Cheilitis Granulomatosa (Miescher Melkersson Rosenthal Syndrome)


Article Author:
William Gossman
Mahima Agrawal
Radia Jamil
Amani Gharbi


Article Editor:
Sidharth Sonthalia


Editors In Chief:
Sisira Reddy
Joseph Nahas
CHOKKALINGAM SIVA


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
7/11/2019 9:54:54 PM

Introduction

Cheilitis granulomatosa (CG) is a rare chronic disease characterized by a recurrent firm swelling of one or both lips, and, histologically, by a granulomatous infiltrate. An isolated granulomatous machrochelitis defines the cheilitis granulomatosa of Miescher (CGM).[1][2]

The Melkersson-Rosenthal syndrome (MRS) is characterized, in its complete form, by a classical triad of symptoms: recurrent or persistent orofacial edema (facial and lip edemas), plicated or fissured tongue (lingua plicata), and relapsing peripheral facial nerve paralysis. Most of the cases of MRS present with partial symptoms. CGM is the most common monosymptomatic form of MRS.[3][4]

Other diagnoses which are also a part of the orofacial granulomatosis group must be eliminated. The orofacial granulomatosis, first individualized in 1985, by Wiesenfeld et al., is a syndrome grouping noninfectious and nonnecrotizing granulomatous involvement of the lips, oral cavity, and face, in addition to the CG, sarcoidosis, and Crohn disease.[5]

Etiology

The etiology of CG is still unknown. Several etiologies of different orders have been evocated: genetic, inflammatory, allergic and microbial. There is not a clear etiological mechanism.[6][7]

The postulated etiological factors include:

  • Genetic predisposition: Genetic origin has been suggested considering some cases with involvement of other family memebers, however it still remains unporven and no HLA association has been found in patients with CG compared to the general population.
  • Immunologic factors: CG is a chronic inflammatory condition, characterized by a predominant T helper 1-mediated immune response. The main anomaly is probably a local alteration of innate immunity of lip mucosa in response to various antigens whose insufficient purification leads to a persistent granulomatous reaction.
  • Allergic factors: Allergy to dental materials, foodstuffs and food additives, has been suspected, but the causal relationship is not well established.
  • Microbial factors: Several microbial agents have been incriminated, as eventual factors of de-regulation of the immune response. Studies have included especially Mycobacterium tuberculosis and paratuberculosis, Borrelia burgdorferi, Saccharomyces cerevisiae, and Candida albicans. Nevertheless, with conflicting results, the role of these germs in the pathogenesis of CG remains uncertain.
  • Hypersensitivity to ultraviolet (UV)-B radiation.
  • As part of the spectrum of Crohn's disease - Although early studies suggested that CG may represent an extra-intestinal variant of Crohn's disease with overt gastrointestinal disease developing much later, the counterfact that CG is found in less than 1% patients with Crohn disease cannot be ignored.

Epidemiology

CG is an uncommon disease of undefined incidence and prevalence. One study estimated incidence to be 0.08% of the general population. It may have onset in all age groups, but most commonly seen in adults with peak incidence reported between 20 to 40 years of age. It rarely affects children. However, in two recently published articles, 30 cases in pediatricpatients have been described. Most of the literature suggests an equal sex distribution, however some authors reported that it is more frequently reported in females. Rare familial cases have also been reported.

Histopathology

Histological examination is not necessary for the diagnosis of the complete form of MRS, which can be easily established based on clinical findings. Nevertheless, the histological analysis is necessary for incomplete forms including CGM, especially to eliminate the differential diagnosis of sarcoidosis, Crohn's disease, and other granulomatous disorders including cutaneous tuberculosis, leishmaniasis and leprosy, especially in endemic areas.

The histological characteristics of CG (including CGM and MRS) are granulomatous infiltrate constituted by epithelioid cells and multinucleate giant cells, without caseous necrosis, associated with some degree of lymphedema and fibrosis. These histopathological features are not constant, and their absence should not formally exclude the diagnosis of CG.

History and Physical

MRS consists of a triad of recurrent or persistent orofacial (lips and/or face) swelling, peripheral facial nerve paralysis, and fissural or scrotal tongue.[8][9]

Labial swelling is initially characterized by recurrent edematous swellings mimicking angioedema, subsequently after many episodes, it becomes persistent and indurated. It is a firm non-erythematous non-painful swelling affecting one or both lips. Only in few cases, the labial swelling can cause difficulties in speech or may result in drooling.

The complete classical triad is uncommon and maybe observed in one-fourth to one-third of the patients. In the complete form of MRS, all symptoms rarely appear simultaneously, and long intervals between the occurrence of paralysis and the first swelling have been reported. The disease evolves by flare-ups; nevertheless, a permanent edema of the lips, and sometimes on the face, can gradually be observed. The oligosymptomatic and monosymptomatic forms are most frequent at the beginning of the disease, and they represent 40% of the cases.

CGM or Miescher syndrome corresponds to an incomplete form of MRS in 28% of the cases. Thus, it represents the most common form of MRS. It generally affects the upper lip and less frequently the lower lip. In addition, changes in the buccal, palatal, sublingual, and gingival mucosa are anecdotally reported.

Oral manifestations of sarcoidosis and Crohn’s disease may mimic those of CGM or MRS.[10][11][12]

Evaluation

Histopathology should be considered and if positive (vide supra) may be extremely helpful in diagnostic confirmation.

Investigations to rule out sarcoidosis (HR-CT scan of chest, serum ACE levels) and PPD testing maybe done as per the clinical scenario.

Since the period between the onset of lip swelling and appearance of typical symptoms of Crohn's disease is highly variable and unpredictable, the role of investigations like colonoscopy or gastroduodenoscopy with biopsies in patients without gastrointestinal symptoms remains controversial.

Treatment / Management

The rarity of this disease explains the empiricism of therapeutic proposals and the absence of controlled studies. An effective medical treatment is not available at present. The proposed symptomatic treatments are simply intended to avoid or space recurrences, particularly in the edematous stage. The treatment aims to relieve these patients and to improve their quality of life often very disturbed by the unsightly and distressing nature of macrocheilitis and oro-facial edema. The spontaneous disappearance of the disease is rare but has been reported.

Corticosteroid therapy is a classic treatment for CG. It may be administered locally, topically or intralesionally, and at times systemic corticosteroid for short courses (prednisolone: 0.3 to 0.7 mg/kg/d; 25 to 50 mg/d) maybe tried. Other treatments have also been tried for their anti-inflammatory or immunomodulatory effects such as topical tacrolimus, or oral clofazimine, thalidomide, dapsone, and doxycycline, with inconsistent results.

Finally, immunosuppressive treatments such as mycophenolate mofetil, and azathioprine, as well as inhibitors of tumor necrosis factor-alpha (TNF-alpha) have been tried, alone or in combination, in isolated cases and small series with inconsistently positive results.

Fumaric Acid esters have given good reesults in 50 % of the cases (who were refractory to other modalities).

The cheiloplasty reduction is possible when the lesions are fixed and not evolving.

Differential Diagnosis

The list of differentials of lip swelling are many, including:

  • Acquired angioedema due to C1 deficiency
  • Hereditary Angioedema (HANE)
  • Glandular cheilitis
  • Dental abscess
  • Crohn's Disease
  • Cutaneous manifestation of various granulomatous disorders including sarcoidosis, tuberculosis, leishmaniasis, leprosy, Wegener Granulomatosis, 

The histopathology of angioedema is not granulomatous. Moreover conditions like HANE often have a family history and episodic bouts of abdominal pain. Dental abscess can be ruled out with thorough dental examination and swabs. differentiation from other granulomatous disorders has been discussed above (vide supra)

Prognosis

Owing to scarcity of literature, poor understanding of pathophysiology and modest response to therapy, the over all prognosis of the CG spectrum or OFG is not encouraging. Monosymptomatic form, i.e. CGM may resolve with the treatments mentioned above. MRS has the poorest prognosis with no published evidence on the response of neurological complications of MRS to treatment.

Complications

As such CGM is a benign disorder. But since CG may be a part of MRS, occurence of facial palsy later is a distinct possibility.

If CG in an individual is representative of evolving Crohn's Disease, then complications of inflammatory bowel disease may occur

Deterrence and Patient Education

The patient should be counseled about the possibility of lip swelling representing CGM alone but also cautioned to report if facial paresis develops, it maybe suggestive of MRS. Careful counseling and explanation about the availability of limited therapeutic options is important.

Pearls and Other Issues

CG is a rare disorder with a difficult diagnosis, characterized by recurrent or persistent idiopathic swelling of the one or both lips due to granulomatous inflammation. When isolated, it defines the Miescher syndrome. However, other clinical signs may be associated such as facial nerve paralysis and fissured tongue, which complete the triad of MRS. The etiopathogenesis and the etiology of CG are still obscure, and the treatment, therefore, remains uncertain.

In addition to the unsightly nature of this condition and the significant psychological impact, there maybe local complications like excessive lacrimation, dry eyes, disorders of salivary secretion and dysgeusia.

Possible familial cases should be searched. Further studies are needed to explain the pathophysiology and find other more effective therapeutic alternatives.

Enhancing Healthcare Team Outcomes

As mentioned earlier, since the patient may present to a primary care physician/surgeon as well as a specialist including dermatologist, dentist, ENT specialist, or nurse, all the care providers should be cognizant about the condition and its associations. Since maximum work on this condition has been done by dermatologists, other physicians/surgeon/specialists should not delay from referring the patient early. Similarly, meticulous examination for facial paresis may need the ENT specialist or even a neurologist. Thus, interdisciplinary coordination is vital in the management of this condition.

The rarity of this disease explains the empiricism of therapeutic proposals and the absence of controlled studies. An effective medical treatment apparently is not available at present. The proposed symptomatic treatments are simply intended to avoid or space recurrences, particularly in the edematous stage. The treatment aims to relieve these patients and to improve their quality of life often very disturbed by the unsightly and distressing nature of macrocheilitis and oro-facial edema. The spontaneous disappearance of the disease is rare but has been reported.


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Cheilitis Granulomatosa (Miescher Melkersson Rosenthal Syndrome) - Questions

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A 33-year-old female presents to the clinic with firmly swollen lips for three months. She does not have a history of any hives or similar swelling in the past. She denies any gastrointestinal symptoms. An oral mucosal examination is unremarkable. Lip biopsy reveals non-caseating granulomas. Chest x-ray and HRCT scan are within normal limits. Which of the following is the best initial therapy for this patient?



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A 65-year old lady presented with 1.5 years history of persistently swollen lips presents to the clinic for follow-up. She reports episodic flare-ups (with redness and pain), especially after intake of packaged foods. She does not complain of any respiratory difficulty, urinary problem, sinusitis, any cutaneous eruption, or ocular complaint. However, she does report off and on diarrhea with episodic abdominal pain and gradual weight loss for the past 3-4 years. Oral examination reveals fissured and swollen buccal mucosa with corrugations. The tongue does not show fissuring. Gingivae appear healthy and pale. There is no significant lymphadenopathy. Cervical nerve examination is within normal limits. Lip biopsy shows non-caseating granulomatous inflammation. A patch test reveals her to be moderately allergic to benzoates. Which of the following evaluations should be considered most important for her further management and early prevention of complications?



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A 30-year-old woman presents with persistent swelling of the lower lip since three months associated with mild discomfort. She gives history of recurrent swelling of the lower lip for few months prior to this which used to resolve spontaneously in 3-4 days with or without medications. She is taking tablet cetirizine 10 mg daily without any relief in the swelling. There are no systemic complaints, and she denies history of fever, the appearance of wheals, any new drug intake/dietary changes, or history of similar complaints in any of the family members. Examination reveals a woman of normal height and weight with asymmetric soft to firm swelling of the lower lip more over the right side, which is nontender and non-erythematous with no surface erosions or ulceration. The rest of the oral cavity is unremarkable. There is no palpable regional lymphadenopathy, and her systemic examination is within normal limits. Her complete blood count and serum biochemistry are normal. Which of the following is the most appropriate next step in the management plan?



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A 33-year-old man presents with asymptomatic persistent lip swelling for the past 4 to 5 months. He denies a history of wheals, prior allergies, drug intake, or any topical applications. Examination reveals irregularly enlarged firm nontender lips with few fissures and crusting at places. There is also irregular firm swelling of gingival mucosa causing loosening of a few teeth. There are no palpable cervical lymph nodes. A biopsy from the lower lip demonstrates well defined non-caseating epithelioid cell granulomas in the deeper subcutaneous planes. Which of the following is the least likely to be helpful in this patient's management?



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A 14-year-old girl presents with persistent firm swelling of the lower lip for one year that prevents her from fully opening the mouth. She also looks underweight and gives a history of intermittent pain abdomen and diarrhea with occasional blood in stools. Examination reveals firm swelling of the lower lip with moderately deep longitudinal fissures and few resolving aphthae. Anthropometry shows that she is underweight and short for her age. Blood reports show anemia. Biopsy from the swelling reveals granulomatous infiltrate comprising of epithelioid cells, Langhans giant cells, and lymphocytes. Colonoscopy shows cobblestoning of the intestinal mucosa along with ulceration at places. Which of the following is the most appropriate treatment option?



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Cheilitis Granulomatosa (Miescher Melkersson Rosenthal Syndrome) - References

References

Cancian M,Giovannini S,Angelini A,Fedrigo M,Bendo R,Senter R,Sivolella S, Melkersson-Rosenthal syndrome: a case report of a rare disease with overlapping features. Allergy, asthma, and clinical immunology : official journal of the Canadian Society of Allergy and Clinical Immunology. 2019;     [PubMed]
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González-García A,Barbolla Díaz I,Sifuentes Giraldo WA,Patier-de la Peña JL, Miescher syndrome: An uncommon cause of recurrent swelling of the lips. Reumatologia clinica. 2017 Nov - Dec;     [PubMed]
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Răchişan AL,Hruşcă A,Gheban D,Căinap S,Pop TL,Băican A,Fodor L,Miu N,Andreica M, Granulomatous cheilitis of Miescher: the diagnostic proof for a Melkersson-Rosenthal syndrome. Romanian journal of morphology and embryology = Revue roumaine de morphologie et embryologie. 2012;     [PubMed]
Martini MZ,Galletta VC,Pereira EM,De Sousa SC,Lemos CA,Migliari DA, Orofacial granulomatosis of the lip: a report of 2 cases with histological and immunohistochemical analyses and intralesional corticotherapy. Minerva stomatologica. 2010 Oct;     [PubMed]
Antoszczyk G,Obtułowicz A,Czarnobilska E,Wojas-Pelc' A, [Melkersson-Rosenthal syndrome--diagnostic and therapeutic problems]. Przeglad lekarski. 2008;     [PubMed]
LeBoit PE, From Sweet to Miescher and back again. The American Journal of dermatopathology. 2006 Aug;     [PubMed]
Grinspan D,Borda JM,Casalá A,Díaz J,Abulafia J, [Melkersson-Rosenthal's syndrome. Its relation to Miescher granulomatous macrocheilia and Bernier-Boeck-Schaumann disease]. Archivos argentinos de dermatologia. 1967 Sep;     [PubMed]

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