Eosinophilic granuloma of lymph nodes--a variant of histiocytosis X

Langerhans Histiocytosis of the Choledochus in an Adult Patient with a History of Disseminated Disease

A 43 year-old man with a 15-year history of disseminated Langerhans histiocytosis (LH) in complete clinical remission was admitted with jaundice and abdominal pain. Pathological examination demonstrated LH in the choledochus associated with sclerosing cholangitis in the liver. Immunohistochemistry for S-100 protein and electron microscopy of the choledochus tissue showed Langerhans cell-like elements in the infiltrate. Our findings suggest that, in patients with disseminated Langerhans histiocytosis, liver function should be monitored, particularly, for signs of biliary obstruction, and demonstrate that such a finding is possible in adults.

Cutaneous Hematolymphoid and Histiocytic Proliferations in Children

This article focuses on cutaneous hematopoietic neoplasms that are more likely to be encountered in the pediatric age-group and includes both lymphoproliferative and histiocytic disorders. The cutaneous hematologic disorders in children have a different epidemiologic profile to what is seen during adulthood. Although mycosis fungoides is the most frequent form of cutaneous lymphoma in adults, it is very rare in children. Because lymphoblastic leukemias and lymphomas are more frequent in the pediatric setting, cutaneous leukemic infiltrates are relatively common in this age-group. Similarly, histiocytic disorders are more common in children, particularly Langerhans cell histiocytosis and juvenile xanthogranuloma. Notably, the histiocytic disorders have undergone significant modifications on their nomenclature in the basis of the molecular characteristics that are present in them. A summary of the most frequent cutaneous hematopoietic disorders in children will be discussed further in this review.

Histiocytosis disorders in Northeast Egypt: epidemiology and survival studies (a 5-year study)

Histiocytosis disorders include a wide group of disorders characterized by monocytes, macrophages and dendritic cell infiltration of different tissues. There are few clinico-epidemiologic studies of such disease. Our study was designed to look at the clinico-epidemiological features and outcome of patients with histiocytosis disorders in Northeast Egypt. Twenty-seven cases with histiocytosis disorders accrued over a 5-year period were analyzed and classified as having unifocal, multifocal, or multisystem disease. They were 14 males and 13 females. Twenty-two patients representing 81.5% of cases were more than two years of age while 5 patients (18.5%) were less than 2 years. Lymphadenopathy was the commonest presentation (55.55%) followed by bone lesions (44.44%). Involvement was unifocal in 12, multifocal in 10, and multisystem in 5 cases. The histological features were relatively uniform regardless of the clinical severity, and consisted of Langerhans cells, eosinophils, histiocytes, plasma cells, giant cells and fibrosis. The treatment consisted of a combination of surgery, chemotherapy, and/or radiotherapy. Lymphadenopathy was the most common clinical presentation in our locality. Response to treatment was poor in patients with multisystem disease. Patients with age less than 2 years were more likely to have increased risk of morbidity and mortality, due to widespread disease.

Sonography of biopsy-proven Langerhans cell histiocytosis in lymph nodes of the neck

OBJECTIVE

The purpose of this series is to describe the sonographic findings of lymph nodes of the neck involved by Langerhans cell histiocytosis (LCH).

METHODS

We reviewed and interpreted available images of lymph nodes in patients with cervical lymphadenopathies involved by LCH for the past decade. In all patients, each abnormal lymph node was pathologically confirmed by the use of a sonographically guided core needle biopsy or an incisional biopsy.

RESULTS

We characterized 3 different kinds of imaging findings for cervical lymph nodes involved by LCH: (1) a lymphomalike lesion, (2) a lesion similar to reactive lymphadenopathy, and (3) a cystic lymph node.

CONCLUSIONS

There was no specific imaging finding to diagnose lymphadenopathy involved by LCH. In our study, we characterized 3 different imaging patterns of lymph node involvement by LCH. This study represents an initial step to organize specific findings for LCH.

Langerhans cell histiocytosis infiltration into pancreas and kidney

An 18-month-old male presented with a swelling of the neck for 2 months. A presumptive diagnosis of Langerhans cell histiocytosis (LCH) was made on fine needle aspiration cytology from the lymph node. The child received chemotherapy. He remained well for around 10 months, when he represented with loose stools, cough, and respiratory distress. His condition deteriorated over a few hours culminating in death. A partial autopsy revealed LCH infiltration in liver, pancreas, and kidneys along with bronchopneumonia. The pancreatic and renal infiltration by LCH is extremely rare.

Lymph node involvement by Langerhans cell histiocytosis: a clinicopathologic and immunohistochemical study of 20 cases

Twenty cases of Langerhans cell histiocytosis (LCH) involving lymph nodes with no other sites of disease are presented. The patients were 12 men and 8 women between 3 months and 68 years of age. Seven patients were younger than 11 years; the other 13 patients were older than 16 years. Clinically, all patients presented with lymphadenopathy and underwent excisional biopsy; clinical and imaging studies did not reveal abnormalities in other organs. Cervical lymph nodes were most commonly involved; other lymph nodes involved included axillary, inguinal, and supraclavicular. Histologically, LCH in lymph nodes had 3 main architectural patterns: (1) preserved nodal architecture with subtle involvement, (2) subtotal effacement of nodal architecture, and (3) total effacement of nodal architecture. There was a gradient of involvement by LCH from focal sinus involvement to diffuse sinus involvement and from focal paracortical involvement to diffuse paracortical involvement. In some cases, focal involvement was initially unrecognized because of the subtle nature of the changes in the lymph node, posing difficulties for diagnosis. Langerhans cells in the involved areas showed strong positivity by immunohistochemical studies for S100 protein and CD1a in all 11 cases assessed. In conclusion, LCH can initially manifest clinically with involvement limited to lymph nodes. Recognition of the different patterns of LCH, particularly cases with subtle involvement, is important for recognizing this disease and separating LCH from other more common causes of lymphadenopathy.

Clinical implication of dermatopathic lymphadenopathy among Japanese: a report of 19 cases

To clarify the clinicopathologic and immunohistochemical features of dermatopathic lymphadenopathy not associated with mycosis fungoides among Japanese, 19 patients were studied. Seventy-four percent of the patients were more than 50 years old (median; 63 years, mean 61 years). Systemic symptoms such as fever were recorded in 68% and multicentric lymphadenopathy was noted in 83% of patients. An association of autoimmune disease or positivity of autoantibodies was recorded in 6 patients. Five patients showed cutaneous hypersensitivity reactions to a drug. Histologically, in addition to the dermatopathic lymphadenopathy, numerous immunoblasts were observed in 2 cases and sheet-like proliferation of mature plasma cells in 3 cases. Various atypical or malignant lymphoproliferative disorders exhibiting immunologic abnormalities such as angioimmunoblastic T-cell lymphoma or autoimmune disease-associated lymphadenopathy frequently occur in middle-aged and elderly patients. At least some of the patients with dermatopathic lymphadenopathy should be clinicopathologically differentiated from these lymphoproliferative disorders.

Nosology and pathology of Langerhans cell histiocytosis

The pathology of LCH is continuing to be defined and diagnostic features clarified as unprecedented research is done. Although the etiology of LCH remains unknown, new information on cytokines, viruses, immunologic dysfunction, cell surface antigen expression, and clonality in the disease are providing essential pieces of the puzzle.

Langerhans cell histiocytosis research. Past, present, and future

This article reviews the various investigative events that led to the endorsement of the term Langerhans cell histiocytosis for the various clinicopathologic conditions previously called Hand-Schüller-Christian disease, Abt-Letterer-Siwe disease, eosinophilic granuloma of bone, and histiocytosis X. The different denominations reflect the changing conceptual approaches to the so-called reticuloendothelial system and the successive acquisition of new ultrastructural and immunocytochemical data.

Hepatic nodules as single organ involvement in an adult with Langerhans cell granulomatosis. A case report

Liver involvement manifesting as hepatomegaly in Langerhans cell granulomatosis (LCG) is well known, but the definitive diagnosis is generally possible because other organs are involved. We report a 41-year-old white man who presented with cholestasis and liver nodules as an isolated hepatic LCG. The diagnosis of LCG was suspected based on routine histopathologic examination; the diagnosis became definitive 4 years later when Birbeck granules were found in the liver, an uncommon occurrence in this organ. This is an unusual presentation of a benign form of this disease and one of the first that reported Birbeck granules in the liver.

Langerhans' cell histiocytosis of the lung in association with mediastinal lymphadenopathy

A 17 year old female was seen because of a non-productive cough and one episode of blood-tinged sputum. A computerized tomography (CT) scan of the chest showed multiple small cystic lucencies in the upper lobes. The mediastinal CT window revealed concurrent mediastinal lymphadenopathy. An open lung biopsy showed Langerhans' cell histiocytosis (LCH). The significance of nodal involvement in LCH of the lung is not known, but raises the possibility of regional LCH and warrants a further search for bone or visceral involvement as well as closer follow-up and monitoring of patients.

Eosinophilic granuloma of lymph node: case report with cytohistologic, immunohistochemical, and flow cytometric observations

A case study of eosinophilic granuloma (Langerhans cell histiocytosis) of lymph node in a 32-year-old white man is presented. Clinical, cytologic, histologic, immunohistochemical, and flow cytometric findings are reported. Intraoperative cytologic findings can serve as valuable adjuncts to the frozen section, in this case serving as the sole method for diagnosis. This case is presented in light of the rarity of node-based eosinophilic granuloma and the absence of flow cytometric immunophenotypic findings in the literature.

Eosinophilic granuloma of lymph node. A case report

Eosinophilic granuloma confined to the lymph node of a 25-year-old Japanese woman is reported. She presented with a low-grade fever and pain in the left cervical region. A finger-tip-sized cervical lymph node was excised for histological study. Microscopically, the normal architecture of the lymph node was distorted, and histiocytoid cells had proliferated mainly in the sinus. Numerous eosinophils and an appreciable number of large multinucleated cells were also observed. Ultrastructurally, Birbeck granules were found in the cytoplasm of the histiocytoid cells. Immunohistochemically, the proliferating cells and multinucleated cells were found to be positive for S-100 protein but negative for lysozyme in the cytoplasm. The patient has been well without recurrence for 10 months after the lymph node biopsy.

Reversible hepatomegaly and diabetes mellitus in an adult with disseminated histiocytosis X

Histiocytosis X rarely disseminates in an adult. The authors describe an unusual patients who presented with multiple areas of cutaneous and bone involvement. During the course of his disease he developed massive hepatomegaly. Aggregates of vacuolated histiocytes were found on liver biopsy. He subsequently developed diabetes mellitus complicated by ketoacidosis. Both his hepatomegaly and diabetes resolved spontaneously. No pancreatic nor pituitary abnormalities were identified. The combination of histiocytosis X, hepatomegaly, and diabetes mellitus has not been previously reported. The medical literature is reviewed with an emphasis on disseminated histiocytosis X in adults and the mechanism of glucose intolerance in liver disease.

Letterer-Siwe disease in adults

Histiocytosis X (HX) is a rare disorder of histiocytic proliferation characterized by a broad spectrum of clinicopathologic disease. An unusual case of Letterer-Siwe disease (LSD) or subacute disseminated HX in a 71-year-old woman is presented. The patient had a 3-year history of splenomegaly before skin lesions developed. She presented to our clinic at 1.5 years later and the diagnosis of HX was made by skin biopsy. Topical nitrogen mustard (NM) therapy resulted in complete clearing of cutaneous lesions. Her condition was stable over the next 10 months. However, she subsequently suffered a rapid and fatal dissemination of her disease. Systemic treatment with prednisone, vinblastine sulphate, and suppressin A (SA) (a calf thymus derived hormone preparation that specifically induces suppressor T-cells) was ineffective. Characteristic histopathologic, immunohistochemical, and electron microscopic findings of HX are illustrated. A review of the adult cases of LSD and treatment options for HX are presented and discussed.

The cytogenesis of macrophages and osteoclast-like giant cells in bone tumors with special emphasis on the so-called fibrohistiocytic tumors

Recent investigations have suggested that osteoclasts and osteoblasts belong to different cell systems: osteoclasts originate from hemopoietic stem cells, most probably via precursors of the mononuclear phagocyte system. Osteoblasts, however, arise from local mesenchyme. The present classification of bone tumors issued by the WHO, however, is still based on the assumption of osteoclasts and osteoblasts being merely different manifestations or differentiations of the same basic cell type. Consequently, histiocytes or macrophages as well as osteoclast-like giant cells are interpreted in most bone tumors as an autochthonous component of the tumor. In the present study, this theory is contradicted by histological immunohistological, electron microscopic, and autoradiographic-electron microscopic results on a larger number of osteosarcomas, chondromas, chondrosarcomas, chondroblastomas, aneurysmal bone cysts, giant cell tumors of bone, malignant fibrous histiocytomas, fibrosarcomas, desmoplastic fibromas, Ewing's sarcomas, fibrous dysplasias, nonossifying fibromas, and malignant hemangioenkdotheliomas of bone. In order to elucidate the role of macrophages and osteoclast-like giant cells, different monoclonal antibodies were applied to bone tumor specimens as markers of mononuclear macrophages and giant cells. The concept of what is called fibrohistiocytic tumors should be reconsidered. Immunohistological studies have shown that in malignant fibrous histiocytoma as well as in giant cell tumors of bone only a certain portion of macrophages will react with the highly specific antibodies, whereas the majority of tumor cells are negative. This finding alone suggests that the infiltration of macrophages is a reactive phenomenon. It is in agreement with earlier autoradiographic and electron microscopic investigations on giant cell tumors of bone, confirming that only the fibroblast-like tumors are actually proliferating. These data were verified in the present study with the aid of double labeling immunohistological techniques, using antibodies against mature tissue macrophages and others against a proliferation-associated nuclear antigen. Only the fibroblast-like cells, which do not react with the macrophage-specific antibody, will express the proliferation-associated nuclear antigen. Analogous results were obtained in malignant fibrous histiocytoma. We may infer from these results that the majority of these tumors must be neoplasms of local mesenchyme, mostly in fibroblastic differentiation, while the considerable number of macrophages is seen as a reactive phenomenon.(ABSTRACT TRUNCATED AT 400 WORDS)

Dermal Langerhans' cell tumor in chronic myelomonocytic leukemia

Disseminated dermal tumors in a 71-year-old male represented the first clinical manifestation of a chronic myelomonocytic leukemia. The dermal infiltrate in one of the nodules consisted predominantly of closely packed pleomorphic Langerhans' cells (LC) with typical Birbeck granules and a strong reactivity for S-100 protein. The simultaneous presence of immature myeloid cells led to the suspicion of an underlying myeloproliferative disorder. The diagnosis of chronic myelomonocytic leukemia was subsequently confirmed by bone marrow histology and blood picture. Although some peritrabecular foci of histiocytic cells were detected in bone marrow, no LC could be identified by electron microscopy and histochemical methods. Tumorous aggregates of LC in myeloproliferative disorders have not been described in the literature. Histiocytosis X and related diseases could be definitely excluded in the present case. This case obviously suggests an interrelation between the myeloproliferative disease and the focal accumulation of LC in the dermis. In animal studies by Katz et al. LC have been shown to originate in the bone marrow, whereas the origin of LC in man is still a matter of discussion. The present case supports the hypothesis that LC in man are also of myeloid origin. The neoplastic blood monocytes could be the precursors of the dermal LC. This differentiation did not take place in the bone marrow but only in the dermis where LC occur under nonneoplastic conditions ("homing").

Interdigitating cell sarcoma. A morphologic, immunohistologic, and enzyme-histochemical study

A 58-year-old man presented with an unusual sarcoma of the cervical lymph node. The tumor also involved the mesenteric lymph node and jejunum. Tumor cells possessed intracytoplasmic S100 protein, Leu-3a (T4), and HLA-DR antigens. The neoplastic cells also showed membranous ATPase activity. LeuM1, T6, Leu1, Leu2a, B1, lysozyme, and immunoglobulin were not recognized. Their fine structure was similar to that of interdigitating cells. These data are consistent with derivation from lymph node interdigitating reticulum cell.

Biologic characterization of human bone tumors IX. Occurrence of macrophages

Fifty bone tumors were investigated using immunohistological methods for an assessment of the amount and nature of macrophage infiltration. Polyclonal antibodies against lysozyme, alpha 1-antichymotrypsin, and alpha 1-antitrypsin were used as markers, besides certain monoclonal antibodies against blood monocytes and mature tissue macrophages. Particularly high macrophage infiltration was found in malignant fibrous histiocytomas, giant cell-containing osteosarcomas, giant cell tumors of bone, and aneurysmal bone cysts. Moderate infiltrates were seen in some highly malignant osteosarcomas, in fibrosarcoma, and in chondroblastoma. A low macrophage content was observed in some osteosarcomas, in Ewing's sarcomas, chordomas, fibrous dysplasias, aggressive fibromatoses, and cartilage tumors. Osteoclast-like giant cells showed distinctly positive reactions with the monoclonal antibody against mature tissue macrophages. In fibrohistiocytic tumors (MFH, giant cell tumor, non-ossifying fibroma) only macrophages gave positive reactions with those antibodies, whereas the reaction of spindle-shaped tumor cells was always negative. These results strongly indicate that the macrophages found in bone tumors (including those of fibrohistiocytic type) result from reactive infiltration. The autochthonous tumor cells are most probably derived from local mesenchymal cells, and are thus cytogenetically unrelated to the infiltrating macrophages.

Reduced epidermal Langerhans cell densities in patients with pulmonary malignancies do not correlate with anergy or nutritional status

Epidermal Langerhans cell (ELC) densities are markedly reduced in a number of clinical situations including anergic sarcoidosis patients. To help determine whether this reduction is related to the anergic or nutritional status of the patient, we examined the non-sun-exposed epidermis of 23 hospitalized patients with various malignancies (MP), 10 hospitalized control (HC) patients without malignancy, and 24 biopsies from historical control (HIC) patients. There was no significant difference in the density of HLA-DR+ ELC among HC, HIC, or patients with nonpulmonary malignancy (primary or metastatic). Six patients with pulmonary malignancy had significantly fewer HLA-DR+ and OKT6+ epidermal cells. The reason ELC densities are reduced specifically in pulmonary malignancies remains under study.

An unusual presentation of histiocytosis X

A 20-year-old, single Saudi man was examined in the outpatient clinic in January 1980, complaining of ulcers in the groin, discharge from the right ear, and gum enlargement of 2 years' duration. Also in 1980, ulcerating lesions developed in both axillae. One year later the patient was admitted to the hospital for spontaneous pneumothorax, and in the same year a small nodule in the upper left eyelid and fissuring of the nails were noted. In 1982, the patient complained of perianal ulceration and rapidly enlarging submandibular swelling with multiple sinuses and ranula.

Solitary Langerhans' cell granulomatosis of the stomach associated with gastric carcinoma

A case of Langerhans' cell granulomatosis associated with gastric adenocarcinoma is reported. A review of the literature demonstrate an association of this entity with Hodgkin or non-Hodgkin lymphomas alone. The discussion is centred on differential diagnosis from the pseudo-sarcoid granulomatous reaction. Further reports may assist in classifying the granulomatous reaction to tumours into two types, epithelioid and Langerhans.

Thymus in untreated systemic histiocytosis X

Histology, ultrastructure, and lymphocyte subsets were evaluated in thymic tissue obtained from a child with disseminated histiocytosis X (HX) prior to therapy. Extensive medullary infiltration by typical HX cells was associated with active destruction of thymic epithelium, medullary pseudocysts, and prevalence of calcospherites, some of which were in HX cells. The presence of minimally affected Hassall bodies indicates that the thymus was probably normal prior to onset of disease. Conventional studies of immunologic function showed no deficits, but reduction of OKT6- and OKT8-labeled lymphocytes in a thymic suspension may mean that thymic processing of lymphocytes was impaired. Destruction of thymic epithelium occurs regularly in HX, but it may be an insignificant epiphenomenon resulting from the affinity of HX cells for squamous epithelium.

Histiocytosis: nosology and pathobiology

The histiocytoses represent a heterogeneous group of conditions. Their common denominator is the proliferation and the activation of the mononuclear phagocyte system (MPS). On the basis of recent advances in the knowledge of the distribution, biology, and behavior of the MPS, the following classification is proposed. Reactive and secondary histiocytoses related either to a chronic parasitic intracellular infection or to a patent or latent immunodeficiency state. Some well-established conditions belong to this category--i.e., familial lympho-histiocytosis, cytophagic sinus histiocytosis, Omenn's reticulosis. The dystrophic histiocytoses associated with the storage of either exogenous or endogenous material. It is prudent to separate the storages of homogeneous and chemically defined lipid material (such as cerebroside, sphingomyelin, etc.) from those of heterogeneous lipid material. Proliferative histiocytoses: it is crucial to distinguish the malignant histiocytosis from the histiocytosis X, which seems to be associated with a nonmalignant proliferation of a subpopulation of the MPS, the Langerhans cell system.

[Leukemoid eosinophilic reaction in angioimmunoblastic adenopathy]

A case of eosinophilic leukemoid reaction is described. This picture is seldom encountered during the course of angio-immunoblastic adenopathy. After reviewing various diagnoses and pointing out similar cases of the literature, the authors discuss the possible pathophysiologic mechanisms of eosinophilia in this disorder.

Immunohistochemical and ultrastructural analysis of the proliferating cells in histiocytosis X

The cellular nature of the proliferating histiocytes in 6 cases of histiocytosis X was studied immunohistochemically and ultrastructurally. Immunohistochemically, S-100 protein was detected both in the cytoplasm and the nuclei of histiocytosis X cells as well as Langerhans cells in normal oral epithelium. These cells were always negative for lysozyme, alpha 1-antitrypsin, alpha 1-antichymotrypsin and immunoglobulins. S-100 protein was not detected in lysozyme-positive histiocytes and multinucleated giant cells often showed the signs of phagocytosis. Thus, S-100 protein appears to be a useful immunohistochemical marker for histiocytosis X cells. Ultrastructurally, Birbeck granules noticed in histiocytosis X cells were never seen in the phagocytic histiocytes with numerous lysosomes and phagosomes. These results emphasized the heterogeneous nature of the proliferating histiocytes involved in the lesions. Since histiocytosis X cells share characteristics, not only ultrastructurally but also immunohistochemically, with Langerhans cells, the hypothesis that histiocytosis X may be fundamentally an abnormal proliferation of Langerhans cells has been further supported.

Histiocytosis X

To clarify salient issues pertaining to histiocytosis X--a syndrome that includes Letterer-Siwe disease, Hand-Schuller-Christian disease, and eosinophilic granuloma--the authors review the epidemiologic data and the histologic, morphologic, and clinical bases for diagnosis and prognosis. Histiocytes are defined and their possible histogenesis outlined, and Langerhans cells, which may be a leading element in active lesions, are characterized. The authors outline hypothetic pathogenetic schema, which they recommend be tested by recently developed immunologic and genetic means, since histiocytosis X, at least in its disseminated form, remains an unpredictable disease for which there is no proven effective therapy.

Immunohistochemical differentiation between histiocytic and lymphoid neoplasms

Lysozyme has, until recently, been accepted as the only reliable immunohistochemical marker of benign and malignant histiocytes. Using this marker, very few lymphoreticular neoplasms of histiocytic origin are recognized and more recently alpha-1-anti-trypsin has been shown to be a better marker of malignant histiocytes. By immunizing rabbits with highly purified human blood monocytes we have obtained an antiserum (S22) which stains histiocytes and neutrophils in paraffin sections with a high degree of specificity. Using this antiserum and antisera to lysozyme and alpha-1-anti-trypsin we have stained paraffin sections of tissues containing reactive histiocytes, histiocytic proliferations, leukaemic infiltrates and lymphoreticular tumours of histiocytic and T-cell origin. Our results show that alpha-1-anti-trypsin is the most reliable marker of malignant histiocytes but that the as yet uncharacterized antigen defined by S22 may offer a promising alternative.

Primary eosinophilic granuloma of the larynx

A rare case of primary eosinophilic granuloma of the larynx in a 49-year-old man is reported. The patient remains asymptomatic after a follow-up of three years. This is the third case reported in the world literature.