Eosinophilic granuloma of the calvarium: is conservative management a valid option? Illustrative case and systematic review of the literature

INTRODUCTION

Eosinophilic granuloma (EG) is the most common form of Langerhans cell histiocytosis, presenting as a single osteolytic lesion of the calvarium. Its diagnosis is based on typical clinical and radiological features. While surgical resection has been the standard treatment for EG, growing evidence favors watchful waiting, as unifocal calvarial lesions appear to frequently undergo spontaneous remission. However, histopathological confirmations of this hypothesis are still very limited.

METHODS

Methods. Here, we report a case of EG with typical clinical and radiological features which, due to intervening circumstances, was resected in a delayed fashion. Moreover, we perform a systematic review of the literature on conservative management of EG.

RESULTS

In our case, histological examination showed ongoing bone regeneration with no traces of the disease. Through our literature review, we found 47 cases of calvarial EG managed with watchful waiting. No active intervention was required in 43 cases (91%). Four patients (9%) received surgery or chemotherapy due to the persistence/progression of symptoms or family request. Three reports other than ours documented spontaneous disease remission in surgically resected EG upon histopathological examination.

CONCLUSION

Our report provides further evidence that watchful waiting can be a reasonable option in the management of single calvarial EG.

Eosinophilic granuloma of the clavicle in an 11-year-old Chinese girl: A case report

RATIONALE

Eosinophilic granuloma (EG) - the most common form of Langerhans cell histiocytosis - occurs rarely, and manifestations with only rib and clavicle involvement are extremely rare. EG symptoms often include pain, swelling, and soft tissue mass. The clinical diagnosis of bone EG is complex, and the differential diagnosis includes Ewing sarcoma, tuberculosis, multiple myeloma, lymphoma, primary bone malignancy, and other osteolytic lesions.

PATIENTS CONCERN

The patient was an 11-year-old female who found a subcutaneous mass at the junction of the right clavicle and sternum 2 days before presenting at the clinic without apparent triggers. Initially, we considered a subcutaneous cyst or inflammatory mass. Color ultrasound and computed tomography examination revealed osteomyelitis. Finally, the patient was diagnosed with EG after a pathological tissue biopsy, and the child recovered after surgery and anti-infective treatment.

DIAGNOSIS

The patient underwent surgery to remove the tumor at a specialist hospital and was diagnosed with EG by pathological examination.

INTERVENTION

The patient went to a specialist hospital for surgery to remove the mass and underwent anti-infective treatment.

OUTCOMES

The patient recovered after surgical resection and antibiotic treatment.

LESSONS

In this report, we emphasize that the clinical presentation of EG in children is not specific. Furthermore, examining age, history, presence of symptoms, and the number of sites is essential to make a correct diagnosis, and a histological examination is necessary to confirm the diagnosis.

Eosinophilic Granuloma of the Liver Mimicking Metastatic Liver Tumor

We herein report a case of coagulation necrosis with granulation and eosinophilic infiltration of the liver. A 37-year-old woman was diagnosed with a new mass lesion in the liver 1 month after breast cancer surgery and admitted for a further examination. Because the tumor occurred immediately after surgery, it was considered essential to determine whether or not it was a metastatic liver tumor from breast cancer. A percutaneous liver tumor biopsy revealed eosinophilic granuloma of the liver, which is considered to have a high possibility of visceral larva migrans with suspected gnathostomiasis infection. A detailed medical history and histological diagnosis are important for making a differential diagnosis.

Pandora's box: eosinophilic granuloma at the cerebellopontine angle-should we open it?

BACKGROUND

Langerhans cell histiocytosis (LCH) is a disorder of immature LCH cells, eosinophils, macrophages, lymphocytes, and multinucleated giant cells. Eosinophilic granuloma (EG) is a focal form of LCH that presents mostly in the skull, femur, vertebrae, pelvis, mandible, and ribs. Intracranial presentation of EG is very rare in the literature.

CASE DESCRIPTION

A 17-year-old boy visited our clinic with headache, dizziness, and tinnitus that were present for 2 months. Brain MRI depicted a lesion at the right cerebellopontine angle. The lesion was hypointense on T1-weighted and hyperintense on T2-weighted brain MR images. The lesion enhanced homogenously after I.V. contrast material administration. Pre-operative diagnoses were vestibular schwannoma and meningioma. Surgery was planned. Retrosigmoid approach was preferred in the surgery. The lesion was excised partially. Pathological analysis depicted cell infiltration composed of eosinophils besides histiocytes, plasma cells, and lymphocytes in different amounts. CD1a was positive yet S100 was negative. Final diagnosis was eosinophilic granuloma. Post-operative course was uneventful. The patient was referred to pediatric oncology unit, and steroid therapy was initiated. Post-operative follow-up brain MRIs showed that the lesion had regressed further than immediate post-operative images by only steroid use. In long-term follow-up, new lesions appeared on the patient's skin in multiple locations and in the sclera of his left eye. At the last follow-up (3 years post-operatively) skin and scleral lesions were noticed to have regressed spontaneously and the intracranial structures were tumor free.

DISCUSSION AND CONCLUSION

To the best of our knowledge, EG at the cerebellopontine angle has not been presented in the literature. What makes our case further unique is its negativity for S-100 antigen. Eosinophilic granuloma should be kept in differential diagnosis of mass lesions presented at the cerebellopontine angle, especially in children and young adults with high eosinophils and lymphocytes in their peripheral blood. Sole steroid trials could be conveyed in suspicious cases before any further intervention. If the lesions do not regress or enlarge with time, surgery should be considered. However, long-term follow-up of these patients is necessary since natural history of the disease has not been defined, yet.

Thoracoscopic Transillumination in Chest Wall Resection

Determining the extent of chest wall resection during en bloc lung cancer operations is often difficult secondary to the location of these tumors. We describe a hybrid technique that employs video-thoracoscopy and chest wall transillumination to determine the appropriate margin of resection.

Multifocal Langerhans Cell Histiocytosis in an Adult

Eosinophilic granuloma (EG) is the most common and benign form of the spectrum of disorders referred to as Langerhans cell histiocytosis (LCH). Langerhans cell histiocytosis is primarily regarded as a pediatric disease, with few adult cases of multifocal EG of bone reported. We report a case of multifocal EG in a 48-year-old woman, who presented with right knee pain. Radiographs showed a small lytic lesion in the medial femoral condyle. Diagnosis was confirmed by ultrasound-guided biopsy. She had had a previous EG lesion excised from her skull. Whole-body bone scan demonstrated a new skull lesion in the right diploic space, which was confirmed by magnetic resonance imaging. The patient underwent curettage, bone grafting, and prophylactic internal fixation of the right distal femur lesion. The skull lesion was treated with repeat craniectomy. Two years later, she developed a new lesion in the right distal femoral metaphysis, which was treated with intralesional corticosteroid injections. Now, more than 1 year later, the patient is pain-free with no evidence of new or recurrent disease. Because multifocal EG is a rare diagnosis in adults, appropriate clinical suspicion, in combination with radiographic findings and histologic examination, is essential for correct diagnosis and treatment.

Resection of benign vertebral tumors by minimally invasive techniques

BACKGROUND CONTEXT

Benign tumors of the vertebrae are generally an uncommon cause for surgery. Complete removal of these tumors requires in most cases extensive surgical technique that consists of generous surgical exposure followed by laminectomy, facetectomy, and sometimes even an instrumented fusion.

PURPOSE

The aim was to describe our experience in performing resection of benign vertebral tumors, using a minimally invasive surgical (MIS) approach.

STUDY DESIGN

This was a retrospective review of case records.

PATIENT SAMPLE

Patients who underwent MIS, resection of benign vertebral tumors.

OUTCOME MEASURES

Complete neurologic examination and pain evaluation, as measured by the visual analog scale (VAS). Secondary outcomes included postoperative spinal instability assessment and surgical margins examinations.

METHODS

Patients were evaluated preoperatively and postoperatively at 1, 3, and 6 months intervals clinically and radiographically using plain radiographs and postoperative computed tomography (CT) scans. Final pathologic report, operative time, blood loss, complications, and hospital length of stay were also recorded.

RESULTS

Between 2009 and 2013, 14 patients underwent MIS, resection of benign vertebral tumors at our institution. Mean follow-up time was 4 years. There were eight men and six women with a mean age of 27 years (range 16-68 years). For tumors located in the posterior elements, a direct posterior approach was used. Tumors located at the pedicle of the vertebra were excised using a transpedicular approach, and tumors protruding into the foramen were excised using the transforaminal approach. The transcanal approach was used when decompression of the thecal sac or nerve root was required, and the retroperitoneal transpsoas approach was used for tumors located in the vertebral body. Complete removal of these tumors was achieved in all cases, and was verified by a follow-up CT scan. Pathology revealed osteoid osteoma in five patients, osteoblastoma in three patients. Eosinophilic granuloma, fibrous dysplasia, and fibroid adenoma were found in one case each. Average VAS pain score improved from 7.7 (7-9) to 2.8 (0-7) after surgery.

CONCLUSIONS

Minimally invasive techniques are a valuable choice for the treatment of benign osseous tumors of the spine. A larger, long-term study is in progress. In the meantime, we suggest surgeons experienced with both open and MIS surgery should consider these techniques.

Ependymosarcoma with eosinophilic granular cells

Ependymosarcoma is a new entity of malignant gliomas composed of ependymal and sarcomatous components. Were port a rare case of ependymosarcoma with eosinophlic cells which occurred to the right trigon of the lateral ventricle.A 62-year-old man complained of headaches over a 2-month period. A hard, gray mass was found in the right trigon of the lateral ventricle during the operation.Although he received radiation and chemotherapy, the patient died due to tumor disseminating through the whole brain within 7 months after the operation. The histological examination revealed that the anaplastic glial components intermingled with the sarcomatous components. Immunohistochemically, sarcomatous cells were positive for α smooth muscle actin and desmin. However, anaplasticglial cells were not positive for these markers. In addition, Masson trichrome stain showed a plethora of collagen fibers between sarcomatous cells, but no collagen fibers were produced by the glial tumor cells. Solid focal papillary lesions of the glial tumor showed dot-like epithelial membrane antigen and diffuse cytoplasmic D2-40 immunoreactivity. Based on the above findings, these anaplastic glial tumor cells should show focal ependymal differentiation, and sarcomatous cells show myofibroblastic differentiation. In addition, almost 10%of the tumor cells in the neoplasm showed bright eosinophilic granules in the cytoplasm. These cytoplasmic eosinophilic granules and bundles were negative on PAS staining. Intracytoplasmic eosinophilic granules of tumor cells were strongly positive for αB-crystallin, HSP 27 and GFAP, respectively. These findings suggest that the clinicopathological characteristics of the present case should be consistent with the criterion of ependymosarcoma by Rodriguez et al.

[Surgical treatment combined with oral administration of indomethacin for eosinophilic granuloma of the skull: report of a pediatric case]

A 13-year-old girl presented headache for 5 d upon admission to hospital. An initial CT revealed 3 lesions located in her skull, the sizes of which were 2.5 cm×3.2 cm,1.2 cm×1.0 cm,0.3 cm×0.3 cm, respectively. The largest lesion was resected by surgery and confirmed as eosinophilic granuloma by pathology. After surgery, she took oral indomethacin 25 mg b·i·d for 3 months and tolerated it well. CT scan was performed 3 months and 1 year later, and the results showed that the unresected lesions shrank progressively and the defected bones were regenerated and healed one year later after operation.

Eosinophilic granuloma of the temporal bone in an adult: controversies in the management

Eosinophilic granuloma is a rare, benign, lesion characterized by uncontrolled proliferation of Langerhan's cells. It is commonly found in a bone and has been described in almost every bone in the body. It usually affects children and is seldom found in adults. A case of 60-year-old adult male with an eosinophilic granuloma of the right temporal bone with infiltration of the temporal and infratemporal fossa and osteolysis of the squama of the temporal bone is presented. Diagnostic procedure and course of treatment are described. Controversies in the management and different approaches in therapy of such lesion are discussed because there is no agreed treatment protocol established.

Surgical treatment of eosinophilic granuloma of the infratemporal fossa: a successful treatment option

The patient was a 16-year-old girl complaining about progressive swelling on the right side of her face, right headache, and right orbital proptosis. A CT scan revealed a lytic mass centered in the greater wing of the right sphenoid bone with extension into the orbit, middle cranial fossa, and infratemporal fossa. The patient underwent a subtemporal-preauricular infratemporal fossa approach, which allowed complete resection of the tumor, with a low morbidity. The pathological diagnosis was eosinophilic granuloma. At 36 months after the initial treatment the patient is free of disease. We conclude that lesions of this complex anatomic area are a challenge to biopsy and treat and they could be treated only with radical surgery with low morbidity, at centers with expertise in skull base surgery.

Operative case of Langerhans'cell histiocytosis of the skull with dural invasion. An immunohystochemical study of ki-67 expression of eosinophilic granuloma: case report and review of the literature

Eosinophilic granuloma (EG), Letterer-Siwe disease and Hand-Schuller-Christian disease are collectively called Langherans-cell histiocytosis (LCH). While the latter two are systemic diseases, the former is a localized form of histiocytosis. Solitary EG of the skull are rare lesions characterized by a natural history not well defined yet. In this context, we report a case of a 23-year-old male suffering for a recurrent and progressive right parietal headache. On computed tomography (CT) it was observed an ostelytic lesion which on magnetic resonance imaging (MRI) appeared as an hyperintense soft mass on both T1 and T2 weighted images. The lesion showed a marked and heterogeneous enhancement after gadolinium administration. The surgical excision was complete and the severe headache disappeared. Immunohistochemical analysis of the specimen indicated an eosinophilic granuloma characterized by Ki-67 nuclear antigen expression with a labeling index of 20%. In the pertinent literature we have found two aggressive cases of EG showing the Ki-67 expression with a respectively 6.2% (occipital bone granuloma) and 10% (parietal bone granuloma) labeling index. That high proliferative activity suggests a local Langherans' cell proliferation along with an exuberant inflammatory response and also explains the aggressive clinical course and the rapid expansion of the lesion observed in some rare cases of solitary EG. This is the third case-report of calvarial EG characterized by Ki-67 nuclear antigen expression.

Traumatic ulcerative granuloma with stromal eosinophilia. A case report and short literature review

We introduce a case of 53-year-old female with rapidly developing tongue ulceration clinically mimicking squamous cell carcinoma of the oral mucosa. After a microscopic examination traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) was diagnosed. In a short literature review, we characterize this entity, analyse its aetiology and nature. Differential diagnosis is also discussed.

[Diagnosis and treatment of eosinophilic granuloma of long bones in children]

OBJECTIVE

To investigate the operative procedure and the effectiveness of eosinophilic granuloma (EG) of long bones in children.

METHODS

Between January 2005 and December 2009, 14 patients with EG of long bones were treated. There were 9 boys and 5 girls, aged from 1 to 13 years (mean, 6.5 years). The locations were femur in 5 cases, humerus in 4 cases, tibia in 2 cases, fibula in 1 case, and femur complicated with tibia in 2 cases. The disease duration was 7 days to 10 months (median, 2 months). X-ray films showed that osteolytic destruction had clear boundary, which did not involve the epiphyseal plate. Of 14 cases, 12 cases of tumor were treated by curettage, autologous iliac bone or combined artificial bone graft repair, and 2 cases were treated by resection, autologous iliac reconstruction, plate and screw fixation. Five cases complicated with pathological fracture underwent reduction and fixation.

RESULTS

All cases were diagnosed pathologically as having EG. All incisions healed by first intention. A total of 12 patients were followed up 1 to 4 years (mean, 2 years). The X-ray films showed tumor focus and pathological fracture healed within 3 to 4 months (mean, 3.5 months). Tibial lesion was found in 1 case of femoral tumor after 8 months, and was cured after reoperation. No recurrence occurred in other 11 cases. According to comprehensive assessing standard of X-ray film and joint function, the results of all cases were excellent.

CONCLUSION

EG of long bones in children is more common in the femur and humerus. Tumor curettage and autologous iliac bone graft repair is an effective method, and postoperative prognosis is good. There may be multiple lesions, so long-term follow-up is needed.

Vanek's polyp or inflammatory fibroid polyp. Case report and review of the literature

BACKGROUND

Intussusception in an adult must make us suspect the presence of a tumor (benign or potentially dangerous) as the most frequent cause. Accurate diagnosis is of great importance in order to provide appropriate treatment and improve patient prognosis.

CLINICAL CASE

We report the case of a 42-year-old male with abdominal pain. We performed a CT and found a small bowel intussusception. Definitive diagnosis according to the surgical specimen was inflammatory fibroid polyp (Vanek's polyp).

CONCLUSIONS

Vanek's polyp is a benign lesion that occurs most frequently in the stomach and secondarily in the small bowel. Generally, it is uncommon, and its etiology is not completely known. Accurate diagnosis is done with immunohistochemistry. Because of the consequences that depend on the size and location of the lesion, it may be considered a malignant lesion. Treatment is resection.

Langerhans cell histiocytosis of the sphenoid sinus: a case report

Langerhans cell histiocytosis (LCH), previously known as histiocytosis X, is a rare disorder characterized by clonal proliferation and excess accumulation of pathologic Langerhans cells causing local or systemic effects. Bone is the most common organ involved and a single skull lesion is the most frequent presentation of childhood LCH. However, sphenoid sinus is an uncommon condition of involvement in LCH. Here we report a case of LCH in the sphenoid sinus, which occurred in a seven-year-old girl who presented initially with headache. The girl had suffered from headache for one month before she went to an otorhinolaryngologist one week before. Magnetic resonance imaging (MRI) showed a lesion of inflammatory granuloma. Surgery was performed and the disease was diagnosed pathologically as single-site LCH via hematoxylin-eosin (H&E) and immunohistochemical staining.

Resolution of eosinophilic granuloma after minimal intervention. Case report and review of literature

Langerhans cell histiocytosis (LCH), previously known as histiocytosis X, is a rare, proliferative disorder in which the accumulation of pathologic Langerhans cells leads to local tissue infiltration and destruction. The incidence of LCH is estimated to be one case per 200,000 children per year. The role of the dentist is important in early and accurate evaluation, staging and diagnosis of LCH, because it may mimic more common diseases, such as juvenile periodontitis and osteomyelitis. There are multiple treatment options, but the response is unpredictable. The aim of this paper is to give a short, introductory overview on current diagnostic and treatment strategies for LCH in the oral and maxillofacial region and to present a case of LCH that mimicked juvenile periodontitis and was resolved following extraction of affected teeth. The history, radiological appearance, differential diagnosis, histopathology and treatment options for the patient are discussed.

[Surgical management of solitary eosinophilic granuloma of the calvaria. Two case reports]

Langerhans cell histiocytosis is a systemic disease resulting from the oligoclonal proliferation of Langerhans cells, occurring most commonly in children and young adults. The focal form of the disease, also known as eosinophilic granuloma, most frequently involves the calvaria. We present two cases of calvarial eosinophilic granulomas that were surgically removed. These tumors are reputed to have an excellent prognosis, even if local recurrences and systemic dissemination can occur during the follow-up. The authors discuss the pathogenesis and the evolutive profile but also the therapeutic management of solitary eosinophilic granuloma of the calvaria.

[Eosinophilic granuloma of the mandible--a case report]

BACKGROUND

Langerhans cell histiocytosis is characterized by a clonal proliferation of Langerhans cells. The clinical manifestation varies from a localized lesion (eosinophilic granuloma) to a systemic disease. The diagnosis can only be confirmed histopathologically. A comprehensive staging is necessary to determine the extent of the disease and to establish an adequate therapy.

CASE REPORT

We report on a 27 years old patient who was referred to our clinic with the diagnosis of an osteomyelitis of the mandibular angle and a pathological fracture after extraction of tooth 38 one month before. Curettage and primary bone grafting were performed. In the histological examination of the specimen infiltrates of a Langerhans cell histiocytosis were found. The clinical and radiological staging demonstrated a solitary mandibular lesion (eosinophilic granuloma). After wound healing a low-dose radiotherapy with 6 Gray was performed. Two years after completion of the therapy the patient is asymptomatic and does not show any evidence of recurrence.

CONCLUSION

Langerhans cell histiocytosis has to be included in the differential diagnosis of osteolytic lesions of the mandible. A low-dose radiotherapy is a reasonable and well-tolerated treatment option.

[Operative case of eosinophilic granuloma of the skull with dural invasion]

Eosinophilic granuloma is the localized form of Langerhans' cell histiocytosis. There are several reports of magnetic resonance (MR) imaging of eosinophilic granuloma of the skull, however there are few reports about dural enhancement. We report an operative case of eosinophilic granuloma of the skull with dural invasion. A 42-year old man was admitted to our hospital. He was neurologically intact and there were no other osseous or soft tissue lesions. CT showed an osteolytic lesion in the left parietal bone. MR images showed the lesion as isointense on T1-weighted, and high intense on T2-weighted images. T1-weighted images with Gd-DTPA demonstrated the mass which was enhanced with dural surface and subgaleal tissue. The angiogram demonstrated a tumor stain fed by the left occipital artery. Bone scintigraphy demonstrated a solitary lesion showing peripheral uptake with a central defect. The patient underwent craniectomy with removal of the dura and a subgaleal lesion. Histological examination revealed characteristic eosinophilic granuloma with dural invasion. No recurrence of the lesion was demonstrated 6 months after surgery.

Percutaneous vertebroplasty for eosinophilic granuloma of the cervical spine in a child

We report a case of eosinophilic granuloma at the fourth cervical vertebra in a 10-year-old girl presenting with a 1-month history of cervical pain and stiffness. This lesion was histologically diagnosed by needle biopsy and then treated by percutaneous vertebroplasty. After the procedure, the cervical pain and stiffness resolved rapidly. The height of the vertebral body remained stable without further collapse over a 6-month follow-up period.

Eosinophilic granuloma of the orbit: report of two cases

We present clinical, radiological, and histopathological findings and treatment results of two infants with orbital eosinophilic granuloma. Both patients presented at 1 year of age with unilateral proptosis, periorbital edema, and a superotemporally located, ill-defined orbital mass on computed tomographic (CT) imaging, with bone erosion in one patient. After subtotal excision, histopathological examination revealed eosinophilic granuloma, and the proptosis resolved with no sign of orbital tumor recurrence or systemic involvement at 12 and 23 months follow-up. Eosinophilic granuloma is a rare childhood orbital tumor that may or may not present with osteolytic change.

[Ischemic eosinophilic granuloma and pulmonary histiocytosis with a regressive course]

Langerhans' histiocytosis or histiocytosis X is a rare intrinsically benign disease producing a destructive tumor with a variable clinical presentation and an often unpredictable clinical course. Focal forms such as eosinophilic granuloma of the bone only require minimal care but the gravity of multisystem forms causing organic dysfunction sometimes require aggressive chemotherapy. Bone involvement is generally observed in children mostly boys. Both sporadic and chronic forms are noted. We report a case observed in a 17-year-old adolescent who presented an exceptional association of bony destruction of the pelvis with extended asymptomatic pulmonary involvement. The lung disease led to the initial diagnosis and optimal surgical, pathological and radiological management.

Spinal Langerhans' cell histiocytosis in a young adult: case report and therapeutic considerations

We report an unusual case of spinal Langerhans' cell histiocytosis of the cervicothoracic junction in a young adult man. A 17-year-old male was referred to our institution with a 3-week history of cervicothoracic pain associated to a weakness of his right upper limb. Computed tomography and magnetic resonance imaging showed a collapsed T1 vertebral body with epidural soft tissue showing mass effect on spinal cord. The patient underwent a classic anterior cervicotomy. Complete removal of the lesion could be achieved, but the soft consistency of C7 and T2 body precluded a solid anterior fixation and an extended resection of C7 and T2 body had to be performed. Then a C6 - T3 stabilisation using an anterior plate fixation and cyanomethylacrylate graft was performed. Postoperative course was uneventful. At 2 years follow-up, the patient was asymptomatic and radiological workup showed a perfect stability of anterior fixation system. Aggressive surgical management of eosinophilic granuloma should be considered in some selected cases particularly when spinal instability or neurological deficit occurs. In this young patient a modified anterior cervicotomy allowed a comfortable approach to the anterior aspect of T3 vertebra for spinal fixation.

Eosinophilic granuloma: bilateral temporal bone involvement

Eosinophilic granuloma is an uncommon condition that is characterized by unifocal or multifocal osteolytic lesions that often affect the skull. Unilateral lesions of the temporal bone are not uncommon, but bilateral temporal bone lesions are rare. In fact, to the best of our knowledge, fewer than 20 such cases have been reported during the past 40 years. We report a new case of bilateral temporal bone eosinophilic granuloma, and we review the disease process and its treatment.

Intradural Eosinophilic Granuloma with Intraparenchymal Invasion: A New Growth Pattern

BACKGROUND

Eosinophilic granuloma is a form of Langerhans' cell histiocytosis, most commonly involving the skeletal system. We present the first case of an eosinophilic granuloma originating from the dura mater with secondary parenchymal and osseous invasion.

CASE REPORT

A 32-year-old man was referred to us for headache and swelling in the right parietal region and a history of minor head trauma. The radiological and surgical findings were suggestive of meningosarcoma. Intraoperatively the lesion was found to originate from the dura mater. Histological diagnosis was eosinophilic granuloma. After a 21-month follow-up period, MRI was negative.

CONCLUSION

Intradural development is a possible growth pattern of eosinophilic granuloma. An inflammatory process of the dural membrane with migration of Langerhans' cells could be the physiopathological basis for the formation of intradural eosinophilic granuloma. This is a mechanism similar to that of chronic subdural haematoma formation. Histological demonstration of eosinophilic granuloma cells around the lesion margin suggests the need to remove dura mater peripherally to the lesion.

[Unifocal eosinophilic granuloma of the temporal bone]

We present a case of a twelve year old child with a eosinophilic granuloma of the temporal bone. The eosinophilic granuloma is the most frecuent and most benign form of the histiocytosis of the Langerhans cells. The frecuency of the othological manifestations of this condition varies between 15-60 percent and radiologically, the images are characterized by litho-lesions with sharp edges. The diagnosis is histological and the treatment includes surgical intervention accompanied by inter-lesion corticoid-therapy and/or radiotherapy.

Primary solitary eosinophilic granuloma of the brain and postoperative radiotherapy: a clinical case

A case of solitary eosinophilic granuloma (EG) of the brain in a 53-year-old woman is presented. The tumor developed in the anterior cranial fossa causing destruction of the skull basis and the retrobulbar space, accompanied by vision impairment. The tumor was partially excised and the patient was irradiated postoperatively with 40 Gy 6 MV x-rays, followed by 10 cycles of chemotherapy. Follow-up computed tomography (CT) showed no response at 30 Gy and no progression during chemotherapy. Attention is drawn to cases of EG indolent in growth but resistant to radiation and chemotherapy.

Eosinophilic granuloma of the skull: a retrospective analysis

BACKGROUND

The authors describe 9 cases of children with eosinophilic granuloma (EG) of the skull and report on their clinical manifestations, treatment, and prognosis.

METHOD

Nine consecutive patients were diagnosed as EG of the skull and confirmed pathologically between 1996 and 2005. In the present study, multi- and single-system Langerhans' cell histiocytosis without skull involvement were excluded. Patients with EG of the skull were divided into two groups: (1) those with only a single bone lesion and those with (2) multiple bone lesions. Surgical removal was performed between 2 and 10 years of age (mean, 4.2 years).

RESULTS

Eight (88.9%) of the study subjects were found to have a single bone lesion at diagnosis, and 1 had multiple bone lesions. Seven patients had a painless skull mass and 2 patients had a painful skull mass. Total removal was performed in all 9 patients. Eight patients received postoperative chemotherapy or indomethacin as adjuvant therapy. Of the 8 patients who received adjuvant therapy, 4 were treated with indomethacin and the remaining 4 received methotrexate-based chemotherapy. Eight patients did not experience EG recurrence, however, 1 patient developed additional lesions 2 years after surgical excision.

CONCLUSIONS

EG of the skull is a clinicopathological entity with a good outcome. However, therapies and prognoses are dependent on age at diagnosis and the number of bony involvements.

Aggressive eosinophilic granuloma of the parietal bone. An immunohystochemical study of Ki-67 expression

Solitary eosinophilic granuloma (EG) of the skull is a rare lesion, the natural history of which is still to be defined. We report a case of a 26-year-old female who presented with progressive headache and nausea accompanied by a painful firm mass in her left parietal region, which grew very rapidly during the last two weeks before admission. Computed tomography scan showed an osteolytic lesion, which on magnetic resonance imaging appeared hyperintense on both T1- and T2-weighted images, with marked and heterogeneous enhancement after gadolinium administration. Total surgical excision of the lesion was performed and histopathological diagnosis was compatible with eosinophilic granuloma. Immuno-histochemical study of Ki-67 antigen expression was also performed with a labelling index of 10%. In a review of the pertinent literature, we found one case report showing a Ki-67 labelling index of 6.2% in a patient harboring EG of the occipital bone. These two relatively high percentages of proliferative activity suggest a role of local Langerhans'cell proliferation, along with that of inflammatory response, in the aggressive clinical course and rapid expansion observed in some rare cases of solitary eosinophilic granuloma.

Solitary spinal eosinophilic granuloma in children

Solitary vertebral eosinophilic granuloma is said to be a rare spinal condition in children. 'Vertebra plana' is considered as the typical radiological feature of the involved vertebra; but it could be observed only in 40% of the patients. We have studied three pediatric patients with solitary vertebral eosinophilic granuloma. Their complaint was pain and/or stiffness of the back. Two of them developed neurological deficits in their lower limbs. The diagnosis in imaging (plain radiographs, computed tomography scan and magnetic resonance imaging) varied from one case to another. Histopathology confirmed the diagnosis of eosinophilic granuloma. These three patients underwent an open biopsy and a resection of the spinal lesion achieved with or without interfixation. The outcome was satisfactory in these three cases after a mean follow-up period of over 2 years (from 23 to 27 months).

Torticollis secondary to posterior fossa and cervical spinal cord tumors: report of five cases and literature review

Torticollis is either congenital or acquired in childhood. Acquired torticollis is not a diagnosis but rather a sign of an underlying disorder. The causes of acquired torticollis include ligamentous, muscular, osseous, ocular, psychiatric, and neurologic disorders and may be a symptom of significant abnormalities of the spinal cord and brain, such as spinal syrinx or central nervous system neoplasia. Torticollis is rarely considered to be an initial clinical presentation of posterior fossa and cervical spinal cord tumors. We report five cases of pediatric tumors with torticollis at the onset: an astrocytoma originating from the medulla oblongata, another presumptive astrocytoma of the spinal cord located between C1 and C6 cervical vertebrae (not operated), an ependymoma located throughout the whole cervical spinal cord extending into the bulbomedullary junction, an astrocytoma originating from the bulbus and extending into the posterior fossa, and another case of a eosinophilic granuloma located extradurally through the anterior and posterior portions of the vertebral bodies from C3 to C7 producing the collapse of the sixth cervical vertebra. All five cases were seen in children, aged between 3 and 12 years. All these cases reflect the misinterpretation of this neurological sign and the lack of association with the possibility of spinal or posterior fossa tumor. This delay in the diagnosis of these diseases led to progressive neurological deterioration and to the increase in the tumor size, which made surgical intervention difficult and the prognosis unfavorable. Although torticollis secondary to tumors is rarely seen, it is necessary to be kept in mind in the differential diagnosis.

Assessment of the efficacy of cryosurgery in the treatment of granuloma faciale

BACKGROUND

Granuloma faciale (GF) is an uncommon dermatosis of unknown pathogenesis. Multiple treatments have been proposed with varying results. We report nine cases treated successfully with cryosurgery and we review the literature.

OBJECTIVES

To study the efficacy, tolerability and safety of cryosurgery techniques in the treatment of GF.

METHODS

Nine immunocompetent adults with GF were treated by cryosurgery. The initiation of the therapy was preceded by a 60-day washout period in all subjects using other medication. Two different techniques were used (open-spray and contact cryo-probe).

RESULTS

All patients were treated successfully. Apart from mild postinflammatory hypopigmentation in two patients that resolved within 4 months, no other adverse event was mentioned. During an average 24-month follow-up period after the integration of therapy, no recurrences were observed.

CONCLUSIONS

Cryosurgery is an efficient, safe, inexpensive, easily used method for this uncommon dermatosis, which can be proposed as a treatment of first intention.

[A case of advanced granuloma eosinophylicum maxillae]

INTRODUCTION

We present a case of an advanced granuloma eosinophilicum of maxillary location in a 76 years old man who was admitted to our Department with symptoms of chronic pain in right zygomatic region.

MATERIAL AND METHOD

We want to lay emphasis on long lasting, low symptomatic development of this kind of tumor and to insist on very carefull otorhinolaryngological and as well radiological examination.

RESULTS

According to literature there are many methods used in the therapy of such cases begining with operations, through radiotherapy, the use of steroids or cytostatic drugs and also different combinations of mentioned possibilities. In our case we applied an operation without further radiotherapy and didn't observe any symptoms of recurrence so far.

CONCLUSIONS

Granuloma eosinophilicum and its multifocal variety e.i. Hand-Schueller-Christian disease require different patterns of treatment depending on its location, tendency to recurrence and the age of affected person.

Langerhans' cell histiocytosis: a case report of an eosinophilic granuloma of the mandible treated with bone graft surgery and endosseous titanium implants

Eosinophilic granuloma is the localized and most benign form of Langerhans' cell histiocytosis. The disease shows a particular predilection for the head and neck region and usually involves the skull bones, where it manifests as well-defined lytic lesions on standard radiographs. The case of an extensive lesion involving the body of the mandible in a 52-year-old man is reported. Operative procedures consisted of enucleation of the lytic lesion and follow-up with clinical examinations and computerized tomographic studies of the mandible at 2, 12, and 18 months postoperatively. Reconstructive surgery without radiotherapy was performed with an autologous bone graft from the iliac crest and implant placement to provide support for a dental restoration.

Solitary eosinophilic granuloma of the sternum

We report a rare case of eosinophilic granuloma of the sternum in a 25-year-old woman, who presented with anterior chest pain and a tender mass over the sternum. Total-body bone scintigraphy and computed tomography scanning of the thorax revealed an isolated lytic lesion of the manubrium. An open biopsy showed the typical histologic appearance of an eosinophilic granuloma. Surgical curettage of the solitary lesion was performed, and the sternal defect was filled with a bone replacement material. At the 2-year follow-up, no local recurrence was found, and the patient was in good health.

Intestinal anisakiasis in Italy: a case treated by emergency surgery

Anisakiasis is a fish-borne zoonotic disease. A case of intestinal anisakiasis in a woman who had consumed raw marinated anchovies was reported. The intestinal localization resulted in occlusive acute abdomen which required an emergency surgical treatment. The histological examination of the eosinophilic granuloma removed from the resected colon revealed the presence of larval nematodes of the genus Anisakis as causative agents.

Unusual location of eosinophilic granuloma

Eosinophilic granuloma EG is a benign self-limiting disease, which belongs to the spectrum of Langerhans' cell histiocytosis LCH. The etiology of LCH remains unknown, although the evidence indicates that it is a clonal proliferative disorder of Langerhans cells, it has also been characterized as reactive disorder, neoplastic process and a berrant immune response. Eosinophilic granuloma is characterized by single or multiple skeletal lesions occurring predominately in children, adolescents and young adults, it accounts for 70% of LCH. It is more common in males, and the common sites are the skull, mandible, ribs, spines and long bones particularly the femur and the humerus. The estimated incidence of EG is 3-4 per million of the population. Vertebral bone involvement is rarely seen and usually affects the vertebral body. We are reporting an unusual case of EG in a female child presented with a solitary lesion at posterior element of lumbar vertebra.

Eosinophilic granuloma of the skull associated with epidural haematoma: a case report and review of the literature

INTRODUCTION

Eosinophilic granuloma (EG), a benign bone lesion, represents a focal form of histiocytosis X. Here, the authors report a case of an extremely rare presentation of a solitary EG of the skull.

CASE REPORT

A 9-year-old boy presented with headache and vomiting for 3 days. His examination was unremarkable except for a tender mass in his left occipital region. Radiological studies revealed a huge bilateral epidural haematoma under the occipital bone, extending supratentorially and infratentorially, and a nonenhanced, epidural, soft tissue mass overlying the left transverse sinus. Evacuation of the epidural haematoma was performed and it was noted that the left transverse sinus wall was eroded by the EG at one point with venous oozing.

REVIEW OF THE LITERATURE

The acute presentation of a solitary EG of the skull with an epidural haematoma was described in only four cases in the literature. This is the first documented case in terms of the origin of an epidural haematoma.

Unusual location of eosinophilic granuloma

Eosinophilic granuloma EG is a well-recognized benign form of Langerhans cell histiocytosis, most commonly involving the skull bones. In this paper, we report an 8-year-old girl with EG of posterior element of vertebra; she had complete resolution with surgical curettage and bone grafting.

Adult Eosinophilic Granuloma of the Lumbar Spine with Atypical Dissemination

Vertebral Eosinophilic Granuloma (EG) is a frequently reported disease, but further dissemination rarely occurs when the initial lesion is in the lumbar region. We present a case of EG, initially located in L5 vertebra, which disseminated to the skeletal bones and pulmonary system months after total excision in an adult.

Solitary eosinophilic granuloma of sternum

Primary bone tumors of the chest wall are uncommon, although a wide variety of both benign and malignant tumors arise within the chest wall. Among those tumors, sternal tumors are rare and usually malignant. We report an extremely rare case of eosinophilic granuloma developed in the sternum in a 30-year-old woman. She presented anterior chest pain and somewhat tender mass over the sternum. Chest roentgenogram, computed tomography scanning of the thorax, and total body bone scintigraphy revealed an isolated lytic lesion in the corpus sterni. A tru-cut biopsy of the mass exhibited the typical histologic appearance of eosinophilic granuloma. The solitary lesion was removed completely surgically. This rare condition should be kept in mind in differential diagnosis of sternal lesions.

Eosinophilic granuloma of the atlas presenting as torticollis in a child

STUDY DESIGN

This report describes a case of successful surgical treatment of eosinophilic granuloma of the atlas in a 3.5-year-old boy who presented with torticollis.

OBJECTIVE

The purpose of this report was to illustrate the rare clinical presentation of eosinophilic granuloma in the atlas.

SUMMARY OF BACKGROUND DATA

Eosinophilic granuloma, a benign solitary lesion that commonly affects children, has a variable clinical course. Although eosinophilic granuloma has been reported to occur in the cervical spine, there have been only five reported cases of eosinophilic granuloma affecting the atlas. The management of eosinophilic granuloma ranges from observation and immobilization of the cervical spine to surgical excision.

METHODS

The tumor was located on the left lateral mass of the atlas. Biopsy and curettage were performed through an oblique incision through the posterior border of the sternocleidomastoid muscle. A histopathologic evaluation confirmed the diagnosis of eosinophilic granuloma.

RESULTS

The patient tolerated the procedure with no complications, and his torticollis has completely resolved.

CONCLUSION

Eosinophilic granuloma of the atlas initially presented in this patient as torticollis. Biopsy for confirmation of diagnosis and curettage for treatment provided a successful outcome in this patient. We suggest biopsy of the lesion and histopathologic evaluation to confirm the diagnosis in atypical cases.

Spontaneous resolution of lumbar vertebral eosinophilic granuloma

Eosinophilic granuloma (EG) is a rare disease but is more common in adults than children. It's often self-limiting. Spinal involvement is rare. It is the localized and most benign form of Langerhans' cell histiocytosis (previously known as histiocytosis X), characterised by lytic lesions in one or more bones. Spontaneous resolution of vertebral body lesions is very rare. In this case, the patient had one EG in a cervical vertebra and a similar lesion in a lumbar vertebra. This case is important because it featured a symptomatic lesion in the cervical spine accompanied by an asymptomatic lesion in a lumbar vertebra. We treated the cervical lesion by surgical fusion and followed the lumbar lesion up conservatively, with the patient in a corset. After 8 years of follow-up, control MRI showed that the lumbar lesion had spontaneously resolved.

Surgical treatment of eosinophilic granuloma in the thoracic spine in patients with neurological lesions

Eosinophilic granuloma is a benign, self-limited condition most commonly seen in children around 10 years of age. There is no known cause concerning its etiology. The lesion is usually solitary and can involve the whole vertebral body with massive destruction and vertebral collapse ('coin lesion') but this appearance is not pathognomonic. Vertebral collapse may lead to neurological symptoms that might be severe. We describe two cases of eosinophilic granuloma, in which the patients have thoracic pain, numbness and weakness in their legs. Radiography, computed axial tomography and magnetic resonance imaging showed vertebral collapse and compression of the spinal cord. A biopsy was performed and the diagnosis of eosinophilic granuloma was confirmed by histological analysis. Both patients were treated surgically and they had gradual recovery of neurological deficit after the surgery.

Solitary eosinophilic granuloma of the cervicothoracic junction causing neurological deficit

We report a case of spinal eosinophilic granuloma with aggressive course. Initially, a conservative management was decided upon, but neurological deterioration of the patient prompted us to undertake a more aggressive attitude, with surgical excision and postoperative radiotherapy. The clinical and radiological features, and the different options of treatment are discussed, and the literature is reviewed.