD30 is commonly expressed on activated B- and T-cells and is a useful histological marker for a spectrum of LPDs, including Hodgkin lymphoma. Yet many non-neoplastic cutaneous disorders, such as atopic dermatitis, drug reactions, molluscum contagiosum, and scabies, can contain CD30 positive cells [1, 3]. The CD30 positivity of some TUGSE lesions is most probably a sign of an unspecific T- and/or B-cell activation, as suggested by Segura and Pujol , who considered eosinophilic ulcer of the oral mucosa to be a nonspecific locotypic reaction rather than a distinct entity.
The majority of the TUGSE cases available in the literature are published in oral and maxillofacial pathology journals [6, 7, 9, 12, 13]. In the dermatological literature, similar cases are only rarely described . To recommend adequate treatment strategies, more cases and systematic analyses are needed, in order to draw attention to this entity, to understand the process of formation of TUGSE, and to uncover targetable pathogenetic pathways.
As TUGSE may mimic malignancy or infectious diseases, biopsy is mandatory and should be combined with thorough clinical examination. A screening for infectious diseases (mainly syphilis, EBV, and HIV infections) must be performed routinely. In the majority of cases, the lesions resolve spontaneously, obviating the need of further actions other than clinical follow-up, which is advisable even in complete remission. The pathogenesis of TUGSE lesions is still under debate, although local traumatic events and a locotypic immune response have been suggested to be major contributing factors.
The authors would like to thank Dr. Selina Ackermann for editorial assistance.
All authors were involved in the preparation of this manuscript. BB and JM wrote the manuscript. BB performed the oral examination, and performed the biopsy. BB and JM have carried out the follow-up examinations. AT performed the histopathological investigations and revised the manuscript. CK has performed clinical supervision of the case and revised the manuscript. All authors read and approved the final manuscript.
There is no funding for this work.
Ethics approval and consent to participate
Ethical approval was obtained from the ethics committee Nordwest and Central Switzerland to report a TUGSE case with literature review to describe the dignity and differential diagnosis of this rare and hardly known entity (register number 2016/274). Informed consent was obtained from the patient for case description and photo material.
Consent for publication
We obtained the patient’s consent for publication.
The authors declare that they have no competing interests.
- 8.Fede F. Della produzione sottolinguale, o malattia del Riga. Atto Congresso italiano di pediatria. Atto Congresso italiano di pediatria 1890. Napoli 1891. p. 251–260.Google Scholar
- 10.Popoff S. Documents Iconographiques, fig. 450. Annales Dermatologie et Syphilographie; 1956. p. 83.Google Scholar
- 14.Meier VS, Rufle A, Gudat F. Simultaneous evaluation of T- and B-cell clonality, t(11;14) and t(14;18), in a single reaction by a four-color multiplex polymerase chain reaction assay and automated high-resolution fragment analysis: a method for the rapid molecular diagnosis of lymphoproliferative disorders applicable to fresh frozen and formalin-fixed, paraffin-embedded tissues, blood, and bone marrow aspirates. Am J Pathol. 2001;159(6):2031–43.CrossRefGoogle Scholar
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.