Orbital involvement in multifocal fibrosclerosis

Non-specific orbital inflammation: Current understanding and unmet needs

Non-specific orbital inflammation (NSOI) is a noninfectious inflammatory condition of the orbit. Although it is generally considered the most common diagnosis derived from an orbital biopsy, it is a diagnosis of exclusion, meaning that the diagnosis requires exclusion of a systemic process or another identifiable etiology of orbital inflammation. The clinical diagnosis of NSOI is ill-defined, but it is typically characterized by acute orbital signs and symptoms, including pain, proptosis, periorbital edema, chemosis, diplopia, and less commonly visual disturbance. NSOI poses a diagnostic and therapeutic challenge: The clinical presentations and histological findings are heterogeneous, and there are no specific diagnostic criteria or treatment guidelines. The etiology and pathogenesis of NSOI are poorly understood. Here we recapitulate our current clinical understanding of NSOI, with an emphasis on the most recent findings on clinical characteristics, imaging findings, and treatment outcomes. Furthermore, gene expression profiling of NSOI and its implications are presented and discussed.

Graves'-like orbitopathy in a patient with chronic autoimmune pancreatitis

BACKGROUND

Graves' orbitopathy is an inflammatory orbital disease that represents the commonest extrathyroidal manifestation of Graves' disease. Autoimmune pancreatitis (AIP) is a rare inflammatory disease characterized by prominent lymphocytic infiltration and fibrosis of the pancreas causing organ dysfunction.

SUMMARY

This report provides the first clinical description of severe Graves'-like orbitopathy occurring in association with AIP. Although there was no clear evidence of autoimmune thyroid disease or dysfunction in our patient, the clinical course of his orbitopathy was related to that of AIP, the relapses of orbital inflammation being temporally coincident.

CONCLUSIONS

Our data suggest that shared autoantigens between the pancreas and the orbit might be responsible for the unusual disorder observed in our patient.

Visual field deficit: a rare initial symptom of autoimmune pancreatitis

An autoimmune pancreatitis (AIP) patient with metachronous and multiple extrapancreatic lesions is reported. Initial symptoms were proptosis, oculomotor deficits, and a visual field deficit of the left eye, and swelling of bilateral lacrimal glands. Swelling of the right salivary gland and elevated serum levels of hepatobiliary enzymes were detected. AIP associated with IgG4-related orbital pseudotumor, IgG4-related sclerosing dacryoadenitis and sialadenitis, and IgG4-related sclerosing cholangitis was diagnosed. All symptoms and lesions improved with steroid therapy. Although an orbital pseudotumor is a rare extrapancreatic lesion of AIP, we should know that AIP patients may describe unusual symptoms such as abnormal visual field.

[Chronic or subacute orbital inflammation (inflammatory pseudotumors)]

Subacute or chronic orbital inflammation can cause proptosis or painful myositis. It is either primitive or secondary to systemic diseases such as polyarteritis nodosa or Wegener's granulomatosis. Corticosteroids are the basic treatment, allowing biopsy and thus anatomopathological diagnosis. Some authors advocate surgery.

[Orbital pseudotumors and Riedel's thyroiditis: case report]

INTRODUCTION

We report a case of a patient with orbital pseudotumors associated with Riedel's thyroiditis. This association of unknown etiology may be related to idiopathic multifocal fibrosclerosis that includes retroperitoneal fibrosis, mediastinal fibrosis, sclerosing cholangitis, Riedel's thyroiditis, and orbital pseudotumors.

CASE REPORT

A 44-year-old woman was referred for a bilateral inflammatory malignant exophthalmos with progressive optical neuropathy (bilateral visual acuity<1/20). Imaging studies demonstrated bilateral exophthalmos (grade III) with compression of the both optic nerves by extensive tumoral infiltration. The general work-up showed a compressive goiter, with the histopathologic examination establishing the diagnosis of Riedel's thyroiditis. Orbital biopsy and antithyroid antibody testing were not contributive. Systemic corticosteroid associated with total thyroidectomy resulted in regression of the symptoms within 3 months.

DISCUSSION

The coexistence of bilateral orbital pseudotumor and Riedel's thyroiditis is the most common situation found for idiopathic multifocal fibrosclerosis. We discuss the differential diagnosis with thyroid-associated orbitopathy and orbital lymphoma. This observation is original because the diagnosis was reached by ophthalmic manifestation. The ophthalmologist should be able to identify this pathology to optimize the diagnostic and the therapeutic strategy.

CONCLUSION

In case of exophthalmos, a complete assessment should be made, including radiological and histopathological orbital and thyroid work-up.

Subglottic and tracheal stenosis associated with multifocal fibrosclerosis

This is the first case report in the literature of idiopathic subglottic and tracheal stenosis in a patient diagnosed with multifocal fibrosclerosis (MFS). The patient had unilateral orbital pseudotumour, bilateral pretibal cutaneous manifestations and raised thyroid antibodies, which might indicate subclinical thyroid involvement. Urgent permanent tracheostomy was needed. The patient also underwent tracheal dilatation for her dysphonia. There was no evidence of brain, lung, liver or renal involvement. Although extremely rare, laryngologists should consider the possibility of such a diagnosis in a stridulous patient with multifocal fibrotic manifestations.

Hyper-IgG4 disease: report and characterisation of a new disease

BACKGROUND

We highlight a chronic inflammatory disease we call 'hyper-IgG4 disease', which has many synonyms depending on the organ involved, the country of origin and the year of the report. It is characterized histologically by a lymphoplasmacytic inflammation with IgG4-positive cells and exuberant fibrosis, which leaves dense fibrosis on resolution. A typical example is idiopathic retroperitoneal fibrosis, but the initial report in 2001 was of sclerosing pancreatitis.

METHODS

We report an index case with fever and severe systemic disease. We have also reviewed the histology of 11 further patients with idiopathic retroperitoneal fibrosis for evidence of IgG4-expressing plasma cells, and examined a wide range of other inflammatory conditions and fibrotic diseases as organ-specific controls. We have reviewed the published literature for disease associations with idiopathic, systemic fibrosing conditions and the synonyms: pseudotumour, myofibroblastic tumour, plasma cell granuloma, systemic fibrosis, xanthofibrogranulomatosis, and multifocal fibrosclerosis.

RESULTS

Histology from all 12 patients showed, to varying degrees, fibrosis, intense inflammatory cell infiltration with lymphocytes, plasma cells, scattered neutrophils, and sometimes eosinophilic aggregates, with venulitis and obliterative arteritis. The majority of lymphocytes were T cells that expressed CD8 and CD4, with scattered B-cell-rich small lymphoid follicles. In all cases, there was a significant increase in IgG4-positive plasma cells compared with controls. In two cases, biopsies before and after steroid treatment were available, and only scattered plasma cells were seen after treatment, none of them expressing IgG4. Review of the literature shows that although pathology commonly appears confined to one organ, patients can have systemic symptoms and fever. In the active period, there is an acute phase response with a high serum concentration of IgG, and during this phase, there is a rapid clinical response to glucocorticoid steroid treatment.

CONCLUSION

We believe that hyper-IgG4 disease is an important condition to recognise, as the diagnosis can be readily verified and the outcome with treatment is very good.

Multifocal fibrosclerosis combined with idiopathic retro-peritoneal and pericardial fibrosis

A 70-year-old man who had been diagnosed with retroperitoneal fibrosis (RPF) was admitted to our hospital complaining of dyspnea. Imaging studies showed massive pericardial effusion. His condition deteriorated and pericardiostomy was performed. A biopsy of the pericardium revealed marked fibrosis with infiltration of lymphocytes, which was identical to RPF findings. A diagnosis of multifocal fibrosclerosis was made. Despite aggressive treatment, he died with clinical signs of cardiovascular failure. The autopsy specimen revealed proliferation of fibrosis with infiltration of lymphocytes in multiple organs. Even after successful decompression of urinary obstruction for RPF, long-term follow-up is necessary in these patients because of the possibility of other fatal complications such as pericardial fibrosis.

Idiopathic orbital inflammation with extraorbital extension: case series and review

Idiopathic orbital inflammation (IOI) is a well-recognised pathological process usually confined to the orbit. It is an orbital mass lesion characterised by infiltration of soft tissues by inflammatory cells and fibrous tissue. It is essentially a diagnosis of exclusion. Extraorbital extension (EOE) is rare and, to the best of the authors' knowledge, inclusive of our series, there have been 22 cases of IOI with EOE reported in the literature. We describe four patients with IOI with EOE-their presentation, histopathological findings and management strategies. Histopathology of three patients revealed sclerosing and one had a nonspecific variant of IOI. In our series, all four patients required additional immunosuppression. Hence, corticosteroid therapy often needs to be supplemented by radiotherapy and/or immunosuppressive therapy.

Idiopathic fibrosclerosis of bilateral orbits, bilateral ureters, thyroid: A case report and review of the literature

INTRODUCTION

Idiopathic multifocal fibrosclerosis is a rare disorder which is usually misdiagnosed in the clinics. We try to make a review of the literature about this large spectrum syndrome and treatment modalities other than surgery. Our patient interestingly have both fibrosclerosis of bilateral ureters, orbits and thyroid. Steroids, radiotherapy, tamoxifen, vitaminD3, colchisine was found to be in effective in treatment of progressive fibrosis.

Multifocal fibrosclerosis: a case of thyroiditis and bilateral lacrimal gland involvement

A patient with invasive fibrous thyroiditis (Riedel's thyroiditis), dysphagia, and bilateral lacrimal gland involvement is described. Resolution of the thyroid mass and orbital swellings followed corticosteroid therapy. The unusual ocular features of this case are briefly discussed and the use of corticosteroid and other immunosuppressant therapy in multifocal fibrosclerosis is reviewed.

[Pulmonary hyalinising granuloma: report of 2 original cases with cervicofacial and orbital involvement]

INTRODUCTION

Pulmonary hyalinizing granuloma is a rare fibrosing nodular disease of the lung characterized by its histological appearance, which includes at the center of the lesion a dense network of concentric hyalinized collagen lamella surrounded by perivascular lymphoplasmacytic infiltrate that rarefies in the center of the nodule.

EXEGESIS

We report two new cases: the first with laryngeal (endoluminal tumor-like), orbital (subeyelid nodule) and mesenteric (9 x 6 cm mass) location of hyalinizing granuloma; the second with cervical, facial (trismus), orbital (pseudotumor) and limb (ankylosing elbow) fibrosis.

CONCLUSION

The extrapulmonary diffusion of the disease is extremely rare. In one of the cases, with corticosteroids and after a follow-up of 12 months, the pulmonary tumors vanished but the fibrosis resolved only partially.

Panhypopituitarism associated with severe retroperitoneal fibrosis

A 43-year-old man, with a history of central diabetes insipidus diagnosed 3 years previously, complained about reduced libido. An MRI scan showed a suprasellar lesion just below the supraoptic recess of the third ventricle. A stereotactically guided biopsy revealed fibrous glia, but no other specific tissue and no inflammatory cells. Two months later the patient presented with fatigue and muscular weakness. Tertiary adrenal failure and hypothyroidism were diagnosed by endocrine function tests and therapy with levothyroxine and hydrocortisone was started. Another 2 months later the patient was admitted with giddiness, nausea, peripheral oedema and oliguria. Radiological imaging and an open transperitoneal kidney exploration showed severe fibrosis around both ureters. Histological examination confirmed the diagnosis of idiopathic retroperitoneal fibrosis. Presumably the suprasellar tumour was the first manifestation of retroperitoneal fibrosis. Once the diagnosis 'idiopathic retroperitoneal fibrosis' is confirmed, fibrotic manifestations and complications involving extra-retroperitoneal tissues including the endocrine system, should be sought.

Intraocular involvement in multifocal fibrosclerosis

OBJECTIVE

To report the clinical and histopathologic findings of intraocular involvement in a patient with multifocal fibrosclerosis and the response of the patient's choroidal masses to external beam radiotherapy.

DESIGN

Case report with clinicopathologic correlation of enucleated eyes.

METHODS

The patient was studied by clinical observation, contact B- and A-scan ultrasonography, orbital magnetic resonance imaging, fluorescein angiography, indocyanine green angiography, choroidal biopsy, and gross and histopathologic examination of the enucleated eyes. Tissue obtained at an earlier laparotomy was also reviewed. External beam radiotherapy was used when high-dose corticosteroid and low-dose methotrexate therapy failed to decrease the size of the choroidal masses or improve the patient's vision.

MAIN OUTCOME MEASURES

Changes in the clinical and ultrasonographic size of the choroidal masses, the clinical appearance of these masses, and the patient's visual acuity in response to external beam radiotherapy were monitored premortem. Histopathologic findings in the enucleated eyes were compared with the changes in previous abdominal and choroidal biopsy specimens and with tissue alterations reported in multifocal fibrosclerosis.

RESULTS

Biopsy of the choroidal mass revealed a fibrosclerosing process similar to that found in the abdomen. The patient received external beam radiotherapy with disappearance of the masses. Fibrosclerosing changes similar to those seen in the abdomen were observed replacing the choroid in the enucleated eyes.

CONCLUSIONS

Multifocal fibrosclerosis may involve the choroid with histopathologic changes similar to those that have been described in other locations in the body. External beam radiotherapy may be an effective treatment for intraocular involvement by multifocal fibrosclerosis.

Riedel's thyroiditis in multifocal fibrosclerosis: CT and MR imaging findings

Riedel's thyroiditis is a rare disorder of unknown etiology and may be seen isolated or as a part of multifocal fibrosclerosis. It is important to distinguish Riedel's thyroiditis from thyroid carcinoma. Reports about imaging features of Riedel's thyroiditis are limited in the radiologic literature. We describe herein CT and MR imaging features of Riedel's thyroiditis in a case of multifocal fibrosclerosis with previously unreported radiologic observations.

Idiopathic sclerotic inflammation of the orbit with left optic nerve compression in a patient with multifocal fibrosclerosis

We present the MR imaging findings in a 43-year-old male patient with bilateral idiopathic sclerosing inflammation of the orbit. Bilateral enhancing retrobulbar masses, with concentric compression of the retrobulbar segment of the left optic nerve, were seen. MR imaging proved to be the only means to distinguish between the different intraorbital structures and to determine the exact site of optic nerve compression. To our knowledge, this is the first documented case of MR imaging findings of this entity.

Crystal-storing histiocytosis and immunocytoma associated with multifocal fibrosclerosis

AIMS

Crystal-storing histiocytosis is a rare disorder described in patients with lymphoproliferative diseases, mainly in cases of multiple myeloma but also in lymphoplasmacytic lymphoma (immunocytoma). Most cases involve one single organ which, in the majority, is related directly to the presence of tumour. We describe a 44-year-old man with a clinical picture of multifocal fibrosclerosis (with mesenteric panniculitis, peritoneal, mediastinal and orbital fibrosis) in which the autopsy showed a systemic infiltrate of crystal-storing histiocytes and functional alteration of the organs involved, associated with IgG-kappa type immunocytoma.

METHODS AND RESULTS

Histology showed a systemic infiltration, with a predilection for adipose tissue, by a diffuse cellular infiltrate composed of small lymphocytes, plasmacytoid lymphocytes and plasma cells, admixed with large number of crystal-storing histiocytes. Intracytoplasmic crystals were not identified either in the plasma cells or plasmacytoid lymphocytes. The neoplastic cells and the crystalline inclusions displayed reactivity with antibodies for IgG and the kappa light chain. A polymerase chain reaction study for the IgH gene showed a monoclonal rearrangement. Ultrastructural studies showed needle-shaped crystals surrounded by a single unit membrane.

CONCLUSION

This case is, to the authors' knowledge, the first to be described in which crystal-storing histiocytosis is associated with a clinical picture of multifocal fibrosclerosis, which suggests that lymphoproliferative processes should be considered in the differential diagnosis of the various conditions associated with multifocal fibrosclerosis.

Systemic multifocal fibrosclerosis

We describe a case of hydronephrosis as a result of retroperitoneal fibrosis in a patient who had previous sclerosing lobulitis of the breast. To the best of our knowledge this is the first reported association between these two conditions in the english literature. We presume these conditions are linked and unify them under the general heading of systemic multifocal fibrosclerosis.

Diffuse pancreatic fibrosis: an uncommon feature of multifocal idiopathic fibrosclerosis

Multifocal idiopathic fibrosclerosis (MIF) is a rare syndrome characterized by exuberant fibrosis involving diverse organ systems. MIF is manifest by varying combinations of the following conditions: mediastinal fibrosis, retroperitoneal fibrosis, orbital pseudotumor, Riedel's thyroiditis, and sclerosing cholangitis. Less common features of MIF include Dupuytren's contractures, lymphoid hyperplasia, Peyronie's disease, vasculitis, testicular fibrosis, and pachymeningitis. Fibrosis arising from the pancreas has been previously described in two patients with MIF. We report a 58-yr-old white man with MIF manifest as orbital pseudotumor, sclerosing cholangitis, lymph node hyperplasia, and diffuse pancreatic fibrosis.

What is orbital pseudotumor?

We have reviewed the literature in order to delineate the clinicopathologic definition of orbital pseudotumor, also called idiopathic nonspecific orbital inflammation. The clinical picture of orbital pseudotumor varies widely, with signs of mass effect, inflammation and/or infiltration. On computed tomography, orbital pseudotumor presents as a unilateral focal or diffuse mass. The histopathologic hallmark of orbital pseudotumor is a mixed inflammatory infiltrate with fibrosis of varying degree. Contrary to an old belief, orbital pseudotumor is not related to orbital reactive lymphoid hyperplasia (pseudolymphoma) and is not a lymphoid tumor. Atypical histopathologic findings of orbital pseudotumor include dominant sclerosis, granulomatous inflammation, vasculitis, and tissue eosinophilia. In the absence of systemic fibroinflammatory, granulomatous, and vasculitic disease, these atypical histopathologic patterns can be considered to represent subclasses of orbital pseudotumors rather then distinct entities. Clinical and prognostic characteristics of both histopathologically classical and atypical orbital pseudotumors appear to be heterogeneous. The etiology of orbital pseudotumor is unknown, but infection, autoimmune disorder, and aberrant wound healing have all been put forward as possibilities. In conclusion, orbital pseudotumor is one distinct disease albeit with many clinical and histopathologic guises.