Angiolymphoid Hyperplasia With Eosinophilia. F 55, Lower Lip

8/9/2019 Angiolymphoid Hyperplasia With Eosinophilia. F 55, Lower Lip

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Angiolymphoid Hyperplasia withAngiolymphoid Hyperplasia with

EosinophiliaEosinophilia

Spencer Rusin M4, CUMCSpencer Rusin M4, CUMC

Deba P Sarma, MDDeba P Sarma, MDOmahaOmaha


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Patient PresentationPatient Presentation

F 55, presents with a 10F 55, presents with a 10--month history of :month history of :

NonNon--ulcerated, painless nodule (0.5 cm)ulcerated, painless nodule (0.5 cm)

on her lower lipon her lower lip No history of trauma or earNo history of trauma or ear--nosenose--throatthroat

disease.disease.


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Differential DiagnosisDifferential Diagnosis

MucoceleMucocele

Lymphocytoma cutisLymphocytoma cutis

Granuloma facialeGranuloma faciale Benign and malignant tumors of skin andBenign and malignant tumors of skin and

adnexaeadnexae

Kimura diseaseKimura disease

OthersOthers


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A well circumscribedA well circumscribed

dermal noduledermal nodule

composed of centralcomposed of centralangiomatous vascularangiomatous vascular

proliferation withproliferation with

stromal and peripheralstromal and peripheral

infiltrates ofinfiltrates of

lymphocytes andlymphocytes andeosinophils.eosinophils.

H&E: low power


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Proliferation of small blood vessels, lined by enlargedProliferation of small blood vessels, lined by enlargedendothelial cells (epitheliod in appearance) with uniform ovoidendothelial cells (epitheliod in appearance) with uniform ovoid

nuclei and intracytoplasmic vacuoles.nuclei and intracytoplasmic vacuoles.


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Prominent eosinophilic and lymphocytic infiltrationProminent eosinophilic and lymphocytic infiltration


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Lymphoid aggregate with follicle formation amongst theLymphoid aggregate with follicle formation amongst the

vascular proliferative cells.vascular proliferative cells.


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ImmunostainsImmunostains

CD 3CD 3 Peripheral lymphocytes: PositivePeripheral lymphocytes: Positive

CD 20CD 20 -- Peripheral lymphocytes: PositivePeripheral lymphocytes: Positive

CD31CD31 Vascular epitheliod endothelial cells:Vascular epitheliod endothelial cells:PositivePositive

CK AE1/3CK AE1/3 -- NegativeNegative

SS--100100 -- NegativeNegative


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CD 31 stain highlights the endothelial cells demonstrating aCD 31 stain highlights the endothelial cells demonstrating a

strong angiogenesis component to the nodule.strong angiogenesis component to the nodule.


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DiagnosisDiagnosis

Angiolymphoid hyperplasia with eosinophiliaAngiolymphoid hyperplasia with eosinophilia

(ALHE)(ALHE)


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Differential DiagnosisDifferential Diagnosis

ALHEALHE

Primarily a localizedPrimarily a localizedhyperplasiahyperplasia

InfrequentInfrequentlymphadenopathylymphadenopathy

20%20%

Rare blood eosinophliaRare blood eosinophlia

Histology:Histology:

VascularVascularproliferation>inflammaproliferation>inflammatory cellstory cells

Epitheliod endothelialEpitheliod endothelialcells lining bloodcells lining bloodvesselsvessels

Eosinophils presentEosinophils present

Kimura DiseaseKimura Disease

Systemic involvement:Systemic involvement: LymphadenopathyLymphadenopathy Blood eosinophliaBlood eosinophlia Nephrotic syndrome asNephrotic syndrome as

a result of glomerulara result of glomerularIgE deposition.IgE deposition.

Histological presentation ofHistological presentation ofKimura disease differs fromKimura disease differs from

ALHE in two factors.ALHE in two factors. Vascular proliferationVascular proliferation


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ALHEALHE

General presentation:General presentation:

Range from asymptomatic to itchy orRange from asymptomatic to itchy or

painful erythematous nodules, 2painful erythematous nodules, 2--3cm in3cm indiameter.diameter.

The nodules may pulsate or bleed.The nodules may pulsate or bleed.


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PrePre--auricular lesions of ALHE.auricular lesions of ALHE.


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ALHEALHE Hypotheses regarding ALHEs origin:Hypotheses regarding ALHEs origin:

Reactive process to insect bitesReactive process to insect bites

Hyperestrogen statesHyperestrogen states

Immunologic mechanismsImmunologic mechanisms

Reactive vascular proliferation subsequent toReactive vascular proliferation subsequent toinflammation associated with traumatized bloodinflammation associated with traumatized blood

vesselsvessels One study reported a history of trauma in only 9%One study reported a history of trauma in only 9%

of 116 patients with ALHEof 116 patients with ALHE


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ALHEALHE

Age: 20Age: 20--50 years, M = F50 years, M = F

Locations affected by ALHE:Locations affected by ALHE:

Head and neck:Head and neck:

Specifically the forehead, scalp, and skin aroundSpecifically the forehead, scalp, and skin aroundears.ears.

Trunk and genitaliaTrunk and genitalia

Three documented cases of ALHE affecting the lip.Three documented cases of ALHE affecting the lip.


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ALHEALHE

Progression of ALHE:Progression of ALHE:

Most common course: ALHE remains stableMost common course: ALHE remains stable

Infrequent outcome: ALHE spontaneouslyInfrequent outcome: ALHE spontaneouslyregressesregresses

Chronic nature of ALHE necessitates treatment.Chronic nature of ALHE necessitates treatment.

Recurrence rate ranges from 33Recurrence rate ranges from 33--50%50%


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TreatmentTreatment

Medical:Medical:

IsoretinoinIsoretinoin

CorticosteroidsCorticosteroids

interferon alfainterferon alfa--2b2b

Benefits:Benefits:

Improved cosmetic outcomesImproved cosmetic outcomes

Limitations:Limitations:

Relies on patient complianceRelies on patient compliance Not a permanent cureNot a permanent cure


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TreatmentTreatment

Surgical:Surgical:

Laser therapyLaser therapy

Carbon dioxide laserCarbon dioxide laser

Ultralong pulsed dye laserUltralong pulsed dye laser

Nd:Nd:YAG laserYAG laser

Benefits:Benefits:

Improved cosmetic outcomeImproved cosmetic outcome

Limitations:Limitations: Multiple treatmentsMultiple treatments

Adversely affected by the depth of invasion orAdversely affected by the depth of invasion orsize of vesselssize of vessels


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TreatmentTreatment

Surgical:Surgical:

ExcisionalExcisional

Simple surgical excisionSimple surgical excision

Mohs surgeryMohs surgery

Benefits:Benefits:

Excision of the arterial and venous segments atExcision of the arterial and venous segments atthe base decrease recurrencethe base decrease recurrence

Limitations:Limitations: ScarringScarring


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ReferencesReferences

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Angiolymphoid Hyperplasia With Eosinophilia. F 55, Lower Lip