eMedicine Specialties > Radiology > Musculoskeletal

Eosinophilic Granuloma, Skeletal

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist, North Manchester General Hospital, The Pennine Acute NHS Trust, Manchester UK
Muthusamy Chandramohan, MBBS, DMRD, FRCR, Consultant Radiologist, Bradford Teaching Hospitals, UK; Ian Turnbull, MB, ChB, MD, DMRD, FRCR, Lecturer, Department of Radiology, University of Manchester; Consulting Neuroradiologist, Hope Hospital, Salford, Manchester and North Manchester General Hospital, UK; Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute

Updated: May 14, 2008

Introduction

Background

Eosinophilic granuloma (EG) is the benign form of the 3 clinical variants of Langerhans cell histiocytosis, which include Letterer-Siwe disease, Hand-Schüller-Christian disease, and EG (formerly termed histiocytosis X).

EG is characterized by single or multiple skeletal lesions, and it predominantly affects children, adolescents, and young adults. Solitary lesions are more common than multiple lesions. When multiple lesions occur, the new osseous lesions appear within 1-2 years. Any bone can be involved; the more common sites include the skull, mandible, spine, ribs, and long bones.^{[1,2,3 ]}

Symptoms include localized pain, tenderness, swelling, fever, and leukocytosis. Lesions usually begin to regress after approximately 3 months, but they may take as long as 2 years to resolve.

Chest radiograph in a 9-year-old boy who presented with mid dorsal pain. Note the collapsed vertebra and paraspinal soft tissue mass.

Transaxial nonenhanced CT scans of the skull in a 28-year-old woman who presented with a palpable swelling over the calvarium. Scanogram of the patient's skull shows a geographic lytic lesion within the parieto-occipital region. Transaxial scan through the vertex, examined in a bone window, shows an expanding lytic lesion within the diploic space (see also Images 4-5 in Multimedia).

Radionuclide bone scans in a 28-year-old woman with a palpable swelling over the calvarium (same patient as in Images 3-4 in Multimedia) show a solitary lesion within the skull and a photon-deficient mass surrounded by a rim of intense activity. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

External carotid angiogram in a 10-year-old boy with swelling of the left mandible (same patient as in Image 6 in Multimedia) shows an avascular mass within the mandible with stretching of the vessels around the lytic lesion. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

T1-weighted nonenhanced sagittal MRI through the spine in a 9-year-old boy with mid dorsal pain (same patient as in Images 9-10 in Multimedia) shows the vertebra plana. Note the preserved disk spaces. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

Pathophysiology

EG is a benign disorder that affects children and young adults, particularly males. The solitary bone lesion may be asymptomatic, or it may cause bone pain because of expansion of the medullary bone. Pathologic fractures may ensue.^{[1,4,5 ]}

The distinctive morphologic lesions of the entire group of Langerhans histiocytosis disorders consist of expanding erosive accumulations of histiocytes, usually within the medullary cavity. Microscopically, proliferation of foamy and vacuolated histiocytes is associated with a variable admixture of neutrophils, eosinophils, lymphocytes, and plasma cells. The concentration of eosinophilic infiltrate varies from scattered mature cells to sheetlike masses of cells. Occasionally, areas of bone necrosis may interrupt the cellular infiltrate. The foamy cells may also be amassed in clumps, but because these clumps represent phagocytosis of lipid debris, they are of no clinical significance.

Any bone can be involved, but the calvarium, ribs, and femur are particularly common sites. Solitary lesions are more common than multiple ones. When the lesions are multiple, new osseous lesions occur within 1-2 years; the condition is still classified as EG. Radiologists need to be aware that additional EG of bone, occurring as long as 4 years after initial diagnosis, should be interpreted as a localized form of Langerhans cell histiocytosis. This differentiation is important because the prognosis is more favorable with focal disease with multifocal disseminated disease, which involves organs other than the skeletal system. Similar lesions may occur within the lungs, skin, and stomach, either as a unifocal lesion or as part of multifocal disease.^{[4 ]}

Lung involvement occurs in 20% of patients with EG and in an older group (age, 20-40 y). Lung involvement has a strong association with smoking. Diffuse pulmonary infiltrates may be a manifestation of a covert osseous EG. In 50-75% of patients, the disease is monostotic. Skull involvement is seen in 50% of patients.^{[6 ]}Rarely, the growing epiphysis is involved with EG; in most such cases, transphyseal extension can be demonstrated, both by the radiologic findings and the histopathologic results.^{[7 ]}

Frequency

United States

EG, or unifocal Langerhans cell histiocytosis, is the most common benign form in the Langerhans cell histiocytosis group. EG is found in 60-80% of patients with Langerhans cell histiocytosis.

International

The exact incidence of EG is unknown.

Mortality/Morbidity

The prognosis is usually excellent, with spontaneous resolution by fibrosis occurring within 1-2 years. In other instances, curettage, excision, or local irradiation leads to cure, although some authorities believe that the rate of spontaneous resolution of osseous and extraosseous lesions is unaffected by the mode of therapy.^{[7 ]}

• Unifocal lesions occurring at certain sites may lead to complications. A lesion of the mastoid process may extend into the middle ear, destroy the ossicles, and lead to deafness, whereas a lesion in the mandible may lead to floating teeth and fractures.
• Pathologic fractures may complicate rib and long bone lesions and cause vertebra plana. The prognosis for patients with vertebra plana resulting from EG is favorable in terms of symptomatic improvement and the restoration of vertebral height. For patients with vertebra plana, conservative orthopedic treatment involving immobilization with a brace is usually sufficient to allow optimal vertebral remodeling.^{[8 ]}

Sex

The male-to-female ratio is 3:2.

Age

The age range of patients with EG is 2-30 years. The highest frequency occurs in patients aged 5-10 years; 75% of patients with EG are younger than 20 years.

Presentation

Most patients have no symptoms. The diagnosis is usually based on radiographic demonstration of a destructive bone lesion arising from the marrow cavity and on characteristic morphologic findings. Localized bone pain and focal tenderness may occur as a result of bone erosion and, rarely, a pathologic fracture. A swelling or mass may be palpable at the site of osseous involvement. Rarely, children present with fever and leukocytosis. Involvement of the mastoid process may occur with intractable otitis media with a chronic discharge. Mandibular involvement may present as gingival and continuous soft tissue swelling.^{[1 ]}

Eosinophilic granuloma may masquerade as an aggressive periodontitis.^{[9 ]}Eosinophilic granuloma should therefore be considered when an expanding lytic jaw lesion is encountered.

A spinal EG infrequently produces neurologic deficits in children, which may result in spinal instability.^{[2,10,11 ]}

Preferred Examination

Plain radiography is the mainstay in the diagnosis of EG, although a specific diagnosis cannot always be made without bone biopsy because children and adolescents are not spared skeletal neoplasms. Radionuclide study, CT, MRI, and, occasionally, angiography are complementary examinations. Any or all may be used to arrive at a diagnosis.^{[1,12,13 ]}

Limitations of Techniques

A wide variety of bone lesions may mimic EG; these include infections, traumatic lesions, and neoplasms. A false-negative diagnosis of EG is exceptional when plain radiographic findings are used, although difficulty may be encountered with lesions in areas with more complex anatomy, such as the posterior elements of the vertebral bodies. In these cases, conventional tomography or CT may useful. With radionuclide scanning, the false-negative rate is 30%.

Differential Diagnoses

Other Problems to Be Considered

Skull^{[3 ]}

Venous lake
Meningocele, encephalocele, and cranium bifidum
Arachnoid granulation
Parietal foramen
Epidermoid cyst
Hemangioma
Cholesteatoma
Fibrous dysplasia
Metastasis
Surgical defect
Osteomyelitis

Vertebra plana

Fracture
Metastasis, lymphoma, leukemia, plasmacytoma, chordoma, aneurysmal bone cyst, and Ewing sarcoma
Hemangioma
Osteomyelitis

Long bones

Ewing sarcoma
Chronic osteomyelitis
Brodie abscess
Chondroblastoma

Lungs

Other interstitial lung diseases

Radiography

Findings

Chest radiograph in a 30-year-old woman who presented with shortness of breath and a palpable swelling over the right parietal region. The radiograph shows an interstitial lung pattern with a honeycomb appearance in the upper zones (see also Image 2 in Multimedia).

Lateral skull radiograph in a 30-year-old woman with shortness of breath and a palpable swelling over the right parietal region (same patient as in Image 1 in Multimedia) shows 2 purely lytic lesions in the frontoparietal region of the skull. The larger parietal lesion has beveled edges, suggestive of an eosinophilic granuloma. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

Plain radiograph of the pelvis in a 10-year-old girl shows a lytic lesion of eosinophilic granuloma within the left ileum. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

Chest radiograph in a 9-year-old boy who presented with mid dorsal pain. Note the collapsed vertebra and paraspinal soft tissue mass.

Anteroposterior radiograph of the dorsal spine in a 9-year-old boy with mid dorsal pain (same patient as in Image 9 in Multimedia). These results confirm the chest radiographic findings.

• In descending order of frequency, sites involved with monostotic osseous disease include the calvarium, mandible, ribs, long bones of the upper extremity, pelvis, and vertebrae (see Images above and Images 1-2, 6-10 in Multimedia).
• When tubular bones are involved, diaphyseal and metaphyseal localization is more frequent than epiphyseal localization. Epiphyseal lesions may cross the open physeal plate.
• The skull is affected in one half of patients.^{[3,6 ]}
  • The diploic space of the parietal and temporal bones are usually involved.
  • Skull lesions are lytic, with a beveled edge or sharp and serrated margins and the absence of sclerosis in calvarial lesions.
  • Sclerosis may occur around orbital lesions.
  • Marginal sclerosis may occur during the healing phase in up to 50% of patients with a calvarial lesion.
  • A hole-within-a-hole appearance may occur as a result of uneven erosion of the inner and outer tables of the skull.
  • A soft tissue mass overlying the skull defect may be obvious and, often, clinically palpable.
  • A soft tissue mass is occasionally seen with orbital lesions, with or without underlying bone erosion.
  • A button sequestrum is seen because a central bone opacity within a lytic lesion is an unusual presentation.
• Mandibular lesions may be associated with gingival and soft tissue swelling and floating teeth (see Image below and Image 6 in Multimedia).

Anteroposterior radiograph of the mandible (left image) in a 10-year-old boy who presented with swelling of the left mandible. A lytic expanding lesion is seen within the ramus of the left mandible. An oblique view of the mandible (right image) shows floating teeth within the lytic bone lesion) (see also Image 7 in Multimedia).

• The ribs show lytic expansile lesions, which may be associated with pathologic fractures.
• Long bones below the knees and distal to the elbows are rarely involved.
  • Lesions are lytic, round or oval, and expansile, with ill-defined or sclerotic margins.
  • The medullary cavity may be expanded and may be associated with cortical thinning, intracortical tunneling, and erosion of the cortex, as well as an adjacent soft tissue mass.
  • Laminated periosteal new bone formation is common around the involved segment of bone.
  • Spread across growth plates is unusual.
  • Tubular long bone lesions may appear rapidly over 3 weeks.
• The scapulae and pelvis show destructive lesions.
• Periosteal elevation is minimal, and some lesions show sclerotic margins, particularly lesions occurring in the supra-acetabular regions.
• Vertebral destruction may lead to flattening of the vertebral body, which is termed vertebra plana and is a finding that is much more common in children than in adults.^{[8,10,11 ]}
  • Vertebra plana is more common in the dorsal spine.
  • Associated kyphosis has not been described, but scoliosis can occur.
  • EG can produce expansile lytic lesions of the vertebral bodies and the posterior vertebral elements.
  • An associated paraspinal mass may occasionally occur.
  • Involvement of the second cervical vertebra is extremely rare; it may cause atlantoaxial instability.^{[14 ]}
• Lung involvement is seen in as many as 20% of patients, with an incidence of 0.05-0.5 per 100,000 patients annually.
  • Lung lesions are seen in an older subset of patients, ie, those aged 20-40 years.
  • Plain radiographic findings may demonstrate an alveolar pattern in an early stage, which may be followed by nodular shadows (3-10 mm) and/or a reticulonodular pattern with a predilection for the apices.
  • Eventually, fibrosis and a honeycomb lung may ensue.
  • Recurrent pneumothoraces occur in 20% of patients.
  • Hilar lymphadenopathy and pleural effusions are rare.

Degree of Confidence

Plain radiography remains the mainstay of diagnosis in patients with EG, although a specific diagnosis cannot always be made without bone biopsy because children and adolescents are not spared skeletal neoplasms.

False Positives/Negatives

A wide variety of bone lesions may mimic EG, including infections, traumatic lesions, and neoplasms (see Differentials). A false-negative diagnosis of EG made by using plain radiographs is exceptional, although difficulty may be encountered with lesions in areas with more complex anatomy, such as the posterior elements of the vertebral bodies; in these cases, conventional tomography or CT may useful.

Computed Tomography

Findings

Transaxial nonenhanced CT scans of the skull in a 28-year-old woman who presented with a palpable swelling over the calvarium. Scanogram of the patient's skull shows a geographic lytic lesion within the parieto-occipital region. Transaxial scan through the vertex, examined in a bone window, shows an expanding lytic lesion within the diploic space (see also Images 4-5 in Multimedia).

Transaxial nonenhanced CT scans through the vertex in a 28-year-old woman with a palpable swelling over the calvarium (same patient as in Image 3 in Multimedia), examined in a brain window. Images show destruction of both the outer and inner tables of skull; however, no brain involvement is noted.

Degree of Confidence

CT is considerably better than plain radiography and conventional tomography in depicting an intracranial extension of EG.

False Positives/Negatives

CT appearances of EG are nonspecific, and a variety of inflammatory and neoplastic processes may mimic EG.

Magnetic Resonance Imaging

Findings

T1-weighted nonenhanced sagittal MRI through the spine in a 9-year-old boy with mid dorsal pain (same patient as in Images 9-10 in Multimedia) shows the vertebra plana. Note the preserved disk spaces. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have recently been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans.

As of late December 2006, the FDA had received reports of 90 such cases of NSF/NFD. Worldwide, over 200 cases have been reported, according to the FDA. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on thewhites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.

Degree of Confidence

The value of using MRI for patients with EG lies in the sensitivity of MRI; its specificity is low. However, the cost of the procedure and the procedural problems encountered in imaging young children confer no advantages over plain radiography.

False Positives/Negatives

The soft tissue component around the osseous lesion has poor definition and shows signal inhomogeneity; the appearance may mimic that of a malignant tumor, infection, or stress fracture.

Nuclear Imaging

Findings

Radionuclide bone scans in a 28-year-old woman with a palpable swelling over the calvarium (same patient as in Images 3-4 in Multimedia) show a solitary lesion within the skull and a photon-deficient mass surrounded by a rim of intense activity. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

Bone lesions in all types of Langerhans cell histiocytosis are not gallium-67 (⁶⁷ Ga) citrate–avid, but⁶⁷ Ga imaging may be helpful for detection of nonosseous lesions. Hence, it is useful in the initial assessment and serial follow-up imaging of patients with Langerhans cell histiocytosis. Thallous chloride-201 uptake detected on single-photon emission CT (SPECT) scans has been reported in a patient with skull EG, which was photon deficient on an ^99m Tc methylene diphosphonate uptake study.^{[12 ]}

Degree of Confidence

Radiographic examination and radionuclide bone imaging are complementary techniques in detecting bone lesions in bone marrow disorders, including EG. Scintigraphy is more useful in cases of unifocal EG than in cases of multifocal disease, in which radiography is superior.

False Positives/Negatives

Negative radionuclide findings occur in 35% of patients with known EG in whom plain radiographic findings are positive.

Angiography

Findings

External carotid angiogram in a 10-year-old boy with swelling of the left mandible (same patient as in Image 6 in Multimedia) shows an avascular mass within the mandible with stretching of the vessels around the lytic lesion. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

Degree of Confidence

In most instances, angiography has little or no role in the investigation of EG.

False Positives/Negatives

Most lesions included in the differential diagnosis of EG are avascular; therefore, differentiation on the basis of angiographic results is usually not possible.

Intervention

Percutaneous biopsy is an accepted means of obtaining tissue for analysis to aid in the diagnosis of indeterminate metastatic disease.^{[13 ]}Needle biopsy for tissue sampling in primary osseous neoplasms is more controversial; however, needle biopsy is useful and may be diagnostic in the workup of patients with inflammatory bone lesions and EG. The diagnostic yield of a needle biopsy has been reported to be 50-94% in malignant bone lesions but is less accurate in benign disease. The low complication rate of 0.2% makes the percutaneous approach an attractive alternative to open surgical biopsy.

The prognosis is usually excellent, with spontaneous resolution by fibrosis occurring within 1-2 years. In other instances, curettage, excision, or local irradiation leads to cure, although some authorities believe that the rate of spontaneous resolution of osseous and extraosseous lesions is unaffected by the mode of therapy.^{[1,5 ]}

Pathologic fractures may complicate rib and long bone lesions and cause vertebra plana. The prognosis in patients with vertebra plana resulting from EG is favorable in terms of symptomatic improvement and the restoration of vertebral height. Conservative orthopedic treatment of patients with vertebra plana through immobilization with a brace is usually sufficient to allow optimal vertebral remodeling.

In cases with neurologic impairment (rarely seen in adults), surgical decompression and short fusion of the spine may be necessary. Rarely, the growing epiphysis may be involved by EG, in which case diagnosis demands accurate biopsy and histopathologic analysis so that treatment and prognosis can be individualized.

Medicolegal Pitfalls

• A solitary EG lesion can present a diagnostic and treatment dilemma for the orthopedic surgeon. Pathologists, pediatricians, radiologists, and orthopedic surgeons must consider the wide range of skeletal neoplasms that may occur in children and adolescents.
• Obtaining a tissue diagnosis is important. It is also important to keep in mind that, although EG is usually a benign form of bone disease, in rare cases, it may be the presenting manifestation of the more serious multifocal Langerhans cell histiocytosis; in such cases, the prognosis is more guarded.
• A variety of disappearing bone tumors and tumorlike conditions may affect the skeleton in children. Therefore, surgery or invasive treatment should be instituted only after a careful workup is performed.
• Rarely, the growing epiphysis may be involved by EG, and accurate biopsy and histopathologic analysis is required for diagnosis.

Multimedia

Media file 1: Chest radiograph in a 30-year-old woman who presented with shortness of breath and a palpable swelling over the right parietal region. The radiograph shows an interstitial lung pattern with a honeycomb appearance in the upper zones (see also Image 2 in Multimedia).

Media file 2: Lateral skull radiograph in a 30-year-old woman with shortness of breath and a palpable swelling over the right parietal region (same patient as in Image 1 in Multimedia) shows 2 purely lytic lesions in the frontoparietal region of the skull. The larger parietal lesion has beveled edges, suggestive of an eosinophilic granuloma. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

Media file 3: Transaxial nonenhanced CT scans of the skull in a 28-year-old woman who presented with a palpable swelling over the calvarium. Scanogram of the patient's skull shows a geographic lytic lesion within the parieto-occipital region. Transaxial scan through the vertex, examined in a bone window, shows an expanding lytic lesion within the diploic space (see also Images 4-5 in Multimedia).

Media file 4: Transaxial nonenhanced CT scans through the vertex in a 28-year-old woman with a palpable swelling over the calvarium (same patient as in Image 3 in Multimedia), examined in a brain window. Images show destruction of both the outer and inner tables of skull; however, no brain involvement is noted.

Media file 5: Radionuclide bone scans in a 28-year-old woman with a palpable swelling over the calvarium (same patient as in Images 3-4 in Multimedia) show a solitary lesion within the skull and a photon-deficient mass surrounded by a rim of intense activity. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

Media file 6: Anteroposterior radiograph of the mandible (left image) in a 10-year-old boy who presented with swelling of the left mandible. A lytic expanding lesion is seen within the ramus of the left mandible. An oblique view of the mandible (right image) shows floating teeth within the lytic bone lesion) (see also Image 7 in Multimedia).

Media file 7: External carotid angiogram in a 10-year-old boy with swelling of the left mandible (same patient as in Image 6 in Multimedia) shows an avascular mass within the mandible with stretching of the vessels around the lytic lesion. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

Media file 8: Plain radiograph of the pelvis in a 10-year-old girl shows a lytic lesion of eosinophilic granuloma within the left ileum. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

Media file 9: Chest radiograph in a 9-year-old boy who presented with mid dorsal pain. Note the collapsed vertebra and paraspinal soft tissue mass.

Media file 10: Anteroposterior radiograph of the dorsal spine in a 9-year-old boy with mid dorsal pain (same patient as in Image 9 in Multimedia). These results confirm the chest radiographic findings.

Media file 11: T1-weighted nonenhanced sagittal MRI through the spine in a 9-year-old boy with mid dorsal pain (same patient as in Images 9-10 in Multimedia) shows the vertebra plana. Note the preserved disk spaces. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

References

1. Azouz EM, Saigal G, Rodriguez MM, Podda A. Langerhans' cell histiocytosis: pathology, imaging and treatment of skeletal involvement. Pediatr Radiol. Feb 2005;35(2):103-15. [Medline].

2. Haouimi AS, Al-Hawsawi ZM, Jameel AN. Unusual location of eosinophilic granuloma. Saudi Med J. Oct 2004;25(10):1489-91. [Medline].

3. Park SH, Park J, Hwang JH, Hwang SK, Hamm IS, Park YM. Eosinophilic granuloma of the skull: a retrospective analysis. Pediatr Neurosurg. 2007;43(2):97-101. [Medline].

4. Vanhoenacker FM, De Beuckeleer LH, De Roeck F, et al. Metachronous eosinophilic granuloma of bone. JBR-BTR. Oct 2000;83(5):234-7. [Medline].

5. Greis PE, Hankin FM. Eosinophilic granuloma. The management of solitary lesions of bone. Clin Orthop. Aug 1990;(257):204-11. [Medline].

6. Yang JT, Chang CN, Lui TN, Ho YS. Eosinophilic granuloma of the skull--report of four cases. Changgeng Yi Xue Za Zhi. Dec 1993;16(4):257-62. [Medline].

7. Yanagawa T, Watanabe H, Shinozaki T, et al. The natural history of disappearing bone tumours and tumour-like conditions. Clin Radiol. Nov 2001;56(11):877-86. [Medline].

8. Raab P, Hohmann F, Kuhl J, Krauspe R. Vertebral remodeling in eosinophilic granuloma of the spine. A long- term follow-up. Spine. Jun 15 1998;23(12):1351-4. [Medline].

9. Silvestros SS, Mamalis AA, Sklavounou AD, Tzerbos FX, Rontogianni DD. Eosinophilic granuloma masquerading as aggressive periodontitis. J Periodontol. May 2006;77(5):917-21. [Medline].

10. Greenlee JD, Fenoy AJ, Donovan KA, Menezes AH. Eosinophilic granuloma in the pediatric spine. Pediatr Neurosurg. 2007;43(4):285-92. [Medline].

11. Fenoy AJ, Greenlee JD, Menezes AH, Donovan KA, Sato Y, Hitchon PW, et al. Primary bone tumors of the spine in children. J Neurosurg. Oct 2006;105(4 Suppl):252-60. [Medline].

12. Flores LG 2nd, Hoshi H, Nagamachi S, et al. Thallium-201 uptake in eosinophilic granuloma of the frontal bone: comparison with technetium-99m-MDP imaging. J Nucl Med. Jan 1995;36(1):107-10. [Medline].

13. Carrasco CH, Wallace S, Richli WR. Percutaneous skeletal biopsy. Cardiovasc Intervent Radiol. Jan-Feb 1991;14(1):69-72. [Medline].

14. Osenbach RK, Youngblood LA, Menezes AH. Atlanto-axial instability secondary to solitary eosinophilic granuloma of C2 in a 12-year-old girl. J Spinal Disord. Dec 1990;3(4):408-12. [Medline].

Keywords

EG, Langerhans cell histiocytosis, histiocytosis X, Letterer-Siwe disease, Hand-Schüller-Christian disease, skeletal eosinophilic granuloma, unifocal Langerhans cell histiocytosis, solitary skeletal lesions, bone lesions, multiple skeletal lesions, skeletal lesions, solitary bone lesions, multiple bone lesions

Contributor Information and Disclosures

Author

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist, North Manchester General Hospital, The Pennine Acute NHS Trust, Manchester UK
Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies: American Institute of Ultrasound in Medicine, Royal College of Physicians, Royal College of Physicians and Surgeons of the United States, Royal College of Radiologists, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Coauthor(s)

Muthusamy Chandramohan, MBBS, DMRD, FRCR, Consultant Radiologist, Bradford Teaching Hospitals, UK
Disclosure: Nothing to disclose.

Ian Turnbull, MB, ChB, MD, DMRD, FRCR, Lecturer, Department of Radiology, University of Manchester; Consulting Neuroradiologist, Hope Hospital, Salford, Manchester and North Manchester General Hospital, UK
Disclosure: Nothing to disclose.

Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute
Sumaira MacDonald, MBChB, PhD, MRCP, FRCR is a member of the following medical societies: British Medical Association, Royal College of Physicians, and Royal College of Radiologists
Disclosure: Nothing to disclose.

Medical Editor

Michael A Bruno, MD, Associate Professor, Departments of Radiology and Medicine, Pennsylvania State University College of Medicine; Director, Radiology Quality Management Services, Milton S Hershey Medical Center, Pennsylvania State University College of Medicine
Michael A Bruno, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, Society of Nuclear Medicine, and Society of Skeletal Radiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Murali Sundaram, MBBS, FRCR, FACR, Consulting Staff, Department of Diagnostic Radiology, The Cleveland Clinic Foundation
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, EdM, Professor, Department of Radiology, Vice Chairman for Radiology Informatics, Section Head of Musculoskeletal Radiology, University of Washington
Felix S Chew, MD, MBA, EdM is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

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