Bilateral lung transplantation for Castleman disease with end-stage bronchiolitis obliterans

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.

[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.