Necrobiotic xanthogranuloma with lambda paraproteinemia: case report of successful treatment with melphalan and prednisone

BACKGROUND

Necrobiotic xanthogranuloma (NXG) is a rare non-X histiocytosis with conspicuous lesions on the periorbital skin.

METHODS

A diabetic patient presented with NXG and a previous diagnosis of necrobiosis lipoidica on the legs over a period of almost 2 years before the development of the typical lesions of NXG on the periorbital regions, back, thighs and legs. The patient was found also to have developed lambda paraproteinemia.

RESULTS

Treatment with melphalan and prednisone resulted in great improvement of cutaneous lesions and paraproteinemia remission.

CONCLUSION

This case report details how melphalan and prednisone can be administered in the successful treatment of necrobiotic xanthogranuloma with lambda paraproteinemia.

[Bilateral necrobiotic xanthogranuloma of the eyelids with associated paraproteinemia: Case report and review of literature]

BACKGROUND

Necrobiotic xanthogranuloma is a rare disorder which predominantly affects the periorbital region and is frequently associated with paraproteinemia and lymphoproliferative diseases.

PATIENT AND METHODS

A 49-year old woman presented with bilateral, yellowish, subcutaneous lesions involving all four eyelids. These lesions have developed over the last year. Additionally, similar skin lesions developed on the trunk and the lower extremities. Two years ago, the patient had a bilateral episcleritis. An incisional biopsy was taken form the lesion. In addition, we reviewed the literature concerning similar cases.

RESULTS

Histologic examination revealed a granulomatous process consisting of histiocytes, foamy cells, multinucleated giant cells (touton- and foreign body-type) and associated with necrobiotic collagen and cholesterol clefts. General examination revealed the presence of a paraproteinemia of the IgG-typ associated with a hyperlipidemia. The patient was treated with a low dose chemotherapy which resulted in improvement of signs and symptoms. We could identify in the literature 75 similar cases. The mean age of those patients was 53 years.

CONCLUSION

The clinical and histologic findings in our patient were typical for a necrobiotic xanthogranuloma with associated paraproteinemia. The most favorable treatment response has been reported with low doses of systemic administered chemotherapeutic agents in combination with radiation therapy; however, the mortality due to underlying diseases is high.

Necrobiotic xanthogranuloma with two monoclonal paraproteins and no periorbital involvement at presentation

A patient with necrobiotic xanthogranuloma is presented to highlight the clinico-pathological features of this rare condition which must be differentiated from atypical necrobiosis lipoidica. The patient is unusual in that he has two associated monoclonal paraproteins and did not have periorbital involvement at presentation.

Necrobiosis lipoidica in a 9-year-old girl with new-onset type II diabetes mellitus

Necrobiosis lipoidica (NL) is an idiopathic dermatologic condition that is strongly associated with, but not pathognomonic for, diabetes mellitus. It is more commonly seen in women than men and in adults than children. We present the youngest child, to our knowledge, diagnosed with NL at initial presentation with type II diabetes mellitus. We review the literature and discuss pathogenesis, clinical features, and treatment options for NL.

[Necrobiotic xanthogranuloma with skin and liver amyloidosis]

BACKGROUND

Necrobiotic xanthogranuloma is a largely unknown disease. Both the frequency of this disease and the involvement of internal organs have clearly been underestimated until now.

CASE REPORT

A patient was admitted because of ulcerating, xanthomatous, subcutaneous nodules, scleritis and conjunctivitis. Laboratory studies revealed an elevated erythrocyte sedimentation rate, a monoclonal IgG-lambda protein, a pancytopenia and later a hypocomplementemia. Furthermore, a hepatosplenomegaly and esophageal varices were found. A skin biopsy specimen showed a granulomatous infiltrate consisting of lymphocytes, histiocytes, plasma cells, foam cells as well as Touton and bizarre-appearing foreign-body giant cells and cholesterol clefts typical of necrobiotic xanthogranuloma besides a deposit of amyloid. A liver biopsy sample disclosed an amyloidosis of the parenchyma, too. Neither a therapy with chlorambucil and prednisolone nor with interferon alpha-2a resulted in improvement.

CONCLUSION

Apart from treatment of skin lesions and ophthalmic manifestations further investigations are necessary because necrobiotic xanthogranuloma can be associated with malignancy and can involve internal viscera like lungs, heart and liver.

[Perforating necrobiosis lipoidica: 2 cases]

INTRODUCTION

Perforating necrobiosis lipoidica is a rare clinical form of necrobiosis lipoidica and is almost always associated with diabetes. Necrotized tissue is usually eliminated via transfollicular perforations.

CASE REPORT

We report two cases of perforating necrobiosis lipoidica associated with type II diabetes mellitus. The characteristic clinical feature was the presence of keratotic plugs around the periphery of the lesions. Transfollicular perforation predominated in the first case. The second also presented epidermal perforation.

DISCUSSION

There have been only 6 cases of perforating necrobiosis lipoidica in the literature. To our knowledge, this is the first case report of transepidermal elimination. We confirmed the constant association between this perforation type and diabetes mellitus.

[Granulomatosis disciformis Miescher]

We describe granulomatosis disciformis Miescher in a 57-year old female patient with typical clinical manifestation: disc-shaped plaques with slight central sclerosis and lesions resembling necrobiosis lipoidica and granuloma anulare. Histology revealed an infiltrate mainly composed of macrophages and lymphocytes and small foci of necrobiotic collagen and of new collagen formation. We review the literature on granulomatosis disciformis and nosology, concluding--as do most authors--that granulomatosis disciformis is a characteristic variant within the spectrum of cutaneous noninfectious granulomatous disease lying in between generalized granuloma anulare and necrobiosis lipoidica.

An unusual case of giant dermatofibroma in a patient with diabetes mellitus and necrobiosis lipoidica

A case of nine dermatofibromata, including a giant one, associated with necrobiosis lipoidica and diabetes mellitus type II is reported. This case is unusual because of the number and size of the tumors and their association with the above-mentioned pathologic conditions.

Necrobiosis lipoidica treated with topical tretinoin

Necrobiosis lipoidica is often resistant to therapeutic intervention. Lesions are atrophic and frequently ulcerate. A case is presented in which atrophy was diminished by the application of topical tretinoin. The practical and theoretical use of topical tretinoin in this disorder is reviewed.

Necrobiotic xanthogranuloma with paraproteinemia

Necrobiotic xanthogranuloma (NXG) is a rare skin disease mimicking necrobiosis lipoidica diabeticorum clinically and histologically. However, its association with paraproteinemia, and the evolution of hematologic malignancies in some cases, established NXG as a separate clinicopathologic entity. A typical case with indolent course is described.

Subcutaneous granuloma annulare of the eyelid. A case report

A rare case of subcutaneous granuloma annulare of the eyelid is reported. A diabetic patient developed a unilateral periorbital tumorous mass. Biopsy revealed subcutaneous palisading granuloma. By microscopy and immunohistology, other granulomatous reactions including necrobiosis lipoidica could be ruled out. Since treatment with dapsone was without effect, the tumor was surgically excised. The differential diagnosis and the literature are briefly discussed.

Chronic balanitis with palisading granuloma: an atypical genital localization of necrobiosis lipoidica responsive to pentoxifylline

We report a case of necrobiosis lipoidica located on the glans penis of a patient without diabetes mellitus. Both clinical and histologic features favor the diagnosis of necrobiosis lipoidica, even though the location is unusual. Treatment with pentoxifylline was effective. The differential diagnosis is discussed.

Periorbital necrobiosis lipoidica

Images

[Histological simulators of Kaposi's sarcoma in the initial phase]

Early Kaposi's sarcoma might be simulated by many different conditions, especially when the vascular component is prominent. the criteria suggested to differentiate early Kaposi's simulators are discussed. We found that these criteria are high in sensibility but low in specificity, therefore, we suggest using these criteria only when they are found in clusters.

[Necrobiosis lipoidica without diabetes mellitus (diagnostic and therapeutic possibilities)]

The goal of the present study was to follow the clinical behaviour of 6 non diabetic patients (5 females and 1 male, aged 23-68) suffering from necrobiosis lipoidica. Thickening of the basalmembrane of capillaries could be confirmed by electron microscopy, although the histological structure of skin alterations are not different from those observed in diabetes mellitus. Three patients (2 females and one male) showed impaired glucose tolerance, 2 other patients had increased levels of total cholesterol, whereas one patient suffered from both metabolic disturbances. After treatment with ASA (acetylsalicylic acid, 1.0 g/day) and dipyridamole (200 mg/day) for six weeks, the decrease of platelet in vitro aggregation in platelet rich plasma could be observed by stimulation with arachidonic acid, epinephrine, ADP and collagen, respectively. Healing of the exulceration of skin lesion could be detected by the use of the combined treatment of ASA and dipyridamole in 4 cases.

[Transcutaneous measurement of oxygen and carbon dioxide pressure in necrobiosis lipoidica]

Transcutaneous measurement of oxygen pressure (PcO2) and carbon dioxide pressure (PcCO2) was performed in nine patients with histologically confirmed necrobiosis lipoidica. None of the patients had diabetes mellitus. All measurements were taken at the lower leg. In each case, the atrophic center, the inflamed border, and the surrounding clinically normal skin of necrobiosis lipoidica were examined at 44 degrees C sensor temperature (maximal vasodilatation). Statistically significant hypoxia was found in the area of necrobiosis lipoidica, which was even more pronounced in the inflamed border. Inhalation of 100% oxygen provoked a marked increase in the PcO2 in the lesion, but the values were still significantly lower than in the normal skin. At the edge of the lesions the PcCO2 was significantly elevated. These findings support a vascular origin of necrobiosis lipoidica, involving reduced vascular perfusion combined with diffusion block.

Necrobiosis lipoidica diabeticorum with cholesterol clefts in the differential diagnosis of necrobiotic xanthogranuloma

The histopathologic findings in 331 cases of necrobiosis lipoidica diabeticorum seen during a 50-year period were reviewed. Three cases showing cholesterol cleft formation were found. All 3 cases were associated with severe diabetes mellitus. The differential diagnosis of importance is necrobiotic xanthogranuloma. Common features included extensive hyaline necrobiosis and foreign-body giant cells. Atypical and Touton-type giant cells are more common in necrobiotic xanthogranuloma. Vascular changes in necrobiotic xanthogranuloma may include granulomatous involvement of muscular walls with thrombosis. Explanations for cholesterol cleft formation are offered. When cholesterol clefts are seen in biopsy specimens of necrobiosis, necrobiotic xanthogranuloma must be ruled out. In addition, when found in necrobiosis lipoidica diabeticorum, these clefts may imply diabetes mellitus with complications.

Sarcoidosis with extensive cutaneous ulceration. Unusual clinical presentation

A 70-year-old white woman with sarcoidosis and insulin-resistant diabetes mellitus presented with extensive cutaneous ulcerations. Both the cutaneous lesions and the systemic features of sarcoidosis showed a dramatic improvement during oral corticosteroid therapy. When extensive cutaneous ulcerations are present, it is important to consider sarcoidosis, as these may be the only presenting sign of the disease. Unlike ulcerated necrobiosis lipoidica diabeticorum, sarcoidal ulcerations may respond well to treatment with oral corticosteroids.