Combined immunological and histochemical analysis of skin and lymph node lesions in histiocytosis X

Langerhans Cell Histiocytosis of the Nose and Maxilla: A Rare Presentation

Langerhans cell histiocytosis (LCH) is a disease characterized by localized and generalized proliferation of the histiocytes. It is a locally aggressive condition. The clinical presentation is highly variable and can range from isolated, self-healing skin or bone lesions to life-threatening multisystem disease. It can present as a unifocal or multifocal disease. The majority are present in the head and neck region, but the involvement of Paranasal sinuses is rare. Here we describe a 64-years-old female who presented with a slow-growing left nasal mass for 1 year. Evaluation of the patient was suggestive of malignancy, but the biopsy report turned out to be Langerhans cell histiocytosis; subsequently left, total maxillectomy was done. We hereby present a unique case of LCH with isolated nose and paranasal sinus involvement.

Methods of Simultaneous Visualization of Cytoplasmic Enzyme Reactivity and Cell Surface Antigens (by Cytochemistry Combined with Immunocytochemistry) in Individual Hematopoietic and Lymphoid Cells

Enzyme cytochemistry alone, and more recently, immunocytohistochemistry have been satisfactorily used by hematologists and hematopathologists for the study, diagnosis and classification of human hematological and lymphoproliferative disorders. To enhance the potential of these techniques, the possibility of combining immunocytohistochemical techniques with enzyme cytohistochemistry with simultaneous visualization of both reaction products has been examined by some investigators. This approach has been applied to normal, reactive and neoplastic material using mainly cell suspensions and frozen sections, with the aim of improving cell identification in specimens containing different cell types, of determining the cytochemical profiles of well-defined lymphocyte subpopulations and of establishing the cell surface phe-notypes of cells that are positive for certain enzymes. In this paper, published reports on this subject are reviewed and compared with the experience of our study group.

Modulation of HLA-DR and CD1a expression on human cornea with low-dose UVB irradiation

PURPOSE

To evaluate the effects of low-dose UVB irradiation of HLA and CD1a expression and the toxic effects of UVB on human corneas.

METHODS

24 pairs of human corneas from 24 donors were studied. One cornea from each pair was randomly irradiated with UVB (100 mJ/cm2) after enucleation. All corneas were then organ-cultured for 2, 7, 14 or 21 days. Endothelium was studied after enucleation and organ culture. Following preservation, corneas were evaluated by means of light microscopy, morphometry and TEM. HLA and CD1a staining was performed using an immuno-alkaline-phosphatase technique.

RESULTS

Endothelial cell loss during organ culture averaged 9.1% in the UVB group and 9.2% in the control group (NS). The number of rosette and reformation figures (p = 0.004) and the coefficient of variation (p = 0.014) were higher in the control group. Epithelial sloughing was more accentuated in the UVB group. We observed the same moderate ultrastructural injuries in both groups. In the epithelium, the average number of HLA-DR+ cells per field was 0.12 in the UVB group and 0.42 in the control group (p = 0.035). In the stroma, these figures were respectively 1.04 and 1.34 (p = 0.026). In the epithelium, the average number of CD1a + cells was respectively 0. 025 and 0.078 (p = 0.019). In the preservation mediums, the average percentage of CD1a + cells was 0.07% in the UVB group and 0.27% in the control group (p = 0.014).

CONCLUSIONS

Low-dose UVB (100 mJ/cm2) decreases HLA-DR and CD1a expression of organ-cultured human corneas and induces moderate corneal injuries. Low-dose UVB might be useful for preventing allograft rejection.

Eosinophilic granuloma of bone and biochemical demonstration of 49-kDa CD1a molecule expression by Langerhans-cell histiocytosis

Histiocytic cells infiltrating the lesions in eosinophilic granuloma of bone as well as in cutaneous histiocytosis X were studied using a murine monoclonal antibody (MA) produced with proliferating cells from an eosinophilic granuloma of bone. This MA reacts with Langerhans cells (LC) of normal human skin or mucous membranes and with proliferating cells of eosinophilic granuloma of bone and skin lesions of Letter-Siwe disease, as shown by immunohistochemistry and immunogold labelling. As other murine MA's obtained after immunization with human cortical thymocytes, this MA immunoprecipitates the 49-kDa CD1a antigen found on human LC and thymic-cell surfaces but not its breakdown product after treatment with trypsin, as demonstrated by analysis of immunoelectron labelling, cytofluorometry and gel electrophoresis. This first production of a CD1a MA from an eosinophilic granuloma supports the concept of Langerhans-cell histiocytosis.

Extracellular deposition of eosinophil major basic protein in orbital histiocytosis X

Although eosinophils are prominent in orbital lesions of patients with histiocytosis X (Langerhans' cell histiocytosis), little is known of their pathogenic significance in the disease. To determine whether eosinophils degranulate and deposit toxic proteins in orbital histiocytosis X, the authors examined lesions by indirect immunofluorescence for localization of the core granule protein (major basic protein) outside of eosinophils. Four patients with histiocytosis X were studied: three with eosinophilic granuloma and one with Hand-Schüller-Christian disease. Tissue eosinophilia was prominent in all specimens; striking extracellular deposition of eosinophil major basic protein was noted in three patients, and focal deposition was present in the fourth patient. Orbital specimens obtained at autopsy from patients without orbital disease were studied as control specimens; no tissue eosinophilia or deposition of eosinophil major basic protein was observed. These findings indicate that eosinophils likely degranulate in lesions of orbital histiocytosis X and may participate in the pathogenesis of the disease.

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.

Immunohistochemical and ultrastructural study of histiocytosis X and non-X histiocytoses

The diagnostic reliability of ultrastructural and immunohistochemical examinations on routinely processed biopsy specimens of cutaneous histiocytic proliferations (histiocytosis X, n = 7; juvenile xanthogranuloma, n = 4; necrobiotic xanthogranuloma, n = 2; traumatic granuloma of the tongue, n = 1) was evaluated. S-100 protein, peanut agglutinin, and the antibody Mac-387 were used as markers for histiocytes. The frequency of Birbeck granule-containing cells in seven histiocytosis X lesions did not correspond with the number of S-100+ or peanut agglutinin+ cells. All neoplastic histiocytosis X cells were positive for S-100 protein and peanut agglutinin but were negative for Mac-387. Histiocytes of juvenile xanthogranuloma, necrobiotic xanthogranuloma, and traumatic granuloma were strongly positive for Mac-387 but were negative for S-100 protein and peanut agglutinin, except for the peanut agglutinin-reactive Touton giant cells. Mac-387 reliably differentiates histiocytic proliferations of the monocyte/macrophage system from those of the dendritic cell system. For the diagnosis of histiocytosis X, both S-100 protein and peanut agglutinin positivity in histiocytes is as reliable as ultrastructural demonstration of Birbeck granules.

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.

Bone marrow monocytes in histiocytosis X acquire some phenotypic features of Langerhans cells in long term bone marrow cultures

Bone marrow cells of a patient with Letterer-Siwe disease were cultured for three weeks in long-term bone marrow culture (LTBMC) conditions and examined at one-week intervals with a large panel of monoclonal antibodies by immunohistochemistry and by the immunogold transmission electron microscopy (immunoTEM) technique. Although at diagnosis the bone marrow showed a slight increase of monocytes with a normal phenotype, a rapid expansion of cells expressing CD1a and CD1c was observed already after 1 week of culture. A progressive increase in CD4, CD11b and CD11c expression was also observed. ImmunoTEM of cultured cells demonstrated that CD1a+ cells had macrophage-like morphology, and did not contain Birbeck granules. These findings indicate that bone marrow monocytes acquire some phenotypical features of Langerhans cells in LTBMC and support the hypothesis that these cells may derive directly from a bone marrow monocytic precursor.

Periodontal manifestations of adult onset of histiocytosis X

Histiocytosis X, a reticuloendothelial disorder, includes the three clinical syndromes: Letterer-Siwe and Hand-Schuller-Christian diseases and eosinophilic granuloma of the bone. Twenty-eight cases of adult onset of histiocytosis X involving the head and neck region were found in the literature during the past 20 years; 15 cases were confined to this area, out of which 13 involved jaw bones. Characteristic signs and symptoms of periodontal disease were observed in 22 out of 28 cases (79%) with the lower molar area as a predominant site. A case report of a non-osseous chronic disseminated histiocytosis X with periodontal involvement is presented. The importance of histiocytosis X, as an entity that should be kept in mind as a differential diagnosis of a process where destructive periodontitis is involved, is discussed.

Comparison of peanut agglutinin and S100 stains in the paraffin tissue diagnosis of Langerhans cell histiocytosis

We compared peanut agglutinin and S100 stains on paraffin embedded material from a variety of sites involved in Langerhans cell histiocytosis (LCH). The two techniques were comparable in terms of ease of performance, time taken and cost. Peanut agglutinin produced dense cell surface and paranuclear staining of the characteristic LCH cells seen in lesions, which was easier to distinguish than the more diffuse cytoplasmic staining produced by the S100 technique. This characteristic staining pattern is more specific than that for the S100 protein which is present in a variety of different cells, including some malignant histiocytes. We recommend that peanut agglutinin be used as a routine diagnostic test for all samples suspected of being LCH.

The phenotypic spectrum of histiocytosis X cells

Proliferating cells in histiocytosis X (histiocytosis X cells) share many structural and immunophenotypic features with Langerhans cells, leading to the assumption that histiocytosis X represents a proliferative disorder of Langerhans cells. Because, depending on their state of activation and/or differentiation, Langerhans cells exhibit a varying immunophenotype, we investigated whether histiocytosis X cells display a similar phenotypic heterogeneity and, if so, whether the heterogenous biological behavior of histiocytosis X is reflected by differences in the immunophenotype of the proliferating cells. In 21 patients suffering from different clinical manifestations of histiocytosis X, proliferating cells uniformly expressed class I and II alloantigens, T200, CD1, CD4, and S100 protein. In 12 of 21 cases, histiocytosis X cells additionally exhibited immunocytochemically detectable amounts of C3b and C3bi receptors and certain monocyte/macrophage antigens (CDw14, Ki-M1, Ki-M6). This immunophenotypic heterogeneity of histiocytosis X cells could not be correlated with clinical course, prognosis, and final outcome of the disease in a given patient. The capacity of histiocytosis X cells to immunophenotypically mimic various states of Langerhans cell activation and/or differentiation, however, underscores the concept of histiocytosis X as a proliferative disorder of Langerhans cell origin.

Expression of major histocompatibility class II antigens by Langerhans' cells in cervical intraepithelial neoplasia

Cervical biopsy samples from 67 patients who had various grades of cervical intraepithelial neoplasia (CIN) or who showed evidence, in the form of koilocytosis, of human papillomavirus (HPV) infection of the uterine cervix, and from 10 women with normal cervices were examined. Cryostat sections from the biopsy samples were stained using monoclonal antibodies to T6, a Langerhans' cell marker, and to major histocompatibility complex (MHC) class II antigens (HLA-DP, DQ, and DR). Epithelial Langerhans' cells were reduced in number and showed changed morphology and distribution in koilocytic lesions and in all grades of CIN (p less than 0.01) except CIN I. HLA-DR expression by Langerhans' cells was significantly increased in koilocytic lesions and in CIN grades I and II (p less than 0.05); HLA-DQ expression was significantly increased in all grades of CIN (p less than 0.05) with the increase being most pronounced in CIN I (p less than 0.01). Columnar epithelium expressed MHC class II antigens in all samples tested and squamous epithelium in four of 29 cases of CIN III. These findings support the view that there is a localised disturbance of immune function in both neoplastic cervical epithelium and that infected with papillomavirus.

Letterer-Siwe disease: immunohistochemical evidence for a proliferative disorder involving immature cells of Langerhans lineage

The morphological, ultrastructural and immunophenotypic properties of Histiocytosis-X (H-X) cells were investigated in a lymph node involved by Letterer-Siwe (L-S) disease. H-X cells were T6+ (CD1a), S-100+, T4+ (CD4) and HLA-DR+; in addition they were consistently T11+ (CD2) and were stained by antibodies directed against receptors for transferrin (T9), C3bi (OKM-1/CD11b), IgG-Fc (Leu-11/CD16) and Interleukin-2 (IL-2R/CD25). On immunostained cytosmears, T6+ cells were highly polymorphic and a prominent fraction (45%) showed immature morphology, characterized by lymphoid appearance. Cells expressing macrophage markers (ANAE, AACT, Leu-M3/CD14, PAM-1) were 10-fold fewer than T6+ cells and did not show a lymphoid morphology. At TEM level, H-X cells were characterized by poor content of LC granules and by the presence of myelin-like laminated bodies and of lysosome-like dense bodies. The immunophenotypic properties of H-X cells were compared to those of epidermal Langerhans cells (LCs) and of LCs present in lymph nodes of three cases of dermatophatic lymphadenitis. Epidermal LCs were T6+/HLA-DR+, and sometimes faintly T4+. Lymph node LCs were T6+, S-100+, T4+, HLA-DR+, and showed the same variety of surface receptors detected in H-X cells; furthermore, in a case with massive infiltration of the paracortex by T6+ cells, lymph node LCs were faintly T11+ and some of the T6+ cells had lymphoid aspect. Our findings suggest that the H-X cell population of L-S disease is not homogeneous, but is composed of discrete cell subsets with distinctive antigenic and morphological traits closely resembling those of cells of LC lineage at different maturational stages.

Langerhans cell histiocytosis: an unusual case illustrating the value of immunohistochemistry in diagnosis

The morphological features of Langerhans cell histiocytosis (histiocytosis X) are characteristic but the diagnosis can on occasion be difficult. A case is presented that illustrates the diagnostic value of immunohistochemistry in the differential diagnosis of this condition. The cells of Langerhans cell histiocytosis were found to express CD1, CD4, CD11b and CD11c. They also reacted with EBM11, UCHM1, KB61 and HLA-DR. Occasional cells showed nuclear staining with Ki67, but no other lymphoid antigens were detected. Immunoreactivity of the cells of Langerhans cell histiocytosis with antibodies that recognize antigens present on macrophages provides further evidence for immunological similarities between these cell types.

Immunoperoxidase demonstration of the cellular composition of the normal and coeliac small bowel

Immunohistological analysis of the cellular composition of the small intestinal mucosa in a group of untreated and treated coeliac patients and non-coeliac control subjects was performed using monoclonal antibodies and an immunoperoxidase technique. A characteristic cellular distribution was observed within the normal mucosa. The intraepithelial and lamina propria compartments were occupied mainly by T suppressor/cytotoxic and T helper/inducer cells respectively. Further subdivision of lamina propria T helper/inducer cells with the Leu 8 antibody revealed that these were of the Leu 3a+ Leu 8- phenotype. Macrophages, defined by the RFD7 antibody, were seen to occupy the same microenvironment as T helper/inducer cells. T cells expressing the T cell activation antigen defined by anti-Ta1 were found with the normal lamina propria, although few cells were identified by the anti-Tac antibody. HLA-Dr antigens were expressed by stellate cells within the lamina propria, and also by the epithelial cells of the villi, but not by normal crypt epithelial cells. In untreated coeliac patients the distribution of the various cell types was essentially unchanged, although the number of these cells was markedly increased, including those which expressed the Ta1 antigen. A significant deviation from normal in the expression of HLA-DR antigens was found in the coeliac small bowel: these antigens were expressed not only on the villous epithelial cells but also on the epithelial cells of the crypts. Immunohistological findings in the treated coeliac patients were intermediate between the normal and untreated coeliac groups, and were completely normal in those patients with complete histological resolution of their disease. These results suggest that coeliac disease is accompanied by an enhanced stimulation of the normal mucosal immune response and do not imply a primary pathogenic role for the immune system in this disease.

Immunocytochemical characterisation of cutaneous lymphomas other than mycosis fungoides

The immunophenotypic properties of 25 cutaneous non-Hodgkin lymphomas other than mycosis fungoides or Sezary syndrome were investigated and correlated with clinical and histopathological data. The 11 low grade lymphomas were all of B cell origin, whereas the 14 high grade lymphomas comprised B and T cell tumours, true histiocytic proliferations, and one "nul" cell lymphoid neoplasm. For the high grade lymphomas correct prediction of the immunological phenotype based on morphological criteria was only possible in three cases. In contrast, all of the low grade lymphomas showed the non-epidermotropic infiltration pattern considered to be characteristic of cutaneous B cell tumours. For these conditions, however, immunophenotypic investigations provided a convenient means of improving discrimination between benign (polyclonal) and malignant (monoclonal) lesions, and also showed similarities with nodal lymphomas in terms of expression of lymphoid subset markers and composition of the non-neoplastic white cell infiltrate. No differences were identified between primary and secondary or concurrent cutaneous and extracutaneous lymphomas. Cutaneous non-Hodgkin lymphomas other than mycosis fungoides or Sezary syndrome constitute a heterogeneous group of neoplasms and most of these disorders are likely to represent cutaneous equivalents of nodal malignancies. Immunophenotypic investigations form a useful supplement to their histogenetic characterisation and may provide a common conceptual basis for their classification.

Immunohistochemical study of idiopathic histiocytosis of the mandible and maxilla

Recent evidence suggests that the proliferative cells of idiopathic histiocytosis may be derived from Langerhans cells. In this study, antisera to S-100 protein, HLA-DR (la-like) antigen, muramidase, and alpha 1-antichymotrypsin were tested on formalin-fixed, paraffin-embedded tissue from nine cases of idiopathic histiocytosis using an immunoperoxidase technique. Tumor cells were positive for S-100 protein and HLA-DR antigen but negative for muramidase and alpha 1-antichymotrypsin. Mononuclear phagocytes were positive for HLA-DR antigen, muramidase, and alpha 1-antichymotrypsin but negative for S-100 protein. The immunohistochemical staining pattern of the tumor cells in these cases of idiopathic histiocytosis is similar to that seen for normal Langerhans cells. When these results are coupled with electron microscopic and histochemical data, it would appear that the origin of cells in idiopathic histiocytosis is from the Langerhans cell or its precursor. Thus, this condition might be better designated "Langerhans cell disease."

Enzyme patterns in human endocytotic multinucleate giant cells--a histochemical study

A series of human multinucleate giant cells (MGCs) of the endocytotic type were studied using enzyme histochemical methods for dehydrogenases, glycosidases, phosphatases, and peptidases. Several enzyme patterns were found. The subgroup of MGCs associated with inflammatory granulomatous processes (sarcoidosis, granulomatous myositis, familial granulomatosis, lymphogranuloma, granulomatous cholangitis) was characterized by high activities of nonspecific esterase (NE) and tartrate-sensitive acid phosphatase (AcPase-Ts). There was no detectable activity of peptidases or tartrate-resistant isoenzyme of acid phosphatase (AcPase-Tr). This enzyme equipment was indistinguishable from that in mononuclear precursors in the granulomas. The other MGCs of the series displayed enzyme patterns substantially different from their monocytic precursors (blood monocytes and Langerhans cells). The subgroup of foreign body associated MGCs (resorption of fat, keratin, and suture material) was characterized by high activities of NE, AcPase-Tr, and greatly variable activities of both peptidases studied. The latter lacked predilection for certain subcellular regions. The subgroup of osteoclasts and so-called giant cell tumours (osteoclastoma, giant cell tumour of soft parts, giant cell epulis of peripheral, and central types) displayed very low activity of NE, high activity of AcPase-Tr, and strong activities of peptidases. The latter were localized near the surface membrane of the polykarya. MGCs in histiocytosis X (HX) differed from the previous group by higher values of NE in average. All MGC types had common denominator in the absence of alkaline phosphatase activity, on average intense dehydrogenase activities, mostly low beta-glucuronidase and highly variable alpha-mannosidase activities. The enzyme pattern heterogeneity is discussed with regard to the phenomenon of enzyme induction and depression occurring in course of polykaryon production. The variability of phenomenon may reflect reactive adaptation to varying functional demands imposed on MGCs under different conditions.

Human macrophages and T-lymphocyte subsets infiltrating nodules of Onchocerca volvulus

The nature of the lymphoid infiltrate in nodules of Onchocerca volvulus was assessed using monoclonal antibodies to lymphoid cell surface markers. Although B cells were generally absent, T cells were present, but in variable amounts. The ratio of T4+ (helper phenotype) to T8+ (suppressor-cytotoxic phenotype) was usually in the normal peripheral blood range of about 3, although ratios ranging from 1 to 10 were seen in selected areas of the onchocercoma. The possibility of immunosuppression through dominance of T4+, Leu-8+ cells (suppressor-inducer phenotype) within the T4+ population was also excluded. The T cells did not tend to concentrate in close proximity to the parasite, and there was no general bias in favour of the T suppressor cell phenotype (T8) within the infiltrate. Macrophages and dendritic cells were consistently observed and consisted of three defined cell types in approximately equal proportions: normal, unactivated macrophages (HLA-DR-, acid phosphatase positive), activated macrophages (HLA-DR+, acid phosphatase positive) and cells of dendritic morphology (HLA-DR+, acid phosphatase negative). These results are discussed in relation to immune suppression in filariasis.

Solitary eosinophilic granuloma of the lateral orbital wall

Two children (aged 18 and 23 months at the initial examinations) were each ultimately found at surgery to have a solitary eosinophilic granuloma of the lateral orbital wall. Both patients had a symptomatic period of six weeks during which time other diagnoses were considered: bacterial preseptal cellulitis and mumps dacryoadenitis in the first case and traumatic recurrent orbital hematoma in the second. Diagnostic difficulties stemmed from confusing features in their histories, as well as the location of the lesion and the deceptively minimal swelling relative to the actual size of the lesion. Follow-up ten and 18 months after curettage of the two lesions showed no recurrence or evidence of systemic involvement. Although most reported cases describe the orbital frontal bone as the site of origin in the orbit, our cases demonstrated that unifocal eosinophilic granuloma may occur in the lateral wall of the orbit.

A distinctive cutaneous malignant neoplasm expressing the Langerhans cell phenotype. Synchronous occurrence with B-chronic lymphocytic leukemia

The authors describe a 63-year-old woman who developed a histologically distinctive malignant cutaneous neoplasm composed of large pleomorphic cells with abundant cytoplasm and multilobate, often clefted nuclei that occasionally contained small nucleoli. This neoplastic cell population metastasized to a regional lymph node already involved by a B-cell derived chronic lymphocytic leukemia expressing surface IgMk, BA-1, and OKT1. The large metastatic tumor cells lacked surface immunoglobulin, B-lymphocyte associated antigen BA-1, T-lymphocyte associated antigens OKT1 and OKT3, and the monocyte/macrophage markers lysozyme and alpha 1-antichymotrypsin. These tumor cells expressed HLA-DR antigens, adenosine triphosphatase (ATPase), OKT6, and contained S-100 protein, i.e., they expressed the phenotype peculiar to epidermal Langerhans cells. The typical clinical and histologic features of Histiocytosis X were absent. Thus, this case appears to represent a distinctive cutaneous neoplasm composed entirely of malignant cells of dendritic cell origin which, by immunophenotypic and histochemical analysis, appear to be related to epidermal Langerhans cells.

Immunocytochemical characterization of pulmonary histiocytosis X cells in lung biopsies

Morphologic and immunohistochemical studies were made of open lung biopsies from 9 patients with pulmonary histiocytosis X (HX) and 12 patients with other conditions, and of skin biopsies from patients with cutaneous sarcoidosis, Chester-Erdheim disease, and eruptive histiocytoma. The monoclonal antibody OKT6 was detected with the use of goat anti-mouse IgG labeled with fluorescein (FITC) for light microscopy, and sheep antimouse Fab'2 fragment of IgG labeled with horseradish peroxidase (HRP) for immunoelectron microscopy. The presence of S-100 protein was revealed by an antibody prepared against bovine S-100 protein, using sheep anti-rabbit IgG labeled with FITC for light microscopy and with HRP for immunoelectron microscopy. OKT6 antibody and S-100 protein were detected simultaneously by double labeling with FITC and rhodamine. In all patients with pulmonary HX, the major cellular components (HX cells) of the granulomas showed labeling of the plasma membranes by OKT6 and of the cytoplasm by the anti S-100 protein antibody. The double-labeling technique demonstrated that the same cells carried both reactivities. Immunoelectron microscopy showed that the reactive cells had all the structural characteristics of Langerhans cells, including Langerhans cell granules. Cells reacting with OKT6 showed discrete internal labeling in some of the Langerhans granules, especially those in continuity with the plasma membranes. However, internal labeling of Langerhans granules was not demonstrated in preparations for the localization of S-100 protein. Control samples of sarcoid lesions and other pulmonary lesions unrelated to HX did not show any reactivity except in Langerhans cells; a skin lesion from a patient with eruptive histiocytoma contained OKT6-positive cells which did not have Langerhans granules.

Histiocytosis X: an ophthalmological review

Of 76 children with histiocytosis X 18 had orbital involvement, and four developed additional neuro-ophthalmic complications. No instance of intraocular involvement was detected. Among those patients with ophthalmic involvement the main problems were bilateral or unilateral proptosis, ptosis, papilloedema, optic atrophy, and seventh nerve palsy. Only one patient developed a severe visual defect. Management of the ophthalmological complications depends not only on the extent of the orbital disease but also on the degree of systemic involvement. Overall management by a paediatric oncologist is mandatory.

Langerhans' cells and macrophages in eosinophilic granuloma. An enzyme-histochemical, enzyme-cytochemical, and ultrastructural study

Biopsy material of six patients with eosinophilic granuloma (EG) was investigated by electron microscopic and enzyme-histochemical methods for acid phosphatase (AcP), leucyl-beta-naphthylamidase (LA), adenosine triphosphatase, and alpha-naphthyl-acetate esterase (NE). Paraplast sections were used for demonstration of lysozyme with an immunoperoxidase method. Results of staining for these different enzymes suggested the existence of two separate sets of histiocytic cells: one type with "dot-like" AcP staining and negative for NE and lysozyme; and the other with diffuse AcP staining, positive for NE and lysozyme, and often showing signs of phagocytosis. The first type presumably represented Langerhans' cells and also often showed positive staining for LA. Macrophages were generally negative for LA. Electron microscopic study confirmed the impression gained from enzyme-histochemical studies. No intermediate cell types between Langerhans' cells and genuine macrophages were seen. From these results it is concluded that in EG no transformation exists between Langerhans' cells and macrophages. The latter are presumably of reactive nature.

Histiocytosis X cells and Langerhans cells: enzyme histochemical and immunologic similarities

The proliferating cell in histiocytosis X has been thought to be an abnormal Langerhans cell since the identification in 1965 of the characteristic X-bodies morphologically identical to the Birbeck granules of epidermal Langerhans cells. This conclusion is based primarily on this finding and on morphologic similarities at the light microscopic level. Enzyme histochemical data have been somewhat conflicting and have not provided strong support for this conclusion. Recently, immunohistochemical studies have shown data consistent with a Langerhans cell origin for histiocytosis X cells. This study documents the presence of nonspecific esterase, acid phosphatase, and adenosine triphosphatase in both Langerhans cells and histiocytosis X cells. Both types of cells also react with antibodies directed against widely distributed leukocyte antigens (HLA-A,B,C; Ia; L3B12); Langerhans cell/thymocyte antigen [Leu 6(T6)]; histiocyte antigen (Leu-M3); helper T-cell/histiocyte antigen [Leu-3(T4)]; and S-100 protein. These results complement earlier immunologic studies and add enzyme histochemical data that strongly support the concept of histiocytosis X as a proliferative disorder of cells of Langerhans lineage.

Usefulness of enzyme-1 and immunohistochemistry in the diagnosis of juvenile xanthogranuloma

Skin biopsies from two children with juvenile xanthogranuloma were studied. Enzyme- and immunohistochemistry was used to establish the mononuclear phagocytic nature of the proliferating dermal elements. The usefulness of both techniques in the diagnosis and the differential diagnosis of this disease is suggested.

Expression of HLA-DR antigens in nasopharyngeal carcinoma: an immunohistological analysis of the tumour cells and infiltrating lymphocytes

A panel of conventional and monoclonal antibodies was used to examine the immunohistological characteristics of malignant epithelial cells and infiltrating lymphocytes in frozen sections of nasopharyngeal carcinoma (NPC) biopsies from 10 Tunisian patients. Three main categories of cells were identified. (1) Tumour cells which were positive for Epstein-Barr nuclear antigen, HLA-ABC and keratin determinants. In most samples, the tumour cells also expressed variable amounts of HLA-DR antigens. The presence of HLA-DR antigens has not been previously reported in NPC and may be a contributory factor in effecting the transfer of Epstein-Barr virus to the epithelial cells. (2) Infiltrating lymphocytes which were mainly composed of T inducer (T4+) and T suppressor/cytotoxic (T8+) cells although one sample contained predominantly immature T cells expressing the HTA-I+ cortical thymocyte phenotype. Few B cells or natural killer cells were demonstrated. (3) Large HTA-I+ dendritic cells which were invariably present within the tumour masses. These were morphologically and phenotypically similar to antigen presenting Langerhans cells which are usually located in the skin but also found in other epithelial sites. These cells may be a residual population from the normal nasopharynx or represent part of a specific immunological response to the presence of Epstein-Barr virus in the epithelial cells.

B- and T-lymphocytes in ocular disease

Ocular inflammatory diseases and ocular adnexal lymphoid tumors have become less obscure and intimidating by virtue of our ability to study the infiltrates in these various diseases for their B-lymphocyte and T-lymphocyte composition. Comparisons are also possible between lymphocytic profiles in the peripheral blood and the precise composition of the in situ infiltrates within the ocular tissue themselves. The availability of monoclonal antibodies, which can determine T-lymphocytic subsets such as T-helper cells and T-suppressor/cytotoxic cells, natural killer cells, and monocytes-histiocytes, has provided a powerful technology for the delineation of the distinctive immune composition of the inflammatory infiltrates, as well as any possible disturbances in T-cell immunoregulation. B-lymphocytes produce immunoglobulins, which may be misdirected as autoantibodies in local or systemic autoimmune diseases. Immunoglobulin-mediated and therefore B-cell derived conditions include vasculitis, progressive cicatricial ocular pemphigoid, Mooren's corneal ulcer, scleritis, and hay fever and vernal conjunctivitis. Other diseases in which B-lymphocytes, their immunoglobulin products or immune complexes formed with presently unknown antigens are potentially at fault are chronic non-specific uveitis; iridocyclitis in Behcet's syndrome; Fuch's heterochromic syndrome, ankylosing spondylitis, and Reiter's syndrome; Graves' disease; and idiopathic inflammatory orbital pseudotumor and myositis. T-cells do not produce immunoglobins, but rather secrete lymphokines or interact directly with receptors or determinants on viruses or target tissues (eg. immunosurveillance against neoplasia); it is possible that some autoimmune diseases are the result of neo-antigens on the surfaces of host tissues that have been coded for by a cryptic inciting virus. T-cell diseases include phlyctenulosis graft rejections, graft versus host disease, and possibly sympathetic ophthalmia and temporal arteritis. Natural killer cells are involved in many of the same diseases as cytotoxic T-cells, except that the former require no period of sensitization (natural immunity), whereas cytotoxic T-cells must undergo an antigen-specific blast transformation (acquired immunity of the delayed hypersensitivity type). In many diseases in which B-cell derived auto-antibodies are at fault, there may be local tissue or systemic T-cell imbalances, with a reduction in T-suppressor cells and a relative augmentation in T-helper cells, thereby facilitating production of misdirected auto-antibodies.(ABSTRACT TRUNCATED AT 400 WORDS)

Immunological and histochemical analysis of regional variations of epidermal Langerhans cells in normal human skin

Epidermal Langerhans' cells (LC) were enumerated in normal human skin from various anatomical sites using a monoclonal antibody (NA1/34) to human thymocyte antigen (HTA-1) and the standard ATPase reaction on frozen sections. The same population of cells was identified with each technique. LC densities were found to be significantly higher in hair bearing skin than in skin from the palm and sole. LC were also identified in hair follicles (where the numbers decreased from the superficial to the deep portions) and sebaceous glands but in no other adnexal structure. Normal numbers were encountered in patients who had received radiotherapy or systemic chemotherapy for malignant disease for periods of greater than two months before death. As LC are important antigen presenting cells, the variation in their density suggests that the immunological properties of normal skin may not be uniform throughout the body. This may be related to the varying anatomical distribution of some skin disorders with an immunological basis.

Langerhans' cells and T cells in human skin tumours: an immunohistological study

In this study normal skin and a range of skin tumours, both benign and malignant, have been examined using monoclonal antibodies to identify the distribution and morphology of Langerhans' cells and T cells, the distribution of T lymphocytes and their subsets have been analysed using monoclonal anti-T cell antibodies. The results indicated that Langerhans' cells can be reliably identified in both normal and malignant skin biopsies using monoclonal antibodies. A striking finding to emerge was that in benign skin lesions Langerhans' cells were increased, whereas in malignant tumours they were not only markedly depleted or absent but also grossly stunted and deformed in outline. The majority of lymphocytes surrounding these skin tumours were shown to be T cells with helper cells outnumbering suppressor cells by a ratio from 2 to 5:1. This study shows the usefulness of immunohistological techniques using monoclonal antibodies for examining the morphology and distribution of Langerhans' cells in skin pathology. In addition they are particularly appropriate for identifying their topographical relationships with other immunologically important cells such as T cells.

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.

Spontaneous remission of multi-system histiocytosis X

Two infants presented with biopsy-proven histiocytosis X affecting multiple sites. Since neither showed evidence of organ failure or of constitutional upset, no specific therapy was given. In each case there was long-lasting spontaneous regression of disease. Analysis of blood mononuclear cells revealed a raised T4:T8 (helper:suppressor T lymphocyte) ratio at diagnosis but a normal ratio during remission. These observations support the argument that multi-system histiocytosis X, even in infants (Letterer-Siwe disease), is not a malignancy and that an "expectant" treatment policy may be indicated in selected patients.

The distribution of lymphoid and macrophage like cell subsets of sarcoid and Kveim granulomata: possible mechanism of negative PPD reaction in sarcoidosis

Immunohistological observations of lymphoid and non-lymphoid cell subsets in biopsies of sarcoid skin granulomas have been compared with positive Kveim tests and the sites of PPD injection in sarcoid patients. Monoclonal antibodies have been used in indirect immunofluorescence often in combination with histochemical methods for the detailed characterization of the cells involved. The antibodies used included two new reagents, RFD-1 and RFD-2, which react with interdigitating cells and acid phosphatase positive macrophages, respectively. Sarcoid granulomas had a distinctive pattern of organization though there was a heterogeneity of macrophage like and T lymphoid cells. In the centre, predominantly HLA-DR+, acid phosphatase positive macrophages (RFD-2+) were seen and the lymphoid cells were almost exclusively T4+. At the periphery of the granulomas the HLA-DR+ dendritic cells were ACP negative and RFD-1+. Here T8+ cells were admixed with the T4+ population. The Kveim granuloma had fewer RFD-2+, macrophages and therefore the RFD-1+ cells were more evenly distributed, but the other cells showed a similar distribution to the established lesions. The PPD injection sites contained fewer T cells than the normal control infiltrates in PPD positive healthy individuals. The T4+/T8+ ratios were about 3:2. The most likely explanation for the PPD anergy in sarcoidosis is the sluggish traffic of T4+ cells which could be due to the sequestration of T4+ cells in sites of ongoing inflammation.

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.

Langerhans' cells in human cervical epithelium: an immunohistological study

Langerhans' cells are intraepithelial dendritic cells believed to be important in the recognition and processing of exogenous antigens. They were demonstrated by immunohistological methods in cervical tissue obtained from 10 subjects ranging in age from 30 weeks gestational age to 62 years. Langerhans' cells were clearly delineated in all tissue sections and appear to form a relatively constant component of both the transformation zone and ectocervical epithelium. In addition to Langerhans' cells, a population of T lymphocytes characterized as predominantly T-cytotoxic/suppressor cells have also been demonstrated. The interaction between Langerhans' cells, T lymphocytes and stromal macrophages and their relation to antigen recognition is discussed.

Haematoxylin counterstaining of immunofluorescence preparations

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