A hard lobulated submucosal nodule on the lower lip

A 47-year-old man presented to the Stomatology service at the Department of Oral Medicine at the A.C. Camargo Cancer Center with a swelling in the lower lip with 3 months of duration. The patient disclosed a family history of cancer (his father had lung cancer, and his mother had skin cancer). He denied comorbidities, systemic alterations, and use of medications. On clinical examination, an isolated submucosal nodule with a lobulated surface covered by intact normochromic mucosa exhibiting poorly delimited margins, fixed to the adjacent tissue, measuring 2.5 cm in and located in the midline of the lower labial mucosa was observed. Moreover, the lesion was hardened on palpation exam. The extraoral examination did not reveal the signs of asymmetry, lymphadenopathy, or mucocutaneous lesions (Figure 1). The diagnosis was oral sarcoidosis. An incisional biopsy was performed, and histopathological exam revealed multiple granulomas with a sarcoid pattern, in addition to the presence of multinucleated giant cells exhibiting an asteroid body. Computed tomography of the chest demonstrated hilar lymphadenopathy and solid pulmonary nodules. Sarcoidosis can occur in multiple organs, especially the lungs, lymph nodes, eyes, and skin (Bouaziz et al., 2012; Sève et al., 2021). In the head and neck region, the salivary glands are more frequently affected, resulting in xerostomia and edema (Poate et al., 2008). Oral manifestations of sarcoidosis are rare and normally involve the tongue, buccal mucosa, palate, and gingiva (Bouaziz et al., 2012). Oral lesions may be the only sarcoidosis manifestation or a part of the generalized occurrence of the disease (Armstrong et al., 2004). Lesions may be asymptomatic and manifest as occasionally ulcerated submucosal nodules or papules or appear as a well-circumscribed brownish-red or violaceous swelling. Erythema and swelling are common findings in cases with gingival involvement (Armstrong et al., 2004; Kolokotronis et al., 2009). Bone involvement is characterized by ill-defined radiolucency with occasional cortical erosion without bone expansion (Motswaledi et al., 2014). Although uncommon, the literature demonstrates that oral lesions can be the first manifestation of the disease in approximately one to two-thirds of cases (Al-Azri et al., 2012), reinforcing the importance of considering the disease as a differential diagnosis. In our case, the patient had pulmonary involvement and the intraoral biopsy allowed an early diagnosis of the disease. This conduct is crucial because nearly 20% of patients with sarcoidosis can progress to advanced pulmonary sarcoidosis, which can lead to significant loss of lung function, respiratory failure, and death (Gupta et al., 2023). The treatment of sarcoidosis consists of the administration of systemic corticosteroids, mainly in the acute phase, surgical excision, or expectant management (Shahabinejad et al., 2023). In our case, excision of the oral lesion was performed due to localization and small size of the nodule. Moreover, the expectant management was considered for pulmonary involvement. This case highlights the variable clinical presentation of the sarcoidosis, especially considering that the oral manifestation may be the first sign of the disease and late diagnosis could lead to severe systemic complications and even death (Figure 2). The oral lesion was completely removed. Due to the patient had no respiratory symptoms and only discreet tomographic lesions, quarterly follow-ups with a multidisciplinary team were purposed. At the 1 year of follow-up, there were no signs of intraoral recurrence or systemic symptoms. Yuri de Lima Medeiros: Conceptualization; investigation; writing – original draft. Maria Emília Mota: Conceptualization; investigation; writing – original draft. Clóvis Antonio Lopes Pinto: Resources; validation; visualization. Maria Stella Moreira: Data curation; supervision; writing – review and editing. Fábio Abreu Alves: Data curation; supervision; writing – review and editing. Graziella Chagas Jaguar: Conceptualization; investigation; supervision; writing – review and editing. All authors have no conflicts of interest to disclose. The patient reported in this manuscript provided written informed consent for the publication of the case details.