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Parihar M, Kashif A, Neema S. Multicentric reticulohistiocytosis: A diagnostic challenge. Med J Armed Forces India 2023; 79:352-355. [PMID: 37193515 PMCID: PMC10182282 DOI: 10.1016/j.mjafi.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 05/01/2021] [Indexed: 11/26/2022] Open
Abstract
Multicentric reticulohistiocytosis, also called as lipoid dermato-arthritis is a rare form of non-Langerhans cell histiocytosis characterised by nodular and papular skin lesions containing characteristic bizarre multinucleate giant cells with ground glass cytoplasm. The disease commonly involves the skin, mucosa, synovium, and internal organs with cutaneous nodules and progressive erosive arthritis being the most common presenting features. We report a case of a 61-year-old male presenting with multiple swellings over distal part of fingers for 6 years without involvement of joints. A diagnosis of multicentric histiocytosis was made based on typical histopathological features of sheets of histiocytes and multinucleate giant cells with ground glass eosinophilic cytoplasm. The disease has a low incidence and about 300 cases have been reported so far in literature. The present case is being reported as it is uncommon for the disease to present in absence of arthritis.
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Affiliation(s)
- M.K.S. Parihar
- Graded Specialist (Pathology), Command Hospital (Northern Command), C/o 56 APO, India
| | - A.W. Kashif
- Associate Professor, Department of Pathology, Armed Forces Medical College, Pune, India
| | - Shekhar Neema
- Associate Professor, Department of Dermatology, Armed Forces Medical College, Pune, India
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Xu XL, Liang XH, Liu J, Deng X, Zhang L, Wang ZG. Multicentric reticulohistiocytosis with prominent skin lesions and arthritis: A case report. World J Clin Cases 2022; 10:7913-7923. [PMID: 36158473 PMCID: PMC9372849 DOI: 10.12998/wjcc.v10.i22.7913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/14/2021] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Multicentric reticulohistiocytosis (MRH) is a rare non-Langerhans histiocytosis of unknown etiology characterized by papulonodular skin lesions and progressive, erosive arthritis. To date, there have been approximately 300 cases of MRH reported worldwide. The majority of patients are Caucasian from western countries, and Asian patients are rare. Here, we report a case of MRH in a Chinese patient.
CASE SUMMARY A 38-year-old male was admitted to the hospital with a rash that had persisted for over 2 years and bilateral knee pain for over 1 year. The patient’s symptoms had previously been misdiagnosed as eczema when there were only skin symptoms and was finally diagnosed as MRH after a skin biopsy of the left upper back. The patient was treated with glucocorticoids combined with an immunosuppressive regimen. While the skin lesions on both arms, abdomen, and back subsided, the skin lesions on the rest of the body did not increase. The interphalangeal joints of both thumbs and bilateral knee joints remained swollen and painful.
CONCLUSION The case will help clinicians better identify and treat this disease in the absence of epidemiological studies or randomized controlled data.
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Affiliation(s)
- Xiao-Li Xu
- Department of Geriatrics, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu Province, China
| | - Xiao-Hong Liang
- Department of Geriatrics, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu Province, China
| | - Juan Liu
- Jiangsu Engineering Research Center for Tumor Immunotherapy, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu Province, China
| | - Xu Deng
- Department of Pathology, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu Province, China
| | - Lu Zhang
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu Province, China
| | - Zhi-Gang Wang
- Department of Geriatrics, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu Province, China
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Singer SB, Thomas C, Lezcano C, Robbins M, Gordian A, Nori S, Granter SR, Merola JF, O'Malley JT. Polyarthralgias and Papulonodules in a 56-Year-Old Woman. Arthritis Care Res (Hoboken) 2018; 70:925-930. [PMID: 29342504 DOI: 10.1002/acr.23516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 01/09/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Sean B Singer
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cristina Thomas
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cecilia Lezcano
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark Robbins
- Harvard Vanguard Medical Associates/Atrius Health, Boston, Massachusetts
| | - Amparo Gordian
- Harvard Vanguard Medical Associates/Atrius Health, Boston, Massachusetts
| | - Sarita Nori
- Harvard Vanguard Medical Associates/Atrius Health, Boston, Massachusetts
| | - Scott R Granter
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph F Merola
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John T O'Malley
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Varilla V, Taxel P, Tannenbaum S. Metastatic Inflammatory Breast Cancer Associated With Multicentric Reticulohistiocytosis Successfully Treated With Zoledronic Acid. Clin Breast Cancer 2016; 16:e203-e207. [PMID: 27435627 DOI: 10.1016/j.clbc.2016.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/27/2016] [Accepted: 06/17/2016] [Indexed: 11/26/2022]
Affiliation(s)
| | - Pamela Taxel
- Division of Endocrinology and Metabolism, UConn Health, Farmington, CT
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Toz B, Büyükbabani N, İnanç M. Multicentric reticulohistiocytosis: Rheumatology perspective. Best Pract Res Clin Rheumatol 2016; 30:250-260. [DOI: 10.1016/j.berh.2016.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 07/13/2016] [Indexed: 12/22/2022]
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Macía-Villa CC, Zea-Mendoza A. Multicentric reticulohistiocytosis: case report with response to infliximab and review of treatment options. Clin Rheumatol 2014; 35:527-34. [DOI: 10.1007/s10067-014-2611-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 03/31/2014] [Accepted: 04/01/2014] [Indexed: 12/01/2022]
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8
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Trotta F, Colina M. Multicentric reticulohistiocytosis and fibroblastic rheumatism. Best Pract Res Clin Rheumatol 2013; 26:543-57. [PMID: 23040366 DOI: 10.1016/j.berh.2012.07.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2012] [Indexed: 12/22/2022]
Abstract
Multicentric reticulohistiocytosis (MRH) and fibroblastic rheumatism (FR) are uncommon disorders with similar joint and skin manifestations. They are usually included among the non-Langerhans histiocytoses, but recent insights drive some criticism. The diagnosis is often challenging and must be confirmed by the histological typical features. If the skin manifestations are missing, the arthritic complaints may be confused with those of other rheumatic disorders. In these cases, only a careful clinical and radiological evaluation leads to the correct diagnosis. The natural course of the diseases may rapidly develop into disabling manifestations, making an aggressive treatment strongly recommendable. There is emerging evidence that anti-tumour necrosis factor-α agents and bisphosphonates are promising drugs for MRH, while a course of methotrexate and steroids seems to be the best option for FR. Finally, the clinician should be aware that in many cases MRH, but not FR, is associated with a large number of systemic manifestations and with malignancy. This eventuality must be accurately ruled out.
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Affiliation(s)
- Francesco Trotta
- Section of Rheumatology, Department of Clinical and Experimental Medicine, University of Ferrara, Ferrara, Italy.
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Islam AD, Naguwa SM, Cheema GS, Hunter JC, Gershwin ME. Multicentric Reticulohistiocytosis: a Rare Yet Challenging Disease. Clin Rev Allergy Immunol 2013; 45:281-9. [DOI: 10.1007/s12016-013-8362-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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10
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Yang HJ, Ding YQ, Deng YJ. Multicentric reticulohistiocytosis with lungs and liver involved. Clin Exp Dermatol 2009; 34:183-5. [DOI: 10.1111/j.1365-2230.2008.02795.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Infiltration of Histiocytes and Multinucleated Giant Cells in the Myocardium of a Patient With Multicentric Reticulohistiocytosis. J Clin Rheumatol 2009; 15:25-6. [DOI: 10.1097/rhu.0b013e31817d1197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Benucci M, Sulla A, Manfredi M. Cardiac engagement in multicentric reticulohistiocytosis: report of a case with fatal outcome and literature review. Intern Emerg Med 2008; 3:165-8. [PMID: 18265939 DOI: 10.1007/s11739-008-0102-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2006] [Accepted: 01/18/2007] [Indexed: 10/22/2022]
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13
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Weenig RH, Mehrany K. Dermal and Pannicular Manifestations of Internal Malignancy. Dermatol Clin 2008; 26:31-43, vii. [DOI: 10.1016/j.det.2007.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Luz FB, Gaspar NK, Gaspar AP, Carneiro S, Ramos-e-Silva M. Multicentric reticulohistiocytosis: a proliferation of macrophages with tropism for skin and joints, part I. Skinmed 2007; 6:172-8. [PMID: 17618169 DOI: 10.1111/j.1540-9740.2007.05810.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The authors present part I of a review of multicentric reticulohistiocytosis, a rare systemic proliferative disease of histiocytes of unknown cause. It is clinically characterized by cutaneous and mucosal nodules and by osteoarticular lesions. The disease occurs in outbreaks that progress in severity, with spontaneous regression, but usually leaving incapacitating arthritis and disfiguring facial lesions. The authors discuss the historical, epidemiologic, and clinical aspects of this disease.
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Affiliation(s)
- Flávio Barbosa Luz
- Sector of Dermatology, University Hospital HUCFF/UFRJ and School of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
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Abstract
Many inflammatory, metabolic and infectious diseases affect the skin and joints. Most of these, such as rheumatoid arthritis and systemic lupus erythaematosus, are considered to be rheumatic conditions with secondary skin involvement. However, several primary cutaneous diseases are associated with arthritis and may even present with joint symptoms prior to cutaneous lesions. Common skin disorders, such as acne and psoriasis, have well-known musculoskeletal manifestations. Other less common conditions, such as dermatomyositis, multicentric reticulohistiocytosis, pyoderma gangrenosum, Sweet's syndrome and various cutaneous vasculitides, also have frequent joint involvement. This review will discuss the clinical presentation, both cutaneous and musculoskeletal, diagnosis and management of these disorders.
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Affiliation(s)
- Joshua Levin
- Department of Dermatology, University of Pennsylvania, PA 19104, USA
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Newman B, Hu W, Nigro K, Gilliam AC. Aggressive histiocytic disorders that can involve the skin. J Am Acad Dermatol 2006; 56:302-16. [PMID: 17097374 DOI: 10.1016/j.jaad.2006.06.010] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Revised: 05/16/2006] [Accepted: 06/19/2006] [Indexed: 10/24/2022]
Abstract
Histiocytoses are a heterogeneous group of disorders that are characterized by the proliferation and accumulation of reactive or neoplastic histiocytes. Three classes of histiocytoses have been defined: class I, Langerhans cell disease; class II, non-Langerhans cell histiocytic disease without features of malignancy; and class III, malignant histiocytic disorders. Although the disorders in classes I and II usually have a benign appearance on histology and are commonly non-aggressive and self-healing, some can cause debilitating or even fatal outcomes. Such cases beg the question: what stimulates aggressive behavior of a classically benign disease? New molecular information may now provide insight into the driving force behind many of the aggressive histiocytoses. In this article, we review Langerhans cell disease and seven aggressive histiocytoses that can involve skin, discuss histologic features that may forecast a poor prognosis, and discuss the molecular findings that help to explain the pathophysiology of these aggressive histiocytic disorders.
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MESH Headings
- Histiocytosis/classification
- Histiocytosis/pathology
- Histiocytosis/physiopathology
- Histiocytosis, Langerhans-Cell/diagnosis
- Histiocytosis, Langerhans-Cell/pathology
- Histiocytosis, Langerhans-Cell/physiopathology
- Histiocytosis, Non-Langerhans-Cell/diagnosis
- Histiocytosis, Non-Langerhans-Cell/pathology
- Histiocytosis, Non-Langerhans-Cell/physiopathology
- Histiocytosis, Non-Langerhans-Cell/therapy
- Humans
- Lymphohistiocytosis, Hemophagocytic/pathology
- Lymphohistiocytosis, Hemophagocytic/physiopathology
- Necrobiotic Disorders/diagnosis
- Necrobiotic Disorders/pathology
- Necrobiotic Disorders/physiopathology
- Necrobiotic Disorders/therapy
- Prognosis
- Sea-Blue Histiocyte Syndrome/pathology
- Sea-Blue Histiocyte Syndrome/physiopathology
- Sea-Blue Histiocyte Syndrome/therapy
- Skin Diseases/diagnosis
- Skin Diseases/pathology
- Skin Diseases/physiopathology
- Skin Diseases/therapy
- Xanthogranuloma, Juvenile/pathology
- Xanthogranuloma, Juvenile/physiopathology
- Xanthogranuloma, Juvenile/therapy
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Affiliation(s)
- Brenda Newman
- Department of Dermatology, Case/University Hospitals of Cleveland, Ohio 44106-5028, USA
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Abstract
We describe a 33-year-old woman with a 2-year history of rheumatoid arthritis-like joint changes and a 1-year history of papulonodules on the fingers, ears, oral mucosa, forearm, elbows and thighs, and erythematous plaques on the buttocks. Six months after the onset of the cutaneous lesions she had dyspnoea, 3 months later she developed a husky sound. Biopsies from the nodules on the ear and left forearm revealed multinucleated giant cells with eosinophilic 'ground-glass' cytoplasm. Bronchoscopy revealed that there were nodules in the bronchus. A biopsy taken from a nodule from the bronchus was consistent with multicentric reticulohistiocytosis. Fibrostic laryngoscopy showed a mass 1.5 x 2.0 cm(2) in size on the left aryepiglottic fold and posterior commissure. Magnetic resonance imaging revealed a large pleural effusion and pericardiac effusion. Ultrasound revealed splenomegaly and peritoneal fluid. Combination therapy with prednisone, cyclophosphamide and methotrexate significantly improved cutaneous and joint symptoms. The huge cutaneous erythematous plaques and the generalized systemic involvement make this case interesting.
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Affiliation(s)
- Y H Liu
- Department of Dermatology, Peking Union Medical College Hospital, and the Chinese Academy of Medical Sciences, Beijing, China.
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Bogle MA, Tschen JA, Sairam S, McNearney T, Orsak G, Knox JM. Multicentric reticulohistiocytosis with pulmonary involvement. J Am Acad Dermatol 2003; 49:1125-7. [PMID: 14639398 DOI: 10.1016/s0190-9622(03)00036-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Melissa A Bogle
- St. Joseph Hospital, 6555 Travis Street, Houston, TX 77030, USA
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Abstract
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.
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Affiliation(s)
- J David Outland
- Department of Medicine, Division of Dermatology, University of Louisville, Kentucky, USA
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Ka MM, Leye A, Dangou JM, Ka EF, Diallo S, Mbengue M, Ndongo S, Diop TM. [Multicentric reticulohistiocytosis with a 20-year follow-up ]. Rev Med Interne 2002; 23:779-83. [PMID: 12378831 DOI: 10.1016/s0248-8663(02)00674-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Multicentric reticulo-histiocytosis also known as lipoid dermoarthritis is a rare systemic disease leading to a massive osteoarticular destruction and systemic complications. EXEGESIS This case report is a 44 year old black woman who was first seen with a rheumatoid arthritis clinical presentation associated with the presence of rheumatoïd factor. Five years later the diagnosis has been reconsidered after skin nodules histological examination. After that the patient has been lost from the follow up clinic. After a twenty years evolution she presented a complex clinical picture including: a cutaneous syndrome with a non pruriginous and hyperchromic papulonodular rash on the arms and fore-arms; a very destructive polyarthritis with major handicap; and systemic manifestations like cardiomyopathy with heart failure. The heart failure treatment associated first corticosteroids and secondary chloroquine was successful. CONCLUSION The rheumatoid factor presence should not avoid to consider the possibility of multicentric reticulohistiocytosis in case of polyarthritis associated with a papulonodular rash. Then skin biopsy must be performed. The severity of osteoarticular and systemic lesions require an early prescription of a treatment for which there is so far no compromise.
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Affiliation(s)
- M M Ka
- Clinique médicale I, CHU A.-Le Dantec, avenue Pasteur, BP 6237, Dakar Etoile, Sénégal.
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Hiramanek N, Kossard S, Barnetson RS. Multicentric reticulohistiocytosis presenting with a rash and arthralgia. Australas J Dermatol 2002; 43:136-9. [PMID: 11982572 DOI: 10.1046/j.1440-0960.2002.00577.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A case of multicentric reticulohistiocytosis in a 53-year-old woman with a history of generalized cutaneous eruptions followed by arthralgia is presented. A thorough malignancy screen was performed with negative results. Treatment was commenced with oral prednisone 20 mg daily, which rapidly resulted in marked improvement of joint symptoms and resolution of self-perceived functional disability. As there was little improvement of her rash, oral azathioprine was added at 100 mg daily. Both drugs were well-tolerated and the patient was discharged from hospital on these medications. Two months later the azathioprine was reduced to 50 mg per day orally, following a small rise in hepatic transaminases. Within 4 months there had been dramatic improvement in the rash and cutaneous nodules with complete remission of the arthralgia and pruritus. During this time the oral prednisone had gradually been decreased to 10 mg daily. To date only the periungual nodules persist.
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Affiliation(s)
- Navaz Hiramanek
- Department of Dermatology, Royal Prince Alfred Hospital, Camperdown, New South Wales 2050, Australia
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Suga K, Ogasawara N, Motoyama K, Hara A, Matsunaga N, Muto T. Ga-67 scintigraphic findings in a case of multicentric reticulohistiocytosis. Clin Nucl Med 2002; 27:144-5. [PMID: 11786753 DOI: 10.1097/00003072-200202000-00020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kazuyoshi Suga
- Department of Radiology, Yamaguchi University School of Medicine, Ube, Japan
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Abstract
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.
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Affiliation(s)
- F B Luz
- Sector of Dermatology, HUAP-UFF, Universidade Federal Fluminense, Niteroi, Brazil.
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