An intriguing case of swollen lip

Dear Editor,

A 60-year-old man, known case of stage-4 non-small lung carcinoma with brain metastases, presented to the dermatology clinic with complaints of lower lip persistent swelling associated with minor erosions for 10 days. As per his history, contrast-enhanced computed tomography neck and thorax was performed 11 days ago using iodinated contrast medium (ICM). After 12 hours of the procedure, he noticed asymptomatic periorbital and lower lip edema [Figure 1]. He consulted for these complaints and was given antihistamines with topical antibiotics for the same. Gradually, over 2-3 days, there was extensive lower lip edema with minute mucosal erosions, probably due to constant environmental exposure, such that he was unable to eat properly and was forced to survive on a liquid diet only.

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Figure 1:

Gigantic swelling of lower lip with superficial mucosal ulceration and minute points of pus-discharge (white arrow) along with per-orbital puffiness in the patient.

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On clinical inspection, a diagnosis of idiosyncratic reaction to ICM was made that usually presents as Iodide mumps in larger salivary glands due to iodine accumulation in salivary glands and is benign in nature. He was treated with oral dexamethasone 0.3 mg/kg bodyweight for 5 days followed by tapering over a week duration, along with antihistamines and a topical antibiotic. The swelling subsided in 1 week, such that the patient was able to take his meals properly [Figure 2]. Salivary gland enlargement, otherwise known as iodide mumps, is a rare adverse reaction to the administration of iodine present in contrast media or a few medicines, with a very minimal incidence of around 1–2% only.^[1] As for the pathogenesis, it might be an idiosyncratic reaction, or in a few patients with renal impairment, increased salivary gland secretion and accumulation of iodide may resemble a mumps-like condition.^[2] Mostly, major salivary glands are affected by this condition, but in our case, the minor labial glands were affected by this condition. As our patient did not have renal impairment, this presentation was likely idiosyncratic in nature. Differentials to be considered in such scenarios include angioedema, infectious sialadenitis, or Ludwig’s angina. The timing of swelling, along with careful history, helps us make a clear diagnosis.

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Figure 2:

Nearly complete resolution of lower lip (white arrow) swelling post 1 week of systemic therapy in the same patient.

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Other adverse effects of iodinated contrast material include injection site reaction, flushing, urticaria or angioedema, and severe cutaneous adverse drug reaction like toxic epidermal necrolysis.

The rarity of this case stems from the fact that no previous report shows only lip involvement without submandibular swelling till now.