Langerhans cell histiocytosis with extensive spinal and thyroid gland involvement presenting with quadriparesis: an unusual case in an adult patient

Intradural extramedullary eosinophilic granuloma of the spine with emergency presentation: A case report

Background

Intradural extramedullary spinal eosinophilic granuloma is a very unusual manifestation of Langerhans Cell Histiocytosis (LCH) that is typically misdiagnosed due to its nonspecific clinical and radiological features.

Case Description

We report a case of a 22-year-old female patient who presented with acute onset paraplegia. The magnetic resonance imaging was initially suggestive of tuberculoma, which is prevalent in tuberculosis-endemic regions. Intraoperative findings and histopathology, however, established the diagnosis of LCH. The lesion was intradural, and CD1a and S-100 protein staining demonstrated classic Langerhans cells.

Conclusion

The paper stresses the need for a multidisciplinary team in the proper diagnosis and handling of spinal LCH. Further research is needed to develop optimal management protocols for this rare condition.

Spontaneous Thyroid Hemorrhage Caused by Langerhans Cell Histiocytosis: A Case Report and Literature Review

PURPOSE

Langerhans cell histiocytosis (LCH) is a rare clonal disorder of Langerhans antigen-presenting cells. However, thyroid LCH involvement is relatively rare. We present the first case of spontaneous thyroid hemorrhage due to LCH progression and discuss the clinical features, diagnosis, and treatments of thyroid LCH in a literature review.

METHODS

Clinical data were collected. Previously published articles on thyroid LCH involvement were reviewed to assess the clinical features, diagnosis, and treatments for thyroid LCH.

RESULTS

A 54-year-old female presented with a multi-system LCH, affecting the uterus, liver, pituitary gland, and thyroid gland. Clinical stability was achieved after systemic chemotherapy. After 7 years of regular follow up, the patient complained of a sudden painful neck swelling and progressive dyspnea. Computed Tomography revealed bilateral goiter with hematoma, and the patient was diagnosed with spontaneous thyroid bleeding based on her clinical symptoms and radiological findings. The patient was incubated to relieve airway compromise and partial thyroidectomy was performed for definitive treatment. Pathological evaluation further confirmed the diagnosis of thyroid LCH. The patient recovered well after surgery.

CONCLUSION

Spontaneous thyroid bleeding due to thyroid LCH progression is extremely rare. Treatments for LCH vary depending on the severity of the disease. We suggest that, for patients with multi-system LCH with thyroid lesion, long-term active surveillance of thyroid hormone concentrations, and thyroid gland volume is required. Physicians should be alert of the potentially life-threatening spontaneous thyroid hemorrhage when aggravated diffuse goiter and hypothyroidism appear. Further investigation is required to establish the guidelines for thyroid LCH treatment.

Langerhans Cell Histiocytosis in the Adult Lumbar Spine - A Case Report and Literature Review

Introduction:

Langerhans cell histiocytosis (LCH) in spine is a benign disorder that mainly affects children and is rare in adults. The treatment of LCH in adults is still controversial. The literature is drought with reports regarding management of LCH in adults with pathological fracture. We report a case of LCH at L5 vertebra in an adult patient treated with posterior stabilization, decompression, and anterior corpectomy and reconstruction.

Case Presentation:

A 30-year-old manual laborer working in Middle East, presented to us with severe pain in the lower back (VAS-8) with the right lower limb radiculopathy for 6 months. Radiological investigations revealed to have a solitary osteolytic lesion with pathological fracture at L5 vertebral body. MRI showed hyperintense lesion in T2 sagittal images and hypointense in T1 sagittal images in L5 vertebral body. PET scan showed metabolically active lesion involving L5 vertebra body and right ischium. CT-guided biopsy from L5 vertebral body was performed, but was inconclusive. The patient underwent surgical management in the form of posterior stabilization L4-S1 and transpedicular biopsy. The sample was sent for frozen section and confirmed the presence of neoplasia but did not provide sufficient information about the nature of pathology. Intraoperatively, the decision was made to do anterior excision biopsy, corpectomy, and reconstruction with titanium mesh cage filled with cement. The precise diagnosis of LCH was established on histopathological examination and confirmed with immunohistochemistry positivity for CD1a and S100. The patient had immediate relief of his back pain and radicular pain. He was able to resume his daily activities at 1 month after the surgery. At 2-year follow-up patient was asymptomatic and no local recurrence was noticed.

Conclusion:

Surgical excisionfor LCH in adults should be considered in patients with refractory low back pain with pathological fracture, neurological deficits, or spinal instability.

Treatment of unstable distal-third clavicule fractures using minimal invasive closed-loop double endobutton technique

Background

Clavicle fractures are common clinical problems, accounting for approximately 10% of all fractures. Neer’s type II fractures disrupt the integrity of the coracoclavicular ligament and, therefore, are inherently unstable, requiring an extended period time to achieve bone union and being associated with a high rate of non- or malunion. Restoration of the stability of the distal clavicle is an important factor to decrease the rate of non- or malunion. As such, the aim of our study was to describe our technique of indirect osteosynthesis, using a minimally invasive closed-loop double endobutton (TightRope) technique for fixation of unstable (Neer’s type II) distal clavicle factures, and to evaluate the short-term clinical outcomes.

Methods

Fifteen patients with a Neer’s type II fracture of the distal clavicle were treated surgically using the TightRope fixation, between January 2016 and December 2017. Clinical and radiological results were assessed using the American Shoulder and Elbow Surgeons Shoulder Score (ASES) and the Constant score.

Results

Definitive fracture healing was achieved in most of the patients. No major complication was identified over a mean follow-up of 9 months, and none of the patients required additional surgery related to the index procedure. At the last follow-up, all patients had recovered functional range of motion of the shoulder, with high Constant and ASES scores, and low pain score.

Conclusion

The use of TightRope fixation provided sufficient stability to reduce the medially displaced fragment of the Neer’s type II fracture, with satisfactory radiological and clinical outcomes achieved over a mean follow-up of 9 months. Future studies on the long-term outcomes are needed.