Langerhans Cell Histiocytosis


Article Author:
Cara Tillotson


Article Editor:
Bhupendra Patel


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Jon Parham
Abigail Frank
Jon Sivoravong


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Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/3/2019 10:54:59 PM

Introduction

Langerhans cell histiocytosis (LCH) is an idiopathic condition characterized by proliferation of abnormal Langerhans cells (antigen-presenting immune cells). The disease has characteristics of both an abnormal reactive process and a neoplastic process. It may present initially as a rash. It can be disseminated and involve bone marrow, lungs, liver, spleen, lymph nodes, gastrointestinal (GI) tract, and the pituitary gland. Prognosis varies depending on presentation and organ involvement. LCH can occur at any age but is most common from birth to age 15 years. There is wide variation in presentation, treatment, and prognosis among individuals. Referral and long-term follow up with an oncologist are important in the management of LCH. [1][2][3]

Etiology

The cause of LCH is unknown and continues to be a debate; however, most agree that LCH is either a reactive or neoplastic process. [4][5][6]

LGH has multiple cytokines involved, there is good survival in isolated lesions, and it can have spontaneous remissions. These characteristics support a reactive process. 

However, LGH also can have organ infiltration. The widespread disease is associated with increased mortality, it typically responds to chemotherapy, and there has been at least one study that demonstrated an association with the BRAF gene mutation. These characteristics support a neoplastic process. 

Epidemiology

Langerhans cell histiocytosis is rare. It occurs in 1 to 2 newborns per million per year. The incidence in children < 15 years is 4 to 5 cases per million per year. In adults, the Langerhans is about 1 to 2 cases per million per year. It may occur at any age but is more likely to occur in those < 15 years of age. [7]

Pathophysiology

The pathophysiology of LCH is unknown. Langerhans cells are dendritic antigen-presenting cells. The abnormal cells in LCH have abnormal proliferation and lower antigen-presenting capability. LCH lesion also contains inflammatory cells and cytokines such as T lymphocytes, eosinophils, neutrophils, and macrophages. It is thought that the combination or interaction of these cells accounts for the continued proliferation of the abnormal Langerhans cells. Regardless, abnormal proliferation into tissue causes disease, based on location at presentation. For example, bone marrow infiltration may lead to decreased blood cell production. 

Histopathology

The histological features of LCH are variable and influenced by the age of lesions and their location.

The primary lesion is granulomatous with an influx of eosinophils, macrophages, T cells and multinucleated cells. The Birbeck granule is the microscopic hallmark of the disorder but may not be seen in lesions of the spleen, liver, and GI tract.

History and Physical

Symptoms and physical exam will depend on organ involvement at the time of presentation. 

The rash is the most common presentation. In children, the rash may be misdiagnosed as seborrhea or atopic dermatitis but will not respond to typical treatment for these disorders. The rash of LCH ranges from a single lesion to widespread involvement. Characteristics include scaly papules, nodules, or plaques and can resemble seborrheic dermatitis. One may distinguish LCH by the presence of petechiae, bloody crusting, or firmly indurated nodules.

Bony involvement occurs in about 78% of patients. Solitary osseous lesions are usually incidentally found and may include the skull, hip/pelvis, femur, or ribs. This bony involvement may present incidentally, when obtaining imaging for another complaint, or may produce bone pain. 

Pulmonary lesions occur in 20% of patients, and lymph node involvement in 30%. As such, the patient may present with pulmonary symptoms or lymphadenopathy. Hepatosplenomegaly may be present as well. 

Langerhans cell histiocytosis also has a predilection for infiltration of the pituitary and causing diabetes insipidus. If this is the initial presentation, the patient may have polyuria, polydipsia, dilute urine, and hypernatremia. 

Evaluation

Biopsy of the involved site (usually skin) is required to confirm the diagnosis. Lesions will stain positive for S-100 and CD-1a. Cytoplasmic Birbeck granules will be present on electron microscopy. When the diagnosis is confirmed, workup for systemic involvement should include a skeletal survey, abdominal ultrasound, complete blood count (with bone marrow biopsy if indication of bone marrow involvement), and evaluation for diabetes insipidus. [8][9][10][9]

CT scanning or MRI

Both CT scan and MRI are invaluable for assessing the hypothalamic-pituitary area. Fluorodeoxyglucose (FDG) PET scanning also is being used to assess patients with LCH. The technique is far more sensitive than bone scan for early detection of disease in the spleen, lymph nodes, and lung. In fact, FDG PET scan is now also being routinely used to monitor disease during treatment.

Other Tests

  • Pulmonary function testing may help identify asymptomatic patients with lung involvement

  • Small bowel series is recommended in patients with failure to thrive, diarrhea, and malabsorption

  • Neurological and visual testing

  • Auditory testing

  • Recent studies suggest that CSF fluid can be used to detect biomarkers like glial fibrillary acidic protein to evaluate the onset of disease and response to therapy.

  • Skin biopsy can establish the diagnosis[11][12]

Treatment / Management

Treatment varies greatly depending on the involved organs. If the disease is isolated, observation alone may be appropriate. Surgical removal of an isolated area is also a treatment option. Isolated skin lesions may resolve on their own, especially if they present in infancy (congenital self-healing reticulohistiocytosis), or may be treated with topical steroids, oral methotrexate, or thalidomide. Chemotherapy and radiation may be used for more systemic involved cases. There are several different chemotherapy protocols that have been used; currently, protocols are using prednisone and vinblastine, though other regimen options include vincristine, cytosine arabinoside, prednisone, cladribine, or pamidronate. [13]

Late complications are common; therefore, follow up with oncology is crucial. Complications include diabetes insipidus, growth failure, delayed puberty, tooth loss, mandibular bone loss, hearing loss, secondary cancers, neurologic/cerebellar effects, liver disease, and pulmonary fibrosis. 

Prognosis

More than 50% of children under the age of 2 with disseminated Langerhans cell histiocytosis will die of the disease, but those with localized disease may have a prolonged life-span. For those who have been treated and do not have more lesions at 12 to 24 months, a full recovery can be expected. When there is lung involvement, the prognosis is not good. However, patients with isolated skin involvement and a solitary lymph node involvement tend to have a good prognosis.

Unfortunately, nearly 50% of patients with Langerhans cell histiocytosis are prone to a variety of complications which include the following:

  • Musculoskeletal disability

  • Skin scarring

  • Diabetes insipidus

  • Hearing impairment

  • Neuropsychiatric problems like depression, anxiety, and intellectual impairment

  • Pulmonary impairment

  • Secondary malignancies like lymphoblastic leukemia and sodi tumors

  • Growth retardation

  • Liver cirrhosis

Pearls and Other Issues

Prognosis depends on whether the initial presentation was a low-risk disease (isolated to the skin, lymph nodes, or pituitary gland) or high-risk disease (involving the spleen, liver, bone marrow, lung, or skeleton). Mortality may be low for isolated lesions (< 5%) and as high as 50% for the more widespread disease. 

Enhancing Healthcare Team Outcomes

The management of LCH is with a multidisciplinary team that includes oncology nurses. The key is to make an early diagnosis.Healthcare workers need to be aware that the rash is the most common presentation. In children, the rash may be misdiagnosed as seborrhea or atopic dermatitis but will not respond to typical treatment for these disorders. The rash of LCH ranges from a single lesion to widespread involvement. Characteristics include scaly papules, nodules, or plaques and can resemble seborrheic dermatitis. One may distinguish LCH by the presence of petechiae, bloody crusting, or firmly indurated nodules.

The outcomes of LCH depend on its presentation. Those with disseminated disease will die within 24-48 months. Those with localized disease do have a better prognosis but the quality of life is reduced.


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Langerhans Cell Histiocytosis - Questions

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Birbeck granules on electron microscopy are usually seen in what disease?



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A child presents with a triad of diabetes insipidus, proptosis, and radiographic defects in skull bones. A bone biopsy reveals that the lesions consist of eosinophils and dendritic cells. These findings are typical of which disease?



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Which of the following is NOT a clinical feature of Langerhans cell histiocytosis?



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Which of the following findings does NOT go along with a diagnosis of Langerhans cell histiocytosis?



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A 4-year-old girl has been treated for scalp seborrheic dermatitis but is not improving. She has developed polyuria and polydipsia. What is the most likely diagnosis?



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A 35-year-old male is transported by paramedics to the emergency department with acute onset of chest pain and shortness of breath when coughing. He has had a 4-month history of progressive shortness of breath, weight loss, and dry cough. He smokes 1.5 packs of cigarettes a day and has for 15 years. He has no other past medical history, has no risk factors for HIV, and takes no medications or herbal supplements. He is found to have a 75 percent pneumothorax on the left with nodular infiltrates at the right base, not involving the costophrenic angel. A chest tube is placed. CT shows multiple small cystic spaces at the apices and bilateral nodular opacities at the lung bases. Select the most important treatment.



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In regards to the disorders classified as interstitial lung disease, which of the following is true?



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Langerhans Cell Histiocytosis - References

References

Wang YC,Li ZZ,Yin CY,Jiang LJ,Wang L, [Langerhans cell histiocytosis involving the oral and maxillofacial region: an analysis of 12 cases]. Zhongguo dang dai er ke za zhi = Chinese journal of contemporary pediatrics. 2019 May;     [PubMed]
Rao J,Rao Y,Wang C,Cai Y,Cao G, Cervical langerhans cell histiocytosis mimicking cervical tuberculosis: A Case report. Medicine. 2019 May;     [PubMed]
Allen A,Matrova E,Ozgen B,Redleaf M,Emmadi R,Saran N, Langerhans' cell histiocytosis of the temporal bone in an adult with central diabetes insipidus. Radiology case reports. 2019 Jul;     [PubMed]
Panaite L,Shadman M, Concurrent diagnosis of classical Hodgkin lymphoma and Langerhans cell histiocytosis. Blood. 2019 May 9;     [PubMed]
Kambouchner M,Emile JF,Copin MC,Coulomb-Lherminé A,Sabourin JC,Valle VD,Sileo C,Le Pointe HD,Bégueret H,Galmiche L,Lambilliotte A,Paraf F,Piche M,Piguet C,Rullier A,Secq V,Serre I,Bernaudin JF,Donadieu J, Childhood pulmonary Langerhans cell histiocytosis: a comprehensive clinical-histopathological and BRAF{sup}V600E{/sup} mutation study from the French national cohort. Human pathology. 2019 May 2;     [PubMed]
Narayanasamy Rajavelu T,Abimannane A,Chinnaiah Govindhareddy DK,Kayal S,Kar R, Langerhans' Cell Histiocytosis Masquerading as Caroli's Disease. Journal of pediatric hematology/oncology. 2019 Apr 24;     [PubMed]
Su M,Gao YJ,Pan C,Chen J,Tang JY, Outcome of children with Langerhans cell histiocytosis and single-system involvement: A retrospective study at a single center in Shanghai, China. Pediatric hematology and oncology. 2018 Oct - Nov;     [PubMed]
Langerhans Cell Histiocytosis Treatment (PDQ®): Health Professional Version 2002;     [PubMed]
Abla O,Jacobsen E,Picarsic J,Krenova Z,Jaffe R,Emile JF,Durham BH,Braier J,Charlotte F,Donadieu J,Cohen-Aubart F,Rodriguez-Galindo C,Allen C,Whitlock JA,Weitzman S,McClain KL,Haroche J,Diamond EL, Consensus recommendations for the diagnosis and clinical management of Rosai-Dorfman-Destombes disease. Blood. 2018 Jun 28;     [PubMed]
Yeh EA,Greenberg J,Abla O,Longoni G,Diamond E,Hermiston M,Tran B,Rodriguez-Galindo C,Allen CE,McClain KL, Evaluation and treatment of Langerhans cell histiocytosis patients with central nervous system abnormalities: Current views and new vistas. Pediatric blood     [PubMed]
Vielgut I,Liegl-Atzwanger B,Bratschitsch G,Leithner A,Radl R, Langerhans-cell histiocytosis of the cervical spine in an adult patient: Case report and review of the literature. Journal of orthopaedics. 2017 Jun;     [PubMed]
Biswas A,Donahoe M, The many faces of Pulmonary Langerhans Cell Histiocytosis. Sarcoidosis, vasculitis, and diffuse lung diseases : official journal of WASOG. 2014 Oct 20;     [PubMed]
DiCaprio MR,Roberts TT, Diagnosis and management of langerhans cell histiocytosis. The Journal of the American Academy of Orthopaedic Surgeons. 2014 Oct;     [PubMed]

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