An update of the benign proliferative monocyte-macrophage and dendritic cell disorders

Unilateral Adult Xanthogranulomatous Infiltration of the Conjunctiva, Limbus and Sclera Leading to a Combined Ophthalmic Artery and Central Retinal Vein Occlusion

Objective

To describe the features of a female patient with a biopsy-proven xanthogranulomatous infiltration of the conjunctiva, limbus and sclera who had an exudative retinal detachment, combined ophthalmic artery and central retinal vein occlusion unilaterally.

Method

A-53-year old otherwise healthy woman presenting with a painful visual loss in her right eye underwent an ophthalmic examination, meticulous systemic work-up and histopathologic assessment.

Results

Ophthalmic examination revealed multiple subconjunctival masses, upper limbal infiltrations, trace cells in the anterior chamber, pale looking posterior fundus, 360 degree scattered retinal hemorrhages and marked exudative retinal detachment in her right eye. Left eye was completely normal.A biopsy taken from one of the subconjunctival masses demonstrated a diffuse infiltration of the histiocytes and this was interpreted as a xanthogranulomatous infiltration with the help of immunohistochemical staining techniques.

Conclusion

Present case is the only reported adult case with xanthogranulomatous-like infiltration of the eyeball featuring both anterior and posterior segment involvement without any concomitant major systemic disturbances.

Raised numbers of IgG4-positive plasma cells are a common histopathological finding in orbital xanthogranulomatous disease

PURPOSE

To determine the relation of orbital xanthogranuloma with IgG4-related disease.

METHODS

Retrospective consecutive case series over a period of 25 years. We searched our charts for histologically confirmed orbital xanthogranuloma. Patient files were reviewed for clinical and follow up data including presence or absence of systemic non-ophthalmic manifestations of IgG4 related disease. Slides were re-examined and histopathological classification was re-assessed. Sixteen cases of orbital xanthogranuloma were evaluated. Immunohistochemical stains for IgG and IgG4 were performed. Positive immunohistochemical staining required increased IgG4-positive plasma cells in the involved tissues scored as >50 per high-power field, with IgG4/IgG ratio >0.40.

RESULTS

According to the criteria described above 8/16 (50%) cases showed increased numbers of IgG4-positive plasma cells in the specimens. Two of these patients may have had signs of systemic disease.

CONCLUSION

Raised numbers of IgG4-positive plasma cells are a common finding in histopathological specimens of xanthogranulomatous disease of the orbit and are often not indicative for IgG4 related systemic disease.

Necrobiotic xanthogranuloma of the parotid gland

OBJECTIVES

To highlight the first reported case of necrobiotic xanthogranuloma of the parotid gland. We also review the clinical presentations and treatments for this rare condition.

METHOD

Case report and review of necrobiotic xanthogranuloma.

RESULTS

A 48-year-old man presented with a right parotid mass. Fine needle aspiration cytology was suggestive of Warthin's tumour, for which the patient underwent a subtotal parotidectomy. The final histopathological diagnosis was necrobiotic xanthogranuloma.

CONCLUSIONS

Necrobiotic xanthogranuloma may clinically mimic commoner tumours such as Warthin's tumour. Once diagnosed, the clinician should be wary of extracutaneous manifestations and paraproteinaemias. Because of the variability of presentation, there is no consensus on the best treatment for necrobiotic xanthogranuloma, which may include surgery, chemotherapy, interferon, plasmapheresis and radiation therapy.

Adult xanthogranulomatous disease of the orbit and ocular adnexa: new immunohistochemical findings and clinical review

BACKGROUND/AIMS

Adult xanthogranulomatous disease involving the ocular tissues is rare and poorly understood. Adult onset xanthogranuloma (AOX), adult onset asthma and periocular xanthogranuloma (AAPOX), necrobiotic xanthogranuloma (NBX), and Erdheim-Chester disease (ECD) are the four syndromes within this disorder, which is diagnosed by characteristic histopathology. Experience with eight cases prompted a multi-institutional effort to study the histopathology, immunohistochemistry, clinical findings, and systemic associations in this disorder.

METHODS

22 cases, including histopathological slides, were compiled. Published reports were identified by an English language Medline search (1966-2005) and review of reference citations. Each case in this series and the literature was classified as one of four syndromes and then analysed for age onset, sex, skin xanthoma, orbital location, immune dysfunction, internal organ and bone lesions, treatment, and outcome. The histopathology in each of these cases was reviewed by two pathologists. Immunhistochemical stains (CD3, CD4, CD8, L26) were performed in 14 cases where unstained slides were available.

RESULTS

137 cases were compiled. There was no sex or age difference between syndromes. AOX, AAPOX, NBX affect the anterior orbit, ECD tends to be diffuse and intraconal. Skin lesions are found in all the syndromes. Immune dysfunction was noted in all cases of AAPOX and NBX; 11% of NBX and all ECD patients had internal organ disease. Treatment included surgery, corticosteroids, other chemotherapeutic agents, radiotherapy, and combinations of these. No AOX or AAPOX deaths occurred; 66% of ECD patients died. All 22 cases had xanthoma cells; most had Touton giant cells. Lymphocytes were present in all cases and occurred as aggregates (mostly in AAPOX) or diffuse populations mixed with fibroblasts (mostly in ECD). Immunohistochemistry revealed the majority of these to be CD8+. Necrosis was most marked in NBX.

CONCLUSION

Adult xanthogranuloma of the orbit is rare, making prospective evaluation or meta-analysis impossible. The best treatment is unknown but seems to be with multiagent chemotherapy guided by histopathological, immunohistochemical, and systemic findings.