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Open Access Full Text Article                                                          Case Report

Gingival Plasma Cell Granuloma Mimicking Malignancy in a Pediatric Patient with Poor Oral Hygiene and Malnutrition: A Case Report

Nadya Jeihan Riyani *¹, Nuri Fitriasari ², Nanan Nur’aeny ³

¹ Oral Medicine Residency Program, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia;

² Oral Health Polyclinic, Oral Medicine Division, Dr. Hasan Sadikin Central General Hospital, Bandung, Indonesia;

³ Department of Oral Medicine, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia

 

 

BACKGROUND

Plasma cell granuloma (PCG) is an uncommon benign inflammatory lesion characterized by a dense polyclonal plasma cell infiltrate within a fibrovascular stroma and commonly referred as an inflammatory pseudotumor due to its clinical and histologic resemblance to neoplasms ¹. Although most cases are reported in the lung, extrapulmonary PCG has been discovered to be in the gastrointestinal tract, central nervous system, and the oral cavity. Oral involvement of PCG is reported rare with gingival localization is unusual with only limited number of cases reported most in adult patients ^{1, 2}.

Gingival PCG clinically presents as an exophytic or polypoidal mass with ulceration or bleeding and close to mimic malignancy lesions. Aggressive fibromatosis and pediatric rhabdomyosarcoma can also be considered when evaluating rapidly enlarging gingival masses in pediatric cases as these conditions may closely resemble PCG in their early clinical course. Irritative lesions with mass like appearance in gingiva such as pyogenic granuloma or fibroma may also considered as differential diagnoses ³.

Histopathological examinations are needed to determine the definitive diagnosis to distinguish the lesions from malignancy ⁴. Predisposing factors include chronic irritation from poor oral hygiene, local trauma, drug-related gingival overgrowth, and systemic vulnerabilities such as malnutrition ^{5, 6}.

This case describes gingival PCG in pediatric patient clinically mimicking malignancy associated with poor oral hygiene and malnutrition. This report aims to highlight diagnostic challenges, discuss the systemic and hematologic findings, and the importance of histopathology and multidisciplinary management in distinguishing PCG from malignant lesions.

CASE PRESENTATION

A 3-year-old boy was referred due to gingival swelling and bleeding two weeks after a traumatic fall. The patient received blood transfusion in the previous hospital and due to no improvement on gingival condition and constant bleeding, the patient was referred to Hasan Sadikin Central General Hospital. The patient was treated under multidisciplinary department consisting of Oral and Maxillofacial Surgery, Pediatrics, and Oral Medicine. Informed consent was obtained and approved by the patient’s parents.

The patient was initially suspected with aggressive fibromatosis for the gingival lesion with rhabdomyosarcoma and pyogenic granuloma as the differential diagnosis. The patient also diagnosed anemic due to severe bleeding on the gingiva, coagulant factor disorder, and malnutrition. The treatment interventions included intravenous tranexamic acid, intravenous vitamin K, ceftriaxone, folic acid by Department of Pediatrics. Nutritional correction was also provided for malnutrition condition caused by inadequate nutritional intake resulting from severe bleeding. The patient was also received blood transfusion due to decrease in hemoglobin levels (6.1 g/dL) and severe bleeding.

The patient referred to Department of Oral Medicine with increased hemoglobin levels (10.6 g/dL) post-transfusion. Intraoral examination showed poor oral hygiene evaluated clinically the oral cavity showed plaques almost on every region of the teeth, multiple decays, and radix. The patient also reported had never cleaned his teeth. There was also erythematous gingival enlargement with pseudomembrane on gingival margins and bleeding was presence on almost every region of the gingiva (Figure 1; A-F). Oral debridement with hydrogen peroxide (H₂O₂) 1.5% and normal saline was performed, oral metronidazole and amoxicillin were prescribed, and the patient was instructed to maintain the oral hygiene by cleaning the teeth and oral cavity using gauze moistened with chlorine dioxide mouthwash two times a day in the morning and night before sleep, and to compress the swollen and bleeding gingiva using gauze soaked with chlorin dioxide mouthwash for around 1-5 minutes, three times a day.

On the next day, there was slightly improvement on oral hygiene showed by decreasing plaques on upper and lower anterior and lower right posterior teeth, and gingival swelling on labial region of lower anterior gingiva was decreased (Figure 1; G-L), pain was still present on almost every region of swollen gingiva, oral hygiene instruction was performed by the patient’s parents as instructed and the patient showed no allergies or discomfort to the mouthwash, the patient was scheduled for incisional biopsy. Two days after the incisional biopsy, there was slight pain on the biopsied gingiva (lower right posterior and anterior gingiva, upper anterior gingiva) when evaluated by palpation and the biopsied gingiva is still in the healing process, minor bleeding and pseudomembrane tissue were still present on the gingival margin (Figure 1; M-R). There was a decrease in hemoglobin levels (8.0 g/dL) and the patient received another blood transfusion. The patient continued to maintain oral hygiene by cleaning the teeth and oral cavity using gauze moistened with chlorin dioxide mouthwash and to compress the swollen and bleeding gingiva using gauze soaked with chlorin dioxide mouthwash for around 1-5 minutes, three times a day.

 

 

                 

Figure 1: Intraoral findings showed gingival swelling on almost every region of gingiva alongside with erythematous and pseudomembrane on gingival margin and bleeding (A-F); Slightly improvement on gingiva of the labial region of the mandible and overall conditions on second visit (G-L); Two days after incisional biopsy performed (M-R); Ten days after incisional biopsy performed, the oral hygiene and gingival swelling showed good improvement (S-X). 

 

Ten days after the biopsy, the gingival swelling healed, there was no bleeding and pain reported, the oral hygiene also showed good improvement (Figure 1; S-X). The laboratory findings showed normal levels of hematology parameter (Hemoglobin, hematocrits, leucocytes, erythrocytes, and platelets) with slightly increased in red blood cell distribution width-coefficient of variation (RDW-CV) and red blood cell distribution width-standard deviation (RDW-SD) levels and decreased in Iron Serum levels indicating anemic conditions due to blood loss and multiple blood transfusion history.

Histopathological examination resulted gingival plasma cell granuloma, characterized by stratified squamous epithelium with nuclei within normal limits. The underlying fibrocollagenous connective tissue stroma exhibited dense infiltration of plasma cells, lymphocytes, and histiocytes, along with vascular dilation and areas of hemorrhage. No signs of malignancy were presented (Figure 2).

 
 

Figure 2: Histopathological picture in H&E stain 40x (A) and 100x (green rectangle; B) magnification showed stratified squamous epithelium with no malignancy signs. On the subepithelial showed fibrocollagenous connective tissue with a very dense infiltration of chronic inflammatory cells predominantly plasma cells, lymphocytes and histiocytes with vascular dilation and area of hemorrhage.

 

 

DISCUSSION AND CONCLUSION

Gingival PCG is an uncommon lesion but of clinical importance because it can resemble neoplastic conditions. It has been reported that gingival enlargements initially suspected as malignancies, later confirmed as PCG after histopathology demonstrated polyclonal plasma cell proliferation ^{1, 2}. This diagnostic dilemma underscores the essential role of biopsy and histological confirmation in patients presenting with atypical gingival swellings.

The differential diagnosis for gingival PCG is broad. Common reactive entities include pyogenic granuloma and fibroma. Malignant lesions such as aggressive fibromatosis and rhabdomyosarcoma must also be considered. The diagnostic should be confirmed by histopathological findings. Aggressive fibromatosis presents as a firm, infiltrative gingival or jaw-associated lesion of myofibroblastic origin, often requiring wide resection due to local invasion ⁷, such lesions clinically overlap with PCG when there is rapid growth and severity. Pediatric rhabdomyosarcoma, the most common soft tissue sarcoma in pediatric patient, may appear as a rapidly enlarging gingival or alveolar mass with ulceration and bleeding, features that overlap with PCG and highlight the diagnostic challenge ⁸. In cases of fibromatosis, histopathology reveals spindle-shaped fibroblasts in interlacing fascicles, variable collagenous stroma, some mitotic activity but low cytologic atypia, distinct from rhabdomyosarcoma which shows marked pleomorphism, high mitosis, and markers like desmin or myogenin positivity ^7–9.

Histopathological examination is crucial for differentiating PCG from malignancy lesions such as aggressive fibromatosis and rhabdomyosarcoma. Lu et al. described multiple gingival PCG lesions in a 15-year-old, showing dense plasma cell infiltration without atypia, with no recurrence at 2-year follow-up ². Similarly, Pandav et al. detailed gingival PCG associated with chronic periodontitis, where excision and supportive periodontal therapy achieved resolution, and histopathology confirmed the absence of atypia and polyclonal plasma cell infiltration ¹. Across reported cases, PCG histopathological findings typically reveals dense plasma cell infiltrates, fibrovascular or fibromyxoid stroma, occasional Russell bodies, and chronic inflammatory cells such as lymphocytes and histiocytes, but importantly, no malignant cytologic atypia ^{1, 2, 4}.

Local factors mostly contribute significantly to PCG development. In the present case, lifelong absence of oral hygiene practices indicated by widespread plaques almost on every region of the teeth, multiple decays, and radix likely predisposed to severe inflammatory conditions on the oral cavity. Chronic poor oral hygiene promotes plaque-induced inflammation, creating a microenvironment rich in pro-inflammatory cytokines such as IL-6 that promote plasma cell differentiation and angiogenesis, explaining the vascular, hemorrhagic clinical features of PCG ^10–12.

Elevated serum IL-6 levels are also associated with poor nutritional intake. Recent study reported that patients with recurrent aphthous stomatitis (RAS) with higher level of serum IL-6 and reactive oxygen spesies (ROS) were significantly associated with poor nutritional intake and atopy, supporting the link between systemic vulnerabilities and worsened mucosal inflammation. The study suggests that cytokine-driven inflammation may exacerbate mucosal damage in nutritionally compromised individuals ^{13, 14}. In addition to cytokine-driven inflammation, low hemoglobin levels may contribute to malnutrition, since anemia is often associated with inadequate intake of hematinic nutrients such as folic acid, iron, and vitamin B12, which are commonly obtained from green leafy vegetables and red meat proteins ¹⁵. The patient’s oral condition compromised nutritional intake, leading to reduced hemoglobin levels and subsequent malnutrition. The patient also received folic acid supplementation from the Department of Pediatrics, consistent with studies showing that folate deficiency elevates homocysteine, disturbs oral epithelial blood supply, and causes tissue damage, while supplementation improves hematologic parameters and supports mucosal healing in conditions of bleeding and malnutrition ¹⁶. Systemic conditions, particularly malnutrition, may exacerbate oral lesion severity. Malnutrition compromises mucosal integrity, delays wound healing, and impairs immune function, which increases the inflammatory response to local irritation ^17–20. Although direct evidence linking malnutrition to PCG is limited, clinical severity in this pediatric patient case supports its contributory role. Furthermore, hematologic abnormalities complicated the conditions. Elevated RDW-CV and RDW-SD indicate anisocytosis, commonly associated with nutritional anemia or post-transfusion effects ^{21, 22}. Raised serum iron was likely secondary to multiple transfusions, which increase iron stores ^{23, 24}. While not directly implicated in PCG pathogenesis, these findings illustrate systemic instability and highlight the importance of a multidisciplinary approach.

Management of gingival PCG involves complete surgical excision, elimination of local irritants, and correction of systemic vulnerabilities. In both adult and pediatric cases, recurrence is uncommon if excision is complete and predisposing factors are controlled ^{1–3, 25}. In the present case, clinical improvement paralleled reinforcement of oral hygiene and nutritional correction, highlighting the value of comprehensive care. In addition to surgical excision, strict oral hygiene measures play an essential role in improving gingival conditions in PCG. This includes professional debridement, plaque control, and antiseptic rinses. Evidence from a recent case report in a patient with beta-thalassemia major demonstrated that spooling with hydrogen peroxide, the use of chlorine dioxide mouthwash, systemic antibiotics, and scaling, combined with oral hygiene instructions, effectively reduced gingival enlargement, bleeding, and inflammation ²⁶. Although the underlying systemic condition was different, the improvement highlights the importance of comprehensive oral hygiene management as an adjunct to lesion control. Similarly, in this case, gingival condition improved significantly after reinforcement of oral hygiene practices and adjunct antiseptic use, supporting the role of local plaque control in reducing lesion severity and preventing recurrence. Importantly, distinguishing PCG from malignancy through histopathological confirmation remains crucial to avoid mismanagement or delay in oncologic referral when malignant mimics are suspected.

In pediatric patients with systemic vulnerabilities such as poor oral hygiene and malnutrition, gingival plasma cell granuloma (PCG) may present with unusual severity and mimic malignancy. Histopathological confirmation and a multidisciplinary approach remain crucial to ensure diagnostic accuracy, avoid mismanagement, and achieve favorable outcomes. In this case, lesion improvement paralleled reinforcement of oral hygiene and nutritional support, underscoring the importance of controlling local and systemic factors.

Acknowledgments: The author would like to thank the patient’s family for giving consent for the publication of this case, including the images. The authors would also like to thank the staff of the Department of Oral Maxillofacial Surgery, the Department of Pediatric, and the Department of Anatomical Pathology for their kind help and support. 

Conflict of Interest: The author(s) report no conflicts of interest in this work. 

REFERENCES 

1. Pandav AB, Gosavi A V, Lanjewar DN, Jagadale R V. Gingival plasma cell granuloma. Dent Res J (Isfahan). 2012;9(6):816. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC3612237/

2. Lu W, Qi GG, Li XJ, He FM, Hong B. Gingival Plasma Cell Granuloma: A case Report of Multiple Lesions. Journal of Clinical Pediatric Dentistry. 2020;44(6):439-41. Available from: https://pubmed.ncbi.nlm.nih.gov/33378465/ https://doi.org/10.17796/1053-4625-44.6.8 PMid:33378465

3. Jhingta P, Mardi K, Sharma D, Bhardwaj V, Bhardwaj A, Saroch N, et al. An Enigmatic Clinical Presentation of Plasma Cell Granuloma of the Oral Cavity. Contemp Clin Dent. 2018;9(1):132. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5863397/ https://doi.org/10.4103/ccd.ccd_816_17 PMid:29599600 PMCid:PMC5863397

4. El-Bastawesi AM, Ibrahim MMA, El-Sissy NA. Significance of Kappa and Lambda Immunohistochemical Expression in the Diagnosis of Oral Plasma Cell Granuloma. Mansoura Journal of Dentistry. 2023;11(1):26-30. Available from: https://www.mansjdent.com/home/vol11/iss1/4 https://doi.org/10.61793/2812-5479.1116

5. Strączek A, Szałkowska J, Sutkowska P, Srebrna A, Puzio N, Piasecka A, et al. Impact of nutrition on the condition of the oral mucosa and periodontium: A narrative review. Dent Med Probl. 2023;60(4):697-707. https://doi.org/10.17219/dmp/156466 PMid:38133993

6. Sheetal A, Hiremath VK, Patil AG, Sajjansetty S, Sheetal Kumar R. Malnutrition and its Oral Outcome - A Review. J Clin Diagn Res. 2013;7(1):178. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC3576783/ https://doi.org/10.7860/JCDR/2012/5104.2702 PMid:23449967 PMCid:PMC3576783

7. Yang J, Tian X, Zhou K, Wu Y. A case report of mandibular aggressive fibromatosis in a pediatric patient: diagnostic challenges and surgical management. Int J Surg Case Rep. 2025;130:111286. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC12017844/ https://doi.org/10.1016/j.ijscr.2025.111286

8. Komatsu Y, Kawai T, Miura S, Takeda Y, Yamada H. Rhabdomyosarcoma in the maxillary gingiva of a child patient. J Surg Case Rep. 2021;2021(7):rjab322. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8326001/ https://doi.org/10.1093/jscr/rjab322 PMid:34345404 PMCid:PMC8326001

9. Alam M, Sadeghi HMM, Mashhadiabbas F, Alamdari MI. Aggressive fibromatosis in the submandibular region of a child. Clin Case Rep. 2022;10(4):e05761. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9019870/ https://doi.org/10.1002/ccr3.5761 PMid:35474988 PMCid:PMC9019870

10. Gulati R, Ratre MS, Khetarpal S, Varma M. A Case Report of a Gingival Plasma Cell Granuloma in a Patient on Antihypertensive Therapy: Diagnostic Enigma. Front Dent. 2019;16(2):144. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6874842/ https://doi.org/10.18502/fid.v16i2.1366 PMid:31777856 PMCid:PMC6874842

11. Mazurek-Mochol M, Bonsmann T, Mochol M, Poniewierska-Baran A, Pawlik A. The Role of Interleukin 6 in Periodontitis and Its Complications. Int J Mol Sci. 2024;25(4):2146. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10889213/ https://doi.org/10.3390/ijms25042146 PMid:38396821 PMCid:PMC10889213

12. Yee M, Kim S, Sethi P, Düzgüneş N, Konopka K. Porphyromonas gingivalis stimulates IL-6 and IL-8 secretion in GMSM-K, HSC-3 and H413 oral epithelial cells. Anaerobe. 2014;28:62-7. Available from: https://www.sciencedirect.com/science/article/abs/pii/S1075996414000614 https://doi.org/10.1016/j.anaerobe.2014.05.011 PMid:24887636

13. Nur’aeny N, Gurnida DA, Suwarsa O, Sufiawati I. Serum level of IL-6, reactive oxygen species and cortisol in patients with recurrent aphthous stomatitis related imbalance nutrition intake and atopy. Journal of Mathematical and Fundamental Sciences. 2020;52(3):286-96. https://doi.org/10.5614/j.math.fund.sci.2020.52.3.3

14. Nur’aeny N, Sufiawati I, Suwarsa O, Gurnida DA. Serum IL-6 levels of atopic patients with recurrent aphthous stomatitis (RAS). Padjadjaran Journal of Dentistry. 2019 Mar 29;31(1):20. https://doi.org/10.24198/pjd.vol31no1.21223

15. Wahyuni IS, Fatriadi F, Prisinda D, Putri FM, Nuraeny N, Hidayat W. Pengalaman Karies, Kadar Haemoglobin, Berat Badan dan Tinggi Badan pada Anak dengan Lesi Mukosa Oral. Odonto: Dental Journal. 2017;4(2):79. https://doi.org/10.30659/odj.4.2.79-84

16. Qisty MA, Wahyuni IS, Nur’aeny N. Nutritional Status of Patient with Recurrent Aphthous Stomatitis: A Systematic Review of Observational Study. Journal of International Dental & Medical Research. 2022;15(3):1379. Available from: https://openurl.ebsco.com/contentitem/gcd:159483985?sid=ebsco:plink:crawler&id=ebsco:gcd:159483985

17. Al-Kalisi M, Al-Hajri M, Al-Rai S. Relationship between Undernutrition and Periodontal Diseases among a Sample of Yemeni Population: A Cross-Sectional Study. Int J Dent. 2022;2022:7863531. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8901342/ https://doi.org/10.1155/2022/7863531 PMid:35265136 PMCid:PMC8901342

18. Berg Y, Gabay E, Božić D, Shibli JA, Ginesin O, Asbi T, et al. The Impact of Nutritional Components on Periodontal Health: A Literature Review. Nutrients. 2024;16(22):3901. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11597335/ https://doi.org/10.3390/nu16223901 PMid:39599688 PMCid:PMC11597335

19. Jar AA, Alghoraibi MG, Mahjoub WK, Almajed AA, Alghadyan AK, Marwan AHB. Nutritional deficiencies and their impact on gum health. Int J Community Med Public Health. 2025;12(1):540-4. Available from: https://www.ijcmph.com/index.php/ijcmph/article/view/13543 https://doi.org/10.18203/2394-6040.ijcmph20244069

20. Pranadwista ZF, Hasanah NT, Nur’aeny N. Clinical Investigation of Patients with Oral Hematoma and Anemia Linked to Symptoms of Indigestion: A Case Report. Int Med Case Rep J. 2024;17:757-63. https://doi.org/10.2147/IMCRJ.S479028 PMid:39220374 PMCid:PMC11363933

21. Salvagno GL, Sanchis-Gomar F, Picanza A, Lippi G. Red blood cell distribution width: A simple parameter with multiple clinical applications. Crit Rev Clin Lab Sci. 2015;52(2):86-105. Available from: https://pubmed.ncbi.nlm.nih.gov/25535770/ https://doi.org/10.3109/10408363.2014.992064 PMid:25535770

22. Lippi G, Cervellin G, Sanchis-Gomar F. Red blood cell distribution width: A marker of anisocytosis potentially associated with atrial fibrillation. World J Cardiol. 2019;11(12):292. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6937412/ https://doi.org/10.4330/wjc.v11.i12.292 PMid:31908729 PMCid:PMC6937412

23. Rasel M, Hashmi MF, Mahboobi SK. Transfusion Iron Overload. StatPearls. 2024; Available from: https://www.ncbi.nlm.nih.gov/books/NBK562146/

24. Sawicka-Żukowska M, Krętowska-Grunwald A, Topczewska M, Krawczuk-Rybak M, Grubczak K. Is Serum Ferritin a Predictor of Blood Transfusions Outcome and Survival in Childhood Lymphomas and Solid Tumors? Cancers (Basel). 2024;16(22):3742. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11593196/ https://doi.org/10.3390/cancers16223742 PMid:39594698 PMCid:PMC11593196

25. Gulati R, Ratre MS, Khetarpal S, Varma M. A Case Report of a Gingival Plasma Cell Granuloma in a Patient on Antihypertensive Therapy: Diagnostic Enigma. Front Dent. 2019;16(2):144. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6874842/ https://doi.org/10.18502/fid.v16i2.1366 PMid:31777856 PMCid:PMC6874842

26. Karina D, Fitriasari N, Mandalas HY, Andhika R, Wahyuni IS, Wijaya I. Multidisciplinary Management of Oral Manifestations in Pregnant Women with Beta-Thalassemia Major: A Case Report. Int Med Case Rep J. 2024;17:709-17. Available from: https://www.tandfonline.com/doi/pdf/10.2147/IMCRJ.S464296 https://doi.org/10.2147/IMCRJ.S464296 PMid:39081554 PMCid:PMC11288352