Cheilitis Granulomatosa Workup

Updated: Jun 21, 2018
  • Author: Alan Snyder; Chief Editor: William D James, MD  more...
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Workup

Approach Considerations

Laboratory studies

Serum angiotensin-converting enzyme (SACE) testing may be performed to help exclude sarcoidosis. Patch tests may be used to help exclude reactions to metals, food additives, or other oral antigens [32] ; some cases of granulomatous cheilitis may be associated with such sensitivities. If found, avoidance of the implicated allergen is recommended. Decreased iron, hemoglobin, ferritin, folate, and elevated C-reactive protein, celiac antibodies, serum IgE, and alkaline phosphatases have been documented to be associated with orofacial granulomatosis (OFG); however, evidence is insufficient that any of these are consistent markers of the disease. [5]

Imaging studies

OFG is the term given to granulomatous lesions similar to those of Crohn disease, found on oral biopsy, but where there is no detectable systemic Crohn disease, though this may be detected later. [33] Gastrointestinal tract endoscopy, radiography, and biopsy may be used to help exclude Crohn disease. Chest radiography or gallium or positron emission tomography (PET) scanning may be performed to help exclude sarcoidosis and tuberculosis. Panorex dental films may be obtained to assess for the presence of a chronic dental abscess.

Procedures

A biopsy of the swollen lip or orofacial tissues is indicated but often shows only lymphoedema and perivascular lymphocytic infiltration during the early stages and may only later show granulomas. A biopsy may help to exclude Crohn disease, sarcoidosis, lymphoma, and other conditions in the differential diagnosis.

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Histologic Findings

Histologic changes are not always conspicuous or specific in many cases of long duration; the infiltrate becomes denser and pleomorphic, and small, focal, noncaseating, sarcoidal granulomas are formed that are indistinguishable from Crohn disease or sarcoidosis.

The inflammatory response is probably mediated by cytokines such as tumor necrosis factor-alpha and by protease-activated receptors (PARs), matrix metalloproteinases (MMPs), and cyclo-oxygenases (COXs). There is submucosal chronic inflammation with many Th1 and mononuclear, interleukin 1–producing cells; large, active, dendritic B cells; and noncaseating granulomas. [34] Small granulomas occur in the lymphatic walls in some cases. Similar changes may be present in cervical lymph nodes.

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