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Pyogenic Granuloma of the Distal Trachea: A Case Report

Udoji, Timothy N. MD*; Bechara, Rabih I. MD*,†

Journal of Bronchology & Interventional Pulmonology: July 2011 - Volume 18 - Issue 3 - p 281–284
doi: 10.1097/LBR.0b013e318228f3b1
Brief Reports
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Pyogenic granuloma (PG), also known as lobular capillary hemangioma, is a common, acquired, non-neoplastic, vascular lesion that is often found on the skin and oral mucosa. The term “pyogenic granuloma” is a misnomer, as the lesion does not contain purulent material and is not a granuloma. Lesions have also been reported in the gastrointestinal tract and during pregnancy. PG is a smooth or lobulated, red lesion on a sessile or pedunculated base that varies in size from a few millimeters and rarely exceeds 2.5 cm. The etiology of PG remains unclear but they are thought to develop spontaneously or after local minor trauma where excess production of angiogenic growth factors have been implicated. Trachea PG lesion is rare and there is only 1 known report in the literature. Our case is unique, given the location of the lesion and our treatment using bronchoscopic cryosurgery.

*Division of Pulmonary, Allergy, and Critical Care Medicine

Interventional Pulmonary Program, Emory University School of Medicine, Atlanta, GA

Disclosure: The authors have no conflicts of interest to report.

Reprints: Rabih I. Bechara, MD, Emory Interventional Pulmonary Program, 1365 Clifton Road, TEC 4th Floor, Clinic A, Pulmonary Department, Atlanta, GA 30322 (e-mail: rbechar@emory.edu).

Received June 9, 2011

Accepted June 10, 2011

Pyogenic granuloma (PG), also known as lobular capillary hemangioma, is a common, acquired, non-neoplastic vascular lesion that is often found on the skin and oral mucosa.1–3 PG is an angiogenesis disorder and the name “pyogenic granuloma” is a misnomer, as the lesion does not contain purulent material and is not a granuloma.2,3 PG lesions have been reported in multiple locations.2,4–10 Specifically, cutaneous PG occurs in all age groups and has equal sex prevalence except for oral mucosal lesions, which seem to be more common in women.11,12 The lesion is usually a smooth or multilobulated, red to purple, and sessile or pedunculated lesion that rarely exceeds 2.5 cm in size.1–3 Definitive diagnosis relies on histopathologic examination, which reveals variably sized capillaries arranged in lobules in a connective tissue stroma.2,3,13 The etiology of PG lesion remains unclear. Lesions can develop spontaneously or as a sequelae of local irritation and minor trauma.2–7 In addition, bacterial and viral infection, hormonal stimuli, and angiogenic and granulation tissue growth factors are believed to play a role in the development of these lesions.2,7

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CASE REPORT

A 55-year-old African American man with a medical history significant for hypertension and a 40 pack-year smoking history presented to our clinic for evaluation of hemoptysis. Two days earlier, he experienced a choking sensation while eating peanut at home. During the coughing spell, he expectorated approximately 1 cup of bright-red blood mixed with fresh clots, which prompted him to present to the emergency room. He had no past history of hemoptysis or hematemesis. He worked as a welder and had quit smoking 4 years ago. Physical examination revealed partial dentition but without any sign of gingival disease or oral lesions. His lung and heart examination were also unremarkable. Hemoglobin was 13.6 g/dL, and the rest of the complete blood count, complete metabolic panel, international normalized ratio, and partial thromboplastin time were normal. Computed tomography of his chest with intravenous contrast did not reveal any parenchymal lung disease, but it showed a 0.4×0.5 cm soft tissue lesion on the left lateral wall of the distal trachea with adjacent thickening of the trachea wall (Fig. 1). The patient did not have a history of previous intubation or other airway surgery. Flexible bronchoscopy revealed a 0.5 cm hyperemic, pedunculated, polypoid tracheal lesion located approximately 1.5 cm from the main carina (Fig. 2). The rest of the trachea had normal mucosa and lumen. He underwent a complete excision of the tumor using a flexible cryoprobe (ERBE, Teubingen, Germany) during the flexible bronchoscopy (Fig. 2). The procedure was without complication, and mild bleeding that occurred did not require instillation of Neo-Synephrine. Histopathologic examination revealed variably sized capillaries arranged in a lobular pattern. The lobules were separated by fibrous stroma without any accompanying inflammatory cells (Fig. 3). There were no malignant cells, and the diagnosis of PG was made. At follow-up 3 months later, he denied any recurrent hemoptysis, and flexible bronchoscopy did not reveal any recurrent tracheal lesion.

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

FIGURE 3

FIGURE 3

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DISCUSSION

PG is a common, acquired, non-neoplastic vascular lesion that is often found on the skin and oral mucosa.1–3 In the oral cavity, the gingiva is the most affected site and accounts for 75% of all cases.3 There are multiple reports of PG in the nasal cavity,6,9 penis,7,10 during pregnancy,2 and in the gastrointestinal tract.4,5 Although the gastrointestinal and respiratory tracts share the same embryological origin, yet there are far more reports of gastrointestinal PG lesions compared with only 1 known report of tracheal PG lesion.8

According to a recent epidemiology study, there is equal prevalence of skin PG in all age groups and in both sexes.11 The same study suggested higher female prevalence for mucosal PG secondary to sex hormonal influence.11 Patients are usually asymptomatic, but the most common presenting symptom is bleeding.8 PG are usually smooth or multilobulated, red to purple-colored lesion on a sessile or pedunculated base.1–3 PG lesions vary in size from a few millimeters and rarely exceed 2.5 cm.2

PG lesions are often confused with true hemangiomas and Kaposi sarcoma.7 Definitive diagnosis is made with histopathologic examination, which reveals variably sized capillaries in a lobular pattern within a connective tissue stroma on H&E stain (Fig. 3).2,3,13 The stroma is often edematous and filled with a dense neutrophilic infiltrate.12 Immunohistochemical staining for cluster of differentiation molecule 34 and 31 will show endothelial cells lining the capillary loops.5,14 PG has 2 histologic phases: young lesions, which are vascular in appearance and primarily consisted of capillaries, in contrast to old lesions, which are collagenous in appearance.2

The etiology of PG remains elusive. The lesion can develop spontaneously and can been seen after minor trauma or local irritation in which excess local production of angiogenic growth factors and cytokines has been implicated.2,6,7 Bacterial and viral infections plus sex hormone imbalance during pregnancy are also thought to influence the development of these lesions.2,7

Treatment of PG focuses on the removal of causative irritants (ie, oral plaques for gingival PG) and source of local trauma, which may lead to regression of the lesion. Although these lesions are benign, localized recurrence is common.13 Surgical excision provides diagnostic and therapeutic treatment for skin PG. Other nonsurgical treatment approaches, which have mainly been reported for cutaneous lesions, include cryotherapy, laser therapy, sclerotherapy, and topical imiquimod.15,16

Gastrointestinal PGs have been treated with surgical resection and endoscopic snare polypectomy. Okada et al4 reported successful endoscopic resection of an 8-mm sessile lesion in the midesophagus. Park et al5 also reported successful endoscopic snare polypectomy of a 10-mm semipedunculated lesion in the second portion of the duodenum. These patients did not have recurrent PG lesion after 6 and 14 months of follow-up, respectively.4,5

Cryoablation is an effective treatment for cutaneous PG with a low recurrence rate. A retrospective review examined the treatment of 1162 cutaneous PG with 19 different treatment modalities.13 The rate of PG recurrence with cryotherapy was 1.62% compared with 2.94% with surgical excision. Irani et al8 used forceps excision biopsy for complete removal of the 3-mm tracheal lesion. In contrast, our patient's tracheal lesion was removed using a flexible cryoprobe (ERBE, Teubingen, Germany) during flexible bronchoscopy (Fig. 2).

Our case is unique, as it highlights the successful use of cryoablation for the diagnosis and treatment of this rare distal tracheal PG. At 12-week clinical follow-up, our patient denied any recurrent hemoptysis. A repeat flexible bronchoscopy did not show any tracheal lesion as well.

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REFERENCES

1. Veres G, Lukovich P, Gyorffy H. Pyogenic granuloma. J Pediatr Gastroenterol Nutr. 2011;52:1
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5. Park SY, Park CH, Lee WS, et al. Pyogenic granuloma of the duodenum treated successfully by endoscopic mucosal resection. Gut Liver. 2009;3:48–51
6. Lee HM, Lee SH, Hwang SJ. A giant granuloma in the nasal cavity caused by nasal packing. Eur Arch Otorhinolaryngol. 2002;259:231–233
7. Spinelli C, Giacomo MD, Bertocchini A, et al. Multiple pyogenic granuloma of the penis in a four-year-old child: a case report. Cases J. 2009;2:7831
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10. Eickhorst KM, Nurzia MJ, Barone JG. Pediatric pyogenic granuloma of the glans penis. Urology. 2003;61:644
11. Harris MN, Desai R, Chuang TY, et al. Lobular capillary hemangiomas: an epidemiologic report, with emphasis on cutaneous lesions. J Am Acad Dermatol. 2000;42:1012–1016
12. Moffatt DC, Warwryko P, Singh H. Pyogenic granuloma: an unusual cause of massive gastrointestinal bleeding from the small bowel. Can J Gastroenterol. 2009;23:261–264
13. Lee J, Sinno H, Tahiri Y, et al. Treatment options for cutaneous pyogenic granulomas: a review. J Plast Reconstr Aesthet Surg. 2011 doi:10.1016/j.bjps.2010.12.021.
14. Nichols GE, Gaffey MJ, Mills SE, et al. Lobular capillary hemangioma: an immunohistochemical study including steroid hormone receptor status. Am J Clin Pathol. 1992;97:770–775
15. Fallah H, Fisher G, Zagarella S. Pyogenic granuloma in children: treatment with topical imiquimod. Australas J Dermatol. 2007;48:217–220
16. Georgiou S, Monastirli A, Pasmatzi E, et al. Pyogenic granuloma: complete remission under occlusive imiquimod 5% cream. Clin Exp Dermatol. 2008;33:454–456
Keywords:

pyogenic granuloma; lobular capillary hemangioma; flexible cryoprobe; bronchoscopy; cryotherapy

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