Unusual case of inflammatory spinal epidural mass (Castleman syndrome)

Unicentric Castleman's Disease Presenting As Back Pain

Castleman's disease is a rare disorder caused by a polyclonal proliferation of B lymphocytes and plasma cells. Half of all cases of multicentric Castleman's disease are associated with HIV or Kaposi's Sarcoma. Typically, unicentric Castleman's disease presents as an enlarged thoracic lymph node but can present in multiple other body areas, such as the head and neck. This case report presents a rare large extrathoracic mass causing back pain in a 71-year-old man.

Thoracic Paraspinal Castleman Disease in a Young Mexican-American Man with Postcoital Hematuria

BACKGROUND

Castleman disease (CD) is an uncommon disorder of deregulated lymphoproliferation with unicentric (UCD) and multicentric forms based on extent of nodal involvement. Gross resection with histopathologic analysis remains the gold standard for diagnosis of UCD and is curative in most cases. Symptomatic paraspinal UCD is a rare presentation with potentially dangerous complications, and its tendency to mimic more common spinal tumors presents a significant diagnostic challenge.

CASE PRESENTATION

A 25-year-old Hispanic man with no past medical history was evaluated for a known left-sided paraspinal mass that was incidentally discovered during an emergency department work-up for hematuria. Computed tomography on initial presentation revealed a 5.3 cm × 3.3 cm × 4.8 cm heterogeneously enhancing left paraspinal mass adjacent to the T11 vertebral body with tonguelike extension into the T11-T12 neural foramen. Although he remained neurologically intact throughout most of the diagnostic work-up, an inconclusive biopsy, worsening hematuria, and late-onset radiculopathy with severe back pain prompted surgical intervention. Microscopic histomorphology was consistent with CD. He continued to have intermittent hematuria and dysuria postoperatively, but repeat computed tomography at 7 months confirmed no recurrence of the mass.

CONCLUSIONS

Compared with previous reports, our case of postcoital hematuria and radiculopathy accompanying a paraspinal thoracic mass in a young Mexican-American man is a unique presentation. Awareness and early consideration of UCD in the work-up of a paraspinal mass may spare affected patients adverse and dangerous sequelae, such as spinal cord compression and excessive intraoperative hemorrhage.

Causes and patterns of spine trauma in children and adolescents in Saudi Arabia: implications for injury prevention

BACKGROUND AND OBJECTIVES

Knowledge regarding traumatic spine injuries (TSIs) is essential for effective prevention strategies, particularly in the developing world, where majority of the population is younger and organized prevention programs are scarce. Therefore, our objective was to describe TSI mechanisms, demographics, patterns, and outcomes in children and adolescents.

DESIGN AND SETTINGS

Retrospective chart review in a major trauma center from May 2001 to May 2009 in Riyadh, Saudi Arabia.

PATIENTS AND METHODS

Detailed chart reviews were done for all consecutive TSI patients ≤18 years old.Cases were identified through the trauma database registry that included admitted patients.

RESULTS

Of the 3796 cases identified, 120 cases (3.2%) sustained 141 TSIs (mean age: 13.5 years; males:83.8%). TSI was most common among children from 16 to 18 years old. Overall, motor vehicle collision (MVC)was the most common injury mechanism (60.8%). However, younger patients (<12 years) sustained more pedestrian injuries (40.6%). Among MVC cases with known seat belt statuses (43.8%), 90.6% were not wearing seat belts. The cervical spine level was the most commonly affected (55.8%) region, especially in children <12 years old (88%). More than 1 affected spinal level was found in 23.3% cases. Spinal cord injuries were found in 19.2% cases. Overall, mortality was 8.3%, and half of these mortalities were secondary to pedestrian injuries. A total of 22.7% of cases were discharged with neurological deficits.

CONCLUSION

The high frequency and severity of MVC and pedestrian injuries observed in the present study raise significant concerns regarding the safety of children on the roads. Spine involvement was age specific;younger patients tended to have more cervical injuries, and older patients exhibited more thoracic spine involvement.

Angiofollicular lymph node hyperplasia resembling a spinal nerve sheath tumor: a rare case of Castleman's disease

BACKGROUND CONTEXT

Angiofollicular lymph node hyperplasia (Castleman's disease) is a lymphoproliferative disorder of unknown etiology. Although uncommon, the localized form of this disease can manifest in the central nervous system, typically as a meningeal-based intracranial lesion. Castleman's disease involving the spine is exceedingly rare. This represents only the second reported case of a patient with Castleman's disease whose presentation mimicked that of a spinal nerve sheath tumor.

PURPOSE

We report a rare case of angiofollicular lymph node hyperplasia that mimicked a spinal nerve sheath tumor and was treated with gross total resection.

STUDY DESIGN

Case report.

PATIENT SAMPLE

A 31-year-old female with angiofollicular lymph node hyperplasia presenting with a paraspinal mass.

OUTCOME MEASURES

The patient's outcome was based on clinical history, physical and radiographic examinations.

METHODS

A 31-year-old woman with a mediastinal mass previously diagnosed as sarcoid via biopsy presented with the new onset of radicular pain and radiographic enlargement of her mass. Magnetic resonance imaging demonstrated a 4.3x5.7x6.0 cm homogenously enhancing soft-tissue lesion that emanated from and widened the T3/T4 neural foramen on the left. The differential diagnosis based on the location of the lesion and imaging characteristics included schwannoma, neurofibroma, paraganglioma, sarcoid, and lymphoma. Gross total resection was performed via thoracotomy. Histological examination identified angiofollicular lymph node hyperplasia (Castleman's disease) of the hyaline-vascular subtype. The patient did not receive adjuvant chemotherapy or radiation therapy.

RESULTS

The patient had resolution of her symptoms without any clinical or radiographic evidence of recurrence at 1-year follow-up using magnetic resonance imaging with and without contrast.

CONCLUSIONS

Castleman's disease is a rare pathologic entity that should be considered in the differential diagnosis of a patient with a paraspinal mass. Spine surgeons should be aware of this diagnosis as it has treatment and follow-up implications that differ from the neoplasms it can mimic. Complete surgical excision is an effective treatment for solitary lesions. Screening for concurrent and future malignancies in these patients is prudent.

Multicentric hyaline-vascular type Castleman disease presenting as an epidural mass causing paraplegia: a case report

A 30-year-old woman presented with a 1-year history of cervical lymph node enlargement and paraparesis of 2 weeks' duration. Magnetic resonance imaging revealed an epidural mass extending from the second to fifth thoracic levels causing compressive myelopathy. The cervical lymph node biopsy revealed hyaline vascular multicentric Castleman disease. She was given dexamethasone and radiation therapy to the involved spine followed by 8 cycles of CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) chemotherapy. The patient achieved complete remission and is disease free 24 months after treatment. The case is being reported in view of its rarity and achievement of complete remission with chemotherapy and radiation therapy.

Giant Lymph Node Hyperplasia (Castleman's Disease) as a Rare Cause of Back Pain

Giant lymph node hyperplasia (Castleman's disease) is a nonneoplastic lymphoproliferative disorder of unknown etiology that usually occurs in the chest. Its morphological recognition is based on a composition of various histological features. The mass is often asymptomatic, but it can cause nonspecific thoracic symptoms, such as regional pain. This disease can be found wherever lymph nodes are present, but two-thirds of these tumors are found in the chest, along the tracheobronchial tree in the mediastinum or lung hilus. However, we experienced an unusual case of Castleman's disease as a cause of back pain that was localized in the posterior mediastinum bordering the chest wall.

Castleman disease of the spine mimicking a nerve sheath tumor

✓ Castleman disease is a rare lymphoproliferative disease of unknown cause. In most cases, afflicted patients present with a mediastinal mass although the disease may manifest in numerous other sites, including intracranially and rarely intraspinally. The authors report on the case of a 19-year-old woman who presented with a large paraspinal mass emanating from the T7–8 neural foramen. The morphological and signal characteristics revealed on magnetic resonance imaging were similar to those of nerve sheath tumors. The patient underwent open biopsy sampling of the lesion, and results of a pathological evaluation revealed hyaline-vascular type Castleman disease. She underwent radiotherapy and remains symptom-free with a radiographically stable lesion 1 year later. Although the disease has been reported to mimic a meningioma when encountered in intracranial locations, to the authors' knowledge, this is the first case of the disorder mimicking a nerve sheath tumor. When the diagnosis of Castleman disease is made, good results can be obtained with partial resection and radiotherapy.

Laparoscopic Treatment of Unicentric Castleman's Disease with Abdominal Localization

We report a case of unicentric Castleman's disease (angiofollicular lymph node hyperplasia) with abdominal localization, that was treated laparoscopically. The patient, a 23-year-old male, was referred to our unit for subtle symptoms of recurrent palpitations and vague abdominal pain. His physician had prescribed an abdominal echtomograph, which showed a mass located at the lower and anterior lower splenic pole. In order to reach a definite diagnosis and prescribe adequate treatment, a diagnostic laparoscopy was performed. Exploration of the abdominal cavity helped detect a well-vascularized solid round mass at the level of the left hypochondrium, with a vascular pedicle; the lesion was detached, and the pedicle sectioned using an Endo-GIA 40. The postoperative course was regular and the patient was discharged on postoperative day 2. The laparoscopic approach enabled the resection of the lesion (with consequent histological diagnosis) and exploration of the peritoneal cavity with the advantages of minimal invasiveness, magnified images, and more rapid recovery). The pathology was totally resolved, with satisfactory results in terms of recovery, postoperative pain, and cosmesis.

Intracranial Localized Castleman's Disease-Case Report-

A 68-year-old woman presented with generalized clonic seizure following a 2-month history of initiative loss, incoherent speech, headache, and left hemiparesis. No systemic signs or symptoms were seen and laboratory studies were within normal range. Computed tomography and magnetic resonance imaging demonstrated a well-delineated small mass with homogeneous enhancement in the right parietal convexity, associated with unusually extensive perifocal edema compared to the size of the mass. Cerebral angiography showed a faint stain fed by the middle meningeal artery. These imaging features were very similar to those of meningioma. Full recovery from the symptoms was achieved by total removal of the lesion and no recurrence was found after 3 years. Histological examination identified the hyaline-vascular type of angiofollicular lymph node hyperplasia (Castleman's disease). Castleman's disease involving the central nervous system is rare, with only 12 previous cases, but should be considered in the diagnosis of intracranial meningeal tumors. The treatment of choice for localized Castleman's disease is complete surgical resection, which is curative in most of the cases.

Castleman's disease in a child presenting with a partly mineralized solitary meningeal mass

We report a case of solitary intracranial childhood Castleman's disease (CD) presenting with a sudden onset of partial seizures due to a meningeal and cortical mass lesion. The patient was a previously healthy 8-year-old girl who developed a new onset of simple partial seizures with motor signs. On physical examination, she was neurologically intact. Other findings included low-grade fever, mild microcytic anemia and lymphopenia. Magnetic resonance imaging (MRI) of the brain revealed a left posterior parietal, partly mineralized, contrast-enhancing meningeal mass with cortical invasion and adjacent white matter edema. A complete surgical resection of the dural-based component and a subtotal resection of the adherent, invasive cortical lesion were performed. Pathohistology and flow cytometry of the dural-based lesion disclosed a hyaline-vascular type of CD with striking proliferation of polyclonal B lymphocytes, scattered plasma cells and extensive multifocal cortical mineralization. At the 6-month follow-up, the patient was seizure free on antiepileptics and had returned to normal daily activities. MRI showed no residual lesion, and a workup for systemic disease was negative.

Endocrine aspects of neurosarcoidosis

The involvement of the hypothalamus and/or pituitary gland by granulomatous, infiltrative or autoimmune diseases is a rare condition of non-tumoral-non-vascular acquired hypothalamic dysfunction and hypopituitarism. In this paper, we present the case of a 26-year-old woman, who showed an amenorrhea-galactorrhea syndrome with hypogonadotropic hypogonadism due to an isolated hypothalamic-peduncular localization of neurosarcoidosis. Acquired GH deficiency was also demonstrated. This clinical case provided the opportunity for a review of the endocrine aspects linked to brain infiltrative diseases that may affect the hypothalamic-pituitary function, with a focus upon neurosarcoidosis. Sarcoidosis is a pathogen-free granulomatous disease that affects both the central and peripheral nervous system in 5-16% of patients. In most cases, such involvement by sarcoidosis occurs within a multi-systemic disease, but disease localization limited to the nervous system may also be observed. Endocrine manifestations of neurosarcoidosis disclose "chameleon-like" clinical pictures, which are usually expressed by the evidence of hypothalamic dysfunction, diabetes insipidus, adenopituitary failure, amenorrhea-galactorrhea syndrome, in isolated fashion or variedly combined. More rarely, inappropriate anti-diuretic hormone secretion, isolated secondary hypothyroidism, adrenal insufficiency or altered counter-regulation of glucose homeostasis have been reported. Neurosarcoidosis is often hard to diagnose, especially when the neurological localization of the disease is not accompanied by other systemic localizations or by specific signs of the disease, and when the lesion is too deep to obtain bioptic confirmation. The study of cerebrospinal fluid and blood lymphocyte sub-populations, integrated by MRI and nuclear scans (67GalIium uptake and 111Indium-pentetreotide, Octreoscan), may be helpful for a correct diagnosis. Therapy with corticosteroid and immunosuppressive drugs, such as cyclosporine A, and other treatment approaches to neurosarcoidosis are also accounted for.

Castleman's disease and spinal cord compression: case report

OBJECTIVE AND IMPORTANCE

Castleman's disease is a rare lymphoproliferative disorder most often found in the mediastinum. Localized forms are usually benign, whereas multicentric forms may be aggressive. We report a patient with Castleman's disease who presented with spinal cord compression, and we review previously published cases of Castleman's disease involving the central nervous system. To our knowledge, this is only the second case of Castleman's disease presenting as a spinal epidural mass with cord compression.

CLINICAL PRESENTATION

A 44-year-old otherwise healthy woman presented acutely with difficulty walking. Examination revealed mild myelopathy in her legs. Magnetic resonance imaging revealed a posterior epidural mass compressing the thoracic spinal cord at T3-T5.

INTERVENTION

Thoracic laminectomy and gross total resection of the lesion were performed. Pathological examination of the lesion identified the hyaline-vascular type of Castleman's disease. The patient's symptoms resolved postoperatively.

CONCLUSION

Castleman's disease presenting as a spinal epidural mass lesion with cord compression is rare. Surgical treatment can result in an excellent outcome.

Intracranial Castleman's disease of solitary form. Case report

This 62-year-old woman presented with clumsiness in her right hand. Magnetic resonance imaging demonstrated a small lesion mimicking a meningioma, which had arisen from the tentorium and contained notable edema. Full recovery was achieved by total removal of the lesion, which was diagnosed as a lymphoid mass resembling giant lymph node hyperplasia on histological examination. The lack of notable findings on whole-body and laboratory studies was compatible with a rare case of intracranial Castleman's disease of solitary form. The authors document clinical, neuroradiological, and pathological features of this rare disease.