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Diffuse Lip Swelling

Case Challenge Number: 30

Diagnostic Information

Medical Work-Up The patient was taking levothyroxine sodium. His medical history included a thyroidectomy for the treatment of childhood hyperthyroidism. Medical evaluation for this patient’s lesion included North American patch testing which revealed a positive response only to thimerosal (a preservative in vaccines and skin test antigens). The patient’s serum angiotensin converting enzyme levels were normal, and chest films revealed no pulmonary involvement. He denied any gastrointestinal symptoms. Oral Examination The patient’s lower lip was markedly larger than his upper lip, and his tongue was mildly fissured (Figures 1 and 2).

Figure 1.Diffuse bilateral swelling of the lower lip.

Figure 2.The tongue exhibits a central midline fissure, plus mild fissuring along the lateral borders.

His oral hygiene was fair, and all of his first and second molars had amalgam restorations. Bitewing and periapical radiographs showed no evidence of significant periodontal bone loss or apical rarefaction. All mandibular anterior teeth responded to cold and electric pulp testing, and no evidence of a draining sinus or parulis could be detected. Periodontal probing revealed a 5 mm sulcus depth on the mesial of #14, but no other probing depths were beyond 4 mm. Biopsy Findings A 0.3 x 0.3 x 0.4 cm punch biopsy was obtained from the patient’s lower labial mucosa. Sections showed unremarkable surface epithelium in association with underlying connective tissue and lobules of accessory salivary glands (Figures 3 and 4).

Figure 3.Medium-power photomicrograph showing focal granuloma formation within a background of loose, edematous connective tissue. (Hematoxylin and eosin stain)

Figure 4. High-power photomicrograph of a granuloma which is characterized by a well-circumscribed collection of epithelioid histiocytes, multinucleated giant cells, and lymphocytes. (Hematoxylin and eosin stain)

Scattered chronic inflammatory cells were seen in the connective tissue as well as several well-defined, non-necrotizing granulomas consisting of collections of epithelioid histiocytes and multinucleated giant cells. Special stains were negative for fungal and mycobacterial organisms. No evidence of foreign material was observed in the submitted specimen.