Melkersson-Rosenthal syndrome and Crohn's disease

Melkerrson-Rosenthal Syndrome, a rare case report of chronic eyelid swelling

Abstract

Melkerrson-Rosenthal syndrome is a rare disorder of unknown etiology. The classical triad of recurrent facial paralysis, swelling of the face, lips and deep furrowed tongue (Lingua Plicata) is seen in very few cases, majority of the patients often present with one or two symptoms only, which often leads to misdiagnosis and mismanagement. Clinically these symptoms vary from days to years, which further delay the definitive diagnosis and symptoms may eventually become permanent. The cause of this entity is not very well understood, but thought to be attributable to multiple entities including genetic and Infectitious. As this entity has been associated with numerous other clinical entities, diagnosis often remains an exclusion process. Methods: A middle age male with a chronic history of heavy eyelids with skin indurations predominately around left eye was presented to ophthalmology clinic. Physical examination revealed a deep furrowed tongue. The skin biopsy from left eyelid revealed a non-specific granulomatous lesion. The clinical correlation of facial swelling and deep plicated tongue prompted the differential of MRS Results: Histologically a non-specific granulomatous lesion was seen in dermis. As a rule, other causes of granulomatous diseases were ruled out especially Crohn’s disease and sarcoidosis. Polarization failed to reveal any foreign body. Conclusions: The finding of granulomatous lesion and clinical picture led to the definite diagnosis of Melkerrson-Rosenthal syndrome. Association with rosacea was other findings. Clinically his sign and symptoms are under control and no occurrence of symptoms has been noted so far.

Virtual slides

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Orofacial granulomatosis: presentation, pathology and management of 13 cases

BACKGROUND

Orofacial granulomatosis (OFG) comprises of a group of conditions, all characterized histologically by the presence of granulomatous inflammation.

METHODS

This diagnosis may be determined by exclusion from other conditions that may present with similar clinical and histopathologic features. These include Melkersson-Rosenthal syndrome (MRS), Miescher's cheilitis (an oligosymptomatic form of MRS), Crohn's disease, and sarcoidosis.

RESULTS

A great deal of attention has been devoted to the similarity and overlap in clinicopathologic and histomorphologic features of these conditions, suggesting that they may actually represent a spectrum within a single overarching entity. In the review of the 13 cases of OFG retrieved from the files of the Long Island Jewish Medical Center, Department of Dental Medicine, we describe their presentation, clinicopathologic features, and management. These cases comprise examples of MRS (in its oligosymptomatic forms) and Crohn's disease. The similarity, kinship, and overlap between the cases presented are clearly demonstrated.

CONCLUSION

In addition, based upon our observations and review, we propose the notion that oral manifestations of Crohn's disease may be classified as an oligosymptomatic form of MRS.

Cheilitis granulomatosa: overview of 13 patients with long-term follow-up--results of management

BACKGROUND

Cheilitis granulomatosa, often regarded as a subtype of orofacial granulomatosis, is characterized by recurrent or persistent swelling of one or both lips. Classically, a non-necrotizing granulomatous inflammation is seen at histologic examination. Although a relationship has been proposed between Melkersson-Rosenthal syndrome (and the monosymptomatic form, cheilitis granulomatosa) and Crohn's disease on the basis of the orofacial swelling and similar histology, several studies of Melkersson-Rosenthal syndrome have not found an association with Crohn's disease.

METHODS

The clinical features, histopathology, association with Crohn's disease, and results of nonsurgical and surgical therapy in 13 patients with cheilitis granulomatosa were investigated in a retrospective case study with a mean follow-up period of 8.2 years.

RESULTS

There was a low chance of developing Crohn's disease. Most patients in this study responded to nonsurgical treatment modalities. Patients with deterioration of lip swelling usually responded to intralesional injections with triamcinolone or to short courses of systemic glucocorticoids. Nonsteroidal systemic modalities, such as clofazimine, hydroxychloroquine, or sulfasalazine, were alternatives to glucocorticoid regimens, thus avoiding the long-term side effects of corticosteroids. Surgical intervention should only be performed in severely disfiguring cases.

CONCLUSIONS

The management of cheilitis granulomatosa remains a challenge. As this study revealed a low chance of developing Crohn's disease, it does not seem justified to inform patients with cheilitis granulomatosa of the possibility that they might develop Crohn's disease. Patients with a negative history of gastrointestinal complaints should not be exposed to routine investigations of the gastrointestinal tract.

Infliximab for the treatment of orofacial Crohn's disease

Orofacial manifestations of Crohn's disease can be difficult to diagnose and treat. We report a case in which the orofacial lesions occurred 7 years prior to the diagnosis of underlying inflammatory bowel disease. The patient was refractory to mesalamine and systemic corticosteroids but responded to infliximab, the chimeric monoclonal antibody to tumor necrosis factor (TNF-alpha). A review of the literature of the orofacial granulomatoses is presented as well.

Granulomatous cheilitis and Crohn's disease in a 3-year-old boy

Granulomatous cheilitis and Crohn's disease are disorders of unknown etiology. There are case reports describing their coincidence and pointing out the necessity of ruling out systemic disorders once the diagnosis of granulomatous cheilitis is made. However, such reports are few and the causal association of both diseases is controversial in the literature. We report the youngest patient so far, a 3-year-old boy, who had granulomatous cheilitis and Crohn's disease simultaneously. This coincidence so early in life strongly suggests that both represent manifestations of the same disease.

Orofacial granulomatosis and Crohn's disease

Orofacial granulomatosis is a clinical entity of either unknown or specific causation. Specific causes include sarcoidosis, chronic infective granulomas, and Crohn's disease. The remainder of cases are idiopathic, but the clinical presentations of orofacial swellings and intraoral mucosal lesions are similar. So, too, are the histopathologic findings of noncaseating granulomas, edema, and chronic lymphoproliferative infiltrate. Crohn's disease is not responsible for all forms of orofacial granulomatosis, but the orofacial manifestations of the disease may herald its diagnosis.

Melkersson-Rosenthal syndrome

Melkersson-Rosenthal syndrome is a triad of recurrent orofacial swelling, relapsing facial paralysis, and fissured tongue. However, the classic triad is not frequently seen in its complete form. Monosymptomatic and oligosymptomatic forms are more common. The histological findings of sarcoid-like granuloma in skin or mucosal biopsy specimens support the diagnosis. The course is chronic but benign. Treatment is difficult, but intralesional or systemic corticosteroids may be helpful.

Management of cheilitis granulomatosa

Peripheral facial nerve palsy, recurrent or persistent oral or facial swelling, and fissured tongue constitute a triad of symptoms known as Melkersson-Rosenthal syndrome. Granulomatous labial enlargement, known as cheilitis granulomatosa, is considered the single most important diagnostic feature of this syndrome. This lesion has been difficult to treat. This article describes a case of 8 months' duration of cheilitis granulomatosa of the lower lip, which was successfully managed with intralesional steroid injections.

Orofacial granulomatosis associated with delayed hypersensitivity to cobalt

Orofacial granulomatosis is a distinct clinical and pathological entity characterized by swelling of the lips and lower half of the face. Ulceration of the oral mucosa may also occur. Granulomas are seen histologically. Orofacial granulomatosis may occur in the Melkersson-Rosenthal syndrome, granulomatous cheilitis of Miescher, oral Crohn's disease, sarcoidosis and focal dental sepsis. The increased prevalence of atopy in patients with orofacial granulomatosis and the association with food intolerance suggests the possibility of a role for allergy in at least some cases.

Melkersson-Rosenthal syndrome: a review of 36 patients

The Melkersson-Rosenthal syndrome is an uncommon condition of uncertain pathogenesis and cause. The classic triad of signs includes recurrent orofacial edema, recurrent facial nerve palsy, and lingua plicata. We retrospectively reviewed the medical records of 36 patients (24 women and 12 men) with elements of the Melkersson-Rosenthal syndrome. The complete triad was present in 9 (25%) patients. Orofacial involvement was the dominant feature; it occurred in all 36 patients and was the presenting sign in 15 (42%). Lingua plicata occurred in 18 (50%) patients, and peripheral facial paralysis was present in 17 (47%). Fourteen biopsy specimens were obtained, all from the orofacial region. Eight specimens revealed the classic pathologic picture of granulomatous cheilitis. No etiologic agent was identified in any of the patients. Diagnosis is difficult when all features of the triad are not present. A conservative treatment approach is recommended.

Melkersson-Rosenthal syndrome and cheilitis granulomatosa. A clinicopathological study of thirty-three patients with special reference to their oral lesions

Thirty-three patients (seventeen females and sixteen males), six with complete and twenty-seven with abortive forms of Melkersson-Rosenthal syndrome (MRS) have been studied. Only patients with histologic granulomatous involvement were included in the study. The onset of MRS occurred predominantly during the second decade of life; the disease had a median duration of 6 1/2 years and a range of 6 months to 31 years. Recurrent lip swelling gradually turning into a permanent enlargement was the dominating sign, but changes in the buccal, palatal, sublingual, and gingival mucosa were frequently recorded as well. Peripheral facial paralysis occurred in 20 percent of the patients and plicated tongue in 40 percent. Laboratory investigations showed no specific changes. The elimination of odontogenic infectious foci was followed by regression or disappearance of the swellings in eleven of sixteen patient, suggesting a pathogenic mechanism. The present study does not seem to justify resections of the swellings when exacerbations are still occurring. A conservative approach is recommended.