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Year : 2013  |  Volume : 56  |  Issue : 4  |  Page : 468-469
Lipid lymphadenopathy


Department of Histopathology, Mubarak Al Kabir Hospital, Jabriya, Kuwait

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Date of Web Publication18-Jan-2014
 

How to cite this article:
George SA, Issam F. Lipid lymphadenopathy. Indian J Pathol Microbiol 2013;56:468-9

How to cite this URL:
George SA, Issam F. Lipid lymphadenopathy. Indian J Pathol Microbiol [serial online] 2013 [cited 2019 Dec 10];56:468-9. Available from: http://www.ijpmonline.org/text.asp?2013/56/4/468/125379


A 29-year-old woman presented to the medical casualty with a 6 months history of fever of unknown origin, associated with weight loss and night sweats. Her past medical history was significant for recurrent gluteal abscesses associated with fever, which followed an intramuscular injection of unknown nature in the gluteal region. Her hematological workup revealed a marked normochromic normocytic anemia and high ESR. There was no evidence of leukocytosis or lymphocytosis. Blood and urine culture showed negative growth. Radiological investigations which included chest X-Ray and abdominal ultrasonography were within normal limits. Physical examination revealed the presence of a painful right inguinal mass judged to be a lymphadenopathy and also showed black raised pigmented skin lesions in the gluteal region bilaterally. Fine needle aspiration of the inguinal mass showed reactive lymphoid tissue. She was placed on antibiotic treatment but showed no response. The inguinal mass was surgically removed and submitted for histological evaluation. The excised specimen was a grey white nodular soft tissue mass which measured 5 × 2 × 3.5 cm in size and had a yellowish cut surface with multiple cystic spaces containing slimy material [Figure 1]. Microscopy showed multiple lipid granulomas with central foci of calcification rimmed by foamy histiocytes and apoptotic debris [Figure 2]. Microcyst formation and fat globules were seen dispersed throughout the parenchyma [Figure 3] and these fat globules were stained by Oil red O [Figure 4]. No refractile particles or microorganisms were noted. A final diagnosis of lipid lymphadenopathy was rendered. Our patient is currently asymptomatic and doing well.
Figure 1: Lymph node with yellowish cut surface and microcysts

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Figure 2: Lipid microgranuloma (H and E, ×400)

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Figure 3: Lipid vacuoles and microcysts (H and E, ×200

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Figure 4: Oil Red O staining the lipid droplets

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   Discussion Top


Lipid lymphadenopathy is defined as lymphadenopathy with foreign-body reaction to lipids of endogenous or exogenous origins. Lipogranuloma commonly manifests clinically as palpable lymphadenopathy and subcutaneous nodules or can involve other components of reticuloendothelial system (bone marrow, liver, spleen). [1] Being rare, lipogranulomas have been reported in penis, nasal septum and eyelids. Endogenous causes of lipids include hematomas, cholesterol deposits, xanthomatous lesions, tumors, fat emboli, and necrotic fat and also can develop in peribiliary lymph nodes in case of chronic cholecystitis, cholelithiasis etc. Lipogranulomas via endogenous etiology is noted to be a more rare occurrence. The sources of exogenous lipids include contrast media used in lymphangiography or bronchography, lipid based substances injected into hemorrhoids and oils used as depot vehicles to allow slow release of injected drugs and paraffin-based emollients. [2] Histopathological features include lipid microcysts and lipid granulomas with foamy histiocytes and foreign body giant cell reaction around lipid droplets. The vacuoles seen in endogenous lipid degeneration are typically much smaller than those seen with exogenous lipid material. Our case showed the classical features of lipogranuloma. Given the patient's history of gluteal intramuscular injections, the etiology of the lipogranuloma can be traced to some form of exogenous lipid material deposited in this site and had followed the lymphatic drainage to inguinal lymph node. The exogenous fat is removed eventually in days to weeks or it may take months or years. [2]

The differential diagnoses include Whipple disease, fungal infections, Mycobacterial infections, sarcoidosis and silicone lymphadenopathy. The lesions in Whipple disease are distinguished by the presence of PAS-positive inclusions. Special stains and microbiological studies can rule out other infectious causes. Silicone lymphadenopathy differs from lipogranulomatous lymphadenopathy as the former is characterized by the presence of multinucleated foreign body-type giant cells containing refractile particles of foreign material. Sarcoidosis forms well-defined granulomas without intracellular or extracellular vacuoles. Partial or total fatty metamorphosis of lymph nodes that takes place as part of ageing, obesity or after radiation treatment is another differential but this lacks significant granulomatous or inflammatory reaction. [3]

Although lipid adenopathy is rare, this should be among the differential diagnosis of patients presenting with inguinal lymph node enlargement and this case also serves as a reminder that common complaints can be a sign of significant pathology.

 
   References Top

1.Rywlin AM, Ortega R. Lipid granulomas of the bone marrow. Am J Clin Pathol 1972;57:457-62.  Back to cited text no. 1
    
2.Cockayne SE, Lee JA, Harrington CI. Oleogranulomatous response in lymph nodes associated with emollient use in Netherton's syndrome. Br J Dermatol 1999;141:562-4.  Back to cited text no. 2
    
3.Smith T. Fatty replacement of lymph nodes mimicking lymphoma relapse. Cancer 1986;58:2686-8.  Back to cited text no. 3
    

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Correspondence Address:
Smiley Annie George
Department of Histopathology, Mubarak Al- Kabir Hospital, Jabriya
Kuwait
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.125379

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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