Eosinophilic Granuloma (Histiocytosis X) Treatment & Management
- Author: Eleanor M Summerhill, MD, FACP, FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
Inpatient admission is indicated in pulmonary Langerhans cell histiocytosis X (PLCH) patients only to manage complications related to the disease as listed below.
Patients with superimposed respiratory infections, such as pneumonia, may require inpatient treatment.
Patients with spontaneous pneumothorax may require chest-tube placement and subsequent in-patient care. The recurrence rate of secondary spontaneous pneumothorax in PLCH is high. Therefore, some experts recommend surgical intervention, such as mechanical pleurodesis, parietal pleurectomy, or talc insufflation, to prevent further occurrences after the initial episode.
Acute respiratory failure necessitating in-patient management may occur as the result of a superimposed respiratory infection or spontaneous pneumothorax. Respiratory failure may also occur as a manifestation of end-stage disease.
Smoking cessation is the most important medical intervention for pulmonary Langerhans cell histiocytosis X (PLCH). Smoking cessation often stabilizes the disease and sometimes leads to regression. It is also helpful in preventing bronchogenic carcinoma. Largely because of the rarity of PLCH, well-designed, prospective, randomized data regarding therapy are lacking.
The use of corticosteroids is controversial. Corticosteroids may be considered in patients with a persistence of clinically significant pulmonary or constitutional symptoms or those with documented progression of disease. Corticosteroid therapy is not indicated in patients with normal lung function. Recommendations for the use of corticosteroids are based largely on retrospective data and expert opinion.
Investigational therapies include interleukin-2 (IL-2) and anti–tumor necrosis factor-alpha (anti–TNF-alpha). Both agents have been reported to improve outcomes in pediatric disseminated histiocytosis. This finding may lead to the investigation of their use in adult PLCH.
Useful adjunctive therapies include the following:
Supplemental oxygen therapy for those with clinically significant hypoxemia (SaO 2 < 89% or PaO 2 < 55 mmHg) at rest or with exertion
Aggressive treatment for pulmonary infections with prompt initiation of antibiotic therapy
Bronchodilator therapy in the presence of an obstructive ventilatory defect
Lung transplantation is an option for select patients with advanced disease. Recurrence of pulmonary Langerhans cell histiocytosis X (PLCH) has been reported in the transplanted lung.
Refer patients with suspected pulmonary Langerhans cell histiocytosis X (PLCH) to a pulmonary disease specialist.
Exercise and pulmonary rehabilitation are encouraged in pulmonary Langerhans cell histiocytosis X (PLCH). These activities may improve the patient's functional status, even if they have no effect on disease progression.
Spontaneous pneumothorax is a common complication (10-20%) in pulmonary Langerhans cell histiocytosis X (PLCH).
PLCH is associated with an increased risk of malignancy, including Hodgkin and non-Hodgkin lymphoma, myeloproliferative disorders, and bronchogenic carcinoma.
Pathologic fracture may occur at the site of bone lesions.
Diabetes insipidus occurs in 10-15% of patients and indicates disease in the central nervous system.
Pulmonary artery hypertension and cor pulmonale may develop as a result of hypoxemia and/or vascular disruption due to PLCH lesions.
Effective antismoking measures can prevent pulmonary Langerhans cell histiocytosis X (PLCH). See Medscape's Smoking Resource Center.
In the care of patients with pulmonary Langerhans cell histiocytosis X (PLCH) , important considerations include the patients' smoking history and current smoking status, the presence or absence of extrapulmonary disease and constitutional symptoms, and close monitoring for progression of pulmonary disease.
Pulmonary artery hypertension is a known complication of infiltrative lung diseases, and in PLCH the magnitude of pulmonary artery hypertension may be greater than expected for given the degree of hypoxemia or level of impairment on pulmonary function testing.
The increased risk of pulmonary malignancies must be considered.
Smoking cessation counseling and adjunctive pharmacologic therapy with bupropion and nicotine replacement are key components of long-term management.
Perform pulmonary function testing and radiographic studies every 3-6 months, as the patient's clinical condition warrants.
Assess arterial oxygen saturation both at rest and with activity.
Echocardiography should be considered in all patients with clinically significant dyspnea in order to screen for pulmonary artery hypertension.
If echocardiographic results suggest moderate-to-severe pulmonary artery hypertension, these findings should be further evaluated and confirmed with right-heart catheterization.
At the time of catheterization, the response to vasodilators may also be assessed.
Patients should be vaccinated annually for influenza and should also receive the pneumococcal vaccine.
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