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Ng SW, Zakawi FA, Shanmuganathan J, Al-Yahya SN. Langerhans Cell Histiocytosis in Paediatric Zygoma Swelling. Indian J Otolaryngol Head Neck Surg 2022; 74:5905-5909. [PMID: 36742809 PMCID: PMC9895686 DOI: 10.1007/s12070-021-02480-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/20/2021] [Indexed: 02/07/2023] Open
Abstract
Langerhans cell histiocytosis (LCH) is a rare neoplasm characterized by accumulation of histiocytes in various tissues. It has a wide clinical spectrum and its presentation may mimic clinical features of common diseases. High level of suspicion is required for early diagnosis. Here is a rare case of a rapidly aggressive LCH which first presented with right zygomatic swelling.
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Affiliation(s)
- Syiao Wei Ng
- Otorhinolaryngology Department, Hospital Sultanah Aminah, Jalan Persiaran Abu Bakar Sultan, 80100 Johor Bahru, Johor Malaysia
| | - Faredza Aliyaa Zakawi
- Otorhinolaryngology Department, Hospital Sultanah Aminah, Jalan Persiaran Abu Bakar Sultan, 80100 Johor Bahru, Johor Malaysia
| | - Jothi Shanmuganathan
- Otorhinolaryngology Department, Hospital Sultanah Aminah, Jalan Persiaran Abu Bakar Sultan, 80100 Johor Bahru, Johor Malaysia
| | - Syarifah Nafisah Al-Yahya
- Otorhinolaryngology Department, Hospital Sultanah Aminah, Jalan Persiaran Abu Bakar Sultan, 80100 Johor Bahru, Johor Malaysia
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Kim HJ, Hong YH. Idiopathic multicentric Castleman disease presenting progressive reticular honeycomb infiltration of lung and immunoglobulin G and immunoglobulin G4 dominant hypergammaglobulinemia. Yeungnam Univ J Med 2021; 39:153-160. [PMID: 34218552 PMCID: PMC8913918 DOI: 10.12701/yujm.2021.01039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/25/2021] [Indexed: 11/11/2022] Open
Abstract
Multicentric Castleman disease (MCD) is an uncommon systemic lymphoproliferative disorder that may cause multiple organ damage. Castleman disease-associated diffuse parenchymal lung disease (DPLD) has not been well studied. A 32-year-old man was referred to our hospital for progressive generalized weakness, light-headedness, and dyspnea on exertion for more than one year. Laboratory evaluations showed profound anemia, an elevated erythrocyte sedimentation rate, and an increased C-reactive protein level with polyclonal hypergammaglobulinemia. Chest radiography, computed tomography (CT), and positron emission tomography-CT scan demonstrated diffuse lung infiltration with multiple cystic lesions and multiple lymphadenopathy. In addition to these clinical laboratory findings, bone marrow, lung, and lymph node biopsies confirmed the diagnosis of idiopathic MCD (iMCD). Siltuximab, an interleukin-6 inhibitor, and glucocorticoid therapy were initiated. The patient has been tolerating the treatment well and had no disease progression or any complications in 4 years. Herein, we report this case of human herpesvirus-8-negative iMCD-associated DPLD accompanied by multiple cystic lesions, multiple lymphadenopathy, and polyclonal hypergammaglobulinemia with elevated immunoglobulin G (IgG) and IgG4 levels. We recommend a close evaluation of MCD in cases of DPLD with hypergammaglobulinemia.
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Affiliation(s)
- Hyun-Je Kim
- Division of Rheumatology, Department of Internal Medicine, CHA Gumi Medical Center, CHA University, Gumi, Korea
| | - Young-Hoon Hong
- Division of Rheumatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Fadhel Alvarez A, Patel SP, Brasher MI, Ruggiero JE, Aneji C. Langerhans cell histiocytosis: Presentation in a preterm neonate. Cancer Rep (Hoboken) 2021; 5:e1472. [PMID: 34156158 PMCID: PMC8842702 DOI: 10.1002/cnr2.1472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 11/11/2022] Open
Abstract
Background Langerhans cell histiocytosis (LCH) is a rare disorder in which Langerhans cells (LC) accumulate in the skin or other organs and cause tumor formation or organ damage. Cutaneous lesions can vary widely and do not predict extent of systemic disease or prognosis. Case We present a premature infant with skin findings, multisystem involvement, and immunohistochemical markers consistent with multisystem LCH. Conclusion Limited data from preterm neonates with LCH suggest that prognosis is particularly poor, with even limited cutaneous disease often rapidly progressing to become fatal, although diagnosis is not always prompt. Early diagnosis and treatment may affect prognosis.
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Affiliation(s)
- Ana Fadhel Alvarez
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
| | - Shaily P Patel
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
| | - Maya I Brasher
- Department of Pediatrics, Division of Neonatology, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
| | - Jaclyn E Ruggiero
- Department of Pediatrics, Division of Neonatology, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
| | - Chiamaka Aneji
- Department of Pediatrics, Division of Neonatology, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
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Abstract
The age-dependent development of the bone marrow follows a constant pattern and has an impact on the localization and morphology of various bone marrow processes. Physiological, reactive and benign bone marrow alterations must be differentiated from inflammatory or malignant infiltrations. In many cases, a specific age distribution pattern and typical morphological characteristics in magnetic resonance imaging (MRI) enable a diagnostic classification. The only adequate imaging modality that can provide information about the bone marrow composition is MRI.
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Affiliation(s)
- Sebastian Berg
- Kinderradiologie, Universitätsklinik Freiburg, Mathildenstraße 1, 79106, Freiburg, Deutschland.
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Kemps PG, Hebeda KM, Pals ST, Verdijk RM, Lam KH, Bruggink AH, de Lil HS, Ruiterkamp B, de Heer K, van Laar JAM, Valk PJM, Mutsaers P, Levin M, Hogendoorn PCW, van Halteren AGS. Spectrum of histiocytic neoplasms associated with diverse haematological malignancies bearing the same oncogenic mutation. J Pathol Clin Res 2021; 7:10-26. [PMID: 32852896 PMCID: PMC7737785 DOI: 10.1002/cjp2.177] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/18/2020] [Accepted: 06/25/2020] [Indexed: 12/14/2022]
Abstract
Histiocytic disorders are a spectrum of rare diseases characterised by the accumulation of macrophage-, dendritic cell-, or monocyte-differentiated cells in various tissues and organs. The discovery of recurrent genetic alterations in many of these histiocytoses has led to their recognition as clonal neoplastic diseases. Moreover, the identification of the same somatic mutation in histiocytic lesions and peripheral blood and/or bone marrow cells from histiocytosis patients has provided evidence for systemic histiocytic neoplasms to originate from haematopoietic stem/progenitor cells (HSPCs). Here, we investigated associations between histiocytic disorders and additional haematological malignancies bearing the same genetic alteration(s) using the nationwide Dutch Pathology Registry. By searching on pathologist-assigned diagnostic terms for the various histiocytic disorders, we identified 4602 patients with a putative histopathological diagnosis of a histiocytic disorder between 1971 and 2019. Histiocytosis-affected tissue samples of 187 patients had been analysed for genetic alterations as part of routine molecular diagnostics, including from nine patients with an additional haematological malignancy. Among these patients, we discovered three cases with different histiocytic neoplasms and additional haematological malignancies bearing identical oncogenic mutations, including one patient with concomitant KRAS p.A59E mutated histiocytic sarcoma and chronic myelomonocytic leukaemia (CMML), one patient with synchronous NRAS p.G12V mutated indeterminate cell histiocytosis and CMML, and one patient with subsequent NRAS p.Q61R mutated Erdheim-Chester disease and acute myeloid leukaemia. These cases support the existence of a common haematopoietic cell-of-origin in at least a proportion of patients with a histiocytic neoplasm and additional haematological malignancy. In addition, they suggest that driver mutations in particular genes (e.g. N/KRAS) may specifically predispose to the development of an additional clonally related haematological malignancy or secondary histiocytic neoplasm. Finally, the putative existence of derailed multipotent HSPCs in these patients emphasises the importance of adequate (bone marrow) staging, molecular analysis and long-term follow-up of all histiocytosis patients.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Biomarkers, Tumor/genetics
- Erdheim-Chester Disease/genetics
- Erdheim-Chester Disease/pathology
- Erdheim-Chester Disease/therapy
- Fatal Outcome
- GTP Phosphohydrolases/genetics
- Genetic Predisposition to Disease
- Histiocytic Sarcoma/genetics
- Histiocytic Sarcoma/pathology
- Histiocytic Sarcoma/therapy
- Humans
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Leukemia, Myelomonocytic, Chronic/genetics
- Leukemia, Myelomonocytic, Chronic/pathology
- Leukemia, Myelomonocytic, Chronic/therapy
- Male
- Membrane Proteins/genetics
- Middle Aged
- Mutation
- Phenotype
- Proto-Oncogene Proteins p21(ras)/genetics
- Retrospective Studies
- Treatment Outcome
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Affiliation(s)
- Paul G Kemps
- Department of PaediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - Konnie M Hebeda
- Department of PathologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Steven T Pals
- Department of PathologyAmsterdam University Medical CentersAmsterdamThe Netherlands
| | - Robert M Verdijk
- Department of PathologyErasmus MC University Medical Center RotterdamRotterdamThe Netherlands
- Department of PathologyLeiden University Medical CenterLeidenThe Netherlands
| | - King H Lam
- Department of PathologyErasmus MC University Medical Center RotterdamRotterdamThe Netherlands
| | - Annette H Bruggink
- PALGA Foundation (Nationwide Network and Registry of Histopathology and Cytopathology)HoutenThe Netherlands
| | - Heleen S de Lil
- Department of HaematologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Bart Ruiterkamp
- Department of HaematologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Koen de Heer
- Department of HaematologyAmsterdam University Medical CentersAmsterdamThe Netherlands
- Department of HaematologyFlevoziekenhuisAlmereThe Netherlands
| | - Jan AM van Laar
- Department of Internal MedicineErasmus MC University Medical Center RotterdamRotterdamThe Netherlands
- Department of ImmunologyErasmus MC University Medical Center RotterdamRotterdamThe Netherlands
| | - Peter JM Valk
- Department of HaematologyErasmus MC University Medical Center RotterdamRotterdamThe Netherlands
| | - Pim Mutsaers
- Department of HaematologyErasmus MC University Medical Center RotterdamRotterdamThe Netherlands
| | - Mark‐David Levin
- Department of Internal MedicineAlbert Schweitzer ZiekenhuisDordrechtThe Netherlands
| | | | - Astrid GS van Halteren
- Department of PaediatricsLeiden University Medical CenterLeidenThe Netherlands
- Princess Máxima Center for Paediatric OncologyUtrechtThe Netherlands
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Desbarats C, Adnot J, Bastien AV, Trost O. [Langerhans cell histiocytosis revealed by a temporomandibular joint disorder: Report of a case and review of the craniofacial expressions]. Rev Med Interne 2019; 41:50-53. [PMID: 31474430 DOI: 10.1016/j.revmed.2019.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/17/2019] [Accepted: 08/15/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Langerhans cell histiocytosis (HL) is a rare disease that can affect all tissues. Oral manifestations such as mucosal ulcer and tooth mobility are often the first signs of the disease. We report a rare case of mandibular condyle unifocal HL mimicking a temporomandibular joint disorder. CASE REPORT A 44-year-old patient presented with a left temporomandibular disorder with painful left preauricular swelling. The imaging assessment found a bone lesion of the left mandibular condyle. A curettage with biopsy was used to diagnose HL. Six months later, the patient had no more pain. DISCUSSION The craniofacial clinical expressions of HL mainly concern the bones, which can cause: pain, swelling, fracture, compression of noble organs. The other sites are: oral cavity, skin, lymph nodes, or eyes. Isolated forms are generally benign, and their treatment is discussed between abstention and non-aggressive surgery.
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Affiliation(s)
- C Desbarats
- Service de chirurgie maxillo-faciale et stomatologie, centre hospitalo-universitaire de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - J Adnot
- Service de chirurgie maxillo-faciale et stomatologie, centre hospitalo-universitaire de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - A V Bastien
- Service de chirurgie maxillo-faciale et stomatologie, centre hospitalo-universitaire de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - O Trost
- Service de chirurgie maxillo-faciale et stomatologie, centre hospitalo-universitaire de Rouen, 1, rue de Germont, 76000 Rouen, France; Laboratoire d'anatomie, faculté de médecine de Rouen, 22, boulevard Gambetta, 76000 Rouen, France; Institut national de la santé et de la recherche médicale (Inserm), LIMICS UMR-1142, 76000 Rouen, France.
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Tamefusa K, Ishida H, Washio K, Ishida T, Morita H, Shimada A. Remission of Congenital Multi-system Type Langerhans Cell Histiocytosis with Chemotherapy. Acta Med Okayama 2019; 73:61-65. [PMID: 30820055 DOI: 10.18926/amo/56459] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Patients with multi-system (MS)-type langerhans cell histiocytosis (LCH) show poor outcomes, especially congenital MS LCH cases were shown in high mortality rate. We experienced a congenital case of MS LCH with high risk organs, who needed intensive respiratory support after birth. Even though intensive chemotherapy was discontinued, this patient's lung LCH lesions gradually became reduced and his respiratory condition recovered; therefore, we restarted and completed maintenance chemotherapy. The patient maintained complete remission for more than 4 years after the end of chemotherapy. Our case suggests that congenital MS LCH even with severe organ involvement can be treated successfully with chemotherapy.
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Affiliation(s)
- Kosuke Tamefusa
- Department of Pediatrics, Okayama University Hospital, Okayama 700-8558, Japan
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Sugimoto K, Ueda S, Okada M, Takemura T. Membranoproliferative glomerulonephritis associated with Rosai-Dorfman disease. Clin Nephrol Case Stud 2017; 5:54-9. [PMID: 29043148 DOI: 10.5414/CNCS108856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 06/06/2016] [Indexed: 11/18/2022] Open
Abstract
Rosai-Dorfman disease is also known as sinus histiocytosis with massive lymphadenopathy. Extranodal Rosai-Dorfman disease has been reported in ~ 43% of cases; the most frequent extranodal sites – skin, soft tissue, bone, respiratory tract, and eye – are usually involved in association with lymphadenopathy. Lack of lymph node involvement is rare, especially when patients manifest renal disease. Here, we describe a patient who developed membranoproliferative glomerulonephritis when lymphadenopathy was absent. During follow-up for sinus histiocytosis, a 7-year-old Japanese boy developed proteinuria and hematuria. No renal abnormality was present in ultrasound imaging. Histologic examination of a renal biopsy specimen disclosed moderate mesangial proliferation, focal thickening of glomerular capillary walls, and mesangial interposition. Mononuclear cells infiltrated the interstitium. Immunofluorescence showed intense IgG, C3, and C4 reactivity in portions of the mesangium and glomerular capillary walls. Electron microscopy depicted nodular deposits in mesangial, endocapillary, and subepithelial areas. Immunohistochemistry for S-100 protein, CD68, and lysozyme was positive within the interstitium. CD1a staining was absent. These findings were diagnostic for membranoproliferative glomerulonephritis. Multidrug therapy, including methylprednisolone and mizoribine, improved urinary findings and induced complete remission of both diseases. To the best of our knowledge, this is the first report of Rosai-Dorfman disease complicated by renal disease in the absence of concurrent nodal involvement. Clinicians should be alert to this diagnostic possibility.
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Duan MH, Han X, Li J, Zhang W, Zhu TN, Han B, Zhuang JL, Wang SJ, Cao XX, Cai HC, Chen M, Yang C, Zhou DB. Comparison of vindesine and prednisone and cyclophosphamide, etoposide, vindesine, and prednisone as first-line treatment for adult Langerhans cell histiocytosis: A single-center retrospective study. Leuk Res 2016; 42:43-6. [PMID: 26859782 DOI: 10.1016/j.leukres.2016.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 12/29/2015] [Accepted: 01/24/2016] [Indexed: 01/25/2023]
Abstract
OBJECTIVE We compared the efficacy and clinical outcomes of vindesine and prednisone (VP) and cyclophosphamide, etoposide, vindesine, and prednisone (CEVP) regimens as first-line treatment for multisystem (MS) or multifocal single system (SS-m) adult Langerhans cell histiocytosis (LCH). METHOD Clinical features, treatment response, and survival of adults with Langerhans cell histiocytosis treated at our center from January 2001 to January 2015 were reviewed retrospectively. RESULTS Forty-five adult MS or SS-m LCH patients were treated (N=31, CEVP group; N=14, VP group). Both treatment groups had similar gender distributions, patient ages, and extent of disease. The non-active disease rate for both groups was 70.0% and 64.3% (P=0.775), respectively. Median follow-up was 74.9 (range: 2.8-183.6) months and recurrence rates were 71.0% and 78.6% (P=0.593), respectively. The need for second-line therapy was 64.5% and 71.4% (P=0.649), respectively, and mortality rates were 9.7% and 15.4% (P=0.586), respectively. Neutropenia occurred in 48.4% of CEVP-treated patients and 7.1% of VP-treated patients (P=0.008). CONCLUSIONS CEVP or VP regimens for the treatment of adult SS-m or MS LCH showed similar efficacies, and both regimens were associated with high disease recurrence and the need for second-line therapy.
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Affiliation(s)
- M-H Duan
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - X Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - J Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - W Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - T-N Zhu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - B Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - J-L Zhuang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - S-J Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - X-X Cao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - H-C Cai
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - M Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - C Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - D-B Zhou
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
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Park IKS, Park IK, Kim EK, Kim S, Jeon SR, Huh JR, Suh CW. Langerhans cell histiocytosis followed by Hodgkin's lymphoma. Korean J Intern Med 2012; 27:459-62. [PMID: 23269889 PMCID: PMC3529247 DOI: 10.3904/kjim.2012.27.4.459] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 05/21/2008] [Accepted: 06/13/2008] [Indexed: 11/27/2022] Open
Abstract
A 22-year-old man was referred to our institution due to lower back pain and was diagnosed with Langerhans cell histiocytosis of the thoracic and lumbar spine. The patient achieved complete remission with radiotherapy and chemotherapy. One year later, right cervical lymphadenopathy was observed and Hodgkin's lymphoma was confirmed on biopsy. The patient was treated with chemotherapy and autologous stem cell transplantation, and experienced no further symptoms. Further, no evidence of recurrence was observed on follow-up imaging. This report discusses the association between Langerhans cell histiocytosis and Hodgkin's lymphoma.
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Affiliation(s)
- IK Soo Park
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Keun Park
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Kyoung Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ryong Jeon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Ryung Huh
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Cheol Won Suh
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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