Melkersson-rosenthal syndrome G51.2

Chronic, systemic, granulomatous inflammation with the classic symptom triad: Cheilitis granulomatosa, facial paresis, lingua plicata. The full picture of the syndrome is rare, more frequent are differently pronounced minus variants. That of E. Melkersson and C. Rosenthal is now increasingly referred to under the broader term"orofacial granulomatosis" and more generally defined as "recurrent uni- or bilateral orofacial swelling with cranial nerve dysfunction or paresis".

The incidence of MRS in adults is reported to be 1:1250 (Ziem et al. 2000). In children the full picture of MRS is rare.

Unknown, to be discussed: constitutional abnormality, hereditary or acquired disturbance of the autonomous defence system, inflammatory, possibly infection-allergic reactions to different antigens.

In about 30% of patients a familial occurrence is reported (Feng et al. 2014). An autosomal dominant inheritance is being discussed? Possibly the responsible gene is located on the chromosome 9p11.

The average age at manifestation is 14.1 years (Feng et al 2014).

The fully developed syndrome is only observed in a minority of patients in larger groups. Mono- and oligosymptomatic cases are the rule (>80%); they are also found as initial indicative manifestations.

Typical is a variable course of symptoms with circumscribed facial swelling, mostly lip swelling (initially recurrent, later persistent, usually unilateral) and facial nerve palsy. The changes are functionally and cosmetically disturbing for the patient, sometimes even painful.

• Circumscribed facial swelling:
  • Cheilitis granulomatosa (by far the most frequent partial manifestation of Melkersson-Rosenthal syndrome).
  • Further partial manifestations are described as circumscribed swellings of the cheeks, eyelids, forehead, palate, gingiva, tongue, (see also macroprosopitis), buttocks and anogenital region (see also granulomatous lymphangitis of the scrotum and penis)
• Facial nerve palsy (in 19.4% of cases): Mostly unilateral, in 25% of cases bilateral, always of the peripheral type.
• Lingua plicata in 54% of cases (normal population 13%). Assignment to cardinal symptoms is abandoned in recent years, has only indicator function.
• Minor symptoms: Due to their frequent and constant occurrence, they are of great importance in the diagnosis. They are found with decreasing frequency:
  • Crohn's disease (6.8%)
  • Migraine headaches (5.7%)
  • Paresthesia in the swelling area
  • Disturbances of tear secretion
  • Redness
  • Itching
  • Nausea/nausea
  • secretion disorders of the salivary glands or nasal mucosa
  • Swindle
  • Tingling
  • facial sweating
  • Acroparesthesia
  • Heat sensation
  • Globus feeling in the throat
  • acoustic sensations.
  • systemic lupus erythematosus (2.3%)

• Erysipelas recidivans: Characteristic history with early erysipelas tetrade (fever, redness, painful swelling, acute lymphadenopathy). Laboratory: signs of inflammation.
• Herpes simplex recidivans: Typical interval-like course with signs of evident herpes simplex on the skin.
• Upper lip furuncle: Acute course with circumscribed dolent swelling. Often purulent abscess tip.
• Macrochelia of other cause: No variable course. Mostly evident underlying diseases like exfoliative chelitis and others.
• Facial nerve palsy of other cause: not combined with other partial symptoms of Melkersson-Rosenthal syndrome.

So far, there are no approved therapies for this clinical picture.

• Improvements can be achieved with clofazimine (e.g. Lamprene). Early use in particular improves the chances of success, initially 100 mg/day p.o. over 10 days, then alternating 100 mg 3-4 times/week over 6 months, possibly repeated after a 3-month break. In the absence of success the dosage can be doubled.
• Alternatively (better therapy modality): Fumaric acid ester (e.g. Fumaderm®) in the usual dosage. This therapy approach has been the subject of personal experience as well as several published cases (G. Hauck 2017). Remark: This therapy should be planned over a period of >12 months!
• Alternative: Continuous intake of non-steroidal anti-inflammatory drugs such as ibuprofen (e.g. Ibuprofen Heumann 400-800 mg/day).
• Alternative: Systemic glucocorticoids are often recommended, but in our experience they show only moderate success. Prednisolone (e.g. Decortin H) initially 40-60 mg/day p.o. over 2-4 weeks, followed by a slow dose reduction.
• Alternatively: Omalizumab (Nettis E et al. 2018)
• Other procedures: Various therapy attempts with chloroquine, diuretics, DADPS, acetylsalicylic acid, nicotinic acid amide and others are described with doubtful success.

Thrustworthy, chronic, years-long, possibly life-long course. Quoad vitam good, quoad sanationem bad. Spontaneous remission possible.

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