Primary intracranial plasma-cell granuloma: a case report and review of the literature

A patient with primary intracranial granuloma with difficulty in differential diagnosis: A case report and literature review

There are few reports about primary intracranial granulomas without an identifiable infectious history. A 25-year-old male with intracranial granuloma. The patient presented with a history of tinnitus with intermittent headache for 1 week. Consequently, MRI showed pronounced and extensive enhancement lesions in the left frontal lobe involved in the cerebral longitudinal fissure cistern and the inside of the right frontal lobe, accompanied by a moderate degree of oedema; The lesion was a pilomyxoid astrocytoma preoperatively. Following a systemic examination, gross total resection of the lesion was performed, and postoperative pathological examination revealed the presence of inflammatory lesions. The patient exhibited notable symptom amelioration post-surgery, leading to discharge after the treatment. Subsequently, a sequential treatment involving steroid therapy was administered, resulting in successful patient recovery.

Intracranial Inflammatory Myofibroblastic Tumor: A Literature Review and a Rare Case Misdiagnosed as Acoustic Neuroma

Inflammatory myofibroblastic tumor (IMT) stands as a rare neoplasm, initially documented by Bahadori and Liebow in 1973; however, its biological behavior and underlying pathogenesis continue to elude comprehensive understanding. Throughout the years, this tumor has been designated by various alternative names, including pseudosarcomatoid myofibroblastoma, fibromyxoid transformation, and plasma cell granuloma among others. In 2002, the World Health Organization (WHO) officially classified it as a soft tissue tumor and designated it as IMT. While IMT primarily manifests in the lungs, the common clinical symptoms encompass anemia, low-grade fever, limb weakness, and chest pain. The mesentery, omentum, and retroperitoneum are subsequent sites of occurrence with intracranial involvement being exceedingly rare. Due to the absence of specific clinical symptoms and characteristic radiographic features, diagnosing intracranial inflammatory myofibroblastic tumor (IIMT) remains challenging. Successful instances of pharmacological treatment for IIMT indicate that surgery may not be the sole therapeutic recourse, thus underscoring the imperative of an accurate diagnosis and apt treatment selection to improve patient outcomes.

Intracranial Inflammatory Myofibroblastic Tumor: A Review of 49 cases

Inflammatory Myofibroblastic Tumor (IMT) is a rare pathologic entity that was first described in 1973. This lesion is most commonly found in the lungs, but other organs' involvement has also been reported. Intracranial location of Inflammatory Myofibroblastic Tumor is rare, and the first case was reported in 1980. An intriguing fact about the intracranial IMT is its resemblance with meningioma on clinical presentation and neuroimaging. We came across a case of intracranial Inflammatory Myofibroblastic Tumor (IIMT) in a 27-year-old male who presented with recurrent episodes of seizures and was diagnosed as meningioma on neuroimaging. The lesion did not subside with medical management and kept on progressing in size. The patient had to undergo surgery, and diagnosis of Inflammatory Myofibroblastic Tumor was ascertained on histopathology. This 'surprise' diagnosis prompted us to review the literature on all cases of IIMTs reported to date to better understand the entity and its implications. In this review article, we present our observations regarding various studied parameters, including patient profile, clinical presentation, site of involvement, focality of the lesion, special associations, and lines of management of the 49 published cases of IIMTs.

IgG4-Related Disease in the Frontal Convexity Concomitant with Smoldering Multiple Myeloma: A Case Report and Review of the Literature Regarding Therapeutic Implications

BACKGROUND

We have reported an extremely rare case of a frontal convexity tumor diagnosed as IgG4-related disease (IgG4-RD) with unique neuroradiological images.

CASE DESCRIPTION

A 64-year-old man with a history of monoclonal gammopathy of undetermined significance and conservative treatment had presented with a left facial spasm. Computed tomography showed a high-density round tumor with perifocal edema in the right frontal convexity. Magnetic resonance imaging demonstrated unique findings, including low signal intensity on T1- and T2-weighted, fluid-attenuated inversion recovery, and diffusion-weighted images, with slight gadolinium enhancement. The tumor was totally removed via right frontal craniotomy. It had been located in the subdural space, was not adherent to the dura, and was less vascular than meningiomas. Histological investigation demonstrated plasma cells that were strongly positive for IgG4 and contained κ and λ light chains at a ratio of 1.5:1. The serum IgG4 level was elevated. The tumor met the diagnostic criteria for IgG4-RD. The patient was followed up for 3 years during postoperative adjuvant steroid therapy. The steroid therapy was discontinued, and during the next 4 years, neither tumor recurrence nor symptoms were observed.

CONCLUSION

Intracranial IgG4-RD with smoldering monoclonal gammopathy of undetermined significance is extremely rare. We reviewed the differential diagnosis of plasma cell granuloma and plasmacytoma, therapeutic implications, and clinical outcomes. Complete resection of a conspicuous and solitary IgG4-RD lesion in the frontal convexity is simple and could provide a cure with less-aggressive adjuvant therapy.

Cranio-spinal Rosai Dorfman disease: case series and literature review

Rosai-Dorfman disease (RDD) is a rare condition similar to lymphomas, presenting with cervical lymphadenopathy in young adults. Extra-nodal involvement is relatively common but involvement of the central nervous system (CNS) is rare. Cranial RDD presents with symptoms of raised intracranial pressure, focal or generalised seizures, while spinal RDD presents with pain, peripheral neurological deficits and radiculopathy. In contrast to other similar neoplastic or degenerative conditions affecting the CNS, RDD is a benign, non-infective, granulomatous disorder. Radiologically cranio-spinal RDD often mimics commoner dural-based lesions like meningioma, with only subtle radiological differentiating findings on Magnetic Resonance Imaging (MRI). The histopathology of RDD is diagnostic. Surgical excision is preferred modality of treatment. However, adjuvant therapies like steroids and radiation may help controlling residual or recurrent disease. There are multiple sporadic reports and short case publications in the literature, often focusing on a particular aspect of RDD. In this study, authors aim to present five cases of craniospinal RDD, and comprehensive review of literature and highlight neurological complications of systemic RDD.

Inflammatory Myofibroblastic Tumor Presenting with Diabetes Insipidus in an Eight-Year-Old Boy: A Case Report

Inflammatory myofibroblastic tumors (IMT) develop as a non-neoplastic proliferation of myofibroblasts in a myxoid to collagenous stroma admixed with inflammatory cells. The symptoms depend on the specific location of the tumor, which can be anywhere, but is particularly in the respiratory system. Thus, patients with IMT can present with a variety of findings. A pediatric patient with IMT who presented with cough, breathlessness, polyuria-polydipsia, and convulsions is described in this report.

Relapsing intracranial plasma cell granuloma: A case report

Plasma cell granuloma is a pathological entity reported in nearly every organ system; however, intracranial cases remain rare. In the current case report, we present a case of intracranial plasma cell granuloma with the longest known follow-up period in the literature. Medical follow-up over 14 years, detailing four recurrences following the patient's initial presentation and management, is presented. The patient's treatment course consisted of three craniotomies, 3,600-cGy fractionated radiation and two courses of glucocorticoid therapy. In addition to disease surveillance using clinical examination and imaging, this case represents the first description of the clinical utility of analyzing changes in an inflammatory blood marker, the erythrocyte sedimentation rate, which coincided with recurrence and response to therapy.

Immunoglobulin G4-positive Sclerosing Idiopathic Orbital Inflammation: New Neuro-ophthalmological Presentations

We report two rare cases of biopsy proven Immunoglobulin G4-related sclerosing orbital inflammation (IgG4SOI). The first case had intracranial involvement which, to our knowledge, is the first IgG4SOI case with serum cerebrospinal fluid abnormalities and the second case had an unusual presentation of a compressive optic neuropathy and systemic lymphadenopathy.

Laparoscopic resection of a gastric plasma cell granuloma: a case report

Plasma cell granuloma, also known as inflammatory myofibroblastic tumour or inflammatory pseudotumour, is a nonneoplastic process characterized by an unregulated growth of inflammatory cells. It most commonly occurs in the lung and upper respiratory tract, and only six other cases of gastric plasma cell granuloma exist. There are no other cases of intragastric laparoscopic resection of this type of lesion. Here, we present a case of a 60-year-old gentleman who had gradual onset epigastric discomfort and was thought to have a gastrointestinal stromal tumour on gastroscopy. Subsequent imaging and laparoscopic transgastric resection of the lesion confirmed the presence of a plasma cell granuloma. We discuss the aetiologies, presentation, investigation, and treatment of this rare disorder and make recommendations on the management.

Magnetic resonance imaging of intercranial plasmocytic granuloma

The objective of this study is to determine characteristic magnetic resonance imaging (MRI) features of intracranial plasmocytic granulomas. Pathological confirmation of three patients with intracranial pathologically confirmed plasmocytic granuloma are presented. Clinical records as well pre- and postgadolinium-enhanced images from each patient are reviewed. The location of the abnormalities is compared with previous reported cases of plasmocytic granulomas, to determine if there is a characteristic finding in this disense. The predominance of this abnormality in the pediatric and young adult patient was striking. On T(1)-weighted MRI, plasmocytic granulomas appear as hypointense lesions, with isointense appearance on T(2) images, and significant, variable patterns of enhancement after the infusion of gadolinium. Typically, the lesion is infiltrating, and causes little mass effect. A dural based lesion, as well as a sellar region abnormality and an infiltrating cortical lesion with little mass effect in the pediatric or young adult age group may lead the observer to suspect the diagnosis of plasmocytic granuloma.

Intraventricular inflammatory pseudotumor: report of two cases and review of the literature

Inflammatory pseudotumors (IP) are non-neoplastic lesions characterized by collagenous stroma and polyclonal mononuclear infiltrates. It is best characterized in the lung, but can occur in the CNS, mimicking a neoplastic process. We discuss the available literature and our cases in order to elucidate best medical practices when confronted with such a lesion. We report on two cases of intraventricular inflammatory pseudotumor in patients who presented with symptoms of CSF obstruction. Both patients were treated surgically with significant clinical improvement. Histopathologically, both specimens revealed a plasma cell granuloma variant of IP. A Medline search for English articles identified 46 cases of CNS IP, only eight of which were located within the ventricle. As with our case, most patients presented due to CSF obstruction or mass effect. Radiographically, the lesions have a variable appearance although most enhanced with gadolinium. Complete resection was achieved in 67% with a 12% rate of recurrence. With incomplete resection or biopsy alone, progression is seen despite steroid or radiation administration. Malignant transformation was only reported once. CNS IP is a rare pathological entity that cannot be diagnosed through clinical presentation or radiographic characteristics, but rather through a careful neuropathological inspection. The available literature suggests that complete resection with close follow-up is necessary.

Rosai-Dorfman disease isolated to the central nervous system: a report of six cases

We reviewed the diagnosis and treatment of six patients with CNS Rosai-Dorfman disease (RDD). Lesions were located in the cerebral convexity, middle cranial base, parasaggital, petrous orbit, and thoracic spine. Preoperatively, all the lesions were misdiagnosed as meningioma. Histopathology of all CNS lesions showed a characteristic feature called emperipolesis, where small lymphocytes or plasma cells were engulfed in histiocyte cytoplasm. Total resection of lesions was performed in all cases, and at an average follow-up of 15 months, all patients are alive and well with no evidence of recurrence. Preoperative diagnosis of CNS RDD is challenging. Surgical removal of lesions is an effective treatment. More research is needed to clarify the effectiveness of other treatment options such as radiosurgery and corticosteroid therapy.

Meningeal plasma cell granuloma with relapsing polychondritis

✓ Relapsing polychondritis (RP) is a rare systemic disease characterized by recurrent inflammation of the cartilaginous structures and connective tissue. Central nervous system lesions in association with RP have occasionally been reported, but intracranial mass lesions have not been described. The authors report the first such case, in which a 51- year-old man presented with parasagittal meningeal plasma cell granuloma with RP. The mass was subtotally resected and adjuvant radiotherapy was administered. The patient did not experience any recurrence of the lesion during an 8-year follow-up period. In this case, the exact diagnosis of RP was made based on symptoms of respiratory tract chondritis, which was successfully treated by the placement of tracheobronchial stents.

Primary plasma cell granuloma of petrous bone

Plasma cell granulomas are rare intracranial lesions that can mimic a variety of intracranial tumours. As they are usually benign lesions, their identification assumes importance. We report a case of plasma cell granuloma in a 52-year-old man presenting with features of left sided V, VII and bilateral VIII nerve involvement who underwent subtotal excision of the lesion. The relevant literature is reviewed.

Inflammatory pseudotumors of the central nervous system: report of 3 cases and a literature review

Inflammatory pseudotumors (IPs), mostly benign lesions characterized by fibrotic ground tissue and polyclonal mononuclear infiltrate, may affect all organ systems. IPs originating in the central nervous system (IP-CNS) are very rare, and their distinct histopathologic features are poorly characterized. Three otherwise healthy patients (age 8, 15, and 17 years) presented with focal neurologic symptoms (seizures, n = 2; headaches, n = 1), corresponding to a left temporal, left occipital, and left frontal IP, respectively, extending from meningeal structures into brain tissue. After resection, no recurrence was observed in patient 1 during 5 years of follow-up, whereas patient 2 developed a rapidly progressive local recurrence and a second intracerebral lesion despite antiviral, immunosuppressive, antibiotic, and radiation therapy. In patient 3, who also showed local recurrences, sequential histopathologic investigations revealed transformation to a semimalignant fibrohistiocytic tumor. In this patient, anaplastic lymphoma kinase (ALK) expression was also positive, whereas it was negative in patient 1. A detailed literature analysis confirmed that most IP-CNS arise from dural/meningeal structures (n = 34). Intraparenchymatous (n = 7), mixed intraparenchymatous/meningeal (n = 4), and intraventricular lesions (n = 7) or IP extending per continuitatem from intracerebral to extracerebral sites (n = 5) were rare. The recurrence rate was 40% within 2 years in general. It was increased after incomplete resection and in female patients (multivariate Cox regression model, P < 0.02). Although rare, IP-CNS are important differential diagnoses among tumor-like intracranial lesions. Their potential risk of malignant transformation and high risk of recurrence necessitate close follow-up, especially when resection is incomplete. Prospective multicenter trials are needed to optimize classification and treatment of this rare inflammatory lesion.

Plasma cell granuloma of the pituitary gland. Case report

BACKGROUND

Plasma cell granuloma, one of the subtypes of inflammatory pseudotumor, is non-neoplastic proliferation of plasma cells and occurs extremely rarely in the intracranial space. We encountered a case of plasma cell granuloma in the pituitary gland, which initially presented with left oculomotor palsy.

CASE DESCRIPTION

A 34-year-old female presented with left ptosis. Magnetic resonance image (MRI) demonstrated an intrasellar mass extending to the pituitary stalk with dural enhancement. The lesion was subtotally resected by a transsphenoidal approach. Histopathological findings showed that the resected mass consisted of mature plasma cells, and some cells had infiltrated the surrounding normal pituitary tissue. Immunohistochemical study demonstrated that these cells were positive for leukocyte common antigen, kappa and lambda light chains of IgG, indicating polyclonality of these plasma cells.

CONCLUSIONS

We propose that, in the case of an intrasellar mass with unusual neurological symptoms including oculomotor palsy, inflammatory disease of the pituitary gland such as plasma cell granuloma should be included in the differential diagnosis.

Rosai-Dorfman disease isolated to the central nervous system: a report of 11 cases

Sinus histocytosis with massive lymphadenopathy, also known as Rosai-Dorfman Disease (RDD), is an idiopathic histiocytic proliferation affecting lymph nodes. Although extranodal involvement has been reported in diverse sites, central nervous system (CNS) manifestation, particularly in the absence of nodal disease is uncommon. We report 11 cases of RDD primary to the CNS without evidence of other sites of involvement. The cases included 7 males and 4 females ranging in age from 22 to 63 years (mean: 41 y). The patients presented with headaches, seizures, numbness, or paraplegia. Eight cases involved the cranial cavity and three cases, the spinal canal. Lesions were most often extra-axial and dura based. Only one presented in the CNS parenchyma. Histologically, the lesions consisted of variable numbers of pale-staining histocytes with emperipolesis often overshadowed by extensive lymphoplasmacytic infiltrates and fibrosis in the background. Special stains for organisms were negative. By immunohistochemical analysis, the characteristic histiocytes were positive for S100 protein and CD68 and negative for CD1a. Treatment consisted of surgical biopsy or excision. Follow-up, available for 10 cases with intervals ranging from 5 days to 42 months (mean: 15 mo), disclosed one patient dying of operative complications 5 days after biopsy and nine patients with no evidence of disease progression RDD should be considered in the differential diagnosis of inflammatory lesions of the CNS. Our study suggests that this entity may have been misdiagnosed in the past as plasma cell granuloma or inflammatory pseudotumor.

Extensive subdural mass

An unusual case of a 62-year-old man with focal seizures, tinnitus, and progressive left hemiparesis due to an extensive subdural plasma cell granuloma is presented. Five-year clinical and radiologic follow-up demonstrating the chronic yet progressive nature of this granuloma is presented. This is the first report of focal calcification seen in an intracranial plasma cell granuloma. The imaging, neuropathologic, and clinical characteristics of this rare lesion are reviewed.

Solitary meningeal plasmacytomas

BACKGROUND

Solitary extramedullary plasmacytoma (SEP) represents a rare separate clinical pathological entity; it is radiosensitive, curable, and unrelated to myeloma. Only 15 cases have been reported.

PATIENTS AND METHODS

Authors report two well documented cases of dural plasmocytomas mimicking meningiomas. This paper points out differences between plasmacytomas, with very different initial presentation, and other meningeal tumors including extensive radiological investigations. Diagnostic options and outcomes are discussed.

CONCLUSION

With solitary plasmacytomas, radiological diagnosis is difficult to assess. Serum is generally free of monoclonal protein. The importance of the most recent techniques in ruling out other pathological entities is stressed. Histopathological examination is required to document a monoclonal type of plasma cell tumor. Treatment includes surgery and radiotherapy. Differential radiological diagnosis will be discussed.