A 20-year-old male kidney transplant recipient presented with a fever and dental pain from a mass in his lower mandible. Imaging showed a cystic space occupying lesion involving his wisdom tooth. Surgical excision of the mass and extraction of the impacted teeth was performed. Histopathology revealed the mass was a giant cell reparative granuloma. This lesion is a benign non-neoplastic tumor that can develop from local trauma or vascular injury. It is rarely reported in kidney transplant patients and careful monitoring of parathyroid hormone levels and immunosuppression is important for management.

1. GIANT CELL REPARATIVE GRANULOMA LONG TERM POST KIDNEY TRANSPLANTATION
AHMED AKL1, MOHAMED ABDEL MENEAM2, FAKHER ELDIN SAID2, AHMED DONIA1, MOHAMED SAFTAWY1, MONA ABDEL RAHIM3, BEDEIR ALI-EL-DEIN1,
AYMAN REFAIE1.
1 UROLOGY&NEPHROLOGY CENTER, MANSOURA UNIVERSITY, MANSOURA, EGYPT.
2 DENTAL&ORAL SURGERY DEPARTMENT, DENTAL FACULTY, MANSOURA UNIVERITY, MANSOURA, EGYPT.
3PATHOLOGY DEPARTMENT, UROLOGY&NEPHROLOGY CENTER, MANSOURA UNIVERSITY, MANSOURA, EGYPT.
CASE
INTRODUCTION
FIGURES
CONCLUSION
A 20-year-old male kidney transplant recipient since 2010 on triple immunosuppression; oral steroids, tacrolimus, mycophenolate mofetil. He is suffering graft
transplant glomerulopathy with serum creatinine 2.4 mg/dl, HB 6.5, wbcs 17 x 10^3. He was presented to emergency department with fever 40 C, dental pain and
dental mass on the left lower mandible [Figure 1]. Panoramic x-ray showed displacement of the wisdom tooth with space occupying lesion [Figure 2.A] . CT mandible
confirms the diagnosis and showed that space occupying lesion is cystic in nature [Figure 2.B, C]. Intravenous fluids and broad spectrum empirical antibiotics was
started for 3 days with no improvement, fever reaching 40.7 C. Swap culture revealed normal mouth flora. Intensive care in the form of frequent cold foments and
cold fluids to control the body temperature. Blood transfusion with washed RBCs, HB improved to 12.5 mg/dl to prepare the patient for surgery. The patient was
referred to the operating theater, under general anesthesia, dental surgeons extracted the wisdom & the 8th teeth. They excised the mass in-between completely
with curettage of the area [Figure 1.B]. Coagulation diathermy was used to control the bleeding then continued sutures was taken to close the wound in the gum
[Figure 1.B, 3.A]. Post-operative, the patient condition improved dramatically, body temperature became normal 37 C, serum creatinine dropped to 2.1 mg/dl, HB
12.5 mg/dl, WBCs 12 x 10^3. Histopathology analysis of the extracted mass revealed reparative (central) gaint cell granuloma [Figure 3.B]. Patient received a
complete course of meropenem and discharged home.
Giant cell reparative granuloma are a reason for much research and discussion, since there are many theories to explain its etiologic and clinical manifestations. It is a benign lesion, therefore
proper diagnosis avoids mutilating radical treatments. Curattage is still used with high success rates. In kidney transplanted patient, carful assessment of parathyroid hormone status and
possible modification of immunosuppression.
REFERENCES
FIGURE 2: RADIOLOGICAL ASSESSMENT OF THE ORAL LESION.
A) PANORAMIC X-RAY [MAGNIFICATION1:1] B) CT OF THE MANDIBULE
FIGURE 1: CLINICAL PICTURE OF LEFT LOWER MANDIBULAR SWELLING
B] AFTER REMOVAL OF THE SWELLING AND EXTRACTION OF
THE THIRD AND WISDOM TOUTH.
A] BEFORE REMOVAL OF THE SWELLING. C) CT OF THE WISDOM TOUTH.
FIGURE 3: THE LEFT LOWER MANDIBULAR MASS.
A] REMOVED 8TH TOUTH (1), SOFT TISSUE MASS (2) & WISDOM TOUTH (3).
(1)
(2)
(3)
B] HISTOPATHOLOGY: Large number of giant cells amidst spindle cells of
fibroblasts and myofibroblasts and areas of heamorrhage, Hx&Ex200.
UROLOGY&NEPHROLOGY CENTER
MANSOURA, EGYPT
Giant cell granuloma of the respiratory tract or Central Giant Cell Granuloma (CGCG) is considered an intraosseous, non-neoplasm tumor,
responsible for less than 7% of all the mandible expansive lesions, its most common site of involvement [1-3]. The mechanism by which
these lesions are formed is still uncertain. Local causes suggested are trauma and vascular injuries, and the systemic causes reported in the
literature associate the development of CGCG with syndromes such as, Neurofibromatosis I, Noonan syndrome and hormonal disorders such
as hyperparathyroidism and pregnancy [4].
The clinical manifestation can evolve in a few weeks or take years, it is usually associated with tumor expansion and its respective
compressive effects on adjacent structures, with a possibility for local discomfort; however, overt pain is less frequent. Clinically speaking,
the differential diagnosis of CGCG goes from a cyst all the way to a malignant lesion, and one must investigate the level of aggressiveness,
how fast it develops, inflammatory characteristics, pain and dental mobility [4]. CGCG radiographic characteristics are not pathognomonic,
they are radiolucent uni or multilocular images, well outlined and with peeled off margins [5]. One important aspect used to define lesion
location and extension and to plan CGCG treatment is the ordering of a CT scan [1,4]. Radiographically speaking, differential diagnoses are
cysts, periapical granulomas, ameloblastomas, keratocysts, myxomas and sarcomas. We believe that this is the first reported case of CGCG in
kidney transplanted patient.
1. Sobrinho FPG, Martins AC, Queiroz LS et al. Granuloma reparativo de células gigantes dos seios etmoidal e maxilar. Rev Bras Otorrinolaringol. 2004;70(4):555-60.
2. Arda HN, Karakus MF, Ozcan M, Arda N, Gun T. Giant cell reparative granuloma originating from the ethmoid sinus. Int J Pediatr Otorhinolaryngol. 2003;67(1):83-7.
3. De Corso E, Politi M, Marchese MR, Pirronti T, Ricci R, Paludetti G. Advanced giant cell reparative granuloma of the mandible: radiological features and surgical treatment. Acta Otorhinolaryngol Ital. 2006;26(3):168-72.
4. Franco RL, Tavares MG, Bezerril DD et al. Granuloma de células gigantes central. Rev Bras Patologia Oral. 2003;2:10-6.
5. Adornato MC, Paticoff KA. Intralesional corticosteroid injection for treatment of central giant-cell granuloma. Case report. JADA. 2001;132: 186-90.