Rhinoscleroma associated with Rosai-Dorfman reaction of regional lymph nodes

Rosai-Dorfman disease of the oral cavity

First described by J Rosai and R F Dorfman in 1969, Rosai-Dorfman disease (RDD) is a benign, self-limiting histiocytosis of unknown etiology. It is usually seen in the first two decades of life. The most frequent clinical presentation is painless, bilateral cervical lymphadenopathy accompanied by fever, weight loss, and an elevated ESR. However, RDD without nodal involvement is extremely rare, and the most common extranodal location is the head and neck region, mainly affecting the nasal cavity, pharynx, and paranasal sinuses. Oral location of RDD is occasional; according to our knowledge, only 17 cases of oral Rosai-Dorfman disease without lymph node involvement have been found in the literature. Because of the rarity of these isolated oral presentations, the clinical and radiological aspects need to be more studied. This article aims to present a rare case of oral Rosai-Dorfman disease without nodal involvement, detail the clinical and radiological signs, and the treatment strategy used in our patient.

Extra Nodal Rosai-Dorfman Disease Originating in the Nasal and Paranasal Complex and Gnathic Bones: A Systematic Analysis of Seven Cases and Review of Literature

Rosai-Dorfman disease (RDD) is a benign, self-limiting histiocytosis of unknown etiology. The classic form of the condition includes a painless cervical lymphaenopathy accompanied by fever, weight loss and an elevated ESR. Extra nodal RDD (ENRDD) is most frequent in the head and neck. Thirty-eight cases of ENRDD have been described. Seven cases of ENRDD were identified in our pathology biopsy services. The demographic and clinical information was tabulated logically on the basis of age, gender, location and presence or absence of symptoms, treatment and follow-up. Radiographic and histopathological features were also examined. The findings in these cases were correlated with those available from the previously reported cases. Six cases affected women and one case was diagnosed in a male. The age ranged from 22-55 years. Three cases presented as a nasal mass. One of these lesions extended into the paranasal sinuses. One case was located in the maxilla and extended to involve the maxillary sinus. Three cases were diagnosed in the mandible. The maxillary and one mandibular lesion (Case 2) resulted in significant painful irregular bone destruction with a non-healing socket and tooth mobility respectively. One mandibular lesion was asymptomatic (Case 6). The third case affecting the mandible presented as a rapidly expansile mass following a tooth extraction (Case 7). Nasal masses presented with symptoms of obstruction. Nasal masses were excised with no recurrence from up to 2-3 years of follow-up. The mandibular lesions were curetted aggressively. The oral mass in Case 7 was excised synchronously. No recurrence up to 2 years was recorded in Case 2. Follow-up information is not available for Cases 6 and 7. The maxillary lesion was not intervened surgically. The patient has persistent but stable disease for a follow-up period of 2 years. ENRDD is rarely considered in the differential diagnosis in the absence of lymph node involvement. Lesions of ENRDD resemble many other histiocytic and histiocyte-rich lesions of the head and neck. This makes the diagnosis of ENRDD challenging with the potential for under diagnosis or misdiagnosis and delay in treatment.

Solitary extranodal Rosai-Dorfman disease of the mandible: an exceedingly rare presentation

Sinus histiocytosis with massive lymphadenopathy, generally known by the name of Rosai-Dorfman disease is a rare benign condition principally affecting cervical lymph nodes. Concurrent extra-nodal disease frequently occurs, however, solitary extra-nodal disease involving the mandible is exceedingly rare with less than five reported cases in the English literature. We describe a case of primary involvement of the mandible in a 27-year-old female, and discuss the differential diagnosis of this disease with other histiocytic lesions.

Is it a Metastatic Disease: A Case Report and New Understanding of Rosai-Dorfman Disease?

Rosai-Dorfman disease (RDD) is a rare histiocytic proliferative disorder, whose etiology remains unclear. Most patients experience a limited clinical course followed by recovery; however, a small subset of patients show persistence over years, with death occurring in a few cases because of multiorgan involvement. About 40% of patients have extranodal manifestations, with skin and meninges being the main extranodal sites. Cutaneous involvement occurs in approximately 10% of cases; however, RDD seldom affects the skin alone. In this study, the authors report the case of a 58-year-old woman who first presented with a cutaneous mass on the left inner thigh, then on the right wrist, and on the right chest area for the third time. She was misdiagnosed with nonspecific inflammatory disease at the first and second subcutaneous lesions. After the third excision surgery, the patient was diagnosed with RDD based on the hematoxylin and eosin stain and immunohistochemical staining results. The authors retrospectively reviewed the tissue slides from the previous 2 surgeries; interestingly, all the 3 tissue specimens demonstrated similar morphological features. Some RDD cells were observed in the walls of blood vessels in the tissue, with some invasion in the lumen of the vessels; therefore, the authors inferred that the second and third occurrences of RDD in locations different from the first-time lesion were caused by the vascular invasion of RDD cells from the first-time lesion.

Imaging of scleroma in the head and neck

We review the appearance of scleroma in the head and neck on imaging. Scleroma is a chronic granulomatous disease that primarily affects the nasal cavity, but the pharynx and larynx may also be involved. On imaging, nasal scleroma appears as bilateral or unilateral expanded homogeneous nasal masses that may exhibit hyperintense signal on T(1) weighted images. Pharyngeal scleroma commonly narrows the pharyngeal lumen and may involve the soft and hard palate. Imaging is essential to detect the extent of subglottic stenosis in patients with laryngeal scleroma. Rarely, scleroma may involve the orbit or the middle ear. Imaging is essential for the early diagnosis of scleroma and for differentiating it from other granulomatous and neoplastic lesions. Also, imaging is important for treatment planning and follow-up of patients after therapy.

Variable extent of emperipolesis in the evolution of Rosai Dorfman disease: Diagnostic and pathogenetic implications

This study examines variation of morphologic features, including emperipolesis, during the evolution of a case of Rosai Dorfman Disease (RDD). A 44-year-old male patient with RDD affecting the salivary glands, cervical lymph nodes, nasal and maxillary sinus mucosa had a waxing and waning course over two and a half years, with episodic sudden increase in size followed by involution and then a static course with moderate sized swellings. Multiple aspirations and biopsies were performed, which form the basis of this study. Four classical cases of RDD on aspirates and another four on biopsy were analyzed for comparison, with quantification of the number of lymphocytes engulfed by histiocytes (emperipolesis). Three nasal biopsies and one salivary gland excision of the index case, performed during acute exacerbation, showed chronic inflammation and foamy histiocytes without emperipolesis, the aspirate showing emperipolesis nil in 45%, 1-3 lymphocytes in 15%, 4-10 in 36% and > 10 in 4%. Two aspirations and one lymph node biopsy done from static phase showed classical features of RDD with extensive emperipolesis, the aspirate from left cervical lymph node showing emperipolesis nil in 2%, 1-3 in 5%, 4-10 in 35% and > 10 in 58% while right cervical lymph node aspirate showed emperipolesis nil in 9%, 1-3 in 21%, 4-10 in 29% and > 10 in 41%. A biopsy performed from involuting cervical lymph node showed extensive apoptosis and vasculitis without foamy histiocytes or emperipolesis. For comparison, eight classical RDD cases showed abundant emperipolesis with mild variation. Emperipolesis is variable in RDD depending on disease activity, which has differential diagnostic relevance and demonstrates the natural history of this rare disease.

[Rosai-Dorfman disease: therapeutic issues in 2 cases]

Rosai-Dorfman disease (RDD) is a benign lymphoproliferative disorder characterized by cervical lymph node enlargement with a consistent risk of airway compression and esthetic damage. Extranodal localizations are also described. There is no therapeutic consensus for pediatric forms of RDD. Through 2 pediatric cases with nodal involvement in 1 patient and a sinonasal and soft tissue localization in the other, we focus on the management problems of both nodal and extranodal RDD.

Factors associated with recurrence and therapeutic strategies for sinonasal Rosai-Dorfman disease

BACKGROUND

The purpose of this study was to explore the factors associated with the recurrence of Rosai-Dorfman disease (RDD) in the nasal cavity and paranasal sinus.

METHODS

In this study, we conducted a review of the English-language literature published between 1969 and 2010 on the recurrence of and treatment strategies for sinonasal RDD.

RESULTS

To our knowledge, 126 cases of RDD have been reported to date. Of the 126 patients, 32 (25.4%) had no recurrence or were alive with no evidence of disease; remission occurred in only 1 patient (0.7%); 69 patients (54.8%) had a recurrent, persistent, or progressive course; and 6 patients (4.8%) died from the disease. In patients with recurrent, persistent, and progressive disease, there was no significant tendency for lymph node involvement.

CONCLUSION

Sinonasal RDD is generally described as benign. However, recurrence and fatal outcome have been reported. Our results suggest that the initial modality may affect the recurrence of RDD.

B Lymphocyte Subsets in Patients with Rhinoscleroma

Objective. To identify the presence of B lymphocytes in the rhinoscleroma granulomas as a possible precursor of plasma cells, whose presence has always been described but whose role is still unclear.

Study Design. Case series with chart review.

Setting. Sapienza University of Rome.

Methods. The study was carried out on 6 patients (3 women, 3 men). The following parameters were examined for each patient: clinical manifestations, number of leukocytes, lymphocytes and lymphocyte subsets (CD3+, CD4+, CD8+, and CD19+) in blood samples, time from the onset of symptoms, biopsies, and expression of CD3, CD4, CD8, and CD20 antigens in tissue samples with immunohistochemical techniques.

Results. In this study, the values of CD3+, CD4+, and CD8+ T lymphocyte subsets in venous peripheral blood are in line with previously reported data, whereas CD19+ lymphocyte cells tended to show an ambiguous behavioral pattern. In tissue samples, approximately one-third of the T lymphocyte population showed a CD3+/CD8+ immunophenotype (cytotoxic/suppressor), and two-thirds of the T lymphocytes expressed a CD3+/CD4+ immunophenotype (helper/inducer). The authors also identified an unexpected large amount of CD20+ non-plasmacellular B cells in addition to the plasma cells usually detected in rhinoscleroma biopsies.

Conclusions. This study demonstrates the presence of B lymphocytes in rhinoscleroma tissue. It is presumable that the mature B cells activated by antigenic stimulation of Klebsiella rhinoscleromatis are the precursors of the plasma cells typically found in the granuloma of rhinoscleroma.

Polypoid intranasal mass caused by Rosai-Dorfman disease: a diagnostic pitfall

BACKGROUND

Rosai-Dorfman disease is a rare, idiopathic, histiocytic proliferative disorder with a distinctive microscopic appearance, which was formerly thought to be a disease process limited to lymph nodes. However, extranodal involvement has been documented in less than half of the reported patients, but rarely without associated lymphadenopathy.

CASE REPORT

We report the case of a 43-year-old Senegalese woman who presented with a polypoid, intranasal mass caused by Rosai-Dorfman disease. A diagnosis of a granulomatous process, including rhinoscleroma, was initially discussed. The correct diagnosis was made histologically by demonstrating aggregates of histiocytes with large amounts of cytoplasm, emperipolesis and protein S100 antigen expression. Despite using ancillary methods (molecular biology and electron microscopy), we failed to demonstrate any associated pathogen.

CONCLUSION

Diagnosis of Rosai-Dorfman disease can be very difficult, in particular in adults from Africa with pure, isolated, intranasal localisation, in whom clinical and radiological features may mimic other infectious or neoplastic disorders. The diagnosis is made based on the histological presence of large histiocytes with lymphophagocytosis. Moreover, immunohistochemical analysis of these histiocytes using anti-protein S100 antibody shows strong positivity.

Histiocytose sinusale de Rosai-Dorfman

Rosai-Dorfman disease, or sinus histiocytosis with massive lymphadenopathy, is a benign histiocytic proliferation that can cause large lymph node masses, most often cervical. Visceral damage is not rare. Diagnosis requires histologic examination: intrasinus histiocytic proliferation with cells showing emperipolesis or lymphocytophagocytosis. These histiocytes have a normal activated phenotype. Association with immunological abnormalities or autoimmune events, most often autoimmune cytopenia, is possible. This association is a poor prognostic factor. Clinical course is generally spontaneously favorable. There is nonetheless a substantial risk of compression associated with large tumor masses, especially in cases of retro-orbital or epidural involvement. Expectant management is most often appropriate. Treatment is reserved for forms that are directly threatening, progressive, or when poor prognostic factors are present. The treatment, when it is indicated, is not codified. It combines, according to the individual case, surgery, corticosteroids, antimetabolites and interferon alpha.

Modification of lymphocyte subsets in patients with rhinoscleroma

PURPOSE

Rhinoscleroma is a rare, chronic, granulomatous disorder of the upper airways. This disease presents some etiopathogenetic aspects that are not yet clear. Infection by Klebsiella rhinoscleromatis is fundamental for the onset of the disease, but it is impossible to reproduce rhinoscleroma experimentally only via infection with the bacteria both in man and in animals. Furthermore, this disease mainly affects blood-related people and occurs in certain geographic areas. In this context, we present a study that brings to light some of the quantitative abnormalities of the lymphocyte subsets.

MATERIALS AND METHODS

The study group consisted of 5 patients with rhinoscleroma. The following parameters were studied for each patient: clinical manifestations, histologic examinations, number of leukocytes, lymphocytes, and lymphocyte subsets.

RESULTS

In all patients, we noted the following: There was a relative reduction of the CD4+ cells, an absolute increase of the CD8+ cells, and an inversion of the CD4+/CD8+ ratio. There was an absolute increase of the CD56+ cells and cytotoxic cells that coexpress CD8+CD56+ antigens. There was a relative reduction of the CD3+ cells, and the CD19+ cells tended to show an ambiguous behavioral pattern.

CONCLUSION

We believe that K. rhinoscleromatis does not play a major role in the etiopathogenesis of rhinoscleroma. However, we do believe that the anomalous behavior of the immune system can favor rhinoscleroma.