Alectinib In the Treatment of Systemic Juvenile Xanthogranuloma of Infancy With ALK Translocation

This observational case series examines the diagnosis and treatment of 2 patients with systemic juvenile xanthogranuloma treated with alectinib.

Role of FDG PET/CT in the Evaluation of Therapy Response in Systemic Juvenile Xanthogranuloma

ABSTRACT

Juvenile xanthogranuloma, a rare type of non-Langerhans cell histiocytosis, is mostly seen in childhood and adolescence and generally manifests as widespread skin lesions. It rarely shows systemic involvement. Although the cutaneous form is often self-limited, systemic form is quite aggressive. Here we report the findings of FDG PET/CT scans during the course of cladribine therapy in a 6-year-old girl with systemic juvenile xanthogranuloma.

Extensive "stalagmite" epi-iridic juvenile xanthogranuloma simulating diffuse melanoma in a 16-year-old girl

A 16-year-old girl noted worsening redness and photophobia of the right eye that had previously been treated unsuccessfully with sequential courses of topical antibiotics and topical corticosteroids. Clinical examination revealed diffuse flakelike thickening of the iris surface, pupillary margin, and anterior chamber angle, suggesting diffuse iris melanoma. Anterior segment optical coherence tomography depicted the mass as an epi-iridic deposit with "stalagmite" surface appearance. Fine-needle aspiration biopsy confirmed an atypical histiocytic proliferative disorder consistent with juvenile xanthogranuloma. Aggressive topical corticosteroid treatment was started. There were no systemic findings. Following therapy, the lesion resolved completely.

Early severe coronary heart disease and ischemic heart failure in homozygous familial hypercholesterolemia: A case report

RATIONALE

Familial hypercholesterolemia (FH) is a common inherited cause of coronary heart disease (CHD) and premature death in an early age. Nevertheless, an ischemic heart failure (IHF) associated with FH seems to be rare, and an early diagnosis and therapy could influence the prognosis.

PATIENT CONCERNS

In this 13-year-old girl, multiple xanthomas began to develop from the first day of birth. Until June, 2017, she was admitted to our center due to edema, oliguria, and dyspnea during exertion, which was attributed to a recent respiratory infection.

DIAGNOSIS

Homozygous FH (HoFH), CHD, and IHF.

INTERVENTIONS

The patient has been treated with statin, ezetimibe, aspirin, and traditional heart failure (HF) medications. In addition, the beta-blocker was simultaneously administered.

OUTCOMES

Genotypes of this proband indicated homozygous mutations of low-density lipoprotein receptor (LDLR) and some co-segregated mutations, such as von Willebrand factor (VWF) and fibroblast growth factor receptors. At 6-month follow-up, we found a decreased level of plasma lipid profile, in addition to a significant improvement in 6-minute walk distance and functional class. Echocardiography indicated nonsignificant improvements in the structure and function of the heart.

LESSONS

This case report indicates that HoFH can lead to dramatically progressive endothelial damages and ventricular remodeling, severe atherosclerosis, even IHF. Genetic outcomes indicate IHF with HoFH could possibly result from LDLR mutations and some co-segregated mutations influencing endothelial function and cardiovascular remodeling. In a short-term follow-up, a combination of statins, ezetimibe, aspirin, and traditional HF agents is safe and effective for IHF with HoFH, and there is a need for further identification of drugs to ameliorate endothelial function and cardiovascular remodeling which may play an important role in long-term treatment.

Optical coherence tomography characteristics of epi-iridic membrane in a child with recurrent hyphema and presumed juvenile xanthogranuloma

We report a case of spontaneous hyphema in a 6-month-old girl with no history of trauma and no visible iris mass. Subtle green-blue heterochromia was noted in the right eye. The iris crypts in the right eye appeared flattened by a thin, transparent layer on the iris surface. Anterior segment optical coherence tomography (AS-OCT) disclosed a thin homogenous membrane overlying the entire iris surface in the right eye. Fluorescein angiography revealed diffuse hyperfluorescence without neovascularization. These features were suggestive of diffuse iris juvenile xanthogranuloma. Sub-Tenon's triamcinolone acetate plus topical corticosteroids eyedrops resolved the condition within 1 month.

[An ocular variant of juvenile xanthogranuloma]

INTRODUCTION

Juvenile xanthogranuloma is primarily a skin disease, which occurs mainly in young children. Occasionally a juvenile xanthogranuloma can be found isolated in the eye, particularly in the iris. Early detection and treatment are crucial.

CASE DESCRIPTION

A two-year-old boy was referred to the hospital with a reddish-brown, well-vascularised discoloration of the iris of the right eye, with no further symptoms. An ocular juvenile xanthogranuloma was suspected. After treatment with glucocorticoids the lesion disappeared completely, which confirmed the diagnosis.

CONCLUSION

Ocular juvenile xanthogranuloma should be considered in all young patients with a vascularised tumour of the eye that is increasing in size. Knowledge of this disease can prevent severe complications or even blindness.

[Cladribine is highly effective in the treatment of Langerhans cell histiocytosis and rare histiocytic disorders of the juvenile xanthogranuloma group]

Cladribine (2-chlorodeoxyadenosine) is metabolised and phosphorylated in a cell up to 2-chloroadenosine triphosphate which is the actual effective form of the drug. The greatest accumulation of 2-chloroadenosine triphosphate is in the most active cells, where activating (phosphorylation) enzyme, deoxycytidine kinase, has the highest activity, whereas inactivating enzyme (dephosphorylation), cytoplasmic 5-nucleotidase, has the lowest activity. A very good ratio of the both enzymes for high effectiveness of cladribine is in resting and proliferating lymphocytes. Therefore, cladribine is an effective medication for hairy cell leukemia, Waldenström macroglo-bulinemia but also for chronic -B-lymphocytic leukemia. However, such high concentrations of 2-chloroadenosine triphosphate are reached in some cells of histiocytic lines, in monocytes and also in Langerhans dendritic cells. That's why cladribine is highly effective medication in treating Langerhans cell histiocytosis and also in treating diseases of the juvenile xanthogranuloma group. In the paper we present a survey of published experience with cladribine in patients with Langerhans cell histiocytosis. The effectiveness of cladribine in the childhood form of Langerhans cell histiocytosis is investigated only in 1 multicentric clinical study, other data are taken from single case reports or small series studies. Cladribine was used in 60 adult patients altogether and in 51 of them (85%) treatment response (CR + PR) was achieved. In the group of childhood patients cladribine was used in 182 cases and treatment response (CR + PR) was reached in 110 (60.4%) thereof. One possible explanation for a higher number of therapy responses in adults is lower Langerhans cell histiocytosis aggressiveness in adults than in children. Another explanation is the fact that therapy responses in adults are summarized only from case reports and smaller cohorts, whereas in children, case reports and also results of a prospective randomized clinical study are included. Diseases of the juvenile xanthogranuloma group are much more rare than Langerhans cell histiocytosis and so the number of publications is smaller. In total, 7 publications describe therapy response of cladribine in some of the juvenile xanthogranuloma forms (Erdheim-Chester disease, disseminated juvenile xanthogranuloma and localized form of plane xanthoma type). Cladribine was also effective in CNS infiltration by Langerhans cell histiocytosis cells or juvenile xanthogranuloma cells.

CONCLUSIONS

Cladribine is a highly effective medication used in treating Langerhans cell histiocytosis. It is very good tolerated in monotherapy. Therefore, it is suitable for initial therapy of adults with multifocal or multisystem form of Langerhans cell histiocytosis. Furthermore, it has the use in treating relapses after some other initial therapy. According to published experience, it is an effective drug for diseases of the juvenile xanthogranuloma group (Erdheim-Chester disease, diffuse juvenile xanthogranuloma and also Rosai-Dorfman disease).

Glaucoma in Juvenile Xanthogranuloma

Juvenile xanthogranuloma (JXG) is a benign histiocytic skin disorder mainly encountered during infancy. Approximately 10% of cases exhibit ocular manifestations leading to serious complications. Specifically, secondary glaucoma can result in severe and blinding eye disease. We present a case of a two-month-old female with JXG related glaucoma in order to demonstrate the classic presentation and the problems commonly encountered in treating this disease. The natural history, pathogenesis, and treatment of the condition are then discussed and the pertinent literature reviewed. JXG should be considered in any case of unilateral glaucoma that presents in infancy.

Subdural effusion in a CNS involvement of systemic juvenile xanthogranuloma: a case report treated with vinblastin

Juvenile xanthogranuloma (JXG) is one of the most common non-Langerhans cell histiocytosis in children. Usually cutaneous, there are disseminated forms. However, neurological localization remains exceptional. A 7-month-old boy had been admitted for subdural effusion due to non-accidental head injury and skin nodular lesions. A biopsy of a skin lesion was considered suggestive of JXG. Skin, eyes, brain, lungs, liver, and testicles were involved. Systemic treatment of JXG was begun with vinblastine. It allowed the regression of skin, lung, and CNS lesions. At age of 11 years, he had not reappearance of the xanthogranuloma. This report emphasizes the possible presentation of xanthogranuloma with subdural effusions, the organs which should be examined in case of disseminated forms and the efficiency of vinblastin.

Successful therapy of systemic xanthogranuloma in a child

Systemic juvenile xanthogranuloma is a rare disease in children. A 10-year-old boy who showed renal, pulmonary, and liver involvement is reported. He had pulmonary invasion, renal mass, and nodular liver lesions but no bone involvement. The diagnosis was confirmed by renal biopsy, which revealed foamy, lipid-laden macrophages with positive CD68, but negative CD1a and S-100. The patient was treated with pulse high-dose methylprednisolone (10 mg/kg/d for 3 d for 6 courses). On 1-year follow-up period after 6 courses therapy was resulted in remarkable regression in renal and liver lesions.

Isolated juvenile xanthogranuloma in the bone marrow: report of a case and review of the literature

We report a case of juvenile xanthogranuloma limited to involvement of the bone marrow in a 6-week-old male infant. Evaluation of the bone marrow was a part of the workup for peripheral blood cytopenia. Examination showed hypercellular marrow with paratrabecular clusters of lipidized histiocytes positive for CD68, CD4, and factor XIII(a) and negative for S100 and CD1a. Clinical and radiological workup showed no associated skin lesions or osseous or visceral involvement. The patient was started on chemotherapy with clinical improvement and gradual decreased bone marrow involvement. The child is alive and well at 16 months of age. This case represents, to the best of our knowledge, the 1st documented case of juvenile xanthogranuloma with isolated bone marrow involvement sparing skin and viscera.

[Juvenile multiple xanthogranuloma in a patient with Langerhans cell histiocytosis]

We present the case of a 10-week-old girl who had erythematous papules with a yellowish hue from birth with diagnosis of Langerhans cell histiocytosis, that was accompanied by a lytic lesion in the skull and hepatic involvement. After several months of treatment with prednisone and vinblastine with skin and systemic improvement, several rounded erythematous papules with a yellowish hue appeared in the right cheek. The biopsy showed a histiocytic infiltrate with positivity for CD68 and negative staining for S100 and CD1a, with a final diagnosis of juvenile xanthogranuloma. This association has been previously described in the literature in few cases. Although several hypotheses have been suggested, the causal relationship between both entities has still not been demonstrated.

Treatment of severe disseminated juvenile systemic xanthogranuloma with multiple lesions in the central nervous system

Juvenile xanthogranuloma (JXG), one of the most common forms of Langerhans-dendritic cell proliferation in young children, usually presents as spontaneously regressing cutaneous lesions. JXG with systemic (extracutaneous) involvement is a rare histiocytic disorder in which significant morbidity and death may occur. The systemic type, especially combined with multiple central nervous system lesions in young children, has a very poor prognosis. The patient described here presented with disseminated disease including lungs, liver, kidneys, ribs, scalp, and central nervous system. The patient was treated with multiagent chemotherapy based on the Langerhans cell histiocytosis II treatment protocol. The regimen used included an additional intrathecal therapy with methotrexate and prednisolone to control central nervous system lesions. The patient was treated for 28 months and has been in remission for almost 5 years.

Systemic form of juvenile xanthogranuloma: report of a case with liver and bone marrow involvement

Systemic form of juvenile xanthogranuloma with involvement of liver and bone marrow is reported in a 2-month-old female infant who presented with hepatosplenomegaly, severe anemia, and thrombocytopenia. There was no skin lesion, nor bone lesion. The enlarged liver has generalized yellowish spots. The diagnosis of juvenile xanthogranuloma was made by pathologic findings of marrow and portal tract infiltration by S-100 negative, CD1a negative, CD68 positive, and Factor XIIIa positive large pale to foamy histiocytes with Touton giant cells, and lack of Langerhans cell granule by electron microscopic examination. The patient was treated with Vinblastine and Etoposide, and experienced slow and gradual disease regression in one year. To the best of knowledge, this is the first documented case of bone marrow involvement in systemic juvenile xanthogranuloma.

Successful treatment of congenital systemic juvenile xanthogranuloma with Langerhans cell histiocytosis-based chemotherapy

Juvenile xanthogranuloma (JXG), one of the most common forms of non-Langerhans cell histiocytosis (LCH), usually presents in young children as spontaneously regressing cutaneous lesions. However, the systemic type of JXG is difficult to treat in newborn infants, and fatal cases have been reported. In the patient described here, solid masses were discovered by fetal sonography during the 38th gestational week. At birth she had multiple tumors on the back, cheek, and hip as well as marked hepatosplenomegaly accompanied by respiratory failure. Laboratory results indicated pancytopenia, obstructive liver dysfunction, and coagulopathy. Brain magnetic resonance imaging revealed a tumor at the left pontine angle, and dysmorphic histiocytes were present in her spinal fluid. She was diagnosed with systemic JXG by histopathologic findings of the hip mass. The LCH-based multiagent chemotherapy including cytarabine, vincristine, methotrexate, and prednisolone ameliorated the symptoms rapidly. She was treated for 12 months and is currently doing well as a normally developing 2-year-old.

Eosinophilic granuloma of the atlas presenting as torticollis in a child

STUDY DESIGN

This report describes a case of successful surgical treatment of eosinophilic granuloma of the atlas in a 3.5-year-old boy who presented with torticollis.

OBJECTIVE

The purpose of this report was to illustrate the rare clinical presentation of eosinophilic granuloma in the atlas.

SUMMARY OF BACKGROUND DATA

Eosinophilic granuloma, a benign solitary lesion that commonly affects children, has a variable clinical course. Although eosinophilic granuloma has been reported to occur in the cervical spine, there have been only five reported cases of eosinophilic granuloma affecting the atlas. The management of eosinophilic granuloma ranges from observation and immobilization of the cervical spine to surgical excision.

METHODS

The tumor was located on the left lateral mass of the atlas. Biopsy and curettage were performed through an oblique incision through the posterior border of the sternocleidomastoid muscle. A histopathologic evaluation confirmed the diagnosis of eosinophilic granuloma.

RESULTS

The patient tolerated the procedure with no complications, and his torticollis has completely resolved.

CONCLUSION

Eosinophilic granuloma of the atlas initially presented in this patient as torticollis. Biopsy for confirmation of diagnosis and curettage for treatment provided a successful outcome in this patient. We suggest biopsy of the lesion and histopathologic evaluation to confirm the diagnosis in atypical cases.

Juvenile xanthogranuloma: concurrent involvement of skin and eye

PURPOSE

To report a novel presentation of ocular involvement in juvenile xanthogranuloma (JXG).

CASE REPORT

A 1-year-old boy with the concurrent skin and eye involvement of JXG is presented. The ocular problems included spontaneous hyphema, secondary glaucoma, and 360-degree involvement of the limbus, iris, and angle.

RESULTS

To reduce the intraocular pressure (IOP), treatment was started with drops of timolol, betamethasone, and atropine and acetazolamide suspension. After 6 months of medical treatment, the skin lesions did not change, but the iris lesion enlarged without hyphema. The IOP in the right eye was controlled by the medications.

CONCLUSION

Although JXG is an uncommon disease, it is one of the most important causes of spontaneous hyphema in children. Iris involvement, spontaneous hyphema, and secondary glaucoma are the most common ocular problems. Corneal involvement often is characterized by a yellowish protrusion of the limbus along with blood staining of recurrent hyphema and elevated IOP. In this report, we describe an unusual case of JXG with 360-degree limbus, iris, and angle involvement. To our knowledge, this is the first report in the medical literature of 360-degree limbus involvement in JXG.

Juvenile xanthogranuloma of the iris in an adult

Juvenile xanthogranuloma is a self-limited skin disorder of young children that uncommonly affects the eye. Juvenile xanthogranuloma has been described in adults, but reported intraocular involvement is extremely rare. We report a case of juvenile xanthogranuloma diagnosed in a 25-year-old man who was seen with nontraumatic hyphema and iridocyclitis. Diagnosis was made from a biopsy specimen obtained from a suspicious skin lesion. Topical and systemic steroids, radiation therapy, and finally immunosupression were required to eliminate the iris tumor clinically and resolve the patient's recurrent symptoms.

[Diffuse xanthogranuloma as a cause of infantile heterochromia]

A 7-month-old female infant presented with a heterochromia and an anisocoria. A spontaneous hyphema and a secondary glaucoma had developed. Under topical and systemic steroid therapy the eye improved continuously. At the time of the last ocular examination the hyphema had resorbed, and the intraocular pressure was normal. Heterochromia had almost completely vanished, and dilation of the pupil was much better. Since even a massive juvenile xanthogranuloma of the iris responds well to steroids, operative and radiation treatment should be limited to cases refractory to antiinflammatory drug therapy.

Early treatment of juvenile xanthogranuloma of the iris with subconjunctival steroids

Five infants with biopsy proved juvenile xanthogranuloma of the iris were reviewed. Early treatment with subconjunctival injection of steroids and topical steroid drops resulted in regression of the lesion in four patients. One patient, reviewed at the age of 8 months after glaucoma which had developed secondary to the iris xanthogranuloma, had been treated by surgery alone: the visual outcome was very poor.

Congenital macronodular juvenile xanthogranuloma of the eyelid

A large congenital eyelid mass prevented an infant from elevating his eyelid successfully. A small punch biopsy was initially interpreted as "consistent with a dermatofibrosarcoma protuberans." On the basis of this diagnosis, radical surgery was advised. Dermatofibrosarcoma protuberans, however, rarely affects children and seldom appears in the head and neck area. Because of the discrepancy between clinical and pathologic diagnoses, additional biopsies were performed, which disclosed the lesion to be a juvenile xanthogranuloma. The mass regressed after intralesional injections of corticosteroids. This is the first clinicopathologic description of congenital macronodular juvenile xanthogranuloma affecting the eyelids. The variability in the histologic composition of this large lesion may lead to a mistaken diagnosis of an aggressive condition that may provoke unnecessary radical surgery.

Solitary orbital involvement with juvenile xanthogranuloma

A newborn girl was noted to have a smooth superonasal orbital and preseptal mass at the time of birth. The mass enlarged slightly over 3 months and a biopsy revealed histiocytes and Touton giant cells, compatible with juvenile xanthogranuloma. The infant had no other manifestations of juvenile xanthogranuloma. The mass subsided after systemic corticosteroid therapy was administered. Solitary orbital involvement with juvenile xanthogranuloma is exceedingly rare and most of these patients are found to lack the typical cutaneous lesions. Observation, oral prednisone, or low-dose radiotherapy are recommended forms of treatment.

Subconjunctival steroid in the management of uveal juvenile xanthogranuloma: a case report

Uveal juvenile xanthogranuloma (JXG) is a rare intraocular tumor which usually occurs in very young children. Most reported cases of successfully treated uveal juvenile xanthogranuloma have received systemic steroids, irradiation or excision. Some cases have responded to topical steroids alone. We report a case of JXG with recurrent hyphemas and elevated intraocular pressures despite the use of topical steroid. This patient responded to the addition of subconjunctival steroid injection. This is the first report to our knowledge demonstrating a response to periocular steroid supplementation for uveal JXG unresponsive to topical steroids.

Juvenile xanthogranuloma

Juvenile xanthogranuloma (JXG) is a disease of unknown etiology and pathogenesis which was first recognized by dermatologists. The ocular complications provide the primary concern and notably affect the iris, producing spontaneous hemorrhages in the anterior chamber. Secondary glaucoma and blindness are real threats unless the condition is recognized in the early stages and satisfactory treatment instituted. Other ocular manifestations include epibulbar lesions with corneal involvement and proptosis due to orbital lesions of JXG.

Juvenile oculodermal xanthogranuloma

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