Clinical and pathological features of bronchiolitis obliterans requiring lung transplantation in paraneoplastic pemphigus associated with Castleman disease

Unicentric Castleman disease complicated with bronchiolitis obliterans: A single-centre retrospective study from China

Bronchiolitis obliterans (BO) is a rare and life-threatening complication of unicentric Castleman disease (UCD), which is considered the leading cause of death in UCD. However, few studies focused on the characteristics of UCD patients complicated with BO. This single-centre, retrospective study of 281 patients diagnosed with UCD identified 18 patients (6.4%) with BO. UCD-BO patients had a significantly lower age at UCD diagnosis than the UCD without BO group. 94.4% of UCD-BO patients had deep lymph nodes involvement and 83.3% of them had paraneoplastic pemphigus, which were both significantly higher than UCD without BO. Median forced expiratory volume in 1 s of predicted was 20.9% (10%-41.9%) and 83.3% patients had severe BO. All patients underwent complete resection for UCD. 61.1% patients developed BO after surgery. UCD-BO patients had a poorer overall survival than UCD without BO. Among severe BO, 11 patients did not receive lung transplantation and two of them died, with 62.5% (95% CI, 20.8%-100%) of estimated 5-year overall survival. Four patients underwent lung transplantation and they all survived. UCD-BO patients had distinct clinical identity. Complete resection could neither alleviate BO nor prevent BO progression. Lung transplantation is a vital treatment for improving prognosis for patients with severe BO.

A case report of Castleman disease with paraneoplastic pemphigus and bronchiolitis obliterans: Challenges and key takeaways

INTRODUCTION

Castleman disease is a rare lymphoproliferative disorder, subdivided into three types: unicentric Castleman disease, idiopathic multicentric Castleman disease and human herpesvirus-8 (HHV8) associated multicentric Castleman disease. The retroperitoneum comprises only 13 % of the cases.

CASE PRESENTATION

We report a case of a 36-year-old female who presented with skin lesions in a dermatology clinic. Her CT scan revealed a left retroperitoneal soft tissue mass that measured 5.6 × 7.8 × 6.7 cm. On laparoscopy, a 10 × 5 cm retroperitoneal mass located in close proximity to the left renal vessels was noted. Histopathology revealed dense lymphoid infiltrate with follicular hyperplasia having atretic germinal centres, confirming the diagnosis of Castleman disease.

DISCUSSION

Paraneoplastic pemphigus (PNP) and bronchiolitis obliterans (BO) are complications associated with Castleman disease. PNP is always associated with an underlying neoplasm and diagnosis of PNP should prompt work up for underlying malignancy. BO is a progressive and debilitating condition that responds poorly to medical therapy and lung transplant is the only viable treatment option. On account of vascular nature of these lesions, pre operative embolization should be considered. Ureteric stenting may also be helpful to delineate ureters while dissecting retroperitoneal mass.

CONCLUSION

Mucocutaneous lesions suspicious for PNP should be thoroughly investigated and necessary imaging must be obtained to look for underlying neoplastic process. CT scan is an effective diagnostic modality; however, it has its limitations and PET/CT may provide additional benefits in diagnosis. Prior to resection, careful surgical planning, including ureteric stenting and pre-operative embolization may be required.

Lichenoid paraneoplastic pemphigus in a patient presenting with follicular lymphoma: a review of the literature

Paraneoplastic pemphigus (PNP) is a rare, autoimmune, mucocutaneous blistering disease that is almost always associated with a confirmed or occult neoplasm. PNP often presents with characteristic features of intractable stomatitis and polymorphous cutaneous eruptions, including blisters and lichenoid dermatitis caused by humoral and cell-mediated autoimmune reactions. We present the following case of a patient with follicular lymphoma (FL) who developed lichenoid PNP involving the buccal mucosa and lateral tongue. We also summarize the literature, discussing current proposed mechanisms, guidelines, and treatment of this unique disease. While patients can achieve complete remission from their underlying neoplasm, most patients with PNP do not have a good survival time with a 5-year survival rate of only 38%. This case sheds light on an uncommon occurrence, highlights the need for further studies around PNP as it relates to FL, and suggests that T cell immunosuppressive therapy may be effective in treating FL patients with PNP.

[Paraneoplastic pemphigus with underlying Castleman's disease in a 16-year-old girl]

Paraneoplastic pemphigus is a rare, life-threatening autoimmune disease that is clinically characterized by mostly extensive and refractory mucosal erosions and polymorphous skin lesions. We report here on a 16-year-old girl with isolated oral erosions, in whom mucosal pemphigoid was initially suspected and after treatment with prednisolone and dapsone marked improvement was achieved. However, a few months later the patient developed massive respiratory insufficiency as a result of bronchiolitis obliterans, so that a lung transplant was planned. As part of the preparatory diagnostic workup, unicentric, abdominally localized Castleman's disease was diagnosed, which ultimately led to the diagnosis of paraneoplastic pemphigus as evidenced by envoplakin autoantibodies. Tumor resection and subsequent lung transplantation achieved good results with sustained mucocutaneous remission.

Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome: Part I. Clinical overview and pathophysiology

Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome (PNP/PAMS) is a highly fatal autoimmune blistering disease. The condition occurs in patients with underlying benign or malignant neoplasms, most commonly lymphoproliferative disorders. Both humoral and cell-mediated immunities contribute to the pathogenesis, and autoantibodies against plakin family proteins are characteristic. Patients typically present with severe stomatitis and polymorphous skin lesions, which are often resistant to treatment. Bronchiolitis obliterans (BO) is a frequent complication which contributes to the high mortality rate of PNP/PAMS. Given the rarity of this disorder and heterogeneity of clinical presentation, clinicians should maintain a high index of suspicion for PNP/PAMS to avoid delayed diagnosis. In this first part of a two-part continuing medical education (CME) series, risk factors, pathogenesis, and clinical features of PNP/PAMS are discussed.

Castleman disease of plasma cell type accompanied with bronchiolitis obliterans: a case report and review of the literature

BACKGROUND

Castleman disease, also known as giant lymph node hyperplasia or angiofollicular lymph node hyperplasia, is a highly heterogeneous clinicopathological entity that belongs to the family lymphoproliferative disorders. Castleman disease accompanied by bronchiolitis obliterans is uncommon and often poses a great diagnostic challenge, which is easily confused with respiratory diseases and impeding the correct diagnosis and treatment. The main aim in presenting such rare case studies is to raise awareness and expand the diagnostic horizon of clinicians for appropriate management.

CASE PRESENTATION

Here, we present a 69-year-old Chinese male who was admitted to our hospital due to right chest pain for 6 months, accompanied by cough, expectoration, and fever. Laboratory examinations revealed elevated immunoglobulin G and C-reactive protein, and normal serum levels of tumor markers and interleukin-6. Computed tomography scan detected diffuse bronchial wall thickening and patchy area of air trapping consistent with small airway disease. Pulmonary function test showed mild small airway obstructive ventilation dysfunction and moderate decrease in diffusion capacity. The pathological result of the right axillary lymph node was consistent with the plasma cell type Castleman disease. According to the above examinations, the patient was finally diagnosed with the plasma cell type Castleman disease accompanied with bronchiolitis obliterans. He received immunosuppressive medication after surgery and has been followed up for 11 months. Now the patient is currently in stable condition without recurrence.

CONCLUSION

Castleman disease is a rare lymphoproliferative disorder with a variety of symptoms. At present, the treatment of Castleman disease accompanied with bronchiolitis obliterans is mostly based on experiences or previous case reports, and there is no standard treatment. Here, we report an uncommon case of Castleman disease accompanied with bronchiolitis obliterans in which the patient received immunosuppressive medication after surgery and has been followed up for 11 months without experiencing a recurrence, which may deepen and extend our understanding of this disease.

Paraneoplastic pemphigus misdiagnosed as juvenile dermatomyositis: A case report

Paraneoplastic pemphigus (PNP) is a rare autoimmune skin disease closely related to tumors, characterized by a maculopapular rash with mucosal pain, bronchiole occlusion, and respiratory failure may occur over time, even resulting in death. We report a rare case of a child with autoimmune PNP misdiagnosed as juvenile dermatomyositis (JDM), and summarize the key points of differentiation of clinical manifestations and auxiliary examinations of PNP and JDM. When the diagnosis is not clear because the patient has features not typical of JDM, then skin biopsy and other diagnostic studies should be considered prior to any immunosuppressive therapy, as this could potentially obscure and delay the diagnosis of malignancy.

S2k guidelines on the management of paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome initiated by the European Academy of Dermatology and Venereology (EADV)

BACKGROUND

Paraneoplastic pemphigus (PNP), also called paraneoplastic autoimmune multiorgan syndrome (PAMS), is a rare autoimmune disease with mucocutaneous and multi-organ involvement. PNP/PAMS is typically associated with lymphoproliferative or haematological malignancies, and less frequently with solid malignancies. The mortality rate of PNP/PAMS is elevated owing to the increased risk of severe infections and disease-associated complications, such as bronchiolitis obliterans.

OBJECTIVES

These guidelines summarize evidence-based and expert-based recommendations (S2k level) for the clinical characterization, diagnosis and management of PNP/PAMS. They have been initiated by the Task Force Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology with the contribution of physicians from all relevant disciplines. The degree of consent among all task force members was included.

RESULTS

Chronic severe mucositis and polymorphic skin lesions are clue clinical characteristics of PNP/PAMS. A complete assessment of the patient with suspected PNP/PAMS, requiring histopathological study and immunopathological investigations, including direct and indirect immunofluorescence, ELISA and, where available, immunoblotting/immunoprecipitation, is recommended to achieve a diagnosis of PNP/PAMS. Detection of anti-envoplakin antibodies and/or circulating antibodies binding to the rat bladder epithelium at indirect immunofluorescence is the most specific tool for the diagnosis of PNP/PAMS in a patient with compatible clinical and anamnestic features. Treatment of PNP/PAMS is highly challenging. Systemic steroids up to 1.5 mg/kg/day are recommended as first-line option. Rituximab is also recommended in patients with PNP/PAMS secondary to lymphoproliferative conditions but might also be considered in cases of PNP/PAMS associated with solid tumours. A multidisciplinary approach involving pneumologists, ophthalmologists and onco-haematologists is recommended for optimal management of the patients.

CONCLUSIONS

These are the first European guidelines for the diagnosis and management of PNP/PAMS. Diagnostic criteria and therapeutic recommendations will require further validation by prospective studies.

Skin disorders and interstitial lung disease: Part II-The spectrum of cutaneous diseases with lung disease association

Part 2 of this 2-part CME introduces dermatologists to noninfectious inflammatory skin diseases associated with pulmonary involvement. In many cases, dermatologists may be the first physicians recognizing respiratory complications associated with these diagnoses. Because pulmonary involvement is often the leading cause of morbidity and mortality, dermatologists should be comfortable screening and monitoring for lung disease in high-risk patients, recognizing cutaneous stigmata of lung disease in these patients and referring to pulmonary specialists, when appropriate, for prompt treatment initiation. Some treatments used for skin disease may not be appropriate in the context of lung disease and hence, choosing a holistic approach is important. Interstitial lung disease and pulmonary hypertension are the most common pulmonary complications and a significant cause of mortality in autoimmune connective tissue diseases, especially systemic sclerosis, dermatomyositis, and mixed connective tissue disease. Pulmonary complications, notably interstitial lung disease, are also common and life-threatening in sarcoidosis and vasculitis, while they are variable in neutrophilic and autoimmune blistering diseases.

Approche thérapeutique des maladies de Castleman : l’émergence des thérapies ciblées

The spectrum of Castleman disease encompasses several different disorders. Nowadays three different forms of the disease are individualized: unicentric Castleman disease, multicentric HHV-8 associated Castleman disease and idiopathic multicentric Castleman disease. In the latter a severe form called TAFRO syndrome (thrombocytopenia, anasarca, myelofibrosis, renal dysfunction, and organomegaly) tend to be individualized. Improvement in the classification and understanding of the physiopathology of CD have allowed improvement in treatment strategies. Treatment of rare but often severe manifestations, such as paraneoplastic pemphigus and bronchiolitis obliterans in unicentric CD and hemophagocytic syndrome and/or Kaposi' sarcoma in HHV8 associated CD, are better adapted. Most of current treatment strategies are based on retrospective and very few prospective studies. Both anti-IL6/6R and anti-CD20 biotherapies have greatly improved the management of certain forms of the disease. We report in this review the most relevant studies and national or international expert consensus statements for the treatment in the different types of CD. © 2022 Published by Elsevier Masson SAS on behalf of Société nationale française de médecine interne (SNFMI).

Clinical and pathological features of bronchiolitis obliterans requiring lung transplantation in paraneoplastic pemphigus associated with Castleman disease

Summary at a glance

Bronchiolitis obliterans in paraneoplastic pemphigus associated with Castleman disease possesses the progressive nature even when it is treated with intensive medical therapy. Antibodies were at least in low titers before the Lung transplant and remain negative after the procedure. Explanted lungs showed coexistence of cellular destructive bronchiolitis and constrictive bronchiolitis.

Background

Bronchiolitis obliterans (BO) in paraneoplastic pemphigus (PNP) associated with Castleman disease (CD) possesses the progressive nature of pulmonary disease even when it is treated with intensive medical therapy. Lung transplantation (LT) offers an acceptable form of treatment.

Methods

We conducted a retrospective study of two cases of BO in PNP associated with CD who underwent LT between March 2017 and March 2020 at the China‐Japan Friendship Hospital. We also included one case from the literature.

Results

In this patient series, PNP was the primary clinical presentation in all patients, and it was accompanied by respiratory symptoms before/after CD excision. In spite of being treated with various combinations of immunosuppressive and anti‐inflammatory agents, the patients had great or total improvement in mucosal erosions, whereas their pulmonary function test (PFT) deteriorated gradually or sharply. The duration times from disease onset to timing of LT were 1, 2 and 5 years. All antibodies were negative or were present at low titers before the LT procedure and remain negative after the procedure. The histopathological features of explanted lungs showed cellular and coexistent destructive bronchiolitis and constrictive bronchiolitis in two cases. Granulation with numerous foamy macrophages, scattered giant cells and cholesterol clefts were especially prominent in case one.

Conclusion

BO in PNP associated with CD had poor clinical outcomes. LT was preferable choice in end‐stage BO when PNP and CD were controlled.