Concurrent Mastoid Cellulitis and Langerhans Cells Histiocytosis: A Challenging Diagnosis

Diagnosis and treatment of adult Langerhans cell histiocytosis in the rib: a case report and literature review

BACKGROUND

Langerhans cell histiocytosis (LCH) is a rare proliferative disease caused by the proliferation of Langerhan's cells and aggregation in multiple organs. Rib involvement is extremely rare and easily misdiagnosed. The biologic behavior of LCH is largely unknown, and it is of utmost importance to differentiate it from tuberculosis and tumors. Herein, we present a male adult diagnosed with Langerhans cell histiocytosis of the rib which was successfully treated with surgery.

CASE DESCRIPTION

This study retrospectively reports a rare case of rib-only LCH in a 34-year-old male patient who complained of persistent stabbing pain in the left chest and back for 45 days. The pain increased after bending, and was accompanied by chest tightness, shortness of breath, and night sweats. The patient denied any family history of LCH. CT showed an isolated mass on the left chest wall invading the seventh posterior rib. The diagnosis was confirmed by immunohistochemical staining and pathological analysis. The immunohistochemistry showed VIM (+), Ki-67 (+30%), CD1a (+), CD 68 (+) and S-100 (+). After surgical resection, the patient was followed up for more than 5 years without recurrence or complication. In addition, we reviewed and summarized 11 reported LCH cases with rib involvement, in which patients were either asymptomatic, or reported chest or back pain. Surgical resection was the main therapy in each case, and after 4-63 months of follow up, all patients were disease-free.

CONCLUSIONS

This case presents a rare instance of adult LCH in the rib. Pathological typical Langerhans cells and positive protein S100, CD1a, and CD207 are the key evidences for LCH, and surgical resection is currently an effective therapy with satisfactory outcomes.

Otologic Manifestations of Langerhans Cell Histiocytosis: A Systematic Review

OBJECTIVE

To perform a systematic review to investigate common otologic manifestations of Langerhans cell histiocytosis, the incidence of these findings, methods for diagnosis, as well as medical and surgical management.

DATA SOURCES

PubMed/MEDLINE, Embase, and Cochrane Library.

REVIEW METHODS

A search of PubMed/MEDLINE, Embase, and Cochrane Library for all articles published between 1963 to 2020 was performed with variations and combinations of the following search terms: Langerhans cell histiocytosis, eosinophilic granuloma, Letterer-Siwe, Hand-Schüller-Christian, otitis, otologic, ear. A review of the references of all included articles was also conducted.

RESULTS

Sixty-two articles encompassing 631 patients met inclusion criteria. Otologic symptoms at presentation were found in 246 (39%) patients in the reported studies with 48% reporting bilaterality. The mean age was 14.8 years with a male predominance (64%). The most common otologic presenting symptom was otorrhea (46%). A majority had the multisystem variant (52%). The most common treatment modalities were chemotherapy (52%), followed by surgery (50%), systemic steroids (45%), and radiotherapy (31%). Surgery was performed in 75.8% with unisystem involvement and in 50.6% with multisystem involvement. The most effective treatments included radiotherapy (56% success rate, 17% of treated patients), systemic steroids (44% success, 20% treated), chemotherapy (41% success, 21% treated), and surgical modalities (36% success, 19% treated).

CONCLUSIONS

Otologic manifestations that occur with the multisystem variant or are at high risk for central nervous system involvement necessitate systemic treatment. For unifocal lesions, surgery is recommended. Lastly, radiotherapy should be reserved for extensive lesions involving vital structures or presenting in older patients.

Temporal Bone Langerhans Cell Histiocytosis: An Uncommon Bilateral Presentation

Langerhans cell histiocytosis (LCH) is a rare condition that presents clinically in various ways. The cause and subsequent development of LCH are idiopathic and not fully understood. This disease is mainly seen in childhood. It is rare to have bilateral temporal bone LCH as the initial presentation. LCH can affect many organs. However, the bilateral involvement of the temporal bone is very uncommon. Therefore, we believe documenting cases of this presentation can lead to a better understanding of the epidemiology and prevalence of the disease, which can contribute to its management planning.

A one-year-old boy was referred to a tertiary otolaryngology clinic with bilateral postauricular swelling, hearing loss, but no tenderness or ear discharge. During the patient evaluation, a CT scan was requested to further investigate the bilateral swelling, which showed bilateral bony destructive lesions in the temporal bone area. Next, the patient was scheduled for a biopsy of this lesion under general anesthesia. A biopsy of the right mastoid confirmed the diagnosis of LCH. The patient was started on LCH IV protocol for multifocal bone lesions (MFB) with special site induction. A follow-up fluorodeoxyglucose positron emission tomography/CT (FDG PET/CT) was performed on the whole body with the impression of mild interval improvement of the temporal bones’ masses bilaterally with stable bilateral cervical lymphadenopathy.

LCH is a rare pathology that requires comprehensive effort from various medical and surgical teams to reach the right diagnoses and start the patient on the best available treatment plan.