Orofacial granulomatosis: review on aetiology and pathogenesis

Orofacial Granulomatosis among Pediatric Patients Well Controlled by Corticosteroid Treatment: A Rare Case Series

Orofacial granulomatosis (OFG) is a rare disease entity characterized by nonnecrotizing granulomatous inflammation in the oral and maxillofacial regions, typically characterized by recurrent or persistent edema, primarily in the lips and occasionally in the gingiva. OFG is often associated with Crohn's disease and sarcoidosis, and an accurate diagnosis requires systemic examination of patients. Pediatric patients possess unique oral conditions where dental plaque rapidly forms, especially during tooth replacement due to tooth crowding. Moreover, controlling oral hygiene can be challenging, rendering it difficult to distinguish plaque-induced gingivitis from nonplaque-induced gingivitis. We elucidate the reports of pediatric patients who developed OFG in the lips and/or gingiva alone, which was well controlled through corticosteroid treatment. The patients demonstrated recurrent lips and/or gingival swelling with redness, which failed to improve despite oral health care and treatment with antibiotics and/or corticosteroid ointment. Incision biopsy was performed, which demonstrated granulomatous inflammation. Further systemic examination ruled out Crohn's disease and sarcoidosis and confirmed OFG diagnosis. Corticosteroid treatment orally or through gargling was administered to the patients, which provided improvement of symptoms after 1 month. As OFG may be associated with intractable diseases, monitoring the patient regularly is crucial. Pediatric patients with OFG require a collaborative approach with pediatricians and pediatric dentists to manage their oral and overall health.

Wenn es kein Angioödem ist, was dann? Diagnostisches Vorgehen bei Gesichtsödemen

Gesichtsödeme sind ein relativ häufiges Symptom bei Patienten allergologischer und dermatologischer Kliniken. Die Differentialdiagnose ist breit gefächert und die endgültige Diagnose kann manchmal eine Herausforderung für den Kliniker sein. Das faziale Angioödem selbst umfasst verschiedene Ätiopathologien (histaminerg, bradykinininduziert und weitere), die von anderen Ursachen des Gesichtsödems differenziert werden sollten, etwa allergischer Kontaktdermatitis, granulomatösen Erkrankungen, inflammatorischen Ursachen, Infektionen, Neoplasmen oder paraneoplastischen Syndromen, Autoimmunerkrankungen und anderen Entitäten, die hier als „Sonstige“ bezeichnet werden. Um die richtigen Untersuchungen anzuordnen und eine gezielte Therapie zu verordnen, ist ein angemessener diagnostischer Ansatz ausschlaggebend. Diese Übersicht konzentriert sich auf Entitäten, die mit Gesichtsödem einhergehen, und fasst ihre klinischen Charakteristika zusammen.

If not angioedema, what is it? Diagnostic approach to facial edema

Facial edema is a relatively frequent clinical presentation encountered in patients seen in allergology and dermatology clinics. The differential diagnosis is broad, and sometimes the definitive diagnosis can be a challenge for the clinician. Facial angioedema itself encompasses different etiopathologies (histaminergic, bradykinergic, etc.) that must be distinguished from other causes of facial edema, such as allergic contact dermatitis, granulomatous conditions, inflammatory causes, infections, neoplasms or paraneoplastic syndromes, autoimmune diseases, among other entities hereby referred as miscellanea. A proper diagnostic approach is essential to order the appropriate tests, as well as to prescribe a targeted treatment. This review focuses on entities that present with facial edema and summarize their characteristic clinical features.

Gingival Orofacial Granulomatosis Clinical and 2D/3D Microscopy Features after Orthodontic Therapy: A Pediatric Case Report

Orofacial granulomatosis (OFG) represents a heterogeneous group of rare orofacial diseases. When affecting gingiva, it appears as a chronic soft tissue inflammation, sometimes combined with the enlargement and swelling of other intraoral sites, including the lips. Gingival biopsy highlights noncaseating granulomatous inflammation, similar to that observed in Crohn’s disease and sarcoidosis. At present, the etiology of OFG remains uncertain, although the involvement of the genetic background and environmental triggers, such as oral conditions or therapies (including orthodontic treatment), has been suggested. The present study reports the results of a detailed clinical and 2D/3D microscopy investigation of a case of gingival orofacial granulomatosis in an 8-year-old male patient after orthodontic therapy. Intraoral examination showed an erythematous hyperplasia of the whole gingiva with a granular appearance occurring a few weeks after the installation of a quad-helix. Peri-oral inspection revealed upper labial swelling and angular cheilitis. General investigations did not report ongoing extra-oral disturbances with the exception of a weakly positive anti-Saccharomyces cerevicae IgG auto-antibody. Two- and three-dimensional microscopic investigations confirmed the presence of gingival orofacial granulomatosis. Daily corticoid mouthwashes over a period of 3 months resulted in a slight improvement in clinical signs, despite an intermittent inflammation recurrence. This study brings new insights into the microscopic features of gingival orofacial granulomatosis, thus providing key elements to oral practitioners to ensure accurate and timely OFG diagnosis. The accurate diagnosis of OFG allows targeted management of symptoms and patient monitoring over time, along with early detection and treatment of extra-oral manifestations, such as Crohn’s disease.

Non-infectious granulomatous disorders of the upper lip: clinicopathological analysis of 11 patients

Background

Non-infectious granulomatous disorders of the upper lip represent a special chapter of oral and maxillofacial pathology. In this work we report a case-series of this process, to analyse its main clinicopathological features and find differential data that allow us improve its diagnosis and understand its pathogenesis.

Methods

We present 11 cases of non-infectious granulomatous disorders of the upper lip, 8 women and 3 men with an age range of 29–84 years, who have been attended at the Oral Medicine Department of the IUCT (France) and the Oral Medicine Unit of the UPV/EHU (Spain). All clinicopathological data were collected in a specific protocol.

Results

We recognized 4 different subtypes of non-infectious granulomatous disorders of the upper lip: (1) associated with Crohn’s disease (1 case), (2) associated with foreign body (2 cases), (3) associated with gingivitis lichenoid-like (4 cases), (4) idiopathic (4 cases).

Conclusions

Clinicopathological differences were identified between these subtypes. A good differential diagnosis is necessary in all cases to rule out the presence of local or systemic etiopathogenic factors.

Orofacial granulomatosis: A case report and a proposal of a diagnostic algorithm for oral granulomatous lesions

Orofacial granulomatosis (OFG) is an uncommon chronic inflammatory disorder with multifactorial etiology and pathogenesis affecting the orofacial region which appears usually as a persistent and/or recurrent swelling that may involve one or both the lips and/or recurrent ulcers along with other orofacial features. The diagnosis of OFG is challenging and it should be ruled out from other conditions characterized by granulomatous inflammation. This article describes a case of a 30-year-old female patient with upper lip swelling as the main manifestation without any systemic involvement and we have also laid down a proposal of a diagnostic algorithm for differential diagnoses and treatment modalities for OFG which could be helpful for the clinician and dentists alike to rule out other granulomatous disorders thus in effective management of OFG.

Melkersson-Rosenthal syndrome in the context of sarcoidosis: a case report

Background

Melkersson–Rosenthal syndrome is a rare disease characterized by the triad of recurrent orofacial swelling with facial paralysis and fissured dorsal tongue. Histologically, noncaseating granulomatous inflammation occurs that confirms the diagnosis. Overlaps between granulomatous diseases such as sarcoidosis and Crohn’s disease are described. Systemic corticosteroid therapy is the treatment of choice for acute attacks.

Case presentation

We here present a case of a 59-year-old White woman suffering from Melkersson–Rosenthal syndrome with a past history of sarcoidosis on therapy with leflunomide in combination with low-dose tacrolimus successfully treated with the anti-leprosy drug clofazimine after failure of systemic steroid therapy.

Conclusions

We propose clofazimine as an alternative treatment in steroid-refractory cases.

Association between cheilitis granulomatosa and odontogenic infections: A case-control study

The association between cheilitis granulomatosa and dental infections (dental caries and apical periodontitis) is still not well understood. Herein, we aimed to investigate the association in large hospital cases with cohort controls. Cheilitis granulomatosa cases (n = 181) were retrieved from Peking University Hospital of Stomatology and age- and sex-matched to controls (n = 181). The χ² -test, Student's t-test, and Mann-Whitney U-test were used to compare the differences between groups. The χ² -test and odds ratio were used to verify if there was an association and risk relationship. The results showed that both dental caries and apical periodontitis were associated with cheilitis granulomatosa (p < 0.001). Individuals with cheilitis granulomatosa had approximately a twofold increased frequency of dental caries than those without cheilitis granulomatosa (104/181, 57.5% vs. 53/181, 29.3%) (p < 0.001). The odds ratio of dental caries occurring in the case group compared to the control group was 3.211. The frequency of apical periodontitis in patients with cheilitis granulomatosa was significantly greater than in those without cheilitis granulomatosa (109/181, 60.2% vs. 28/181, 15.5%) (p < 0.001). The odds ratio was 8.272. Moreover, apical periodontitis was also locationally related to cheilitis granulomatosa (p < 0.001). Collectively, our study showed that the foci of dental infections are associated with cheilitis granulomatosa, suggesting that proper treatment of focal teeth may be important in the management of cheilitis granulomatosa.

Pathological and Immunohistochemical Characteristics of Granuloma and Lymphatics in Cheilitis Granulomatosa

ABSTRACT

Cheilitis granulomatosa (CG) is an idiopathic, rare, and chronic granulomatous disorder involving the lips. We characterized the pathological and immunohistopathological findings of these granulomas and their relationship with the lymphatic vessels. Pathologically confirmed cases of primary CG from 2001 to 2016 were collected. Cases of inflammatory cheilitis without the presence of granuloma were included in the control group. Demographic data, clinical presentation, response to therapy, and pathological differences were compared. Periodic acid-Schiff and acid-fast stains excluded patients having infections. CD68, CD163, and D2-40 stains demonstrated features of granuloma, macrophage polarization, and the relationship between granuloma and lymphatic vessels. Thirteen patients diagnosed with CG were enrolled. Thirteen people were enrolled in the control group. The granulomas were either mononuclear or sarcoidal. They were predominantly positive for CD68 but negative for CD163. Perilymphatic granulomas were found in all patients. Intralymphatic histiocytosis and lymphatic dilatation were more commonly observed in patients diagnosed with CG than those in controls (54% vs. 15%, P = 0.03 and 92% vs. 23%, P < 0.01). TH1 immune response due to CD68+ M1 macrophages results in CG. Perilymphatic aggregation of macrophages and intralymphatic histiocytosis were important pathological clues for diagnosis.

Clinical Profile of Melkersson-Rosenthal Syndrome/Orofacial Granulomatosis: A Review of 51 Patients

BACKGROUND

Melkersson-Rosenthal syndrome (MRS) is a rare disease characterized by the triad of granulomatous cheilitis, fissured tongue, and facial paralysis. Publications concerning large series are rare in the literature.

OBJECTIVES

To describe the clinical and histopathological characteristics of patients with complete and oligosymptomatic forms of MRS.

METHODS

A retrospective records review was performed for the diagnoses of Melkersson-Rosenthal syndrome, granulomatous cheilitis, and orofacial granulomatosis at oral Diseases Clinic of the Department of Dermatology, University of São Paulo, Brazil (2003, 2017).

RESULTS

A total of 51 patients were included, mean age at presentation 35.69 years. Four patients were younger than 18 years. The complete triad of was observed in 10 patients. The rare findings of granulomatous blepharitis, gingivitis and palatitis are presented. Comorbidities included Crohn's disease (5 patients), migraine headaches (1 patient) and convulsions (2 patients). Granulomatous inflammatory infiltrate was detected in 31 biopsies. Medical therapies included included oral and intralesional steroids, thalidomide, dapsone, azathioprine, tetracycline, methotrexate, and surgery, with variable responses.

CONCLUSIONS

Our report meant to draw attention to the clinical spectrum of this rare disorder, mainly to oligosymptomatic forms and rarer presentations.

Melkersson-Rosenthal syndrome misdiagnosed as recurrent Bell's palsy: a case report and review of literature

Background

Melkersson–Rosenthal syndrome (MRS) is a rare neuro-mucocutaneous disorder of unknown cause, clinically characterized by a triad of recurrent facial palsy, orofacial swelling, and fissured tongue. It is frequently seen in females in their second and third decades of life. MRS is diagnosed based on clinical features and it is rarely possible to observe all the classical triad symptoms at the same time. The disorder may cause recurring peripheral facial palsy that is wrongly diagnosed as recurrent Bell’s palsy

Case presentation

A 25-year-old female patient was presented to the neurology clinic of Tikur Anbessa Specialized Hospital in Addis Ababa complaining of recurrent left-side peripheral facial weakness, facial swelling and fissured tongue of 5 days duration. Her past medical history was positive for similar symptoms, for which she was diagnosed with Bell’s palsy and received oral corticosteroid treatment. On examination left side lower facial swelling with flat naso-labial fold and fissured tongue were identified. After excluding other mimickers, she was diagnosed with Melkersson–Rosenthal syndrome and completely recovered with high dose of corticosteroid treatment.

Conclusion

Melkersson–Rosenthal syndrome may present with the classic triads of symptoms, but mostly it shows an incomplete clinical pattern. Therefore, when clinicians including allergists encountered patients with facial swelling and facial palsy, they should have to consider MRS in their differential diagnosis and specifically assess for recurrent facial palsy and fissured tongue. Unlike true angioedema, the facial swelling in MRS often develops gradually and it might cause permanent swelling with cosmetic disfigurement from multiple relapses, which can be prevented by early detection and timely initiation of treatment.

Vaginal tuberculosis as differential diagnosis of cancer: A case report

Tuberculosis remains a worrying public health problem. But if pulmonary tuberculosis’s symptomatology is well known by the medical profession, this is not the case of genital tuberculosis. We take advantage of a case of vaginal tuberculosis to review the international literature about clinical diagnosis, further tests, and treatment of this extremely rare tuberculosis localization.

Orofacial granulomatosis: a questionnaire study among Norwegian dental clinicians

Aims

To evaluate awareness on orofacial granulomatosis (OFG) and oral Crohn disease (oral CD) among Norwegian dental clinicians.

Methods

A precoded questionnaire (QuestBack) was sent electronically to dentists and dental hygienists treating children and adolescents in the public dental service (PDS) in Norway. Data on the clinicians’ knowledge of OFG and oral CD related to working experience were analysed by Chi square tests and bivariate logistic regression analyses.

Results

A total of 1097 clinicians were invited to participate, 778 dentists and 319 dental hygienists; 48.2% returned the completed form. Fifty-four percent of the participants had ≥ 10 year experience of clinical practice. Two-thirds (68.4%) of the dentists and all but one of the dental hygienists graduated in Norway. Approximately half of the respondents were aware of OFG (41.2%) and oral CD (57.8%). One-quarter (24.6%) reported that they most likely had seen a patient with OFG and 20.6% with oral CD. Recently graduated dentists (≤ 10 years ago) were more aware of OFG and oral CD than those who graduated > 10 years ago (p ≤ 0.001). Regarding dental hygienists, this difference was observed for OFG only (p < 0.05). Country of education did not affect the clinicians’ reported knowledge. Approximately 90% would refer a patient suspected of having OFG or oral CD either to a dental specialist or to a physician.

Conclusion

The high prevalence of clinicians observing OFG and oral CD in this study may indicate that OFG and/or oral CD are under-reported and that OFG in particular is more common than hitherto believed. The high frequency of awareness was promising for the benefit of the patients.

Systemic disease or periodontal disease? Distinguishing causes of gingival inflammation: a guide for dental practitioners. Part 1: immune-mediated, autoinflammatory, and hereditary lesions

Periodontitis and gingivitis remain two of the most common diseases that affect the oral cavity. As they are caused by plaque, effective oral hygiene, elimination of plaque-retentive factors and successful periodontal treatment will result in resolution of gingival and periodontal inflammation. Certain systemic diseases can have a clinical appearance similar to periodontal diseases or exacerbate existing periodontitis/gingivitis and vice versa. This paper aims to provide the dental practitioner with an understanding of the manifestations of systemic diseases to the periodontium and highlights elements in the clinical assessment, which will aid in establishing a correct diagnosis. Additional anamnestic and clinical clues are important for distinguishing between plaque-induced and non-plaque-induced lesions. The first part of this compendium covers immune-mediated and hereditary conditions as causes of gingival lesions, which can resemble those caused by dental plaque. The different conditions are presented concisely and exemplified by clinical photographs. Dental practitioners should be aware of the various manifestations of systemic diseases to the periodontium in order to offer appropriate diagnosis and treatment, which can reduce both patient morbidity and mortality.

A 30-year follow-up study of patients with Melkersson-Rosenthal syndrome shows an association to inflammatory bowel disease

Background: Melkersson-Rosenthal syndrome (MRS) is often classified under the term orofacial granulomatosis (OFG). A part of OFG patients eventually develop Crohn's disease (CD), but the relationship between MRS and CD is unknown. Goals: To evaluate the long-term outcomes of MRS patients, with specific interest in bowel-related symptoms. Study: This follow-up study consisted of adult patients with MRS - including the monosymptomatic form, cheilitis granulomatosa (CG) - who had participated in our earlier MRS study (diagnosed after 1995 in Helsinki University Hospital). A phone interview was conducted with 27 patients (77.1% of the patients from the earlier study) and included questions about orofacial symptoms, facial palsy, intestinal symptoms, concomitant illnesses, medications, possible food avoidances and family history. Stool samples were collected to measure faecal calprotectin, a surrogate marker for intestinal inflammation. Results: The median follow-up time from symptom onset was 30 years. Three (11.1%) patients had developed inflammatory bowel disease (IBD); one CG patient developed CD, and two MRS patients with facial palsy developed ulcerative colitis. In addition, several other patients reported intestinal symptoms, but the examination of faecal calprotectin did not indicate intestinal inflammation. Conclusions: There was a connection between MRS and IBD - not only CD but ulcerative colitis as well. Key message Melkersson-Rosenthal syndrome (MRS) is a chronic condition often classified as a subtype of orofacial granulomatosis. Oral manifestations are common in MRS. We found a connection between MRS and inflammatory bowel disease, not only Crohn's disease but ulcerative colitis as well.

The difference in extraintestinal manifestations of inflammatory bowel disease for children and adults

Extraintestinal manifestations (EIMs) are frequently observed in adult and pediatric patients with inflammatory bowel disease (IBD). The most common EIMs involve the joints, skin, and eyes, but they can affect various organs and result in significant morbidity. Since EIMs can appear years before the diagnosis of IBD is made, clinicians should be aware of their various manifestations to help decrease diagnostic delay of IBD and establish appropriate treatment plans.

Idiopathic macrocheilia

A 13-year-boy presented with painless swelling of upper and lower lips accompanied with gingival enlargement. The aetiology for these symptoms included vast pathological varieties but none of them could fit in. Clinical features were similar to orofacial graulomatosis but histopathological examination revealed chronic non-specific infection. Therefore, the final diagnosis was made as idiopathic macrocheilia through exclusion criteria. Management with intralesional triamcinolone acetonide 40 mg, twice a week for 3 weeks, resulted in significant remission in lip swelling without recurrence after a 6-month follow-up.

Management of orofacial granulomatosis: a case report

Introduction: Orofacial granulomatosis is characterized by recurrent swelling affecting the lips, cheeks, and tongue. The rarity of this pathology and the lack of consensus in therapeutic management make the reporting of this clinical case relevant. Observation: A 48-year-old man consulted for labial and gingival orofacial granulomatosis. The treatment consisted of 40 mg/L injections of triamcinolone acetonide once weekly for 3 weeks. The symptoms improved after 1 week of treatment. Comments: The usual treatment for this condition targets the inflammation caused by the lesion. Corticosteroids (clobetasol, triamcinolone acetonide, prednisolone), monoclonal antibodies (infliximab, adalimumab), or TNF-α inhibitors are commonly used. Symptom recurrenceis frequently observed after treatment with corticosteroids. Biotherapies are often used as a second-line treatment. Conclusion: Orofacial granulomatosis symptoms are rare and difficult to diagnose due to its varying manifestations. Common treatments target one of the steps of the inflammatory response. The detection of specific cellular markers is a way to enable a more precise etiological diagnosis and allows for a more targeted therapy.

Detailed Follow-up Study of Pediatric Orofacial Granulomatosis Patients

OBJECTIVES

Orofacial granulomatosis (OFG) is a chronic inflammatory condition affecting the orofacial area. Its connection to Crohn disease (CD) is debated. Our aim was to describe a cohort of pediatric patients with OFG in detail, study the long-term behavior of OFG, and evaluate factors predicting CD in patients with OFG.

METHODS

We invited patients diagnosed with OFG at 2 university hospitals, Finland for a follow-up appointment. Patients (n = 29) were examined by a dentist and an otorhinolaryngologist using a structural schema. Orofacial findings were also recorded using digital photographing. Patients filled in questionnaires about general health and special diets. Patients' nutrition was evaluated from food records. The findings were compared between patients with OFG only and OFG with CD.

RESULTS

Patients with CD had more findings in the orofacial area (total score for orofacial findings median 11) compared to patients with OFG only (total score median 7.5). There was no statistically significant difference in the type of lesions between these groups, except the upper lip was more often affected in patients with CD (n = 11) than in patients with OFG only (n = 0). Most of the patients had normal otorhinolaryngological findings. All patients with elevated anti-Saccharomyces cerevisiae antibody A levels had CD (n = 6) and they presented with more orofacial findings (total score) than patients with normal levels of anti-S cerevisiae antibody A (P = 0.0311).

CONCLUSIONS

Long-term follow-up of pediatric-onset patients with OFG shows good prognosis. Patients with OFG do not seem to have otorhinolaryngological comorbidity. Anti-S cerevisiae antibody A may serve as a factor to indicate the possible presence of underlying CD in patients with OFG, but further studies are requested.

A Diagnostic Approach to Recurrent Orofacial Swelling: A Retrospective Study of 104 Patients

OBJECTIVE

To identify patients evaluated in an outpatient setting at our institution with a presentation of recurrent orofacial swelling and to review the spectrum of causes to outline a diagnostic approach.

PATIENTS AND METHODS

A retrospective study of 104 patients with more than 1 episode of orofacial swelling lasting for more than 5 days identified through a keyword search of the electronic health record from January 2, 2000, through July 5, 2011.

RESULTS

Patients were categorized according to final cause of orofacial swelling: idiopathic orofacial granulomatosis, solid facial edema due to rosacea and acne vulgaris, Crohn disease, contact dermatitis, sarcoidosis, exfoliative cheilitis, lichen planus, actinic cheilitis, cheilitis glandularis, lymphedema, miscellaneous, and multifactorial. Granulomatous inflammation was noted on biopsy in 40 of 85 patients (47%). Oral involvement was associated with Crohn disease (P<.001), and facial and periorbital swelling was associated with solid facial edema in the setting of rosacea and acne vulgaris (P<.001).

CONCLUSION

The broad range of diagnoses responsible for recurrent orofacial swelling underscores the diagnostic challenge and importance of a thorough multidisciplinary evaluation to identify underlying causes.

Clinicopathological diagnosis of orofacial granulomatosis

Orofacial granulomatosis is a rare chronic inflammatory disorder characterized by persistent or recurrent soft tissue swellings, oral ulceration, and other orofacial features in the absence of an identifiable granulomatous disease. We report a case of a 61-year-old woman with recurrent ulcerations and swellings in her oral mucosa. She was diagnosed as orofacial granulomatosis based upon clinicopathological correlation after exclusion of other granulomatous diseases and showed a favorable response to systemic corticosteroid treatment.

The role of exclusive enteral nutrition in the management of orofacial granulomatosis in children

BACKGROUND

Orofacial granulomatosis (OFG) is a term used to describe a persistent, painless swelling of lips and orofacial region. It can be associated with ulceration, gingival hypertrophy and cobble stone appearance of the buccal mucosa. OFG is commonly associated with Crohn's disease and can precede the intestinal manifestation of the disease. Exclusive enteral nutrition (EEN) is a recognized treatment for induction of remission for Crohn's disease. The aim of this study was to review the use of EEN in the management of OFG in children.

METHODS

Retrospective review of medical records of all children diagnosed with OFG between 2007 and 2012 was conducted. Presence of comorbidities, progression to inflammatory bowel disease (IBD) and response to EEN was evaluated.

RESULTS

Twenty-nine children were included, mean age at diagnosis was 9 years (standard deviation 3.9) years. Ten children had isolated OFG and 19 had OFG and IBD, of which 12 presented with OFG and IBD and 7 developed IBD later. Median time to progression to IBD was 33 months (inter quartile range: 9.8-85.5). Twenty-two children completed 6 weeks of EEN, and 19 showed clinical improvement in the OFG appearance.

CONCLUSION

EEN appears to be an effective treatment option for children with isolated OFG or OFG and IBD.

Case report of cheilitis granulomatosa and joint complaints as presentation of Crohn's disease

Cheilitis granulomatosa is characterized by granulomatous lip swelling. We report a case of a 13-year-old girl who presented with orofacial swelling and arthralgia, who eventually was diagnosed with Crohn’s disease, which was successfully treated with infliximab and azathioprine combination therapy. Recurrent or persistent orofacial swelling should prompt consideration of cheilitis granulomatosa, and further diagnostic evaluation to exclude the presence of Crohn’s disease seems warranted.

Clinicopathological significance of Melkersson-Rosenthal syndrome

Melkersson-Rosenthal syndrome (MRS) classically shows a triad of orofacial swelling, fissured tongue and facial palsy, more commonly the oligosymptomatic form. The orofacial swelling is characterised by swollen reddish-brown non-pruritic lips and facial oedema. In one-third to one half of patients, fissured tongue is seen, which also aids in diagnosis. The histological finding of MRS includes non-caseating, sarcoidal granulomas, but their absence does not exclude the diagnosis. All these findings together form a basis for a cautious search for confrontational reasons for the symptom complex of MRS.

Orofacial Granulomatosis

Orofacial granulomatosis (OFG) is an uncommon chronic inflammatory disorder of the orofacial region. It is characterized by subepithelial noncaseating granulomas and has a spectrum of possible clinical manifestations ranging from subtle oral mucosal swelling to permanent disfiguring fibrous swelling of the lips and face. Etiopathogenesis is unknown. A range of systemic granulomatous disorders, including Crohn disease and sarcoidosis, may cause orofacial manifestations that cannot be distinguished from those of OFG. Treatment of OFG has proven difficult and unsatisfactory, with no single therapeutic model showing consistent efficacy in reducing orofacial swelling and mucosal inflammation.

Orofacial granulomatosis in children: think about Crohn's disease

BACKGROUND

The term orofacial granulomatosis is conventionally used to describe patients with granulomatous lesions affecting the orofacial tissues, in absence of intestinal lesions. Lip swelling and facial swelling are the most common clinical signs. Despite the fact that histologically it is not distinguishable from Crohn's disease, and that both diseases have a chronic/recurrent course, the relationship between orofacial granulomatosis and Crohn's disease is still debated.

METHODS

Herein we present five cases of orofacial granulomatosis.

RESULTS

All patients presented concomitant Crohn's disease, supporting the hypothesis that orofacial granulomatosis and Crohn's disease may be one single disease. Thalidomide was effective in inducing remission of oral and intestinal symptoms in all five cases and could be considered a valid treatment opportunity for these patients.

CONCLUSIONS

Orofacial granulomatosis and Crohn's disease may be part of the same disease; both may respond to thalidomide.

Orofacial granulomatosis as a presenting feature of Crohn's disease

An 11-year-old girl was referred to oral medicine with persistent facial swelling. She was diagnosed with orofacial granulomatosis (OFG) and was treated conservatively for 7 years, with no evidence of systemic illness. Aged 17 she re-presented with a flare up of her OFG, watery diarrhoea and fluctuating febrile episodes. Inflammatory markers were raised and an MR enterogram revealed terminal ileal Crohn's disease. This case highlights that OFG may precede the onset of intestinal Crohn's disease.

Buccal localization of Crohn's disease with long-term infliximab therapy: a case report

INTRODUCTION

Cheilitis granulomatosa causes persistent idiopathic lip swelling and ulceration and it can sometimes be recognized as a unique or early manifestation of Crohn's disease. Spontaneous remission is rare and with the lack of controlled trials, different therapeutic approaches have been used. Some cases have been treated with an exclusion diet in the attempt to rule out diet allergens, while the most popular treatments include antibiotics such as tetracycline and clofazimine tranilast, benzocaine topical or intralesional steroids, and cheiloplasty, with different outcomes.

CASE PRESENTATION

We describe the case of a 23-year-old Caucasian man, primarily diagnosed with cheilitis granulomatosa for a severe lower lip swelling, and then with Crohn's disease of the terminal ileum and anus. Treatment of Crohn's disease with an anti-tumor necrosis factor alpha agent (infliximab) successfully induced remission of both the gastrointestinal disease and the oral lesion.

CONCLUSIONS

Our recommendation is that physicians should be able to recognize cheilitis granulomatosa as a possible marker of a more complex systemic disease and proceed first with an accurate physical examination, and further suggest investigations of the bowel. In cases of Crohn's disease, a therapy with biological agents can be successful.

Idiopathic orofacial granulomatosis - a diagnostic and treatment challenge

Orofacial granulomatosis is an uncommon disease, usually presenting as recurrent or persistent swelling of the soft tissues, predominantly lips - termed as Cheilitis Granulomatosa. Though various aetiological factors like foreign body reactions, infections, Crohn's disease and Sarcoidosis have been implicated in the disease process. Delayed Hypersensitivity reaction with a predominant Th1-mediated immune response provide further evidence to the etiopathogenesis in Orofacial granulomatosis. The term Idiopathic Orofacial Granulomatosis is used in cases with unknown aetiology. This case report describes Idiopathic Orofacial granulomatosis in a 25-year-old male patient with persistent upper lip swelling and gingival enlargement. Management with intralesional triamcinolone acetonide 40mg, twice a week for three weeks, resulted in significant remission without recurrence after a eight month follow up.

Association between orofacial granulomatosis and Crohn’s disease in children: Systematic review

AIM: To review pediatric cases of orofacial granulomatosis (OFG), report disease characteristics, and explore the association between OFG and Crohn’s disease.

METHODS: We conducted a systematic review according to the PRISMA guidelines. We searched Medline, LILACS, Virtual Health Library, and Web of Knowledge in September 2013 for cases of OFG in the pediatric age range (< 18 years), with no language limitations. All relevant articles were accessed in full text. The manual search included references of retrieved articles. We extracted data on patients’ characteristics, disease characteristics, association with other diseases, and treatment. We analyzed the data and reported the results in tables and text.

RESULTS: We retrieved 173 reports of OFG in children. Mean age at onset was 11.1 ± 3.8 years (range: 2.0-18 years). Prevalence in males was significant higher than in females (P < 0.001), with a male:female ratio of 2:1. Gastrointestinal signs or symptoms were present in 26.0% of children at the time of OFG diagnosis. Overall, 70/173 (40.4%) children received a concomitant diagnosis of Crohn’s disease. In about half (51.4%) of the cases the onset of OFG anticipated the diagnosis of Crohn’s disease, with a mean time between the two diagnoses of 13.1 ± 11.6 mo (range: 3-36 mo). Overall, 21/173 (12.1%) of the children with OFG had perianal disease, while 11/173 (6.4%) had a family history of Crohn’s disease. Both perianal disease and a family history of Crohn’s disease were significantly associated with a higher risk of Crohn’s disease diagnosis in children with OFG [relative risk (RR) = 3.10, 95% confidence interval (CI): 2.46-3.90; RR = 2.74, 95%CI: 2.24-3.36, P < 0.0001 for both). Treatment of OFG included steroids (70.8% of children) and other immunosuppressive drugs (42.7%), such as azathioprine, thalidomide and infliximab.

CONCLUSION: High prevalence of Crohn’s disease in children with OFG suggests that OFG may be a subtype of Crohn’s disease.

Orofacial Granulomatosis in Children can be the Initial Manifestation of Systemic Disease: A Presentation of Two Cases

Orofacial granulomatosis is a chronic granulomatous condition characterized by relapsing and remitting lip swelling and oral involvement that may include deep ulcers, tags and cobblestone formation. It occurs as an independent entity but also in conjunction with systemic diseases such as tuberculosis, sarcoidosis and Crohn’s disease. The clinical presentation is not indicative of concomitant systemic disease. To highlight the importance of thorough examination to rule out systemic disease, we present two childhood cases of orofacial granulomatosis, one of which was associated to Crohn’s disease.

Unusual manifestations of a common gastrointestinal disorder

We present an instructive case of a 13-year old male who presented with bilateral scrotal redness, swelling and tenderness, but with a normal testicular exam. His scrotal swelling persisted despite treatment with intravenous antibiotics, and on further history he reported 2 years of intermittent upper lip swelling. After a referral to a dermatologist, a lip biopsy showed granulomatous changes and he was referred to the gastroenterology department. A gastroscopy and colonoscopy was performed and histology confirmed non-caseating granulomas consistent with Crohn's disease (CD). Eighteen months after the diagnosis of CD he developed perianal disease with a fistula and distal anal stricture. He was successfully treated with insertion of a seton and escalation of therapy to azathioprine and infliximab. CD is a phenotypically diverse chronic inflammatory condition with an increasing incidence in Australia and other Western countries. Non-typical presentations, such as perianal manifestations or orofacial granulomatosis, can be the only presenting symptom in CD, and this highlights the importance for a high degree of clinical suspicion. Genital involvement is rare, but reported.

Idiopathic orofacial granulomatosis with varied clinical presentation

Orofacial granulomatosis is a granulomatous disease of orofacial region, which can occur for a variety of reasons. The clinical features are highly variable and sometimes so insidious that signs and symptoms are not frequently severe to cause alarm. The lips are most commonly involved with persistent/recurrent swelling. The medical history is very important as Crohn's disease and sarcoidosis can present oral manifestation. Other causes like mycobacterial infection, foreign body reaction, fungal infection, and allergy were excluded with further investigation to establish diagnosis. Here and we report a case of orofacial granulomatosis with a review of the literature.

Clinical behaviour and long-term therapeutic response in orofacial granulomatosis patients treated with intralesional triamcinolone acetonide injections alone or in combination with topical pimecrolimus 1%

BACKGROUND

Orofacial granulomatosis (OFG) is a relapsing inflammatory disorder of unknown aetiology and non-standardized treatment protocols. The aim of this study was to assess the clinical behaviour and long-term therapeutic response in OFG patients treated with intralesional triamcinolone acetonide (TA) injections alone or in combination with topical pimecrolimus 1%, as adjuvant, in those patients partially responders to TA.

METHODS

We analysed data from 19 OFG patients followed-up for 7 years. Demographic characteristics, clinical behaviour and long-term therapeutic response were investigated.

RESULTS

Eleven (57.9%) OFG patients treated with intralesional TA injections therapy reached first complete clinical remission in a mean time of 10 ± 2.2 (95% CI, 8.5-11.5) weeks, while eight (42.1%) patients, partially responders to intralesional TA injections, were treated with TA injections plus topical pimecrolimus 1%, as adjuvant, achieving complete clinical remission in a mean time of 29.8 ± 7.8 (95% CI, 23.2-36.3) weeks. Relapses occurred in four TA responder patients with a disease-free time of 35.8 ± 8.7 (95% CI, 21.9-46.4) weeks and in five patients treated with TA and topical pimecrolimus 1% with a disease-free time of 55.8 ± 18.5 (95% CI, 32.8-78.8) weeks. Patients were followed-up for a mean time of 56.3 ± 18.2 (95% CI, 47.6-65.1) months. At last control, all 19 patients were in complete clinical remission.

CONCLUSION

These preliminary data suggest that intralesional TA injections still represent a mainstay in the treatment of OFG. It is unclear the role of topical pimecrolimus, as adjuvant, in leading OFG patients, partly responders to intralesional TA injections, to a complete clinical remission.

Orofacial granulomatosis: A case report with review of literature

Orofacial granulomatosis (OFG) encompasses conditions characterized by non-necrotizing granulomatous inflammation of the oral and maxillofacial region that present clinically as labial enlargement, perioral and/or mucosal swelling, oral ulcerations, and gingivitis. The unifying term “OFG” has been introduced to integrate the spectrum of various disorders, including Melkersson-Rosenthal syndrome and granulomatous cheilitis (which is sometimes considered to be a monosymptomatic form of Melkersson-Rosenthal syndrome), and has been shown to be associated with Crohn's disease, sarcoidosis, and infectious diseases such as tuberculosis. Although various etiological agents such as food substances, food additives, dental materials, and various microbiological agents have been implicated in the disease process, its precise pathogenesis is yet to be elucidated. Delayed type of hypersensitivity reaction appears to play a significant role, although the exact antigen inducing the immunological reaction varies in individual patients. However, evidence for the role of genetic predisposition to the disease is sparse. The underlying immunological mechanism appears to show some similarities between OFG and Crohn's disease, emphasizing the need for more comparative studies of the two entities. The aim of this article is to report a case of OFG, along with a detailed literature review of the facts and variations associated with its nomenclature, clinical presentation, and etiology. It also projects the challenges that a professional has to face in the diagnosis and treatment planning of such cases.

Facial biometrics of peri-oral changes in Crohn's disease

Crohn's disease is a chronic relapsing and remitting inflammatory condition which affects any part of the gastrointestinal tract. In the oro-facial region, patients can present peri-oral swellings which results in severe facial disfigurement. To date, assessing the degree of facial changes and evaluation of treatment outcomes relies on clinical observation and semi-quantitative methods. In this paper, we describe the development of a robust and reproducible measurement strategy using 3-D facial biometrics to objectively quantify the extent and progression of oro-facial Crohn's disease. Using facial laser scanning, 32 serial images from 13 Crohn's patients attending the Oral Medicine clinic were acquired during relapse, remission, and post-treatment phases. Utilising theories of coordinate metrology, the facial images were subjected to registration, regions of interest identification, and reproducible repositioning prior to obtaining volume measurements. To quantify the changes in tissue volume, scan images from consecutive appointments were compared to the baseline (first scan image). Reproducibility test was performed to ascertain the degree of uncertainty in volume measurements. 3-D facial biometric imaging is a reliable method to identify and quantify peri-oral swelling in Crohn's patients. Comparison of facial scan images at different phases of the disease revealed precisely profile and volume changes. The volume measurements were highly reproducible as adjudged from the 1% standard deviation. 3-D facial biometrics measurements in Crohn's patients with oro-facial involvement offers a quick, robust, economical and objective approach for guided therapeutic intervention and routine assessment of treatment efficacy on the clinic.

Service evaluation of patients with orofacial granulomatosis and patients with oral Crohn's disease attending a paediatric oral medicine clinic

AIM

Presenting features associated with orofacial granulomatosis (OFG) and oral Crohn's disease (OCD) are varied, making successful diagnosis and management difficult. The aim of this service evaluation was to establish a profile of patients with these conditions attending a paediatric oral medicine clinic and to determine their overall satisfaction with the care received.

STUDY DESIGN

A retrospective case note analysis to establish the patient profile and a postal patient satisfaction questionnaire for service evaluation.

METHODS

All patients with OFG and OCD who had attended the joint paediatric dentistry/oral medicine clinic at Charles Clifford Dental Hospital, Sheffield in the previous 14 years were included in the study. Hospital case notes were retrospectively reviewed and patient demographics, clinical features, investigations, diagnosis, treatment and outcomes of treatment were recorded. An anonymous patient satisfaction questionnaire using the Healthcare Satisfaction Generic Module of the Paediatric Quality of Life Inventory (PedsQLTM) was distributed to all patients by mail.

RESULTS

A total of 24 patients (13 females and 11 males) were identified. Median age at presentation was 11 years (SD± 3.79, range 2-15). Fifteen patients (63%) were diagnosed with OCD, and 9 (37%) with OFG. Overall, the most common orofacial feature was oral ulceration (75%) followed by lip/facial swelling (71%), angular cheilitis (67%) and mucosal cobblestoning (67%). Differences in presentation were seen between the two conditions with oral ulceration (87%) and mucosal cobblestoning (80%) being the most frequently observed features of OCD and lip swelling (78%) and angular cheilitis (67%) being the most common features of OFG. 58% of patients reported relief of symptoms through treatment. Thirteen patient satisfaction questionnaires were completed (54%). 85% (n=11) felt the overall care received in the clinic was 'excellent'.

CONCLUSIONS

This service evaluation highlights the variety of presenting features of OFG and OCD. Despite only a moderate response to treatment, patient satisfaction with the service was high, emphasising the importance of good communication when managing children with chronic, debilitating conditions.

Skewed T-cell receptor variable β repertoire and massive T-cell activation in idiopathic orofacial granulomatosis

Orofacial granulomatosis (OFG) is a clinicopathologic entity describing oral lesions with noncaseating granulomas including a spectrum of diseases such as the Melkersson-Rosenthal syndrome. The involvement of abnormal T-cell responses has been suggested in the pathogenesis of OFG although few and contrasting data are currently available on this issue. In a patient with OFG, we observed virtually complete CD4 and CD8 T-cell receptor (TCR) β-chain variable region (BV) repertoires at the lesion level and in circulation. However, oligoclonal profiles were found in CD4 and, to a greater extent, in CD8 subsets. These findings were seen in association with a massive peripheral T-cell activation, decreased naive T cells, reduced thymic output, altered cytokine production, and increased apoptosis. Our data, pointing to a random influx of T cells at the site of inflammation, argue against the hypothesis of a main allergen acting at the level of oral mucosa. The profound dysregulation of the peripheral T-cell compartment suggests that OFG should be regarded as a systemic disorder with localized manifestations.

[Successful primary infliximab treatment of orofacial Crohn's disease without gastrointestinal manifestation]

Crohn's disease is a chronic inflammatory bowel disease that can involve the whole gastrointestinal tract. The orofacial manifestation of Crohn's disease, which is rare, can develop irrespective of intestinal involvement. These orofacial lesions are often misdiagnosed as simple oral ulcers. Corticosteroids are the mainstay of therapy for orofacial Crohn's disease. However, infliximab, the chimeric monoclonal antibody to tumor necrosis factor-a, is now considered as a primary treatment because of the disease's relatively high rate of steroid resistance. We present a case of deep oral ulcer and periorbital swelling in a 65-year-old woman. She was diagnosed with intestinal Crohn's disease 7 years ago, which was in remission after treatment with an immunosuppressive agent (azathioprine). The patient was given the diagnosed with orofacial Crohn's disease and successfully treated with infliximab.