Non-Langerhans cell histiocytosis with peripheral joint destruction and mediastinal lymph node invasion: The continuous feature spectrum of clinical multicentric reticulohistiocytosis and microscopical xanthoma disseminatum

Yi-Hsiang Yu; Chih-Hung Lee; Shang-Hung Lin

doi:10.4103/ds.ds_48_19

CASE REPORT

Year : 2020 | Volume : 38 | Issue : 3 | Page : 176-179

Non-Langerhans cell histiocytosis with peripheral joint destruction and mediastinal lymph node invasion: The continuous feature spectrum of clinical multicentric reticulohistiocytosis and microscopical xanthoma disseminatum

Yi-Hsiang Yu, Chih-Hung Lee, Shang-Hung Lin
Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan

Date of Submission	17-Jul-2019
Date of Decision	01-Dec-2019
Date of Acceptance	09-Dec-2019
Date of Web Publication	24-Apr-2020

Correspondence Address:
Shang-Hung Lin
Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Road, Niaosong Dist, Kaohsiung City 83301
Taiwan

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ds.ds_48_19

Abstract

The non-Langerhans cell histiocytoses (non-LCH) are rare and benign histiocytic disorders. We present a 61-year-old female with progressive skin-colored nodules on the face and extremities. The skin biopsy showed dermal infiltration of foamy histiocytes. Further imaging study showed erosive arthritis and lymphadenopathy. The microscopical feature of anterior mediastinal lymph node was similar to that in the skin. Thus, the diagnosis is non-LCH with joints and lymph nodes involvement. This patient presented both the clinical manifestations of multicentric reticulohistiocytosis (MRH) and histologic findings of xanthoma disseminatum (XD), indicating the plausible association and the shared disease spectrum of MRH and XD.

Keywords: Arthritis, lymphadenopathy, non-Langerhans histiocytosis

How to cite this article:
Yu YH, Lee CH, Lin SH. Non-Langerhans cell histiocytosis with peripheral joint destruction and mediastinal lymph node invasion: The continuous feature spectrum of clinical multicentric reticulohistiocytosis and microscopical xanthoma disseminatum. Dermatol Sin 2020;38:176-9

How to cite this URL:
Yu YH, Lee CH, Lin SH. Non-Langerhans cell histiocytosis with peripheral joint destruction and mediastinal lymph node invasion: The continuous feature spectrum of clinical multicentric reticulohistiocytosis and microscopical xanthoma disseminatum. Dermatol Sin [serial online] 2020 [cited 2023 May 29];38:176-9. Available from: https://www.dermsinica.org/text.asp?2020/38/3/176/283212

Introduction

Histiocytic disorders represent a heterogeneous group of diseases derived from the proliferation of histiocytes. In 1987, the Histiocyte Society first described the classification of histiocytosis with three categories: Langerhans cell or non-Langerhans cell-related and malignant histiocytoses.^[1] The non-Langerhans cell histiocytoses (non-LCH) refer to a family of histiocytosis characterized by the absence of Langerhans cells or do not meet the criteria for the diagnosis of LCH.^[2] LCH can affect any organ of the body, and the most common sites are the bones, skin, and lymph nodes. However, non-LCH are mostly localized to the skin and mucosa, and systemic manifestations are uncommon. Here, we present an extremely rare case of cutaneous non-LCH with joints and lymph nodes involvement.

Case Report

This 61-year-old female started to develop extensive itchy skin-colored nodules on the face, neck, and limbs 7 months ago. She also experienced joint deformity and joint pain over her fingers, wrists, and elbows. She lost her body weight at 10 kg in 7 months. Physical examination showed numerous discrete-to-confluent, skin-colored, and mild shiny papulonodules on the forehead, nasolabial folds, chin, neck, and dorsal hands [Figure 1]a and [Figure 1]b. Our tentative diagnosis was multicentric reticulohistiocytosis (MRH) and leprosy due to the presence of papulonodular cutaneous lesions along with peripheral arthritis. Laboratory data revealed elevated lactate dehydrogenase (505 U/L), slightly elevated total cholesterol (239 mg/dL), and normal triglyceride level (118 mg/dL). The anti-dsDNA, anti-extractable nuclear antigen screen, rheumatoid factor, and serum paraproteins were all within normal limits. The skin biopsy from the hand showed many infiltrative foamy and vacuolated histiocytes with amphophilic cytoplasm and round nuclei in the dermis [Figure 1]d and [Figure 1]e. However, the absence of multinucleated eosinophilic histiocytes unfavored the diagnosis of MRH. In addition, there was no extracellular lipid in the adipophilin stain. The histiocytes were positive for CD68, negative for adipophilin, negative for S100, and negative for CD1a [Figure 1]f. The Fite's acid-fast stain did not show leprosy bacilli. Therefore, the diagnosis was established as non-LCH based on histopathology and immunohistochemistry.

Figure 1: (a) The lesions showed numerous discrete-to-confluent, skin-colored, papulonodules on the face, forehead, nasolabial folds, and neck. (b) Multiple skin colored nodules on the dorsal hands with joints deformity. (c) Radiograph of the bilateral hands showing joint space narrowing and erosive changes involving the distal interphalangeal and proximal interphalangeal joints (white arrows) along with soft-tissue swelling. (d) Skin pathology of right elbow skin showed abundant foamy cell infiltration in the dermis and extending into the epidermis (H and E stain, ×20). (e) High-power image demonstrated numerous foamy histiocytes (H and E stain, ×200). (f) Positive CD68 immunostaining (×100). (g) Computed tomography of the chest revealed anterior mediastinal lymphadenopathy (green arrow)

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Further examination of hand X-ray showed irregular subchondral bone with osteolysis of the phalanges and joint space narrowing of both the hands [Figure 1]c. We arranged systemic workup for malignancy surveys due to unintentional weight loss in few months. There are no specific findings from cardiac echography, renal echography, panendoscopy, and colonfiberscopy. Of note, chest computed tomography reported a 4.7-cm soft-tissue mass at the anterior mediastinum with lymphadenopathy [Figure 1]g. Surgical removal of the lymph node by mediastinoscope revealed abundant foamy histiocytes. Immunohistochemical staining of the histiocytes was also positive for CD68, negative for S100, and negative for CD1a. The morphology and immunohistochemistry features were similar and remnant as that in skin biopsy. Taken together, the diagnosis was non-LCH with joints and lymph nodes involvement. The skin lesions and joint mobility improved significantly by oral prednisolone at 20 mg/day over 1 year of follow-up. The bony destruction was stable, and soft-tissue swelling resolved. Her joint mobility and deformity also improved.

Discussion

The non-LCH consists of a heterogeneous of disorders with different clinical presentations, pathogenesis, and morphology. This case presented clinical, pathological, and immunohistochemical findings that are consistent with non-LCH. The case also showed a rare extension of the proliferative histiocytes to the lymph nodes and associated with peripheral joint destruction in non-LCH.

Currently, several variants of non-LCH tend to occur in a cutaneous and generalized distribution over the body, such as the subgroup of cutaneous non-LCH with a major systemic component. In the classification, this subgroup of disorders is further subdivided into the xanthogranuloma (XG) family: xanthoma disseminatum (XD) and non-XG family: MRH.^[3] Clinically, approximately 60% of patients may develop polyarthralgia and joint damage in MRH.^[4] On the other hand, it is uncommon for the lesion extending into bone or joint in XD, and only three cases were reported in the last 20 years.^[5],[6],[7] Besides, lymph nodes involvement was extremely rare in XD and MRH.^[8]

MRH patients are usually 50–60-year-old women. Lesions are reddish-brown papules, nodules, or tumors and predominate on the face, forearm, and hands. Arthropathy and synovitis are the features of MRH, which often causes destructive arthritis. MRH is also associated with autoimmune disease. In about 25% of the patients, MRH is associated with malignancy.^[9] The histiocytes of MRH bear copious pink histiocytes and multinucleated giant cells, with eosinophilic, finely granular, and ground-glass cytoplasm. The histiocytes and multinucleate giant cells are positive for CD68 and CD163 but negative for CD1a and S100. They reacted variably with factor XIIIa^[10] [Table 1].

Table 1: Clinical presentation, histologic findings, and immunohistochemical staining patterns of cutaneous non-Langerhans histiocytoses with a major systemic component

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The characteristic histologic feature of XD is the presence of scalloped macrophages with foamy cells in early lesions, while the late lesions have a mixture of macrophages, foamy cells, and Touton giant cells. Immunohistochemical staining of histiocytes is positive for CD68 and factor XIIIa but negative for CD1a and S100 protein.^[11] Therefore, XD cannot easily be excluded due to the histologic and immunohistochemical pictures of abundant foamy histiocyte infiltration in our case. However, clinically, XD patients are younger with male predominance. XD typically shows widespread brown-to-yellow papules and nodules involving the face and trunk, including the fflexural regions. The mucosa sites are often affected. Respiratory, ocular, and central nervous system involvement could be found in patients, but the diabetes insipidus is usually mild and transient.^[12],[13] Importantly, the skeletal involvement in patients with XD is rare.

In the present case, papulonodular skin lesions distribution of the face, neck, and dorsal hands with severe polyarthritis were consistent with the clinical features in the diagnosis of MRH. However, based on the microscopical pathology, our patient was in favor of XD due to the presence of numerous foamy histiocytes and a lack of eosinophilic histiocytes and ground-glass multinucleate giant cell. This is the interesting part that the diagnosis of non-LCH is based on histopathology, and further differentiation of different subgroups is supported by immunophenotypic and the clinical presentations. Therefore, clinicopathologic overlap makes it difficult to place some patients exactly into one definite entity.^[14],[15] To our knowledge, there were few similarly documented cases presenting as the combination of generalized xanthoma and destructive arthritis consistent with MRH.^{[16],[17],[18],[19]} One similar case had an association with double cancers.^[18] Interestingly, recently, two cases reported a good response to adalimumab;^[19] some people thought these are variants of MRH. However, none of these patients developed lymphadenopathy. Our case is the only case with prominent foamy histiocytic infiltration of lymph nodes and could be considered as a clinical variant of non-LCH group.

Generally, the non-LCH is a self-limiting disease but may persist for years. The patients with non-LCH may have extracutaneous manifestations. Prompt recognition and treatment is recommended to avoid irreversible inflammation period.^[20],[21] Currently, there is no standard treatment for these cases, and various immunosuppressant agents including systemic steroids, methotrexate, and tumor necrosis factor-alpha blocker of adalimumab have been tried with different results. In our experience, progressive joint destruction in this patient with non-LCH benefits from systemic steroid.

Conclusion

We report a case presenting MRH clinically but XD microscopically. Not only skin and joints but also mediastinal lymph nodes could be involved in patients with non-LCH. Appropriate treatment and prolonged follow-up are mandatory.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that her name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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