Ultra-rare cystic disease

A patient with Eradheim-Chester disease presenting with progressive cystic lung lesions and confirmed pulmonary artery hypertension: a case report

BACKGROUND

Erdheim-Chester disease (ECD), a rare type of non-Langerhans cell histiocytosis, was classified as a haematopoietic tumour by the World Health Organization (WHO) in 2016. It involves multiple systems and is challenging to diagnose due to its broad spectrum of clinical manifestations. The pulmonary manifestations of ECD lack specificity. We present a case of ECD with pronounced cystic lung abnormalities to increase awareness of the disease among pulmonologists and expedite diagnosis and treatment.

CASE PRESENTATION

We report the case of a 44-year-old male who presented with intermittent fever, cough, bilateral leg pain, extensive xanthomas on his face, and extensive pulmonary cystic changes noted on imaging following a pulmonary stab wound incident. Thoracoabdominal enhanced computed tomography (CT) revealed progressive cystic changes in the lungs, notably in the upper lungs and subpleural areas; thickened interlobular septa; circumferential wall thickening of the left subclavian artery; uneven thickening of the aortic wall; and soft tissue shadows in the right atrium of the heart. Bone scintigraphy revealed bilateral symmetric long-bone uptake. Despite his advanced lung abnormalities, he exhibited no hypoxia. Notably, echocardiography indicated severe pulmonary artery hypertension, and right heart catheterization confirmed increased mean pulmonary artery pressure at 37 mmHg and elevated pulmonary vascular resistance. Pathology examination of transbronchial lung biopsy and the facial xanthomas confirmed the presence of ECD-characteristic histiocytes, and genetic testing revealed a BRAF V600E mutation. Treatment with dabrafenib improved respiratory symptoms and facial xanthomas, although some symptoms persisted. Follow-up CT showed reduced interstitial lesions but more pronounced cystic changes.

CONCLUSIONS

This case of ECD illustrates rare pulmonary cystic changes alongside pulmonary arterial hypertension, challenging typical presentations of ECD. This is the first documented instance of pulmonary hypertension associated with ECD, broadening the understanding of its potential complications. These findings emphasize the need for considering ECD in the differential diagnosis of atypical cystic lung lesions, especially when accompanied by systemic symptoms such as xanthomas and bone pain.

Correlation of classic history, imaging and pathology with novel genetics in Birt-Hogg-Dubé syndrome

A spontaneous pneumothorax may be the heralding manifestation of diffuse cystic lung disease (DCLD). Historically, these diagnoses were differentiated by unique clinical, radiographic and tissue pathology characteristics. With recent advancements in genomics, several forms of DCLD can now be diagnosed through genetic testing and patients can thereby avoid undergoing an invasive lung biopsy. We present a case of a young patient with recurrent spontaneous pneumothoraces associated with a rare DCLD, Birt-Hogg-Dubé syndrome, that exemplifies the manifestations of this disease through classic history, imaging and pathology, along with the diagnostic utility of novel genotypic technology in the modern era.

Lung carcinoma with diffuse cysts repeatedly misdiagnosed as pulmonary infections and lymphoid interstitial pneumonia: A case report

INTRODUCTION

Diffuse cystic lung diseases comprise a heterogeneous group of pulmonary disorders, with most cases being benign and malignant instances being rare.

CASE REPORT

We present an unusual case of lung adenocarcinoma characterized by the progressive diffusion of cystic lesions. The patient, initially diagnosed with a pulmonary infection and lymphoid interstitial pneumonia, underwent repeated misdiagnoses. Ultimately, the diagnosis was confirmed using radial endobronchial ultrasound-guided-transbronchial cryobiopsy (rEBUS-TBCB). A 44-year-old male was admitted to the hospital with a persistent cough and expectoration of bloody sputum for over 6 months. Thoracic computed tomography revealed widespread cystic lesions and nodules. Despite multiple misdiagnoses, rEBUS-TBCB successfully confirmed the presence of lung adenocarcinoma and identified an echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) E13:A20 gene rearrangement. The patient was subsequently transferred to a local hospital for oral targeted drug therapy, which resulted in a favorable response.

CONCLUSION

In conclusions, transbronchial lung biopsies often provide inadequate specimens for confirming diffuse cystic lung diseases. In contrast, the utilization of rEBUS-guided TBCB offers superior diagnostic capabilities, as it enables the collection of larger lung biopsies with higher diagnostic yields and fewer complications compared to surgical lung biopsy.

Cystic lung disease in adult Indigenous Australians in the Northern Territory of Australia

INTRODUCTION

Indigenous Australians have a high prevalence of chronic lung diseases. However, no previous studies have reported on cystic lung disease in an Indigenous patient cohort.

METHODS

This report describes 20 adult Indigenous patients noted to have incidental lung cysts on chest computed tomography (CT) while being referred to undergo lung function tests in the Northern Territory of Australia.

RESULTS

Of the total 20 Indigenous patients demonstrating presence of pulmonary cysts on chest CT scan, 13/20 (65%) were males with a mean age of 49.9 years (range 24-74 years), with no significant difference in age between males and females. The majority reported a smoking history and spirometry demonstrated moderate reduction in lung function parameters. While there was no pattern in the size or location of cysts, most demonstrated multiple cysts (55% had ≥5 cysts) with bilateral involvement (65%), alongside a range of concurrent pulmonary radiological abnormalities. The aetiology for lung cysts was largely unknown.

CONCLUSION

This is the first report to illustrate cystic lung disease within an Indigenous population. Further radiology studies are required to investigate the causes and prognostications of cystic lung disease in Indigenous patients.

A case report of lymphangioleiomyomatosis with retroperitoneal masses in pregnancy

Background

Lymphangioleiomyomatosis (LAM) is a rare, gradually advancing tumor of unknown origin. It is distinguished by the anomalous proliferation of pulmonary smooth muscle cells and predominantly manifests in women of childbearing age. In this study, we aim to present a noteworthy case of LAM accompanied by lymphangioleiomyoma in the retroperitoneal space during pregnancy, a scenario susceptible to misdiagnosis.

Case presentation

A 31-year-old woman, facing an unintended pregnancy, presented during the 13th week with a cystic-solid mass exhibiting abundant blood signals in the pelvic cavity, as revealed by routine obstetrical ultrasound. Concurrently, her chest CT disclosed diffuse thin-walled cavities in both lungs. Despite the absence of clinical symptoms, the patient abandoned pregnancy and underwent a complete curettage. However, 24 days post-operation, she was readmitted for further assessment, revealing an enlargement of the mass encompassing the abdominal aorta and inferior vena cava, along with compression on the middle and lower segments of the ureter. After a multi-disciplinary discussion and patient explanation, an exploratory laparotomy was performed, resulting in the complete removal of the tumor. Intraoperative pathological examination and immunohistochemical staining indicated a retroperitoneal mass devoid of malignant evidence. The comprehensive morphologic and immunophenotypic features substantiated the diagnosis of lymphangioleiomyomatosis. The postoperative course was uneventful, culminating in the patient's discharge.

Conclusion

The consideration of Lymphangioleiomyomatosis (LAM) with a retroperitoneal tumor is crucial in the differential diagnosis of pelvic and abdominal masses. The preoperative diagnosis of this tumor poses a challenge, as ultrasound or CT scans may not yield definitive results. Accurate diagnosis necessitates not only a pathological examination of the retroperitoneal mass but also the correlation with the patient's chest High-Resolution Computed Tomography (HRCT) findings and corresponding clinical manifestations. Optimal management involves radical surgery, with surgeons comprehensively factoring in both fetal and maternal conditions when formulating a treatment plan.

Lymphangioleiomyomatosis With Atypical Presentation Following Pneumothorax: A Case Report

Lymphangioleiomyomatosis (LAM) is a rare systemic disease that typically presents like cystic lung disease. High-resolution computed tomography (CT) is the recommended imaging technique, with cysts being the hallmark: typically multiple, well-circumscribed, thin-walled, with a variable diameter (usually <2 cm) and widespread in distribution. The gold standard for diagnosis is a biopsy. LAM should be considered in the differential diagnosis of cystic lung diseases. The authors report a case of LAM presenting with a pneumothorax, which due to its atypical imaging characteristics, mimicked another uncommon cystic disease. A multidisciplinary approach is crucial when dealing with presentations of rare diseases.

Lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is an ultra-rare, slowly progressive neoplastic cystic disease, belonging to the group of PEComas. It can occur sporadically or associated to tuberous sclerosis complex disease and affects mainly women in child-birth age. Dyspnoea is the most frequent symptom referred to the time of diagnosis, however spontaneous pneumothorax may be a typical presentation associated to extrathoracic manifestations, such as renal angiomyolipomas. In the last decade, important advances in understanding molecular mechanisms underlying the LAM pathogenesis have been reached. It has allowed to obtain improvements in the research of novel biomarkers, treatment and a better management of the disease.

Diagnostic performance of VEGF-D for lymphangioleiomyomatosis: a meta-analysis

Objective:

VEGF-D is a potential biomarker for lymphangioleiomyomatosis (LAM); however, its diagnostic performance has yet to be systematically studied.

Methods:

We searched PubMed, EMBASE, Scopus, Web of Science, and Cochrane Library to identify primary studies on VEGF-D in relation to the diagnosis of LAM. The quality of the studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Summary estimates of diagnostic accuracy were pooled using a bivariate random effects model. Subgroup and sensitivity analyses were performed to explore possible heterogeneity. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was applied to rate the quality of evidence and indicate the strength of recommendations.

Results:

Ten studies involving 945 patients were of high risk in quality, as assessed using the QUADAS-2. The pooled diagnostic parameters were indicated as follows: sensitivity = 0.82 (95% CI, 0.71-0.90); specificity = 0.98 (95% CI, 0.94-0.99); and diagnostic OR = 197 (95% CI, 66-587). The AUC of summary ROC analysis was 0.98. The subgroup and sensitivity analyses revealed that the overall performance was not substantially affected by the composition of the control group, prespecified cutoff value, the country of origin, or different cutoff values (p > 0.05 for all). A strong recommendation for serum VEGF-D determination to aid in the diagnosis of LAM was made according to the GRADE.

Conclusions:

VEGF-D seems to have great potential implications for the diagnosis of LAM in clinical practice due to its excellent specificity and suboptimal sensitivity.

Erdheim-Chester disease: a comprehensive review from the ophthalmologic perspective

Erdheim-Chester disease (ECD) is a rare clonal histiocytic neoplasm with less than 1200 documented cases to date. The disease is life-threatening and difficult to recognize, although increasing awareness as well as the integration of clinical, imaging, pathology information , and genetic studies have led to a recent exponential increase in new reported cases. ECD affects multiple organs and systems, including skeletal, neurologic, and cardiovascular. Pulmonary, retroperitoneal, and cutaneous lesions have also been reported in various combinations. Until the discovery that more than half of ECD patients harbor the BRAF-V600E mutation or other mutations in the mitogen-activated protein kinase (MAPK) and RAS pathways, Interferon-a was the first-line treatment. Nowadays BRAF and MEK-inhibitors targeted therapies are the mainstay of treatment. Ophthalmologic involvement occurs in 25% -30% of ECD cases, usually in the form of orbital involvement presenting with exophthalmos and ophthalmoplegia. Other ophthalmologic manifestations include palpebral xanthelasmas, anterior uveitis and vitritis, optic disk edema, choroidal infiltration, recurrent serous retinal detachment, retinal drusen-like deposits and retinal pigment epithelial changes. ECD patients can also present with ocular symptoms as a result of adverse effects of the treatment regimens. In some cases with smoldering or protean symptoms, the emergence of eye manifestations triggered the diagnosis. Ophthalmologists have to be aware of the disease, recognize the constellation of ECD symptoms, and contribute to the diagnosis, treatment, and follow-up of ECD patients.