Angiocentric lesions of the head and neck

Primary intraorbital inflammatory lumpy lesion: A rare case report

RATIONALE

Eosinophilic angiocentric fibrosis (EAF) is considered to be a kind of benign IgG4-related disease, and it is more often found in the nasal cavity. We present a pretty rare case of orbital EAF that is unlike any other reported case for this case is an IgG4 negative orbital EAF and successfully treated by the fronto orbitozygomatic approach surgery.

PATIENT CONCERNS

This is a 68-year-old man from a rural area of Inner Mongolia Autonomous Region, went to our hospital for a 2-month history of vision loss with a local hospital orbital computer tomography which showed that there was a lesion in his left orbit. The inspection of the patient revealed that the patient left eye was protruding outward and the left eyelid unable to complete open or close. And his left eyeball movement had difficulty in all directions. Postoperative pathology diagnosed that this was a case of IgG4-negative EAF case.

DIAGNOSES

Orbital EAF.

INTERVENTIONS

Surgical radical resection and postoperative glucocorticoid therapy.

OUTCOMES

After surgery, the left eye vision of this patient increased to 0.6 tested in the standard logarithmic visual acuity chart. And his left eyeball movement dysfunction and eyeball outward protruding get a partially relief.

LESSONS

EAF occurring in the orbit is a very rare disease and immunohistochemical results of EAF can be IgG4 negative.

A clinical case of orbital inflammatory pseudotumor as the primary expression of eosinophilic angiocentric fibrosis

Eosinophilic angiocentric fibrosis (EAF) is an infrequent and slowly progressive disease, represented by fibroinflammatory lesions of unknown origin, which mainly involves the sinonasal structures and upper respiratory tract. Occasionally, it can affect the orbit and ocular adnexa causing symptoms such as proptosis, globe displacement and periorbital edema. In very rare cases, ocular manifestation as an orbital inflammatory pseudotumor can be the primary localization of the disease. Current literature proposes a relation between EAF and immunoglobulin G4-related disease spectrum. We describe the case of a 69-year-old man presented with antecedents of left periorbital edema, epiphora and retroocular pain. Examination showed a nonaxial proptosis, severe limitation in left eye adduction and lateral globe displacement. Orbital imaging revealed a left medial orbital mass with involvement of the inferior rectus and the medial rectus muscles. An orbital biopsy of the mass illustrated an inflammatory infiltrate with a notable eosinophilic component, "onion-skin appearance" of vessels and surrounding concentric fibrosis, highly suggestive of EAF. Further investigations showed a high expression of IgG4 and excluded other possible diseases. There was a favorable evolution of the orbital inflammatory pseudotumor following a 4-month treatment course with oral glucocorticoids. Abbreviations: EAF = Eosinophilic angiocentric fibrosis, CT = Computed tomography, MRI = Magnetic resonance imaging, GPA = Granulomatosis with polyangiitis, EGP = eosinophilic granulomatosis with polyangiitis, MPA = microscopic polyangiitis, ANCA = Anti-neutrophil cytoplasmic antibodies, Ig = Immunoglobulin.

Eosinophilic Angiocentric Fibrosis: A Review and Update of Its Association With Immunoglobulin G4-Related Disease

Eosinophilic angiocentric fibrosis is a rare indolent lesion of the head and neck region that has characteristic histologic findings of onionskin fibrosis and prominent eosinophils. Its pathogenesis has been poorly understood and has been most commonly attributed to hypersensitivity or previous trauma. Recently, the lesion has been included in the spectrum of immunoglobulin G4 (IgG4)-related disease. However, few of the existing cases of eosinophilic angiocentric fibrosis have been evaluated for IgG4⁺ and IgG⁺ plasma cells. Therefore, we provide an update on the clinical and histologic features of eosinophilic angiocentric fibrosis to increase awareness of the entity and encourage its further characterization as an IgG4-related disease.

Granuloma Faciale and Eosinophilic Angiocentric Fibrosis: Similar Entities in Different Anatomic Sites

BACKGROUND

Eosinophilic angiocentric fibrosis (EAF) and granuloma faciale (GF) share several histopathologic features, including eosinophil-rich inflammation, microangiitis, and progressive fibrosis. Concurrent presentation of EAF and GF suggests a pathogenetic link between them.

OBJECTIVES

To identify histologic findings that tell them apart and construe the pathogenetic mechanisms behind each morphologic variable, 14 immunohistochemical markers were used to study the cells subpopulations in 14 cases of GF and 3 cases of EAF.

MATERIALS AND METHODS

The lesions were classified according to their stage of development. The antibodies studied were: CD4, Foxp3, CD8, granzymes A and B, perforin, granulysin, CD20, CD56, CD68, ICAM-1, CD34, CD105, and 1A4.

RESULTS

The intensity of the sclerotic response and the density of 1A4-immunostained cells were significantly higher in EAF. In both diseases, CD68 cells were the most numerous, followed by CD20, CD8, and CD4 cells. About 30% of cells expressed ICAM-1. Among cells with cytotoxic granules, granulysin-positive cells were the most frequent.

CONCLUSIONS

Differences between GF and EAF were found to be mostly like due to anatomic site (usually skin of the face vs. sinonasal cavity) and stage of the disease development (usually earlier in cutaneous lesions because of their visibility). Innate and adaptive immunity, including B cells, T cells, and cytotoxic granules have a role in their pathogenesis.

Orbital Compartment Syndrome in Eosinophilic Angiocentric Fibrosis

A 43-year-old man reported right visual loss after biopsy of an intranasal mass, which improved after treatment at another hospital. On first examination at our hospital, his visual acuity was 1.2 OD, and MRI showed a right intraorbital mass involving the ethmoid sinus. His visual acuity decreased to 0.08 OD 12 days after orbital biopsy, with right globe tenting shown by MRI. An emergent lateral canthotomy and cantholysis were performed. The histopathological diagnosis was eosinophilic angiocentric fibrosis, and treatment with intravenous methylprednisolone (125 mg/day) and oral diaminophenyl sulfone (75 mg/day) was started immediately after surgery. One month later, the diaminophenyl sulfone was discontinued and cyclophosphamide (50 mg/day) was started. The methylprednisolone and cyclophosphamide doses were tapered over 9 months and 7 months, respectively. At the 1.5-year follow-up examination, his visual acuity was 1.0 OD. The lesions did not grow in size.

Nasal Eosinophilic Angiocentric Fibrosis with Orbital Extension

Eosinophilic angiocentric fibrosis (EAF) is an extremely rare, chronic, benign, idiopathic disorder that mostly affects the upper respiratory tract, particularly the nasal cavity, and features progressive submucosal perivascular fibrosis. To the best of our knowledge, only seven cases of EAF with orbital involvement have been reported. We report a case of sinonasal EAF with orbital extension that presented with left nasolacrimal duct obstruction. A 35-year-old man presented with left epiphora, proptosis, anterolateral globe displacement and nasal obstruction. Endoscopic sinus examination showed a firm, gritty, creamy, yellow, fibrous, adherent mass of maxillary sinus. Diagnosis was established with histopathological examination of excisional biopsy of the lesion. Although EAF is very rare, it should be considered in the differential diagnosis of lesions of upper airway tract, particularly the nasal cavity. Biopsy is necessary for diagnosis and treatment planning. Resecting of the involved tissues completely is essential for prevention of recurrence.

Neuropathology of substance use disorders

Addictions to licit and illicit drugs are chronic relapsing brain disorders that affect circuits that regulate reward, motivation, memory, and decision-making. Drug-induced pathological changes in these brain regions are associated with characteristic enduring behaviors that continue despite adverse biopsychosocial consequences. Repeated exposure to these substances leads to egocentric behaviors that focus on obtaining the drug by any means and on taking the drug under adverse psychosocial and medical conditions. Addiction also includes craving for the substances and, in some cases, involvement in risky behaviors that can cause death. These patterns of behaviors are associated with specific cognitive disturbances and neuroimaging evidence for brain dysfunctions in a diverse population of drug addicts. Postmortem studies have also revealed significant biochemical and/or structural abnormalities in some addicted individuals. The present review provides a summary of the evidence that has accumulated over the past few years to implicate brain dysfunctions in the varied manifestations of drug addiction. We thus review data on cerebrovascular alterations, brain structural abnormalities, and postmortem studies of patients who abuse cannabis, cocaine, amphetamines, heroin, and "bath salts". We also discuss potential molecular, biochemical, and cellular bases for the varied clinical presentations of these patients. Elucidation of the biological bases of addiction will help to develop better therapeutic approaches to these patient populations.

Myocbacterium-avium intracellulare associated inflammatory pseudotumor of the anterior nasal cavity

In this case report, we describe an unusual case of mycobacterial associated inflammatory pseudotumor that occurred in a patient with a previous history of cocaine abuse. We discuss inflammatory pseudotumor (IPT) in general and emphasize the rare entity where an associated mycobacterial infection is seen. The histogenesis is not yet completely understood. The lesion can pose challenges for practicing pathologists and a misdiagnosis of malignancy can occur at multiple facets. A discussion about the differential diagnosis and clues to make the distinction is presented. In addition to spindle cell proliferation, the presence of a background of mixed inflammatory cell infiltrate and foamy macrophages are clues to make the diagnosis. In the case of mycobacteria associated IPT, Acid Fast Bacilli (AFB) stains will easily highlight the organisms confirming the diagnosis.