IOURNAL Of l h e
AmeRICaN
AAB
AcaDemY
OF
DerMaTOLOGY VOLUME 26 III
II
III
NUMBER 5 II [I[H ?
[[m[
PART 2
MAY 1992
I
Distribution of adhesion molecules, IgE, and CD23 in a case of angiolymphoid hyperplasia with eosinophilia Peter yon den Driesch, MD, a Matthias Gruschwitz, MD, a Herrmann Schell, MD, a and Wolfram Sterry, M D b Erlangen and Ulm, Federal Republic of Germany Angiolymphoid hyperplasia with eosinophilia developed in a 13-year-old boy. The immune phenotype of infiltrating cells and the distribution of adhesion molecules of the integrin, immunoglobulin, and selectin families were analyzed with monoclonal antibodies. The infiltrate consisted mainly of helper lymphocytes, monocytes, eosinophils, CD1 + dendritic cells, and mast cells. A CD23/Fce receptor was present on 40% of these cells, and surface bound IgE was present on 30% of these cells. The latter was found on all cell types. A cellular adhesion molecule analysis revealed that the proliferating endothelial cells were expressing constitutive ICAM-1, LFA-3, VLA-1, VLA-3, VLA-5, a6, and/33-integrin chain as well as activation-dependentVLA-2, VCAM- I, and human lymphocyte antigen-DR. Theinfiltrating cells expressed LFA-1 and CD2, the correlating ligands for ICAM-1 and LFA-3. Our studies support previous observations of an unusual IgE-mediated immune reaction, and suggest an additional pathogenic role for adhesion events in the development of the pathognomonic cellular composition in angiolymphoid hyperplasia with eosinophilia. (J AM ACADDERMATOL 1992;26:799-804.) Angiolymphoid hyperplasia with eosinophilia (ALHE), a term proposed by Wells and Whimster 1 and used in subsequent reports, 2, 3 describes a subcutaneous angioproliferating tumor with a characteristic inflammatory infiltrate that consists mainly of lymphocytes and eosinophils. Epithelioid hemangioma was used synonymously by Enzinger and Weiss 4 to describe the characteristic histologic appearance of the proliferating plump epithelioid or histiocytoid5 endothelial cells with rounded nuclei, abundant acidophilic cytoplasm, and intracytoplasmic vacuoles. A related condition was described in 1948 by
From the Department of Dermatology, University Erlangen-N~irnberg,a and the Department of Dermatology, University of Ulm.6 Supported by the J. and F. Marohn Foundation and in part by Bundesministeriumfilr Forsehung und Technologic. Reprint requests: Peter yon den Drieseh, MD, DermatologiseheUniversit~tsldinik, Hartmannstr. 14, D-8520 Erlangen, Federal Republic of Germany. 16/4/32425
Kimura et al. 6 in young Japanese men; it is now termed Kimura's disease (KD). 7 Many subsequent reports debated the relationship between these diseases and suggested characteristic differences,s'l~ Nevertheless, as in this case (Table I), it may be difficult to classify a single case because of the close relationship between these diseases. We use the term ALHE as best characterizing the disease in this patient. Googe and Mihm s stated in 1987 that the prominent vessels in KD closely resemble high endothelial venules (HEV). In normal lymph nodes these vessels express receptors involved in lymphocyte homing pathways, the socalled cellular adhesion molecules.ll, 12The pathognomonic cellular inflammatory infiltrate suggests that cell-cell adhesions play a role in the pathogenesis of ALHE/KD. Therefore we investigated the expression of these molecules in a case of A L H E immunohistochemically with a battery of monoclonal antibodies. Earlier investigations disclosed the presence of IgE in the center of lymphoid follicles in KD l~, 14
799
800
Journal of the American Academy of Dermatology
von den Driesch et al.
T a b l e I. Criteria for the discrimination of A L H E and KD 8-1~ ALHE
........
Midd[e-aged woman No lymph node involvement Normal serum IgE Blood eosinophilia rare No organ manifestation Histologic findings Proliferation of epithelioid endothelial cells, multilayered More variable infiltrate No fibrosis
Present case
[
X X
(x) X
X Variable X X
KD
Young man Frequent lymph node involvement Elevated serum IgE Characteristic eosinophilia Organ manifestation (i.e., renal) Monolayered HEV-like ECs Lymphocytic predominance with formation of lymph follicles Early fibrosis
HE V, High endothelialvenule,
and near the vessel walls in ALHE. t5 This led to the hypothesis that A L H E / K D is an unusual manifestation of an immediate type of allergy. To reevaluate this theory, we also investigated the distribution of IgE and CD23/FcE receptors with single- and double-staining immunohistochemical procedures. CASE REPORT A 13-year-old boy had an asymptomatic tumor on his right preauricular area for 3 months. Atopic diseases had appeared in first-degree relatives but not in the patient. On physical examination, firm, confluent, subcutaneous tumors with intense arterial pulsation were palpable in the left supra- and preauricular regions. The overlying skin was slightly erythematous. Regional lymph nodes were not enlarged. Some clinical signs of atopy were present: white dermatographism, xerosis, keratosis pilaris, and Dennie-Morgan folds. A complete blood count was normal except for eosinophilia of 25% (1000/mm3). Results of liver and kidney function tests, serum electrolytes, serum protein electrophoresis, and urine analysis were within normal limits. Serum IgE level was 98 IE/ml. Candida albicany was cultured from the stool and oral saliva probes. No specific IgE antibodies against C. albicans were found in a radioallergosorbent test. Selective angiography revealed tortuosity of the external carotid artery without evidence of arteriovenous shunts. Prominent anastomoses were present, with superficial temporal and external occipital arteries showing similar tortuosity (Fig. 1). A histologic examination of a biopsy specimen of the preauricular area revealed nodular infiltrations around a central artery, which showed intimal proliferation and a disrupted internal elastic lamina. This was surrounded by numerous capillary spaces of varying diameter lined by large endothelial cells (ECs) of epithelloid appearance
(Fig. 2). A dense cellular infiltrate composed mainly of small and medium-sized lymphocytes, macrophages, and numerous eosinophils filled the intervascular areas. No lymphoid follicles or nuclear abnormalities could be found. Toluidine blue staining revealed that about 4% of the infiltrating cells (ICs) had cytoplasmatic granules. Results of direct immunofluorescence staining with rabbit antisera against human IgA, IgM, IgG, C3, C lq, and fibrinogen were negative. Complete excision of the involved area was performed, and no relapse occurred in 18 months. For 6 months after the excision, recurrent episodes of blood eosinophilia up to 35% occurred without clinical symptoms. RESULTS Methods
Immunostains were performed on the cryoconserved excised material. 6/~m sections were stained with the alkaline phosphatase anti-alkaline phosphatase (APAAP) methodJ 6 Leu-4, Leu-3a, Leu2a, Leu-M3, Leu- 12, Leu- 15, a - h u m a n lymphocyte antigen ( H L A ) - D R , and a-interleukin (IL)-2 receptor antibodies were obtained from Becton Dickinson, Heidelberg, Federal Republic of Germany. Additional commercially available monoclonal antibodies used were OKT6 and OKM5 (Ortho Diagnostic Systems, Neckargmtind, Federal Republic of Germany); TI]-9 and a-CD 16 (Biotech, Frankfurt, Federal Republic of Germany); a-Fce receptor, Ber-H2, 150/95, a-elastase (Dakopatts A / S , Glostrup, Denmark); IOP 49e, IOT-[6, E124.28, and GPIIIa (Immunotech S.A., Marseille, France); and a-IgE (Hybritech, San Diego, Calif.). The following monoclonal antibodies were personal gifts: TS 2/7, TS 2-18, TS 2-9, and RR 1-1 (Springer TA, Boston, Mass.); El-6 and H18/7 (Bevilaqua MP, Boston);
Volume 26 Number 5, Part 2 May 1992
Adhesion molecules and IgE in ALHE
801
Fig. 1. Selectiveangiographyof carotid artery: Tortuosity of external carotid, superficial temporal, and external occipital arteries. Fig. 2. High-powerphotomicrographof ALHE: Toluidineblue staining best demonstrates epitheloidappearance of endothelialcells. (X300.) Fig. 3. Staining for surface IgE. (Alkalinephosphataseand antialkalinephosphatase stain; X:50.) Fig. 4. Staining for ICAM-1. (Alkaline phosphatase and antialkaline phosphatase stain; X 150.) J143 (Klein CE, Ulm, Federal Republic of Germany); 10Gll (yon den Borme AEG, Amsterdam, Netherlands); B-5G10 (Hemler ME, Boston); GOH3 (Sonnenberg A, Amsterdam, Netherlands); Ki-M8 (Radszun H J, Kiel, Federal Republic of Germany); and 27E10 (Sorg C, Mtinster, Federal Republic of Germany). CD designation and specificity of these antibodies are shown in Table II. Staining for each antibody was performed on at least three slides of different sites of the tumor. Indirect immunofluorescence studies were performed as described previously. 17In double-staining experiments purified murine monoclonal antibodies were detected by TRITC conjugated goat antimouse IgG (Dianova, Hamburg, Federal Republic of Germany), and a polyclonal rabbit IgE antibody
was detected by FITC conjugated antirabbit immunoglobulin (Dakopatts A/S, Glostrup, Denmark).
Cellular analysis ICs. The infiltrate was mainly (50%) composed of CD3 + CD4 + helper lymphocytes, as well as 30% Leu-M3 + or OKM5 + macrophages. CD1 + dendritic cells represented up to 20% of the infiltrate. Variable amounts of eosinophils were intermingled. CDS-bearing lymphocytes represented a minor part (
AmeRICaN
AAB
AcaDemY
OF
DerMaTOLOGY VOLUME 26 III
II
III
NUMBER 5 II [I[H ?
[[m[
PART 2
MAY 1992
I
Distribution of adhesion molecules, IgE, and CD23 in a case of angiolymphoid hyperplasia with eosinophilia Peter yon den Driesch, MD, a Matthias Gruschwitz, MD, a Herrmann Schell, MD, a and Wolfram Sterry, M D b Erlangen and Ulm, Federal Republic of Germany Angiolymphoid hyperplasia with eosinophilia developed in a 13-year-old boy. The immune phenotype of infiltrating cells and the distribution of adhesion molecules of the integrin, immunoglobulin, and selectin families were analyzed with monoclonal antibodies. The infiltrate consisted mainly of helper lymphocytes, monocytes, eosinophils, CD1 + dendritic cells, and mast cells. A CD23/Fce receptor was present on 40% of these cells, and surface bound IgE was present on 30% of these cells. The latter was found on all cell types. A cellular adhesion molecule analysis revealed that the proliferating endothelial cells were expressing constitutive ICAM-1, LFA-3, VLA-1, VLA-3, VLA-5, a6, and/33-integrin chain as well as activation-dependentVLA-2, VCAM- I, and human lymphocyte antigen-DR. Theinfiltrating cells expressed LFA-1 and CD2, the correlating ligands for ICAM-1 and LFA-3. Our studies support previous observations of an unusual IgE-mediated immune reaction, and suggest an additional pathogenic role for adhesion events in the development of the pathognomonic cellular composition in angiolymphoid hyperplasia with eosinophilia. (J AM ACADDERMATOL 1992;26:799-804.) Angiolymphoid hyperplasia with eosinophilia (ALHE), a term proposed by Wells and Whimster 1 and used in subsequent reports, 2, 3 describes a subcutaneous angioproliferating tumor with a characteristic inflammatory infiltrate that consists mainly of lymphocytes and eosinophils. Epithelioid hemangioma was used synonymously by Enzinger and Weiss 4 to describe the characteristic histologic appearance of the proliferating plump epithelioid or histiocytoid5 endothelial cells with rounded nuclei, abundant acidophilic cytoplasm, and intracytoplasmic vacuoles. A related condition was described in 1948 by
From the Department of Dermatology, University Erlangen-N~irnberg,a and the Department of Dermatology, University of Ulm.6 Supported by the J. and F. Marohn Foundation and in part by Bundesministeriumfilr Forsehung und Technologic. Reprint requests: Peter yon den Drieseh, MD, DermatologiseheUniversit~tsldinik, Hartmannstr. 14, D-8520 Erlangen, Federal Republic of Germany. 16/4/32425
Kimura et al. 6 in young Japanese men; it is now termed Kimura's disease (KD). 7 Many subsequent reports debated the relationship between these diseases and suggested characteristic differences,s'l~ Nevertheless, as in this case (Table I), it may be difficult to classify a single case because of the close relationship between these diseases. We use the term ALHE as best characterizing the disease in this patient. Googe and Mihm s stated in 1987 that the prominent vessels in KD closely resemble high endothelial venules (HEV). In normal lymph nodes these vessels express receptors involved in lymphocyte homing pathways, the socalled cellular adhesion molecules.ll, 12The pathognomonic cellular inflammatory infiltrate suggests that cell-cell adhesions play a role in the pathogenesis of ALHE/KD. Therefore we investigated the expression of these molecules in a case of A L H E immunohistochemically with a battery of monoclonal antibodies. Earlier investigations disclosed the presence of IgE in the center of lymphoid follicles in KD l~, 14
799
800
Journal of the American Academy of Dermatology
von den Driesch et al.
T a b l e I. Criteria for the discrimination of A L H E and KD 8-1~ ALHE
........
Midd[e-aged woman No lymph node involvement Normal serum IgE Blood eosinophilia rare No organ manifestation Histologic findings Proliferation of epithelioid endothelial cells, multilayered More variable infiltrate No fibrosis
Present case
[
X X
(x) X
X Variable X X
KD
Young man Frequent lymph node involvement Elevated serum IgE Characteristic eosinophilia Organ manifestation (i.e., renal) Monolayered HEV-like ECs Lymphocytic predominance with formation of lymph follicles Early fibrosis
HE V, High endothelialvenule,
and near the vessel walls in ALHE. t5 This led to the hypothesis that A L H E / K D is an unusual manifestation of an immediate type of allergy. To reevaluate this theory, we also investigated the distribution of IgE and CD23/FcE receptors with single- and double-staining immunohistochemical procedures. CASE REPORT A 13-year-old boy had an asymptomatic tumor on his right preauricular area for 3 months. Atopic diseases had appeared in first-degree relatives but not in the patient. On physical examination, firm, confluent, subcutaneous tumors with intense arterial pulsation were palpable in the left supra- and preauricular regions. The overlying skin was slightly erythematous. Regional lymph nodes were not enlarged. Some clinical signs of atopy were present: white dermatographism, xerosis, keratosis pilaris, and Dennie-Morgan folds. A complete blood count was normal except for eosinophilia of 25% (1000/mm3). Results of liver and kidney function tests, serum electrolytes, serum protein electrophoresis, and urine analysis were within normal limits. Serum IgE level was 98 IE/ml. Candida albicany was cultured from the stool and oral saliva probes. No specific IgE antibodies against C. albicans were found in a radioallergosorbent test. Selective angiography revealed tortuosity of the external carotid artery without evidence of arteriovenous shunts. Prominent anastomoses were present, with superficial temporal and external occipital arteries showing similar tortuosity (Fig. 1). A histologic examination of a biopsy specimen of the preauricular area revealed nodular infiltrations around a central artery, which showed intimal proliferation and a disrupted internal elastic lamina. This was surrounded by numerous capillary spaces of varying diameter lined by large endothelial cells (ECs) of epithelloid appearance
(Fig. 2). A dense cellular infiltrate composed mainly of small and medium-sized lymphocytes, macrophages, and numerous eosinophils filled the intervascular areas. No lymphoid follicles or nuclear abnormalities could be found. Toluidine blue staining revealed that about 4% of the infiltrating cells (ICs) had cytoplasmatic granules. Results of direct immunofluorescence staining with rabbit antisera against human IgA, IgM, IgG, C3, C lq, and fibrinogen were negative. Complete excision of the involved area was performed, and no relapse occurred in 18 months. For 6 months after the excision, recurrent episodes of blood eosinophilia up to 35% occurred without clinical symptoms. RESULTS Methods
Immunostains were performed on the cryoconserved excised material. 6/~m sections were stained with the alkaline phosphatase anti-alkaline phosphatase (APAAP) methodJ 6 Leu-4, Leu-3a, Leu2a, Leu-M3, Leu- 12, Leu- 15, a - h u m a n lymphocyte antigen ( H L A ) - D R , and a-interleukin (IL)-2 receptor antibodies were obtained from Becton Dickinson, Heidelberg, Federal Republic of Germany. Additional commercially available monoclonal antibodies used were OKT6 and OKM5 (Ortho Diagnostic Systems, Neckargmtind, Federal Republic of Germany); TI]-9 and a-CD 16 (Biotech, Frankfurt, Federal Republic of Germany); a-Fce receptor, Ber-H2, 150/95, a-elastase (Dakopatts A / S , Glostrup, Denmark); IOP 49e, IOT-[6, E124.28, and GPIIIa (Immunotech S.A., Marseille, France); and a-IgE (Hybritech, San Diego, Calif.). The following monoclonal antibodies were personal gifts: TS 2/7, TS 2-18, TS 2-9, and RR 1-1 (Springer TA, Boston, Mass.); El-6 and H18/7 (Bevilaqua MP, Boston);
Volume 26 Number 5, Part 2 May 1992
Adhesion molecules and IgE in ALHE
801
Fig. 1. Selectiveangiographyof carotid artery: Tortuosity of external carotid, superficial temporal, and external occipital arteries. Fig. 2. High-powerphotomicrographof ALHE: Toluidineblue staining best demonstrates epitheloidappearance of endothelialcells. (X300.) Fig. 3. Staining for surface IgE. (Alkalinephosphataseand antialkalinephosphatase stain; X:50.) Fig. 4. Staining for ICAM-1. (Alkaline phosphatase and antialkaline phosphatase stain; X 150.) J143 (Klein CE, Ulm, Federal Republic of Germany); 10Gll (yon den Borme AEG, Amsterdam, Netherlands); B-5G10 (Hemler ME, Boston); GOH3 (Sonnenberg A, Amsterdam, Netherlands); Ki-M8 (Radszun H J, Kiel, Federal Republic of Germany); and 27E10 (Sorg C, Mtinster, Federal Republic of Germany). CD designation and specificity of these antibodies are shown in Table II. Staining for each antibody was performed on at least three slides of different sites of the tumor. Indirect immunofluorescence studies were performed as described previously. 17In double-staining experiments purified murine monoclonal antibodies were detected by TRITC conjugated goat antimouse IgG (Dianova, Hamburg, Federal Republic of Germany), and a polyclonal rabbit IgE antibody
was detected by FITC conjugated antirabbit immunoglobulin (Dakopatts A/S, Glostrup, Denmark).
Cellular analysis ICs. The infiltrate was mainly (50%) composed of CD3 + CD4 + helper lymphocytes, as well as 30% Leu-M3 + or OKM5 + macrophages. CD1 + dendritic cells represented up to 20% of the infiltrate. Variable amounts of eosinophils were intermingled. CDS-bearing lymphocytes represented a minor part (
