Volume 4, Issue 1 , Pages 14-16, January 2009
Pyogenic granuloma as a complication of prolonged nasogastric tube insertion in an immuno-compromised host
Article Outline
Summary
Pyogenic granuloma is a polypoidal capillary hemangioma that occurs on the skin and mucosal surface. Trauma, hormonal changes seen in pregnancy and use of the oral contraceptive pill have a role in its pathogenesis. Except for the oral cavity, involvement of gastrointestinal tract is quite rare and there are no reports of hypopharyngeal involvement. We report a case of hypopharyngeal pyogenic granuloma most likely secondary to prolonged nasogastric tube insertion in an immuno-compromised host.
Keywords: Pyogenic granuloma, Chemotherapy, Lobular capillary hemangioma, Gastroesophageal reflux, Hypopharynx
1. Introduction
Pyogenic granuloma (PG) is a lobular capillary hemangioma that presents as a polypoidal red mass that varies in size from several millimeters to a few centimeters. It is friable, bleeds easily and in the early stages resembles granulation tissue [1]. The lesion is found on the skin (particularly the lips, face, fingers), mucosal surface of the oral cavity and tongue. It is a benign tumor thought to be a response to trauma or hormonal factors [1] and excision is generally curative. Except for oral cavity, there are only a few cases of PG involving gastrointestinal tract reported in literature [2], [3] and none were mentioned arising from hypopharynx. The presence of periungual PG associated with chemotherapeutic agents (systemic 5-fluorouracil and capecitabine) [4], [5] and tongue involvement [6] following bone marrow transplantation indicate that chemotherapy and or immunosupression may also play a role. We report a case of hypopharyngeal PG secondary to prolonged nasogastric tube (NGT) insertion in an immuno-compromised child.
2. Case report
A 4-year-old boy with Down's syndrome was admitted at the Stollery Childrens hospital for right hip pain, painful left elbow and lethargy for 6 weeks. There was a history of croup twice in the past with no prior history of general anesthetic procedures. Bone marrow aspirate was consistent with pre-B cell acute lymphoblastic leukemia and was started on the Childrens Onology Group (COG) protocol which consisted of dexamethasone, vincristine, and pegaspargase. One week into his chemotherapy he was having difficulty tolerating oral intake and a NGT was inserted. Following the second course of vincristine, the patient developed mild hoarseness which progressively worsened. Flexible bronchoscopy revealed mild supraglottic edema with bilateral laryngeal paralysis secondary to vincristine. Two days following this procedure, his respiratory status worsened and was admitted to the Pediatric Intensive Care Unit and intubated for 2 days. The vincristine was interrupted and he required bi-level positive airway pressure at nighttime to stabilize his sleep disordered breathing. On day 36 of therapy, his bone marrow aspiration revealed remission.
Six weeks following NGT insertion, he underwent a laryngoscopy which showed that there was some return of laryngeal movement bilaterally. However, there was a large mass arising from the post-cricoid region, firm to touch and had a frond-like appearance (Fig. 1). There was no evidence of vocal cord fixation. A biopsy was taken followed by a microdebrider assisted reduction. A percutaneous gastrostomy was also done at the same time. Biopsy from the hypopharyngeal mass was reported as PG. The microscopic appearance demonstrated the presence of a florid neovascular proliferation associated with a mixed inflammatory infiltrate and reactive fibroblasts. The surfaces were often eroded, associated with tissue edema with numerous vessels showing concentric adventitial fibrous thickening, infiltrated by neutrophils (Fig. 2).
Fig. 1.
Laryngoscopy (6 weeks post nasogastric tube insertion), showing a large post-cricoid mass with frond-like appearance.
Fig. 2.
Florid neovascular proliferation with a mixed inflammatory infiltrate and reactive fibroblasts. Eroded surfaces with associated tissue edema and numerous vessels showing concentric adventitial fibrous thickening, infiltrated by neutrophils (H+E X40).
A month after the initial debridement, a suspension laryngoscopy and esophagoscopy was repeated and remnant of the granuloma was once again debrided and triamcinalone was injected into its base. A repeat laryngoscopy done 2 months later showed that the laryngeal paralysis had resolved and there was no recurrence of the granuloma.
3. Discussion
PG is a common angiomatous proliferation that occurs on the skin and mucosal surfaces. The lesion is essentially a capillary hemangioma that has a unique lobular organization and this pattern easily distinguishes it from other vascular tumors. In a review of 73 cases from oral and nasal mucosa Mills et al. [7] concluded that the most common site of involvement was the lip followed by nasal cavity. Trauma, hormonal changes seen in pregnancy and use of the oral contraceptive pill have a role in its pathogenesis [7]. Concomitant use of a NGT is a significant risk factor for the development of mucosal erythema and granuloma formation [8] and can compromise the upper and lower esophageal sphincters allowing gastroesophageal contents to bathe the posterior glottis.
Drug-induced cases of PG have been described from use of topical and systemic retinoids and antiretroviral agents such as indinavir [4]. Periungual PG have been reported with administration of chemotherapeutic agents (capecitabine [5] and systemic 5-fluorouracil [4]). Involvement of tongue has been reported in patients on cyclosporine therapy secondary to chronic graft-versus-host disease [6].
Development of PG in our patient could have resulted from a combination of factors such as mucosal trauma due to prolonged duration of NGT insertion, increased patient susceptibility to gastroesophageal reflux and the possible vincristine induced immunodeficiency may have also played a role.
In conclusion, we report the rare occurrence of hypopharyngeal PG. The factors that may have played a role in its development are prolonged NGT feeding, gastroesophageal reflux disease and chemotherapy. As these factors coexist frequently in oncology patients, it is quite conceivable that many cases are missed.
References
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- . A 15-year-old boy with an esophageal pyogenic granuloma and subsequent Barrett's esophagus (with videos). Gastrointest. Endosc. 2007;65(7(June)):1086–1088(Epub 2007 April 23.A)
- . Pyogenic granuloma arising from vallecula. Otolaryngol. Head Neck Surg. 2006;134(1(January)):175–176
- . Multiple periungual pyogenic granulomas following systemic 5-fluorouracil. Austr. J. Dermatol. 2006;47:130–133
- . Pyogenic granuloma-like lesions during capecitabine therapy. Br. J. Dermatol. 2002;147:1270–1272
- Pyogenic granuloma of the tongue early after allogeneic bone marrow transplantation for multiple myeloma. Leuk. Lymph. 2000 Apr;37(3–4):445–449
- . Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma: a study of 73 cases from the oral and nasal mucous membranes. Am. J Surg. Pathol. 1980;4:470–479(from PG3)
- . Laryngeal injuries after short- versus long-term intubation. J. Voice. 1998;12(3(September)):360–365
PII: S1871-4048(08)00032-4
doi:10.1016/j.pedex.2008.04.004
© 2008 Elsevier Ireland Ltd. All rights reserved.
Volume 4, Issue 1 , Pages 14-16, January 2009
