Multicentric reticulohistiocytosis

Skin Manifestation Associated With Multicentric Reticulohistiocytosis

ABSTRACT

Multicentric reticulohistiocytosis (MRH) is a rare multisystem disorder, primarily affecting the skin and joints. As severe joint damage is a possible symptom, early diagnosis and therapeutic intervention are required. Cutaneous lesions present with characteristic features such as discrete reddish nodules, especially on acral locations. Additionally, the face, scalp, trunk and extremities are also affected. Xanthomatous plaques are also seen on the face. The cutaneous manifestations of MRH are various, which therefore should be differentiated from several diseases. In particular, MRH has been reported to assume clinical appearances resembling Gottron papules, periungual erythema, V-neck erythema, shawl sign, and poikiloderma associated with dermatomyositis. Histopathologic features show proliferation of multinucleated giant cells with abundant eosinophilic granular ground glass-like cytoplasm in the dermis. Multicentric reticulohistiocytosis is occasionally paraneoplastic and is associated with internal malignancies. The appropriate therapies are still challenging, and oral prednisolone, immunosuppressants, and recent biologics are used. In this article, cutaneous lesions, histopathology, and pathogenesis of MRH are mainly discussed from a dermatological perspective. It is important, not only for dermatologists but also for rheumatologists and orthopedists, to be able to distinguish between the various types of skin lesions brought on by MRH. Cutaneous signs are important diagnostic clues and assessment tools for therapeutic efficacy.

Multicentric reticulohistiocytosis: the Mayo Clinic experience (1980–2017)

Objectives

Multicentric reticulohistiocytosis (MRH), a rare histiocytic disease that can mimic other rheumatic conditions, may be associated with cancer and other autoimmune disorders. To better understand the disorder and its other associations, we aimed to evaluate clinical correlates and outcomes of all patients with MRH seen at Mayo Clinic, Rochester between 1980 and 2017.

Methods

A retrospective medical record review was conducted to identify all patients with MRH between 1 January 1980 and 30 April 2017.

Results

We identified 24 patients with biopsy-proven MRH (58% female, 75% Caucasian, median age at diagnosis 52 years, median follow-up of 2.3 years). All patients had cutaneous and articular involvement; 23 (96%) patients had papulonodular skin lesions (87% periungual and dorsal hand) and seven (30%) mucosal nodules; and 22 (92%) patients had arthralgias, 21 (88%) joint effusions and 13 (54%) synovitis. Most frequently used therapies included corticosteroids, cyclophosphamide, methotrexate and bisphosphonates. Biologics were used in four patients. Nine patients had symptomatic resolution at 1 year and 12 partial improvement. Radiological findings included erosive changes in three (60%) patients and arthritis mutilans in two patients (40%). Twenty-nine per cent of patients had a concomitant autoimmune disease and 25% malignancy including melanoma, endometrial, peritoneal and lung carcinoma. The 5-year survival rate was 85% (95% CI: 74, 100%).

Conclusion

To our knowledge, this is the largest single-centre series of patients with MRH highlighting the rarity of the condition and an unmet need for treatment options that can allow sustained disease remission. It also highlights the need for a high vigilance for malignancy and autoimmune diseases.

Multicentric Reticulohistiocytosis with Dermatomyositis-like Eruptions

A 68-year-old man presented with polyarthritis, proximal muscle weakness, and erythema of the face, arms, neck, and anterior chest that resembled the V-neck sign. Initially, dermatomyositis (DM) was considered because of the erythema, polyarthritis, and muscle weakness. He also had mediastinal and hilar lymphadenopathy on contrast-enhanced computed tomography. Unexpectedly, a biopsy of the forehead skin revealed numerous multinucleated giant cells. A biopsy of a solitary nodule on the dorsum of his right middle finger revealed similar multinucleated giant cells with ground-glass cytoplasm, leading to the diagnosis of multicentric reticulohistiocytosis (MRH). Although MRH is rare, it should be remembered that MRH can mimic DM.

Multicentric reticulohistiocytosis (MRH): case report with review of literature between 1991 and 2014 with in depth analysis of various treatment regimens and outcomes

Multicentric reticulohistiocytosis is a rare disease affecting skin and joints primarily and rarely other organs. We present a case report of this disease and an extensive review of the literature. We reviewed the data between 1991 and 2014 and extracted 52 individual cases. Only articles in English were chosen after checking for relevance. The articles were studies and data was extracted into excel spread sheets and later used to compute such variables like frequency, mean and percentage of distribution of various clinical manifestations. The treatments used in these articles were critically analyzed and graded for their relative efficacy for skin and joint manifestations. The grades were 0 = worse, 1 = no benefit/condition remained same, 2 = improvement without resolution, and 3 = resolution. This article also reports the demographic, clinical, laboratory and pathological data from the reviewed articles. Authors attempted to discuss the findings of this review in depth to help manage this condition and proposed a treatment algorithm to help clinicians approach this rare and challenging disease.

Multicentric reticulohistiocytosis with elevated cytokine serum levels

Multicentric reticulohistiocytosis (MRH) is an uncommon non-Langerhans cell histiocytosis of unknown etiology. It is a multisystem disorder characterised by a papulonodular skin eruption, mainly in the extensor surfaces, and destructive polyarthritis. Histologically, either cutaneous lesions or the synovium show a dense dermal infiltrate of histiocytes and multinucleated giant cells with an eosinophilic granular material in the cytoplasm. In the immunohistochemical analysis these cells stain positively with monocyte/macrophage markers (CD68 and CD45), as well as with certain cytokines (tumor necrosis factor-α, interleukin 1β and interleukin 6). Moreover, recent reports suggest an osteoclastic nature of the infiltrating cells, as they stain strongly with osteoclast tissue lytic markers including tartrate-resistant acid phosphatase and cathepsin K. We report a case of MRH presenting with clinical features of dermatomyositis. Furthermore, the patient showed elevated cytokine serum levels that lowered after therapy.

Reticulohistiocytosis

Reticulohistiocytoses consist of a rare group of diseases caused by CD68+ macrophage proliferation. Several advances have been achieved in relation to the receptors involved in these diseases. This knowledge will clarify the physiopathologic mechanisms of the reticulohistiocytoses and direct better therapeutic approaches for patients.

Multicentric reticulohistiocytosis

Multicentric reticulohistiocytosis is a rare granulomatous disease of unknown etiology, characterized by cutaneous nodules and destructive arthritis. Skin lesions can cause significant deformity, and approximately half of affected patients develop a severe disabling arthritis. The disease is often associated with malignancy; however, the paraneoplastic nature of multicentric reticulohistiocytosis is not established. The diagnosis is confirmed by the presence of oncocytic ("ground-glass") histiocytes and multinucleated giant cells on histopathology of the cutaneous nodules and the synovial membrane.

Clinical and pathologic findings of paraneoplastic dermatoses

Paraneoplastic dermatoses comprise a heterogeneous group of noninherited skin conditions that manifest internal malignancy. Familiarity with paraneoplastic dermatoses is important to both clinician and pathologist alike, as recognition of such a condition offers opportunity for early diagnosis and treatment of internal malignancy; monitoring for tumor recurrence; and insight into pathophysiology which may yield possible clues to treatment. Herein are reviewed 16 of the best established paraneoplastic dermatoses that display distinctive clinical and pathologic findings.

LEARNING OBJECTIVE

At the conclusion of this leaning activity, participants should be able to recognize, diagnose, and describe the clinical and pathologic findings of paraneoplastic dermatoses.

Immunohistochemical profile of multicentric reticulohistiocytosis

BACKGROUND

There is enough evidence to support the knowledge that multicentric reticulohistiocytosis (MR) is a histiocytic proliferative disorder; however, the type of histiocytes involved is not well established.

OBJECTIVE AND METHODS

To study the nature of cells present in MR lesions by studying the immunohistochemical profile of three new cases and reviewing 23 cases reported in the literature.

RESULTS

MR histiocytic cells are positive for vimentin, CD68, and CD45, negative for S-100 protein, CD34, and XIIIa factor, and weak reactors for thrombomodulin. Small activated histiocytes are MAC387 positive. Lymphocytes, mainly CD4+ cells, are found in MR infiltrates.

CONCLUSIONS

The MR immunophenotypic pattern does not suggest a type I or type II dendrocyte or a Langerhans cell origin. On the other hand, it points to a different cell derived from the monocyte-macrophage line. CD4+ cells may be responsible for activating the proliferation of histiocytic cells. Small histiocytic MAC387+ cells are likely to become the MR multinucleated giant cells.

Multicentric reticulohistiocytosis with pulmonary involvement

Multicentric reticulohistiocytosis (MRH) is a rare and possibly devastating systemic disorder characterized by tissue infiltration by histiocytes and multinucleated giant cells. The disease commonly involves the skin, joints, and mucous membranes, with the rare involvement of other organ systems. We describe a patient with MRH presenting with papules and nodules on both hands and a rapidly progressive arthritis who may have had pulmonary involvement of the disease.

Multicentric reticulohistiocytosis presenting with clinical features of dermatomyositis

Multicentric reticulohistiocytosis (MRH) is a rare disorder with proliferating histiocytes that develop into multinucleated giant cells with "ground-glass" cytoplasm. The disease presents with a rapidly destructive, sometimes permanently debilitating, polyarthritis and a papulonodular eruption, generally of the face and hands. We present 3 cases of MRH in which the initial clinical diagnosis was thought to be dermatomyositis (DM). The cutaneous findings in these cases included an erythematous, predominantly photodistributed macular and papular eruption clinically consistent with DM. However, skin biopsy specimens revealed the diagnosis of MRH. This previously unreported clinical similarity between MRH and DM is significant because the treatment options and future complications vary greatly between the 2 diseases. Thus, it is important to consider the possibility of multicentric reticulohistiocytosis when evaluating a patient with the clinical diagnosis of dermatomyositis.

Multicentric reticulohistiocytosis in a 14-year-old girl

Multicentric reticulohistiocytosis is a rare multisystem disorder in which an infiltration of histiocytic cells causes papulonodular skin lesions and potentially a destructive polyarthritis. The active disease typically resolves spontaneously after 5-8 years, but the articular destruction can lead to permanent joint deformities. We present a case of multicentric reticulohistiocytosis in a 14-year-old girl. The number of papules on her hands decreased in number and her arthritic symptoms improved after 4 months of oral naproxen. Thirty months later her joint symptoms remained inactive and only six very small papules remained on her hands. Small flexor deformities were present in the distal interphalangeal joints of both index fingers. This case is an example of how multicentric reticulohistiocytosis can be a relatively stable and self-limited disease but still cause permanent joint deformities.

Multicentric reticulohistiocytosis

BACKGROUND

Multicentric reticulohistiocytosis (MR) is a rare histiocytic systemic disease mainly affecting the skin and synovia.

OBJECTIVE

To present the main and newest aspects of MR.

METHOD

A review of the current medical literature, composing a retrospective study of 96 case reports published world-wide since 1977.

RESULTS

Facial and hand skin nodules with symmetric arthritis were the most frequent clinical presentation. The pathognomonic sign of'coral beads' and vermicular erythematous lesions bordering nostrils, seems to be very characteristic of MR. There is a significant association with cancer. Histiocytic cells of MR are best characterized on immunohistochemistry by its immunoreactivity for vimentin, CD68 and CD45 and non-reactivity for S-100 protein, CD34 and factor XIIIa. Although the outcome of the disease is usually very limiting for the patients, treatment with immunosuppressive drugs may be useful.

CONCLUSION

MR is a unique histiocytic proliferative disease with a peculiar immunophenotypic pattern and distinctive clinical and histopathological aspects.

Multicentric reticulohistiocytosis in a child

A case of multicentric reticulohistiocytosis in an 8-year-old girl, which is a diagnosis rarely seen in children, is presented. Multicentric reticulohistiocytosis is a disorder of unknown aetiology, predominantly affecting the joints, skin and mucosa. Joint symptoms, but not cutaneous lesions, have improved with treatment with methotrexate.

Multicentric reticulohistiocytosis associated with recurrent breast carcinoma

Multicentric reticulohistiocytosis (MRH) is a rare systemic disorder that most often affects women in the fourth to fifth decades of life and is characterized by widespread cutaneous papules and nodules, often associated with a destructive arthritis. The characteristic histologic feature of the skin lesions, and of other affected organs, is the presence of histiocytes and multinucleated giant cells containing abundant eosinophilic cytoplasm with a "ground glass appearance." Approximately 30% of the patients have an underlying malignancy suggesting MRH may be a paraneoplastic phenomenon. We describe a case of MRH associated with recurrent, metastatic breast carcinoma.

Multicentric reticulohistiocytosis

We describe a 42-year-old man with a five-year history of arthritis mutilans-like destructive joint changes and with a one-year history of nodules on the fingers, ears, oral mucosa, pharynx, larynx, vocal cords, some being ulcerated and haemorrhagic. He was diagnosed as having rheumatoid arthritis; however, biopsies from the nodules on the oral mucosa and ear revealed multicentric reticulohistiocytosis. The large nodule over the olecranon process, simulating a rheumatoid nodule but diagnosed as multicentric reticulohistiocytosis with biopsy; ulcerated and haemorrhagic nodules on the oral mucosa; and rapidly progressive joint destructions make our case interesting.

A unique presentation of multicentric reticulohistiocytosis in pregnancy

We describe a patient with multicentric reticulohistiocytosis who presented, during the second trimester of pregnancy, with symmetric polyarthritis, marked erythematous, pulsatile synovial swelling of the distal interphalangeal joints of both hands, and widespread telangiectasias. She did not have the typical skin manifestations of multicentric reticulohistiocytosis. The erythema and pulsatility of the synovial swellings of the distal interphalangeal joints resolved after delivery, but she continued to have widespread active synovitis, which did not resolve until treatment with low-dose oral methotrexate was instituted.

Skin and bones. II

Skin disorders in which a radiograph may detect associated bony changes or abnormalities of calcification are discussed. They are grouped into eight categories: (1) inherited diseases (e.g., alkaptonuria, neurofibromatosis); (2) congenital disorders (e.g., Sturge-Weber and Proteus syndromes); (3) inflammatory conditions (e.g., dermatomyositis, sarcoidosis); (4) infections (e.g., dental sinus, syphilis); (5) neoplasias (e.g., histiocytosis, mastocytosis); (6) drug- and environment-induced (e.g., acroosteolysis, retinoid toxicity); (7) calcinosis cutis; and (8) osteoma cutis. The first part of this review, published in the August 1991 issue of this JOURNAL, dealt with the first two categories; part II discusses categories 3 through 8.

Multicentric reticulohistiocytosis: systemic macrophage disorder

Multicentric reticulohistiocytosis is a rare multisystem disorder that reflects a reactive inflammatory response to an undetermined stimulus. While the disease is characterized as a dermatoarthritis, multiple organ systems including cardiac and skeletal muscle, the pleura and gastrointestinal tract have been involved in reported cases. The synovitis can be quite destructive with arthritis mutilans developing in a substantial percentage. The dermatitis may be particularly disfiguring when the face is involved. This chapter describes the clinical and laboratory features of the 33 cases of MRH previously reviewed by Barrow and Holubar and an additional 33 cases that have appeared in the medical literature since that report. We note an apparent decline in frequency of some manifestations of MRH. This may be due in part to the nature of the recent reports which often present a brief clinical report and focus primarily on specific disease associations, unusual manifestations, new organ system involvement or treatment regimens. The primary cell involved in the reactive inflammatory response of MRH is the phagocytic tissue histiocyte (macrophage). While uncontrolled proliferation of these reticulohistiocytes is seen in several infectious and malignant conditions there is presently no direct evidence of a particular organism or neoplasm involved in the aetiopathogenesis of MRH. There is evidence of tuberculosis exposure in one third of cases with active tuberculosis present in 5%. Likewise, malignancies are reported concomitantly with MRH in 15-28% of cases. The therapeutic trend in MRH is to treat early and aggressively to prevent the devastating arthropathy and disfiguring cutaneous sequelae. This recommendation, however, is largely based on anecdotal reports and thus the physician encountering a case of MRH needs to proceed with circumspection.

[Multiple rare tumors of the hand: a case of multifocal reticulohistiocytosis]

The authors report the case of a woman operated for multiple dorsal nodes of the fingers with a lytic appearance on X-rays of the distal joints. The histopathology concluded on multicentric reticulohistiocytosis which is a very rare disease (fewer than 100 cases) affecting the hand (90%), skin and joints, and other organ systems. The prognosis is not good as the disease is disabling to the hand and malignant diseases may occur in 15 to 25% of cases. No treatment, even very aggressive, has been shown to be truly effective.

Reticulohistiocytoma cutis--review of 15 cases and an association with systemic vasculitis in two cases

We reviewed 15 cases of reticulohistiocytoma cutis (RHC). Three cases were of solitary lesions. Four cases were associated with a destructive arthritis but no other systemic features. One additional patient had a destructive arthritis and lesions of reticulohistiocytoma in synovium, larynx, and mucosa. Three patients had associated xanthelasma. Two cases were associated with internal malignancy (metastatic malignant melanoma, adenocarcinoma of the bowel). Two cases were sequentially associated with systemic vasculitis (Wegener's granulomatosis, periarteritis nodosa). This occurrence of systemic vasculitis in RHC patients is unique. RHC may have variable cutaneous and systemic manifestations and associations with malignancy and immunoinflammatory diseases, including vasculitis.

Multicentric reticulohistiocytosis in a child with sclerosing lesion of the leg. Immunohistopathologic studies and therapeutic trial with systemic cyclosporine

Multicentric reticulohistiocytosis affecting a 13-year-old boy induced a sclerosing change of the leg. The cellular infiltrate comprising activated T lymphocytes and macrophages and human lymphocyte antigen (HLA)-DR expression by keratinocytes in lesional skin all suggest the involvement of cellular immune reactions. We administered systemic cyclosporine but could not obtain a favorable effect without a concomitant low dosage of prednisone.

Multicentric reticulohistiocytosis accompanied by oral and temporomandibular joint manifestations

A case of multicentric reticulohistiocytosis in a 56-year-old man with oral and temporomandibular joint manifestations is presented, which demonstrates typical clinical features of skin and mucosal nodules, and polyarthritis.

Multiple skin tumors of indeterminate cells in an adult

An adult patient with multiple unusual histiocytic tumors of the skin is described. As shown by immunohistologic study, electron microscopy, and immunoelectron microscopy, the tumors represent circumscribed proliferations of the Langerhans cell-related indeterminate dendritic cells of the skin. This distinct cutaneous histiocytosis may represent a paraneoplastic syndrome.