Cherubism With Bilateral Mandible and Maxilla Involvement: A Case Report

Cherubism is a rare, nonneoplastic, self-limiting fibro-osseous that occurs in children. Affected children usually appear normal at birth. Lesions are characterized by the replacement of bone with fibrovascular tissue containing many multinucleated giant cells. Most studies have reported cherubism to be familial and with bilateral involvement of the mandibles. The authors describe a nonfamilial case of cherubism, involving both the mandible and the maxilla, in a 4-year-old female child with slowly enlarging, painless, symmetrical swelling of both cheeks.Cherubism is a rare disease that is usually limited to the mandible, but the maxilla may be involved. Computed tomography scan and biopsy are helpful for early diagnosis.

Clinicoradiologic features of cherubism: a case report and literature review

Cherubism is a rare, hereditary, nonneoplastic bone disease. It is characterized by clinically evident bilateral, painless enlargements of the jaws that are said to give the patient a "chubby" appearance. This article presents a case of cherubism in a 5-year-old girl with painless bilateral swelling. Panoramic radiographs and a computed tomography scan showed bilateral multilocular radiolucent areas with cortical expansion. Histopathologic examination revealed proliferating fibrous connective tissue containing numerous multinucleated giant cells.

Cherubism: a case report

Cherubism is a familial benign fibro-osseous disease of the jaws. On radiography, the lesions exhibit bilateral multinuclear radiolucent areas. Histopathology reveals multinucleated giant cells in the background of proliferating fibrous connective tissue. Mutations in the SH3BP2 gene are identified as the cause of cherubism. A 12-year-old girl with prominence of the lower face was investigated. Her chief complaint was her facial appearance with asymmetrical swelling of the cheeks. Clinical and radiographic examinations, and biopsy, biochemical analysis and genetic investigations were performed.

Anti-tumor necrosis factor treatment in cherubism--clinical, radiological and histological findings in two children

Cherubism is a rare and disfiguring genetic disorder with excessive bone resorption and multilocular lesions in the mandible and/or maxilla. The disease-causing gain-of-function mutations in the SH3-binding protein 2 (SH3BP2) gene result in increased myeloid cell responses to macrophage colony stimulating factor and RANK ligand, formation of hyperactive osteoclasts (giant cells), and hyper-reactive macrophages that produce excessive amounts of the inflammatory cytokine tumor necrosis factor α (TNF-α). Recent findings in the cherubism mouse model suggest that TNF-α plays a major role in disease pathogenesis and that removal of TNF-α prevents development of the bone phenotype. We treated two children with cherubism with the TNF-α antagonist adalimumab for approximately 2.5 years and collected extensive clinical, radiological and histological follow-up data during the treatment. Histologically the treatment resulted in a significant reduction in the number of multinucleated giant cells and TNF-α staining positivity in both patients. As evaluated by computed tomography and magnetic resonance imaging, the lesions in Patient 1 showed either moderate enlargement (mandibular symphysis) or remained stable (mandibular rami and body, the maxilla). In Patient 2, the lesions in mandibular symphysis showed enlargement during the first 8 months of treatment, and thereafter the lesions remained unchanged. Bone formation and resorption markers remained unaffected. The treatment was well tolerated. Based on our findings, TNF-α antagonist may decrease the formation of pathogenic giant cells, but does not result in lesion regression or prevent lesion expansion in active cherubism. TNF-α modulator treatment thus does not appear to provide sufficient amelioration for patients suffering from cherubism.

Fine needle aspiration cytologic features of Cherubism: a case report

BACKGROUND

Cherubism is characterized by hereditary and intraosseous fibrous swellings of the jaws. It presents with bilateral mandibular and maxillary involvement in young individuals. Fine needle aspiration cytologic (FNAC) features have rarely been described in the literature; they include smears showing moderate cellularity with spindle cells mixed with multinucleated giant cells of osteoclast type. Therefore, giant cell containing soft tissue and bone lesions are considered in the differential diagnosis.

CASE

A 13-year-old girl presented with bilateral symmetrical mandibular enlargement and was diagnosed as having cherubism on FNAC.

CONCLUSION

We describe the cytomorphologic features of cherubism along with its differential diagnosis on cytology and emphasize that with clinicoradiologic correlation, a specific diagnosis can be offered for a definitive therapeutic approach.

Neurofibromatosis presenting with a cherubism phenotype

We report on a child who presented clinical manifestations of both neurofibromatosis type 1 (NF1) and cherubism. With genetic testing, we found a mutation in the NF-1 gene, confirming the neurocutaneous disorder. Histology when correlated with radiological evaluation of a mandibular biopsy was consistent with cherubism. This is the first report in the literature of a child with proven neurofibromatosis type 1 and cherubism without extragnathic lesions. This emphasises that cherubism is a clinical phenotype that can be associated with a number of germline mutations involving SH3BP2, PTPN11 and NF1.

Non-familial cherubism

Cherubism is a disease that usually affects the jaws in the paediatric population, mostly below five years of age. Radiologically, it closely resembles fibrous dysplasia and other giant cell lesions of the mandible. Computed tomography (CT) is helpful in defining the true extent of cherubic lesions, which is often not possible on radiographs due to the overlapping facial bones. We describe the radiographical and CT features of cherubism in a 12-year-old boy and highlight the ability of multidetector CT and various post-processing techniques to accurately depict the anatomical extent of the cherubic lesions.

Giant cell lesions with a Noonan-like phenotype: a case report

AIM

The purpose of this article is to describe a case of multiple giant cell lesions of the mandible that occurred in a 14-year-old girl with phenotypic characteristics associated with Noonan Syndrome (NS).

BACKGROUND

NS is a dysmorphic disorder characterized by hypertelorism, short stature, congenital heart defects, short and webbed neck, skeletal anomalies, and bleeding diathesis.

REPORT

A 14-year-old girl with a previous diagnosis of NS (sporadic case) presented with multiple radiolucent lesions in the body and ramus of her mandible.

SUMMARY

In terms of clinical behavior and the described radiographic characteristics, giant cells lesions with Noonan-like phenotype can be considered a form of cherubism. Therefore, surgical intervention is not necessary, but radiographic follow-up and observation is very important during the control and gradual regression of the lesions.

Cherubism in siblings: A case report

Cherubism is a benign disease of bones affecting the jaws and giving a characteristic cherubic appearance to the patient. On radiography, the lesions exhibit bilateral multilocular radiolucent areas. Histopathology shows numerous multinucleated giant cells in the background of proliferating fibrous connective tissue. Cherubism can be a solitary case. The present report describe cherubism in two siblings and briefly review the literature on this subject.

A novel mutation in the SH3BP2 gene causes cherubism: case report

Background

Cherubism is a rare hereditary multi-cystic disease of the jaws, characterized by its typical appearance in early childhood, and stabilization and remission after puberty. It is genetically transmitted in an autosomal dominant fashion and the gene coding for SH3-binding protein 2 (SH3BP2) may be involved.

Case presentation

We investigated a family consisting of 21 members with 3 female affected individuals with cherubism from Northern China. Of these 21 family members, 17 were recruited for the genetic analysis. We conducted the direct sequence analysis of the SH3BP2 gene among these 17 family members. A disease-causing mutation was identified in exon 9 of the gene. It was an A1517G base change, which leads to a D419G amino acid substitution.

Conclusion

To our knowledge, the A1517G mutation has not been reported previously in cherubism. This finding is novel.

Cherubism: long-term follow-up of 2 patients in whom it regressed without treatment

Cherubism is a rare hereditary, self-limiting fibrous dysplasia characterised by painless enlargement of the jaws in childhood. Although, it is accepted that the lesions of cherubism are eventually replaced by bone, there have been few long-term follow-up reports with clinicoradiographic documentation of spontaneous remission of the disease, without treatment. We report two cases of cherubic boys who were followed for 17 and 19 years. Clinicoradiographic examination during this period showed regression of the disease without surgical correction.

Radiographic, CT and MRI features of cherubism

Cherubism is a paediatric disease affecting the jaws. It is a close radiological mimic of giant cell lesions of the mandible. The radiographic features of this condition are well known; however, the MR imaging features have not been well described. We describe the radiographic, CT and MR imaging features of cherubism in a 5-year-old girl. We highlight the MR appearances of cherubic lesions and the ability of MRI to not only accurately depict the anatomical extent of the lesions, but also to reveal signal intensity changes in those areas that are apparently normal on radiographs and CT images.

Identification of a novel mutation ofSH3BP2in cherubism and demonstration thatSH3BP2mutations lead to increased NFAT activation

We describe a novel missense mutation (Aspartic acid to Asparagine, p.D419N (g.1371G>A, c.1255G>A) within exon 9 of SH3BP2 in a patient with cherubism, an autosomal dominant syndrome characterized by excessive osteoclastic bone resorption of the jaw. Two siblings and the father were carriers but lacked phenotypic features. Transient expression of p.D419N (c.1255G>A), as well as three previously described exon 9 mutations from cherubism patients (p.R415Q (c.1244G>A), p.D420E (c.1259G>A), and p.P418R (c.1253C>G)) increased activity of NFAT (nuclear factor of activated T-cells), an osteoclastogenic mediator, indicating that cherubism results from gain of function mutations in SH3BP2.

[Clinicopathologic analysis and genetic investigation of two families with cherubism]

OBJECTIVE

To study genetic feature, clinical and histopathological characteristic of two Chinese kindreds with cherubism (CBM).

METHODS

Two Chinese kindreds with CBM were investigated. The affected individuals of two families were analyzed with medical history, clinical manifestations, classified grading system, radiographic assessment, histopathological findings, and hereditary nature.

RESULTS

There were 2 individuals affected with CBM in family A and 3 patients involving three generations in family B. Two probands were diagnosed aggressive form cherubism and classified as grade IV. In histopathological findings, besides varying numbers of multinucleated giant cells in a stroma of fibroblasts and the eosinophilic cuffing surrounding some vessels, actively proliferating areas with clear mitoschisis and relative dormant areas with loose fibrous tissue and bone were also presented in microscopic fields of the lesion.

CONCLUSIONS

Cherubism is caused by autosomal dominant inheritance. The diagnosis should be based on the genetic, clinical, radiological, and pathological aspects of the disease.

Cherubism: a clinical, radiographic, and histopathologic comparison of 7 cases

PURPOSE

Cherubism is an uncommon fibro-osseous disorder of the jaws that presents with varying degrees of involvement and a tendency toward spontaneous remission. Lesions are characterized by replacement of bone with fibrovascular tissue containing abundant multinucleated giant cells. We attempted to study the relationships among the degree of cherubism, the radiographic extent of the jaw lesions, the histopathologic findings, and the clinical course of 7 patients.

PATIENTS AND METHODS

In 7 patients diagnosed with cherubism, we evaluated the degree of fibrosis and perivascular cuffing, the presence of focal hemosiderin deposits, and giant multinucleated cell density (absent, few, moderate, or severe). Clinical course and progression were also assessed using a 4-point scale (improvement, no changes, modest progression, and marked progression).

RESULTS

The patients were followed up for an average of 8.5 years. Two patients exhibited clinical and radiographic improvement, while 3 showed no changes, and 2 progressed despite surgical treatment in 1 of them.

CONCLUSION

The course of cherubism in 1 of our patients may represent evidence of an association between the presence of abundant multinucleated giant cells, an increased extent of the lesions, and a more aggressive behavior of the disease.

The aggressive form of cherubism: report of two cases in unrelated families

Cherubism is a benign lesion that causes painless symmetrical enlargement of the jaws, usually with a familial tendency. We describe in two Chinese families two cases of the aggressive form of cherubism with extensive swelling on both sides of the mandible, typical microscopic findings, and apparent familial history.

Aggressive behaviour of cherubism in a teenager: 4-years of clinical follow-up associated with radiographic and histological features

Cherubism is a rare hereditary fibro-osseous childhood disease characterized by bone degradation and fibrous tissue replacement at the angles of the mandible and at the tuberosity areas of the maxilla that leads to prominence of the lower face and an appearance reminiscent of the cherub's portrayal in Renaissance art. This disease has an autosomal dominant hereditary characteristic. The purpose of this report is to analyse laboratory tests, clinicopathological and radiographic features of cherubism and its intraoral manifestations in a patient during 4-years of follow-up, correlating the features observed in this case with those of the literature. Also discussed is the atypical and aggressive behaviour of this case during puberty.

Cherubism: Review of four affected members in a Kuwaiti family

Cherubism is a rare autosomal dominant fibro-osseous disorder of childhood, mostly limited to the maxilla and mandible. Extra-cranial skeletal involvement is rare. Post-pubertal involution of the process and jaw remodeling occurs in adulthood. The aim of this case report is to present four cherubs, a father and his three daughters, in whom the diagnosis was made based on history, physical examination, laboratory tests and typical radiological features. The imaging characteristics are discussed and the published literature is reviewed.

Temporal bone involvement in cherubism: case report

Cherubism is a rare benign hereditary fibro-osseous disease involving the mandible and maxilla. We report a case of cherubism in a 10-year-old girl for which the panoramic radiograph was insufficient for diagnosis of the disease. Clinical, histological, and radiological findings were discussed. The CT was taken and it confirmed not only the involvement of the jaws but also of the temporal bone. This was not found in the conventional radiograph.

Imaging characteristics of cherubism

OBJECTIVE

We sought to describe the radiographic and imaging features of cherubism.

CONCLUSION

Cherubism is a rare osseous disorder of children and adolescents. Although the radiologic characteristics of cherubism are not pathognomonic, the diagnosis is strongly suggested by bilateral relatively symmetric jaw involvement that is limited to the maxilla and mandible. Imaging typically shows expansile remodeling of the involved bones, thinning of the cortexes, and multilocular radiolucencies with a coarse trabecular pattern.

[Cherubism: the value of imaging and preoperative embolization]

Cherubism is a benign, hereditary, autosomal dominant disease, with variable penetrance and expressivity. It presents as a characteristic indolent deformity of the lower half of the face, associated with multicystic bone tumors. The definitive diagnosis is established by pathology. Radiology contributes greatly to its diagnosis (CT or MRI scan), and preoperative arterial embolization can provide valuable help to the surgeon when excision of this hemorrhagic lesion is necessary. The present article presents a case showing the advantage of this type of devascularization prior to surgery, not previously described in the literature.

Clinical and radiological evaluation of cherubism: a sporadic case report and review of the literature

Many cases have been published on cherubism since Jones described it first time in three children of the same family [Am. J. Cancer 17 (1933) 946]. Cherubism is an autosomal-dominant disorder in which the normal bone is replaced by cellular fibrous tissue and immature bone. Extracranial skeletal involvement is rarely seen in hereditary and non-hereditary forms of the disorder. The mandible is the most severely affected craniofacial component, in which uncontrolled growth of the malady deteriorates the aesthetic balance of the face. Bilateral swelling of the cheeks, mandibular enlargement and maxillary spongious hypertrophy cause orbital manifestations and tendency of eyes looking up to the sky. Thus, the pathognomic clinical feature resembles the appearance of "raised to heaven" Renaissance cherubs. The sporadic case concerns a child affected by cherubism. Radiographic and clinical data of the patient are presented and brief review of the literature is included.

[Imaging of mandibular malformations and deformities]

Mandibular deformities and malformations are quite various. They are mostly identified by clinical examination, but imaging is very useful for surgical planning. CT imaging is essential to evaluate patients with dystrophies such as fibrous dysplasia, neurofibromatosis, Gorlin syndrome and cherubism. Some growth abnormalities lead to a pseudomalformative appearance. Sequelae and ankylosis from condylar fracture, and unilateral mandibular hypoplasia due to capillary-venous malformation require CT or/and MR evaluation. CT with 3D reformations is performed as a complement to clinical evaluation in patients with other growth abnormalities such as orthognathic problems, hypercondylia, and some malformations like lateral facial clefts. MR is helpful for soft tissue evaluation in patients with Parry-Romberg syndrome and Pierre Robin dysostosis.

[Computed tomographic aspects of skull development in a child with cherubism]

The clinical picture of cherubism is similar to that of fibrous dysplasia. The initial clinical appearance involves the deformation of the maxillofacial area with orthodontic disorder. Usually it is found in the mandible giving the child a chubby-faced appearance, and it often occurs together with symmetric submandibular lymph node enlargement. This appearance reminds one of the cherubs seen in art. Only histological evidence for cherubism is inconclusive. The presence of multi-nucleated giant cells resembles fibrous dysplasia. A combination of clinical, radiographical and histological findings eventually leads to the correct diagnosis. An example is given of a patient displaying the typical disease process. Over a period of 12 years, we observed the progression of the disease from its initial appearance in a young child, through the full and characteristic display of a cherubic youth, and finally its regression. In conclusion, we advise restraint in planning surgical intervention. The diseases etiology is not entirely dear. The latest research points to genetic defects that lead to failure in the expression of matrix proteins.

Cherubism: case reports and literature review

Two new cherubism cases have been documented and reported. Both were relatively mild clinically, being a Grade I within Motamedi's I to V clinical grading system. Each presented with bilateral posterior mandibular lesions having a multiloculated radiolucent appearance. In each case, detection with eventual diagnosis evolved from a mandibular molar failing to erupt (tooth No. 19). The partial literature review documented the wide spectrum of clinical expression of this disease and the consequent wide variation in its treatment.

Orbital involvement in cherubism

PURPOSE

To demonstrate the clinical, radiologic, and histopathologic features of a patient with orbital involvement in cherubism that prompted surgical treatment.

DESIGN

Single interventional case report.

INTERVENTION

Findings of the ophthalmic evaluation, computed tomography (CT) scans, intraoperative examination, and light microscopy of the specimens were analyzed.

MAIN OUTCOME MEASURES

Globe displacement, orbital bony lesions detected on CT scans, histopathology, and postoperative results were assessed.

RESULTS

A 27-year-old female was seen with a slowly progressive superonasal globe displacement and a temporal orbital mass bilaterally of 6 years' duration. She had a history of cherubism, but her cheeks and jaws had a normal appearance instead of the bilateral fullness of the lower half of the face typical of the disease. CT scans demonstrated multicystic bony lesions arising from the orbital floors bilaterally. The masses were excised using an anterior transcutaneous transseptal orbitotomy. Histopathology demonstrated numerous giant cells in a fibrovascular stroma, confirming the clinical diagnosis of cherubism. Postoperative recovery was complete.

CONCLUSIONS

Orbital involvement in cherubism may develop beyond puberty, after stabilization or regression of the lesions in the jaws. Patients with cherubism should be routinely evaluated by an ophthalmologist.

Orbital involvement in cherubism

Cherubism is a rare, inherited condition characterized by fibro-osseous lesions of the maxilla and mandible. It has recently been localized to chromosome 4p16.3. The fullness of the lower half of the face and retraction of the lower lids gives the characteristic 'eyes raised to heaven' cherubic appearance. A case report of a 7-year-old girl with extensive orbital involvement of cherubism is presented. The patient underwent multidisciplinary surgery for the bony lesions, which extended from the maxillary antrum into adjacent structures, including extensive extraperiosteal orbital involvement. Cherubism may have orbital manifestations including lower lid retraction, proptosis, diplopia, globe displacement and visual loss due to optic atrophy. Ophthalmologists should be aware of the syndrome, its ophthalmic features and overall management.

Cherubism: a 36-year long-term follow-up of 2 generations in different families and review of the literature

OBJECTIVE

To clarify the relationships between the varying clinical or radiographic features of cherubism.

STUDY DESIGN

Nonparametric statistics were used in a long-term follow-up of 18 patients through 2 generations from 6 Danish families.

RESULTS

The radiographic grade of cherubism was significantly related to sex, maximal buccal bone expansion, course of cherubism, and number of aplasia or ectopic impacted teeth, but it was not related to families. Normal dentition in nonaffected regions was present or was obtained in 14 of 14 patients (age, >14 years). Surgical treatment did not provoke growth of lesional tissue in 22 of 22 cases. Radiographically, the bone structure in the lesional areas was related to age in all grades of cherubism: new bone formation in radiolucent areas (age, >20 years), normal bone structure with multilocular sketches (age, 32 to 39 years), and completely normal bone structure (age, >41 years), also found in 7 of 7 carriers of cherubism (age, >32 years).

CONCLUSIONS

This group analysis verifies the knowledge of cherubism previously based on cumulative reviews of findings in single-family and case reports.

The gene for cherubism maps to chromosome 4p16

Cherubism is an autosomal dominant disorder that may be related to tooth development and eruption. It is a disorder of age-related bone remodeling, mostly limited to the maxilla and the mandible, with loss of bone in the jaws and its replacement with large amounts of fibrous tissue. We have used a genomewide search with a three-generation family and have established linkage to chromosome 4p16. Three other families affected with cherubism were also genotyped and were mapped to the same locus. The combined LOD score is 4.21 at a recombination fraction of 0, and the locus spans an interval of approximately 22 cM.

Cherubism: a radiological and clinical presentation

Cherubism is the hereditary form of the fibrous dysplasia of the jaws, but it may be seen sporadically as well. The disease has a self-limited nature and is rarely apparent before the age of two. There is no need to interfere surgically with these lesions of the mandible or the maxilla unless the child is severely affected, i.e. the disease deteriorates respiration, deglutition, vision, or the psychiatric makeup of the child due to cosmetic reasons. The clinical presentation and radiological evaluation of these children are so typical that the pediatrician and pediatric otolaryngologist need to be informed about this rarely seen disease. A case of a cherubic child, with his clinical appearance as well as his radiological evaluation, and discussion about the clinical outcome are presented.

Non-familial cherubism--a case report

A case of cherubism in a 9 year old boy with no familial history is presented. Clinical features, histologic appearance, radiographic findings, differential diagnosis and rationale for treatment is discussed.

Cherubism: presentation of a case

Cherubism is a rare, fibro-osseous bone disease that affects the jaws. Bilateral enlargement of the mandible produces a full, round lower face. The skin over the cheeks stretches and pulls the lower eyelids down, exposing a thin line of sclera and eyes that are raised, seemingly heavenward. The patient in this report was diagnosed but not treated.