Multicentric Reticulohistiocytosis

Back

Practice Essentials

Multicentric reticulohistiocytosis (MRH) is a rare disease in which papulonodular skin lesions containing a proliferation of true histiocytes (macrophages) are associated with arthritis that primarily affects the interphalangeal joints.[1, 2] (see the image below). MRH is not life threatening and, after an average course of 7-8 years, the disease often goes into remission. However, in 45% of cases, the associated arthritis may cause severe joint destruction known as arthritis mutilans.



View Image

Nodules on a hand with deformed joints from arthritis due to multicentric reticulohistiocytosis.

In addition to the joints, MRH can involve the bones, tendons, and muscles, as well as almost any organ (eg, the eyes, larynx, thyroid, salivary glands, bone marrow, heart, lungs, kidneys, liver, gastrointestinal tract).

MRH has been associated with an underlying internal malignancy in about one fourth of cases, suggesting that it may be a paraneoplastic condition. The proliferating histiocytes in this disease are thought to be reactive and are not themselves malignant.

Signs and symptoms

Joint involvement primarily manifests with symmetric polyarthritis with a predilection for the distal interphalangeal joints. However, several other joints may be affected. The rates of distribution of joint disease are as follows:

Skin involvement generally manifests with translucent reddish-brown to flesh-colored papulonodules varying from 1-2 mm to 1 cm in diameter or larger. Lesions may be isolated from one another, or they may be clustered, sometimes giving them a cobblestone appearance.

The lesions are usually nontender, although some patients may complain of pruritus, which can be diffuse. The nodules grow slowly and rarely ulcerate. Infiltrated plaques may resemble mucinosis. Although MRH lesions have a predilection for the hands and face, they may occur on any surface of the body.

See Presentation for more detail.

Diagnosis

No laboratory studies are specific for MRH. Findings, however, are as follows:

Histiologic studies in MRH reveal the following:

One study demonstrated aberrant expression of CD10 (a 90- to 110-kd cell surface zinc-dependent metalloprotease) in skin and synovial multinucleated giant cells in patients with MRH, whereas expression of CD10 was not detected in other histiocytic lesions, including skin samples of granuloma annulare, giant-cell tendon sheath tumor, ruptured epidermoid cyst, sarcoidosis, xanthogranuloma, and synovial samples of rheumatoid arthritis and pigmented villonodular synovitis.[4]

In a synovial biopsy, lipid-laden giant cells and histiocytes are similar to those seen on skin biopsy; histiocytes are sometimes found after blind synovial biopsies in patients who have unclassified arthritis but no skin lesions.[5]

Routine radiographs of joints may be helpful in the diagnosis of MRH. Changes, which may develop rapidly, are most commonly seen in the proximal or distal interphalangeal joints.

See Workup for more detail.

Management

Although no consistently effective treatment is known for MRH, the associated arthritis may respond to therapy with nonsteroidal anti-inflammatory drugs (NSAIDs).

Systemic corticosteroids, such as prednisone, and/or cytotoxic agents—particularly cyclophosphamide,[6, 7] chlorambucil,[6] and methotrexate,[8, 9, 7, 10] —may also affect the inflammatory response, as well as prevent further joint destruction and cause skin lesions to regress. Azathioprine, cyclosporine, antimalarials, bisphosphonates, leflunomide, and tumor necrosis factor–alpha (TNF-alpha) antagonists have also been used effectively.[11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26] More recently, a case of MRH responsive to tocilizumab has been reported,[27] and carbon dioxide laser has been reported to improve cosmetically disfiguring facial lesions of MRH.[28]

See Treatment and Medication for more detail.

For patient education resources, see Arthritis.

Pathophysiology

The pathogenesis of MRH is unknown but probably has an immunologic basis. Increased interleukin-12, interleukin-1b, interleukin-6, and urokinase have been described and are thought to play a role in bone destruction.[29, 30, 31]

Some studies have demonstrated increased levels of tumor necrosis factor (TNF)–alpha in the blood and in the tissue.[11, 12] A report on one patient with MRH described overexpression of monocyte chemoattractant protein–1 (MCP-1), which is stimulated by TNF-alpha, in the serum and lesional epidermis. In this patient, serum levels of MCP-1 decreased with treatment. The authors hypothesized that MCP-1 may play a role in attracting histiocytes and giant cells in patients with MRH.[32]

In addition, increased osteoclastic activity has been implicated in the pathogenesis of MRH, and synovial macrophages in patients with MRH may possess the ability to differentiate into osteoclasts.[33] These findings may help explain the success of bisphosphonate treatment in some cases.[33, 34]

Etiology

The cause of MRH is unknown, but various associated diseases have been reported in patients with MRH.

Malignancy is the most commonly recognized association with the disorder, having been reported in multiple patients with MRH (perhaps as many as 25-33%); MRH precedes the development of cancer in 73% of these cases. No specific site or type of malignancy has been identified as most commonly found with MRH, and most of the reported specific cancer types have been reported less than 5 times each in the literature.

Reported malignancies include the following:

Because MRH is rare, a reporting bias exists in the literature toward those cases with underlying malignancy, especially previously unreported malignancies. Some of these associations may be a coincidence.

The activity of the arthritis and skin lesions in MRH may or may not correlate with the eradication of the cancer, unlike some paraneoplastic disorders in which removal of the malignancy can produce improvement in the paraneoplastic findings.

Other conditions associated with MRH include the following:

MRH has been reported in a patient with both Sjögren syndrome and systemic sclerosis.[43]

Epidemiology

Worldwide, MRH is very rare and there is no published data on incidence and prevalence. MRH has largely been reported in single case studies, mostly in Western countries and Japan.[43] The average dermatologist, rheumatologist, or orthopedist will see at most 1-2 cases in an entire career.

MRH affects all races, but about 88% of the reported cases have been in white patients. Like many other rheumatologic diseases, females are affected more often than men. The ratio of women to men for MRH has been reported as either 2:1 or 3:1.

Although MRH can occur at any age, but it has been reported primarily in middle-aged adults, with a mean age of 43 years. There are rare reports of MRH occurring during childhood.

Prognosis

MRH is not life threatening and, after an average course of 7-8 years, often goes into remission. The major morbidity of the disease is due to the associated arthritis, which primarily involves the interphalangeal joints. Although the arthritis may wax and wane, it can cause severe joint destruction known as arthritis mutilans in approximately 45% of cases. Therefore, even after the disease remits, some patients are left with deformed, crippled joints. In addition, skin lesions in MRH can result in disfigured, leonine facies.

The prognosis in MRH is also related to that of any associated malignancy. Pulmonary and cardiac involvement are other potential complications. Although these complications are rare, they may confer a poor prognosis.

If cytotoxic agents are used in the treatment of MRH, the patient should be monitored for subsequent development of a malignancy.

History

The primary manifestations of multicentric reticulohistiocytosis (MRH) are joint and skin involvement. Inflammatory joint disease is a presenting symptom in approximately 40% of cases and is the sole symptom in 45% of patients. Although the arthritis may wax and wane, it can rapidly become severe.

Approximately 30% of patients first develop skin papules and nodules (see images below), while another 25% of patients develop skin and joint manifestations at the same time. One tenth to one third of patients report pruritus.



View Image

Multiple erythematous nodules are present on the dorsal hands of this adolescent with an inflammatory arthropathy.



View Image

Multiple erythematous to brown nodules on the fingers.

Nonspecific pulmonary findings, such as pleural effusions and infiltrates, have been reported in association with MRH. Direct pulmonary involvement by MRH is extraordinarily rare but has been reported in 5 cases to date.[44]

Cardiac involvement is also extremely rare, but it has been reported in isolated cases and can manifest with myocardial involvement or pericardial disease.[45, 46, 47, 48]

There is one reported case of hepatic involvement in a patient with MRH and lung involvement.[49]

About one third of patients have constitutional symptoms, such as weakness, weight loss, and fever.

Physical Examination

Arthritis

MRH is a polyarthritis with a predilection for the distal interphalangeal joints but capable of affecting several others (see the image below). The rates of distribution are as follows:



View Image

Nodules on a hand with deformed joints from arthritis due to multicentric reticulohistiocytosis.

Cutaneous lesions

Lesions vary from papules that are 1-2 mm in diameter to nodules that are 1 cm in diameter or larger. Papules and lesions may be isolated from one another, or they may be clustered, sometimes giving them a cobblestone appearance (see the image below). Clustering of papulonodules overlying the periungual areas may result in a characteristic “coral-bead” appearance. Nodules overlying extensor joints may resemble rheumatoid nodules.



View Image

Cobblestone papules on the eyelid and papules on the forehead.

The lesions are usually nontender and may be skin colored, red, or yellowish. The nodules grow slowly and rarely ulcerate. Infiltrated plaques may resemble mucinosis.

The Koebner phenomenon has been reported, wherein trauma to the skin, including from ultraviolet (UV) radiation,[50] gives rise to new lesions.

Although MRH lesions have a predilection for the hands and face, they may occur on any surface of the body. Distribution rates are as follows:

In rare cases (9 reported to date), patients have a photodistribution of lesions simulating dermatomyositis, although it is possible that this manifestation is underrecognized. (See the images below.)[51, 52, 53]



View Image

Erythematous to brown papules overlying the right dorsal hand and wrist and erythematous to violaceous patches over the right dorsal hand and fingers.....



View Image

Erythematous to brown papules and erythematous to violaceous patches overlying the right dorsal hand and fingers, with a crusted erosion overlying the....

Malignancy is associated with MRH in approximately 25% of cases, similar to the observed frequency in dermatomyositis. The presence of features mimicking dermatomyositis in a patient with MRH, however, do not appear to increase the likelihood of malignancy.

About one third of patients have been reported to have xanthelasma, but whether this is related to MRH is unclear.[51]

Approach Considerations

No laboratory studies are specific for multicentric reticulohistiocytosis (MRH). Findings, however, are as follows:

Because some patients with MRH may have an underlying malignancy, evaluation for this is important. Patients ought to have at least a good review of systems to direct appropriate additional studies.

Imaging Studies

Radiography

Routine radiographs of joints may be helpful. Changes, which may develop rapidly, are most commonly seen in the proximal or distal interphalangeal joints. Findings can include the following:

Other modalities

Magnetic resonance imaging (MRI)[56] and computed tomography (CT) scanning[57] have been reported to be helpful, but they are not needed in most cases.

Fluorodeoxyglucose positron emission tomography (FDG-PET)/CT may be useful for identifying the characteristic features of MRH, in addition to screening for a possibly associated malignancy.[58, 59, 60]

Histologic Findings

When the skin lesions are present, skin is the easiest site from which to obtain a biopsy specimen. Histiologic studies in MRH reveal the following (see the images below):

In addition to macrophage properties, the histiocytes may have osteoclastic properties. Those of the osteoclast phenotype express osteoclast selective markers, tartrate-resistant acid phosphatase, and cathepsin K, and they respond to treatment with bisphosphonates.[4]

Stains

The cytoplasm of the histiocytes stains with PAS stain. Although positive staining with Sudan black B and scarlet red indicates the presence of lipid within these cells, they are not usually foamy to the degree found in many other histiocytic disorders.

The cells stain with the usual macrophage markers, such as lysozyme (see the image below), CD68, MAC387, and human alveolar macrophage-56 (HAM-56), as well as CD10 (multinucleated giant cells only).[4] Staining results for S-100, CD1a, CD34, factor XIIIa, or alpha-1-antitrypsin are typically negative.



View Image

Brown immunoperoxidase staining for lysozyme in histiocytes.

Approach Considerations

No therapy consistently improves multicentric reticulohistiocytosis (MRH). After an average course of 7-8 years, MRH often goes into remission, but considerable joint destruction may have already occurred. Many different drugs have been used in MRH, but patient response to therapy is difficult to determine because of the rarity of the disease, lack of controlled studies, and tendency for the remission to complicate evaluation of treatment efficacy.

Depending on its severity, MRH may limit activity. Physical therapy may prevent deformities and relieve symptoms.

Consultations with dermatologists and rheumatologists may be necessary. If internal malignancy occurs, consult with oncologists or surgeons as needed.

Patients with MRH should be monitored at regular intervals to track the activity of the disease and response to therapy.

Medical Care

Although no consistently effective treatment is known for MRH, the associated arthritis may respond to therapy with nonsteroidal anti-inflammatory drugs (NSAIDs).

Systemic corticosteroids, such as prednisone, and/or cytotoxic agents, particularly cyclophosphamide,[6, 7]  chlorambucil,[6]  and methotrexate,[8, 9, 7, 10]  may also affect the inflammatory response, as well as prevent further joint destruction and cause skin lesions to regress. Azathioprine[13, 14]  and cyclosporine[15]  are also reportedly effective in MRH.

Individual patients have reportedly responded to treatment with alendronate and other bisphosphonates.[16, 17]  Antimalarials have also been used in MRH.

Several reports have suggested that combining methotrexate with a tumor necrosis factor (TNF) ̶ alpha antagonist—such as etanercept, infliximab, or adalimumab—is more effective than the use of either alone.[11, 12, 18, 19, 20, 21]

Tocilizumab, an interleukin-6 (IL-6) receptor inhibitor, reportedly caused remission of cutaneous and articular symptoms in a 35-year-old woman whose MRH was refractory to a combination of prednisone and methotrexate.[27]

Surgical Care

Joint replacement may improve function in patients with burned-out disease that has resulted in deformity. Recently, a case of mutilating arthritis of the small joints of the hands due to MRH was reported as having been successfully managed with arthrodesis of the metacarpophalangeal joints.[61]

In the case of internal malignancies, adequate tumor removal may result in the resolution of histiocytosis.[39]

Mahajan et al reported on the case of a patient with MRH in whom confluent, disfiguring papules on the scalp, forehead, nasolabial folds, retroauricular region, and chin were successfully treated with carbon dioxide laser therapy. According to the authors, complete ablation was achieved, with no recurrence seen over an 8-month follow-up period.[28]

Medication Summary

No drug of choice is known for multicentric reticulohistiocytosis (MRH). Most patients are treated with oral prednisone, with or without a cytotoxic/immunosuppressive agent, such as methotrexate, cyclophosphamide, or chlorambucil, or a tumor necrosis factor (TNF)–alpha antagonist. Most of the previously reported therapies are as listed below.

First-line therapies include the following agents:

Second-line therapies include the following:

Prednisone (Rayos)

Clinical Context:  Prednisone is an immunosuppressant for treatment of autoimmune disorders. It may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear cell activity. It stabilizes lysosomal membranes and suppresses lymphocytes and antibody production. Although prednisone is regularly used, it has not been proven to be effective.

Prednisolone (Millipred, Orapred, Orapred ODT, Prelone)

Clinical Context:  Corticosteroids act as potent inhibitors of inflammation. They may cause profound and varied metabolic effects, particularly in relation to salt, water, and glucose tolerance, in addition to their modification of the immune response of the body.

Dexamethasone acetate (Baycadron)

Clinical Context:  This agent decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reducing capillary permeability. Dosage varies with the degree of inflammation and the size of the affected area.

Triamcinolone (Kenalog-10, Kenalog-40, Aristospan)

Clinical Context:  Triamcinolone can be used topically or injected intralesionally. It decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Indomethacin (Indocin)

Clinical Context:  Indomethacin is rapidly absorbed; metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation. This agent inhibits prostaglandin synthesis.

Ibuprofen (I-Prin, Advil, Motrin)

Clinical Context:  Ibuprofen is the drug of choice for mild to moderately severe pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Naproxen (Anaprox, Naprelan, Naprosyn)

Clinical Context:  Naproxen is used for relief of mild to moderately severe pain. It inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which is responsible for prostaglandin synthesis.

Ketoprofen

Clinical Context:  Ketoprofen is used for the relief of mild to moderate pain and inflammation. Small doses are indicated initially in patients with small body size, elderly patients, and persons with renal or liver disease. Doses of over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.

Flurbiprofen

Clinical Context:  Flurbiprofen may inhibit cyclooxygenase, thereby inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

Diclofenac (Voltaren XR, Cataflam, Cambia)

Clinical Context:  This is one of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacological studies. It is believed to inhibit the enzyme cyclooxygenase, which is essential in the biosynthesis of prostaglandins. Diclofenac can cause hepatotoxicity; hence, liver enzymes should be monitored in the first 8 weeks of treatment. It is absorbed rapidly; metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation. The delayed-release, enteric-coated form is diclofenac sodium, and the immediate-release form is diclofenac potassium.

Class Summary

These agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action may be inhibition of cyclo-oxygenase (COX) activity and prostaglandin synthesis. Other mechanisms, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions, may also exist.

Methotrexate (Rheumatrex, Trexall)

Clinical Context:  Methotrexate has an unknown mechanism of action in the treatment of inflammatory reactions; it may affect immune function. This agent ameliorates symptoms of inflammation (eg, pain, swelling, stiffness). Adjust the dose gradually to attain a satisfactory response.

Cyclophosphamide

Clinical Context:  Cyclophosphamide is chemically related to nitrogen mustards. As an alkylating agent, its mechanism of action may involve cross-linking of DNA, which may interfere with the growth of normal and neoplastic cells.

Azathioprine (Imuran, Azasan)

Clinical Context:  Azathioprine is a purine analog that inhibits the synthesis of deoxyribonucleic acid (DNA), RNA, and proteins. It may decrease the proliferation of immune cells, resulting in lower immunologic activity.

Class Summary

Cytotoxic/immunosuppressive agents inhibit key factors in the immune system that are responsible for inflammatory responses. None have been documented to be effective in MRH, except in anecdotal reports.

Leflunomide (Arava)

Clinical Context:  Leflunomide is an immunomodulatory agent. It inhibits pyrimidine synthesis, which, in turn, results in antiproliferative and anti-inflammatory effects.

Class Summary

Disease-modifying antirheumatic drugs (DMARDs) can retard or prevent disease progression and, thus, joint destruction and subsequent loss of function.

Hydroxychloroquine (Plaquenil)

Clinical Context:  Although this agent has not been demonstrated to be effective in studies, anecdotal reports suggest a possible effect. Hydroxychloroquine inhibits chemotaxis of eosinophils and locomotion of neutrophils and impairs complement-dependent antigen-antibody reactions.

Hydroxychloroquine sulfate 200 mg is equivalent to 155 mg hydroxychloroquine base and 250 mg chloroquine phosphate.

Class Summary

Derivatives of 4-aminoquinoline are active against various autoimmune disorders.

Vincristine (Vincasar PFS)

Clinical Context:  The mechanism of action of vincristine is uncertain. It may involve a decrease in reticuloendothelial cell function or an increase in platelet production.

Class Summary

Individual case reports suggest a benefit from the use of TNF-antagonists in MRH.

Adalimumab (Humira)

Clinical Context:  Adalimumab is a recombinant human immunoglobulin G1 (IgG1) monoclonal antibody specific for human TNF. It is indicated for the reduction of inflammation and the inhibition of structural damage progression in moderate to severe rheumatoid arthritis. This agent is reserved for patients who experience an inadequate response to 1 or more disease-modifying antirheumatic drugs (DMARDs).

Adalimumab can be used alone or in combination with methotrexate or other DMARDs. It binds specifically to TNF-alpha and blocks interaction with p55 and p75 cell-surface TNF receptors.

Infliximab (Remicade)

Clinical Context:  Infliximab neutralizes the cytokine TNF-alpha and inhibits it from binding to the TNF-alpha receptor. Consult a rheumatologist concerning its use.

Etanercept (Enbrel)

Clinical Context:  Etanercept is a soluble p75 TNF-receptor fusion protein (sTNFR-Ig). It inhibits TNF binding to cell-surface receptors, thereby decreasing inflammatory and immune responses.

Class Summary

Individual case reports suggest a benefit from the use of TNF-antagonists in MRH.

Alendronate (Fosamax)

Clinical Context:  Alendronate inhibits bone resorption via actions on osteoclasts or osteoclast precursors. Used to treat osteoporosis in men and women, it may reduce bone resorption and the incidence of fracture in the spine, hip, and wrist by approximately 50%.

Alendronate should be taken with a large glass of water at least 30 minutes before eating and drinking, to maximize absorption. Because of possible esophageal irritation, patients must remain upright after taking the medication. Since it is renally excreted, alendronate is not recommended for use in patients with moderate to severe renal insufficiency, ie, creatinine clearance (CrCl) below 30 mL/min or above 3 mg/dL. Consequently, its use in perirenal transplantation is limited.

Pamidronate (Aredia)

Clinical Context:  Pamidronate's main action is to inhibit the resorption of bone. The mechanism by which this inhibition occurs is not fully known. The drug is adsorbed onto calcium pyrophosphate crystals and may block the dissolution of these crystals, also known as hydroxyapatite, which are an important mineral component of bone. There is also evidence that pamidronate directly inhibits osteoclasts.

Risedronate (Actonel, Atelvia)

Clinical Context:  Risedronate is a potent aminobisphosphonate that principally acts by inhibiting osteoclastic bone resorption.

Tiludronate (Skelid)

Clinical Context:  Tiludronate is a sulfur-containing bisphosphonate of intermediate potency between etidronate and newer nitrogen-containing bisphosphonates.

Zoledronate (Reclast, Zometa)

Clinical Context:  Zoledronate inhibits bone resorption. It inhibits osteoclastic activity and induces osteoclastic apoptosis

Class Summary

These agents are analogues of pyrophosphate and act by binding to hydroxyapatite in the bone matrix, thereby inhibiting the dissolution of crystals. Bisphosphonates prevent osteoclast attachment to the bone matrix and osteoclast recruitment and viability.

Author

Alisa N Femia, MD, Assistant Professor, Ronald O Perelman Department of Dermatology, New York University Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey P Callen, MD, Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Disclosure: Received honoraria from UpToDate for author/editor; Received royalty from Elsevier for book author/editor; Received dividends from trust accounts, but I do not control these accounts, and have directed our managers to divest pharmaceutical stocks as is fiscally prudent from Stock holdings in various trust accounts include some pharmaceutical companies and device makers for i inherited these trust accounts; for: Allergen; Celgene; Pfizer; 3M; Johnson and Johnson; Merck; Abbott Laboratories; AbbVie; Procter and Gamble; Amgen.

Ronald P Rapini, MD, Professor and Chair, Department of Dermatology, The University of Texas MD Anderson Cancer Center; Distinguished Chernosky Professor and Chair of Dermatology, Professor of Pathology, University of Texas McGovern Medical School at Houston

Disclosure: Book royalties from Elsevier publishers.

Ruth Ann Vleugels, MD, MPH, Assistant Professor of Dermatology, Harvard Medical School; Associate Physician, Department of Dermatology, Brigham and Women's Hospital; Associate Physician, Department of Immunology and Allergy, Children's Hospital Boston

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Disclosure: Nothing to disclose.

Acknowledgements

Marcel E Conrad, MD Distinguished Professor of Medicine (Retired), University of South Alabama College of Medicine

Marcel E Conrad, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Association of Blood Banks, American Chemical Society, American College of Physicians, American Physiological Society, American Society for Clinical Investigation, American Society of Hematology, Association of American Physicians, Association of Military Surgeons of the US, International Society of Hematology, Society for Experimental Biology and Medicine, and Southwest Oncology Group

Disclosure: No financial interests None None

Rosalie Elenitsas, MD Herman Beerman Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology

Disclosure: Lippincott Williams Wilkins Royalty Textbook editor

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Bryan L Martin, DO Associate Dean for Graduate Medical Education, Designated Institutional Official, Associate Medical Director, Director, Allergy Immunology Program, Professor of Medicine and Pediatrics, Ohio State University College of Medicine

Bryan L Martin, DO is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Osteopathic Internists, American College of Physicians, American Medical Association, and American Osteopathic Association

Disclosure: Nothing to disclose.

Lindsay T (Morgan) Bicknell, MD University of Texas Medical School at Houston

Lindsay T Morgan is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Takeji Nishikawa, MD Emeritus Professor, Department of Dermatology, Keio University School of Medicine; Director, Samoncho Dermatology Clinic; Managing Director, The Waksman Foundation of Japan Inc

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

References

  1. Sroa N, Zirwas MJ, Bechtel M. Multicentric reticulohistiocytosis: A case report and review of the literature. Cutis. 2010 Mar. 85(3):153-5. [View Abstract]
  2. Selmi C, Greenspan A, Huntley A, Gershwin ME. Multicentric reticulohistiocytosis: a critical review. Curr Rheumatol Rep. 2015 Jun. 17 (6):511. [View Abstract]
  3. Luz FB, Gaspar AP, Ramos-e-Silva M, et al. Immunohistochemical profile of multicentric reticulohistiocytosis. Skinmed. 2005 Mar-Apr. 4(2):71-7. [View Abstract]
  4. Tashiro A, Takeuchi S, Nakahara T, Oba J, Tsujita J, Fukushi J, et al. Aberrant expression of CD10 in ground-glass-like multinucleated giant cells of multicentric reticulohistiocytosis. J Dermatol. 2010 Nov. 37(11):995-7. [View Abstract]
  5. Kroot EJ, Weel AE, Hazes JM, Zondervan PE, Heijboer MP, van Daele PL, et al. Diagnostic value of blind synovial biopsy in clinical practice. Rheumatology (Oxford). 2006 Feb. 45(2):192-5. [View Abstract]
  6. Ginsburg WW, O'Duffy JD, Morris JL, Huston KA. Multicentric reticulohistiocytosis: response to alkylating agents in six patients. Ann Intern Med. 1989 Sep 1. 111(5):384-8. [View Abstract]
  7. Liang GC, Granston AS. 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. Arthritis Rheum. 1996 Jan. 39(1):171-4. [View Abstract]
  8. Franck N, Amor B, Ayral X, et al. Multicentric reticulohistiocytosis and methotrexate. J Am Acad Dermatol. 1995 Sep. 33(3):524-5. [View Abstract]
  9. Gourmelen O, Le Loet X, Fortier-Beaulieu M, et al. Methotrexate treatment of multicentric reticulohistiocytosis. J Rheumatol. 1991 Apr. 18(4):627-8. [View Abstract]
  10. Rentsch JL, Martin EM, Harrison LC, Wicks IP. Prolonged response of multicentric reticulohistiocytosis to low dose methotrexate. J Rheumatol. 1998 May. 25(5):1012-5. [View Abstract]
  11. Kovach BT, Calamia KT, Walsh JS, Ginsburg WW. Treatment of multicentric reticulohistiocytosis with etanercept. Arch Dermatol. 2004 Aug. 140(8):919-21. [View Abstract]
  12. Lovelace K, Loyd A, Adelson D, Crowson N, Taylor JR, Cornelison R. Etanercept and the treatment of multicentric reticulohistiocytosis. Arch Dermatol. 2005 Sep. 141(9):1167-8. [View Abstract]
  13. Rudd A, Dolianitis C, Varigos G, Howard A. A case of multicentric reticulohistiocytosis responsive to azathioprine in a patient with no underlying malignancy. Australas J Dermatol. 2011 Nov. 52(4):292-4. [View Abstract]
  14. Hiramanek N, Kossard S, Barnetson RS. Multicentric reticulohistiocytosis presenting with a rash and arthralgia. Australas J Dermatol. 2002 May. 43(2):136-9. [View Abstract]
  15. Saito K, Fujii K, Awazu Y, et al. A case of systemic lupus erythematosus complicated with multicentric reticulohistiocytosis (MRH): successful treatment of MRH and lupus nephritis with cyclosporin A. Lupus. 2001. 10(2):129-32. [View Abstract]
  16. Goto H, Inaba M, Kobayashi K, et al. Successful treatment of multicentric reticulohistiocytosis with alendronate: evidence for a direct effect of bisphosphonate on histiocytes. Arthritis Rheum. 2003 Dec. 48(12):3538-41. [View Abstract]
  17. Satoh M, Oyama N, Yamada H, Nakamura K, Kaneko F. Treatment trial of multicentric reticulohistiocytosis with a combination of predonisolone, methotrexate and alendronate. J Dermatol. 2008 Mar. 35(3):168-71. [View Abstract]
  18. Sellam J, Deslandre CJ, Dubreuil F, Arfi S, Kahan A. Refractory multicentric reticulohistiocytosis treated by infliximab: two cases. Clin Exp Rheumatol. 2005 Jan-Feb. 23(1):97-9. [View Abstract]
  19. Kalajian AH, Callen JP. Multicentric reticulohistiocytosis successfully treated with infliximab: an illustrative case and evaluation of cytokine expression supporting anti-tumor necrosis factor therapy. Arch Dermatol. 2008 Oct. 144(10):1360-6. [View Abstract]
  20. Yeter KC, Arkfeld DG. Treatment of multicentric reticulohistiocytosis with adalimumab, minocycline, methotrexate. Int J Rheum Dis. 2013 Feb. 16(1):105-6. [View Abstract]
  21. De Knop KJ, Aerts NE, Ebo DG, Van Offel JF, Stevens WJ, De Clerck LS. Multicentric reticulohistiocytosis associated arthritis responding to anti-TNF and methotrexate. Acta Clin Belg. 2011 Jan-Feb. 66(1):66-9. [View Abstract]
  22. Cash JM, Tyree J, Recht M. Severe multicentric reticulohistiocytosis: disease stabilization achieved with methotrexate and hydroxychloroquine. J Rheumatol. 1997 Nov. 24(11):2250-3. [View Abstract]
  23. Lonsdale-Eccles AA, Haworth AE, McCrae FC, Young-Min SA. Successful treatment of multicentric reticulohistiocytosis with leflunomide. Br J Dermatol. 2009 Aug. 161(2):470-2. [View Abstract]
  24. Shannon SE, Schumacher HR, Self S, Brown AN. Multicentric reticulohistiocytosis responding to tumor necrosis factor-alpha inhibition in a renal transplant patient. J Rheumatol. 2005 Mar. 32(3):565-7. [View Abstract]
  25. Broadwell AW, Calamia KT, Kransdorf MJ, Ginsburg WW. Healing of erosive disease in multicentric reticulohistiocytosis. J Rheumatol. 2010 Jun. 37(6):1366-7. [View Abstract]
  26. Mavragani CP, Batziou K, Aroni K, Pikazis D, Manoussakis MN. Alleviation of polyarticular syndrome in multicentric reticulohistiocytosis with intravenous zoledronate. Ann Rheum Dis. 2005 Oct. 64(10):1521-2. [View Abstract]
  27. Pacheco-Tena C, Reyes-Cordero G, Ochoa-Albíztegui R, Ríos-Barrera V, González-Chávez SA. Treatment of multicentric reticulohistiocytosis with tocilizumab. J Clin Rheumatol. 2013 Aug. 19(5):272-6. [View Abstract]
  28. Mahajan RS, Shah AC, Nagar A, Freny BE. Treatment of facial lesions of multicentric reticulohistiocytosis by carbon dioxide laser. J Cutan Aesthet Surg. 2013 Jul. 6(3):161-3. [View Abstract]
  29. Lotti T, Santucci M, Casigliani R, Fabbri P, Bondi R, Panconesi E. Multicentric reticulohistiocytosis. Report of three cases with the evaluation of tissue proteinase activity. Am J Dermatopathol. 1988 Dec. 10(6):497-504. [View Abstract]
  30. Gorman JD, Danning C, Schumacher HR, Klippel JH, Davis JC Jr. Multicentric reticulohistiocytosis: case report with immunohistochemical analysis and literature review. Arthritis Rheum. 2000 Apr. 43(4):930-8. [View Abstract]
  31. Nakamura H, Yoshino S, Shiga H, Tanaka H, Katsumata S. A case of spontaneous femoral neck fracture associated with multicentric reticulohistiocytosis: oversecretion of interleukin-1beta, interleukin-6, and tumor necrosis factor alpha by affected synovial cells. Arthritis Rheum. 1997 Dec. 40(12):2266-70. [View Abstract]
  32. Iwata H, Okumura Y, Seishima M, Aoyama Y. Overexpression of monocyte chemoattractant protein-1 in the overlying epidermis of multicentric reticulohistiocytosis lesions: a case report. Int J Dermatol. 2012 Apr. 51(4):492-4. [View Abstract]
  33. Adamopoulos IE, Wordsworth PB, Edwards JR, Ferguson DJ, Athanasou NA. Osteoclast differentiation and bone resorption in multicentric reticulohistiocytosis. Hum Pathol. 2006. 37(9):1176–85.
  34. Islam AD, Naguwa SM, Cheema GS, Hunter JC, Gershwin ME. Multicentric reticulohistiocytosis: A rare yet challenging disease. Clin Rev Allergy Immunol. 2013 Feb 17.
  35. Valencia IC, Colsky A, Berman B. Multicentric reticulohistiocytosis associated with recurrent breast carcinoma. J Am Acad Dermatol. 1998 Nov. 39(5 Pt 2):864-6. [View Abstract]
  36. Hotta M, Minamimoto R, Suzuki D, Takahashi A. Multicentric Reticulohistiocytosis Mimicking Malignancy on 18F-FDG PET/CT. Clin Nucl Med. 2017 Jul. 42 (7):567-568. [View Abstract]
  37. Tan BH, Barry CI, Wick MR, et al. Multicentric reticulohistiocytosis and urologic carcinomas: a possible paraneoplastic association. J Cutan Pathol. 2011 Jan. 38(1):43-8. [View Abstract]
  38. Han L, Huang Q, Liao KH, et al. Multicentric reticulohistiocytosis associated with liver carcinoma: report of a case. Case Rep Dermatol. 2012 May. 4(2):163-9. [View Abstract]
  39. El-Haddad B, Hammoud D, Shaver T, Shahouri S. Malignancy-associated multicentric reticulohistiocytosis. Rheumatol Int. 2011 Sep. 31(9):1235-8. [View Abstract]
  40. Kishikawa T, Miyashita T, Fujiwara E, Shimomura O, Yasuhi I, Niino D, et al. Multicentric reticulohistiocytosis associated with ovarian cancer. Mod Rheumatol. 2007. 17(5):422-5. [View Abstract]
  41. Huang X, Zhang L, Zhang S. Multicentric reticulohistiocytosis with extra-mammillary Paget's disease: a case report. Eur J Med Res. 2013 Oct 29. 18(1):38. [View Abstract]
  42. Rudha Y, Starobinska E, Abdulqader Y, Attya A, Guerrero C, Parperis K. Multicentric reticulohistiocytosis associated with thymic carcinoma. Rheumatology (Oxford). 2017 Oct 1. 56 (10):1706. [View Abstract]
  43. Tariq S, Hugenberg ST, Hirano-Ali SA, Tariq H. Multicentric reticulohistiocytosis (MRH): case report with review of literature between 1991 and 2014 with in depth analysis of various treatment regimens and outcomes. Springerplus. 2016. 5:180. [View Abstract]
  44. West KL, Sporn T, Puri PK. Multicentric reticulohistiocytosis: a unique case with pulmonary fibrosis. Arch Dermatol. 2012 Feb. 148(2):228-32. [View Abstract]
  45. Webb-Detiege T, Sasken H, Kaur P. Infiltration of histiocytes and multinucleated giant cells in the myocardium of a patient with multicentric reticulohistiocytosis. J Clin Rheumatol. 2009 Feb. 15(1):25-6. [View Abstract]
  46. Benucci M, Sulla A, Manfredi M. Cardiac engagement in multicentric reticulohistiocytosis: report of a case with fatal outcome and literature review. Intern Emerg Med. 2008 Jun. 3(2):165-8. [View Abstract]
  47. Lambert CM, Nuki G. Multicentric reticulohistiocytosis with arthritis and cardiac infiltration: regression following treatment for underlying malignancy. Ann Rheum Dis. 1992 Jun. 51(6):815-7. [View Abstract]
  48. Fast A. Cardiopulmonary complications in multicentric reticulohistiocytosis. Report of a case. Arch Dermatol. 1976 Aug. 112(8):1139-41. [View Abstract]
  49. Yang HJ, Ding YQ, Deng YJ. Multicentric reticulohistiocytosis with lungs and liver involved. Clin Exp Dermatol. 2009 Mar. 34(2):183-5. [View Abstract]
  50. Taniguchi T, Asano Y, Okada A, Sugaya M, Sato S. Ultraviolet light-induced Köbner phenomenon contributes to the development of skin eruptions in multicentric reticulohistiocytosis. Acta Derm Venereol. 2011 Mar. 91(2):160-3. [View Abstract]
  51. Fett N, Liu RH. Multicentric reticulohistiocytosis with dermatomyositis-like features: a more common disease presentation than previously thought. Dermatology. 2011. 222(2):102-8. [View Abstract]
  52. Mun JH, Ko HC, Kim MB. Multicentric reticulohistiocytosis masquerading as dermatomyositis: similar and different features. J Dermatol. 2012 Jan. 39(1):104-7. [View Abstract]
  53. Bennassar A, Mas A, Guilabert A, Julia M, Mascaro-Galy JM, Herrero C. Multicentric reticulohistiocytosis with elevated cytokine serum levels. J Dermatol. 2011 Sep. 38(9):905-10. [View Abstract]
  54. Shima N, Murosaki T, Nagashima T, Iwamoto M, Amano Y, Nakano N, et al. Multicentric Reticulohistiocytosis with Dermatomyositis-like Eruptions. Intern Med. 2017. 56 (15):2063-2066. [View Abstract]
  55. Wat M, Sun GS, Rodriguez-Waitkus PM, Hsu S. Granuloma annulare mimicking multicentric reticulohistiocytosis. Dermatol Online J. 2013 Nov 15. 19(11):20400. [View Abstract]
  56. Yamada T, Kurohori YN, Kashiwazaki S, Fujibayashi M, Ohkawa T. MRI of multicentric reticulohistiocytosis. J Comput Assist Tomogr. 1996 Sep-Oct. 20(5):838-40. [View Abstract]
  57. Kamel H, Gibson G, Cassidy M. Case report: the CT demonstration of soft tissue involvement in multicentric reticulohistiocytosis. Clin Radiol. 1996 Jun. 51(6):440-1. [View Abstract]
  58. Asano T, Suzutani K, Watanabe A, Honda A, Mori N, Yashiro M, et al. The utility of FDG-PET/CT imaging in the evaluation of multicentric reticulohistiocytosis: A case report. Medicine (Baltimore). 2018 Aug. 97 (33):e11449. [View Abstract]
  59. Zhang B, Zhou H, Han J, Shi X, Zhang X. 18F-FDG PET/CT Findings in Multicentric Reticulohistiocytosis. Clin Nucl Med. 2016 Apr. 41 (4):333-5. [View Abstract]
  60. Farokhi A, van Vugt RM, Hoekzema R, Nurmohamed MT. Multicentric reticulohistiocytosis: a case report. BMC Res Notes. 2018 Sep 4. 11 (1):647. [View Abstract]
  61. Wade RG, Daivajna S, Chapman P, Murphy JG, Makkuni D. Hand surgery for Multicentric Reticulohistiocytosis: A new avenue of treatment and review of the literature. Int J Surg Case Rep. 2013. 4(8):744-7. [View Abstract]
  62. Motegi S, Yonemoto Y, Yanagisawa S, Toki S, Uchiyama A, Yamada K, et al. Successful Treatment of Multicentric Reticulohistiocytosis with Adalimumab, Prednisolone and Methotrexate. Acta Derm Venereol. 2016 Jan. 96 (1):124-5. [View Abstract]
  63. Macía-Villa CC, Zea-Mendoza A. Multicentric reticulohistiocytosis: case report with response to infliximab and review of treatment options. Clin Rheumatol. 2016 Feb. 35 (2):527-34. [View Abstract]

Nodules on a hand with deformed joints from arthritis due to multicentric reticulohistiocytosis.

Multiple erythematous nodules are present on the dorsal hands of this adolescent with an inflammatory arthropathy.

Multiple erythematous to brown nodules on the fingers.

Nodules on a hand with deformed joints from arthritis due to multicentric reticulohistiocytosis.

Cobblestone papules on the eyelid and papules on the forehead.

Swollen elbow and nodules on the forearm.

Erythematous to brown papules overlying the right dorsal hand and wrist and erythematous to violaceous patches over the right dorsal hand and fingers. The cutaneous changes are in a photodistributed pattern and mimic the changes of dermatomyositis.

Erythematous to brown papules and erythematous to violaceous patches overlying the right dorsal hand and fingers, with a crusted erosion overlying the fourth metacarpophalangeal joint. These cutaneous changes can be easily confused with dermatomyositis.

Histopathology of multicentric reticulohistiocytosis (MRH) skin lesions.

Histopathology of multicentric reticulohistiocytosis (MRH) skin lesions. Higher power demonstrating multinucleated giant cells with eosinophilic ground-glass cytoplasm.

Low-power view of a biopsy sample of large histiocytes and multinucleated giant cells in the dermis.

High-power view of large histiocytes in the dermis.

Brown immunoperoxidase staining for lysozyme in histiocytes.

Multiple erythematous nodules are present on the dorsal hands of this adolescent with an inflammatory arthropathy.

Multiple erythematous to brown nodules on the fingers.

Erythematous, poikilodermatous, mamillated plaque on the anterior chest.

Histopathology of multicentric reticulohistiocytosis (MRH) skin lesions.

Histopathology of multicentric reticulohistiocytosis (MRH) skin lesions. Higher power demonstrating multinucleated giant cells with eosinophilic ground-glass cytoplasm.

Erythematous to brown papules overlying the right dorsal hand and wrist and erythematous to violaceous patches over the right dorsal hand and fingers. The cutaneous changes are in a photodistributed pattern and mimic the changes of dermatomyositis.

Erythematous to brown papules and erythematous to violaceous patches overlying the right dorsal hand and fingers, with a crusted erosion overlying the fourth metacarpophalangeal joint. These cutaneous changes can be easily confused with dermatomyositis.

Nodules on a hand with deformed joints from arthritis due to multicentric reticulohistiocytosis.

Swollen elbow and nodules on the forearm.

Cobblestone papules on the eyelid and papules on the forehead.

Low-power view of a biopsy sample of large histiocytes and multinucleated giant cells in the dermis.

High-power view of large histiocytes in the dermis.

Brown immunoperoxidase staining for lysozyme in histiocytes.