Histiocytic medullary reticulosis associated with cytomegalic inclusion disease. A case report

Malignant Histiocytosis: A Clinicopathologic Study of 18 Consecutive Cases

The clinical records and histologic material of 18 consecutive patients with malignant histiocytosis were reviewed. The age of the patients ranged from 20 months to 72 years (median 35 years). There were 14 males and 4 females (3.5:1). Lymph node and liver enlargement, fever, and skin nodules were the most common physical findings; and leukocytosis was frequently the most abnormal laboratory test. Seven of 18 patients died, and their survival ranged from 1 to 15 months (median 8 months) after histopathologic diagnosis. The histologic findings on lymph nodes, spleen, liver, bone marrow, and skin were investigated with special reference to both the cellular composition and the pattern of lymph node involvement. Vascular invasion of small perinodal vessels was observed in 4 fatal cases. The absence of capsular invasion and the lack of cohesiveness among atypical proliferating histiocytes of malignant histiocytosis appeared to be inconstant. Sequential lymph node biopsies revealed in later stages the extension of the histiocytic proliferation from the sinuses into the cords and the complete obliteration of the nodal structures. The radiologic investigations yielded numerous pathologic findings that were consistent with the dissemination of the disease. Complete response to initial treatment was achieved in patients that were treated with radiotherapy and/or chemotherapy. Complete response with chemotherapy was achieved only when the treatment included adriamycin. The histologic and clinical features of the present series provide further evidence for the recognition of malignant histiocytosis as a distinct clinical and pathologic entity.

Deciphering the role of Epstein-Barr virus in the pathogenesis of T and NK cell lymphoproliferations

Epstein-Barr virus (EBV) is a highly successful herpesvirus, colonizing more than 90% of the adult human population worldwide, although it is also associated with various malignant diseases. Primary infection is usually clinically silent, and subsequent establishment of latency in the memory B lymphocyte compartment allows persistence of the virus in the infected host for life. EBV is so markedly B-lymphotropic when exposed to human lymphocytes in vitro that the association of EBV with rare but distinct types of T and NK cell lymphoproliferations was quite unexpected. Whilst relatively rare, these EBV-associated T and NK lymphoproliferations can be therapeutically challenging and prognosis for the majority of patients is dismal. In this review, we summarize the current knowledge on the role of EBV in the pathogenesis of these tumours, and the implications for treatment.

Virus-associated haemophagocytic syndrome caused by rubella in an adult

Haemophagocytic syndrome is a systemic clinicopathological entity characterized by systemic proliferation of benign haemophagocytic histiocytes, fever, cytopenia, abnormal liver function and, frequently, coagulopathy and hepatosplenomegaly. Its occurrence has been documented in association with viral, bacterial, fungal and parasitic infections, a wide spectrum of malignant neoplasms, autoimmune diseases and drugs. We report a case of rubella virus-associated haemophagocytic syndrome in a previously healthy 29-year-old woman. Blood tests showed cytopenia, especially severe thrombocytopenia, liver dysfunction, hyperferritinaemia and hypercytokinaemia. Bone marrow examination showed many mature histiocytes with active haemophagocytosis. A skin biopsy from the rash revealed perivascular lymphohistiocytic infiltrates with haemophagocytic histiocytes in the upper and mid-dermis. The patient was treated with antibiotics and immunoglobulin, and by supportive measures including platelet transfusion, and recovered completely.

The use of cyclosporin-A in the treatment of virus-associated hemophagocytic syndrome in adults

Virus-associated hemophagocytic syndrome (VAHS) is one of the categories of hemophagocytic syndrome (HPS) which is a clinicopathologic entity characterized by systemic proliferation of benign hemophagocytic cells of the monocyte-macrophage-histiocyte lineage, associated with fever, cytopenia, hepatosplenomegaly, lymphadenopathy, and coagulopathy. The disease affects children and adults after infection with various viruses. However, clinical manifestations are quite different between children and adults. Although the etiology of VAHS is not fully understood, accumulating evidence has revealed dysregulation of the immune system. Standard treatment of VAHS has not been established, yet, but successful trials aiming at immunomodulation have been reported. In this report, current concepts and clinical features of VAHS are reviewed, focusing on the recently introduced cyclosporin A therapy in VAHS in adults.

Malignant histiocytosis associated with autoimmune thrombocytopenia

We describe a patient with malignant histiocytosis whose serum contained an autoantibody against platelet protein. The patient was admitted because of nasal bleeding and high-grade fever. The clinical course was fulminantly progressive and terminated with cerebral hemorrhage. Bone marrow aspirate showed the proliferation of large atypical cells, some of which exhibited phagocytic activity. At postmortem examination, there was diffuse infiltration of these atypical cells in the liver, spleen, kidney, and bone marrow. Morphological, cytochemical, immunohistochemical, and genotypic characteristics suggested that the proliferating cells were derived from the monocyte-macrophage system. Western blot analysis revealed the presence of autoantibody against an approximately 88 kd molecule of platelet proteins. Although the relationship of cause and effect remains to be clarified, this autoantibody appeared to have stimulated thrombophagocytosis of the neoplastic cells.

Fatal panniculitis

The Weber-Christian syndrome (relapsing nodular panniculitis) displays a clinical spectrum varying from short, self-limited, or intermittent disease episodes to persistent disease with fatal outcome. Inflamed adipose tissue is exclusively subcutaneous in some patients and is both subcutaneous and perivisceral in others. Inflammation of fat may induce a focal cutaneous or a systemic extracutaneous histiocytic proliferative response in which hemophagocytosis may be a frequent characteristic. Major causes of death--sepsis, hepatic failure, hemorrhage, and thrombosis--are identical in the patients with and without the systemic histiocytic proliferation. Inflammation in fat, of and by itself, may be associated with significant morbidity and mortality, regardless of specific histopathology or inciting factors.

Reactive hemophagocytic syndrome

Two cases of reactive hemophagocytic syndrome (RHS) are reported, and the clinical and pathological features are compared with other histiocytic proliferative disorders, including familial hemophagocytic lymphohistiocytosis (FHL) and malignant histiocytosis. RHS can be associated with a variety of infections, including viral, bacterial, fungal, and parasitic. RHS may also be familial as exemplified by our 2 cases in siblings. The isolation of an effective agent appears to be the only criterion by which a diagnosis of RHS can be made.

The familial histiocytoses

Several rare disorders characterized by histiocytic hyperplasia are inherited as single-gene Mendelian traits. These familial forms of histiocytosis are heterogeneous and can be clearly distinguished from each other by clinical and genetic criteria. The genetic nature of these disorders can lead to familial recurrence and thus necessitates their distinction from the classical reticuloendothelioses. The clinical manifestations and modes of inheritance of the various familial histiocytoses are reviewed.

Panniculitis associated with cutaneous T-cell lymphoma and cytophagocytic histiocytosis

A 36-year-old woman had a 6-year history of recurrent panniculitis with development of an angiocentric and angiodestructive cutaneous T-cell lymphoma (CTCL) of the helper cell phenotype. She subsequently developed a rapidly progressive fatal syndrome characterized by cytophagocytic histiocytosis and hyperlipidaemia. Cytophagocytic histiocytosis has previously been reported in association with panniculitis, malignancy and infection, but not with CTCL and the precise relationship between panniculitis, CTCL, cytophagocytic histiocytosis and hyperlipidemia is unclear.

A histiocytic medullary reticulosis-like syndrome as the terminal event in lymphocytic lymphoma

Histiocytic medullary reticulosis is a rare disease of the reticuloendothelial system. The diagnosis of this disorder has generally been established by postmortem examination following a rapidly fatal clinical course characterized by fever and pancytopenia. Originally described as a de novo disease of unknown etiology, a histiocytic medullary reticulosis-like syndrome has been more recently found in association with a number of other disorders, the majority being lymphoreticular neoplasms. This report describes a patient with a 9-year history of lymphocytic lymphoma which terminated in a rapidly fatal disease which, clinically and pathologically, was consistent with a diagnosis of histiocytic medullary reticulosis.

Malignant histiocytosis in childhood: clinical study and therapeutic results in 22 cases

Twenty-two children with malignant histiocytosis ranging in age from 2 to 13 1/2 years are described. In 10 cases, the correct diagnosis was only made retrospectively. The most salient pathologic features were found in lymph node biopsy specimens. Fever and wasting were the most prominent symptoms in 21 cases, and abdominal pains were striking in 9. Peripheral lymphadenopathy, mostly of the cervicoaxillary type, was present in 21 patients, with marked tenderness in 14. Abnormal mediastinal and/or paraaortic lymph nodes were detected radiographically in two-thirds of the patients. Other prominent features included subcutaneous inflammatory infiltration in 12 patients and skin nodules in 8. Pleural effusions were seen in 8 children. The haematologic findings are described. Only 5 of 19 children had bonemarrow involvement. Fifteen patients died, one to 45 months from onset of their illness (median survival time, five months). Nine patients are alive with no evidence of disease 21 to 46+ months (median, 40 months) after the time of diagnosis and 8 have currently been off treatment for periods ranging from three to 29 months; they all have been treated with vincristine, prednisone, cyclophosphamide, and adriamycin and 4 have achieved remission after treatment with vinblastine, bleomycin, and CCNU or cytosine-arabinoside. It is concluded from this study that clearly delineated clinical features of malignant histiocytosis in childhood should allow more rapid determination of the proper diagnosis and should result in early treatment by means of intensive systemic combination chemotherapy, which has dramatically improved the prognosis.

Virus-associated hemophagocytic syndrome: a benign histiocytic proliferation distinct from malignant histiocytosis

Nineteen patients whose bone marrow smears showed histiocytic hyperplasia with prominent hemophagocytosis were found to have a clinicopathologic syndrome associated with active viral infection. High fever, constitutional symptoms, liver function, and coagulation abnormalities and peripheral blood cytopenias were characteristic findings. Hepatosplenomegaly, lymphadenopathy, bilateral pulmonary infiltrates, and skin rash were often present. Fourteen of the patients were immunosuppressed. Active infection by herpes group viruses was documented in 14 patients and by adenovirus in 1. The bone marrow of most patients also showed decreased granulopoiesis and erythropoiesis with normal to increased numbers of megakaryocytes. Treatment generally consisted of supportive therapy and withdrawal of immunosuppressive drugs. Thirteen patients recovered. Lymph node biopsy and autopsy material showed generalized histiocytic hyperplasia with hemophagocytosis. The relationship of this disorder to familial hemophagocytic reticulosis, familial erythrophagocytic lymphohistiocytosis, histiocytic medullary reticulosis, and malignant histiocytosis is discussed. Immunosuppressive and cytotoxic therapy may be contraindicated in the treatment of this virus-associated syndrome.

Chemotherapy of malignant histiocytosis in adults

Malignant histiocytosis is a fulminant neoplasm resistent to single agent chemotherapy and resulting in death within 6 months. Sixteen patients have received chemotherapy for this disorder between 1965-1975 at Stanford. Nine patients responded to chemotherapy. Responders had a median survival of 23 months from onset of symptoms and a significantly longer survival than non-responders (p = 0.03). The most promising responses were in seven patients treated with a combination of cyclophosphamide, adriamycin, vincristine and prednisone. Five of the seven responded, with two of the five later relapsing and dying, two having equivocal evidence of disease while on chemotherapy for 6 and 9 months, and one free of disease for 17 months after completing 8 months of chemotherapy. Three patients had central nervous system (CNS) relapses, two during peripheral remission. One of these had control of CNS disease with brain irradiation and intrathecal methotrexate, but all three eventually died. It is hoped that with combination chemotherapy and prophylactic CNS treatment, long term disease-free survivals will be achieved.

Histiocytic medullary reticulosis with parallel increases in serum acid phosphatase and disease activity

Two months after presenting with autoimmune hemolytic anemia, a 57-year-old man developed increased serum acid phosphatase activity. Subsequently, abnormal histiocytes were found in the bone marrow and blood, and 8 months after the onset of his illness lymph node biopsy led to the diagnosis of histiocytic medullary reticulosis. At that time the level of serum acid phosphatase activity was more than 60 times the upper limit of normal and then paralleled the activity of his disease during temporary responses to chemotherapy, rising to over 90 times normal at the time of his death 1 year after presentation. No prostatic malignancy was demonstrated by biopsies or at autopsy, and electrophoretic studies of the serum enzyme suggested that it was of extraprostatic origin. It is postulated that the acid phosphate present in the serum at levels heretofore described only in metastatic carcinoma of the prostate may have arisen from the abnormal histiocytes.

Malignant histiocytosis (histiocytic medullary reticulosis). I. Clinicopatholigic study of 29 cases

The clinical records and histologic material from 29 cases of malignant histiocytosis (MH) have been reviewed, as well as autopsy findings in 14 cases. The mean age was 31 years, with a 2.2:1 male to female preponderance. Major physical findings included temperature elevation, lymphadenopathy, hepatomegaly, splenomegaly, and preterminal jaundice. Common laboratory findings were anemia, leukopenia, and thrombocytopenia. The median survival was 6 months, the mean 14 months, and the range from 1 month to 8 years. The histologic features observed in lymph nodes, liver, spleen, and bone marrow have been emphasized, as well as features useful in differential diagnosis. In contrast to our experience with the non-Hodgkin's lymphomas, bone marrow aspiration was superior to biopsy in assessing marrow involvement. Unusual manifestations included soft tissue infiltration in 5 cases; 2 of these patients presented with a soft tissue mass. The distinctive clinical as well as histologic findings warrant recognition and separation of MH from other hematopoietic disorders.