Cervical spine cord compression by eosinophilic granuloma. Case report

Eosinophilic granuloma is a term reserved for the most often and benign form of disorder known as Langerhans cells histiocytosis. It is a disease of children and adolescents that very rarely affects adults, representing the localized form of a pathological proliferation of histiocytes in bones, like skull and long bones. Vertebral involvement is uncommon, approximately 8% of the cases, being the cervical localization the least affected. Moreover, the involvement of the spinal cord and roots remains a rare occurrence. Only five cases characterized by signs of cervical spinal cord compression have been reported. We report the sixth case in a 42-year-old-man who evolved with resolution of symptoms, and has remained asymptomatic after treatment. The clinical, radiological and histological features and, also, the value, in selected cases, of surgical treatment followed by low-dose radiation therapy is discussed. A review of the pertinent literature is also presented.

[Treatment concepts in osseous manifestations of Langerhans cell histiocytosis]

INTRODUCTION

Patients with Langerhans Cell Histiocytosis (LCH or Eosinophilic granuloma) were assessed from the orthopaedic point of view to give recommendations for the management of the disease.

MATERIAL AND METHODS

The results of 36 cases of histologically proven bony manifestations out of 48 treated cases were reviewed. A retrospective analysis of our treated cases with bony manifestations of LCH between 1970 and 1995 was performed.

RESULTS

Twenty-two cases exhibited isolated bony manifestations, 18 were monoostotic and 4 were polyostotic. We treated 14 cases with multi-organ disease including bony manifestations of LCH. In the cases of exclusive bony manifestations reactivations were rare and usually occurred in other bones.

CONCLUSIONS

In order to assure stability local control is the general goal of orthopaedic treatment. In isolated lesions control can be achieved by excochleation and filling with cancellous bone or prednisolon instillation. Multiple lesions should be treated primarily by systemic drugs and operative procedures are only necessary if severe local problems occur. Additionally, we recommend interdisciplinary cooperation between ortopedic surgeon, pediatrist and pathologist.

Eosinophilic foreign body granuloma after multiple self-administered bee stings

A bee sting can cause a foreign body granuloma of the skin, due to activated macrophages at the stinging site. A 52-year-old woman presented with a large doughnut-shaped ulcerative tumour on the left side of her face. A bean-sized facial papule had grown to a 4.0 x 3.9 x 1.1 cm mass after multiple bee stings induced by herself over a period of 1 year. Histology showed epidermal ulceration with granulomatous inflammatory cell infiltration of many eosinophils. No micro-organisms or foreign bodies were identified. Intralesional triamcinolone acetonide was not effective, but an excellent outcome was obtained using carbon dioxide laser vaporization of the lesion.

[Granuloma eosinophilicum faciei simulating rhinophyma. Therapeutic long-term outcome after surgical intervention]

A 53 year old man presented with a giant variant of granuloma faciale, closely resembling rhinophyma. Therapeutic approaches with cryosurgery and dapsone were unsuccessful. Surgical reconstruction of the nasal skin resulted in an excellent and long lasting effect. We give a short overview of this relatively rare disease, describe an unusual manifestation and discuss the therapeutic possibilities. Surgical procedures seem to offer the best results, despite the inflammatory pathogenesis of the disease.

[Granuloma eosinophilicum faciei--successful cryosurgery treatment of 6 patients]

Six patients with granuloma faciale, including patients with multiple lesions, were treated successfully with cryosurgery. Granuloma faciale is known to be difficult to treat. Cryosurgery is an effective and minimally invasive therapy for this granulomatous inflammation of the skin. It should be considered as an alternative to dapsone.

Recurrence of Langerhans' cell granulomatosis following lung transplantation

A case is presented of pulmonary Langerhans' cell granulomatosis which recurred following lung transplantation and responded to cyclophosphamide. This suggests that the primary abnormality in this condition lies in the Langerhans' cell or precursor dendritic cell.

[Eosinophilic granuloma in the jaw. Report of a case]

The authors describe the eosinophilic granuloma through a case. The difficulty of clinical diagnosis was pointed out. The importance of histologic diagnosis was also claimed, and therapeutic advices were given. Attention was drawn to the importance of the recognition of the disease in time.

[Anesthesia management for a patient with pulmonary eosinophilic granuloma associated with bilateral pneumothorax--general anesthesia with positive pressure ventilation]

Pulmonary eosinophilic granuloma (PEG) is a rare fibroinflammatory disorder and is characterized by a mixed interstitial infiltrate of eosinophils, lymphocytes and Langerhans cells. We experienced anesthetic management for a patient with PEG associated with bilateral pneumothorax. Anesthesia was maintained with epidural anesthesia and general anesthesia using positive pressure ventilation. At first we ventilated with a low airway pressure, but recognized an increase in endtidal CO2. Then we switched to a high airway pressure (= 22 cmH2O) and decreased the concentration of carbon dioxide. No new air leaks were observed by ventilating with the high airway pressure. It was concluded that in anesthetic management for PEG we must be careful about the airway pressure during operation.

Microsurgical excision of a primary isolated hypothalamic eosinophilic granuloma. Case report

Solitary focal eosinophilic granuloma (EG) is one element in the spectrum of diseases associated with Langerhans' cell histiocytosis (LCH). This report documents the occurrence of a primary isolated hypothalamic EG in a man who presented with diabetes insipidus and panhypopituitarism. His treatment consisted of complete microsurgical excision of the lesion. After a 13-month follow-up period, no residual tumor was evident on magnetic resonance imaging and no other lesions were present in peripheral tissues. This case is unique in several respects: 1) it is the third documented case of a primary isolated hypothalamic LCH granuloma diagnosed in a living patient; 2) it is the only known example of complete microsurgical excision of such a lesion in the hypothalamic region; and 3) it demonstrates the efficacy of direct surgery in this scenario, as compared with other treatment modalities such as biopsy and irradiation, suggesting that complete surgical excision may represent the treatment of choice for isolated intracerebral LCH granulomas, being curative in most instances. Also, the literature is reviewed for information about the diagnosis and treatment of this particular type of unifocal brain lesion.

Eosinophilic granuloma of the spine

Twenty patients treated for eosinophilic granuloma of the spine were studied. Only 40% demonstrated the classical radiographic picture of vertebra plana. In 60% a lytic lesion of the vertebral body or the posterior elements was found. Seven patients underwent surgery; the indications were neurological involvement or failure of the biopsy to disclose the diagnosis. At an average follow-up period of 7 years, 17 patients are well and alive with no residual spinal pain, neurological compromise, recurrent disease, or extraskeletal involvement. Vertebral body collapse underwent some regeneration but did not regain full body height. In several patients this resulted in a local deformity. In patients with unifocal spinal eosinophilic granuloma, watchful observation with no treatment other than spinal support is warranted. In patients with neural involvement or multifocal lesions, a more active treatment, including surgery, may be indicated.

[Thoracoscopic surgery for the giant bulla complicating pulmonary eosinophilic granuloma: a case report]

We report a case of pulmonary eosinophilic granuloma (PEG) accompanied with a giant bulla successfully operated with a thoracoscopy. A 24-year-old female had been suffering from recurrent bilateral pneumothoraces with multiple bullae since February 1993. She was diagnosed as PEG with an open lung biopsy in July 1994. Repetitive pleurodesis were efficacious against the pneumothoraces. However, a bulla in the left upper lobe were growing with her respiratory function having worsened to bed rest. In May 1995, thoracoscopic surgery were performed to extinguish the bulla. Trocars were directly introduced into the lumen of the bulla. Ligation of the three communicating bronchial branches and tube drainage made the bulla disappear immediately. The patient had been well for one and a half year postoperatively.

Skin grafting in otology

Proper healing after surgery of the external auditory canal and open-cavity mastoid depend on epithelialization of exposed surfaces. This may be retarded by the formation of abundant granulation tissue or cicatrix, which can be dealt with by the use of thin, split-thickness skin grafts. This technique, which has received little attention in the literature, is described in detail and nine cases treated for various disorders are illustrated. Patient ages ranged from 5 to 80 years and the mean follow-up was 17.2 years. Results, complications, and caveats for successful grafting are presented.

Eosinophilic granuloma of the clivus: case report, follow-up of two previously reported cases, and review of the literature on cranial base eosinophilic granuloma

OBJECTIVE AND IMPORTANCE

To our knowledge, this is the first reported case of the use of stereotactic radiotherapy for an eosinophilic granuloma (EG) of the clivus. We report follow-up information on two previously reported cases and suggest a management plan for this rare lesion.

CLINICAL PRESENTATION

We report the case of a 4.5-year-old boy who presented with a complete abducens palsy on the right with an associated head turn. A computed tomographic scan of his head revealed a lytic lesion on that side, and magnetic resonance imaging showed the mass to be of low intensity on T1-weighted images and of high intensity on T2-weighted images with heterogeneous enhancement.

INTERVENTION

A transnasal stereotactic biopsy was performed, revealing an EG. The patient was treated with stereotactic radiotherapy, and he became symptom-free with radiographic resolution of his lesion. Reviewing the literature, we found 13 series with 87 cases of EG in the petrous portion of the temporal bone. EG in the cranial base occurring outside of the temporal bone or in the temporal bone and extending intracranially is, however, quite rare, with only nine other cases reported, two of them clival.

CONCLUSION

These findings suggest a classification schema in which cranial base EG lesions be grouped with either the more common extracranial petrous temporal bone lesions or the very rare intracranial lesions. Although there are few cases in the literature, treatment results indicate that clival EG, and perhaps all intracranial cranial base EGs, be treated by a biopsy alone, followed by surgery or stereotactic radiotherapy if there is an incomplete resolution of the symptoms or if there is a recurrence.

Eosinophilic granuloma: report of case

This paper related a case of eosinophilic granuloma in an eleven-year-old male child, treated successfully with curettage. The lesion appeared as a single irregular nodule in the left mandibular alveolar crest. A radiolucency was observed in the radiograph apparently causing an expansion of the vestibular and lingual cortical plates and displacement of the germs of the canine and first premolar. The treatment was by curettage, retaining the germs of the teeth involved. Other parts of the body were examined by osteal scintillography. Clinical and radiographic observations were done in the first three months; one year; two years; and five years postoperative with excellent prognosis.

[Oral histiocytosis X with severe upper maxillary destruction]

Histiocytosis X is a group of disorders of the reticuloendothelial system that have different clinical features and common histological characteristics, including abnormal proliferation of Langerhans cells. Eosinophilic granuloma is a localized form of histiocytosis affecting one or more bones. A case report is made of a patient diagnosed as histiocytosis X whose first manifestation was the appearance of an orosinusal communication. The lesions were located in the maxillary bones and produced large osteolytic lesions. No other bones were affected. In spite of surgery and radiotherapy, the disease recurred at 12 months.

Eosinophilic granuloma of C4 causing spinal cord compression

A rare case of vertebral eosinophilic granuloma (C4) causing spinal cord compression is reported. The clinical, histological and radiological features of this pathological entity are discussed. After surgery a complete neurological recovery was observed. The value, in selected cases, of surgical treatment with total removal of the tumour and reconstruction of the spine to ensure spinal stability and to prevent irreversible neurological deficit is emphasized.

[Eosinophilic ulcer of the oral mucosa]

The eosinophilic ulcer is a rare lesion of the oral mucosa; it is a benign disease, the etiology and the pathogenesis are unknown. The authors describe a patient with eosinophilic ulcer of the oral mucosa. The clinical, pathologic and therapeutic aspects of this rare disease are discussed.

Eosinophilic granuloma associated with intratumoral hemorrhage--case report

A 2-year-old boy presented with a rapidly growing soft scalp mass in the left parietal region. Surgical exploration and histological examination demonstrated an eosinophilic granuloma associated with intratumoral hemorrhage. Eosinophilic granuloma should also be considered when a scalp mass lesion exhibits rapid growth.

Solitary eosinophilic granuloma of the pelvis in children. A report of three cases

We present three cases of eosinophilic granuloma of the ilium in children. Imaging investigations (computed tomography and magnetic resonance imaging) did not elucidate the disease but rather revealed patterns more like malignant tumours than a benign condition. However, these investigations were of value in directing the surgeon to the correct site for biopsy.

[Langerhans cell histiocytosis of the temporal bone]

BACKGROUND

The localized form of the Langerhans cell histiocytosis was referred to earlier as eosinophilic granuloma, which has the best prognosis of all histiocytosis syndromes concerning survival. The non-malignant proliferative disorder of the histiocytic system is still of unknown etiology. Characteristic radiographic signs are osteolytic lesions.

PATIENT

We report on an otologic manifestation of a 20-year-old man's temporal bone, which developed three years after a successful treatment of an eosinophilic granuloma of the mandible.

RESULTS

Surgery and low-dose irradiation led to a complete remission of the disease. Other manifestations of the disease were not detected until now.

CONCLUSIONS

In the presence of chronic aural discharge, Langerhans cell histiocytosis must bei considered in differential diagnosis and a histopathological examination should be performed.

Solitary involvement of the fourth thoracic vertebral body with eosinophilic granuloma and development of incomplete paraparesis

This is a report of the case of a 9-year-old boy with solitary involvement of the fourth thoracic vertebral body with eosinophilic granuloma and development of neurologic deficits. Ventral decompression of the spinal cord, removal of the tumor tissue, and anterior arthrodesis succeeded in preventing an increase of the kyphotic deformity of the vertebral body. Complete reversal of the neurologic deficits was seen in the further course.