Mistletoe therapy as a therapeutic option in a child with lymphomatoid papulosis/CD 30-positive cutaneous lymphoproliferative papulosis

Abstract

Lymphomatoid papulosis (LP) is a very rare skin disease in childhood within the spectrum of the CD30-positive lymphoproliferative disorders. The cause of the disease is unknown. Sometimes the disease resolves spontaneously, but also malignant courses are possible, either as a cutaneous or systemic CD 30-positive anaplastic large cell non-Hodgkin lymphoma. In adults between 5% and 20% of the LP-patients develop malignant lymphomas. In children the experiences are limited, but the overall survival seems to be excellent and similar to adults [1] . Different therapeutic regimens are performed. Besides watch-and-wait therapy, topical steroids or PUVA therapy also low-dose methotrexate therapy are treatment options. A 12-year-old girl with weight loss, swelling of the lymph nodes and general weakness was admitted to our integrative pediatric oncology department. Also small erythematous and violaceous papules over the whole body were seen. In the diagnostic the ESR and CRP were elevated and an infectious or autoimmune etiology were ruled out. In MRI the patient showed enlarged left cervical and left axillary lymph node regions. An open biopsy of the suspected lymph nodes and skin-lesions, including bone marrow puncture were performed. The immunhistochemical examination of the lymph nodes showed a malignant ALK-negative CD 30-positive lymphoma. But the immunhistochemical examination of the skin diagnosed a lymphomatoid papulosis. The bone marrow-smear did not show evidence for malignant infiltration. On the basis of the diagnosis lymphomatoid papulosis with involvement of the lymph nodes in a clinical stable patient without strong evidence of a malignant disease and based on experience of a second patient with LP and lymph-node-involvement, a therapy with a mistletoe-preparation intravenously was initiated [2] . We escalated the dosage over 3 days given once per day as an infusion over 3 h. After the third day we continued mistletoe treatment subcutaneously 2 times per week. On the fourth day after beginning of the treatment the size of the cervical lymph nodes were decreasing and new papules were not seen any more. After 1 week of treatment the patient was discharged with almost normal blood samples. Four weeks after starting of the treatment all skin and suspected lymph nodes were vanished, proven by clinical examination and ultrasound. During the follow-up ultrasound was done every month and MRI of the lymph nodes was performed every 3 months. Six months after diagnosis the patient is in a stable remission. The therapy with mistletoe is continued twice per week. In conclusion we present a patient with a rare skin disease (LP) with lymph node involvement who is successful treated with mistletoe as a new promising therapeutic option for patients with lymphomatoid papulosis. Further studies should be initiated.