Crystal-Storing Histiocytosis in Bone Marrow: A Clinicopathologic Study of Eight Cases and Review of the Literature

OBJECTIVES

We report the clinicopathologic characteristics of eight cases of crystal-storing histiocytosis (CSH) with bone marrow (BM) involvement (BM-CSH) and review CSH cases published in the English literature.

METHODS

We queried our pathology database for BM cases with CSH mentioned in the final diagnosis/comments from June 2011 to August 2016.

RESULTS

Eight cases of BM-CSH were identified. The underlying diagnoses consisted predominantly of plasma cell disorders (88%) associated with monotypic κ light chain. In BM aspirates, crystals within histiocytes exhibited a morphologic spectrum including brightly eosinophilic, needle-like, or globule-like. In BM core biopsies, the histiocytes were often in aggregates with intracellular needle-like and/or globular, refractile inclusions.

CONCLUSIONS

BM-CSH is a rare phenomenon and exhibits a heterogeneous crystalline and histiocytic appearance warranting accurate recognition to avoid misinterpretation of a granulomatous condition or storage disorder. In addition, prompt assessment for an underlying B-cell lymphoma or clonal plasmacytic neoplasm is indicated.

Efficacy of intravenous cyclosporine in a case of cytophagic histiocytic panniculitis complicated by haemophagocytic syndrome after visceral leishmania infection

Cytophagic histiocytic panniculitis (CHP) is a rare panniculitis characterized by systemic features, due to histiocytic infiltration along with haemophagocytosis, which may also appear in bone marrow, spleen, lymph nodes, and liver. Haemophagocytic lymphohistiocytosis (HLH) is a group of autoinflammatory disorders, which include macrophage activation syndrome, sometimes observed in the course of systemic autoimmune diseases, such as juvenile chronic polyarthritis, systemic lupus erythematosus or vasculitis, and infection-associated haemophagocytic syndrome; if not promptly recognised and treated, HLH can be fatal. Visceral leishmaniasis (VL) is a systemic disease caused by different forms of Leishmania spp., an intracellular protozoa. VL is endemic in tropical countries such as in the Middle East and the Mediterranean. The typical clinical and laboratory features are fever, hepato-splenomegaly, hypergammaglobulinaemia and pancytopenia. The features of VL may mimic some haematologic diseases. We report a case of cytophagic histiocytic panniculitis and HLH, triggered by a previous visceral leishmania infection. Cyclosporine was quickly effective in this case, after failure of high-dose glucocorticoids, anakinra and etoposide.

Erythema, papules, and arthralgia associated with liver cancer: report of a rare case of multicentric reticulohistiocytosis

We report a rare case of multicentric reticulohistiocytosis (MRH) associated with liver carcinoma. A 36-year-old man who had been diagnosed as having liver carcinoma for 2 years presented with a 2-month history of multiple papulonodules on the face, ears, neck, and upper chest, accompanied by progressive polyarthralgia of the hands, wrists, elbows and knee joints without fever or chills. Skin histology revealed well defined dermal infiltrate consisting of multinucleated giant cells and macrophages having abundant eosinophilic finely granular cytoplasm with ground glass appearance. Further immunohistochemical studies characterized the lesions as positive for CD68, CD45 and Vimentin. A diagnosis of MRH that was associated with liver cancer was made. Treatment with prednisolone for 2 months resulted in a significant improvement of the skin and joint symptoms, but was discontinued due to his significant enlargement and extensive metastases of the liver carcinoma.

Successful treatment with tocilizumab in a case of intralymphatic histiocytosis associated with rheumatoid arthritis

A 75-year-old woman with rheumatoid arthritis (RA) presented with long-term painful erythema on the right upper arm and left elbow. The patient was diagnosed with intralymphatic histiocytosis (ILH) based on the biopsy findings. Because the patient was unresponsive to single-agent treatment with methotrexate, infliximab and etanercept, we switched to tocilizumab (TCZ) treatment, which induced remission of the ILH. Our case suggests that TCZ may be a treatment option for ILH in patients with RA.

[Intralymphatic histiocytosis and cancer of the colon]

Intralymphatic histiocytosis is a condition with nonspecific clinical features but with characteristic histopathological and immunohistochemical findings. It presents as a poorly demarcated erythematous plaque or a lesion similar to livedo reticularis, usually located on the limbs. Histologically, dilated vessels containing mononuclear cells are observed in the reticular dermis. In the past, the majority of these cases were thought to be cases of reactive angioendotheliomatosis or intravascular lymphoma, but the development of more specific immunohistochemical markers showed that these were dilated lymph vessels containing histiocytes, and so were considered as a separate condition. We present the case of a man with a past history of left axillary lymphadenectomy for lymphatic tuberculosis, leukocytoclastic vasculitis, and cancer of the colon. The patient developed an erythematous plaque in the left pectoral region. Histology and immunohistochemical stains of the lesion revealed histiocytes within dilated lymph vessels in the reticular dermis, but no neoplastic cells. We present a new case of intralymphatic histiocytosis in a patient with autoimmune and neoplastic diseases.

Histiocytosis following T-acute lymphoblastic leukemia: A BFM study

The coincidence of T-cell acute lymphoblastic leukemia (T-ALL) and histiocytic disorders, including hemophagocytic lymphohistiocytosis (T-ALL/HLH) and Langerhans cell histiocytosis (T-ALL/LCH), is very seldom and is usually associated with a dismal prognosis. Retrospective statistical analysis of all T-ALL patients, who have been registered in the BFM-ALL trials from 1981 - 2001 and who have subsequently developed a LCH/HLH, in order to identify any common risk factors pre-disposing to the synchronous occurrence of both disorders. Six out of 971 T-ALL patients had either HLH or LCH ( approximately 0.03% of treated T-ALL/year). The mean age at diagnosis of T-ALL/HLH/LCH was significantly lower than in the remaining T-ALL group (4.05 +/- 0.59 vs 8.82 +/- 0.14 years; p = 0.000). The mean initial leukocyte count was higher than in the non-HLH/LCH group (270,700 +/- 60,677 microl(-1) vs 134,141 +/- 5,663 microl(-1); p = 0.074). No hemophagocytosis was seen in the initial bone marrow (BM) smears. Five of 6 patients obtained a good prednisone response (GPR) at day 8 in peripheral blood with <5% blasts at day 15 in BM and all cases were in complete remission (CR) at day 33. The mean time until development of the histiocytosis was 17.95 months (range 2.5 - 33 months). Four patients developed a HLH and 2 a LCH. All patients with HLH showed a multi-organ involvement, while the LCH patients had only local disease. Only the LCH patients survived, while all patients with HLH died. The authors recommend a close follow-up for at least 3 years after diagnosis in younger T-ALL patients with high initial leukocyte count.

Drug-induced hypersensitivity syndrome with rapid hematopoietic reconstitution during treatment for acute myeloid leukemia

Drug-induced hypersensitivity syndrome (DIHS) is a rare but severe life-threatening, drug-induced, systemic hypersensitivity reaction. We report two patients who developed DIHS during treatment for acute myeloid leukemia. Awareness of DIHS is necessary when systemic eruptions and high fever occur in leukemic patients, especially with rapid hematopoietic recovery after chemotherapies.

Cutaneous intralymphatic histiocytosis associated with rheumatoid arthritis: report of a case and review of the literature

Various dermatoses have been described associated with rheumatoid arthritis. Recently, a specific cutaneous lesion termed "intravascular histiocytosis" has been proposed as a new entity among these dermatoses. We report the case of a 50-year-old woman with rheumatoid arthritis for about 10 years who developed erythematous patches on the extensor surface of lower extremities. Histopathologically, the lesions showed intraluminal proliferation of CD68-positive histiocytes in vessels lined with endothelial cells expressing D2-40, a selective marker for lymphatic endothelium.

Crystal storing histiocytosis of the skin associated with multiple myeloma

BACKGROUND

Crystal storing histiocytosis (CSH) imitating rhabdomyoma is a very rare disease entity involving different tissues. The skin is involved in extremely rare cases.

OBJECTIVES

To describe the clinical and histopathological characteristics in a patient with unusually extensive skin involvement.

OBSERVATIONS

A 62-year-old woman presented with a large red infiltrated verrucosus lesion on the anterior aspect of the chest and on the neck. The skin biopsy revealed histiocytes throughout the whole dermis containing thin crystalloid structures in the cytoplasm. Upon histopathological examination, crystal-storing histiocytosis was diagnosed and consequently a hematological examination revealed multiple myeloma IgG Kappa. Skin involvement by CSH proceeded the diagnosis of multiple myeloma by 4 years.

CONCLUSIONS

Phagocytosis of crystals of immunoglobulins by histiocytes (crystals storing histiocytosis) is a rare symptom associated most often with lymphoproliferative disease. The clinical picture is not characteristic, in the histopathologic picture it is striking similarity to rhabdomyoma. The skin involvement by crystal storing histiocytosis can be the first symptom of malignant lymphoma that can proceed the hematological malignancy by years.

Skin disorders with arthritis

Many inflammatory, metabolic and infectious diseases affect the skin and joints. Most of these, such as rheumatoid arthritis and systemic lupus erythaematosus, are considered to be rheumatic conditions with secondary skin involvement. However, several primary cutaneous diseases are associated with arthritis and may even present with joint symptoms prior to cutaneous lesions. Common skin disorders, such as acne and psoriasis, have well-known musculoskeletal manifestations. Other less common conditions, such as dermatomyositis, multicentric reticulohistiocytosis, pyoderma gangrenosum, Sweet's syndrome and various cutaneous vasculitides, also have frequent joint involvement. This review will discuss the clinical presentation, both cutaneous and musculoskeletal, diagnosis and management of these disorders.

Crystal-storing histiocytosis associated with MALT lymphoma of the ocular adnexa: a case report with review of literature

We report a case of crystal-storing histiocytosis (CSH) associated with mucosa-associated lymphoid tissue (MALT) lymphoma of the ocular adnexa. The patient was an 81-year-old woman who presented with a 5-month history of a slowly enlarging tumor on her left lower eyelid. The tumor was 2 cm in the largest diameter, involving both inferior oblique and inferior rectus muscles. Histological examination revealed that the tumor was composed predominantly of sheets of spindle-shaped cells resembling striated muscle cells, and scattered aggregates of atypical lymphoid cells at the periphery of the tumor, showing prominent plasmacytoid differentiation. Immunohistochemical and ultrastructural analyses demonstrated that the spindle-shaped cells were CD68-positive histiocytes containing abundant rod-like and/or rectangular crystals in their cytoplasm, consistent with the diagnosis of CSH. The scattered aggregates of atypical lymphoid cells were diagnosed as MALT lymphoma based upon their immunophenotype, featuring diffusely positive staining for CD20, but negative for CD3, CD5, and CD10, and monotypic expression of IgM-kappa in cells with plasmacytoid differentiation. Although CSH is a well-recognized manifestation in lymphoproliferative disorders in the literature, CSH complicated by MALT lymphoma has only very rarely been reported. Given the rarity of this, difficulties in diagnosis may arise especially in cases where histiocytic proliferation overwhelms the underlying lymphoproliferative diseases.

Dangerous small B-cell clones

The detection of a monoclonal immunoglobulin in serum or urine usually raises concerns about the size of the underlying B-cell-derived clone and possible systemic effects caused by its expansion. However, a small clone can synthesize a very toxic protein, producing devastating systemic damage and protean clinical presentations. The resulting "monoclonal component-related diseases," although difficult to diagnose, may be progressive and even fatal. The monoclonal protein can aggregate and deposit systemically as occurs in light-chain amyloidosis, monoclonal immunoglobulin deposition disease, crystal-storing histiocytosis, and monoclonal cryoglobulinemia. Alternatively, some monoclonal proteins possess antibody activity toward autogenous antigens and cause chronic cold agglutinin disease, mixed cryoglobulinemia, and peripheral neuropathies. Other humoral mediators may contribute to neuropathy in variant disorders such as the POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes) syndrome. The clone synthesizing the noxious monoclonal proteins is often small, and sensitive techniques may be required to detect these immunoglobulins. A delay in diagnosis can allow irreversible organ damage and dramatically shorten survival. Prompt recognition of suggestive signs and symptoms should trigger a thorough diagnostic approach to reach the correct diagnosis quickly, because this is the key to effective therapy. Although the treatment of these conditions is not optimal, significant advances have been made, improving the duration and quality of life.

Hemophagocytic syndrome as a presenting sign of transformation of smoldering to acute adult T-cell leukemia/lymphoma: efficacy of anti-retroviral and interferon therapy

A 55-year-old Caribbean woman with a 6-year history of smoldering adult T-cell leukemia/lymphoma presented with clinical and biological symptoms of hemophagocytic syndrome. An extensive search for infectious diseases was negative. A lymph node biopsy showing large T-cell lymphoma (CD4-, CD25+) and findings of high LDH count and severe lymphocytosis led to the diagnosis of acute adult T-cell leukemia/lymphoma. Anti-retroviral therapy combining zidovudine, lamivudine, and interferon-alpha was started, resulting in rapid control of both hemophagocytic syndrome and symptoms of acute adult T-cell leukemia/lymphoma. Thus, we propose that adult T-cell leukemia/lymphoma must be added to the spectrum of etiologies of hemophagocytic syndrome.

Postarthroplasty histiocytic lymphadenopathy in a patient with uterine carcinoma

INTRODUCTION

Postarthroplasty histiocytic lymphadenopathy is a benign reactive sinus histiocytosis.

CASE REPORT

We report on the case of a 68-year-old woman presenting with pelvic postarthroplasty histiocytic lymphadenopathy after hysterectomy because of uterine carcinoma.

CONCLUSION

This unusual form of histiocytic lymphadenopathy should be included in the differential diagnosis of gynecologic oncology patients who have had joint replacements to avoid misdiagnosis of a neoplasm.

Plasma vascular endothelial growth factor (VEGF) measured in seventy dogs with spontaneously occurring tumours

BACKGROUND

Vascular endothelial growth factor (VEGF) acts specifically on endothelial cells mediating tumour neovascularisation and initiating tumour growth and metastasis. In humans, high VEGF levels are correlated with poorer prognosis but in dogs minimal information on plasma VEGF is available. Therefore, we analysed plasma VEGF in a variety of spontaneous canine tumours.

MATERIALS AND METHODS

Plasma from seventy dogs with various spontaneous tumours was taken prior to radiation therapy. A human VEGF ELISA was used for analysis.

RESULTS

Mean plasma VEGF was 7.2+/-7.8 pg/ml. Mean plasma VEGF level varied among different tumour types with the highest level in oral melanomas (12.4 pg/ml). In patients with sarcomas of soft tissue or bone origin, plasma VEGF levels increased significantly with decreasing haemoglobin concentration (p =0.013).

CONCLUSION

Canine plasma VEGF levels depend on tumour histology, with higher levels found in more aggressive tumours. The negative correlation between plasma VEGF and haemoglobin (hb) is most probably due to tissue hypoxia seen in anaemic animals.

Hemophagocytic syndrome after living-related liver transplantation

Hemophagocytic syndrome (HPS) is a life-threatening hematological disorder in immunocompromised patients. Although the number of patients with HPS following liver transplantation is scarce the outcome is usually fatal. We report a patient who developed HPS following living-related liver transplantation (LRLT) and was treated successfully by a combination of intravenous (IV) immunoglobulin (Ig) and granulocyte colony-stimulating factor (GCSF).

Bone marrow findings in patients with adult Still's disease

OBJECTIVE

Peripheral neutrophilia is one of characteristic laboratory findings in patients with adult Still's disease (ASD). We performed this study to identify the bone marrow findings in patients ASD.

METHODS

We examined 12 bone marrow biopsy specimens from patients with ASD.

RESULTS

The most frequent finding was granulocyte hyperplasia (12/12, 100%) and hypercellularity was observed in 75.0% (8/12) of patients. Plasmacytosis was present in 8.3% (1/12) of specimens. Histiocytosis and reactive hemophagocytosis were found in 25.0% (4/12) and in 16.7% (2/12) respectively.

CONCLUSION

Our results show that bone marrow granulocyte hyperplasia is the main possible mechanism for peripheral neutrophilia and that histiocytic activation is a not infrequent bone marrow findings in patients with ASD.

Post-scabetic nodules: a lymphohistiocytic reaction rich in indeterminate cells

We studied six infants and two adult cases of nodular scabies with immunostains and electron microscopy. All eight cases have had either direct (KOH) or family histories of scabies and were treated with lindane 1% cream or permethrin 5% cream. Family members responded very well, but our patients developed multiple papulo-nodular lesions which were initially very pruritic and, in some cases, persisted from several months to over one year. H & E stain of biopsied tissue sections revealed a heavy perivascular and periappendageal lymphohistiocytic cell infiltration. Immunophenotype of these cells was compatible with Langerhans cells, i.e. CD1A (+), S-100 (+) and HLA-DR (+). Electron microscopy showed that these histiocytic cells satisfied all the ultrastructural criteria of Langerhans cells except for the absence of Birbeck's granules. Lag, a monoclonal antibody for Birbeck's granules, was negative. "Persistent nodules in scabies" or "nodular scabies" seems to represent a prolonged response of indeterminate cells-lymphocytes to mite antigens.

Listeria monocytogenes and recurrent mycobacterial infections in a child with complete interferon-gamma-receptor (IFNgammaR1) deficiency: mutational analysis and evaluation of therapeutic options

We describe the history of a girl with interferon-gamma-receptor (IFNgammaR1) deficiency and studies performed to identify the molecular and clinical characteristics of this recently discovered disorder. This is the first report of a child from Northern Europe with IFNgammaR1 deficiency. The patient, now 7 years old, first presented with swelling and reddening at the Bacille Calmette-Guerin (BCG) vaccination site, swelling of lymph nodes, hepatomegaly, and an unusually severe varicella rash at the age of 4 months. At that time, she was diagnosed with BCG histiocytosis without typical granuloma formation and was treated with antituberculous agents. During the clinical course of her illness, several different types of atypical mycobacteria and (for the first time in an IFNgammaR1-deficient patient) Listeria monocytogenes were detected. Flow cytometric analysis showed that the patient's monocytes could not bind a monoclonal antibody specific for the IFNgamma-receptor. Our analysis of mRNA derived from the alpha-chain (IFNgammaR1) gene of this receptor revealed deletions of 173 bp and 4 bp in cDNA sequences originating from individual alleles. The 173 bp deletion was located between nucleotide positions 200 and 372, exactly matching those of exon 3, and the 4 bp deletion was located between nucleotide positions 561 and 564 of the coding region of the cDNA. Analysis of genomic DNA revealed the presence of a G to T transition at the 5'end of the splice consensus sequence of intron 3, which explains the absence of exon 3. The other allele carried the 4-base-pair deletion (ACTC) at nucleotide positions 15-18 of exon 5. Twelve months after an allo\geneic bone marrow transplantation, the patient had clinically improved.

Foreign body histiocytosis reaction after hip replacement with concomitant metastatic adenocarcinoma in the same lymph node

Infiltration of regional lymph nodes by macrophages has been shown after total joint arthroplasty. These pelvic lymph nodes were obtained most often from patients during staging procedures for carcinoma and may be a diagnostic pitfall in the frozen section diagnosis of nodal metastasis. We report an unusual case of association in the same lymph node between histiocytosis and prostatic carcinoma metastasis. Histiocytosis was caused by wear debris from two different prostheses. Inductively coupled plasma mass spectrometry verified this diagnosis.

Granulocyte-macrophage colony-stimulating factor-associated histiocytosis and capillary-leak syndrome following autologous bone marrow transplantation: two case reports and a review of the literature

Bone marrow (BM) histiocystosis in association with the administration of granulocyte-macrophage colony-stimulating factor (GM-CSF) is a rare phenomenon with few published cases. We report two cases of BM histiocystosis in patients with Hodgkin's disease treated with GM-CSF after autologous bone marrow transplantation. Both patients also developed clinical features of capillary leak syndrome, another rare complication of GM-CSF administration. GM-CSF-induced histiocystosis should now be considered in the differential diagnosis of delayed engraftment post-autotransplant.

Histiocytosis of regional lymph nodes associated with hip replacement

Five cases of pronounced histiocytic reaction in pelvic lymph nodes after hip replacement are demonstrated. Two patients subsequently underwent radical prostatectomies with bilateral lymph node dissections for adenocarcinoma. In three patients, the change was found during autopsy. The sinuses and interfollicular spaces were distended by numerous large macrophages that had bulky eosinophilic cytoplasm. The cells displayed immunoreactivity to KP1 antigen, alpha-1-antitrypsin and lysozyme, providing support for their histiocytic derivation. Polarization microscopy revealed birefringent needle-like particles in their cytoplasm. We think that the histologic appearance of lymph nodes represents a foreign body reaction to fragments of polyester or polyethylene derived from joint prostheses. It is necessary to be aware of this characteristic foreign body reaction in order to avoid confusion with other types of lymph node histiocytosis or with a metastatic tumor.

Kikuchi's histiocytic necrotizing lymphadenitis

Kikuchi's lymphadenitis was first recognized almost 25 years ago in Japan as a histopathologically specific reactive lymphadenitis without clear clinical correlates. The benign self-limiting clinical course and the notorious danger of misdiagnosis as malignant lymphoma together make it important to recognize this lymph node reaction type. We describe 2 typical case histories-young women with a cervical localisation.

[Immunodeficiency and carcinogenesis in patients with chronic active Epstein-Barr virus infection]

Three adult patients with chronic active Epstein-Barr virus infection (CAEBV) had high anti-EBV-VCA antibody, positive anti-EA, low anti-EBNA and were associated with systemic lymphadenopathies and immunosuppression. The case 1 and 2 had elevated serum immunoglobulin levels, and recurrent infections, and case 3 showed pancytopenia. These 3 cases developed both EBV and latent membrane protein (LMP) positive malignant histiocytosis, EBV positive but LMP negative plasmacytoma, and EBV negative acute myelogeneous leukemia, respectively. It was suggested that CAEBV belonged to high risk groups for the development of malignant neoplasms. Since HLA of the case 1 and his father was identical, we conducted a in vitro cytotoxicity test using EBV transformed autologous B lymphocytes, K562 cells, and Raji cells to clarify the association of immunosuppression and HLA. The case 1 showed a low level of specific cytotoxicity to autologous EBV transformed B cells, while his parents were negative for the specific cytotoxicity. The patient and his parents developed inducible cytotoxicity to all targets after in vitro incubation of peripheral mononuclear cells with recombinant interleukin 2 (rIL-2) for 7 days. The patient and his mother showed lower enhancement of cytotoxicity, while HLA identical father could induce good cytotoxic activity to all targets as well as normal controls, indicating that a low IL-2 induced cytotoxic activity observed in CAEBV was independent of HLA associated immunoregulation at least in the case 1. Further studies are required to clarify the exact mechanisms responsible for the development of CAEBV.

Postarthroplasty histiocytic lymphadenopathy in gynecologic oncology patients. A benign reactive process that clinically may be mistaken for cancer

BACKGROUND

A distinctive histiocytosis occurs in the regional draining lymph nodes after large joint replacements, resulting in lymphadenopathy that may mimic cancer both grossly and microscopically. Postarthroplasty histiocytic lymphadenopathy has most often been observed in males during surgery for prostate cancer.

METHODS

The authors present three examples of postarthroplasty histiocytic lymphadenopathy that occurred in gynecologic oncology patients. We studied the clinical, histologic, and immunohistochemical features of all three cases and the ultrastructure of one of them.

RESULTS

Most involved lymph nodes were enlarged, but histiocytosis was also seen in normal sized lymph nodes. Microscopically, histiocytes with abundant granular cytoplasm were present in the lymph node parenchyma, and, to a lesser extent, in the sinuses. Normal lymph node architecture was variably effaced and the histiocytic infiltrate extended focally into the perinodal tissue. Small, black metal particles were present in the histiocytes in every case. Birefringent polyethylene particles were a prominent finding in all three cases as confirmed by positive modified oil red O staining, and, in one case, by electron microscopy. The histiocytes were strongly immunoreactive for CD68, but immunostains for S100 protein, MAC 387, and cytokeratin were negative.

CONCLUSIONS

Enlargement of the lymph nodes in cancer patients who have had large joint replacements may be due to a benign histiocytosis rather than to metastatic cancer. The histologic features of the lymphadenopathy are distinctive and recognizable in routine histologic preparations. Polyethylene wear particles shed from joint prostheses are the most common substances in the histiocytes and are the most likely cause of the histiocytosis.

Hemophagocytosis as a para-neoplastic syndrome in NK cell leukemia

Hemophagocytic syndrome is a proliferative disorder of an activated monocyte-macrophage system and is characterized by fever, hepato-splenomegaly and pancytopenia. The serum level of interferon-gamma in the syndrome is increased but its origin is unknown. Here we describe a case of NK cell leukemia with hemophagocytic syndrome with elevated serum level of interferon-gamma. The levels of various cytokines were monitored during the course and statistic analysis was performed. To identify the clonal component, the NK cell fraction was sorted from the mononuclear layer and was subjected to Southern blot hybridization with a probe for EB virus tandem repeats. The fraction was also stimulated with interleukin-2 and the level of interferon-gamma in the conditioned medium was measured. Levels of M-CSF and interferon-gamma were significantly correlated with the degree of clinical manifestations and laboratory data. Southern blot hybridization revealed monoclonality of an NK cell fraction. The fraction also released interferon-gamma. Since macrophage can be activated through cytokines, the hemophagocytosis might have been triggered by factor(s) released from the abnormal NK cell clone at least in this case.

Granular histiocytosis of pelvic lymph nodes following total hip arthroplasty. The presence of wear debris, cytokine production, and immunologically activated macrophages

Infiltration of regional lymph nodes by macrophages has been demonstrated after total joint arthroplasty. Although lymph nodes regulate the immune response, neither cytokine production nor the degree of immunological activation of cells within these nodes after total joint arthroplasty has been investigated. Pelvic lymph nodes were obtained from five patients who had had a total of eleven arthroplasties in seven hips three to twenty years before a pelvic staging procedure for adenocarcinoma (of the prostate in four patients and of the endometrium in one). All lymph nodes had polyethylene or metal debris as well as effacement of the normal nodal architecture by a histiocytic infiltrate. These changes were bilateral in the patients who had had an arthroplasty of one hip. Analysis of specimens from pelvic lymph nodes on the side of the involved hip demonstrated intense immunohistochemical staining of histiocytes for the major histocompatibility complex class-II antigen HLA-DR, a marker of histiocyte immune activation. In contrast, staining was absent in specimens from the contralateral lymph nodes as well as in those from seven patients who had had a prostatectomy but not a hip arthroplasty. Immunohistochemical staining for interleukin-1beta, tumor necrosis factor-alpha, and interleukin-6 demonstrated a much greater expression of these cytokines in the involved lymph nodes.

CLINICAL RELEVANCE

Additions improvements in total joint replacement will be facilitated by a more thorough understanding of the biological response to the components and materials of implants. While local biological factors leading to failure of prostheses are currently under intense investigation, the mechanisms and importance of regional and systemic immune responses to wear debris require further study.

Neuroradiologic aspects of Chester-Erdheim disease

In three cases of histologically proved Chester-Erdheim disease there was a large anterior epidural lesion from C-3 to L-2 in one patient; dural masses and orbital infiltration in a second patient; and dural, choroid plexus, retroorbital, and hypophyseal lesions in a third patient. Diabetes insipidus, exophthalmia, long bone lesions, and retroperitoneal infiltration were present.

Histiocytic cytophagic panniculitis: a rare late complication of allogeneic bone marrow transplantation

Histiocytic cytophagic panniculitis (HCP) is the name given to the hemophagocytic syndrome when subcutaneous fat is involved. Histologically, it is characterized by phagocytosis of blood elements by histiocytes that appear to be benign. We report this rare skin disease in a 46-year-old patient that occurred 32 months after an allogeneic bone marrow transplantation. This skin disease could be a manifestation of graft-versus-host disease, although the connection remains speculative.

[A case with AML (M4EO) accompanied by recurrent reactive histiocytosis which showed spontaneous remission]

A 30-year-old female was admitted to our hospital complaining of high fever and fatigue. Laboratory findings showed as follows; WBC 41,500/microliter (40% of blasts), Hb 8.5g/dl, platelets 4.4 x 10(4)/microliter. Cytochemical staining of blasts was positive for peroxidase and non-specific esterase with NaF inhibition. Chromosome analysis showed 46, XX, inv (16p+,q-). AML with eosinophilia was diagnosed. During myelosuppression after remission induction therapy, she developed high fever, and did not respond to transfusions. Marrow smears showed the presence of phagocytic histiocytes consisting of 18% total nuclear cells. A diagnosis of reactive histiocytosis (RH) was made. She recovered spontaneously, but suffered two episode of recurrence during subsequent chemotherapy. Reactive histiocytosis is characterized by proliferation of histiocytes which phagocyte blood cells in immunodeficient cases, e.g. a myelosuppressive state after chemotherapy. RH causes high fever and prolonged myelosuppression. It is considered to be one of the poor prognostic factors in AML during chemotherapy, and spontaneous recovery is rare. In this report, the effect of hydrocortisone on histiocytes derived from patient marrow was also investigated in vitro.

Rheumatoid arthritis and B cell lymphoma with pathological changes of reactive histiocytosis

A 67 year old woman with rheumatoid arthritis was admitted to hospital in acute renal failure. Her clinical features included increasing dyspnoea and oedema, and a computed tomogram of the abdomen showed a large mass in the retroperitoneum. Twenty six days later, she died, and a post mortem examination was carried out. The histological changes of the mass indicated B cell lymphoma of diffuse large cell type, with a reactive proliferation of erythrophagocytosing histiocytes. Immunocytochemical studies showed that the histiocytes were positive for CD-68 and lysozyme, but negative for S-100 protein. Such neoplastic B cell proliferation accompanied by activation of benign looking histiocytes with erythrophagocytosis is very rare.

[An adult case of virus-associated hemophagocytic syndrome (VHAS) and a review of this syndrome in adults in Japan]

An adult case of Virus-associated hemophagocytic syndrome (VAHS) was reported and a review of this syndrome in adults in Japan was also made. A 79 year-old woman was referred to our hospital for detailed examination for sustained generalized fatigue lasting for about two weeks. Other clinical manifestations of this patient included fever, generalized lymphadenopathy, hepatosplenomegaly, anemia and mild liver dysfunction. The biopsy of the lymph node revealed hyperplasia of histiocyte with hemophagocytosis. There was also an elevation of IgG antibody against EB virus and the patient was therefore diagnosed to have VAHS. The prednisolone therapy was then initiated and the patient responded to this treatment very well. By the review of the Japanese literatures, seven adult cases of VAHS were found. Based on the descriptions on these cases, the prognosis of this syndrome appeared to be extremely poor which is totally different from VAHS in children. Our case showed a very favourable clinical course following steroid therapy and this suggested that steroid therapy should be considered even at the early stage of this syndrome in adults.