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Hooper MJ, Lee WJ, LeWitt TM, Nguyen C, Griffin T, Chung C, Zhou XA, Guitart J. Epstein-Barr Virus-Associated Lymphomatoid Papules: A Sign of Immunosuppression Resembling Lymphomatoid Papulosis. Am J Dermatopathol 2023; 45:789-800. [PMID: 37982462 PMCID: PMC10662656 DOI: 10.1097/dad.0000000000002479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
ABSTRACT Epstein-Barr virus (EBV)-positive lymphoproliferative disorders associated with immunodeficiency constitute a spectrum of lymphoid and plasma cell proliferations that vary in cytomorphology, immunophenotype, and clinical behavior. CD30-positive cutaneous lymphocytic infiltrates with EBV expression and lymphomatoid papulosis-like presentations have been rarely reported. This retrospective study assessed the clinical and histopathological characteristics of EBV-positive cases with papulonodular morphologies and CD30 positivity seen by Northwestern Medicine Dermatopathology. Twelve patients (7M:5F, mean age 69 years) were presented with papular cutaneous lesions without antecedent patch/plaque disease. Nine cases were associated with known immunosuppression in the setting of transplant-related therapies (n = 4), hematopoietic malignancy (n = 2), post-transplant hematopoietic malignancy (n = 1), and autoimmune disease treatment (n = 2). Two patients had age-related immunosenescence. Four patients demonstrated EBV viremia; for 2 patients, this finding comprised the first sign of immunosuppression. Workup was negative for systemic lymphoma in all patients. Various treatment strategies were used, including observation (n = 3), discontinuation/reduction of immunosuppression (n = 3), rituximab (n = 4), and steroids (n = 4). At mean 30-month follow-up, 4 patients (33.3%) were alive, 3 with and 1 without disease. Eight patients (67.6%) had died, 3 after lesional resolution and 5 with recurrent disease. Biopsies revealed mixed lymphoid infiltrates composed of atypical CD30-positive T cells (n = 5) or B cells (n = 7) with variable EBV-encoded small RNA expression. These cases suggest clinicopathologic presentations resembling lymphomatoid papulosis with atypical, large CD30-positive, EBV-positive cells could comprise first sign of potentially serious immunodeficiency and should prompt evaluation for EBV viremia. These cases also broaden the current picture of immunodeficiency-associated lymphoproliferative disorders to include lymphomatoid papulosis-like clinical presentations.
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Affiliation(s)
- Madeline J Hooper
- Resident Physician, Department of Dermatology, Northwestern University, Chicago, IL
| | - Woo Jin Lee
- Assistant Professor, Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tessa M LeWitt
- Resident Physician, Department of Dermatology, Northwestern University, Chicago, IL
| | - Cuong Nguyen
- Assistant Professor, Department of Dermatology, Northwestern University, Chicago, IL
| | - Teresa Griffin
- Visiting Predoctoral Research Fellow, Department of Dermatology, Northwestern University, Chicago, IL; and
| | - Christopher Chung
- Resident Physician, Department of Dermatology, Northwestern University, Chicago, IL
| | - Xiaolong A Zhou
- Assistant Professor, Department of Dermatology, Northwestern University, Chicago, IL
| | - Joan Guitart
- Professor, Department of Dermatology, Northwestern University, Chicago, IL
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Macklin PS, Fisher R, Stonard C, Matin RN, Ieremia E. Skin-Limited, Methotrexate-Associated Epstein-Barr Virus-Positive Mucocutaneous Ulcer-A Mimicker of High-Grade Lymphoma. A Report of 4 Cases and Review of the Literature. Am J Dermatopathol 2023; 45:519-531. [PMID: 37462204 DOI: 10.1097/dad.0000000000002419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
ABSTRACT Immunodeficiency-associated lymphoproliferative disorders (IA-LPDs) constitute a diverse range of conditions including posttransplant lymphoproliferative disorders, other iatrogenic IA-LPDs, and lymphoproliferative disorders associated with an underlying primary immune disorder or HIV infection. IA-LPDs are clinically and pathologically heterogeneous, and there is a lack of standardization of diagnostic terminology. They can represent a potential serious diagnostic pitfall because the histological features of clinically indolent proliferations may mimic those of high-grade lymphoma. However, correct identification of these entities is essential given that complete remission may occur upon reversal of the underlying cause of immunosuppression without the need for systemic therapy. IA-LPDs presenting in the skin are rare but well documented. One form of iatrogenic IA-LPD, methotrexate-associated lymphoproliferative disorder (MTX-LPD), can present with cutaneous nodules, plaques, or ulcers. Predominantly, MTX-LPD develops in the context of long-term treatment of autoimmune conditions, such as rheumatoid arthritis, dermatomyositis, and Sjögren syndrome, and may be associated with underlying Epstein-Barr virus (EBV) infection. We present 4 cases of cutaneous EBV-positive B-cell MTX-LPD and describe their clinical and morphological findings. Comparison of our histological findings to the diagnostic criteria for EBV-positive mucocutaneous ulcer (EBVMCU) revealed significant overlap, highlighting the intersection between MTX-LPD and EBVMCU. Withdrawal of methotrexate resulted in healing of all lesions at a mean time of 2 months. In summary, close clinicopathological correlation is vital to identify MTX-LPD presenting as cutaneous EBVMCU given that the initial treatment strategy is that of withdrawal of methotrexate without the need for immediate systemic therapy.
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Affiliation(s)
- Philip S Macklin
- Doctor, Department of Cellular Pathology, Oxford University Hospitals, NHS Foundation Trust, Oxford, Oxfordshire, United Kingdom
| | - Rachel Fisher
- Doctor, Department of Dermatology, Royal Berkshire, NHS Foundation Trust, Reading, Berkshire, United Kingdom; and
| | - Christopher Stonard
- Doctor, Department of Cellular Pathology, Oxford University Hospitals, NHS Foundation Trust, Oxford, Oxfordshire, United Kingdom
| | - Rubeta N Matin
- Doctor, Department of Dermatology, Oxford University Hospitals, NHS Foundation Trust, Oxford, Oxfordshire, United Kingdom
| | - Eleni Ieremia
- Doctor, Department of Cellular Pathology, Oxford University Hospitals, NHS Foundation Trust, Oxford, Oxfordshire, United Kingdom
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Watanabe T, Teratani Y. Unusual manifestation of methotrexate-associated lymphoproliferative disorder as a palatal mass. BMJ Case Rep 2022; 15:e250616. [PMID: 36175042 PMCID: PMC9528599 DOI: 10.1136/bcr-2022-250616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Methotrexate-associated lymphoproliferative disorder (MTX-LPD) can occur in the oral cavity, and only a few cases with palatal involvement have been reported. Chemotherapy may be needed if there is no remission after the withdrawal of MTX. We report a case of MTX-LPD presenting with a swelling of the palate that required chemotherapy. A woman in her 70s with rheumatoid arthritis reported a swelling on the left side of the palate. Her condition was diagnosed as Epstein-Barr virus-negative diffuse large B-cell lymphoma (MTX-LPD). Since the mass did not remit after MTX withdrawal, she underwent five courses of chemotherapy. Currently, the patient is in complete remission. In patients on MTX who develop a swelling on the palate, MTX-LPD should be included among the differential diagnostic possibilities. Diagnosis and treatment of MTX-LPD call for consultation with a haematologist. If the mass fails to regress following withdrawal of MTX, appropriate chemotherapy is indicated.
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Affiliation(s)
- Takuma Watanabe
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukina Teratani
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Kawaharada M, Maruyama S, Abé T, Yamazaki M, Kurokawa A, Katagiri W, Takagi R, Hayashi T, Kobayashi T, Tanuma JI. Other iatrogenic immunodeficiency-associated lymphoproliferative disorders in the oral cavity: a clinicopathologic study of 4 cases and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 132:687-697. [PMID: 34511340 DOI: 10.1016/j.oooo.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/16/2021] [Accepted: 05/30/2021] [Indexed: 12/09/2022]
Abstract
OBJECTIVES Other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OI-LPD) have been reported as one of the adverse effects of immunosuppressive therapy. The aim of this study was to describe the clinicopathologic and immunohistochemical features of OI-LPD in the oral cavity. STUDY DESIGN Immunohistochemistry was performed to describe the immunohistochemical features in our 4 cases. The results were analyzed along with 62 cases of oral OI-LPD in the English and Japanese literature to define clinical and pathologic characteristic features. RESULTS In our immunohistochemical analysis, Epstein-Barr virus (EBV)-positive OI-LPD showed a higher percentage of mouse double minute 2-positive cells than EBV-negative samples. A literature survey revealed that OI-LPD (including the present cases) arises primarily in the gingiva, followed by the tongue, and usually occurs with a male-to-female ratio of 1:1.9. The rate of EBV positivity was 93.8%. Further, 31 of 66 patients had osteonecrosis of the jaw and 24 of 31 patients had taken multiple immunosuppressive drugs in combination. CONCLUSIONS We can therefore conclude that the overexpression of mouse double minute 2 in OI-LPD is associated with EBV infection, and the combination of multiple immunosuppressive drugs may be a risk factor for osteonecrosis of the jaw.
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Affiliation(s)
- Masami Kawaharada
- Division of Reconstructive Surgery for Oral and Maxillofacial Region, Faculty of Dentistry & Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan; Division of Oral Pathology, Faculty of Dentistry & Graduate School of Medical and Dental Science, Niigata University, Niigata, Japan
| | - Satoshi Maruyama
- Oral Pathology Section, Department of Surgical Pathology, Niigata University Hospital, Niigata, Japan
| | - Tatsuya Abé
- Division of Oral Pathology, Faculty of Dentistry & Graduate School of Medical and Dental Science, Niigata University, Niigata, Japan
| | - Manabu Yamazaki
- Division of Oral Pathology, Faculty of Dentistry & Graduate School of Medical and Dental Science, Niigata University, Niigata, Japan
| | - Akira Kurokawa
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry & Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Wataru Katagiri
- Division of Reconstructive Surgery for Oral and Maxillofacial Region, Faculty of Dentistry & Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Ritsuo Takagi
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry & Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Takafumi Hayashi
- Division of Oral and Maxillofacial Radiology, Faculty of Dentistry & Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Tadaharu Kobayashi
- Division of Reconstructive Surgery for Oral and Maxillofacial Region, Faculty of Dentistry & Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Jun-Ichi Tanuma
- Division of Oral Pathology, Faculty of Dentistry & Graduate School of Medical and Dental Science, Niigata University, Niigata, Japan.
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Kondo K, Nakamura S, Takahashi M, Kaneko T, Horie N, Shimoyama T. Methotrexate-related lymphoproliferative disorder of the oral region in patients with rheumatoid arthritis. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY MEDICINE AND PATHOLOGY 2016. [DOI: 10.1016/j.ajoms.2015.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Miyashita M, Koike T, Aizawa H, Kurita H. Reversible methotrexate-associated lymphoproliferative disorder (MTX-LPD) associated with Epstein–Barr virus in a patient with rheumatoid arthritis. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY, MEDICINE, AND PATHOLOGY 2015. [DOI: 10.1016/j.ajoms.2014.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Kobayashi JI, Miyazaki A, Sekiguchi T, Hiratsuka H. Spontaneous complete remission of methotrexate-associated extranodal B-cell lymphoma of the buccal mucosa: Review of the literature and report of a case. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY, MEDICINE, AND PATHOLOGY 2015. [DOI: 10.1016/j.ajoms.2014.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Methotrexate-associated lymphoproliferative disorders of the tongue developing in patients with rheumatoid arthritis: a report of 2 cases and a review. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 119:e1-5. [DOI: 10.1016/j.oooo.2014.04.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 03/27/2014] [Accepted: 04/03/2014] [Indexed: 11/23/2022]
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Yamakawa N, Fujimoto M, Kawabata D, Terao C, Nishikori M, Nakashima R, Imura Y, Yukawa N, Yoshifuji H, Ohmura K, Fujii T, Kitano T, Kondo T, Yurugi K, Miura Y, Maekawa T, Saji H, Takaori-Kondo A, Matsuda F, Haga H, Mimori T. A clinical, pathological, and genetic characterization of methotrexate-associated lymphoproliferative disorders. J Rheumatol 2013; 41:293-9. [PMID: 24334644 DOI: 10.3899/jrheum.130270] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Methotrexate-associated lymphoproliferative disorders (MTX-LPD) often regress spontaneously during MTX withdrawal, but the prognostic factors remain unclear. The aim of our study was to clarify the clinical, histological, and genetic factors that predict outcomes in patients with MTX-LPD. METHODS Patients with MTX-LPD diagnosed between 2000 and 2012 were analyzed retrospectively regarding their clinical course, site of biopsy, histological typing, Epstein-Barr virus (EBV) in situ hybridization and immunostaining, and HLA type. RESULTS Twenty-one patients, including 20 with rheumatoid arthritis (RA) and 1 with polymyositis, were analyzed. The mean dose of MTX was 6.1 mg/week and the mean duration of treatment was 71.1 months. Clinically, 5 patients were diagnosed with EBV-positive mucocutaneous ulcer (EBVMCU) and had polymorphic histological findings. The proportion of those patients successfully treated solely by withdrawal of MTX was significantly greater than that of those without EBVMCU (75% vs 7.7%, p = 0.015). The HLA-B15:11 haplotype was more frequent in patients with EBV+ RA with MTX-LPD than in healthy Japanese controls (p = 0.0079, Bonferroni's method). EBV latency classification and HLA typing were not associated with the prognosis of MTX-LPD in our cohort. CONCLUSION Our data demonstrate that patients in the EBVMCU, a specific clinical subgroup of MTX-LPD, had a better clinical outcome when MTX was withdrawn than did other patients with MTX-LPD.
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Affiliation(s)
- Noriyuki Yamakawa
- From the Department of Rheumatology and Clinical Immunology, the Department of Diagnostic Pathology, the Center for Genomic Medicine, and the Department of Hematology and Oncology, Kyoto University Graduate School of Medicine; the Department of Transfusion Medicine and Cell Therapy, Kyoto University Hospital; the HLA Foundation Laboratory, Kyoto, Japan
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Savioli C, Silva CAA, Fabri GMC, Kozu K, Campos LMA, Bonfa E, Sallum AME, de Siqueira JTT. Gingival capillary changes and oral motor weakness in juvenile dermatomyositis. Rheumatology (Oxford) 2010; 49:1962-70. [DOI: 10.1093/rheumatology/keq189] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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