Unilateral mandibular lip anesthesia as the sole presenting symptom of Burkitt's lymphoma: case report and review of literature.

A 28-year-old Hispanic man presented to the Oral and Maxillofacial Surgery clinic at Bellevue Hospital Center with a chief complaint of paresthesia and anesthesia of the mandibular left lip. His history revealed a routine dental prophylaxis received one month earlier, and he reported that 2 days later after treatment he began to feel pain and pressure in the left side of his lower jaw. He was referred to an oral and maxillofacial surgeon who made a panoramic radiograph that did not demonstrate any abnormalities. The patient then sought treatment from his primary care physician and was referred to a neurologist, who ordered a magnetic resonance image (MRI) of the head and routine blood work. The MRI showed no abnormalities and, with the exception of a slight elevation in liver enzymes (aspartate aminotransferase 40, normal range, 0 to 34 U/L; alanine aminotransferase 45, normal range, 5 to 30 U/L), the laboratory results were unremarkable. The patient was started on 200 mg of carbamazepine twice a day. His pain continued to worsen, resulting in an inability to sleep through the night. A sudden onset of numbness in the left mandibular lip and chin area occurred just before his initial presentation to the Oral and Maxillofacial Surgery clinic, 1 month subsequent to the onset of his symptoms. Physical examination revealed a well-nourished, well-developed male. The head and neck examination was unremarkable, with the exception of a left V3 anesthesia. The patient had a well-maintained, full dentition that included 4 functional third molars. A panoramic radiograph failed to demonstrate any cause for the sensory defect. A facial computed tomography (CT) scan was performed, revealing no abnormalities. The patient returned for follow up one week later. The intraand extraoral examination still failed to show any swelling or adenopathy, although the patient complained of increased pain in the right mandibular area and felt that it was beginning to “go numb,” similar to the left side. A bone scan was ordered and the results are shown in Fig 1. The patient returned 5 days later with a significant change in status. He stated that following the bone scan he began to feel weak and had a loss of appetite. This was compounded by the fact that he was unable to eat because of the pain in his jaws. He had also begun to feel pain in the left maxillary region and in his left thigh and lumbar spine. His general appearance had deteriorated, and he had lost significant weight. Skin turgor was decreased, and he appeared to be dehydrated. The head and neck examination revealed bilateral V3 anesthesia and paresthesia of the left posterior maxillary region. At this time, a slight expansion of the left mandibular posterior buccal cortex was noted. The third molars in 3 quadrants were very mobile (Class III), particularly the mandibular right third molar. This visit marked the first time the patient presented with any significant findings, other than anesthesia of V3, where it was possible to localize a region to obtain tissue for microscopic examination. Under local anesthesia, the mandibular right third molar was extracted, and the surrounding tissue was removed for analysis. A specimen was also obtained from the left maxillary tuberosity region. The tissue from both sites was extremely friable, with a globular appearance. The specimens were processed for routine histologic assessment, and the patient was admitted to the hospital for further evaluation.