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| Year : 2002 | Volume
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| Issue : 3 | Page : 393-396 |
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| Esosinophilic granuloma of spine |
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GB Shah, MP Patel, PR Patel
Sheth V.S.General Hospital and Smt.N.H.L. Municipal Medical College, Ahmedabad 380 006, India
Click here for correspondence address and email
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Keywords: Eosinophilic Granuloma, Histiocytosis X, Vertebra Plana
How to cite this article:
Shah G B, Patel M P, Patel P R. Esosinophilic granuloma of spine. Indian J Radiol Imaging 2002;12:393-6 |
 Introduction | |  |
Eosinophilic Granuloma is not a common pathological process in the spine. The thoracic and lumbar regions are affected more. It can present in a moderate form like Hand-Schuller-Christian Disease to the severe form as Letterer-Seiwe Disease. Sometimes it is difficult to diagnose it on clinical and radiological grounds. Histopathological examination confirms the diagnosis, however in some of the patients that too is difficult [1].
Here, we present two patients of Eosinophilic Granuloma; one in the body of C5 vertebra and the other in the body of L5 vertebra.
| Material and Methods (Case History) | | |
Patient No. 1
A 11 years old child, physically active, healthy, had six weeks history of pain in the neck on the posterior aspect. Later on he also had paraspinal spasms. He was treated with analgesics by his family physician.
In February '2000 the patient reported to this institution where spinous physical examination revealed tenderness at C5-6 processes with para-spinal spasm and decreased range of motion of the cervical spine.
Neurologically both the upper and lower limbs were normal. Routine laboratory reports were with in normal limits. He was subjected to radiological examination with plain radiographs followed by a spiral CT scan.
The radiographs showed collapsed body of C5 with intact posterior complex [Figure - 1] and [Figure - 2]. CT scan showed a destructive lesion in body of C5 with marginal involvement of the left pedicle [Figure - 3] and [Figure - 4]. Laminae and joints were normal. No evidence of paraspinal soft tissue mass or involvement of adjacent vertebral bodies was seen
The patient was subjected to surgery with anterior approach. Corpectomy of C5 was done and autologous iliac bone graft was placed for interbody fusion. Post-operative recovery was uneventful. On follow-up after 10 weeks, the patient had good consolidation of the graft on radiograph [Figure - 5] and [Figure - 6]. Clinically he was totally symptom free and fully active.
Per-operatively macroscopic examination of the lesion showed loose, dark bluish, friable, moderately vascular tissue. The histopathological examination revealed the characteristic findings of Histiocytic or Multinucleated Giant cells along with Eosinophils, Reticulo-Endothelial cells and Lymphocytes, suggestive of Eosinophilic Granuloma
Patient No. 2
A 30 years old man, physically active bank officer by profession had a history of low backache for six months for which he had been seen by his family physician and later on by a consultant physician. He was treated for his low backache with analgesics and rubefacient oils before reporting to this institution for further management.
On physical examination he had stiffness and tenderness over the lumbosacral region with decreased flexion and rotation of the lumbar spine. He had free straight leg raising with no neurological deficit in both lower limbs.
Routine laboratory reports were within normal limits. He was subjected to radiological examination with plain radiographs [Figure - 7] and [Figure - 8] initially followed by a spiral CT scan with CT guided biopsy of the lesion [Figure - 9]
Histopathological examination revealed a diagnosis of Eosinophilic Granuloma. He was treated conservatively with analgesics and back support. Gradually he improved clinically and was totally symptom free after a duration of six months.
| Discussion | | |
In 1953 Lichtenstein introduced the term Histiocytosis X, which has histiocytic infiltration of tissues as the predominant pathological process [1]. The three major conditions in this category are 1) Mild form: Eosinophilic Granuloma. 2) Moderate form: Hand-Schuller-Christian Disease. 3) Severe form: Letterer-Seiwe Disease. A clear distinction among these three entities is not always possible on clinico-radiological manifestations [1].
Eosinophilic Granuloma first described by Jaffe and Lichtenstein in 1944, is certainly benign, resembling more an inflammatory process than neoplasm. An infectious cause, perhaps viral, is given some credence as a result of the self-limiting nature of the process in certain individuals and therapeutic effect of antibiotics and steroids. Some supporting data are available on metabolic and genetic factors and immunodeficiency as pathogenetic mechanisms, but in general such evidence is meager [1].
Eosinophilic Granuloma is characterized by Single or multiple skeletal lesions occurring predominantly in children, adolescents and young adults. It represents 70% of the total number of causes of Histiocytosis X and is more common in men than women. Clinical manifestations include local pain, tenderness and there may be a palpable soft tissue mass [2]. Fever and leukocytosis may also be apparent. The common sites are the skull, mandible, ribs, spine and long bones, particularly and the femur and humerus [1].
Of all the skeletal manifestations of Eosinophilic Granuloma, it is the changes of the spine that have received greatest attention. Vertebral destruction can lead to a flattened vertebral body, termed "Vertebra Plana", a finding, which is much more frequent in children than adults [3],[4]. Eosinophilic Granuloma can produce bubbly, lytic, expansile lesions of both the body and posterior elements. The intervertebral disc is usually normal. The thoracic and lumbar spine involvement is more common. Rarely neurologic manifestations ensue [1].
The gross pathologic abnormalities of Eosinophilic Granuloma include a soft, faintly yellow, hemorrhagic lesion consisting of reticulum cells, multi-nucleated giant cells, eosinophils, lymphocytes and plasma cells [1],[5].
A single lytic defect must be differentiated from neoplastic and inflammatory lesions as well as fibrous dysplasia. Multiple lytic lesions may simulate infection, metastasis, lymphoma, leukemia, hyper-parathyroidism with brown tumors and Gaucher's disease [1].
Eosinophilic Granuloma lesions may resolve spontaneously at a rate unaffected by the mode of therapy, which include partial or complete surgical excision, radiation therapy, chemotherapy, steroids, alone or in combination [1],[6],[7]. Surgery is indicated when neurologic affection is found [1],[8]. In rest of the patients, a typical healing response of vertebra plana is found with residual bone sclerosis and coarsening of the trabecular pattern and some times "bone within bone" appearance of interbody osseous fusion [1].
The prognosis in general is related to location and extent of organ involvement. The greater the number of tissues or systems that are affected, the poorer is the prognosis, especially if the liver, lung or hemopoietic systems are involved. The prognosis is also related to the age of the patient at the time of the onset; the younger the patient, the poorer the prognosis [1].
| References | | |
| 1. | Resnick. Orthopedics: Diagnosis of Bone and Joint Disorders. 3rd edition. 1994; volume 4; p2429-2439.  |
| 2. | Agrawal V; Nityanand S. Langerhans Cell Histiocytosis. Journal of Association of Physicians of India. Mar 2000 48; (3); p 346 - 8 ISSN: 0004- 5772. |
| 3. | Floman Y; Bar-On E; Mosheiff R; Mirovsky Y; Robin GC; Ramu N. Eosinophilic Granuloma of Spine. Journal of Pediatric Orthopedics. Part B (United States). Oct 1997 6; (4); p260 - 5 ISSN: 1060 - 152X. |
| 4. | C Villas et al. Eosinophilic Granuloma of the Spine with and without Vertebral Plana; long term follow up of six cases, Journal of Spinal Disorders, 1993 6; (3); p260 - 8. |
| 5. | Katz RL; Silva EG; DeSantos LA; Lukeman JM. Diagnosis of Eosinophilic Granuloma of Bone by Cytology, Histology and Electron microscopy of transcutaneous bone-aspiration biopsy. Journal of Bone and Joint Surgery (United States). Dec 1980; 62 (8); p1284 - 90. |
| 6. | Scarpinati M; Artico M; Artizzu S. Spinal Cord Compression by Eosinophilic Granuloma of the Cervical Spine. Neurosurgical Review (Germany). 1995 18; (3); p209 - 12 ISSN: 0344 - 5607. |
| 7. | Seimon LP; Eosinophilic Granuloma of Spine. Journal of Pediatric Orthopedics. 1981 1; (4); p371 -6. |
| 8. | Kamimura M; Kinoshita T; Itoh H; Yuzama Y; Takahashi J; Ohtsuka K. Eosinophilic Granuloma of Spine: Early Spontaneous Disappearance of Tumor detected on Magnetic Resonance Imaging. Journal of Neurosurgery (United States). Oct 2000 93; (2 suppl); p312 - 6 ISSN: 0022 - 3085. |
Correspondence Address:
G B Shah
12/Gyankunj Society opp.L.G..Hospital, Maninagar, Ahmedabad 380 008
India
 Source of Support: None, Conflict of Interest: None  | Check |
Figures
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9] |
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| This article has been cited by | | 1 |
Eosinophilic granuloma presenting with local osteolysis in an adult lumbar spine |
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| Nakamura, H., Nagayama, R. | | Journal of Clinical Neuroscience. 2008; 15(12): 1398-1400 | | [Pubmed] | |
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