Multicentric plasmocytic Castleman's disease with polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes syndrome and coexistent human herpes virus-6 infection – a possible relationship

Sjögren's and plasma cell variant Castleman disease: a case report

Castleman disease is a rare cause of lymphoid hyperplasia and may result in localized symptoms or an aggressive, multisystem disorder. It can mimic other diseases like lymphoma or tuberculosis. It classically presents as a mediastinal mass that involves the lymphatic tissue primarily but can also affect extra lymphatic sites including the lungs, larynx, parotid glands, pancreas, meninges, and muscles. In HIV and HHV8-negative patients with idiopathic multi-centric Castleman disease, pathogenesis may involve autoimmune mechanisms. We highlight and report a case of a 34-year-old Ghanaian female who was successfully diagnosed and managed for Sjögren's as well as plasma cell variant Castleman disease with combination chemotherapy and rituximab followed by eighteen months maintenance therapy with pulse chlorambucil and prednisolone and three monthly rituximab.

Lymphoproliferative Syndromes Associated with Human Herpesvirus-6A and Human Herpesvirus-6B

Human herpesvirus 6A and 6B (HHV-6A and HHV-6B) have been noted since their discovery for their T-lymphotropism. Although it has proven difficult to determine the extent to which HHV-6A and HHV-6B are involved in the pathogenesis of many diseases, evidence suggests that primary infection and reactivation of both viruses may induce or contribute to the progression of several lymphoproliferative disorders, ranging from benign to malignant and including infectious mononucleosis-like illness, drug induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS), and nodular sclerosis Hodgkin's lymphoma. Herein, we discuss the conditions associated with the lymphoproliferative capacity of HHV-6, as well as the potential mechanisms behind them. Continued exploration on this topic may add to our understanding of the interactions between HHV-6 and the immune system and may open the doors to more accurate diagnosis and treatment of certain lymphoproliferative disorders.

The great mimickers: Castleman disease

Castleman disease (CD) was first described and most commonly occurs in the form of classic hyaline-vascular-type CD with hyperenhancing localized (unicentric) nonneoplastic lymphadenopathy. CD may affect any body region including unusual locations for isolated lymph node enlargement. This makes CD a great mimicker of more common benign and malignant masses in the neck, chest, abdomen, and pelvis. CD masses commonly raise the suspicion of lymphoma, paraganglioma, neuroendocrine tumor, metastatic adenopathy, solid parenchymal tumors, and infectious or inflammatory diseases. The less common plasma cell-type CD, mixed CD, and human herpes virus-8-associated CD (HHV8-CD) are more prone to lead to generalized (multicentric) adenopathy without the typical nodal hyperenhancement and are associated with B symptoms and hematologic and immunologic manifestations. The generalized forms of CD have a worse prognosis, which can approach that of malignancies. CD has multiple known associations with neoplasms, skin diseases, blood dyscrasias, and immunodeficiency, which include certain forms of lymphoma; paraneoplastic pemphigus; polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes syndrome; and plasma cell dyscrasias. Cytokine overproduction (IL-6) is an important pathogenetic factor in the development of CD. The treatment is accordingly variable, from curative or diagnostic resection of a solitary lesion to systemic chemotherapy or anti-IL-6 therapy.

Localized retroperitoneal Castleman's disease: a case report and review of the literature

Introduction

Castleman’s disease, also known as angiofollicular lymph node hyperplasia, is a rare disease with two known expansion types, unicentric and multicentric, which play a major role in determining therapy. We focus here on the unicentric type, which can be treated and cured by surgery. To date, approximately 1000 cases of Castleman’s disease have been reported in the literature.

Case presentation

A 50-year-old Caucasian woman presented to our Department of Hematology and Internal Oncology with increasing fatigue as her sole symptom. Diagnostic investigations including laboratory studies, ultrasound, computed tomography and magnetic resonance imaging were performed. These revealed an interaortocaval, retroperitoneal tumor mass in her upper abdomen as the only manifestation of the disease. No enlarged lymph nodes were detected. We conducted a laparotomy with radical extirpation of the tumor mass (10×9×5.7cm). Complete tumor resection with clear margins was achieved. A pathological analysis of the resected sample showed atypical lymphoid tissue of small to medium cells with some clearly visible nucleoli, enlarged sinusoidal vessels, pleomorphic calcifications and focally preserved germinal-center-like structures. Histological and immunohistochemical analysis confirmed the diagnosis of Castleman’s disease: staining for CD3, CD5, CD10, CD20, CD23, CD79 and Ki-67 was strongly positive in the germinal-center-like structures. Histological findings clearly showed the disease to be the hyaline vascular subtype. Staining for cyclin D1 and CD30 was negative. Expression of CD15 was positive in the enlarged sinusoidal vessels. A supplementary clonality analysis was without pathological findings. Tests for human immunodeficiency virus and human herpes virus 8 were negative and results from a bone marrow biopsy were normal. Our patient recovered well from surgery and was discharged from our hospital. To date, no recurrence of the disease has been detected.

Conclusion

Castleman’s disease is a rare disorder that remains a diagnostic challenge. Radical surgical resection is considered to be the gold standard for treating the unicentric variant of this disease.

Castleman disease: the great mimic

Castleman disease is a nonclonal lymphoproliferative disorder and one of the more common causes of nonneoplastic lymphadenopathy. Because of its diverse manifestations and ability to affect any body region, Castleman disease is a great mimic of both benign and malignant abnormalities in the neck, chest, abdomen, and pelvis. Castleman disease most commonly manifests as unicentric disease (unicentric Castleman disease) with a hyperenhancing lymph nodal mass and should be considered in the differential diagnosis of lymphoma, metastatic adenopathy, and infectious and/or inflammatory diseases that result in adenopathy. Castleman disease includes a spectrum of pathologic variants, including the classic hyaline vascular type, the less common plasma cell variant of Castleman disease, and the more recently described multicentric Castleman disease and Castleman disease associated with human herpesvirus 8. Castleman disease has been associated with the human immunodeficiency virus, lymphoma, POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes) syndrome, paraneoplastic pemphigus, and plasma cell dyscrasias. Aggressive forms of Castleman disease with systemic manifestations may occur. Unicentric hyaline vascular Castleman disease is often curable with surgery; however, multicentric Castleman disease may require steroid treatment, chemotherapy, antiviral medication, or the use of antiproliferative regimens because a surgical procedure cannot be curative in this setting. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.316115502/-/DC1.

Successful treatment with bortezomib and thalidomide for POEMS syndrome associated with multicentric mixed-type Castleman's disease

Polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes syndrome is a rare multi-systematic disorder of uncertain etiology, if associated with multicentric Castleman's disease, it can lead to a more serious condition. We here presented a case of polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes syndrome in a 37-year-old male patient who initially presented with progressive lower limb weakness accompanied by pain, low skin temperature, and hyperpigmentation. He was admitted with increasingly serious dyspnea and lower leg edema. Fluid of serous cavities in the patient were also indicated in ultrasonic inspection and X-ray. Furthermore, biopsy of a left axillary lymph node showed mixed hyaline-vascular and plasma cell type of multicentric Castleman's disease. Administration of bortezomib (Velcade) (1.3 mg/m(2) on days 1, 4, 8 and 11 of a 21-day cycle) combined with thalidomide (100 mg/day and 21-day cycle) dramatically improved the condition of this disease. Of note, in our study, combination therapy of bortezomib and thalidomide successfully improved the condition of the patient with polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes syndrome associated with multicentric Castleman's disease, suggesting that the combination therapy may be an effective therapeutic strategy for the intractable polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes syndrome associated with multicentric Castleman's disease.