Bilateral numb chin syndrome leading to a diagnosis of Burkitt's cell acute lymphocytic leukemia: a case report and literature review

Numb chin syndrome: What all oral health care professionals should know

BACKGROUND

Numb chin syndrome (NCS) is a rare sensory neuropathy involving the mental nerve. Symptoms of NCS are often overlooked because of their apparent innocent nature; however, owing to the frequent association of NCS with malignancies, the opposite should be the rule. Oral health care professionals may be the first to encounter patients with NCS and should be aware of its clinical characteristics in an effort to decrease patient morbidity and mortality.

TYPES OF STUDIES REVIEWED

A search in PubMed (MEDLINE) and the Cochrane Library was performed using the terms numb chin syndrome, numb chin, mental neuropathy, mental nerve neuropathy, and malignant mental nerve neuropathy, yielding 2,374 studies. After inclusion and exclusion criteria were applied, 102 studies remained. Descriptive statistics were performed, analyzing the etiology responsible for NCS, characteristics of NCS including associated symptoms, unilateral or bilateral nature, and information on professionals visited and examinations requested to make a diagnosis.

RESULTS

NCS was associated with malignancy in 29% through 53% of the published cases. Twenty-eight percent of patients initially consulted an oral health care professional with the symptom of a numb chin. Patients more likely to have NCS were those from the ages of 61 through 70 years; 74% were unilateral; and the most common symptoms reported were numbness (100%), paresthesia (18%), and pain (17%). Forty-seven percent of the NCS cases were associated with a recurrent malignancy, and the most prevalent associated diagnoses were breast cancer (32%) and lymphoma and leukemia (24%).

CONCLUSIONS

Oral health care professionals should be aware of the characteristics of NCS as they may be the first health care providers consulted for these symptoms.

PRACTICAL IMPLICATIONS

A thorough medical and dental history as well as a complete cranial nerve screening should be performed on all patients, especially those with numbness, as this may prevent misdiagnosis and allow a timely referral and a substantial improvement of treatment course and prognosis.

Central Nervous System Involvement in Adults with Acute Leukemia: Diagnosis, Prevention, and Management

PURPOSE OF REVIEW

Recent treatment advances in both acute myeloid leukemia and acute lymphoblastic leukemia have drastically improved outcomes for these diseases, but central nervous system (CNS) relapses still occur. Treatment of CNS disease can be challenging due to the impermeability of the blood-brain barrier to many systemic therapies.

RECENT FINDINGS

The diagnosis of CNS leukemia relies on assessment of clinical symptoms, cerebrospinal fluid sampling for conventional cytology and/or flow cytometry, and neuroimaging. While treatment of CNS leukemia with systemic or intrathecal chemotherapy and/or radiation can be curative in some patients, these modalities can also lead to serious toxicities. In the modern era, prophylaxis with intrathecal chemotherapy is the most important strategy to prevent CNS relapses in high risk patients. Accurate risk stratification tools and the use of risk-adapted prophylactic therapy are imperative to improving the outcomes of patients with acute leukemias and preventing the development of CNS leukemia.

Numb chin syndrome as a presentation for acute myeloid leukemia relapse post-hematopoietic cell transplant: Case report and review of literature

NCS is defined as reduced or absent sensation in the chin and lower lip within the distribution of the mental or inferior alveolar nerves. Although commonly associated with local trauma, NCS can indicate an underlying malignancy or can be the presenting symptom of cancer recurrence. We describe a 6-year-old female patient with AML and t(8,21) who underwent allogeneic HCT. Five months post-HCT, the patient presented with right-sided facial pain and numbness in her chin and lower lip consistent with NCS. Two weeks later, the patient had bone marrow relapse indicating AML recurrence. Although NCS remains a rare diagnosis especially in children, in the context of leukemia, it usually indicates an advanced disease or could be a sign of recurrence, and is commonly associated with grim prognosis. Further research is needed to study the link between NCS and specific cytogenetic abnormalities.

Late recurrence of Burkitt's lymphoma in the jaw: numb chin syndrome as the only symptom

The Numb Chin Syndrome (NCS) is defined as facial and oral numbness restricted to the mental nerve’s distribution involving the lower lip, skin of the chin, or gingiva of the lower anterior teeth. Hypoesthesia can occur unilaterally or bilaterally. Although this syndrome is rare, its importance is related to the fact that it represents the clinical manifestations of malignant diseases. Breast cancer and non-Hodgkin lymphoma are the most common cause of NCS. The patient, a 58-year-old woman, treated for a Burkitt Lymphoma (BL) nine years ago, described a two-week history of change in sensitivity and pain in the chin region, without relief with the use of analgesics. She had no headache, speech disturbance, dysphagia, visual disturbance, or other neurological symptoms. No surgical intervention has been performed recently. The intraoral examination revealed a healthy oral mucosa and a small area adjacent to the right mental nerve region that was uncomfortable to palpation. No changes were found in the bone trabeculae at cone-beam computed tomography. The contrasted magnetic resonance features made it possible to identify a change in the mandibular body extending to the entire right side, coinciding with the patient’s complaint, indicating a probable mandibular medullary invasion. The patient was submitted to a biopsy to rule out a possible recurrence of BL. The microscopic findings were consistent with the diagnosis of BL. The present report described a very unusual presentation of late recurrent BL nine years after the first treatment, which manifested as an NCS.

Why is That Chin Numb? A Case of Burkitt's Lymphoma Presenting as Numb Chin Syndrome

We report a case of numb chin syndrome (NCS) that preceded the diagnosis of Burkitt's lymphoma (BL) and discuss our findings with emphasis on metastatic malignancies in general and BL in particular causing NCS. A 73-year-old woman presented with worsening right-sided back pain for a week along with right-sided leg weakness and a progressive thigh and perianal numbness. She reported numbness of the chin which started two weeks prior. MRI showed compression of the cauda equina which was highly suggestive of neoplastic process. After debulking mass surgery, biopsy of the tissue from spine revealed BL. The patient received a round of radiotherapy of spine and multiple rounds of chemotherapy. Six months later she had reoccurrence of lymphoma with metastasis and eventually passed away. Presence of NCS in the setting of an underlying malignancy indicates very poor prognosis. In appropriate clinical setting, NCS should trigger work up for an underlying malignancy.

Acute Myeloid Leukemia Presenting with Numb Chin Syndrome: A Case Report and Review of Literature

Patient: Male, 30-year-old

Final Diagnosis: Acute myeloid leukemia

Symptoms: Jaw numbness and pain

Medication:—

Clinical Procedure: None

Specialty: Hematology

Numb chin syndrome as a presenting symptom of diffuse large B-cell lymphoma with secondary myelofibrosis

Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin's lymphoma that classically presents with rapidly enlarging lymph nodes. We present a 59-year-old man with unusual clinical presentation of numb chin syndrome (NCS) as the first symptom of disease. On evaluation, he was found to have diffuse extranodal skeletal involvement in the form of lytic-sclerotic lesions and minimal lymphadenopathy. Bone marrow biopsy revealed a poorly differentiated tumour with infarction and extensive myelofibrosis. This was subsequently proven to be DLBCL of germinal centre type on immunohistochemical stain. NCS should alarm the clinician to investigate for an advanced underlying malignancy. Extensive myelofibrosis, though described in carcinomas and low grade lymphomas, may also be seen in high grade DLBCL.

Complete progressive ophthalmoplegia and numb chin syndrome, the first clinical manifestations of a lethal abdominal Burkitt lymphoma

A 57-year-old patient was admitted to the Neurology Clinic for hypoesthesia, intense pain in the right chin and double vision. During the hospitalization, the patient developed progressive complete bilateral ophthalmoplegia and numbness of both sides of the chin. Brain CT and MRI scans with gadolinium were normal. Standard laboratory tests on admission were normal. The cerebral spinal fluid examination and the infectious and autoimmune workup were also normal. A thoracic-abdominal and pelvic CT scan revealed two hypodense lesions in the liver, irregular thickening of the gastric and ileal wall, and multiple abdominal adenopathies. Meanwhile, the patient developed marked fatigue, fever, sweats, nausea, vomiting and abdominal pain. An exploratory laparotomy was performed that showed multiple tumours of the small intestinal wall, stomach wall, multiple liver masses in both lobes and appendicular tumour. Histopathological findings of the liver biopsy and appendicular walls revealed Burkitt lymphoma. The patient died two days after surgery by cardiopulmonary arrest. This case underscores the importance of keeping BL in the differential diagnosis of patients with rapidly progressive ophthalmoplegia and numb chin syndrome, with normal brain MRI and CSF examinations.

Bilateral Numb Chin Syndrome as the Initial Presentation of Burkitt's Lymphoma/Leukemia: A Report of Two Cases and Review of the Literature

Numb chin syndrome, also known as mental nerve neuropathy, is a rare sensory neuropathy characterized by paresthesia and hypoesthesia in the area supplied by the mental nerve and its branches. This syndrome may be the first symptom of underlying malignancy or the first sign of recurrence and metastasis in patients with preexisting cancer. In this article, we present two cases with bilateral numb chin syndrome as the first manifestation of Burkitt's lymphoma/leukemia and review the relevant literature. Numb chin syndrome should be considered as a warning sign and raise the suspicion for an underlying malignancy. Bilateral involvement is especially hazardous and must not be underestimated. In fact, an astute neurologist and internist who realizes that chin numbness is a potentially significant symptom can then exclude serious underlying malignancies. Standard diagnostic protocol with different modalities of imaging based on the availability and experience of the radiology team should be mandatory. High index of suspicion should be practiced to avoid delay in diagnosis and progression of the underlying malignancy.

Bilateral Facial Nerve Palsy in Acute B Cell Lymphoblastic Leukemia: A Case Report and Review of the Literature

Acute lymphoblastic leukemia (ALL) is a haematological malignancy that can involve the central nervous system (CNS). Less than 10 % of patients with ALL have CNS involvement at presentation. The cranial nerve most commonly affected is cranial nerve VII although bilateral involvement is rare. Management and outcomes of these patients are not well understood. Moreover bilateral Bells palsy as a presenting symptom of ALL is extremely uncommon. We report a very unusual presentation of ALL with bilateral facial nerve palsy, and discuss the management strategies and outcomes for patients with ALL that present with cranial nerve palsies.

Numb chin syndrome associated with metastatic invasive ductal carcinoma of breast

Numb chin syndrome (NCS), also known as mental nerve neuropathy, is characterized by facial and oral numbness restricted to the distribution of the mental nerve. Although not a common neuropathy, the clinical importance of this syndrome is its frequent association with malignancies. A 56-year-old Indian female reported with a complaint of numbness on the left side of chin. She had undergone a radical mastectomy with axillary lymph node dissection for invasive ductal carcinoma of the right breast 4 years ago. Biopsy revealed tumor cells showing pleomorphic hyperchromatic nuclei arranged in cord and nests leading to a diagnosis of metastatic carcinoma of breast origin. Bone scan showed increased uptake in multiple areas in skull, left hemimandible, multiple vertebrae, multiple ribs on either sides, right clavicle both scapulae and sternum, both humeri, multiple pelvic bones and trochanteric region of left femur. The patient was referred to a tertiary cancer institute where she received palliative hormonal and chemotherapy, which helped with her pain and halted the progression of the metastatic disease for past 22 months. The present case depicts the importance of proper recognition of NCS as it may often be the only symptom of an underlying malignancy or the first evidence of dissemination from a primary site as evident in this case.

Numb Chin Syndrome

"Numb chin syndrome" (NCS) refers to new-onset numbness of the lower lip and chin within the distribution of the mental or inferior alveolar nerves. While this focal numbness may be downplayed or even overlooked by patients and clinicians, in the right clinical scenario this may be the presenting symptom of an underlying malignancy. In the absence of any obvious, temporally related dental cause, there are certain conditions that clinicians should consider including orofacial and systemic malignancies as well as several inflammatory disorders. Thorough diagnostic evaluation should always be performed when no clear cause is evident. This paper will discuss the differential, recommended evaluations, and the prognosis, for a patient presenting with NCS.

A case of mental nerve paresthesia due to dynamic compression of alveolar inferior nerve along an elongated styloid process

Spontaneous paresthesia of the mental nerve is considered an ominous clinical sign. Mental nerve paresthesia has also been referred to as numb chin syndrome. Several potentially different factors have been investigated for their role in interfering with the inferior alveolar nerve (IAN) and causing mental nerve neuropathy. In the present case, the patient had an elongated calcified styloid process that we hypothesized had caused IAN irritation during mandibular movement. This eventually resulted in progressive loss of sensation in the mental nerve region. To our knowledge, this dynamic irritation, with complete recovery after resection of the styloid process, has not been previously reported.