A 69-year-old woman presented with 3 months of progressive gingival swelling unresponsive to antibiotics. She reported 1 month of low-grade fever, malaise, weight loss, and recurrent nasal bleeding. Her medical history included well-controlled hypertension managed with ramipril and hydrochlorothiazide.
Examination showed nontender enlargement of the upper anterior gingiva with a friable, strawberrylike surface and laterocervical lymphadenopathy. Laboratory results showed neutrophilic leukocytosis, anemia, elevated inflammatory markers, and hypergammaglobulinemia. Gingival biopsy demonstrated chronic inflammation with microabscesses and pseudoepitheliomatous hyperplasia.
Chest imaging showed multiple bilateral pulmonary nodules, though fine-needle aspiration was nondiagnostic. Bone marrow biopsy showed CD138-positive plasma cells without malignancy. Corticosteroid therapy (prednisone, 50 mg daily) led to rapid clinical improvement.
Reevaluation of the gingival biopsy showed necrotizing vasculitis and multinucleated giant cells. Combined with positive anti–proteinase 3 antineutrophil cytoplasmic antibodies and pulmonary nodules, these findings confirmed granulomatosis with polyangiitis.
Granulomatosis with polyangiitis is a small- to medium-vessel vasculitis characterized by necrotizing granulomatous inflammation of the respiratory tract. Although the strawberrylike appearance of the gingivae is considered nearly pathognomonic, oral signs occur in 10% to 60% of patients and are rarely an early manifestation. Histopathologic findings may be nonspecific, highlighting the need for clinicopathologic correlation.
Drug-induced gingival overgrowth was excluded because ramipril has no known association. Sarcoidosis was ruled out due to the presence of necrosis and vasculitis. Hematologic malignancy was unlikely given the absence of neoplastic infiltration on biopsy.
The patient improved on corticosteroids.
The authors reported no conflicts of interest.
