Sinus histiocytosis with massive lymphadenopathy: a spectrum of disease associated with immune dysfunction

Strong Coexpression of Transcription Factors PU.1 and Oct-2 in Rosai-Dorfman Disease

OBJECTIVES

Rosai-Dorfman disease (RDD) is a rare disorder characterized by the accumulation of large S100 protein-positive histiocytes that typically exhibit emperipolesis. The recently reported expression of Oct-2 in RDD histiocytes led us to explore whether PU.1, a transcription factor that is required for monocyte and B-cell development, could similarly function as a diagnostic marker in RDD.

METHODS

We evaluated the expression of PU.1 and Oct-2 using immunohistochemistry in 19 patients diagnosed with RDD involving nodal, extranodal, and cutaneous sites.

RESULTS

Both PU.1 and Oct-2 were positive in all cases studied, with a strong intensity of staining in 84% of cases in which more than 50% of the lesional cells were positive. In three patients, both markers showed weak to moderate intensity of staining. Two patients had concomitant RDD and Langerhans cell histiocytosis in which PU.1 stained both types of histiocytes while Oct-2 stained only the RDD component.

CONCLUSIONS

PU.1 emerged as a robust marker with crisp nuclear staining in RDD histiocytes as well as in engulfed inflammatory cells. Strong coexpression of PU.1 and Oct-2 is a useful diagnostic marker in differentiating histiocytic/dendritic cell proliferations.

Review of Rosai-Dorfman Disease: New Insights into the Pathogenesis of This Rare Disorder

Rosai-Dorfman disease (RDD) is a rare histiocytosis typically with bilateral painless cervical lymphadenopathy. Laboratory data are nonspecific, and the presence of emperipolesis in large foamy S-100+ CD1a- histiocytes is the prominent histologic feature. The pathogenesis of RDD still remains elusive. According to published studies, we propose that RDD cells might represent intermediate recruiting monocytes with differentiation blockade. Both disturbance of homoeostasis and inherent genomic alterations could contribute to initiation of the disorder through signal transduction. Several inflammatory molecules such as macrophage colony-stimulating factor, IL-1β, IL-6, and tumor necrosis factor-α also play a pivotal role in the development of this rare entity. Additional studies are needed to further elucidate the essence of the disease.

A rare case of "rosai-dorfman disease"

Sinus histiocytosis with massive lymphadenopathy (SHML) is a benign proliferating histiocytic disorder, predominantly of lymphnodes with extranodal involvement also seen. We present a case of 35 years old female with history of multiple swellings in neck since 1 month duration. On examination patient had painless bilateral cervical lymphadenopathy. No other ENT manifestations noted. Lymphnode biopsy revealed SHML. Abdominal scan and chest X-ray was done which was normal. This case report highlights the clinical, histological aspects of SHML, Rosai-Dorfman disease.

Rosai-Dorfman disease presenting as mediastinal lymphadenopathy: case report and review of the literature

A 6-year-old boy presented with recurrent pneumonia and diarrhoea for 3 years. He had extensive mediastinal lymphadenopathy and atelectasis with low serum levels of IgA, IgG and IgG3. An inguinal lymph node biopsy demonstrated histological and histochemical features of Rosai-Dorfman disease. There was emperipolesis and histiocytes were immune-positive for S100 proteins. He responded to corticosteroids and regular infusions of immunoglobulins.

The effect of multiple micronutrient supplementation on mortality and morbidity of HIV-infected adults: a meta-analysis of randomized controlled trials

Numerous preclinical studies have suggested that micronutrient status is associated with the progression of human immunodeficiency virus (HIV) disease, but results from observational studies are still controversial. The objective was to systematically review the efficacy of multiple micronutrient supplementation on mortality and morbidity in HIV-infected adults. A comprehensive search of the PubMed/MEDLINE, EMBASE and Cochrane Library was performed. Six randomized controlled trials assessing the effect of multiple micronutrient supplementation on HIV-infected adults were included. Relative risk was used as an effect measure to compare the intervention and control groups with fixed-effects or random effects models. Sensitivity analyses were applied to further evaluate heterogeneity. Multiple micronutrient supplementation decreased the mortality and morbidity of HIV-infected adults nonstatistically significantly (RR=0.90; 95% CI, 0.80 to 1.02; p=0.09). Sensitivity analyses revealed that multiple micronutrient supplementation decreased the mortality and morbidity of adults infected with HIV alone statistically significantly (RR=0.75; 95% CI, 0.58 to 0.95; p=0.02), but not adults infected with both HIV and pulmonary tuberculosis (RR=0.97; 95% CI, 0.84 to 1.11; p=0.65). Multiple micronutrient consumption was correlated with reduction of the mortality and morbidity of HIV-infected adults, at least those in developing countries and infected with HIV alone, and should be prescribed by local doctors for those in earlier stages especially.Numerous preclinical studies have suggested that micronutrient status is associated with the progression of human immunodeficiency virus (HIV) disease, but results from observational studies are still controversial. The objective was to systematically review the efficacy of multiple micronutrient supplementation on mortality and morbidity in HIV-infected adults. A comprehensive search of the PubMed/MEDLINE, EMBASE and Cochrane Library was performed. Six randomized controlled trials assessing the effect of multiple micronutrient supplementation on HIV-infected adults were included. Relative risk was used as an effect measure to compare the intervention and control groups with fixed-effects or random effects models. Sensitivity analyses were applied to further evaluate heterogeneity. Multiple micronutrient supplementation decreased the mortality and morbidity of HIV-infected adults nonstatistically significantly (RR=0.90; 95% CI, 0.80 to 1.02; p=0.09). Sensitivity analyses revealed that multiple micronutrient supplementation decreased the mortality and morbidity of adults infected with HIV alone statistically significantly (RR=0.75; 95% CI, 0.58 to 0.95; p=0.02), but not adults infected with both HIV and pulmonary tuberculosis (RR=0.97; 95% CI, 0.84 to 1.11; p=0.65). Multiple micronutrient consumption was correlated with reduction of the mortality and morbidity of HIV-infected adults, at least those in developing countries and infected with HIV alone, and should be prescribed by local doctors for those in earlier stages especially.

Factors associated with recurrence and therapeutic strategies for sinonasal Rosai-Dorfman disease

BACKGROUND

The purpose of this study was to explore the factors associated with the recurrence of Rosai-Dorfman disease (RDD) in the nasal cavity and paranasal sinus.

METHODS

In this study, we conducted a review of the English-language literature published between 1969 and 2010 on the recurrence of and treatment strategies for sinonasal RDD.

RESULTS

To our knowledge, 126 cases of RDD have been reported to date. Of the 126 patients, 32 (25.4%) had no recurrence or were alive with no evidence of disease; remission occurred in only 1 patient (0.7%); 69 patients (54.8%) had a recurrent, persistent, or progressive course; and 6 patients (4.8%) died from the disease. In patients with recurrent, persistent, and progressive disease, there was no significant tendency for lymph node involvement.

CONCLUSION

Sinonasal RDD is generally described as benign. However, recurrence and fatal outcome have been reported. Our results suggest that the initial modality may affect the recurrence of RDD.

Rosai-Dorfman disease with factor XII deficiency

A 17-year-old female patient presented with chronic symmetrical oligoarthritis of both knees and ankles, xerostomia, xerophthalmia, multiple bilateral lymphadenopathies in the cervical region, and bilateral parotid enlargement with the histological finding of chronic sialoadenitis. She had been already given methotrexate, chloroquine, and corticosteroids with the diagnosis of rheumatoid arthritis (RA) before referral to our outpatient clinic. Because her complaints and the lumps did not remit and she could be classified as neither RA nor primary Sjögren's syndrome (SS) according to 1987 ACR RA criteria or European preliminary criteria for SS, lymph node biopsy was repeated and revealed the diagnosis of Rosai-Dorfman disease (RDD) with the histological findings of histiocytes, phagocyting lymphocytes in enlarged sinuses, and mature plasma cells infiltrating the pulpa. All the medications were stopped after the pathological diagnosis of RDD and consulting with the Division of Hematology. She was reevaluated with magnetic resonance imaging, which showed dense infiltrative areas around knee and ankle joints, and computed tomography that showed a soft tissue mass surrounding the descending aorta and upper part of the abdominal aorta. Activated partial thromboplastin time was found to be prolonged in prebiopsy examinations, and factor XII deficiency was detected after detailed hematological evaluation. The symptoms of joint involvement were relieved with nonsteroidal antiinflammatory drugs. She has been followed-up without medication without obvious clinical or laboratory change. We herein report a patient with RDD mimicking RA and SS. We consider that RDD should be kept in mind especially in patients with resistant symptoms to conventional therapies, younger disease onset, and predominant parotid and lymph node enlargement.

Rosai-Dorfman disease: a case with lymphadenopathy and liver involvement

Rosai-Dorfman disease (RDD), originally described as sinus histiocytosis with massive lymphadenopathy, is a rare histiocytic proliferative disorder with a distinctive microscopic appearance. Formerly thought to be a disease process limited to lymph nodes, RDD has now been reported in many organ systems like bone, skin and soft tissue, central nervous system, eye and orbit, and upper respiratory tract. Here we report a case of RDD with hepatic involvement, which is even more rare.

Atypical ocular presentations of Rosai-Dorfman disease

PURPOSE

To report atypical ocular findings of Rosai-Dorfman disease and to determine association with parvovirus 19.

DESIGN

The study is an observational case series of three patients that had atypical ocular presentations of Rosai-Dorfman disease.

METHODS

A multicenter, retrospective case series of 3 patients was evaluated for varied ocular complaints, including enlarging epibulbar masses and uveitis. Histologic specimens were examined retrospectively for parvovirus 19 antigen.

RESULTS

Patients presented with ocular findings prior to or concurrently with systemic findings, with and without associated lymphadenopathy. Two cases presented with epibulbar masses, one with the mass as the only sign of disease while the other exhibited multinodal involvement with bilateral epibulbar masses and anterior granulomatous inflammation. Parvovirus B19 antibody staining was negative in these cases. The final case exhibited bilateral anterior granulomatous inflammation and choroidal infiltrates.

CONCLUSIONS

Ocular findings may be the sole or presenting complaint in Rosai-Dorfman disease prior to recognition of systemic disease and should be considered in the differential diagnosis of epibulbar masses as well as anterior and posterior granulomatous inflammation.

Histologic features of sinus histiocytosis with massive lymphadenopathy in patients with autoimmune lymphoproliferative syndrome

Autoimmune lymphoproliferative syndrome (ALPS) is an inherited disorder associated with defects in Fas-mediated apoptosis, characterized most often by childhood onset of lymphadenopathy, splenomegaly, hypergammaglobulinemia, and autoimmune phenomena. Children with sinus histiocytosis with massive lymphadenopathy (SHML) have a somewhat similar clinical phenotype in which prominent adenopathy also is associated with hypergammaglobulinemia, and autoimmune phenomena are reported in 10-15% of cases. We observed histopathological features of SHML in the lymph nodes of some of our ALPS patients, further suggesting an association between these two disorders. We, thus, reviewed the lymph nodes from 44 patients ALPS type Ia, all of whom were confirmed to have germline mutations in the TNFRSF6 gene encoding Fas (CD95/Apo-1). Eighteen of 44 (41%) patients had a histiocytic proliferation resembling SHML. The affected patients included 15 males and 3 females ranging in age from 11 months to 30 years at the time of the LN biopsy. The lymph nodes contained S-100+ histiocytes with characteristic nuclear features of SHML, and showed evidence of emperipolesis in both hematoxylin and eosin (H and E) and immunostained sections. The extent of the histiocytic proliferation was variable, being confluent in 2 cases, multifocal in 13, and only evident as isolated SHML-type histiocytes in 3. In lymph nodes without confluent SHML changes, increased numbers of CD3+CD4-CD8+ (double negative) alphabeta T-cells, also negative for CD45RO, a feature of ALPS, could be identified in the paracortex. Furthermore, because SHML shares many clinical features with ALPS, we sought evidence of ALPS in sporadic SHML. We attempted to sequence TNFRSF6 DNA from archived tissue of 14 cases of Rosai-Dorfman disease. Full sequencing of the gene was successful in 4 of the cases; no mutations were identified. Nevertheless, our observations suggest that histologic features of SHML are part of the pathologic spectrum of ALPS type Ia. It remains to be determined if some cases of apparently sporadic SHML may be associated with heritable defects in Fas-mediated apoptosis.

Giant intracranial Rosai–Dorfman disease

Rosai-Dorfman disease is a rare, non-neoplastic disease characterized by an unusual proliferation of histiocytic cells. It rarely manifests intracranially, and only 50 cases of intracranial lesions have been reported. We describe an unusual case of a huge, solid mass in the paranasal sinuses, orbits, cavernous sinuses, and suprasellar cisterns. A 29-year-old patient was admitted to our hospital with nasal obstruction and proptosis and visual loss in the right eye. A biopsy was done at another institution and the diagnosis was "pseudotumor of orbit". A right-sided cranio-orbitozygomatic craniotomy combined with a right-sided lateral rhinotomy was used to excise the tumor with right orbital exenteration. The histopathological diagnosis was consistent with Rosai-Dorfman disease. The patient underwent postoperative chemotherapy. Involvement of the central nervous system in Rosai-Dorfman disease is rare, but the disease's ability to mimic other pathologies underlines its importance.

Rosai-Dorfman disease. Report of a case presenting as a midline thyroid mass

To the best of our knowledge, this is the only reported case of isolated involvement by Rosai-Dorfman disease (RDD) of small, anterior cervical-midline lymph nodes, clinically presenting as a thyroid mass. Thyroid parenchymal involvement by RDD has been reported in only 3 cases in the literature. The present case shows involvement of RDD of a pretracheal and thyroid isthmic lymph node in a 38-year-old woman. The progressively enlarging, anterior neck mass was diagnosed as "lymph node" on a fine-needle aspiration biopsy specimen and subsequently interpreted to be an isthmic cyst on ultrasonography. A magnetic resonance imaging scan revealed foci of nodularity in the thyroid isthmus and pretracheal lymph node. Excisional biopsy of the 2 masses revealed typical features of sinus histiocytosis with massive lymphadenopathy in the lymph node. Review of the patient's previous fine-needle aspiration biopsy specimens also revealed the presence of similar features. Currently, the patient is well and has no other manifestation or recurrence of RDD.

Sinus histiocytosis with massive lymphadenopathy: evidence for its relationship to macrophages and for a cytokine-related disorder

AIMS

Sinus histiocytosis with massive lymphadenopathy (SHML) or Rosai-Dorfman disease is a rare histiocytic disorder of unknown origin. Immunophenotypically the histiocytes of SHML express intensively the S100 protein and in addition a panel of macrophage-associated antigens. Their exact relationship to either monocytes/macrophages or immune accessory dendritic cells is, however, still controversial.

METHODS AND RESULTS

In this report recurrent nodal and extranodal manifestations of SHML of a 70-year-old patient were analysed by differential phenotyping using a panel of monoclonal and polyclonal antibodies to macrophage and immune accessory dendritic cell related antigens and by applying nonradioactive in-situ hybridization.

CONCLUSIONS

We conclude that stimulation of monocytes/macrophages via macrophage colony stimulating factor (M-CSF) leading to immune suppressive macrophages represents a main mechanism for the pathogenesis of SHML. The study further provides evidence for the monocyte/macrophage but not dendritic cell differentiation of SHML histiocytes.

Review of sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) of head and neck

The entity known as sinus histiocytosis with massive lymphadenopathy (SHML), or Rosai-Dorfman disease (RD disease), is an uncommon benign proliferation of hematopoietic and fibrous tissue that often presents in the head and neck region. Its initial manifestations most often include a roughly symmetric, painless, bilateral cervical adenopathy, although extranodal disease may develop in a minority of patients. The key histologic feature of SHML is the presence of various numbers of large, pale histiocytic cells that contain within their cellular borders apparently engulfed lymphocytes ("emperipolesis"); these distinctive large, pale cells - RD cells - are S-100 protein-positive by immunostaining and so differ from ordinary histiocytes. Despite its sometimes impressive clinical presentation, SHML is a benign and self-limited disease, whose treatment is aimed largely at controlling its local manifestations (most often by surgical therapy). The microscopic differential diagnosis, particularly in extranodal disease, is at times challenging and can include Langerhans' cell histiocytosis, Hodgkin's disease, non-Hodgkin's lymphoma, metastatic carcinoma, and metastatic malignant melanoma.

Lymphocyte emperipolesis in human glial cells

Astrocytes have been observed to contain intact, viable lymphocytes within their cytoplasm (emperipolesis) in multiple sclerosis plaques and some brain tumors. This study characterizes the adhesive, emperipoletic and phagocytic properties of glial cells in culture. Human fetal and adult astrocytes engaged in adhesion and emperipolesis of lymphocytes. Emperipolesis, and not adhesion, was temperature- and cation-dependent. The CD8 and MHC Class I antigens played a role in emperipolesis. Lymphocytes most often remained viable within the cytoplasm of astrocytes but occasionally underwent lysis or caused disruption of the astrocyte intermediate filaments. The phenomenon of emperipolesis is distinct from phagocytosis, since microglia showed prominent phagocytic properties but did not engage in emperipolesis. Conversely, astrocytes were efficient emperipolites and rarely demonstrated phagocytic properties.

Sinus histiocytosis (Rosai-Dorfman disease) clinically limited to the skin. An immunohistochemical and ultrastructural study

A case study of sinus histiocytosis of Rosai-Dorfman (SH) clinically limited to the skin is presented with immunohistochemical study of the infiltrate, in both paraffin and cryostat sections. Factor XIIIa, a dendrocyte marker, was demonstrated in the cytoplasm of histiocytes. This feature had not been previously reported in this disease. In addition, the cells expressed S100 protein, CD4, CD1a, CD68, and CD11c. This immunophenotyping study suggests that SH could affect the antigen-presenting activity of Factor XIIIa cells, i.e., the skin dermal dendrocyte.

Sinus histiocytosis with massive lymphoadenopathy (Rosai-Dorfman disease). Clinico-pathological analysis of a paediatric case

Histochemical and immunohistochemical studies performed in only a few cases of sinus histiocytosis with massive lymphoadenopathy (SHML) indicated that SHML cells belong to the macrophage--histiocyte system, though their exact origin is still uncertain. We analyzed the morphological, antigenic and enzymatic characteristics of the histiocyte-like cells in one paediatric case of SHML (also named Rosai-Dorfman disease). The SHML cells expressed the S-100 protein, lectins concanavalin A, peanut agglutinin and monocyte-macrophage related antigens CD 11c, CD 14, CD 33, CD 68 and LN 5. Reactivity with other anti-macrophage antibodies (MAC387, lysozyme, alpha-1 anti-chymotrypsin) was variable. The CD1a antigen was present only in scattered cells, whereas HLA-DR and the HLA-DR associated invariant chain were absent. Cytochemistry demonstrated an intense activity of acid phosphatase and non specific esterase of SHML cells. A large amount of medium sized mononuclear cells were located in the sinuses and intersinusoidal tissue. Our findings suggest that SHML cells have intermediate features between phagocytes and Langerhans cells/interdigitating reticulum cells. The heterogeneity of marker expression on SHML cells might be related to the local content of factors (e.g., cytokines), capable of modulating the phenotype of monocyted and derived cells.