Idiopathic Ceroid Histiocytosis of Spleen: Syndrome of the Sea-Blue Histiocyte*

HENRY A. TELOH, M.D., M.S. and ARKADI M. RYWLIN, M.D.

Associate Professor of Pathology, University of Miami School of Medicine, Miami, FL and Attending Pathologist, Jackson Memorial Hospital, Miami, FL 33136 Professor of Pathology, University of Miami School of Medicine, Miami, FL and Director, Department of Pathology and Laboratory Medicine, Mount Sinai Hospital of Greater Miami, Miami Beach, FL 33140

The term ceroid was first applied by 4. It stains positively with the periodic Lillie et al7 to a wax-like, coarse, yellow acid, peracetic acid and performic acid, pigment noted in the cirrhotic livers of rats using the Schiff procedure. maintained on a low protein, low fat diet. 5. It retains acid fast stains. Endicott and Lillie1 subsequently described 6. It is insoluble in dilute acids and this pigment as having a bronze brown alkalis but it is saponified by boiling in 10 color in gross preparations. Microscop percent NaOH. Fatty acids are precipitated ically, it appears as yellow globules 1 to from solution by acids. 20 micra in diameter. Histochemical char acteristics of ceroid were studied exten 7. It is insoluble in alcohols, acetone, sively and were described, in part, as ether, aliphatic and aromatic hydrocarbons, follows: chloroform, carbon tetrachloride, pyridine, 1. It is stained by oil soluble dyes both in acetic anhydride, glycols and glycerol. frozen sections and paraffin prepared tis 8. It is not bleached by permanganate, sues. Oil soluble dyes are readily removed chromic acid, hydrogen peroxide, bromide by acetone and alcohol. Following removal or chlorine water. of the dye, the preparation may be re 9. The Prussian blue reaction is usually stained. negative, but iron positive pigment is some 2. It demonstrates greenish yellow auto times associated with it. fluorescence which fades to pale yellow on 10. It stains strongly with basic fuchsin frozen sections. and methylene blue. 3. It shows golden brown autofluores Experimental studies have shown that cence of unstained paraffin sections. ceroid is the result of oxidation and poly merization of unsaturated lipids.2 At the ° Presented at the Applied Seminar on the Clinical Pathology of the Lipids, November, 1971. present time its exact chemical structure is 176 TELOH AND RYWLIN unknown. Depending upon the degree of There was weight loss of an unstated amount in the past 5 to 6 weeks. There was nausea but no oxidation and polymerization the histo- emesis. The patient denied melena, hemoptysis, chemical reactions may differ somewhat. diarrhea, steatorrhea or anorexia. The patient Autofluorescence appears first, followed by denied excessive alcohol intake but smoked 1 to 1.5 packs of cigarettes daily. There was a history PAS positivity and then acid-fastness.3 of poliomyelitis as a child. Family history was Lipofuscin and ceroid seem to have noncontributory. Dietary habits were unremark able, and there was no apparent excessive intake similar histochemical characteristics. Dif of lipids. ferent physical characteristics have been Pertinent findings on physical examination re postulated by some.18 At present lipofuscin vealed a mild enlargement of upper cervical lymph nodes and a smooth nontender spleen felt 8 cm seems the preferred term for the naturally below the costal margin. Retinal examination was occurring, age-related pigment, while ceroid not recorded. Extensive laboratory investigation revealed no is used for a similar pigment in experi significant positive findings. This included complete mental and pathologic conditions. Objec blood count including differential count, platelets, urinalysis, prothrombin time, partial thrombo tion to the term ceroid has been voiced by plastin time, SMA-12 panel, serum iron and serum Wolman17 who prefers Ciaccio’s chromo iron binding capacity, antinuclear antibody, heterophile, Coombs tests, lipase, amylase, fetal lipoid because it is more inclusive and has hemoglobin, haptoglobin, G-6 -PD, methemalbumin, historical preference. The term, however, serum protein electrophoresis and immunoelectro- phoresis, hemoglobin electrophoresis, and lipid is well established in medical literature. fractionation. Seram cholesterol was 180 mg per Recent delineation of a peculiar syndrome 1 0 0 ml, and triglycerides were 6 8 mg per 1 0 0 ml. Lipoprotein electrophoresis was within normal characterized by splenomegaly, thrombo limits. cytopenia and sea-blue histiocytes has Radiological examination revealed a normal evoked considerable interest. Silverstein et upper gastrointestinal series with splenomegaly. Splenic arteriogram outlined an enlarged spleen al16 has called this entity syndrome of the without evidence of a discrete mass. An IVP was sea-blue histiocyte. Rywlin et al12 have normal. Needle biopsy of liver was normal. Smears of shown that the pigment in one of Silver- a sternal bone marrow aspiration were normal, no stein’s cases was ceroid and have proposed foam cells or sea-blue histiocytes were seen. that the syndrome be renamed idiopathic A splenectomy was done (S-71-856) which re vealed a spleen weighing 450 gm. The capsule ceroid histiocytosis of spleen and marrow, was smooth, thin and intact. The cut surfaces since ceroid containing histiocytes can ac were firm, slightly bulging, and homogeneous dark red. Trabecular structures and lymphoid follicles cumulate in the spleen and bone marrow were not prominent. under different circumstances including A frozen section diagnosis of ‘lipid histocy- tosis, type undetermined” was rendered. On both dietary intake of unsaturated fats, microscopic examination of permanent sections hyperlipoproteinemias, ITP, various hemo there were well-demarcated follicles and trabecular lytic processes and other lipid histiocytoses. structures. The red pulp contained innumerable large histocytic cells occurring singly and in small groups, predominantly in the cords of Billroth.

C a s e R e p o r t Their cytoplasm was finely and coarsely vacuolated to granular; frequently, small regular brown A 27 year old married white man (J.M.H. granules were visible in some of the cells. They 948981) had a history of pain in the left lower were grouped principally around trabecular struc quadrant of the abdomen of three days duration. tures. No abnormal plasma cell infiltrate was Medical history included an appendectomy three noted. years ago at which time splenomegaly was noted. Histochemical characteristics; Since the appendectomy, the patient has had re current episodes of left lower quadrant pain, stab 1. Hematoxylin and eosin stains: finely to bing in nature, occurring about once monthly and coarsely vacuolated cells, some of them contain lasting for 15 to 20 seconds. The episodes of pain ing a fine, uniform brown granularity. increased gradually in frequency and severity; re 2. Periodic acid-Schiff reaction-positive with and cently, the attacks occurred 15 to 20 times daily. without diastase digestion. IDIOPATHIC CEROID HISTIOCYTOSIS OF SPLEEN 177

3. Oil red O-positive in frozen and paraffin described a clinical syndrome associated processed tissues. with an unidentified reticuloendothelial cell 4. Sudan Black B, positive in frozen sections and in paraffin processed tissues. in the bone marrow and spleen in two pa 5. Acid fast stains positive. tients. They divided the cells into two 6 . Giemsa stain: granular sea blue cytoplasm morphologically distinct types: (1) a large seen on splenic imprints. reticuloendothelial-like cell with a single 7. Fluorescence microscopy: tan brown fluores cence seen in formalin fixed unstained sections and nucleus usually eccentrically placed whose in the granules of the sea blue histiocytes of the cytoplasm was packed with blue staining splenic imprints. Final pathological diagnosis was “ceroid histio pigmented granules of variable size and cytosis, idiopathic.” shape whose stain intensity varied from a very light azure blue to a deep sea blue; Review of Literature and (2) a large foamy reticuloendothelial Moeschlin10 first described the occurrence cell with scattered dark granules. This ap of “blue pigment” macrophages in a splenic peared to be a macrophage of the type not puncture and in a marrow film. It was uncommonly noted in the bone marrow. Sawitzky, Hyman and Hyman14 who first Histochemically, the granules were PAS

F ig u r e 1. Low power photomicrograph of spleen showing preservation of the general architecture with numerous foamy histiocytes in the red pulp. (H&E X176) 178 TELOH AND RYWLIN

Figure 2. Red pulp of the spleen containing numerous large histiocytes with foamy cytoplasm. (H&E X 666)

positive before and after diastase, toluidine plasm; (2) with clear or finely vacuolated blue negative, alkaline phosphatase nega cytoplasm; and (3) with brownish yellow tive, acetic-carbol-sudan III negative, Feul- pigment diffusely spread throughout the gen negative, and iron negative. The au cell. Biochemically, there was an increase thors felt that the granules contained in phospholipid and glycolipid. Histochem- mucopolysaccharides. They suggested a ically, the coarse granules were considered syndrome consisting of asymptomatic to be saturated phospholipids, the pig splenomegaly, normal hematological find mented granules nonreducing lipofuscin ings and a benign course. (ceroid), and the fine granules saturated Marshall and Adams9 observed a patient glycosphingoside or glycolipid. with an unusual form of lipidosis associated Malinin8 in 1961 presented a case report with thrombocytopenia and angiomas of the of a 30 year old female with hepatospleno- spleen. The patient had a normal bone megaly. The bone marrow contained two marrow, normal liver and splenomegaly. abnormal cell types: (1) a prominent cell Three types of macrophages were de representing a large reticuloendothelial-like scribed: (1) with coarsely vacuolated cyto cell with a small eccentrically placed nu IDIOPATHIC CEROID HISTIOCYTOSIS OF SPLEEN 179

F i g u r e 3. Red pulp of the spleen. Many of the large histiocytes con tain well-defined ceroid granules. (H&E X666)

cleus whose cytoplasm contained numerous concluded that the granules were composed dark sea blue, densely packed round and of an insoluble unknown chemical complex oval granules; (2) a cell with a foamy containing lipid and protein. cytoplasm, scattered dark blue granules and Silverstein, Young and ReMine in 196415 an eccentric nucleus with a prominent nu presented a case report of a 60 year old cleolus; and (3) an intermediate stage white female with hepatosplenomegaly, represented by cells whose cytoplasm con easy bruising and bleeding. Lipid profile tained vacuoles as well as dark blue gran was normal. The bone marrow contained ules. In the liver, abnormal cells were noted large histiocytes with a cyptoplasm packed in the sinusoids and in periportal connec with large blue staining granules. A few of tive tissue. Histochemically, the cells were the well granulated histiocytes contained PAS positive with and without diastase, pale yellow pigment. Histochemically, the Feulgen negative, and sudanophilic in both cells were PAS positive both before and paraffin and frozen sections after boiling in after diastase digestion, were Sudan Black acetate buffer at pH 4. Metachromasia positive and iron negative. The granules was absent with toluidine blue. Malinin were considered to be a phospholipid or 180 TELOH AND RYWLIN

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F i g u r e 4. Splenic his tiocytes containing Oil Red O positive granules. :* . .$ Frozen section material. I ( X 1664)

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% • glycolipid. The authors considered this to distinct but probably related storage cell be a syndrome characterized clinically by types: (1) Cells varying from 20 to 50 splenomegaly and morphologically by the micra with numerous blue granules scat presence of a distinct unusual histiocyte. tered throughout the cytoplasm; (2) Cells They found no evidence for a familial or 20 to 60 micra in diameter without cyto congenital basis. This case was reexamined plasmic granules but with a foamy vascuo- by Rywlin et al12 and splenic histiocytes lated cytoplasm; and (3) Intermediate were shown to contain abundant ceroid. forms present with only a few granules in Holland4 discussed chronic reticuloendo a vacuolated cytoplasm. The cells were thelial cell storage disease and presented a PAS positive with and without diastase case report of a six year old child with digestion, toluidine blue negative, and asymptomatic hepatosplenomegaly, normal Sudan Black B positive which suggested serum lipid profile, and with normal serum that the lipid was primarily a phospholipid. triglycerides. Studies were done on bone Silverstein, Ellefson, and Ahers16 in 1970 marrow aspiration smears and paraffin sec coined the term “syndrome of the sea-blue tions. He described two morphologically histiocyte” and described the case of a black IDIOPATHIC CEROID HISTIOCYTOSIS OF SPLEEN 181

F ig u r e 5. Splenic his tiocytes with acid-fast positive granules in the cytoplasm. Acid fast stain. (X 1664)

girl observed from 16 months to 10 years of drome characterized by occurrence of a age. She presented with hepatosplenomeg- rare, morphologically distinct blue, granu aly and persistent thrombocytopenia. Bone lated histiocyte associated with splenomeg marrow examination revealed a moderate aly. It was postulated that the syndrome number of sea-blue histiocytes. Sple represented a definite metabolic abnormal nomegaly was done during the course of ity characterized by a relatively benign the child’s illness. Final admission at 10 course with mild purpura or bleeding years of age was preceded by fever and tendency secondary to thrombocytopenia. deepening jaundice. At necropsy the liver It was thought that progressive cirrhosis showed obvious cirrhosis and fatty vacuoles with hepatic failure and death could occur. in parenchymal cells. Previously recorded Jones, Gilbert, Zugibe and Thompson5 cases were reviewed and delineated a syn described two siblings, ages 10 and 12 years 182 TELOH AND RYWLIN

F ig u r e 6 . Splenic his tiocytes with PAS posi tive granules in the cyto plasm. Periodic acid Schiff stain. ( X 1664 )

with the sea-blue histiocytc syndrome. The blue. Liver biopsy revealed cells similar diagnosis was made on the basis of bone to those seen in the bone marrow. The marrow aspirates. Findings of bone mar granules were weakly PAS positive. No row material in the parents and one sibling further histochemical reactions were carried were normal. The authors postulated that out. the disease was a hereditary disorder of Rosner et al11 presented a short case re lipid metabolism similar to Gaucher’s dis port of a 20 year old black man admitted ease and transmitted as an autosomal reces because of grand-mal seizures, fever, right sive trait. supraclavicular adenopathy and a large Saidi et al13 published the account of a nontender firm spleen. Biopsy of the 16 year old Iranian boy admitted for supraclavicular node showed coalescent hepatosplenomegaly which had been noted epithelioid granulomas. No acid fast or since early childhood. There was no docu fungal organisms were noted. The patient mented case of hepatosplenomegaly in the was given antitubercular therapy. A bone family. Bone marrow aspirate contained marrow aspiration showed moderate num many large histiocytes with many cyto bers of “sea-blue histiocytes.” Histochem plasmic granules of varying size and varying ical staining reactions were similar to those stain intensity from light azure to deep previously described by other authors. IDIOPATHIC CEROID HISTIOCYTOSIS OF SPLEEN 183

F i g u r e 7. Splenic im print containing a large histiocyte cell with blue granular cytoplasm ( sea- blue histiocyte) Wright’s stain. (xl& 64)

Comment tions as outlined by Rywlin et al12 or may A seemingly divergent group of cases are be idiopathic as in the patient presented reviewed here which have as a common in this paper. denominator lipid-containing histiocyte oc The studies of Sawitsky et al14 were based curring in the spleen and sometimes in the on bone marrow and splenic smears. The liver and bone marrow and unaccompanied type I ccll contained blue staining pig by any of the biochemical alterations known mented granules when stained with Giemsa to give rise to such cells. Splenic lipid stain. Since the Giemsa reaction for ceroid histiocytes may be associated with hyper is nonspecific12 and since histochemical lipoproteinemia, idiopathic thrombocyto stains for ceroid other than the PAS reac penic purpura, Felty’s syndrome, aplastic tion were not investigated by Sawitsky, it anemia, acute granulocytic leukemia, acute is entirely possible that his cases fall into lymphocytic leukemia, chronic myelogenous the category of what is here called ceroid leukemia, and a number of diverse condi histiocytosis. 184 TEI.OH AND RYWLIN

The type III cell described by Marshall of the bone marrow were PAS positive, and Adams9 contained brownish yellow Sudan Black B positive, Oil Red O positive pigment diffusely spread throughout the before and after cold acetone extraction. cell. Histochemically, the pigmented It was concluded that the histiocytic cyto granules were considered to be nonreduc- plasm contained a glycophospholipid com ing lipofuscin (ceroid). plex. In the case presented by Malinin,8 a type A critical review of the published case II cell in the bone marrow was described reports leads one to the following tentative with a foamy cytoplasm and scattered dark conclusions : blue granules. The granules were PAS 1. Ceroid histiocytosis may be seen in a positive both before and after diastase variety of clinical states and probably there digestion and sudanophilic in both paraffin fore represents a nonspecific morphologic and frozen sections after boiling in acetate response to a diversity of biochemical buffer. This combination of histochemical alterations. properties strongly suggests the presence of 2. Although ceroid containing histiocytes a ceroid-like pigment. may appear in a number of diseases, the The patient described by Silverstein et syndrome described by Silverstein et al16 al15 contained histiocytes in the bone mar may represent a specific entity characterized row. These cells exhibited a cytoplasm with clinically by splenomegaly and anatomically large, blue staining granules and occa by 'the presence of numerous ceroid-con- sionally with pale yellow pigment. The taining histiocytes in the spleen and/or cells were PAS positive before and after bone marrow in the absence of any of the diastase digestion, were Sudan Black posi known biochemical alterations known to tive and iron negative. Silverstein con give rise to such cells. sidered the granules to be a phospholipid 3. The presence of ceroid cannot be as or glycolipid. certained in all the cases reported as syn The sections of the spleen of the first drome of the sea-blue histiocyte because patient described by Silverstein as “syn of incomplete histochemical data. How drome of the sea-blue histiocyte”16 were ever, none of the histochemical reactions examined. The histiocytes had all the histo reported were inconsistent with ceroid. chemical criteria of ceroid and were iden Furthermore, ceroid-containing histiocytes tical with those in the patient presented in stain blue with Giemsa and appear as sea- this paper. blue histiocytes. Also, in five of the cases, In the case of Holland et al,4 cells were including, the present report accepted as described in the bone marrow as having syndrome of the sea-blue histiocyte, the numerous blue granules throughout the histochemical reactions indicated the pres cytoplasm. These granules were PAS posi tive with and without diastase digestion, ence of ceroid. and were Sudan Black B positive, suggest 4. The following cases along with the ing the presence of ceroid but precluding presently reported case can then be rea its identification because of insufficient data. sonably accepted as examples of idiopathic In the two patients described by Jones et ceroid histiocytosis or “syndrome of the al,5 the granules of the sea-blue histiocytes sea blue histiocyte”: IDIOPATHIC CEROID HISTIOCYTOSIS OF SPLEEN 185

Sawitsky, Hyman and Hyman,14 Marshall genesis and repair of the hepatic cirrhosis in rats produced on low protein diets and pre and Adams,9 Malinin,8 Silverstein, Young ventable with choline. Public Health Rep. 57: and ReMine,15 Holland, Hug and Schubert,4 502, 1942. Silverstein, Effelson and Ahers,16 Jones, Gil 8 . M a l in i n , T. I.: Unidentified reticuloendo thelial cell storage disease. Blood 17:675, bert, Zugibe and Thompson,5 Rosner, 1961. Kagen, Dana,11 Saidi, Azizi, Scarlati and 9. M arshall, A. H. E., and Adams, C. W . M .: Sayer,13 and Teloh and Rywlin. Unusual form of lipidosis associated with thrombocytopenia and angiomata of spleen. J. Path. Bact. 76:159, 1958. Summary 10. M o e s c h l in , S.: Splenic Puncture, pp. 24-55, Grune & Stratton, New York, 1951. The general chemical and histochemical 11. R o s n e r , F., K a c e n , M. D., and Dana M.: nature of ceroid is discussed. A case report The sea-blue histiocyte syndrome. New Eng. of “idiopathic ceroid histiocytosis of spleen” J. Med. 282:1100, 1970. is presented. A review of case reports of 12. R y w l i n , A. M., Hernandez, J. A., C h a s t a i n , D. E., a n d P a r d o , V.: Ceroid histiocytosis of idiopathic ceroid histiocytosis is presented. spleen and bone marrow in idiopathic thrombocytopenic purpura ( I T P ) : a contribu tion to the understanding of the sea-blue References histiocyte. Blood 37:587, 1971.

1. E n d ic o t t , K. M., a n d L i l l i e , R. D.: Ceroid, 13. S a id i, R., A z iz i , S. P., S a r l a t i, R., a n d the pigment of dietary cirrhosis of rats. Its S a y e r , N.: Rare variant of lipid storage dis characteristics and its differentiation from orders. Blood 35:533, 1970. hemofuscin. Amer. J. Clin. Path. 20:149, 1944. 14. S a w i ts k y , A., H y m a n , G. A., and Hyman, J. 2 . H a r t r o f t , W. S.: In vitro and in vivo pro B.: An unidentified reticuloendothelial cell in duction of a ceroid-like substance from bone marrow and spleen: report of two cases erythrocytes and certain lipids. Science 113: with histochemical studies. Blood 9:977, 1954. 673, 1951. 15. S il v e r s t e in , M . N., Yo u n g , D . G., R e M i n e , 3. H a r t r o f t , W. S., a n d P o r t a , E. A.: Ceroid. W. H., et al: Splenomegaly with rare morpho Amer. J. Med. Sci. 250:324, 1965. logically distinct histiocyte: a syndrome. Arch. 4. H o l l a n d , P., H u g , G., a n d S c h u b e r t , W. Int. Med. 114:251, 1964. K.: Chronic reticuloendothelial cell storage 16. Silverstein, M. N., E l l e f s o n , R. D., a n d disease. Amer. J. Dis. Child. 110:117, 1965. A h e r n , E . J.: The syndrome of the sea-blue 5. J o n e s , B., G il b e r t , E . F., Z u g ib e , F. T ., a n d histiocyte. New E n g . J. Med. 282:1, 1970. T h o m p s o n , H.: Sea-blue histiocyte disease in 17. W o l m a n , M.: Handbuch der Histochemie, siblings. Lancet, 2:73, 1970. Vol. V, Lipides, second part. Gustav Fischer 6 . K a t t l o v e , H. E., G a y n o r , E., S p iv a c k , M., Verlag, Stuttgart, 1964. a n d G o t t f r ie d , E. L.: Sea-blue indigestion. 18. Z e m a n , W., a n d D y k e n , P.: Neuronal ceroid- New Eng. J. Med. 282:630, 1970. lipofuscinosis (Batten’s Disease): relationship 7. L il l ie , R. D., A s h b u r n , L. L., S e b r e l l , W. to amaurotic family idiocy? Pediatrics 44: H., D a ft, F. S ., a n d L o w r y , J. V.: Histo 570, 1969.

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