Eruptive xanthomata with urate-like crystals

The microscopic manifestations of eruptive xanthomata are variable and although they are most frequently characterized by aggregations of foamy macrophages in the dermis, they can, on occasion, simulate granuloma annulare. We have recently encountered a further unusual histopathological variant of eruptive xanthomata in 3 skin biopsies from 2 patients with hypertriglyceridemia. The lesions had a granuloma annulare-like pattern at low magnification, the exceptional feature being their content of polarizable, needle-shaped crystals. These bore a strong resemblance to monosodium urate monohydrate and displayed negative birefringence under polarized light. In the case of each patient, an initial pathological diagnosis of gout was rendered, and the true nature of the lesions came to light only after clinicopathologic correlation. While it is clear that the chemical composition of these crystals requires further study, recognition of this microscopic variant of eruptive xanthomata should help to reduce errors in diagnosis.

Xanthogranulomatous cholecystitis

Clinical, radiological and pathological findings in 31 patients with xanthogranulomatous cholecystitis have been reviewed. The spectrum of presentation was similar to that of cholelithiasis but fewer patients had biliary colic (17 per cent) and there were more complications (32 per cent). Four patients had a biliary fistula and four a perforated gallbladder with abscess formation. Patients characteristically had gallstones. Appearances often mimicked carcinoma of the gallbladder at ultrasonography and/or laparotomy, with xanthogranulomatous tissue extending to adjacent structures. Xanthogranulomatous cholecystitis and carcinoma of the gallbladder coexisted in three patients. The possibility should be considered that an 'inoperable tumour' of the gallbladder may in fact be xanthogranulomatous cholecystitis, a benign condition that frozen-section biopsy may confirm.

Lipidized meningothelial tumor cells in "xanthomatous" meningioma express macrophage antigen

A case of "xanthomatous" meningioma was examined by light and electron microscopy as well as immunohistology. Lipid-laden "xanthomatous" cells were shown to be meningothelial by all ultrastructural criteria. All tumor cells (lipidized and non-lipidized) expressed vimentin in their cytoplasm, but only the lipidized cells showed the presence of the macrophage marker HAM-56. This finding suggests that, as in some other areas of general pathology, immunological markers may serve as indicators of a specific activity (in this case phagocytosis), rather than merely histogenesis.

[Necrobiotic xanthogranuloma in IgG kappa plasmacytoma and Quincke edema]

Necrobiotic xanthogranuloma is a non-X histiocytosis with unknown pathogenesis. It is associated with paraproteinaemia, and in rare cases with multiple myeloma. A decreased level of C1 inhibitor has been found in several cases without clinical manifestations of Quincke oedema. We report on a patient with necrobiotic xanthogranuloma and myeloma, in whom we found a decreased level of C1 inhibitor and recurrent episodes of manifest Quincke oedema. The indirect detection of auto-antibodies against the paraprotein with development of immune complexes is regarded as an explanation for the consumption of the C1 inactivator and the manifestation of Quincke oedema. The possibility of a causal relationship between paraproteinaemia and necrotic xanthogranuloma is discussed.

[Retroperitoneal xanthogranuloma: a case report]

A 48-year-old man was admitted to our hospital for lumbago. Computerized tomographic (CT) scan, aortography and venacavography indicated a solid retroperitoneal tumor at the right renal hilus. The tumor was removed and right nephrectomy was conducted. Some of the tumor remained owing to strong adhesion to the inferior vena cava and lumbar spine. Histological diagnosis of the resected tumor was retroperitoneal xanthogranuloma. One year after surgery, the CT scan revealed a gradual decrease in size of the remaining retroperitoneal mass.

Generalized normolipemic plane xanthomatosis associated with relapsing polychondritis

Generalized normolipemic plane xanthomatosis is a rare cutaneous disorder, frequently associated with reticuloendothelial diseases and some disorders with inflammation. Relapsing polychondritis is also a rare disease that shows an association with various immune-mediated diseases. We report a case of generalized normolipemic plane xanthomatosis associated with relapsing polychondritis in a 56-year-old Japanese man. We have already reported the clinical picture of relapsing polychondritis as well as an increase in urinary glycosaminoglycans excretion in this patient. During subsequent treatment with various immunosuppressive therapy, including prednisone, methotrexate, azathioprine, or aurothiomalate, multiple elevated yellowish erythematous plaques appeared on his neck approximately 32 months after the onset of relapsing polychondritis. Histologically, these eruptions consisted of perivascular neutrophilic infiltrate with nuclear dust and multiple foam cells among collagen bundles, compatible with those of generalized normolipemic plane xanthomatosis. This combination of two rare diseases has not been reported in the literature to our knowledge.

Mitochondrial complex I and III mutations and neutral-lipid storage in activated mononuclear macrophages and neutrophils: a case presenting with necrotizing myopathy, poikiloderma atrophicans vasculare, and xanthogranulomatous bursitis

We report the case of a 57-year-old woman suffering from xanthogranulomatous bursitis, necrotizing myopathy, and poikiloderma atrophicans vasculare, which are associated with marked accumulation of neutral-lipid storage phagocytes. The observed lipid storage was restricted to activated phagocytes independent of the presence of tissue necrosis and was not seen either in circulating blood leukocytes or in muscle fibers. The patient's daughter disclosed xanthomatous inflammatory reaction with profound delay of wound healing secondary to pelviscopy. Examination of the mitochondrial DNAs of the patient, her daughter, and her two grandchildren revealed two homoplasmic mutations at positions 13708 and 15257 of the mitochondrial genome. We discuss the involvement of these mutations in the pathogenesis of xanthomatous and xanthogranulomatous inflammation. Further investigations are required to test whether impairment of aerobic energy production independent from mitochondrial DNA mutations (eg, by hypoxia or microbial toxins) similarly can cause the accumulation of lipid-laden macrophages and explain the persistency of xanthogranulomatous inflammation.

prostatic xanthoma: a mimic of prostatic adenocarcinoma

Xanthoma is a localized collection of cholesterol-laden histiocytes that is usually idiopathic, but may be seen in patients with hyperlipidemia. We report seven cases of xanthoma involving the prostate, including one arising in a patient with mild hyperlipidemia. Prostatic xanthoma appeared as a solitary microscopic lesion in the peripheral zone (six cases) or transition zone (one case). One needle biopsy specimen with xanthoma was initially interpreted as well-differentiated adenocarcinoma with a clear cell (hypernephroid) pattern, but immunohistochemical studies revealed the histiocytic nature of the proliferation. Five cases (three needle biopsy specimens and two retropubic prostatectomy specimens) contained a solitary xanthoma adjacent to foci of adenocarcinoma. Another xanthoma was present in a transurethral resection specimen with nodular hyperplasia. Although unusual, xanthoma should be considered in the differential diagnosis of clear cell adenocarcinoma and other clear cell proliferations of the prostate, particularly in limited tissue samples, such as from needle biopsies and transurethral resections.

A case of fibrous histiocytoma associated with xanthogranulomatous alteration

We report here an unusual case of fibrous histiocytoma in which an area of xanthogranuloma was observed histologically. Our case suggests that adult xanthogranuloma is a variant of fibrous histiocytoma.

Magnetic resonance imaging in cerebrotendinous xanthomatosis: a prospective clinical and neuroradiological study

We describe MRI findings in 13 persons with typical clinical, EEG, CT and biochemical features of cerebrotendinous xanthomatosis (CTX). MRI showed brain (13/13) and cerebellar (12/13) atrophy and diffuse white matter hypodensity (4/13) presumably reflecting sterol infiltration with demyelination. Focal lesions were rare (2/13). Mass effect, edema or enhancement were not observed. Treatment with chenodeoxycholic acid (CDCA) 750 mg/day orally improved neurological and biochemical abnormalities. MRI appears to be of little value in following improvement after treatment has begun. Otherwise, the MRI studies are very sensitive and useful in diagnosing early incomplete forms of CTX.

Juvenile and adult xanthogranuloma. A histological and immunohistochemical comparison

Thirteen cases of juvenile xanthogranuloma (JXG) and 13 cases of adult-type xanthogranuloma (AXG) were compared at the light and immunohistochemical levels. Histologically, four main cell types (vacuolated, xanthomatized, spindle-shaped, and "oncocytic") were seen in variable proportions (from monomorphous to mixed variants) with different types of giant cells (nonspecific, foreign body, Touton, and "ground-glass"). Giant cells were more prominent in AXG than in JXG; oncocytic cells (characterized by an eosinophilic, slightly granular cytoplasm similar to thyroid oncocytic cells) and mostly periodic acid-Schiff (PAS) negative giant cells with a ground-glass appearance (6 of 26) were not observed in classic JXG (i.e., occurring in children < 2 years old). Immunohistochemically, JXG and AXG gave similar results: most xanthogranuloma cells labeled strongly with KiM1P and vimentin, while HHF35 and HAM56 stained less intensively. Factor-XIIIa (FXIIIa), KP1 (CD68), and HAM56 stained mostly in the periphery of the lesions. Some markers gave variable results: peanut agglutinin (PA), 60%; alpha-1-antitrypsin, 50%; lysozyme, 25%; LN3 (HLA-DR), < 10% of cells positive. Others were negative: S-100, MAC387 (L1 antigen), LeuM1 (CD15), desmin, smooth muscle-specific actin, and QBEND10 (CD34). This profile helps to delineate xanthogranuloma from histological stimulants such as dermatofibroma (which is FXIIIa+, LN3+, KP1-, and PA-) and multicentric reticulohistiocytosis (which is FXIIIa-, KP1+, PA-, and HHF35-).

The spectrum of normolipemic plane xanthoma

Normolipemic plane xanthoma (NPX) is a well-characterized clinicopathologic entity distinct from necrobiotic xanthogranuloma (NXG). We present the case of a patient with the classic clinical course of NPX but with many histologic features in common with NXG, namely, multinucleated lipophages, cholesterol clefts, and degeneration of collagen with associated cellular necrosis (necrobiosis). We suggest that NPX and NXG represent part of a spectrum of xanthomatous dermal reactions associated with paraproteinemias and may be more closely related than previously recognized.

Multiple eruptive cephalic histiocytomas in a case of T-cell lymphoma. A xanthomatous stage of benign cephalic histiocytosis in an adult patient?

A 67-year-old woman had multiple, pinhead-sized, yellowish papules localized to her face, scalp, and neck. A previously diagnosed T-cell lymphoma of low malignancy had been treated with cytostatic drugs. Ultrastructurally the dermal infiltrate consisted predominantly of histiocytic cells in various degrees of differentiation. The cells revealed signs of high metabolic activity and contained well-developed mitochondria, rough endoplasmic reticulum, and lysosomes. Groups of worm-like bodies (comma-shape bodies) and great numbers of coated vesicles in various sizes could be regularly found. Microvillous cell processes formed close interdigitations, and desmosome-like structures occurred between adjacent cell membranes. Lipid storage was present in the form of neutral lipid vacuoles, cholesterol clefts, and myelin-like arrangements of phospholipid membranes. Some multinucleated histiocytic cells, mast cells, lymphocytes, and eosinophilic granulocytes were encountered in the infiltrate. No dermal Langerhans' cells with their characteristic granules were present. Similarities to and differences from benign cephalic histiocytosis, generalized eruptive histiocytoma, and other xanthomatous disorders are discussed.

The use of CO2 laser for the treatment of xanthelasma palpebrarum

CO2 laser has been used for the treatment of 22 patients with xanthelasma palpebrarum. This office procedure done under local anesthesia is fast and easy. The lipomatous yellow plaques are accurately photovaporized in a bloodless field, layer by layer, until the lesion is totally eradicated. The treated area heals by reepithelization, ostensibly with virtually no scar contraction. All our patients were satisfied with their results, rating them from good to excellent. In 5 patients some pigmentation changes were noted. During follow-up periods varying from 15 to 54 months, only 2 (9%) patients had recurrences, which were retreated successfully. We postulate that treatment of xanthelasma palpebrarum by CO2 laser should be seriously considered in most patients.

[Magnetic resonance of the brain and Achilles tendon in cerebrotendinous xanthomatosis]

We report a 31 year old patient with cerebrotendinous xanthomatosis who presented with dementia, tendinous xanthomas, cataracts, pyramidal involvement, cerebellar ataxia and peripheral neuropathy. Cerebral CT scan demonstrated diffuse hypodensity in the white matter in both cerebellar hemispheres while MR detected additional focal alterations in both frontal lobes. MR study of the Achilles tendon showed a diffuse enlargement of the tendon with multiple areas of hypersignals in T1 and T2 demonstrative of the lipid deposits, interpossed between the isosignal zones that may correspond to the inflammatory reaction secondary to the accumulation of cholesterol and cholestanol.

Multiple xanthogranulomas in an adult

Xanthogranulomas develop in adults as well as in children; however, adult cases with multiple lesions are very rare. We report an adult who developed both multiple cutaneous lesions on the face and trunk and lesions on the conjunctiva, oral mucosa and genitalia. We believe that this is the first such case described.

Pancreatic xanthomatous neuropathy associated with hyperlipidemia: a cause of abdominal pain mimicking chronic pancreatitis

"Hyperlipidemic crisis" is a term used to describe episodic abdominal pain in patients with hyperlipidemia. The morphologic correlates of this phenomenon have not been investigated and the etiology of the disorder is uncertain. We report a unique histologic finding in the pancreas of a 34-year-old woman with a 17-year history of episodic abdominal pain, sometimes accompanied by hyperamylasemia. At the age of 18 years, grossly elevated cholesterol and triglyceride levels were documented and type V hyperlipidemia was diagnosed. At the age of 34 years, subtotal pancreatectomy was performed for intractable abdominal pain. Histologic examination identified an increased number of enlarged pancreatic nerves that were infiltrated by foamy macrophages and encircled by fibrous tissue; endoneurial infiltration with macrophages occasionally split nerves into individual fascicles. Otherwise, the pancreas had only minimal fibrosis, nesidioblastosis, mucinous metaplasia of some pancreatic ducts, and scattered small collections of chronic inflammatory cells, subtle features suggesting very mild chronic pancreatitis. We propose that this novel xanthomatous neuropathy mimicked pancreatitis and was one of the underlying pathophysiologic mechanisms of abdominal pain in this patient. Further studies are necessary to document the prevalence of this new entity in patients with hyperlipidemia and to correlate its occurrence with "hyperlipidemic crisis" in those individuals.

Surgical pathology of temporal lobe epilepsy. Experience with 216 cases

The surgical treatment of chronic epilepsies is increasing rapidly. Here we report the histopathologic findings in 216 consecutive surgical specimens of patients with chronic pharmacoresistant temporal lobe epilepsy. In 75 cases (34.7%) there were tumors, all but two of which were of low histopathological grade (WHO grade I or II). The most common tumors were gangliogliomas (34 cases), pilocytic astrocytomas (17 cases), oligodendrogliomas (9 cases), fibrillary astrocytomas (6 cases), and dysembryoplastic neuroepithelial tumors (6 cases). There were 51 cases with non-neoplastic focal lesions and an additional 13 cases with tumors and non-neoplastic focal lesions within the same specimen. The most frequent non-neoplastic focal lesions were microscopic glioneuronal hamartias (32 cases), glioneuronal hamartomas (7 cases), and vascular malformations (13 cases). The hippocampal formation was structurally well preserved in 71 specimens. In 51 of these (71.8%) there was Ammon's horn sclerosis. Presurgical placement of depth electrodes was invariably associated with circumscribed defects of the brain parenchyma. The implantation of subdural electrodes was sometimes followed by chronic inflammatory changes of the leptomeninges. Our findings indicate that in the majority of patients with medically intractable temporal lobe epilepsy there are significant histopathologic findings, many of which are only rarely encountered otherwise.

Necrobiotic xanthogranuloma without periorbital lesions

Cutaneous necrobiotic xanthogranuloma is rare and closely resembles widespread necrobiosis lipoidica. It is important to recognize this skin disorder because of its strong association with paraproteinemia and, in some cases, with a hematologic malignancy. We describe two patients with necrobiotic xanthogranuloma who are unusual in that they had no periorbital involvement, a feature previously believed to be diagnostic of this condition.

Xanthogranulomatous pyelonephritis in a Malaysian population

Xanthogranulomatous pyelonephritis is a clinico-pathological entity that is gaining awareness amongst urologists worldwide. It is an unusual chronic inflammatory lesion involving the kidney that destroys renal parenchyma and may mimic renal carcinoma. It is usually seen in middle-aged women and is associated with urinary tract infections and urinary calculi. Most reports and reviews of this condition come from the West; this study reviews the incidence and presentation of the condition in a Malaysian population.