Disusun Oleh:
Pembimbing:
dr. Nurul Kawakib, Sp.KK
FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2014
HALAMAN PENGESAHAN
Disusun Oleh
:
Willy Agung R. (012096046)
Yulia Utami Anggarani (012096051)
Yuna Noor Rosida (012096052)
Fakultas
: Kedokteran
Universitas
Tingkat
Bagian
Judul
Pembimbing
Latar belakang
jarang
umumnya
terdapat
[8]
[5,
6,
7]
lebih kecil mungkin berkembang pada saat yang sama dengan lesi primer
atau dapat terjadi setelah mencoba pengobatan lesi primer. Lihat gambar
di bawah.
3
Gambar 1
Gambar 3
Gambar 4
Gambar 5
Gambar 6
Patofisiologi
[14, 15]
Epidemiologi
Frekuensi
di Amerika Serikat lesi kulit Granuloma Piogenik mencapai 0,5%
pada bayi dan anak-anak dan juga ditemukan pada mukosa mulut 2%
pada wanita hamil.
Mortalitas / Morbiditas
Kebanyakan granuloma piogenik asimtomatik kecuali untuk kulit
sensitif dan kecenderungan untuk terjadinya perdarahan dengan sedikit
atau tanpa trauma. Lesi ini jinak dan mudah diobati. Jarang, granuloma
piogenik di temukan dilokasi yang tidak biasa, seperti usus yang dapat
menyebabkan perdarahan yang signifikan
lainnya. [19]
Ras
Tidak ada perbedaan substansial yang ditemukan dalam insiden
terjadinya lesi ini.
Seks
Satu studi dari 178 pasien yang ditemukan pada usia lebih muda
yaitu kurang dari 17 tahun melaporkan rasio laki:perempuan adalah
3:2.[20] Pada orang dewasa, granuloma piogenik lebih sering terjadi pada
wanita karena lesi ini berhubungan dengan kehamilan.
Usia
Granuloma piogenik yang paling umum sering ditemukan pada
usia 5 tahun pertama kehidupan. [21]
Sejarah
Fisik
Etiologi
piogenik
telah
dievaluasi
untuk
kehadiran
human
papillomavirus (HPV) karena kutil terjadi pada kelompok usia dan situs
yang sama. Lesi diuji untuk HPV 6,11,16,31,33,35,42 dan 58.Tidak ada
virus yang muncul.
Granuloma piogenik berulang dengan satellitosis merupakan varian
biasa. Pada satu pasien dengan granuloma piogenik berulang dengan
satellitosis,
pewarnaan
Warthin-Starry
dari
lesi
mengungkapkan
10
Prosedur
piogenik
(PG)
untuk
membantu
mengkonfirmasikan
diagnosis.
Histologis
Surgery
12
[43]
jaringan parut minimal, dan efek samping yang serupa dengan yang
diamati pada pasien dewasa. [44]
Konsultasi
Obat Ringkasan
13
Rawat Jalan
Komplikasi
a) Infeksi sekunder
b) Perulangan lesi di lokasi yang sama
c) Kekambuhan beberapa lesi satelit disekitar daerah lesi awal.
d) Pembentukan bekas luka yang dangkal.
e) Granuloma piogenik oral:
Muncul setelah atau selama trisemester kehamilan
Biasanya, granuloma piogenik oral massanya tumbuh lambat dan
tidak minimbulkan cacat besar setelah eksisi yang membutuhkan
perbaikan bedah.
Jarang, tumor besar yang tumbuh dengan pesat terjadi perdarahan
yang signifikan.
Prognosa
14
Background
Pyogenic granulomas (PGs) are benign vascular lesions that occur most
commonly on the acral skin of children.[1, 2] The term pyogenic granuloma
is a misnomer. Originally, these lesions were thought to be caused by
bacterial infection; however, the etiology has not been determined. The
histopathologic appearance is fairly characteristic; the lesion is, in fact, a
lobular capillary hemangioma.[3]
Recognition of pyogenic granuloma as a clinically polypoid or exophytic
circumscribed lesion is of importance to the clinician and pathologist
because this feature distinguishes pyogenic granulomas from most
malignant vascular tumors. Although pyogenic granulomas may be
multiple (especially on the skin) and necrosis is common, invasion of
adjacent structures is not observed. The lesions grow rapidly and are
extremely vascular, frequently bleeding either spontaneously or after
minor trauma.[4] They are usually easily treated with surgical removal but
may recur.
Uncommon variants include pyogenic granuloma with satellitosis,[5, 6, 7]
intravenous
granulomas,[9,
pyogenic
10]
granulomas,[8]
subcutaneous
12, 13]
pyogenic
Satellite
15
Pyogenic granulomas are usually solitary lesions. The fingers and hands
are common locations for these to develop. A history of minor trauma at
the site shortly before development of the lesion is frequent.
16
Pyogenic granulomas may occur at various sites. More than 60% of all
lesions develop on the head and neck.
Pathophysiology
Although most patients (74.2%) do not have a history of trauma or
predisposing dermatologic conditions, in many cases, a history of recent
trauma at the site is present. Large numbers of lesions may occur
following damage to diffuse areas skin by burns or other trauma. [14, 15] A
nitric oxide synthasedependent mechanism is thought to contribute to
angiogenesis and the rapid growth of pyogenic granulomas. They are
benign vascular proliferations, but the specific pathophysiology of these
lesions is unknown.
Epidemiology
Frequency
United States
Pyogenic granulomas account for 0.5% of skin lesions in infants and
children and are also found in the oral mucosa in 2% of pregnant women.
Mortality/Morbidity
Most pyogenic granulomas are asymptomatic except for mild tenderness
and a tendency to bleed with little or no trauma. They are benign and
easily treated. Rarely, pyogenic granulomas in unusual sites such as the
intestines may result in significant bleeding[16,
17, 18]
or other major
complications.[19]
Race
No substantial difference in incidence is found between races.
Sex
One study of 178 patients younger than 17 years reported the male-tofemale ratio as 3:2.[20] In adults, pyogenic granulomas are more common
in females because of pregnancy-related lesions.
Age
Pyogenic granulomas are most common in the first 5 years of life.[21]
18
History
Patients with pyogenic granulomas (PGs) usually seek care because the
lesion has grown rapidly and bleeds easily. Patients or parents may be
concerned because the lesion bleeds with little or no trauma; they are
frequently concerned that the rapid growth and bleeding may indicate a
malignancy.
Important questions include the following:
Does the history include trauma at the site prior to development of the
lesion? Pyogenic granulomas may occur following minor physical
trauma or burns.
How long has the lesion been present? Most pyogenic granulomas
develop rapidly. The mean duration at the time of diagnosis is
approximately 3 months. If the lesion has been present longer than
6 months, the possibility of cutaneous malignancy increases.
Does the lesion bleed easily? Almost all pyogenic granulomas bleed
easily. If the lesion does not bleed with light rubbing, a diagnosis
of pyogenic granuloma is unlikely.
What therapy has been used recently? Nevi, warts, or other lesions may
have been treated with caustic agents or cryotherapy prior to
referral. Such therapy may markedly change the appearance of the
original lesion, causing it to mimic a pyogenic granuloma.
Is the patient pregnant? Oral pyogenic granulomas can develop during
or just after the first trimester of pregnancy. Examine and properly
identify these lesions of pregnancy to avoid misdiagnosis and
overtreatment. These lesions are not generally harmful in
pregnancy; however, induction of labor due to uncontrollable
bleeding from a gingival lesion has been reported.[22, 23, 24, 25, 26, 27]
Has the lesion recurred after surgical treatment? If so, was it excised
and the skin closed primarily or was it treated with shave removal
19
Facial
pyogenic
granulomalike
lesions
during
Physical
Pyogenic granulomas appear as smooth firm nodules, with
or without crusts, and they may have a bright or dusky red color. They
are usually solitary, well circumscribed, dome shaped, 1-10 mm in
diameter, and sessile or pedunculated.
In children, pyogenic granulomas are most commonly
located on the head and neck (62.4%) and, in order of decreasing
frequency, on the trunk (19.7%), upper extremity (12.9%), and lower
extremity (5%). Most (88.2%) occur on the skin, and the rest involve
mucous membranes of the oral cavity and conjunctivae.
In pregnant women, pyogenic granulomas are most often
found on the gingival mucosa[24, 28] but they have been known to appear
in nonoral areas such as the fingers and inguinal crease.
Pyogenic granulomas may occur within a port-wine stain;
the presence of a vascular birthmark in the region of the pyogenic
granuloma may be significant.
Amelanotic melanoma may closely mimic a pyogenic
granuloma in appearance. Closely examine the skin immediately
adjacent to the lesion for any pigmentary irregularity.
20
Causes
Originally, pyogenic granulomas were thought to be caused
by bacterial infection; the etiology has yet to be determined. Postulated
etiologies include viral, hormonal, and, more recently, angiogenic factors.
Pyogenic granulomas have been evaluated for the presence
of human papillomavirus (HPV) because warts occur in similar age
groups and sites. Lesions were tested for HPV 6, 11, 16, 31, 33, 35, 42,
and 58. No viruses were present.
Recurrent pyogenic granuloma with satellitosis is an uncommon
variant. In one patient with recurrent pyogenic granuloma with
satellitosis, Warthin-Starry staining of the lesions revealed clumps of
dark bacilli as found in patients with bacillary angiomatosis.[5] An indirect
immunofluorescence
assay
showed
elevated
immunoglobulin
Procedures
Obtain a biopsy of any lesion suspected of being a pyogenic granuloma
(PG) to confirm the diagnosis.
Histologic Findings
Proliferation of capillaries is present, with prominent endothelial cells
embedded in edematous gelatinous stroma in a characteristic lobular
configuration (see image below).
Inline figure
21
Surgical Care
Treatment of pyogenic granulomas (PGs) most commonly consists of
shave removal and electrocautery or surgical excision with primary
closure.[31] Removal of the lesion is indicated for bleeding due to trauma,
discomfort, cosmetic distress, and diagnostic biopsy. The lesion may be
completely removed during biopsy.
For solitary lesions, a shave excision and electrocautery under local
anesthesia is the treatment of choice. To provide an adequate cure rate, all
vascular granulation tissue must be removed or cauterized.
For large or recurrent lesions, surgical excision with primary closure may
be more effective. One study reported a 43.5% recurrence rate in 23
22
Consultations
Consider referral to a dermatologist if the diagnosis is in doubt or if
the availability of adequate therapy is questionable.
Medication Summary
Despite the necrosis, foul odor, and purulent drainage noted
occasionally with pyogenic granulomas (PGs), antibiotic therapy is rarely
required.
Complications
Significant secondary infection (extremely uncommon)
Recurrence at the original site
Recurrence as multiple satellite lesions in the area
immediately
Prognosis
Prognosis is excellent after simple removal and wound care.
25
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31