the histological features include the presence of newly formed blood vessels and the identifying feature of multinucleated giant cells .
however , to date , there has been no molecular method of distinguishing the variants .
surgical curettage showed high recurrence rate in case of aggressive lesions , so resection with and without continuity defects was reported to prevent recurrence .
intra - lesional injections were considered among the possible means of treatment which may be either intralesional steroid , intralesional calcitonin , intralesional interferon , intralesional bisphosphonates   and denosumab   ( a monoclonal antibody that binds rankl and directly inhibits osteoclastogenesis ) .
the concept of using medical alternatives or adjuncts to surgery was to evade the need for resection and reconstruction in this young group of patients .
we present a case report in which an aggressive variant of central giant cell granuloma was managed using a combined protocol .
the patient presented with cushonoid facial features during the phase of intralesional corticosteroid injection . in response , the surgical team shifted to completing the treatment by surgical curettage .
a nine years old female patient presented with swelling in the left side of the mandible related to the ipsilateral lower first molar .
the chief complaint was pain and localized swelling , the initial diagnosis made by the pediatric department was periapical abscess . a pretreatment radiograph ( fig .
the opt showed well defined radiolucency related to the mandibular left first molar measuring 3.5  cm in antero 
the case was then referred to the oral and maxillofacial department clinic . upon history taking , the patient reported a history of malignancy in large intestine , which had been managed , by chemotherapy .
intraorally , a swelling related to a badly broken down lower left 1st molar which proved to have pulpal exposure was detected ( fig .
a multi slice ct scan over the facial bones with contrast was ordered for further assessment of the lesion s nature .
the multi slice ct showed wide bucco - lingual extension with perforations through both the buccal and lingual bone plates ( figs . 3 , 4 , 5 ) .
the assessment of the collected data at this point led to a differential diagnosis list .
histological analysis depicted multinucleated giant cell most probably of fibroblast origin and extravasated erythrocytes and indicated that the lesion is giant cell lesion ( fig .
laboratory investigations were ordered , which included pth , blood calcium and phosphorus levels and all were within the normal levels , furthermore , renal function tests were also normal ruling out the possibility of primary or secondary hyperparathyroidism .
intra - lesional steroid injections of 5  ml per injection of ( 10  mg / ml triamcinolone ( kenacort - a ) with lidocaine 2% ) was administered with a disposable syringe for 3 months twice weekly .
the follow up monthly opt starting showed gradual increase in the opacity of the radiolucent zone denoting bone apposition ( fig .
e ) . during the follow up period , the patient presented with an increase in weight .
this was associated with features coinciding with moon face appearance and hirsutism associated with cushing s disease ( fig .
this alerted the surgical team to a possibility of cushing disease secondary to the local administration of corticosteroids .
furthermore , laboratory investigations were ordered revealing that na / k level was normal and that serum acth was normal excluding full blown cushing disease . at this point ,
the operating team attributed the appearance to systemic effects secondary to escape of the intralesional steroids to the circulation .
the radioleucent lesion decreased in size gradually over the follow up period . at the end of follow up period ,
accidental intraoperative bleeding took place due to injury of lingual tissues through perforated lingual plate and was stopped by cauterization and packing .
the patient lost about 800  cc of blood and her hb dropped from 12.1 to 9.1 and arterial blood gas before recovery was 7.27 leading to mild acidosis , the anesthetic team managed the acidosis by oxygen administration postoperatively and sodium bicarbonate iv injection and fluid loss by crystalloids .
the post operative biopsy was histologically assessed revealing fibrous tissue free from giant cell and showed with multiple bony trabeculae specks indicating healing process and bony nature of these specks were confirmed by immunohistochemistry using osteopontine ( fig .
however , the patient suffered from pain and infection related to lower left second molar attributed to loss of vitality , the causative tooth was extracted later due to endodontic difficulty .
many studies considered the aggressive form of cgcg as true giant cell tumor of jaw based on resemblance in nature and histological features with giant cell tumor of long bones .
findings of another study conducted by auclair et al . suggest that the gct and the cgcg represent a spectrum of a single disease process modified by the age of the patient and the site of occurrence .
however , the term cgcg is used more in oral and maxillofacial field than the term giant cell tumor of bone .
steroid injections were reported to decrease the inflammatory response within the lesion ( triamcinolone for 6 weeks ) .
the operating team believed the cushonoid presentation could be attributed to the escape of the intralesional steroids toward the highly vascularized lingual tissues .
hence , although direct intravascular injection did not take place , however , the steroids found their way into the circulation through the perforated lingual cortex .
in summary , this case report raises a warning sign when using intralesional corticosteroids in treatment of central giant cell granulomas .
although this treatment line has been proved effective , however , caution should be taken to evade developing the complication for which intralesional injections were preferred to systemic injections .
there is no conflict of interest between our case and any organization or any funding organization .
yasser el hadidi : clinical instructor of oral and maxillofacial surgery , faculty of dentistry , ain shams university responsible for the case starting from presentation till follow up .
amr amin ghanem : lecturer and consultant in department of oral and maxillofacial surgery ain shams university responsible for the treatment plan .
iman helmy : professor of oral pathology performed the histopathological assessment pre and post treatment .
 highlightscentral giant cell granuloma is considered one of the giant cell lesion affecting the oral cavity with variable histological forms ; may be aggressive or non-aggressive.many studies consider giant cell granuloma the same entity as giant cell tumor of long bones.different treatment modalities arise due to its different histological and clinical behavior . 
 treatment may be medical or surgical.intralesional injection is one of the medical lines used in management of cgcg ; with high success and no side effects.in our clinical case , cushing developed in 9 years old patient forced our team to shift toward surgical line and stop intralesional steroid injections . 
Introduction
Presentation of case
Discussion
Conclusion
Conflicts of interest
Sources of funding
Consent
Authors contribution