Macrocheila : which diagnostic orientation ? #3
In the previous post, we questioned the possible etiologies to condider.
Initial situation :
A young man, aged 18, is referred to the oral dermatology consultation Henri Mondor Hospital because of a 2 months persistent lower macrocheilia. The patient has no medical history and takes no MEDICATION. The medical examination reported severe stress episode related to the bachelor degree associated with digestive disorders: diarrhea and constipation. The endo-oral examination revealed : several linear ulcerations of the oral vestibule and nodules in both labial commissure and adjacent buccal mucosa. The tongue has a normal clinical aspect, as the palpation of the tumefied lower lip is painless.
Possible etiologies to consider
Miesher’s cheilitis monosymptomatic form of Melkerson Rozenthal syndrome (SMR)
- Monosymptomatic form (Miescher’s Cheilitis) is defined by a macrocheilitis of the lower lip (and / or upper one) associated with granulomatous without caseous necrosis.
- Clinical Triad: peripheral facial paralysis, swelling lip, plicated tongue
- Host : young patient, African
- Chronic coughing
- General symptoms : fever, arthralgia, erythema nodosum.
- Biological examinations : ESR, CRP, angiotensin converting enzyme (increased)
- Chest X-ray
- Digestive symptoms : diarrhea or constipation
- Vitamin B12 deficiency symptoms : asthenia, anemia (mucocutaneous pallor, tachycardia) sensory distal disorders.
- Endo-oral examination: linear ulcerations of the oral vestibule and TAGs of the buccal mucosa and the labial commissure.
- Biological investigations : ESR, CRP (inflammatory syndrome) NFS, dosage vitamin B12 and Folates (deficiency, macrocytic anemia) anti-ASCA antibodies, colonoscopy and biopsies of colon and ileum.
The patient is referred to the internal medicine service of the Henri Mondor Hospital.
NB1 : the absence of caseating granuloma invalidates the hypothesis of tuberculosis.
NB2 : it is also necessary to look for a foreign body granuloma (injury or trauma) and radiological examination.
NB3 : the combination of Miescher’s cheilitis with Crohn’s disease, sarcoidosis or tuberculosis is regularly reported.