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Malherbe JAJ, Cooney J. A complex case of necrobiotic xanthogranuloma with IgG‐kappa paraproteinemia: Disease regression achieved with melphalan and prednisone combination therapy. Clin Case Rep 2022; 10:e6554. [DOI: 10.1002/ccr3.6554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jacques A. J. Malherbe
- Department of Haematology Fiona Stanley Hospital Murdoch Western Australia Australia
- School of Biomedical Sciences University of Western Australia Crawley Western Australia Australia
| | - Julian Cooney
- Department of Haematology Fiona Stanley Hospital Murdoch Western Australia Australia
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Steinhelfer L, Kühnel T, Jägle H, Mayer S, Karrer S, Haubner F, Schreml S. Systemic therapy of necrobiotic xanthogranuloma: a systematic review. Orphanet J Rare Dis 2022; 17:132. [PMID: 35331271 PMCID: PMC8944121 DOI: 10.1186/s13023-022-02291-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 03/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Even though a plethora of systemic therapies have been proposed for necrobiotic xanthogranuloma (NXG), there is no systematic review on this topic in literature. OBJECTIVE To review all existing literature on the systemic therapy of NXG in order to identify the most effective therapies. METHODS All reported papers in the literature were screened for systemic treatments of NXG. Papers without proper description of the therapies, papers describing topical therapy, and articles without assessment of effectiveness were excluded. Subsequently, we analyzed 79 papers and a total of 175 cases. RESULTS The most effective treatments for NXG are intravenous immunoglobulins (IVIG), corticosteroids, and combination therapies including corticosteroids. CONCLUSIONS Corticosteroids and IVIG should therefore be considered first-line treatments in patients with NXG.
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Affiliation(s)
- Lisa Steinhelfer
- Department of Dermatology, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.,Department of Nuclear Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany.,Department of Radiology, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Thomas Kühnel
- Department of Otorhinolaryngology, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Herbert Jägle
- Department of Ophthalmology, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Stephanie Mayer
- Department of Internal Medicine III, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Sigrid Karrer
- Department of Dermatology, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Frank Haubner
- Department of Otorhinolaryngology, Ludwig Maximilians University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Stephan Schreml
- Department of Dermatology, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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Nelson CA, Zhong CS, Hashemi DA, Ashchyan HJ, Brown-Joel Z, Noe MH, Imadojemu S, Micheletti RG, Vleugels RA, Wanat KA, Rosenbach M, Mostaghimi A. A Multicenter Cross-Sectional Study and Systematic Review of Necrobiotic Xanthogranuloma With Proposed Diagnostic Criteria. JAMA Dermatol 2020; 156:270-279. [PMID: 31940000 PMCID: PMC6990734 DOI: 10.1001/jamadermatol.2019.4221] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 11/07/2019] [Indexed: 11/14/2022]
Abstract
Importance Necrobiotic xanthogranuloma (NXG) is a non-Langerhans cell histiocytosis classically associated with paraproteinemia attributable to plasma-cell dyscrasias or lymphoproliferative disorders. Despite the morbidity of NXG, the literature is limited to case reports and small studies, and diagnostic criteria are lacking. Objective To evaluate the characteristics of NXG and propose diagnostic criteria. Design, Setting, and Participants This multicenter cross-sectional study was conducted at tertiary academic referral centers and followed by a systematic review and a consensus exercise. The multicenter cohort included patients with NXG diagnosed at the Brigham and Women's and Massachusetts General Hospitals (2000-2018), the University of Iowa Hospitals and Clinics (2000-2018), and the University of Pennsylvania Health System (2008-2018). The systematic review was conducted in 2018 and included patients with NXG identified in the Cochrane, Ovid EMBASE, PubMed, and Web of Science databases. The consensus exercise was conducted by 8 board-certified dermatologists to identify diagnostic criteria. Main Outcomes and Measures Demographic factors, comorbidities, clinical features, and treatment response. Results Of 235 included patients with NXG (34 from the multicenter cohort and 201 from the systematic review results), the mean (SD) age at presentation was 61.6 (14.2) years; 147 (62.6%) were female. Paraproteinemia was detected in 193 patients (82.1%), most often IgG-κ (117 patients [50.0%]). A malignant condition was detected in 59 patients (25.1%), most often multiple myeloma (33 patients [14.0%]). The overall rate of paraproteinemia and/or a malignant condition was 83.8% (197 patients). In the multicenter cohort, evolution of paraproteinemia into multiple myeloma was observed up to 5.7 years (median [range], 2.4 [0.1-5.7] years) after NXG presentation. Cutaneous lesions consisted of papules, plaques, and/or nodules, typically yellow or orange in color (113 of 187 [60.4%]) with a periorbital distribution (130 of 219 [59.3%]). The eye was the leading site of extracutaneous involvement (34 of 235 [14.5%]). In the multicenter cohort, intravenous immunoglobulin had the best treatment response rate (9 of 9 patients [100%]), followed by antimalarial drugs (4 of 5 patients [80%]), intralesional triamcinolone (6 of 8 patients [75%]), surgery (3 of 4 patients [75%]), chemotherapy (8 of 12 patients [67%]), and lenalidomide or thalidomide (5 of 8 patients [63%]). The consensus exercise yielded 2 major criteria, which were (1) clinical and (2) histopathological features consistent with NXG, and 2 minor criteria, consisting of (1) paraproteinemia, plasma-cell dyscrasia, and/or other associated lymphoproliferative disorder and (2) periorbital distribution of cutaneous lesions. In the absence of foreign body, infection, or another identifiable cause, fulfillment of both major and at least 1 minor criterion were proposed to establish the diagnosis of NXG. Conclusions and Relevance Necrobiotic xanthogranuloma is a multisystem disorder associated with paraproteinemia and malignant conditions. The proposed diagnostic criteria may advance clinical research and should be validated.
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Affiliation(s)
- Caroline A. Nelson
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - David A. Hashemi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Hovik J. Ashchyan
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zoe Brown-Joel
- University of Iowa Carver College of Medicine, Iowa City
| | - Megan H. Noe
- Perelman School of Medicine at the University of Pennsylvania, Department of Dermatology, Philadelphia
| | - Sotonye Imadojemu
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert G. Micheletti
- Perelman School of Medicine at the University of Pennsylvania, Department of Dermatology, Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Department of Medicine, Philadelphia
| | - Ruth Ann Vleugels
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Karolyn A. Wanat
- Department of Dermatology, University of Iowa Carver College of Medicine, Iowa City
| | - Misha Rosenbach
- Perelman School of Medicine at the University of Pennsylvania, Department of Dermatology, Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Department of Medicine, Philadelphia
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Maeng MM, Godfrey KJ, Jalaj S, Kazim M. Adult xanthogranulomatous disease of the orbit: case report of spontaneous regression and review of treatment modalities. Orbit 2019; 39:31-37. [PMID: 31021176 DOI: 10.1080/01676830.2019.1590421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Adult xanthogranulomatous disease of the orbit is a rare and incompletely understood entity. It can be limited to the orbit or be associated with systemic disease. While routine systemic surveillance is the standard of care for patients with orbital xanthogranulomatous disease, there is no universally accepted protocol for managing periorbital and orbital involvement. The authors report a case of adult orbital xanthogranuloma, without systemic disease, who, after 10 years of observation, demonstrated sustained radiographic regression of the lesions. To the authors' knowledge, this represents one of the first reports of spontaneous regression of untreated orbital xanthogranuloma, and supports observation of lesions that do not compromise ocular function. We present our case in the context of a major review of various treatment strategies described in the literature, including surgical resection, radiotherapy, plasmapheresis, corticosteroids, multiple immunomodulatory medications.
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Affiliation(s)
- Michelle M Maeng
- Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA
| | - Kyle J Godfrey
- Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA
| | - Sanjai Jalaj
- Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA
| | - Michael Kazim
- Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA
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Keorochana N, Klanarongran K, Satayasoontorn K, Chaiamnuay S. Necrobiotic xanthogranuloma scleritis in a case of granulomatosis with polyangiitis (Wegener's granulomatosis). Int Med Case Rep J 2017; 10:323-328. [PMID: 29042820 PMCID: PMC5633293 DOI: 10.2147/imcrj.s145943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The purpose of this study was to describe a case of necrobiotic xanthogranuloma scleritis in a 53-year-old male with unilateral progressive visual loss, scleritis, prolonged fever, and multiple mononeuropathy. Scleral biopsy showed necrosis with small abscess, and the pathological tissues revealed submucosal infiltration of mononucleated foamy histiocytes (xanthoma cells), hemosiderin-laden macrophages, neutrophils, lymphocytes, plasma cells, and erythrocytes without Touton giant cells or cholesterol clefts. Serum protein electrophoresis showed polyclonal gammopathy. All infectious investigations were negative. Afterward, this patient was diagnosed with granulomatosis with polyangiitis based on granuloma found in scleral tissue, vasculitis seen in sural nerve biopsy and positive serologies (C-ANCA and anti-PR3 antibody). He was treated with high-dose corticosteroid and later with intravenous cyclophosphamide monthly. He responded well to treatment, both eye and systemic conditions. Necrobiotic xanthogranuloma scleritis could be an early presentation of granulomatosis with polyangiitis.
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Affiliation(s)
| | | | | | - Sumapa Chaiamnuay
- Department of Medicine, Rheumatology Division, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand
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Adult Xanthogranulomatous Disease of the Orbit: Clinical Presentations, Evaluation, and Management. ACTAS DERMO-SIFILIOGRAFICAS 2017. [DOI: 10.1016/j.adengl.2017.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Ortiz Salvador JM, Subiabre Ferrer D, Pérez Ferriols A. Adult Xanthogranulomatous Disease of the Orbit: Clinical Presentations, Evaluation, and Management. ACTAS DERMO-SIFILIOGRAFICAS 2017; 108:400-406. [PMID: 28262109 DOI: 10.1016/j.ad.2016.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 11/10/2016] [Accepted: 12/02/2016] [Indexed: 01/18/2023] Open
Abstract
Adult xanthogranulomatous disease of the orbit refers to a heterogeneous group of clinical syndromes with differing degrees of systemic involvement and distinct prognoses. The different syndromes all present clinically with progressively enlarging, yellowish lesions of the orbit. Histologically, the lesions are characterized by an inflammatory infiltrate of foam cells and Touton-type multinucleated giant cells. The xanthomatized histiocytes are CD68+, S100-, and CD1a-. There are 4 clinical forms of xanthogranulomatous disease of the orbit: adult xanthogranulomatous disease of the orbit, adult onset asthma and periocular xanthogranuloma, necrobiotic xanthogranuloma, and Erdheim-Chester disease. The treatment of local lesions are treated with systemic corticosteroids and other immunosuppressors. Vemurafenib, tocilizumab, and sirolimus have shown promising results in systemic disease.
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Affiliation(s)
- J M Ortiz Salvador
- Servicio de Dermatología, Hospital General Universitario de Valencia, Valencia, España.
| | - D Subiabre Ferrer
- Servicio de Dermatología, Hospital General Universitario de Valencia, Valencia, España
| | - A Pérez Ferriols
- Servicio de Dermatología, Hospital General Universitario de Valencia, Valencia, España
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Miguel D, Lukacs J, Illing T, Elsner P. Treatment of necrobiotic xanthogranuloma - a systematic review. J Eur Acad Dermatol Venereol 2016; 31:221-235. [DOI: 10.1111/jdv.13786] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 05/02/2016] [Indexed: 01/25/2023]
Affiliation(s)
- D. Miguel
- Department of Dermatology; University Hospital; Jena Germany
| | - J. Lukacs
- Department of Dermatology; University Hospital; Jena Germany
| | - T. Illing
- Department of Dermatology; University Hospital; Jena Germany
| | - P. Elsner
- Department of Dermatology; University Hospital; Jena Germany
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Adult Orbital Xanthogranulomatous Disease: A Review with Emphasis on Etiology, Systemic Associations, Diagnostic Tools, and Treatment. Dermatol Clin 2015; 33:457-63. [PMID: 26143425 DOI: 10.1016/j.det.2015.03.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Adult orbital xanthogranulomatous diseases are rare entities and encompass a group of disorders with varying manifestations that are poorly understood. Taken as a group, there are non-Langerhans histiocytic disorders (type II) that are diagnosed histologically by the presence of foamy histiocytes, Touton giant cells, and varying degrees of fibrosis. Based on the accompanying systemic associations, there are 4 main categories of adult xanthogranulomatous disease: adult-onset xanthogranuloma, adult-onset asthma and periocular xanthogranuloma, necrobiotic xanthogranuloma, and Erdheim-Chester disease. Herein, we discuss the etiopathogenesis, systemic associations, methods of diagnosis, and treatment options for these disorders.
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Abstract
Xanthomas are a common manifestation of lipid metabolism disorders. They include hyperlipemic xanthoma, normolipemic xanthoma, and a related condition, necrobiotic xanthogranuloma (NXG). All 3 forms can be associated with monoclonal immunoglobulin (MIg). In an attempt to improve diagnosis, understanding, and treatment of this association, we retrospectively analyzed a personal series of 24 patients (2 hyperlipemic xanthoma, 11 normolipemic xanthoma, and 11 NXG) and 230 well-documented reports from the literature. With the exception of the nodules and plaques featured in NXG, the clinical presentation of xanthomatous lesions usually resembled that seen in common hyperlipidemic forms and could not be used to suspect MIg-associated xanthomas. Extracutaneous sites were not rare. The MIg was an IgG in 80% of cases. Myeloma was diagnosed in 35%. Hypocomplementemia with low C4 fraction was present in 80% of studied patients. Low C1 inhibitor serum levels were found in 53%. Cryoglobulinemia was detected in 27%. These abnormalities suggest immune complex formation because of interactions between the MIg and lipoproteins and argue in favor of a causal link between MIg and xanthomas. Monoclonal gammopathy therapy could thus be an option. Indeed, among the patients who received chemotherapy, hematologic remission was accompanied by improvement in xanthoma lesions in several cases.
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Al-Faky YH. Epidemiology of benign eyelid lesions in patients presenting to a teaching hospital. Saudi J Ophthalmol 2011; 26:211-6. [PMID: 23960994 DOI: 10.1016/j.sjopt.2011.05.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 05/14/2011] [Accepted: 05/24/2011] [Indexed: 11/15/2022] Open
Abstract
PURPOSE This study evaluates the relative frequency of benign eyelid lesions presented to a teaching hospital in Saudi population. PATIENTS AND METHODS Charts of patients with benign eyelid lesions were retrospectively reviewed from January 2003 to December 2008. Clinical details included demographic data, symptoms and signs, surgical findings, primary diagnosis, and indication for biopsy were analyzed in a histopathologically confirmed benign eyelid lesions. Eyelid lesions were arranged according to their order of frequencies. RESULTS A total of 222 biopsies were evaluated from 181 patients (male 39.2% and female 60.8%). The age of the patient at the time of biopsy ranged from 2 to 87 years old. The most common benign eyelid lesion encountered in our practice was sweat gland hidrocystoma followed by chalazion, skin tag, epidermal cyst, nevus, seborrheic keratosis, xanthelasma, and molluscum contagiosum respectively. Histopathological studies confirmed the clinical diagnosis in 95.9% (213/222) of specimens and was different from the clinical diagnosis in 4.1% (9/222) of the lesions which included seborrheic keratosis (n = 3), pilomatrixoma, steatocystoma, hemangioendothelioma, juvenile xanthogranuloma, calcinosis cutis, and syringocystadenoma papilliferum. No malignant lesion was labeled as benign. CONCLUSION Epidemiology of benign eyelid lesions in Saudi population is different from Far East or Western populations. Sweat gland hidrocystoma with classical clinical features and straightforward diagnosis is the most frequent lesion in our series which could be due to characteristic dry climate.
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Affiliation(s)
- Yasser H Al-Faky
- Ophthalmology Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Guo J, Wang J. Adult orbital xanthogranulomatous disease: review of the literature. Arch Pathol Lab Med 2010; 133:1994-7. [PMID: 19961259 DOI: 10.5858/133.12.1994] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2009] [Indexed: 11/06/2022]
Abstract
This article provides an overview of the pathologic features of adult orbital xanthogranulomatous disease, a rare heterogeneous group of disorders that includes 4 clinical syndromes: adult-onset xanthogranuloma, necrobiotic xanthogranuloma, adult-onset asthma and periocular xanthogranuloma, and Erdheim-Chester disease. The diagnosis is made by biopsy of the lesion, demonstrating tissue infiltration by the hallmarks of xanthoma cells and Touton giant cells. The differential diagnosis is broad, including syndromes within the adult xanthogranulomatous disease category as well as other entities involving the eyelid and the orbital tissues. Because of its rarity and sometimes close similarity to other disease entities, it is often misdiagnosed initially. This article focuses on the morphology and immunohistochemical patterns in diagnosis of adult orbital xanthogranulomatous disease with emphasis on adult-onset asthma and periocular xanthogranuloma in particular, its clinical features and associated systemic manifestations in differential diagnosis, as well as the current management strategy.
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Affiliation(s)
- Jin Guo
- Department of Pathology and Laboratory Medicine, Loma Linda University Medical Center, Loma Linda, California 92354, USA.
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