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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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CASE REPORT
Year : 2015  |  Volume : 22  |  Issue : 4  |  Page : 517-519  

Primary orbital lymphomatoid granulomatosis in a 1-year-old child


1 Division of Ophthalmology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
2 Division of Ophthalmology, Groote Schuur Hospital; Division of Paediatric Ophthalmology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa

Date of Web Publication21-Oct-2015

Correspondence Address:
Shaheer Aboobaker
Division of Ophthalmology, Groote Schuur Hospital, University of Cape Town
South Africa
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-9233.164623

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   Abstract 

Lymphomatoid granulomatosis (LyG) is a rare, angiocentric, angiodestructive, B-cell lymphoproliferative disease, presenting with pulmonary involvement in more than 80% of cases. We describe a case of primary orbital LyG in a 1-year-old child.

Keywords: Lymphomatoid Granulomatosis, Orbit, Pediatric


How to cite this article:
Aboobaker S, Tinley C. Primary orbital lymphomatoid granulomatosis in a 1-year-old child. Middle East Afr J Ophthalmol 2015;22:517-9

How to cite this URL:
Aboobaker S, Tinley C. Primary orbital lymphomatoid granulomatosis in a 1-year-old child. Middle East Afr J Ophthalmol [serial online] 2015 [cited 2019 Jun 18];22:517-9. Available from: http://www.meajo.org/text.asp?2015/22/4/517/164623


   Introduction Top


Lymphomatoid granulomatosis (LyG) is a rare, angiocentric, angiodestructive, B-cell lymphoproliferative disease, presenting with pulmonary involvement in more than 80% of cases. We describe a case of primary orbital LyG in a 1-year-old child.


   Case Report Top


The child's mother became concerned about a progressive swelling of the right eye over a period of weeks. There was no relevant previous medical or birth history and the mother tested negative for human immunodeficiency virus (HIV). Examination revealed gross, nonaxial proptosis associated with periorbital edema, erythema, and nasal conjunctival chemosis [Figure 1]. Ocular motility was restricted horizontally and in elevation. On fundoscopy, there was pale disc swelling on the right, with tortuous retinal vessels.
Figure 1: Right nonaxial proptosis with periorbital edema, erythema, and nasal conjunctival chemosis

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A full blood count showed no leukocytosis and there was no evidence of renal dysfunction. Hepatitis B surface antibody was positive, but hepatitis B surface antigen and core antibody immunoglobulin M were negative. The erythrocyte sedimentation rate was 32 mm (range 0–15). The child was HIV negative, and a lumbar puncture showed no abnormalities. However, further immunological testing identified a nonspecific T-cell immunodeficiency, with low T-cell subsets (absolute and percentages). Due to resource limitations, the specific features of the immunodeficiency could not be further elucidated.

Magnetic resonance imaging revealed a large mass (4.5 cm × 4.6 cm), originating in the right orbit. This extended through the medial orbital wall into the ethmoid air cells, with frontal leptomeningeal enhancement [Figure 2]. There was restricted diffusion centrally and enhancement of the lesional rim. Her chest X-ray was normal.
Figure 2: T1-weighted magnetic resonance imaging showing large medial orbital mass with ethmoidal extension, restricted central diffusion, and rim enhancement

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A transnasal biopsy led to the provisional diagnosis of a diffuse, large B-cell lymphoma. Induction therapy consisting of cyclophosphamide, vincristine, and prednisone was commenced, according to the French Society of Pediatric Ophthalmology LMB89 protocol for large B-cell lymphoma.[1] Later immunohistochemistry showed more than 50 Epstein-Barr virus (EBV) positive cells per high power field (hpf), CD 20 positive B-cells in a background of CD 3 positive T-cells, and tumor cells in and around blood vessels [Figure 3]. These findings are consistent with the diagnosis of LyG Grade III. Ganciclovir was therefore added to her treatment, in addition to methotrexate, cytarabine, and etoposide.[2] Within a week, there was a marked reduction in tumor size on this regime.
Figure 3: Angiocentric and angiodestructive tumor cells occluding a blood vessel

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She then received two induction doses of rituximab, 1-week apart, followed by 6 maintenance doses at 3 weekly intervals. This led to complete tumor resolution on imaging.

Comment

LyG was first described by Liebow et al. in 1972, who reported the largest case series of 152 patients.[3] It is a multisystem disorder, primarily affecting the lungs, but also affects the skin, central nervous system, and kidneys. A mortality rate of 63% has been reported, due to either respiratory failure or progression to malignant lymphoma. The disease is known to be driven by EBV and is often associated with an underlying immunodeficiency.[3],[4] The lesion is graded according to the number of EBV-positive cells/hpf. Grade I lesions exhibit <5 EBV positive cells/hpf; Grade II between 5 and 50 EBV positive cells/hpf; and Grade III >50 EBV positive cells/hpf.[2] Histological features required for diagnosis include: A mixed mononuclear infiltrate of small and large lymphoid cells; CD20 positive large B-cells in a background of CD3 positive small T lymphocytes; central necrosis and positive immunohistochemistry for EBV.[5]

To date, there have been 22 reported cases of LyG with ophthalmic manifestations.[6] These include conjunctival, pupillary, choroidal, retinal, optic nerve, and orbital (including lacrimal gland) involvement.[6],[8] All but one of these cases were described in association with pulmonary or other systemic involvement. The only other report of primary orbital involvement occurred in an otherwise healthy 54-year-old man.[8] The disease is most common after the fifth decade and is very rare is children. There are three previously reported cases of pediatric ophthalmic LyG, in children of ages 7, 8, and 13. Two had neuro-ophthalmologic manifestations and one had choroidal infiltrates.[3],[6],[9] All three were secondary manifestations of primary pulmonary LyG. Due to the rarity of the condition, there is no consensus regarding optimal management. Options include corticosteroids, chemotherapeutic agents (singly or in combination), antiviral agents, radiotherapy, as well as newer agents like rituximab.[10] To our knowledge, this is the youngest reported case of LyG and only the second with primary orbital involvement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Patte C, Auperin A, Michon J, Behrendt H, Leverger G, Frappaz D, et al. The Société Française d'Oncologie Pédiatrique LMB89 protocol: Highly effective multiagent chemotherapy tailored to the tumor burden and initial response in 561 unselected children with B-cell lymphomas and L3 leukemia. Blood 2001;97:3370-9.  Back to cited text no. 1
    
2.
Wilson WH, Kingma DW, Raffeld M, Wittes RE, Jaffe ES. Association of lymphomatoid granulomatosis with Epstein-Barr viral infection of B lymphocytes and response to interferon-alpha 2b. Blood 1996;87:4531-7.  Back to cited text no. 2
    
3.
Liebow AA, Carrington CR, Friedman PJ. Lymphomatoid granulomatosis. Hum Pathol 1972;3:457-558.  Back to cited text no. 3
[PUBMED]    
4.
Katzenstein AL, Peiper SC. Detection of Epstein-Barr virus genomes in lymphomatoid granulomatosis: Analysis of 29 cases by the polymerase chain reaction technique. Mod Pathol 1990;3:435-41.  Back to cited text no. 4
    
5.
Katzenstein AL, Doxtader E, Narendra S. Lymphomatoid granulomatosis: Insights gained over 4 decades. Am J Surg Pathol 2010;34:e35-48.  Back to cited text no. 5
    
6.
Pradeep TG, Cannon P, Dodd T, Selva D. Lacrimal gland involvement in lymphomatoid granulomatosis and review of the literature. J Ophthalmol 2010;2010: pii: 358121.  Back to cited text no. 6
    
7.
Pearson AD, Craft AW, Howe JM. Choroidal involvement in lymphomatoid granulomatosis. Br J Ophthalmol 1991;75:688-9.  Back to cited text no. 7
    
8.
Araki F, Mimura T, Fukuoka S, Tsuji H, Izutsu K, Yamamoto H, et al. Primary orbital lymphomatoid granulomatosis. Br J Ophthalmol 2009;93:554-6.  Back to cited text no. 8
    
9.
Moertel CL, Carlson-Green B, Watterson J, Simonton SC. Lymphomatoid granulomatosis after childhood acute lymphoblastic leukemia: Report of effective therapy. Pediatrics 2001;107:E82.  Back to cited text no. 9
    
10.
Jordan K, Grothey A, Grothe W, Kegel T, Wolf HH, Schmoll HJ. Successful treatment of mediastinal lymphomatoid granulomatosis with rituximab monotherapy. Eur J Haematol 2005;74:263-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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