A woman in Iran reported to a dermatology clinic after suffering from a painful case of "strawberry gums" that had progressively gotten worse over the course of six weeks.
During this time, the 42-year-old suffered from recurrent nosebleeds and developed three necrotic ulcers on her face. She was in pain as the blood vessels in her gums were very inflamed, giving her mouth a "strawberry" appearance, Maryam Ghiasi writes in a case report in the New England Journal of Medicine.
An inspection of the patient's mouth revealed an appearance typical of "strawberry gingivitis", and lab tests and a scan were ordered to confirm the diagnosis.
A scan revealed several pulmonary nodules (small masses of tissue in the lung), which, combined with the results of blood tests showing elevated levels of certain antibodies, allowed doctors to make a diagnosis of strawberry gingivitis caused by granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis).
"Strawberry gingivitis is a rare manifestation of granulomatosis with polyangiitis," Ghiasi writes in the case report. "And its clinical presentation is highly suggestive of the disease."
Granulomatosis with polyangiitis (GPA) is a rare disease caused by inflammation of various tissues, including blood vessels. It's a serious and potentially life-threatening condition, but its exact cause is currently unclear.
"This is called 'strawberry gingivitis' and I think you can figure out why," Dr Joseph Nemeth, a periodontist, said in a video about the case. "However, it's a symptom of a very serious vascular disease. Very often this disease, if not caught early, can be fatal.
"This is an extreme case. This is the most severe [photograph] that I have seen."
If not treated, GPA can cause permanent damage to parts of the body, for example, it can change the shape of the nose or stop the kidneys from functioning properly.
"GPA can be very serious," notes the UK's National Health Service (NHS). "But, with medication, most people can keep it under control and live largely normal lives."
The disease is usually treated with steroid tablets and injections, as well as cyclophosphamide, a medication used in chemotherapy and as an immunosuppressant.
The woman was treated but did not return for her follow-up appointment, so it is unknown whether the treatment was successful in this case.