Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) mimicking oral malignancy: a case series

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is an uncommon benign reactive lesion of the oral mucosa that can mimic malignancy. We report four biopsy-proven cases spanning a wide age range across childhood–adolescence and older adulthood to examine age-specific malignancy mimicry, trauma source, and the dissociation between tissue and peripheral eosinophilia. Four consecutive patients diagnosed at a single tertiary oral and maxillofacial surgery center between December 2025 and May 2026 were reviewed: three pediatric or adolescent males (7, 8, and 17 years) and one 68-year-old woman. Lymphoma was suspected in Case 1, and the remaining cases also warranted exclusion of malignancy on clinical grounds. The likely trauma source varied similarly, from cheek biting and suspected self-injurious behavior to prosthetic trauma on previously irradiated mucosa. Despite eosinophil-rich histology, calculated peripheral eosinophil counts (60–217/µL) remained well below the diagnostic threshold, with normal lymphocyte proportions and inflammatory markers. Two of four patients demonstrated complete mucosal healing, while the other two exhibited a reduction in lesion size compared to baseline. TUGSE presented across different age-related clinical contexts in which malignancy was suspected or required exclusion, with varying plausible sources of mucosal trauma. Neither the clinical pattern of the lesion nor the peripheral blood differential reliably excludes the diagnosis; biopsy must remain the decisive diagnostic step, particularly in pediatric patients with lymphoma-like ulceration and in head and neck cancer survivors with newly developed ulcers.