Sinonasal eosinophilic angiocentric fibrosis: a report of four cases and review of literature

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.

Eosinophilic Angiocentric Fibrosis of the Orbit: A Clinicopathologic Review of 6 Novel Cases With Review of the Literature

PURPOSE

To describe 6 cases and review the current state of knowledge of eosinophilic angiocentric fibrosis (EAF) involving the orbit.

DESIGN

Retrospective clinicopathologic case series and review of the current literature METHODS: Clinical records and histopathologic data of orbit-involving EAF were gathered between 2004 and 2022 from a single academic institution. The patients' presenting clinical symptoms and signs, laboratory data, radiographic studies, and management documentation were collected.

RESULTS

Retrospective review identified 6 novel cases, totaling 31 cases of EAF involving the orbit described as of this writing. Fourteen patients were male, and the average age of presentation was 49.8 years (range 25-78 years). Eighteen patients had concurrent sinonasal involvement, whereas 13 had primary orbital involvement. The median duration of symptoms prior to evaluation was 24 months, with nasal symptoms, proptosis, periorbital swelling, and pain being the most common presenting symptoms. The majority of patients underwent surgical debulking, as well as treatment with glucocorticoids and steroid-sparing agents, such as rituximab, with varied results.

CONCLUSION

EAF involving the orbit is uncommon. The histopathologic findings include a perivascular, eosinophil-rich infiltrate and a pauci-inflammatory storiform type of fibrosis concentrated around small vessels. Orbital involvement usually results from local extension from adjacent sinuses, but primary orbital involvement has been described. Surgical debulking and immunosuppressive agents such as rituximab have been shown to stabilize disease.

Paravertebral fibrous pseudotumor: Four cases of a distinctive tumefactive lesion overlapping with eosinophilic angiocentric fibrosis and tumoral erythema elevatum diutinum

Eosinophilic angiocentric fibrosis (EAF) is a rare tumefactive fibroinflammatory disease with predilection for the upper respiratory tract, characterized by concentric (onionskin) fibrosis around small arterioles with variable intervening storiform fibrosis admixed with chronic inflammatory infiltrates rich in eosinophils. Erythema elevatum diutinum (EED), another autoimmunological disorder that mainly affects acral sites and extensor surfaces, is characterized by neutrophilic leukocytoclastic vasculitis. Rarely, older EED lesions may present as tumefactive nodular (pseudotumoral) fibrous masses closely mimicking EAF. We herein describe four patients (all males) aged 66-70 years who presented with large (median, 7 cm) tumor-like fibrous lesions in the paravertebral region not associated with a known clinical autoimmune disease. All cases were resected surgically with the suspicion of a neoplasm. They displayed a strikingly similar histological appearance with combined features of EAF and nodular fibrous EED. None had evidence of obliterative phlebitis or increased IgG4: IgG ratio. The etiology of this distinctive lesion and its predilection for the paravertebral area of males remains obscure. A distinctive tumefactive localized reaction to trauma caused by degenerative disease of adjacent vertebrae might be a possible explanation.

Eosinophilic angiocentric fibrosis of the sinonasal tract: a case report and review of the literature

Eosinophilic angiocentric fibrosis (EAF) is a rare chronic benign disorder of unknown etiology and is characterized by submucosal thickening and fibrosis in the upper respiratory tract. In this report, we describe a case of EAF in the nasal cavity of a woman who underwent elective surgery for division of adhesions and has had no recurrence during 2 years of postoperative follow-up. A review of the literature on the clinical manifestations of EAF, sites of lesions, management, and outcomes identified 48 articles that included 72 cases. A summary of these reports is presented, including our present case. The most common anatomic site involved was the nose (77.8%), the most common manifestation was nasal obstruction (66.7%), and the most common treatment modality was surgical resection (83.3%). After surgery, 36% of patients remained free of EAF. The most common pharmacologic agent used was a corticosteroid (38.9%).

Eosinophilic angiocentric fibrosis and IgG4-related disease revisited

INTRODUCTION

Eosinophilic angiocentric fibrosis (EAF) has been postulated to lie on the spectrum of IgG4-related disease (IgG4-RD) in a study reported in 2011. However, the aetiology of EAF remains controversial despite increasing literature reporting IgG4-RD targeted investigations in those studies. This review aims to formally evaluate the relationship between EAF and IgG4-RD using the latest 2019 ACR/EULAR classification scheme for IgG4-RD.

METHODS

A literature search was performed on the PubMed database for all studies describing patients diagnosed with EAF. Additionally, two EAF cases were retrospectively identified from our institution and presented. The demographics, clinical presentation, histological and serological data of each patient were analysed.

RESULTS

A total of twenty cases were evaluated, including eighteen patients from fourteen articles in the English literature and two cases from our institution. Six out of twenty (30%) patients with EAF met the criteria for IgG4-RD with the 2019 ACR/EULAR classification scheme.

CONCLUSION

This represents the first attempt at formally evaluating the relationship between EAF and IgG4-RD using a validated set of classification criteria. Using the currently available data, a small proportion of patients with EAF met the criteria for IgG4-RD. However, various limitations of this study suggest that further efforts at disease characterization of EAF may be required.

Algorithmic Approach to Fibroinflammatory Sinonasal Tract Lesions

Fibroinflammatory lesions of the sinonasal tract are one of the most common head and neck lesions submitted to surgical pathology. When the fibroinflammatory pattern represents the lesion (i.e., not surface reactive ulceration), an algorithmic approach can be useful. Separated into reactive, infectious, and neoplastic, and then further divided based on common to rare, this logical progression through a series of differential considerations allows for many of these lesions to be correctly diagnosed. The reactive lesions include chronic rhinosinusitis and polyps, granulomatosis with polyangiitis, and eosinophilic angiocentric fibrosis. Infectious etiologies include acute invasive fungal rhinosinusitis, rhinoscleroma, and mycobacterial infections. The neoplastic category includes lobular capillary hemangioma, inflammatory myofibroblastic tumor, and NK/T-cell lymphoma, nasal type. Utilizing patterns of growth, dominant cell types, and additional histologic features, selected ancillary studies help to confirm the diagnosis, guiding further clinical management.

Eosinophilic Angiocentric Fibrosis in Bilateral Upper Eyelid Conjunctivas: A First Case Report

Patient: Female, 55-year-old

Final Diagnosis: Eosinophilic angiocentric fibrosis

Symptoms: Lid swelling

Medication: Topical eye drops

Clinical Procedure: Resection of conjunctivas

Specialty: Ophthalmology

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.

Nasal Framework Reconstruction in Patient with Eosinophilic Angiocentric Fibrosis

Eosinophilic angiocentric Fibrosis (EAF) is a rare condition involving the sinonasal tract and nasal septum which is mostly considered as a benign condition. EAF could present with progressive nasal obstruction as its most common symptom. In this case report, we try to report a case of middle aged man with nasal septum tumor-link lesion which was diagnosed with EAF. A 45 years old man presented with complete nasal obstruction who described a growing nasal cavity mass for over 6 months. Anterior rhinoscopy revealed bilateral mass with a smooth surface on the nasal septum and mass protruded into both nasal cavities. CT scan showed a 28 × 18 mm soft tissue mass in nasal cavity mostly in right side with erosion of right maxillary alveolar ridge. Microscopic examination of a biopsy taken from the mass showed dense infiltration of inflammatory cells rich in eosinophils as well as perivascular condensation of fibrotic bundles creating onion-skin appearance was noted. The patient went under surgical ablation of the tumor and has been followed up every 2-3 month for about 1 year and there was no evidence of recurrent disease. The complete surgical excision may eradicate the allergic manifestations in the EAF patients and cartilage graft such as rib graft seems to be safe if the reconstruction is needed. It is important to prevent tumor from recurrence by totally resecting the involved tissues.

[Humoral immune diseases: Cutaneous vasculitis and auto-immune bullous dermatoses]

Humoral immunity is the cause of multiple diseases related to antibodies (IgA, IgG, IgM) produced by the patient. Two groups of diseases are identified. The first group is related to circulating antigen-antibody complexes. The antigens are various. They are often unknown. These immune complexes cause a vascular inflammation due to the complement fixation. Consequently, this group is dominated by inflammatory vasculitis. In the second group, the pathology is due to the fixation in situ of antibodies to a target antigen of the skin that is no more recognized by the patient. This group is represented by the auto-immune bullous dermatoses.

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.

A Case Report and Systematic Review of Eosinophilic Angiocentric Fibrosis of the Paranasal Sinuses

OBJECTIVE

There is a paucity of literature discussing prognostic factors or comparing outcomes in eosinophilic angiocentric fibrosis (EAF). This review aims to analyze tumor and patient characteristics as possible prognostic markers and compare surgical approaches.

METHODS

Systematic literature review and case report analyzing available cases of EAF located within the paranasal sinuses.

RESULTS

The literature search yielded 39 articles meeting criteria for a total of 59 cases (including 1 from our institution). Median patient age was 46 years. The most common presenting symptoms were nasal obstruction (69%, n = 41) and change in external nasal appearance (39%, n = 32). The majority of cases (85%) were treated with surgical resection alone or in combination with medication. Of surgical patients, 62% underwent a complete resection with a recurrence rate of 20%. Median follow-up duration was 2 years. Endoscopic approach showed a significant positive correlation with complete resection ( P = .045). Patient sex ( P = .6), tumor location (range, P = .32-.98), lateral rhinotomy ( P = .26), septoplasty ( P = .84), and external rhinoplasty ( P = .28) were not significantly correlated with total resection. Insufficient sample size precluded calculation of predictors of recurrence following surgery.

CONCLUSION

This review suggests that an endoscopic approach to EAF tumor is a viable option, frequently yielding complete resection.

Eosinophilic Angiocentric Fibrosis as a Stenosing Lesion in the Subglottis

Subglottic Eosinophilic Angiocentric Fibrosis (EAF) is an extremely rare disease of an elusive aetiology. It is chronically progressive benign condition that causes narrowing of the subglottic region leading to dysphonia and airway compromise. The diagnosis is historical and imaging is nonspecific. We report a case xc of 56-year-old lady referred to our institution with globus sensation, hoarseness, and mild stridor. Incidental subglottic mass was found at time of diagnostic microlaryngoscopy and biopsy confirmed subglottic EAF. All laboratory investigations were unremarkable. Lesion was removed with laryngeal microdebrider and three courses of intravenous dexamethasone were administered. Patient's postoperative period was uneventful and had remained disease free for 1 year. To date, no consensus has been reached on the optimal treatment of subglottic EAF. We recommend regular follow-up to detect early recurrence.

The Role and Immunobiology of Eosinophils in the Respiratory System: a Comprehensive Review

The eosinophil is a fully delineated granulocyte that disseminates throughout the bloodstream to end-organs after complete maturation in the bone marrow. While the presence of eosinophils is not uncommon even in healthy individuals, these granulocytes play a central role in inflammation and allergic processes. Normally appearing in smaller numbers, higher levels of eosinophils in the peripheral blood or certain tissues typically signal a pathologic process. Eosinophils confer a beneficial effect on the host by enhancing immunity against molds and viruses. However, tissue-specific elevation of eosinophils, particularly in the respiratory system, can cause a variety of short-term symptoms and may lead to long-term sequelae. Eosinophils often play a role in more commonly encountered disease processes, such as asthma and allergic responses in the upper respiratory tract. They are also integral in the pathology of less common diseases including eosinophilic pneumonia, allergic bronchopulmonary aspergillosis, hypersensitivity pneumonitis, and drug reaction with eosinophilia and systemic symptoms. They can be seen in neoplastic disorders or occupational exposures as well. The involvement of eosinophils in pulmonary disease processes can affect the method of diagnosis and the selection of treatment modalities. By analyzing the complex interaction between the eosinophil and its environment, which includes signaling molecules and tissues, different therapies have been discovered and created in order to target disease processes at a cellular level. Innovative treatments such as mepolizumab and benralizumab will be discussed. The purpose of this article is to further explore the topic of eosinophilic presence, activity, and pathology in the respiratory tract, as well as discuss current and future treatment options through a detailed literature review.

Eosinophilic angiocentric fibrosis of the sinonasal tract

Eosinophilic angiocentric fibrosis (EAF) is an exceedingly rare and potentially disfiguring and obstructing benign lesion involving the upper airways. We report two cases of EAF originating from the nasal cavity in a 31-year-old female and a 58-year-old male exhibiting nasal obstructive symptoms, with imaging features and histopathology characteristic of EAF. Surgical excision was performed on one patient with a disfiguring nasal mass at a tertiary referral rhinology practice within a university centre. Summarized are the relevant clinical issues to increase awareness of this disease. The slow progression and rarity of the disease has previously resulted in diagnostic difficulty. We review the limited current literature surrounding the clinical features and treatment options for this progressive and potentially morbid condition. These cases reinforce that, while rare, inflammatory and fibrosing lesions in general should still be considered as part of the differential diagnosis in patients presenting with obstructive lesions in the sinonasal tract.

Eosinophilic Angiocentric Fibrosis of Sinonasal Region: A Rare & Under Reported Entity

Eosinophilic angiocentric fibrosis is a rare pathology of the sinonasal tract and the upper respiratory system characterised by fibrosis with poorly understood pathogenesis. A 47-year-old male presented with a swelling over the dorsum of the nose. The possibility of fungal granuloma was being suggested on Magnetic Resonance Imaging (MRI). Histopathology showed thick collagen bundles whorling around vessels giving an onion skin appearance with focal area of vasculitis. An inflammatory reaction rich in eosinophils along with a fibrotic stroma was seen which was highly characteristic of eosinophilic angiocentric fibrosis. Clinically & microscopically it mimics Granuloma faciale, Wegener's Granulomatosis, Churg-Strauss Syndrome, Kimura's disease and few other granulomatous conditions thus making diagnosis difficult. A probable allergic origin is being suggested because of the typical eosinophil-rich inflammatory reaction. Finally the diagnosis of Eosinophilic Angiocentric Fibrosis was given. It is a diagnosis of exclusion having characteristic histomorphological findings thus biopsy is always required to distinguish it from other lesions whose treatment differs.

Eosinophilic angiocentric fibrosis of the nose and sinuses

BACKGROUND

Eosinophilic angiocentric fibrosis is a rare benign disorder of the upper respiratory tract. It is slow growing and progressive, with characteristic histological appearances.

METHODS

We report the largest single-institution case series of sinonasal eosinophilic angiocentric fibrosis to date, comprising nine patients. The current literature is reviewed, showing emerging evidence that this condition may belong to the immunoglobulin G4-related disease spectrum.

RESULTS

The series comprised five female and four male patients, with a mean age at presentation of 53 years. All were treated surgically. Six patients had no signs of recurrent disease after an average of 8.5 years. One patient went on to develop granulomatosis with polyangiitis (Wegener's granulomatosis), which required immunosuppressive therapy.

CONCLUSION

The first-line management of this rare condition is complete surgical excision. Chronic granulomatous conditions, including granulomatosis with polyangiitis, should be excluded before a diagnosis is made, and patients should be carefully followed.

Sinonasal eosinophilic angiocentric fibrosis: a systematic review

BACKGROUND

Eosinophilic angiocentric fibrosis (EAF) is a benign rare lesion of the upper respiratory mucosa. EAF most commonly presents with an obstructive nasal mass. Due to the rarity of EAF, case reports and case studies have predominated the literature. This systematic review discusses the demographics, clinical presentation, associated findings, management, and outcomes of this uncommon entity.

METHODS

The PubMed database was searched for all articles describing patients diagnosed with sinonasal EAF. Additional cases were examined from the bibliographies of selected articles. Demographics, clinical presentation, associated findings, radiography, management, and outcome were analyzed.

RESULTS

Fifty-two cases were included from 34 articles, including 1 case from our institution. The most common presenting symptom was nasal obstruction (78.8%). Fourteen patients (26.9%) had a previous history of nasal surgery or trauma. Surgical resection alone was the most commonly used primary treatment approach (50.0%), resulting in the greatest proportion of disease-free patients (55.6%) over a median follow-up period of 36 months. A combination of surgery and corticosteroids was the second-most-common treatment modality, used in 28.8% of cases. Of the 40 cases reporting patient outcomes, 100% of patients were alive at follow-up independent of treatment modality.

CONCLUSION

To date, this review contains the largest number of patients with sinonasal EAF. Aggressive surgical resection alone constitutes the most common treatment modality and may be most effective at eradicating disease.

Primary orbital eosinophilic angiocentric fibrosis with intranasal extension

BACKGROUND

Eosinophilic angiocentric fibrosis is a chronic, idiopathic disorder that usually involves the upper respiratory tract and features progressive submucosal perivascular fibrosis of unknown etiology. To our knowledge, only 5 cases of eosinophilic angiocentric fibrosis with primary orbital involvement have been reported.

METHODS AND RESULTS

We report the case of a 46-year-old man with right proptosis and lateral globe displacement caused by a primary eosinophilic angiocentric fibrosis extending from the orbit into the anterior ethmoid. The nasal extension of the lesion helped in establishing the correct diagnosis.

CONCLUSION

Physicians involved in the treatment of orbital pathologies should be familiar with this entity, because it may manifest as an intraorbital mass growing primarily or secondly into the orbit. The clinical manifestations of eosinophilic angiocentric fibrosis with orbital involvement often mimic other more common ophthalmological diseases. Biopsies are necessary for diagnosis and treatment planning, although cures are usually of palliative effect.

Eosinophilic angiocentric fibrosis of the nasal septum

Background. Eosinophilic angiocentric fibrosis (EAF) is a rare benign condition of unknown aetiology that causes stenosis of the upper respiratory tract. It is most commonly found at the nasal septum and sinus mucosa causing mucosal thickening and nasal obstructive symptoms. The diagnosis is mainly based on characteristic histologic findings. Case Report. A 27-year-old young woman presented with a slow growing mass at her anterior nasal septum for over eight years. She complained of persistent nasal obstruction, epistaxis, sometimes diffused facial pain, and chronic headache. 3 years ago, the tumor was partially resected for ventilation and a nasal septum perforation was left. Imaging findings indicated soft-tissue thickening of the anterior part of septum and adjacent lateral nasal walls. Pathological examination showed numerous inflammatory cells infiltrates containing eosinophils, fibroinflammatory lesion with a whorled appearance fibrosis which typically surrounded vessels. A diagnosis of eosinophilic angiocentric fibrosis was made. All laboratory tests were unremarkable. Skin prick test was positive. The tumor-like lesion was totally resected. Conclusions. EAF is a rare benign and progressive disorder causing destruction. Combined with radiological imaging of EAF historical findings contribute to the diagnosis. It is important to prevent tumor from recurrence by total resection of the lesion.