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A rare case of symptomatic ocular pyogenic granuloma in pregnancy

Ashok Kumar, Dhivya; Thajudeen, Heba; Agarwal, Amar

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Indian Journal of Ophthalmology: August 2020 - Volume 68 - Issue 8 - p 1645-1646
doi: 10.4103/ijo.IJO_2239_19
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A 23-year-old primigravida (37 weeks) complained of bleeding from the right eye for 15 days. The patient denied any history of trauma or surgery. On examination, the right upper lid revealed a well-defined, nontender, red, polypoidal smooth-surfaced 5 mm mass in the palpebral conjunctiva with active bleeding [Fig. 1]. Visual acuity was 20/20 in both eyes and fundus was normal. After gynecologist consultation and basic systemic workup (bleeding time 3 minutes and clotting time 6 minutes), she underwent excision biopsy [Fig. 2a and b] with cauterization of the base under 0.5 cc local infiltration of 2% lignocaine. The histopathology showed a lesion with lobules of thin-walled vessels with intervening stromal foci of lymphoplasmacytic infiltration [Fig. 3].

Figure 1
Figure 1:
Actively bleeding upper palpebral conjunctival mass lesion on the day of presentation
Figure 2
Figure 2:
Inactive mass on the day of surgery (a) and after excision with base cautery (b)
Figure 3
Figure 3:
Histopathology micrograph with 10X magnification stained with Haematoxylin and eosin of lobulated capillary hemangioma. The histopathology showed fibro-collagenous tissue covered by mucosa, epithelium showed acanthosis and areas of ulceration and dermis showed a lesion with lobules of thin walled vessels with intervening stromal foci of lymphoplasmacytic infiltration

Discussion

Angelopoulos AP described the lesion as “Hemangiomatous Granuloma” due to the presence of numerous blood vessels and inflammatory pictures histologically.[1] In a case series of 7 pregnant women who developed hemangiomas during pregnancy, it was proposed that hormonal alterations, changes in blood volume contributed to their occurrence.[2] Yuan et al. described the relationship between pyogenic granulomas and angiogenic factors in pregnancy.[3] According to the authors, female hormones not only enhance the expression of angiogenic factors such as basic fibroblast growth factor (FGF) and vascular endothelial growth factor (VEGF) but also decrease cell apoptosis by lessening the expression of tissue necrosis factor-alpha (TNF-alpha).[4] A pregnancy tumor has a prevalence of 0.2–9.6% during gravidity.[5] They commonly appear after the first trimester, grow rapidly, and typically regress after delivery. Complete excision with Histopathological examination (HPE) is the treatment of choice in persistent lesions with bleeding, painful or excessively large. The overall risk of recurrence is about 7% more following prior surgery and warrants close monitoring. The case thus highlights the management of a distressing lid hemangioma in a third-trimester primigravida.

Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.

1. Angelopoulos AP. Pyogenic granuloma of the oral cavity: Statistical analysis of its clinical features J Oral Surg. 1971;29:840–7
2. Barter RH, Letterman GS, Schurter M. Hemangiomas in pregnancy Am J Obst Gynec. 1963;87:625–35
3. Yuan K, Wing LY, Lin MT. Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol. 2002;73:701–8
4. Al-Towerki AA. Pyogenic Granuloma Int Ophthalmol. 1995;1996(19):287–91
5. Reddy NR, Kumar PM, Selvi T, Nalini HE. Management of recurrent post-partum pregnancy tumor with localized chronic periodontitis Int J Prev Med. 2014;5:643–7
Keywords:

Lobular capillary hemangioma; pregnancy; pyogenic granuloma

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