International Journal of Medical and Dental Case Reports (2018), Article ID 060427, 3 Pages

CASE REPORT

“Lobular capillary hemangioma in a rare location” – A case

report
Ramya Rai, Shreya Dasgupta, Prashant Babaji, K. K. Shashibhushan
Department of Pedodontics and Preventive Dentistry, Sharavathi Dental College and Hospital, Shimoga, Karnataka, India

Correspondence: Abstract
Dr. Shreya Dasgupta, A female patient presented with an unusual location of pyogenic granuloma on the
Department of Pedodontics and Preventive
ventral surface of the tongue. These lesions are seen mostly between ages ranging
Dentistry, Sharavathi Dental College and
from 11 to 40 years and occur frequently on gingiva but less frequently on the tongue.
Hospital, Shimoga, Karnataka, India.
Phone: 91-8087056794.
Identification of the primary etiological factors and its removal followed by excisional
E-mail: sdg281291@gmail.com biopsy with definitive histopathological diagnosis was done. Follow-up of the patient
showed no recurrence.
Received 5 March 2019;
Accepted 10 April 2019 Keywords: Capillary, hemangioma, lobular, tongue

doi: 10.15713/ins.ijmdcr.115

How to cite the article:

Rai R, Dasgupta S, Babaji P, Shashibhushan KK.
“Lobular capillary hemangioma in a rare
location” – A case report. Int J Med Dent Case
Rep 2018;5:1-3.

Introduction On inspection, a well-defined, reddish pink solitary localized

Pyogenic granuloma (PG) or Lobular capillary hemangioma
(LCH) is a common benign soft tissue tumor that is thought to
arise from the connective tissue of the skin or mucous membrane.
The term PG paradoxically neither implies to a lesion that is
infectious nor granulomatous, but on the contrary, it is a reactive
inflammatory process to some low-grade chronic irritation.[1]
Occurrence rate of PG is most commonly on the gingiva
(almost 75%) and other affected sites being dorsum of the
tongue, buccal mucosa, and lips.[2] The present case reports with
an unusual location of PG on the ventral surface of the tongue.
Case Report
A 12-year-old female reported to the Department of Pedodontics
and Preventive Dentistry of Sharavathi Dental College and
Hospital with a chief complaint of growth below the tongue for
6 months. No significant medical history was elicited by the patient.
The growth was first noticed 6 months back, and during this
time period, it would spontaneously increase or decrease in size.
Since the past 1  month, the swelling appeared to be gradually
increasing in size and caused discomfort to the patient during
speech and mastication. There was no pain associated with the
swelling.
exophytic growth was seen in the midline of the ventral surface of
the tongue. The surface was smooth with no ulcerations. Miller’s
Class III gingival recession with respect to 31 and 41 was seen on
intraoral examination with moderate calculus [Figure 1].
On palpation, inspection findings were confirmed.
The swelling appeared to be sessile, leaf-  like in shape and
measured approximately 1.5  cm × 0.5 cm in size. It was soft
in consistency, non-mobile, afebrile, non-tender with no thrill
and blanched on the application of pressure. There was no
fluctuation, translucency, or indentation associated with the
lesion.
Based on history and clinical examination, a provisional
diagnosis of PG was given, and surgical excision under local
anesthesia was planned. Before surgery, written consent
was obtained by the patient and also permission for usage of
images for academic purposes was obtained. Routine blood
investigations were within normal range.
Perioral structures were prepared with betadine and the
soft tissues were adequately anesthetized. The tip of the tongue
was sutured and elevated upward to obtain the visibility of the
lesion. A Bard-Parker blade number 15 was used for excision. An
elliptical incision was given at the base of the lesion for its removal
[Figure 2]. Along with the excised lesion, 2 mm of healthy tissue
was also excised. The area was checked for remnants of tissue

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Hemangioma in rare location Rai, et al.

tags and granulation tissue. After which copious irrigation with
povidone-iodine was done and interrupted sutures were placed
with 3–0 silk [Figure  3]. The excised lesion was stored in a
formalin solution and sent for histopathological examination
[Figure 4].
The patient was then recalled after 1 week for suture removal.
2 weeks later, the patient showed healing of the excised area with
the absence of any post-operative complications.
The presence of moderate calculus accounts for the chronic
irritation of the mucosa of the ventral surface of the tongue. The
presence of these two factors synergistically can be considered as
etiological factors of the PG. PG is an inflammatory hyperplasia
affecting the oral tissues possibly caused by the presence of
calculus and foreign material.[5] Due to the raised level of sex

Discussion
The rate of occurrence of PG is between 26.8% and 32% and is
seen mostly in all age groups mostly between 11 and 40 years.[3]
Pathogenesis of the occurrence of PG is unclear; however, many
factors such as trauma ,chronic irritation and hormonal changes
have been suggested. The incidence of the occurrence of PG
is more in females than males in the ratio 3:2.[4] In the present
case, PG was diagnosed in 13-year-old female patient. Menarche
can be one of the reasons for the occurrence of the lesion in this
case as changes in hormonal levels occurs during this phase.

Figure 3: Excised specimen

Figure 1: Pre-operative view of the lesion Figure 4: Interrupted sutures placed

Figure  5: Histopathological section showing proliferating blood

Figure 2: Excisional biopsy of the lesion vessels with mixed inflammatory infiltrate in an edematous stroma

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Rai, et al.
hormone and progesterone in females, the occurrence of LCH
is encountered more in females and similar features are seen in
the present case. Thus, the presence of moderate calculus was
considered as primary etiological factor fuelled with hormonal
changes caused the proliferating growth. Therefore, the patient
first underwent oral prophylaxis where the primary etiological
factor calculus was eliminated. Since the clinical presentation
of PG is variable, it can mimic other oral lesions in children;
thus, differential diagnosis of fibroma, Kaposi’s sarcoma,
metastatic tumor, bacillary angiomatosis, hemangiopericytoma,
and peripheral giant cell granuloma was made,[6,7] therefore
excisional biopsy of the lesion was done for confirmation. Final
diagnosis was made based on the histopathological report.
Histopathological evaluation of the present case revealed
proliferating blood vessels with mixed inflammatory infiltrate in
an edematous stroma [Figure 5]. Thus, histopathological report
is in accordance with the clinical finding.
Two histological variants of PG have been described: LCH
and non-LCH. In LCH, vessels are seen in lobular aggregates
with proliferating blood vessels with small luminal diameter.
Whereas in non-LCH, a vascular core resembling granulation
tissue with focal fibrous tissue is observed.[8] The histological
finding in the present case showed similar finding as LCH.
Surgical excision of the lesion was done using conventional
technique which showed good prognosis with no post-operative
complication. Other alternative techniques are cryosurgery,
laser surgery with Nd: YAG, CO2, and flashlamp pulsed lasers.[9]
Recurrence is rare but hormonal changes during puberty may
cause the lesion to reoccur.[10] Thus, follow-up in such cases is
mandatory.
Conclusion
Many oral lesions may mimic other tumor-like lesions; thus,
patient’s history along with scrutiny of the etiological factors will
help us arrive at a definitive diagnosis which should be confirmed
by proper laboratory investigations such as histopathological
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Hemangioma in rare location
investigation to rule out other neoplastic or non-neoplastic
lesion. In the present case, the removal of the primary etiological
factor, calculus, along with oral health education and follow-up
lead to the successful clinical outcome.
Clinical Significance
Early diagnosis and treatment planning are the essence of
surgery. As the adolescent patient’s value esthetics, it is the duty
of the pedodontist to educate and motivate them.
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