Discussion

• Definitive diagnosis – “eosinophilic ulcer of the oral mucosa” (EUOM) – benign lesion
• Also known as: Traumatic ulcerative granuloma with stromal eosinophilia [TUGSE], traumatic granuloma, ulcerated granuloma, eosinophilicum diutinum, eosinophilic granuloma of soft tissue
• Etiology unclear although trauma plays a major role in the development of lesion
• Bimodal age distribution:
  • 1^st 2 years of life
  • 6^th or 7^th decades

• Riga-Fede is variant of EUOM; it occurs in children <2 years caused by the rubbing of the tongue against newly erupted teeth
  • May be a sign of a neurologic disorder given its self-inflictive nature
  • Associated in children with:
    • Cerebral palsy
    • Riley-Day syndrome (familial dysautonomia)
    • Lesch-Nyhan syndrome
    • Congenital indifference to pain

Presentation

• Non-healing solitary ulcer ~1-2 cm in diameter
• Indurated borders
• Occur on any mucosal surface – predilection for tongue
• Can be symptomatic
• Regional lymph node involvement at times

Histopathology

• Involvement of superficial mucosa and may extend into deeper muscle layers
• Polymorphic inflammatory infiltrate with predominance of eosinophils

Differential Diagnosis

• Traumatic, non-specific ulcer
• Major aphthous ulcer
• Mycobacterial infection
• Viral infection
• Deep fungal infection
• Squamous cell carcinoma

Treatment

• Usually self-limiting
• Eliminate potential sources of trauma
• Palliative treatment with topical analgesics and/or topical or intra-lesional corticosteroids to improve healing
• Excisional removal, cryotherapy and curettage have been reported as possible modes of treatment
• If the lesion persists for >2 weeks, further evaluation and management is required

Patient Considerations

• In the present case, the patient was prescribed high-potency topical corticosteroids but did not follow up subsequently; the status of the lesion is unknown. 
• Insulin-dependent diabetics may be at increased risk of oral soft tissue lesions, specifically, fissured tongue, irritation fibromas and traumatic ulcers.
• Protracted wound healing of the oral mucosa in diabetics has been attributed to factors such as: delayed vascularization, reduction in blood flow, decline in innate immunity, decreases in growth factor production and psychological stress.

References

1. Segura S, Pujol RM. Eosinophilic ulcer of the oral mucosa: a distinct entity or a non-specific reactive pattern? Oral Dis 2008; 14(4): 287-295.
2. El-Mofty SK, Swanson PE, Wick MR, Miller AS. Eosinophilic ulcer of the oral mucosa. Oral Surg Oral Med Oral Pathol 1993; 75(6): 716-722.
3. Yacovone L, Roberson D, Ng MW. Riga-Fede disease: a rare sublingual traumatic ulcerative lesion in a child. Otolaryngol Head Neck Surg 2012; 146(2): 333-4.
4. Chawla O, Burke GA, Macbean AD. The eosinophilic ulcer revisited. Dent Update 2007; 34(1): 56-57.
5. Chatzistamou I, Doussis-Anagnostopoulou I, Georgiou G, Gkilas H, Prodromidis G, Andrikipoulou M, et al. Traumatic ulcerative granuloma with stromal eosinophilia: report of a case and literature review. J Oral Maxillofac Surgery 2012; 70(2): 349-353.
6. Bortoluzzi MC, Passador-Santos F, Capella DL, Manfro, G, Nodari, RJ Jr, Presta AA. Eosinophilic ulcer of oral mucosa: a case report. Ann Stomatol (Roma) 2012; 3(1): 11–13.
7. Guggenheimer J, Moore PA, Rossie K, Myers D, Mongelluzzo MB, Block HM, et al. Insulin-dependent diabetes mellitus and oral soft tissue pathologies. I. Prevalence and characteristics of non-candidal lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 89(5): 563 – 569.
8. Abiko Y, Selimovic D. The mechanism of protracted wound healing on oral mucosa in diabetes. Bosn J Basic Med Sci 2010(3); 10: 186 – 191.
9. Yamano S, Kuo WP, Sukotjo C. Downregulated gene expression of TGF-Bs in diabetic oral wound healing. J Craniomaxillofac Surg 2013(2); 41: e42 – 48.