Treatment of congenital Langerhans cell histiocytosis with cobimetinib

We report a case of congenital multisystem Langerhans cell histiocytosis with cutaneous and hematopoietic involvement. After the failure of first-line (vinblastine and prednisolone) and second-line (vincristine and cytarabine) therapies, treatment with cobimetinib, a mitogen-activated protein kinase (MEK) inhibitor, led to the remission of disease and a sustained response after 11 months of ongoing treatment. Protein kinase inhibitors targeting BRAF or MEK could represent a promising future therapeutic option, also in children with LCH.

A neonatal pustule:Langerhans cell histiocytosis

Langerhans cell histiocytosis (LCH) is a rare, clinically heterogeneous disease that most commonly occurs in pediatric populations. Congenital self-limited LCH is a benign variant of LCH. It most commonly presents as a diffuse eruption and reports of single lesion cases are infrequent in the literature. Even in the case of congenital self-limited LCH, there is potential for future multisystem relapse, making long-term follow-up important. We present a case of single lesion self-limited LCH in a full-term male infant with interesting morphology. Physical examination revealed a painless, 6 millimeter, well-demarcated, papule encircled by erythema with central hemorrhage. An infectious workup was negative and a punch biopsy was obtained, which showed a dermal infiltrate of histiocytes consistent with a diagnosis of LCH. The lesion healed without intervention within three weeks. Our case highlights the need for dermatologists to consider LCH in the differential diagnosis for lesions of varying morphology in children, as proper identification is necessary to monitor for multisystem recurrence.

Congenital cutaneous Langerhans cell histiocytosis and cutaneous mastocytoma in a child

Langerhans cell histiocytosis and mastocytoma are clonal disorders of bone-marrow-derived cells, most commonly seen in the pediatric age. Infiltration of mast cells and Langerhans cells in the same lesion has been published before, but, to our knowledge, this is the first time that the occurrence of two mastocytomas and Langerhans cell histiocytosis is reported. It could be hypothesized that both clonal disorders of bone-marrow-derived cells could have a common origin.

Congenital self-healing reticulohistiocytosis presented with multiple hypopigmented flat-topped papules: a case report and review of literatures

Congenital self-healing reticulohistiocytosis, also known as Hashimoto-Pritzker disease, is a single system Langerhans cell histiocytosis that typically presents in healthy newborns and spontaneously regresses. In the present report, we described a 2-month-old Thai female newborn with multiple hypopigmented flat-topped papules without any internal organ involvement including normal blood cell count, urinary examination, liver and renal functions, bone scan, chest X-ray, abdominal ultrasound, and bone marrow biopsy. The histopathology revealed typical findings of Langerhans cell histiocytosis, which was confirmed by the immunohistochemical staining CDla and S100. Our patient's lesions had spontaneously regressed within afew months, and no new lesion recurred afterfour months follow-up.

Solitary congenital self-healing Langerhans cell histiocytosis: a benign variant of Langerhans cell histiocytosis?

Langerhans cell histiocytosis (LCH) represents a diverse group of diseases with various different clinical presentations and outcomes. We present two cases of solitary CSH-LCH (sCSH-LCH) and highlight certain unique characteristics including the favorable prognosis and lack of documented progression to systemic involvement in reported cases.

Congenital self-healing reticulohistiocytosis: concern for a poor prognosis

Congenital self-healing reticulohistiocytosis (CSHRH) is a rare type of Langerhans cell histiocytosis with potential for relapse and systemic involvement. Whereas CSHRH was traditionally considered a benign disease, there is an approximately 3 percent risk of mortality and a 10 percent chance of relapse. This article, using an extensive review of cases since Hashimoto and Pritzker first described the condition in 1973, highlights the various presentations of CSHRH and reveals high rates of relapse and systemic involvement in cases that specifically address features of CSHRH occurring within the first year of life. The findings from this review will highlight the importance of considering LCH in the differential diagnosis when evaluating a neonate with congenital skin eruptions. Timely diagnosis of CSHRH and treatment of systemic involvement may decrease the likelihood of adverse outcomes. These patients may require closer follow-up and monitoring than previously recommended, especially in the first year of life when relapses and systemic involvement occur most frequently.

Congenital self-healing reticulohistiocytosis - an important diagnostic challenge

AIM

To present current and new knowledge on congenital self-healing reticulohistiocytosis, a benign variant of cutaneous Langerhans cell histiocytosis presenting with skin lesions in the neonatal period.

METHODS

We describe and photo document two cases of this rare disease and review the literature.

RESULTS

Only few newborns have acute access to a neonatal dermatologist, and we demonstrate how the spontaneous cutaneous involution may happen even prior to the first dermatological assessment. As no sole criterion can reliably distinguish the self-healing form from disseminated disease, multidisciplinary assessment and follow-up are essential.

CONCLUSION

Our data document how easily the diagnosis congenital self-healing reticulocytosis may be missed and emphasize the importance and value of instant clinical photographing at the neonatal unit and the use of teledermatology whenever congenital self-healing reticulohistiocytosis is suspected.

[A neonate with a skin rash post partum]

A term-born boy presented with a rash immediately post partum, consisting of erosions, crusts and a few vesicles. Skin biopsy showed dermal infiltration of S100 and CD1a immunopositive histiocytes. The diagnosis was 'congenital Langerhans cell histiocytosis of the skin'.

A congenital, erythematous eruption

A 2-day-old male patient born full-term via uncomplicated vaginal delivery was seen for multiple erythematous, scaly papules that were present at birth. Physical examination showed a well-appearing male with erythematous papules with scale on his scalp, face, trunk, and bilateral upper and lower extremities. A 4 mm punch biopsy was performed on one of the representative papules on his abdomen and subsequent histopathological tests showed multiple Langerhans cells in the papillary dermis with positive CD1a and Langerin stains. There was no extracutaneous involvement. A diagnosis of congenital self-healing Langerhans cell histiocytosis was made.

Congenital solid thigh mass: a report of nonself healing form of langerhans cell histiocytosis

Langerhans cell histiocytosis (LCH) is very rarely seen in the pediatric age group. Self-healing is the usual clinical course in congenital LCH with cutaneous involvement. We describe a newborn with a solid mass in his thigh noticed at birth, without skin manifestations. LCH should be considered in the differential diagnosis of congenital solid masses.

Self-healing Langerhans cell histiocytosis (Hashimoto-Pritzker disease): two Tunisian cases

Self-healing Langerhans cell histiocytosis (SHLCH) is a rare self-limited variant of Langerhans cell histiocytosis that presents at birth or during the neonatal period. It was first described by Hashimoto and Pritzker in 1973. Subsequently, more than 70 cases have been reported in the literature. Regarding age of onset, SHLCH should be divided into congenital SHLCH and rare late-onset type. We report here two additional cases of SHLCH in Tunisian infants. We emphasize the need for long-term follow-up in such patients.

Intraocular Langerhans cell histiocytosis in a neonate resulting in bilateral loss of vision

Intraocular involvement in Langerhans cell histiocytosis (LCH) is rare. We describe the case of a neonate with congenital disseminated LCH involving skin, liver, spleen, and intraocular structures including uvea and retina. Early and aggressive treatment according to the LCH-II treatment protocol was administered and resulted in remission of the disease. However, despite close follow-up and additional local treatment, involvement of intraocular structures resulted in severe long-term ophthalmological sequelae including complete bilateral loss of vision.

Disseminated crusted papules in a newborn

BACKGROUND

Congenital self-healing Langerhans cell histiocytosis (Hashimoto-Pritzker disease) is the rarest form of Langerhans cell histiocytosis, usually confined to the skin and/or mucous membranes. Cutaneous eruption is mostly generalized, papular, nodular or vesicular. Despite impressive clinical presentation in a newborn it infrequently spreads to internal organs (which then portends a grave prognosis, indistinguishable from Letterer-Siwe disease).

CASE REPORT

We presented a full-term newborn, female, 3.3 kg who had a multitude of erythematous and crusted papules, nodules and pseudovesicles distributed all over the body, except for the mucous membranes. A biopsy and haematoxylin--eosin stain revealed dermal infiltration of pleomorphic histiocytes with eosinophilic ground-glass cytoplasm and round to bean-shaped nuclei. Over the next six weeks the eruption gradually subsided leaving no residues, or a few atrophic scars.

CONCLUSION

There is no need for specific treatment of congenital self-healing Langerhans cell-histiocytosis in the absence of multiorgan involvement. However, a close and regular follow-up is necessary to evaluate the children for systemic symptoms and signs.

Solitary congenital self-healing reticulohistiocytosis in monozygotic twins

We report monozygotic twins with congenital self-healing reticulohistiocytosis, whose lesions initially presented as hemorrhagic bullae at birth with rapid progression into crusted papules the following day. Physical examination disclosed crusted papules on the right side of the neck of twin 1 and a similar solitary lesion on the lateral side of the right thumb of twin 2. Excisional biopsy specimen findings of the neck and thumb lesions were consistent with Langerhans cell histiocytosis, which was further confirmed by positive CD1a staining. The lesions resolved completely by 2 months with no evidence of recurrence or systemic involvement. Congenital self-healing reticulohistiocytosis is a rare, self-limited form of Langerhans cell histiocytosis. Although familial clustering in Langerhans cell histiocytosis was previously reported, to the best of our knowledge there is no report suggesting familial clustering in congenital self-healing reticulohistiocytosis. Our patients are interesting in terms of raising the question of whether the presence of congenital self-healing reticulohistiocytosis in monozygotic twins is implicative of a genetic role in its pathogenesis.

Congenital systemic Langerhans cell histiocytosis presenting as hydrops fetalis

Congenital Langerhans cell histiocytosis (LCH) encompasses a wide spectrum of disease involvement and severity. Congenital "self-healing" cutaneous LCH represents one end of the spectrum, whereas the case we encountered represents the other extreme. A rare case of congenital LCH with severe multiorgan involvement presenting as hydrops fetalis is described in this report. Hydrops fetalis has not previously been associated with congenital LCH. The overall clinical features of this infant closely mimicked those of disseminated congenital infection, and he ran a fulminant and rapidly fatal course.

CONCLUSION

A high index of suspicion is required to diagnose congenital LCH in the early neonatal period. Hydrops fetalis is an ominous sign and probably reflects severe systemic disease compromising the well-being of the fetus.

Congenital Langerhans cell histiocytosis: the self-healing variety

Congenital self-healing Langerhans cell histiocytosis (CSHLCH) is a rare variant of Langerhans cell histiocytosis, presenting at birth or in the neonatal period with cutaneous lesions that involute spontaneously. Affected infants are otherwise well with no systemic illness. A case of CSHLCH, probably the first case report from India, is described. The patient presented on the third day of life with multiple papulonodular lesions over the body, with no systemic involvement. The lesions spontaneously regressed by 6 months of age, with no evidence of relapse at 1 year of age. Although CSHLCH is a benign and self-limited condition, long-term follow-up for evidence of relapse is emphasized.

Congenital self-healing langerhans cell histiocytosis with atrophic recovery of the skin: clinical correlation of an immunologic phenomenon

The pathophysiology and pathogenesis of congenital self-healing Langerhans cell histiocytosis (CSHLCH) as well as that of the other types of Langerhans cell histiocytosis is not well understood. Some authors postulate deregulated immunologic mechanisms that result in overproduction of cytokines. We examined a neonate with disseminated papulonodular eruptions containing lymphoid aggregates of B lymphocytes in the chorial layer. The diagnosis of a CSHLCH was made and the follow-up showed a complete involution of the eruptions, leaving atrophic lesions in the sites corresponding to the initial findings. We discuss a possible imbalance of the immune response as a pathogenetic mechanism.

Congenital self-healing Langerhans cell histiocytosis with pulmonary involvement: spontaneous regression

Congenital self-healing Langerhans cell histiocytosis (CSHLCH) is a rare condition which may present at birth or during the neonatal period. It is usually characterized by eruption of multiple, discrete and red-brown papules and nodules which may increase in size and number during the first few weeks of life with spontaneous regression. Systemic signs are usually absent except for occasional mild hepatomegaly. The authors report a case of CSHLCH associated with multiple lung cysts with spontaneous regression. A healthy full term male infant presented at birth with numerous diffuse discrete dark-red papules sized 0.2-1.0 cm scattered on the eyelids, temporal areas of the scalp, neck, palms and soles. Histologic findings were mixed inflammatory infiltration of numerous histiocytes. Immunochemistry findings were S-100 and CDla positive consistent with CSHLCH. Hepatomegaly and multiple lung cysts were detected at 1 month old. Since he was healthy, no medication was given except for close monitoring. At 2 months of age, hepatomegaly was resolved but the liver had sclerosing change. Skin lesions regressed completely at the age of 4 months. Lung cysts were markedly improved at 7 months old and completely resolved at 1 year old. Spontaneous regression in CSHLCH with lung involvement has never been reported in Thailand.

Successful treatment of refractory Langerhans cell histiocytosis with unrelated cord blood transplantation

A 2-month-old girl presented for treatment with a diffuse rash, interstitial pneumonia, otorrhea, and lymphadenopathy. Skin biopsy confirmed Langerhans cell histocytosis by electron microscopy. After receiving multiple courses of chemotherapy, only marginal improvement was achieved, with progressive marrow and liver involvement. The decision was made to pursue a human leukocyte antigen-identical unrelated cord blood transplantation. Two years after transplant, the bone marrow was clear of Langerhans cell histocytosis and 100% donor engraftment. The poor prognosis of patients with an inadequate response to therapy and the presence of organ dysfunction (marrow and liver) substantiated the decision to pursue an unrelated cord blood transplantation.

Histiocytic disorders with spontaneous regression in infancy

The histiocytic disorders are uncommon, have a wide spectrum, and are poorly understood. We describe seven cases developing in infancy, seen during a period of 9 years at Asan Medical Center, Seoul, Korea. Clinically the patients had multiple papules over the face, trunk, and extremities that developed at birth or during infancy. Histopathologic examinations revealed an infiltrate of many histiocytic cells in the upper dermis with or without epidermotropism. Four cases were classified as congenital self-healing reticulohistiocytosis in that the histiocytes were identified as Langerhans cells by positive immunohistochemical staining for S-100 protein, ultrastructural studies showing many Birbeck granules, and spontaneous regression of the lesions within 1-4 months. One infant with a solitary lesion on the forehead was diagnosed as solitary, congenital, indeterminate cell histiocytoma because the histiocytic cells were S-100 protein positive, but meticulous ultrastructural studies did not detect Birbeck granules. The lesion was removed by shave excision. Two cases were classified as generalized eruptive histiocytoma. The histiocytic cells were S-100 protein negative and ultrastructurally Birbeck granules were absent. In one patient, eyeball- or popcornlike lysosomal structures were seen. The lesions regressed completely.

A fatal case of congenital disseminated Langerhans cell histiocytosis

The case of a newborn male infant with congenital Langerhans cell histiocytosis (LCH) is presented. At birth, showed cutaneous lesions (papules and vesicles with a haemorrhagic aspect), mucosal and ganglionic involvement. Biopsy of these lesions led to the diagnosis of LCH. At 24 hours of life the patient began with respiratory, hepatic, hematological and renal dysfunction, and died at 72 hours of life, despite corticoid treatment. LHC with vesicles and a rapid and fatal development, has previously only been described in three patients. The differential diagnosis of a disseminated and hemorrhagic vesicular eruption in a newborn infant is extensive and must include LHC.

Congenital self-healing histiocytosis (Hashimoto-Pritzker)

BACKGROUND

Congenital self-healing Langerhans cell histiocytosis (CSHLCH) is a rare condition, initially seen at birth or in the neonatal period, with generalized papules, vesicles, or nodules. Affected infants are otherwise well and the skin lesions tend to involute spontaneously within weeks to months.

METHODS

Twelve patients with CSHLCH were seen from 1989 to 1998.

RESULTS

Eight patients were girls and four were boys and all presented with lesions at birth which disappeared 1-3 months later. The lesions consisted of numerous brownish-red papules, papulovesicles, crusts, and nodules distributed on the face, limbs, palms, and soles. Two patients had oral mucosal lesions, and one had ulcerated lesions that evolved leaving hypochromic macules. Light microscopy showed a histiocytic infiltrate in the papillary dermis with epidermotrophism. Two cases were studied by electron microscopy: the Langerhans cells showed Birbeck granules and laminated corpus in their cytoplasm. Immunomarking with S100 protein was performed in all 12 patients and was positive. CD1 was also tested in four cases and was positive.

CONCLUSIONS

Because CSHLCH is a rare condition, we emphasize that, although it is usually a benign, self-limited entity, careful evaluation for systemic disease must be performed and long-term follow-up must be carried out to detect evidence of relapse or progression of the disease; this is essential when treating these patients.

[Congenital Langerhans-cell histiocytosis presenting as a varicella infection]

We report on a preterm infant (33rd gestational week) with a varicella-like congenital rash, which initially appeared to respond to therapy with acyclovir. At the age of 3 weeks, lesions were in different stages of evolution and still resembled a varicella zoster virus (VZV) infection. However, since proof of VZV infection was lacking and new lesions erupted at the age of 4 weeks, a skin biopsy was performed which revealed a diagnosis of Langerhans cells histiocytosis. Therapy with prednisone resulted in prompt healing of the lesions.

DISCUSSION

Congenital Langerhans cell histiocytosis is rare and symptoms may vary substantially from case to case. Like in our observation it may be confused with congenital varicella. In case of congenital skin lesions of uncertain etiology a skin biopsy should be performed.

Congenital systemic Langerhans cell histiocytosis (report of two cases)

Two cases of congenital systemic Langerhans cell histiocytosis (LCH), diagnosed and treated in our department from June 1995 until May 1996, are described. The cases concern two neonates (one female and one male) born with necrotic lesions and skin nodules. The diagnosis was confirmed by skin biopsy which showed diffuse infiltration by CD1 antigen and S-100 protein positive histiocytes. The babies didn't present with anemia, hepatosplenomegaly or lymphadenopathy. Hepatic and renal function were normal. In both infants skeletal survey showed no lytic lesions but chest X-rays and high resolution computerized tomography (HRCT) scan revealed diffuse mottling of both lung fields. Bone marrow aspiration showed the presence of histiocytes in percentages of 6% and 10%, respectively. Both babies were treated with prednisolone 1 mg/kg body weight for three months. The first child who is 20 months old, is now well with resolution of skin and pulmonary lesions occurring within one month of the initiation of steroids, while the second, who presented spectacular resolution of skin lesions within the first three weeks of therapy, is also in excellent condition five months after completion of treatment. We conclude that congenital LCH has to be suspected in neonates with persisting skin lesions. If the disease is systemic but without organ dysfunction, treatment with steroids may be beneficial.

Late manifestation of diabetes insipidus in "pure" cutaneous Langerhans cell histiocytosis

We report a case of congenital Langerhans cell histiocytosis (LCH), presenting with a generalized varicelliform rash in an otherwise well newborn. No signs of organ involvement were found on repeated skeletal radiography, abdominal ultrasonography and laboratory studies. A diagnosis of "pure cutaneous" LCH was established. Skin manifestation was unusually severe and recurred during the first 20 months of life, but responded well to combination chemotherapy (methylprednisone, vinblastine) while the child continued to thrive. At the age of 2 years the patient presented with acute onset diabetes insipidus due to infiltration of the hypothalomo-pituitary stalk region. He died for reasons unknown at the age of 28 months.

CONCLUSION

"Pure cutaneous" LCH, frequently also referred to as congenital self-healing LCH, is a variable disorder which may be complicated by late organ involvement. Close follow up and thorough diagnostic evaluation is therefore mandatory.

Congenital "self-healing" Langerhans cell histiocytosis: the need for long-term follow-up

Congenital self-healing Langerhans cell histiocytosis (CSHLCH) is a rare disorder initially seen at birth or in the newborn period with spontaneously involuting skin lesions. In contrast to other forms of Langerhans cell histiocytosis in infancy, such as Letterer-Siwe disease, the prognosis of CSHLCH is generally good. We describe four children with widespread CSHLCH at birth. In all patients a congenital infection was initially suspected. All patients, except one who had transient lower extremity edema and pulmonary symptoms, had an uncomplicated neonatal course, and in all patients skin lesions resolved spontaneously. Two patients showed no further evidence of disease, but one had a cutaneous relapse at age 3 months, and in another a bony relapse that required systemic therapy developed at 6 months of age. CSHLCH is usually a benign, self-limited condition, but careful evaluation for systemic disease must be performed. Long-term follow-up for evidence of relapse or progression of disease is essential.

Vesicular Langerhans cell histiocytosis--an uncommon variant

A case of the congenital self-healing reticulohistiocytosis variant of Langerhans cell histiocytosis is described. The child was born with a widespread blistering eruption, which rapidly resolved leaving papules and erosions. These ultimately healed leaving anetoderma. Congenital self-healing reticulohistiocytosis should be considered in the differential diagnosis of blistering eruptions present at birth.

Nail features in Langerhans cell histiocytosis

We report the case of an infant who presented with isolated cutaneous manifestations of Langerhans cell histiocytosis before the evolution of systemic features. In the transition period, at 9 months of age, nail unit changes became prominent, and persisted throughout the duration of systemic treatment. A change in clinical features coincided with a course of systemic gamma-interferon, which was given because immune paresis was suspected. Nail unit changes are rare in Langerhans cell histiocytosis, and this case illustrates the range of findings, including paronychia, nail fold destruction, onycholysis with subungual expansion, and nail plate loss. The significance of these changes as a prognostic indicator is controversial.

Congenital self-healing reticulohistiocytosis--a benign Langerhans cell disease

An-11-day old girl was seen with brownish nodular lesions scattered over the body with emphasis on the face and scalp. Several lesions had started to involute. Tissue was studied by histopathology, immunohistopathology, routine electron microscopy, and immuno-electron microscopy using cryosubstitution and embedding in K4M. Immunohistopathology revealed that the cells of the dermal infiltrate were Langerhans cells. They expressed Leu 6 and HLA-DR. On routine electron microscopy no Birbeck granules were found in the dermal cells. Birbeck granules in epidermal Langerhans cells were deformed and often situated next to laminated dense bodies. The latter expressed Leu 6 and lysozyme on immuno-electron microscopy. It was concluded that congenital self-healing reticulohistiocytosis is a benign Langerhans cell disease in which Birbeck granules are transformed to laminated dense bodies and possibly degraded by lysosomal enzymes.

Congenital histiocytosis X

Congenital histiocytosis X involving multiple organs is a rare disease that causes rapid mortality in intrauterine and neonatal life. The diagnosis of histiocytosis X (Letterer-Siwe disease) should be considered in a neonate with vesiculated crusting skin lesions. We present clinical, radiographic and histopathological findings in a neonate with congenital histiocytosis who died of respiratory failure due to diffuse infiltration of lungs with histiocytic cells.