Focal eosinophilic granuloma of the temporal lobe. Case report

Solitary Langerhans cell histiocytosis of frontal lobe: a case report and literature review

The brain parenchymal Langerhans cell histiocytosis (LCH) without systemic disease or lytic skull lesions is extremely rare. We report a 23-year-old male presenting with new onset 1 hour seizure with loss of consciousness 20 days prior to admission, and recurrent seizure 2 weeks later. Brain magnetic resonance imaging (MRI) showed an irregularly mass with enhancement involving the right frontal lobe. Microscopically, the lesion was characterized by sheets of Langerhans cells in addition to reactive inflammatory elements. Immunohistochemically, Langerhans cells were positive for Langerin, CD1a and S-100 protein. The patient received no chemotherapy or radiotherapy after surgery. After 24 months of follow-up, no recurrence or other systemic lesions were observed. Although there is no standard treatment for solitary cerebral LCH, the prognosis generally appears to be good.

Multifocal intraparenchymal Langerhans' cell histiocytosis concomitant with an arachnoid cyst in a child: case report and review of the literature

Langerhans' cell histiocytosis is a disease usually found in children and characterized by idiopathic proliferation of histiocytes in the reticuloendothelial system. Intracranial Langerhans' cell histiocytosis presenting as multifocal intraparenchymal lesions is very rare. In this article, the authors report on a 4-year-old boy diagnosed with multifocal intraparenchymal Langerhans' cell histiocytosis concomitant with an arachnoid cyst. After a series of laboratory examinations, the right frontal mass was surgically excised. Histological examinations confirmed the diagnosis of intracranial Langerhans' cell histiocytosis. The patient's intracranial hypertension symptoms were alleviated, and the remaining foci were treated by Langerhans' cell histiocytosis-directed standard chemotherapy. At the 8-month follow-up visit, no recurrence of the excised lesion was found, and no change in the size of other lesions was seen. Supratentorial intracerebral lesions with mass effect and enhancement have rarely been described; in this report, the histological features of and therapeutic options for such a case are discussed.

Cerebral solitary Langerhans cell histiocytosis: report of two cases and review of the literature

Cerebral solitary Langerhans cell histiocytosis (LCH) is a very uncommon condition. We describe two new cases: a 30-year-old man with seizures and a tumour in the left frontal lobe, which was composed of a polymorphic infiltrate with a predominance of histiocytes and eosinophils; and a 65-year-old man with headaches and dysarthria, with a left parietal tumour, which showed a diffuse proliferation of histiocytic cells and areas of necrosis. In both cases, the histiocytes were strongly positive for S-100 and CD1a, and Birbeck's granules were demonstrated by electron microscopy in the first case. Both patients underwent a complete excision of their lesions. The second patient received additional postoperative radiotherapy. They were asymptomatic after 26 and 27 months, respectively. It seems that cerebral solitary LCH is a clinicopathological entity with a good outcome. Only 15 cases of this rare process have been previously reported in the English literature.

Craniospinal Langerhans cell histiocytosis in children: 30 years' experience at a single institution

OBJECTIVES

The goal of this study was to review a large series of patients with Langerhans cell histiocytosis (LCH) who had craniospinal lesions to assess the long-term course, outcome, and efficacy of treatment of the disease.

METHODS

Forty-four patients with LCH who presented to a single pediatric neurosurgical department between 1976 and 2006 were retrospectively reviewed.

RESULTS

This series included 29 boys and 15 girls, ranging in age from 2 months to 13 years, with a mean follow-up duration of 4.5 years. Twenty-seven patients (61%) had unifocal bone lesions, 12 (27%) had multifocal bone disease, 2 (5%) had solitary hypothalamic-pituitary axis lesions, and 3 (7%) had multiple organ involvement at presentation. Five (19%) of the 27 patients with unifocal bone disease and 4 (33%) of the 12 patients with multifocal bone disease had delayed development of new bone lesions during the follow-up period. The time to development of new bone lesions ranged from 1 month to 1 year. Two of the 3 patients with multiple-organ LCH died. Patient age < or = 2 years at the time of initial presentation was a risk factor for both initial multifocality and eventual dissemination. In all patients with initial multifocal bone involvement or later dissemination of unifocal bone disease, LCH was controlled by chemotherapy, except for 2 who were treated by surgery alone. Three patients had histological evidence of spontaneous resolution of their lesions.

CONCLUSIONS

Patients with unifocal LCH can be effectively treated with surgery alone. Very young patients are more likely to have multifocal disease and disseminations, and will usually require chemotherapy to control their disease. Spontaneously regressing lesions need not be resected; however, a biopsy procedure can be performed for diagnostic purposes.

Spontaneous regression of Langerhans cell histiocytosis: a case report

BACKGROUND

Spontaneous regression of Langerhans cell histiocytosis (LCH) has been reported in skin, bone, and pulmonary lesions. However, such phenomena in the central nervous system (CNS) have not been described previously.

CASE DESCRIPTION

A case of LCH in the CNS with spontaneous regression is reported. A 2-year-old boy presented with general convulsion followed by frequent vomiting and diabetes insipidus. Magnetic resonance imaging (MRI) scan revealed numerous multifocal nodules predominantly in the left frontal lobe. The patient underwent surgery to remove part of the frontal lesion. Subsequent to surgery, residual lesions showed regression without any additional treatment, and clinical symptoms also subsided. The multiple lesions disappeared completely and did not relapse during 5-year observation.

CONCLUSION

Surgical resection and/or adjuvant therapy such as radiation and chemotherapy has been performed for the treatment of LCH in the CNS. However, there may be a subgroup of patients with multifocal brain LCH that regress spontaneously. Further clinical study is required to establish the natural course and prognostic factors of this disease.

Isolated primary Langerhans' cell histiocytosis of central nervous system

Solitary eosinophilic granuloma that involves the CNS is an uncommon lesion and most frequently affects the hypothalamus. We report a new and rare case of solitary eosinophilic granuloma of the left temporal lobe in a patient without systemic disease. The diagnosis was confirmed by electron microscopy and immuohistochemical techniques. The treatment of choice is surgical resection. There is a better prognosis in comparison with cases accompanied by systemic disease.

Solitary eosinophilic granuloma of the temporal lobe: case report and review of the literature

A solitary eosinophilic granuloma of the central nervous system is an unusual manifestation of histiocytosis X. A unique case of a solitary eosinophilic granuloma of the right temporal lobe without osseous involvement is described. A 20-year-old man presented with a grand mal seizure. Magnetic resonance imaging demonstrated an intraaxial enhancing mass in the right temporal lobe with marked vasogenic edema. A right temporal craniotomy was performed for resection of the lesion and the diagnosis of an eosinophilic granuloma was confirmed by histopathology. Follow-up MR imaging obtained 5 years following resection demonstrated no recurrence. Solitary eosinophilic granuloma should be considered in the differential diagnosis of enhancing mass lesions affecting the central nervous system. Although the natural history of solitary eosinophilic granulomas remains poorly defined, surgical treatment still remains the mainstay of therapy for these unifocal cerebral lesions.

Central nervous system disease in Langerhans cell histiocytosis

Central nervous system (CNS) disease in Langerhans cell histiocytosis (LCH) is a poorly understood complication of yet unknown frequency. By far the most common manifestation is in the hypothalamic-pituitary system with diabetes insipidus as the leading sign, followed by other endocrinopathies and hypothalamic dysfunction. However, essentially all other parts of the CNS may be involved. On the one hand, space-occupying histiocytic infiltrates may lead to size- and site-depending symptoms, extending from adjacent bone lesions or arising from the meninges or choroid plexus. On the other hand, a progressive neurological deterioration can occur with mainly cerebellar-pontine symptoms. In this article, these clinical patterns are described in correlation with the morphology on MR imaging and histopathology. Further, the therapeutic strategies are reviewed critically, and guidelines for the management of patients with LCH-related CNS disease are presented.

Nosology and pathology of Langerhans cell histiocytosis

The pathology of LCH is continuing to be defined and diagnostic features clarified as unprecedented research is done. Although the etiology of LCH remains unknown, new information on cytokines, viruses, immunologic dysfunction, cell surface antigen expression, and clonality in the disease are providing essential pieces of the puzzle.

Langerhans cell histiocytosis with orbital involvement

PURPOSE

To review three cases of Langerhans cell histiocytosis with orbital involvement that represent a significantly excessive incidence of this rare disease in one community. Current diagnostic criteria and therapeutic modalities related to Langerhans cell histiocytosis are reviewed.

METHODS

Case reports. We present clinical, radiologic, histopathologic, and epidemiologic information on three patients with Langerhans cell histiocytosis.

RESULTS

All three children, born within 18 months of one another, manifested rapidly progressive unilateral proptosis at age 2 years. By computed tomography, all had moderately enhancing lesions with involvement of the sphenoid bone and lateral orbit as well as the temporal lobe of the brain. All patients were treated with a combination of vincristine and prednisone, with variable resolution of their lesions. The occurrence of three cases in children born in Nogales, Arizona/ Mexico, suggests an incidence rate of 40 per million, which is approximately 26 times the expected rate (P = .0001).

CONCLUSIONS

The extraordinarily high incidence and the concentration of cases in both time and space of this cluster implies that Langerhans cell histiocytosis may be a sentinel disease for unusual environmental exposures.

Microsurgical excision of a primary isolated hypothalamic eosinophilic granuloma. Case report

Solitary focal eosinophilic granuloma (EG) is one element in the spectrum of diseases associated with Langerhans' cell histiocytosis (LCH). This report documents the occurrence of a primary isolated hypothalamic EG in a man who presented with diabetes insipidus and panhypopituitarism. His treatment consisted of complete microsurgical excision of the lesion. After a 13-month follow-up period, no residual tumor was evident on magnetic resonance imaging and no other lesions were present in peripheral tissues. This case is unique in several respects: 1) it is the third documented case of a primary isolated hypothalamic LCH granuloma diagnosed in a living patient; 2) it is the only known example of complete microsurgical excision of such a lesion in the hypothalamic region; and 3) it demonstrates the efficacy of direct surgery in this scenario, as compared with other treatment modalities such as biopsy and irradiation, suggesting that complete surgical excision may represent the treatment of choice for isolated intracerebral LCH granulomas, being curative in most instances. Also, the literature is reviewed for information about the diagnosis and treatment of this particular type of unifocal brain lesion.

Solitary Langerhans cell histiocytosis lesion of the parieto-occipital lobe: a case report and review of the literature

A 38 year-old woman with a solitary intracerebral Langerhans cell histocytosis (LCH) lesion is presented, in whom, cerebral magnetic resonance imaging (MRI) revealed a non-enhancing mass in the right parieto-occipital lobe. The surgical specimen consisted of a nodular polymorphic infiltrate of mononuclear histiocytic cells, macrophages, eosinophilic granulocytes, lymphocytes and Langerhans giant cells involving leptomeninges, cerebral cortex and white matter. The histiocytes displayed features of Langerhans cells such as CD1a and S-100 immunopositivity, and of reticulum cells such as Ki-M4P and X-12 immunopositivity. This case as well as ten other cases from the literature are reviewed.

Primary Langerhans' cell histiocytosis of the central nervous system with fatal outcome. Case report

An unusual case of primary parenchymal Langerhans' cell histiocytosis of the central nervous system is reported. The definitive diagnosis was obtained by ultrastructural detection of Birbeck granules and by immunohistochemical evidence of CD1a expression. Despite complete surgical resection, there was an early recurrence with multiple central nervous system metastases leading to a fatal outcome.

Langerhans cell (eosinophilic) granulomatosis. A clinicopathologic study encompassing 50 years

We summarize our experience with 238 cases of Langerhans cell granulomatosis (LCG), 198 of whom were followed for a median period of 10.5 years. Our patients did well unless overtreated, and no deaths were attributed to the disorder itself. The disease may appear in unifocal or multifocal form, and treatment is based on this fact. Virtually all patients recovered completely except for occasional residual orthopedic problems or residual diabetes insipidus. Several of the patients underwent subsequent pregnancies without difficulty. The granulomas primarily occur in bone, but lung, skin, and lymph nodal involvement is not uncommon. Involvement of thyroid, thymus, and other sites is rare. The hallmark of the disease is the accumulation of Langerhans cells (LCs). We review the pathology of LCG by histology, electron microscopy, and immunolabeling. LCs originally were identified in squamous epithelium, but these cells are part of the widespread system of dendritic cells. The latter cells, which arise from CD34+ progenitors, are specialized and efficient antigen-presenting cells for T-cell-mediated immunity. In LCG, however, the major associated cells are not T cells, but mature eosinophils: hence the original name eosinophilic granuloma. Confusion about terminology has been based upon the scanty and rather crude pathology reports in the original literature. The term histiocytosis X was meant to cover a spectrum of three diseases--eosinophilic granuloma, Hand-Schüller-Christian disease (HSC), and Letterer-Siwe disease (LS)--but HSC and LS have no basis in pathology and hence the terms are meaningless. The term HSC has become a synonym for multifocal eosinophilic granuloma (LCG). The term LS has been used in reporting a number of benign, malignant, or unknown conditions. We prefer the term LCG to avoid confusion with the term histiocytosis X because there is evidence that the LC is not a member of the mononuclear phagocyte system and hence not a tissue macrophage, and because the use of the term "histiocyte" has become a convenience in much of the literature when reporting incompletely understood diseases.

Primary eosinophilic granuloma of the oculomotor nerve. Case report

The authors report the occurrence of primary eosinophilic granuloma of the oculomotor nerve without osseous involvement in a 68-year-old man. Histopathological and neuroradiological findings are discussed. This case demonstrates that eosinophilic granuloma should be included in the differential diagnosis of tumor in which cranial nerves are involved.

A clinico-pathological study of adult histiocytosis X involving the brain

Adult histiocytosis X involving the CNS caused progressive spastic paraparesis. The diagnosis was made by immunoreactive anti-S100 protein antibody staining and from the presence of Birbeck granules in biopsy specimens of skin lesions. Neuropathological examination showed massive proliferation and infiltration of S-100 containing histiocyte-like cells and reactive astrocytes throughout the CNS.

Cerebral and brain stem Langerhans cell histiocytosis

Two patients with central nervous system manifestations of Langerhans cell histiocytosis, both with brain stem involvement, are reported. The onset of symptoms was at an age when the diagnosis might not have been considered.

Langerhans' cell histiocytosis and the nervous system

We report two cases of Langerhans' cell histiocytosis with unusual central nervous system (CNS) involvement. The first patient had behavioural disturbances, memory loss and diabetes insipidus. His response to a range of treatments was poor. The second patient presented with seizures and headaches suggestive of raised intracranial pressure. Etoposide (VP16) chemotherapy led to a dramatic clinical and radiological improvement. The various CNS manifestations of Langerhans' cell histiocytosis and their management are discussed.

Solitary Eosinophilic Granuloma in the Frontal Lobe

A rare case of a solitary eosinophilic granuloma in the brain is reported. The mass, located in the right frontal lobe, mimicked a glioma not only grossly, but also by neuroimaging. The lesion was confirmed to be an eosinophilic granuloma by electron microscopy and immunohistochemical staining for S-100 protein and HLA-DR.

Primary histiocytosis X of the parieto-occipital lobe

Immunohistochemical and ultrastructural evidence support the concept that histiocytosis X is the result of proliferation of pathological Langerhans' cells. Central nervous system involvement by histiocytosis X has been commonly described in multisystem disease and in association with lytic skull lesions. Unifocal brain involvement by histiocytosis X without concomitant osseous involvement is rare, with only 14 cases reported in the literature to date. Ten of these cases have involved the hypothalamus; the remaining four have involved the frontal lobe (two cases) and the temporal lobe (two cases). The fifth case of extrahypothalamic unifocal histiocytosis X, the first female case, and the first case with parieto-occipital lobe involvement, is reported. Pathology demonstrated infiltration of brain parenchyma by clusters of characteristic histiocytosis X cells with an admixture of morphologically related giant cells, eosinophils, and lymphocytes. Langerhans' granules were identified in the histiocytosis X cells by electron microscopy. Immunohistochemistry showed strong S-100 protein, HLA-DR, and T6 antigen positivity by the histiocytosis X cells. Therapy included complete surgical excision and postoperative radiation therapy for the incompletely excised lesion. Patients with unifocal extrahypothalamic histiocytosis X may have a better prognosis than patients with localized hypothalamic disease.

Computed tomography demonstration of multiple parenchymal central nervous system nodules due to histiocytosis X

The computed tomography demonstration of multiple parenchymal brain lesions due to histiocytosis X is described. A comparison of follow-up computed tomography and magnetic resonance imaging studies is made.

Intracranial histiocytosis X: a case report

A case of intracranial histiocytosis X that presented radiologically with thickening of the pituitary stalk is presented. The radiologic findings, including a blush seen on angiography, are described.

Primary eosinophilic granuloma of frontal lobe. Diagnostic use of S-100 protein

Solitary eosinophilic granuloma of the frontal lobe of the brain is a rare lesion. A 30-year-old Jordanian man with a history of recurrent bilateral chronic middle ear infections and tuberculosis presented with focal seizures. A solitary right frontotemporal mass was diagnosed by brain biopsy as an eosinophilic granuloma. Immunoperoxidase stains of virtually all histiocytes in the lesion were strongly positive for S-100. Four cases of eosinophilic granuloma and one of Letterer-Siwe disease were also examined, and virtually all histiocytes demonstrated strong S-100 positivity. In comparison, 24 reactive or infectious granulomas were examined for S-100 staining and most showed complete negativity of histiocytes in granulomas for S-100. This is the first report in the literature that has examined the results of S-100 staining in a large number of reactive or infectious granulomas and compared it with S-100 staining in eosinophilic granuloma. This report illustrates that S-100 can be useful in distinguishing eosinophilic granuloma, generally considered to be part of the larger group of histiocytic disorders known as histiocytosis X, from reactive or infectious granulomatous conditions of similar or confusing histology.

Unifocal eosinophilic granuloma of the temporal lobe

The clinical features, treatment, and two-year postoperative course of a 14-year-old boy with unifocal eosinophilic granuloma of the temporal lobe are presented. A literature review of unifocal eosinophilic granuloma of the brain revealed 11 additional cases, 9 of which involved the hypothalamus and 1 each the frontal and temporal lobes. Four of the 9 patients with involvement of the hypothalamus developed multifocal disease, whereas none of the 3 who had frontal or temporal lobe involvement developed multifocal lesions. Effective therapy for eosinophilic granuloma in a single resectable site in the brain appears to be total excision. Low-dose radiation has been used to eradicate locally recurrent disease.

Primary eosinophilic granuloma of the larynx

A rare case of primary eosinophilic granuloma of the larynx in a 49-year-old man is reported. The patient remains asymptomatic after a follow-up of three years. This is the third case reported in the world literature.

Primary eosinophilic granuloma of the frontal lobe

The clinical symptoms, pathological findings and surgical treatment of a case of primary frontal lobe eosinophilic granuloma are presented. Initially a frontal mass was detected that clinically seemed like a low-growth tumor. After operation, the histological, cytochemical and ultrastructural studies showed positive acid phosphatase, alpha-naftil-esterase, oil-red and PAS reactions of tumoral cells and the presence of rod-shaped bodies in proliferative histiocytes, all which confirmed the pathological diagnosis of eosinophilic granuloma. Other osseous or visceral histiocytosis-X signs were not observed. The patient remains asymptomatic after a postoperative follow-up of 2 years.

Focal histiocytosis X of the parietal lobe. Case report

The authors describe a case of histiocytosis X of the parietal lobe presenting as a space-occupying lesion on a computerized tomography scan of the brain. The clinical, radiographic, and therapeutic aspects of the case are discussed. A brief review of the literature is presented.