Complete remission of multicentric reticulohistiocytosis with combination therapy of steroid, cyclophosphamide, and low‐dose pulse methotrexate. Case report, review of the literature, and proposal for treatment

Abstract

We describe a patient with multicentric reticulohistiocytosis in whom complete remission was achieved by sequential combination therapy with steroid, methotrexate, and cyclophosphamide. We reviewed all cases of complete or near-complete remissions of multicentric reticulohistiocytosis reported in the English-language literature and propose a new drug regimen for this rare but potentially disabling disease.Multicentric reticulohistiocytosis is a rare systemic disorder of unknown etiology, characterized by tissue infiltration by histiocytes and multinucleated giant cells. It primarily affects skin, mucous membrane, and joints. Fewer than 200 cases have been reported since the original report by Targett (1,2). The term "multicentric reticulohistiocytosis" was proposed in 1954 by Golts and Laymon (3), and has become widely accepted. Complete remission of the disease has been reported in association with treatment with alkylating agents (4) or methotrexate (5,6) in resistant cases. Herein we describe a patient whose complete remission was achieved by treatment with a combination of steroid, methotrexate, and cyclophosphamide.George C. Liang, MD: Northwestern University Medical School, Chicago, Illinois; Arthur S. Granston CASE REPORTThe patient, a 66-year-old woman, presented in May 1989 with a 6-month history of polyarthritis and a 6-week history of widespread mucocutaneous nodules. Her earlier medical history included hypertension, glaucoma, and stable multiple sclerosis. The arthritis involved her knees, wrists, proximal interphalangeal joints, and metacarpophalangeal joints, in a symmetric pattern. The nodules varied in size (2-20 mm in diameter) and covered all fingers, the forearms, elbows, knees, nasal septum, and tongue. Classic "coral beads" were observed around all nailfolds. Red, confluent, nonpruritic papules were seen on the anterior area of the neck, the upper chest, and the back. Xanthelasmas were noted on both upper eyelids.Laboratory findings were all normal except for elevation of cholesterol levels (cholesterol 244 mg/dl, triglycerides 134 mg/dl, high-density lipoprotein 59 mg/dl, low-density lipoprotein 174 mg/dl). Testing for both rheumatoid factor and antinuclear antibodies yielded negative results. Biopsy of the nodule on the right elbow revealed full-thickness infiltration of the dermis by a dense proliferation of histiocyte-like cells in compact sheets and irregular clusters, with more loosely dispersed cells interspersed between the dermal collagen bundles. The cells were moderately large, oval, polygonal, or slightly elongated, and predominantly mononuclear, generally 10-25 pm in diameter. Multinucleated cells were common, usually containing 2-4 nuclei and rarely, up to 30 nuclei. The nuclei were round-to-oval and slightly pleomorphic, usually 8-14 pm in diameter and uncommonly up to 20 pm, without hyperchrornasia and with small nucleoli. Cytoplasm

Multicentric reticulohistiocytosis

“…MRH also occurs in association with autoimmune diseases in 5-20 % of patients including lupus, scleroderma, hypothyroidism, diabetes, primary biliary cirrhosis, idiopathic inflammatory myopathy, and celiac disease, and has also been reported in association with rheumatoid arthritis and Sjogren's syndrome [11]. Treatment is with steroids or chemotherapeutic agents [12]. Anti-tumor necrosis factor α agents and alendronate may also be efficacious [7].…”

Remissão de retículo-histiocitose multicêntrica com terapia combinada com infliximabe

“…3 As lesões cutâneas freqüentemente se resolvem antes do quadro articular e podem deixar seqüe-las permanentes. 8 Nos casos mais graves, a desfiguração da face é conhecida como "face leonina". As lesões de mucosa podem afetar de 34% a 50% dos pacientes e atingem principalmente língua, lábios, gengivas e septo nasal.…”

“…12 As neoplasias associadas são: carcinomas de mama, estômago, cérvix, pleura, pulmão, ovário, cólon, pân-creas e laringe, bem como o mesotelioma, melanoma maligno, sarcoma, linfoma e leucemia. 8 Não há relato de associação com adenoma hipofisário, que foi diagnosticado na paciente aqui apresentada.…”

Multicentric Reticulohistiocytosis with Dermatomyositis-Like Features: A More Common Disease Presentation than Previously Thought

“…All patients had biopsies consistent with MRH. Using these methods, 27 cases of MRH with dermatomyositis-like features were identified (table 1) [4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27]. …”