Epidemiology and treatment of angiolymphoid hyperplasia with eosinophilia (ALHE): A systematic review

Misdiagnosis of uncommon presentation of Angiolymphoid hyperplasia with Eosinophilia

In 50-year-old female patients, the purple-red papules in the right upper arm were misdiagnosed as molluscum contagiosum or scars. The diagnosis of angiolymphoid hyperplasia with eosinophilia was determined on the basis of the clinicopathological features.

Angiolymphoid hyperplasia with eosinophilia of the external ear

Herein we present the rare case of angiolymphoid hyperplasia with eosinophilia of the external ear treated by surgical resection and full-thickness skin graft. Current diagnosis and management options are reviewed.

Angiolymphoid hyperplasia with eosinophilia in a hand treated with a reverse digital island flap and artificial skin: a case report

BACKGROUND

Angiolymphoid hyperplasia with eosinophilia is a rare nodular skin tumor characterized by eosinophilic invasion and vascular proliferation. Previous reports suggested that irritation and inflammation are the causative factors of this disease. Most cases of angiolymphoid hyperplasia with eosinophilia occur around the auricle, forehead, and scalp; the hand is rarely affected. Moreover, the tumor seldom presents as multiple nodules.

CASE PRESENTATION

A 67-year-old Japanese woman presented with a complaint of skin masses on her left thumb and index finger, which had gradually grown in size over the past few months. A biopsy was performed confirming a diagnosis of angiolymphoid hyperplasia with eosinophilia. The aponeurosis on her index finger was resected and tissue was reconstructed using a reverse palmar digital island flap harvested from the base of her index finger. The thumb lesion was also resected and covered with collagen-based artificial skin. Gradual progression of skin epithelialization followed by healing was noted 2 months after the surgery.

CONCLUSION

Angiolymphoid hyperplasia with eosinophilia is a rare tumor; it is seldom seen in the hands. It is generally treated by surgical resection. It is important to resect a sufficiently large area of the tissue due to the possibility of relapse in some cases. Furthermore, appropriate reconstruction is mandatory after wide margin tumor resection.

Kimura's disease associated with IgA nephropathy: A case report

Kimura's disease (KD) is a rare chronic inflammatory disorder of unknown etiology that manifests as painless subcutaneous lesions in the head and neck. It primarily affects young Asian males and is characterized by peripheral eosinophilia and elevated levels of serum Immunoglobulin (Ig)E. Histologically, a variety of renal lesions have been observed in patients with KD, although IgA nephropathy is rarely reported. In the current study, a case of KD with an atypical manifestation accompanied with IgA nephropathy was reported in a middle-aged Chinese man. The subcutaneous lesion was located on the elbow of the patient. Although the recurrence rate of KD-associated nephrotic syndrome is high, the patient has not experienced relapse following 6 months of pulse treatment with methylprednisone and cyclophosphamide. In conclusion, methylprednisone combined with cyclophosphamide is effective in the treatment of KD-associated IgA nephropathy, and long-term administration of methylprednisone may achieve the effect of preventing KD recurrence.

Epithelioid Hemangioma of the Face

An epithelioid hemangioma is a very rare lesion arising from vascular structures. We encountered 2 cases in atypical locations, one in the orbital and the other in the nasal region. We performed preoperative angiography in addition to the diagnostic imaging recommended in the literature. Angiography highlighted the lesions well, and in one case, it was possible to embolize the arterial trunk of a high-flow lesion. Angiography underscored how such lesions may differ from the vascular perspective, emphasizing the importance of histology in correct diagnosis. Management of both hemangiomas yielded good functional and cosmetic outcomes with no disease recurrence.

Angiolymphoid hyperplasia with eosinophilia with clinical pictures of keratoacanthoma: A rare case report

Angiolymphoid Hyperplasia with Eosinophilia (ALHE) is a benign tumor of the skin which may mimic other benign or malignant lesion of the skin. Practitioners should consider this diagnosis as a differential when encounter such lesion as papule or nodule on the face and scalp area.

VEGF-A Links Angiolymphoid Hyperplasia With Eosinophilia (ALHE) to THSD7A Membranous Nephropathy: A Report of 2 Cases

Autoantibodies against thrombospondin type 1 domain-containing 7A (THSD7A) cause membranous nephropathy (MN); however, the mechanisms involved in THSD7A expression and immunization are uncertain. We present 2 cases of THSD7A-associated MN accompanied by angiolymphoid hyperplasia with eosinophilia (ALHE), a benign tumor characterized by proliferation of plump endothelial cells. Prednisolone therapy, but not surgical resection of ALHE tumors, successfully suppressed eosinophilia and proteinuria in both cases. Because ALHE is characterized by the proliferation of plump endothelial cells, we focused on the roles of vascular endothelial growth factor A (VEGF-A) in MN pathogenesis. We found that plump endothelial cells in ALHE modestly expressed THSD7A in both cases. We also found that eosinophils in ALHE expressed VEGF-A, which upregulated THSD7A expression, especially under T-helper type 2-prone conditions in cultured endothelial cells. Furthermore, double-positive cells for THSD7A and CD83 surrounded the proliferated small vessels. Our results suggest that VEGF-A-induced THSD7A expression outside the kidney may be important for MN pathogenesis.

[A cutaneous case of angiolymphoid hyperplasia with eosinophilia: Presentation of a rare entity]

We report the case of a Caucasian 73-year-old woman, without medical history, who is operated of two lesions of the forehead and the scalp measuring 0.4 and 1cm. There is no adenopathy. Histopathological examination revealed a diffuse vascular proliferation of the dermis and the hypodermis composed of small vessels bordered of plump "epthelioid" endothelial cells. There is no mitotic figure. The stroma is slightly fibrous accompanied by a polymorphic inflammatory infiltrate rich in lymphocytes, sometimes arranged in lymphoid follicles, plasma cells and eosinophils. The proposed diagnosis is angiolymphoid hyperplasia with eosinophilia. This is a rare vascular tumor, benign according with the OMS classification and preferentially observed in the skin. We report a cutaneous case, clinical and histopathological data of the reported cases and present the main differential diagnoses.

Angiolymphoid hyperplasia with eosinophilia (epithelioid hemangioma) of the external auditory canal, an unusual presentation in an adult female: a case report

INTRODUCTION

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare entity that usually occurs as 0.5-3 cm, pink-to-brown nodules on the skin surface and subcutaneous tissues of the head and neck (Al-Muharraqi MA, Faqi MK, Uddin F, Ladak K, Darwish A. Angiolymphoid hyperplasia with eosinophilia (epithelioid hemangioma) of the face: an unusual presentation. Int J Surg Case Rep 2011;2:258-60.; Suzuki H, Hatamochi A, Horie M, Suzuki T, Yamazaki S. A case of angiolymphoid hyperplasia with eosinophilia (ALHE) of the upper lip. J Dermatol 2005; 32:991-5.).

CASE PRESENTATION

A 29-year-old woman presented to our ENT (ear-nose-throat) clinic with multiple, small reddish to pinkish nodules of approximately 1 × 2 cm2 in dimension. A biopsy from the surface of the left external auditory canal skin, where she had severe itching, showed features consistent with Angiolymphoid hyperplasia with eosinophilia ALHE.

DISCUSSION

Whether angiolymphoid hyperplasia with an eosinophilia etiology is a neoplastic or atopic hypersensitivity reaction (unusual reactive process) is controversial. The definitive treatment is surgical excision and follow-up (Al-Muharraqi MA, Faqi MK, Uddin F, Ladak K, Darwish A Angiolymphoid hyperplasia with eosinophilia (epithelioid hemangioma) of the face: An unusual presentation. Int J Surg Case Rep 2011;2:258-60.; Barnes L, editor. Surgical Pathology of the Head and Neck. 3rd edn. New York: Marcel Decker; 2001.).

CONCLUSION

Although ALHE of <3 cm has been rarely reported in the literature, it should be considered in the differential diagnosis of large subcutaneous tumors of the head and neck.

Novel Application of 32P Brachytherapy: Treatment of Angiolymphoid Hyperplasia with Eosinophilia in the Right Auricle with 8-Year Follow-Up

BACKGROUND

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a distinctive benign vascular disease that can be challenging to treat due to inconsistent results for various treatment modalities such as surgical excision, corticosteroids, radiotherapy, laser therapy, and other therapies, so novel approaches are needed to improve treatment outcomes.

MATERIALS AND METHODS

ALHE on the right auricle of a 54-year-old Chinese woman underwent brachytherapy using ³²P simple drug membranes for five times. The ³²P brachytherapy involving simple drug membranes of brachytherapy began by diluting a ³²P solution with 0.9% NaCl solution to produce a radioactivity of 69.2-74.7 MBq/mL(1.87-2.02 mCi/mL). The drug membranes were removed between 48 and 72h after application. There were intervals ranging from 65 to 72d between the membrane application periods, and the last treatment was in June 2010.

RESULTS

After the ³²P brachytherapy, follow-up results over the course of 8 years were promising. The regional symptoms disappeared, the right preauricular swelling decreased, the subcutaneous nodules decreased in size, the exudate disappeared, and the skin appearance improved.

CONCLUSIONS

This case indicated that ³²P brachytherapy may represent a novel ALHE treatment method that produces a favorable long-term outcome.

Angiolymphoid hyperplasia of external ear treated with intralesional radiofrequency ablation

A 21-year-old woman presented with multiple erythematous to skin-coloured dome-shaped firm papules and plaques over the right ear concha and external auditory canal for 1 year. It was associated with occasional itching and bleeding. Her main concern was cosmetic disfigurement. Biopsy showed presence of multiple proliferating blood vessels lined by plump epithelioid endothelial cells surrounded by dense infiltrate of lymphocytes, histiocytes and eosinophils. Other routine investigations were within normal limits. A diagnosis of angiolymphoid hyperplasia with eosinophilia was made. A single sitting of intralesional radiofrequency ablation (Vesalius, coagulation mode; fanning technique) using 18-G intravenous cannula was done. This led to almost complete resolution with no recurrence at 3 months follow-up. There was no evidence of scarring or depigmentation.

Angiolymphoid hyperplasia with eosinophilia: a case report

Background

Angiolymphoid hyperplasia with eosinophilia is a benign neoplasm that includes blood vessel proliferation and a dense eosinophilic inflammatory infiltrate. Mostly, it affects middle-aged adults manifesting as flesh/plum-colored pruritic nodules and papules, most commonly affecting the ear and the periauricular area.

Case presentation

In this case, we report a 13-year-old Caucasian girl with bilateral, huge, protruding, and yellowish nostril masses which were peculiar in location and of gross appearance. At first, the disease proved to be a diagnostic dilemma. After making a diagnosis of angiolymphoid hyperplasia with eosinophilia, the disease also proved to be a therapeutic dilemma. It did not respond to oral prednisolone or to oral indomethacin, and it proved to be resistant to topical steroids. Although surgery is the standard therapeutic approach, it recurred despite multiple surgical attempts. However, the only regimen that seemed to partially control the lesion was intralesional steroids combined with topical tacrolimus ointment.

Conclusions

Angiolymphoid hyperplasia with eosinophilia proves a therapeutic dilemma, because there is a large variety of proposed treatments, yet there is not enough data on most of them. Although the disease is not deadly by itself, it usually presents with disfiguring lesions that grimly affect the patient’s quality of life. This warrants further research and efforts to find an effective cure and a unified therapeutic approach.

Nonepithelial Tumors and Tumor-like Lesions of the Skin and Subcutis in Children

This overview of mesenchymal tumors presenting in the skin and/or subcutis in children brings together the range of neoplasms and hamartomas which are seen in this age-group. It is not surprising from the perspective of the pediatric or general surgical pathologist that vascular anomalies, including true neoplasms and vascular malformations, are the common phenotypic category. Since there is considerable morphologic overlap among these lesions, clinicopathologic correlation may be more important than for many of the other mesenchymal tumors. The skin and subcutis are the most common sites of clinical presentation for the infantile myofibroma which is the most common of fibrous mesenchymal tumors in children. Several of the other mesenchymal tumors are more common adults-like dermatofibrosarcoma protuberans, but nonetheless have an important presence in children, even as a congenital neoplasm. A lipomatous tumor in a young child should be considered as a possible manifestation of an overgrowth syndrome.

Immunoreactivity of Wilms tumor 1 (WT1) as an additional evidence supporting hemangiomatous rather than inflammatory origin in the etiopathogenesis of angiolymphoid hyperplasia with eosinophilia

Background

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare vascular proliferative disorder mainly located in the periauricular region. The etiopathogenesis of ALHE is unknown, and it is still controversial as to whether the entity represents a benign vascular neoplasm or an inflammatory process.

Aim

Recently, the intracytoplasmic staining pattern of Wilms tumor 1 (WT1) on immunohistochemistry has highlighted true vascular neoplasms, such as microvenular hemangioma, tufted angioma, and spindle cell hemangioma, which has made it helpful to distinguish ALHE from vascular malformations, as there is a negative staining pattern in the other entities. We aimed to investigate the immunoreactivity of ALHE specimens for WT1 as well as glucose transporter protein 1 (GLUT1) immunohistochemistry, an important and sensitive marker for the diagnosis of infantile hemangioma, which recently has been described to label other hemangiomas, such as verrucous hemangioma.

Material and methods

Clinical data and histopathological specimens from patients diagnosed with ALHE were reviewed, and immunohistochemical staining and microscopic analysis for WT-1 and GLUT1 were performed.

Results

Intracytoplasmic endothelial staining of WT1 was detected in 19 of 20 ALHE specimens. GLUT1 was not detected in any ALHE specimen.

Conclusions

We conclude that ALHE may represent a true hemangioma (i.e., benign vascular neoplasia) characterized by an eosinophil- and lymphocyte-rich inflammatory component as opposed to the reactive inflammatory dermatosis with a positive intracytoplasmic staining pattern for WT1. As far as we are aware, WT1 staining for ALHE has not been described to date.

Cutaneous Angiolymphoid Hyperplasia in a Dog

A 5-year-old male miniature dachshund was presented with a dermal nodule on the left forelimb that increased to 5 mm in diameter over a 2-month period. Grossly, the nodule was firm, and both the external and cut surfaces were homogeneously pale pink in colour. Microscopically, the nodule was comprised of mainly plump endothelial cells and inflammatory cells; among the latter, lymphocytes were predominant, with few scattered plasma cells, mast cells and macrophages. Lymphoid follicles with germinal centres were often observed. Mitotic figures were not observed amongst the endothelial cells. Immunohistochemically, the endothelial cells were positive for vimentin, factor VIII-related antigen and CD31, and the surrounding cells were positive for smooth muscle actin. Lymphocytes expressed CD3 or BLA36. These findings led to a diagnosis of cutaneous angiolymphoid hyperplasia. To the best of our knowledge, this is the first report of a cutaneous proliferative disorder comprising an admixture of proliferating vascular endothelial cells and lymphocytic infiltration with follicle formation in a dog.

Cutaneous Pseudolymphoma

The term, cutaneous pseudolymphoma (PSL), refers to a group of lymphocyte-rich infiltrates, which either clinically and/or histologically simulate cutaneous lymphomas. Clinicopathologic correlation is essential to achieve the final diagnosis in cutaneous PSL and to differentiate it from cutaneous lymphomas. A wide range of causative agents (eg, Borrelia, injections, tattoo, and arthropod bite) has been described. Based on clinical and/or histologic presentation, 4 main groups of cutaneous PSL can be distinguished: (1) nodular PSL, (2) pseudo-mycosis fungoides, (3) other PSLs (representing distinct clinical entities), and (4) intravascular PSL. The article gives an overview of the clinical and histologic characteristics of cutaneous PSLs.

Angiolymphoid Hyperplasia with Eosinophilia Involving the Occipital Artery: Case Report and Review of Literature

Angiolymphoid Hyperplasia with Eosinophilia (ALHE) is an atypical vascular tumour occurring primarily in the head and neck area, which must be distinguished from Kimura's disease. The lesions can appear as single or multiple grouped intradermal papules or subcutaneous nodules. We report a rare case of ALHE in a 57-year-old female with a large lesion of three nodules involving the right occipital artery which had a long term evolution and we treated it by surgical excision. The definitive histopathological diagnosis was ALHE. Our case report is accompanied by a discussion of clinical, radiological and histological features. Surgical excision with free margins is the treatment of choice but, even though ALHE is considered a benign condition, recurrence is common.

Eosinophilia

Eosinophilia is defined as elevation of eosinophils in the bloodstream (450-550 cell/μL). There are many reasons for eosinophilia to exist, including parasitic disease, allergic disease, autoimmune, connective tissue disease, rheumatologic disease, primary eosinophilia such as hypereosinophilic syndrome, and as part of a malignant state. Primary care physicians should have an understanding of the variety of diseases or situations that can produce eosinophilia and know in what setting referral to specialty care may be warranted.