Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept. 2023;13(3):e2023171 1 Strawberry Gingivitis - A Diagnostic Clue in a Male With Epistaxis and Hemoptysis Adhyatm Bhandari1, Sheetanshu Kumar1, Anuradha Bishnoi1, Rajsmita Bhattacharjee1, Aman Sharma2, Rahul Mahajan1 1 Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India 2 Department of Rheumatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India Citation: Bhandari A, Kumar S, Bishnoi A, Bhattacharjee R, Sharma A, Mahajan R. Strawberry Gingivitis - A Diagnostic Clue in a Male with Epistaxis and Hemoptysis. Dermatol Pract Concept. 2023;13(3):e2023171. DOI: https://doi.org/10.5826/dpc.1303a171 Accepted: February 2, 2023; Published: July 2023 Copyright: ©2023 Bhandari et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding author: Dr Rahul Mahajan, Associate Professor, Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Phone no: 91-172-2756564 E-mail: drrahulpgi@yahoo.com Case Presentation A young male presented with the complaint of gingival swelling which started 15 days before and increased rap- idly in size. He gave a history of productive cough with bouts of streaky hemoptysis for the past 9 months along with episodes of rhinitis, nasal crusting and nasal bleeding for the past 1 month. On mucocutaneous examination, en- largement of maxillary gingiva and lower labial mucosa was observed with granular surface and overlying petechial spots giving an appearance of a “ripe strawberry”. Inves- tigations revealed ground glass opacities in the lungs on contrast-enhanced computed tomography (CECT) chest, maxillary sinusitis on non-contrast computed tomogra- phy scan of the paranasal sinuses (NCCT PNS) and posi- tive cytoplasmic antineutrophil cytoplasmic autoantibody (C-ANCA) serology. On the basis of above findings, a di- agnosis of Wegener granulomatosis (WG) was established and the patient was started on oral corticosteroids and immunosuppressants. Teaching Point WG is characterized by necrotizing and granulomatous vas- culitis predominantly affecting the respiratory tract and kid- neys but may also involve other tissues [1]. Oral involvement in WG is observed in 6%-13% of patients and oral cavity may be the first site of involvement in 5%–6% of cases [1]. Strawberry gingivitis is considered to be a characteristic sign of WG and presents as red to purple enlarged gingiva with petechiae and granular surface resembling an over-ripe strawberry. Other differentials for similar gingival enlarge- ment include drug-induced gingival hypertrophy, hemangi- omas, pyogenic granulomas, Crohn’s disease , sarcoidosis, peripheral giant cell granuloma and Kaposi sarcoma [2]. Presence of characteristic strawberry gingivitis is a vital clue 2 Image Letter | Dermatol Pract Concept. 2023;13(3):e2023171 in the patients of WG who otherwise lack several other typ- ical features. References 1. Almouhawis HA, Leao JC, Fedele S, Porter SR. Wegener's granu- lomatosis: a review of clinical features and an update in diagno- sis and treatment. J Oral Pathol Med. 2013;42(7):507-516. DOI: 10.1111/jop.12030. PMID: 23301777. 2. Siar CH, Yeo KB, Nakano K, et al. Strawberry gingivitis as the first presenting sign of Wegener's granulomatosis: report of a case. Eur J Med Res. 2011;16(7):331-334. DOI: 10.1186/2047- 783x-16-7-331. PMID: 21813375. PMCID: PMC3352006. Figure 1. Diffuse edematous and erythematous gingival hyperplasia with petechial spots giving an appearance of a ripe strawberry.