Histiocytic disorders

Diagnosis and treatment of isolated rib Langerhans cell histiocytosis in an adult: A case report

Langerhans cell histiocytosis (LCH) was first proposed in 1987 to define the disorder characterized by the proliferation of abnormal Langerhans cells. It is more likely to occur in children younger than 15 years of age. Single-site and single-system LCH of rib is rare in adults. We present a rare case of isolated rib LCH in a 61-year-old male patient and expound the diagnosis and treatment of the disease. A 61-year-old male patient who presented with a 15-day history of dull pain in the left chest was admitted to our hospital. PET/CT image showed obvious osteolytic bone destruction and abnormal fluorodeoxy-glucose (FDG) uptake (maximum standardized uptake value: 14.5) in the right fifth rib with local soft tissue mass formation. The patient was eventually confirmed the diagnosis of LCH by immunohistochemistry stain and treated with rib surgery. A thorough review of the literature regarding diagnosis and treatment of LCH is presented in this study.

From dermatitis to central diabetes insipidus

The case report shows a seven-month-old, female infant whose malignancy initially manifested as a seemingly harmless skin condition such as dermatitis. When the patient was three months old, the first symptoms were identified such as atopic and intertriginous dermatitis and milliaria. After a few months, a tumefaction appeared on the neck, behind the left ear, which was treated as an abscess. As the prescribed antibiotic therapy showed no results, the patient underwent a surgical procedure followed by a pathohistological treatment of the lesional tissue suggestive of histiocytosis. The patient was subjected to chemotherapy for a duration of one year. However, one year after the end of the treatment, a recurrence was found, which required an additional, yet successful chemotherapy treatment. As an adverse sequelae, central diabetes insipidus was confirmed.

Langerhans cell histiocytosis in children born 1982-2005 after in vitro fertilization

AIM

In a recent Swedish study, comparing data from the Swedish Cancer Register with the Medical Birth Register including data on IVF, an increased risk of Langerhans cell histiocytosis (LCH) was found in children born 1982-2005 after IVF. Here, we aimed to verify the LCH diagnoses and examine whether any special forms of the disease were overrepresented in this population.

METHODS

Medical records for all children with LCH conceived by IVF were acquired and the diagnosis confirmed or discarded. Disease characteristics were compared with data from children diagnosed with LCH 1992-2001 in the Stockholm County.

RESULTS

We verified LCH in seven children born after IVF, all born prior to 2002. These children did not have milder disease forms. The odds ratio (OR) to develop LCH for the whole group born after IVF was 3.2 [95% confidence interval (CI), 1.4-7.3] and for children born before 2002, 5.2 [95% CI, 2.3-11.9], compared with children in Stockholm County 1992-2001.

CONCLUSION

LCH was overrepresented in children born after IVF prior to 2002. Affected children did not have milder disease forms. These findings may be valuable to understand LCH aetiology. Additional studies on a putative correlation between IVF and LCH in the offspring are encouraged.

Autoimmune hypophysitis: expanding the differential diagnosis to CTLA-4 blockade

Autoimmune hypophysitis is an increasingly recognized disorder that enters in the differential diagnosis of nonfunctioning pituitary masses. The differential diagnosis of these conditions is challenging because of similar clinical presentations and radiological signs. This review describes the essential features of hypophysitis and the other nonfunctioning pituitary masses. It also emphasizes a recently described feature of hypophysitis: its appearance with unexpectedly high frequency in patients receiving treatments that abrogate the function of cytotoxic T lymphocyte antigen 4.

Successful father-to-son stem cell transplantation in a child with hemophagocytic lymphohistiocytosis using a reduced-intensity conditioning regimen

OBJECTIVE

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon disorder, usually lethal without allogeneic stem cell transplantation (SCT).

MATERIALS AND METHODS

We report a 9-month-old boy, the first child of consanguineous parents, diagnosed with HLH and neurological involvement demonstrated by magnetic resonance imaging (MRI), who received an allogeneic SCT from his HLA genetically matched father. Transplant was performed after a reduced-intensity conditioning (RIC) regimen consisting of cyclophosphamide, fludarabine, and melphalan. Graft vs. host disease (GVHD) prophylaxis included cyclosporine a and methotrexate.

RESULTS

An absolute neutrophil count of 0.5 x 10(9)/L was documented on day +20 and a platelet count >20 x 10(9)/L was shown by day 33. Full donor chimerism was showed on day +175. A follow-up brain MRI was reported normal. Twenty months after SCT, the child shows no evidence of HLH or GVHD activity, and has a normal psychomotor development.

CONCLUSION

Given the reduced toxicity of SCT with RIC, it could represent an attractive transplant method for children with HLH, in whom myeloablation plays no role in disease eradication, and in whom mixed chimerism may be enough to cure the disease.

Defining the role of magnetic resonance imaging in unifocal bone lesions of langerhans cell histiocytosis

Localized Langerhans cell histiocytosis (LCH) of bone often presents as a diagnostic challenge. Magnetic resonance imaging (MRI) is frequently used to better delineate most solitary bony lesions. The authors present two cases that illustrate and better define the role of MRI in the evaluation of solitary bone lesions of LCH. In a 3-year-old boy with left-sided hip pain, MRI showed a focal lesion involving the proximal left femur with low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. A tumor was suspected because of the overall imaging characteristics and increased uptake on three-phase nuclear scintigraphy. In a 6-year-old boy with right thigh pain, MRI showed a fluid-containing lesion in the mid-diaphysis of the right femur, suggestive of chronic osteomyelitis and Brodie abscess. MRI was instrumental in showing the extent of the lesions in both cases; however, the final diagnosis of LCH was achieved only with histopathologic confirmation, illustrating the limited diagnostic power of this imaging tool.

Erdheim-Chester disease of the brain: cytological features and differential diagnosis of a challenging case

Erdheim-Chester disease (ECD) is an uncommon, systemic xanthogranulomatous disorder, with distinct clinicopathological features, that is rarely expected preoperatively. We describe a case that presented in the brain of a 26-yr-old male patient and clinically mimicked the appearance of a neoplasm. The final diagnosis was a surprise. In retrospect, the diagnosis was suggested by the intraoperative "squash" preparations, which demonstrated a mixed cellular proliferation of lymphohistiocytic elements and large, multinucleated cells with vesicular nuclei, prominent nucleoli, and abundant cytoplasm. To the best of our knowledge, this is the first report detailing the cytopathological features of ECD.

Langerhans' cell histiocytosis: pathology, imaging and treatment of skeletal involvement

Langerhans' cell histiocytosis (LCH) is manifested in a variety of ways, the most common being the eosinophilic granuloma, a localized, often solitary bone lesion that occurs predominantly in the pediatric age group. The hallmark of LCH is the proliferation and accumulation of a specific histiocyte: the Langerhans' cell. In bone this may cause pain and adjacent soft-tissue swelling, but some lesions are asymptomatic. LCH can involve any bone, but most lesions occur in the skull (especially the calvarium and temporal bones), the pelvis, spine, mandible, ribs, and tubular bones. Imaging diagnosis of the disease in bone is first based on the plain radiographic appearance, which is usually a central destructive, aggressive-looking lesion. In the skull, the lesions develop in the diploic space, are lytic, and their edges may be beveled, scalloped or confluent (geographic), or show a "button sequestrum." Vertebral body involvement usually causes collapse, resulting in vertebra plana. With significant recent improvements in the quality of gamma cameras, imaging techniques, and in studying children, bone scintigraphy at diagnosis and on follow-up usually reveals the sites of active disease, especially when the involvement is polyostotic. CT and MR imaging are very useful in providing detailed cross-sectional anatomic detail of the involved bone, including the bone marrow and the adjacent soft tissues. CT is better suited for demonstrating bone detail and MR imaging for bone marrow and soft-tissue involvement.