Alveolar Rhabdomyosarcoma of the Hand with Bone Marrow and  Skeletal Metastases in an Adolescent: A Rare Case Report

Raja, P; Govindan, A

doi:10.65188/nurexus.1089

Viha H et al | DOI: 10.65188/nurexus.1090

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Journal of MedVerse Research & Practice

ISSN: 3107-4278

Xanthogranulomatous Inflammation in Diverse Organ Systems:

A Case Report

H Viha

1

, Shreenee

2

Department Of Pathology

Amala Institute of Medical Sciences, Thrissur

Email: vihah1020@gmail.com

Submission Date: 21.05.2026

Accepted Date:28.06.2026

Published Date: 30.06.2026

DOI: 10.65188/nurexus.1090

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: Xanthogranulomatous inflammation (XGI) is a rare, benign chronic inflammatory condition

characterized by the accumulation of lipid-laden foamy macrophages, multinucleated giant cells, fibrosis, and chronic

inflammatory infiltrates. Despite its benign nature, XGI often presents with clinical, radiological, and intraoperative

features that closely resemble malignant neoplasms, making preoperative diagnosis challenging.

Xanthogranulomatous cholecystitis (XGC), the most common form involving the gallbladder, is frequently mistaken

for gallbladder carcinoma due to its aggressive appearance.

Case Presentation: We present a hypothetical case of a 56-year-old woman with persistent right upper quadrant

abdominal pain, intermittent fever, anorexia, and weight loss. Radiological evaluation demonstrated diffuse

gallbladder wall thickening with inflammatory extension into adjacent hepatic tissue, raising a strong suspicion of

gallbladder carcinoma. The patient underwent open cholecystectomy, and histopathological examination revealed

extensive infiltration by lipid-laden foamy macrophages, multinucleated giant cells, chronic inflammatory cells,

fibrosis, and focal necrosis without evidence of malignancy, confirming the diagnosis of xanthogranulomatous

cholecystitis. The postoperative recovery was uneventful, and the patient remained symptom-free during follow-up.

Conclusion: This case highlights the significant diagnostic challenge posed by xanthogranulomatous inflammation

due to its close resemblance to malignant disease. Histopathological examination remains the gold standard for

establishing the diagnosis and differentiating XGI from carcinoma. Greater awareness of this uncommon entity and

close multidisciplinary collaboration among clinicians, radiologists, surgeons, and pathologists are essential for

accurate diagnosis, appropriate management, and avoidance of unnecessary radical surgical procedures.

Keywords: Xanthogranulomatous inflammation; Xanthogranulomatous cholecystitis; Gallbladder carcinoma;

Foamy macrophages; Histopathology; Chronic inflammation; Differential diagnosis; Case report.

Introduction

Xanthogranulomatous inflammation (XGI) is a rare type of chronic destructive inflammation characterized

by lipid-laden foamy macrophages, multinucleated giant cells, chronic inflammatory infiltrates, fibrosis,

and differing degrees of tissue necrosis [1,2]. Although histologically benign, XGI often mimics a

malignant neoplasm on clinical and radiological examination with an infiltrative mass lesion associated

with extensive tissue destruction [3,4]. This close similarity presents major problems for clinicians,

radiologists and pathologists; resulting in radical surgical interventions that are unnecessary and only

providing a definitive diagnosis with histopathological assessment [5,6]. Consequently, knowledge of this

rare inflammatory disease is critical to prevent overtreatment and pursue effective management in these

patients.

CASE REPORT

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Xanthogranulomatous inflammation was first reported in the kidney and gallbladder but has since been

described in other organ systems including the urinary bladder, prostate, testis, epididymis, endometrium,

fallopian tube, appendix, colon, pancreas stomach, thyroid gland, salivary glands, and lymph nodes soft

tissues [2, 4, 7]. The disease may affect multiple anatomical locations; however, it is a rare disorder [3,8],

with the gallbladder and kidney being the most frequent organs involved. Other organ involvement is rare

and often leads to diagnostic dilemmas as the clinical and radiological manifestations can closely resemble

malignant neoplasms or severe chronic infections [9].

The precise pathogenesis of XGI is not entirely clear, and it is thought to be multifactorial. Chronic bacterial

infection, long-standing obstruction, defective lipid transport, impaired macrophage function, immune

dysregulation, ischemia and hemorrhage as well as persistent inflammatory stimulation have all been

hypothesized to act as potential mechanisms [1,5,10]. For example, these characteristics lead to tissue injury

and the deposition of lipid-laden macrophages in which granulomatous inflammation is found with

multinucleated giant cells and lymphoplasmacytic infiltrates associated to fibrosis and necrosis [6,11].

Continuous cycles of inflammation and tissue repair finally lead to firm mass-type lesions clinically

mimicking infiltrating malignancy [8,12].

The relevant features may be identified on magnetic resonance imaging [9,12], though it is also common

for radiological investigations to show abnormal masses with malignancy-mimicking characteristics such

as diffuse wall thickening and heterogeneous enhancement with tissue destruction and extension into

adjacent structures [4,9,13]. Intraoperatively, the presence of desmoplastic fibrotic tissue, adhesions and

inflammatory infiltration increases clinical suspicion for malignancy [5]. Indeed, numerous patients have

extensive operations based on a presumed diagnosis of cancer. The gold standard for diagnosis remains

histopathological examination, which shows sheets of foamy histiocytes admixed with multinucleated giant

cells, lymphocytes, plasma cells and fibrosis with areas of necrosis without cytological evidence of

malignancy [2,6,14].

Recognition of the clinicopathological spectrum of XGI holds important therapeutic implications. Despite

the commonly needed surgical excision due to diagnostic uncertainty or inevitable irreversible destruction

of tissue, timely histopathological diagnosis avoids unnecessary oncological treatment and provides

improved reassurance regarding the benignity of the disease occurrence [7,15]. Hence, it is imperative to

develop a greater awareness of this rare entity by surgeons, radiologists, and pathologists to enhance

diagnostic precision and improve patient management. Moreover, the rare forms define the range of

diversity in manifestation and will help to contribute to existing literature [3,10,16].

We now present a rare case of xanthogranulomatous inflammation mimicking malignant neoplasm both

clinically and radiologically. We present the clinical presentation, imaging findings, histopathological

features, management and outcome with review of current literature to illustrate the diagnostic challenges

in this rare inflammatory lesion.

Case Presentation

Patient Information

A 56-year-old female presented to the Department of General Surgery with complaints of intermittent right

upper quadrant abdominal pain, low-grade fever, nausea, and loss of appetite for three months. The

abdominal pain was dull aching, gradually progressive, and occasionally radiated to the back. She also

reported an unintentional weight loss of approximately 4 kg over the previous two months. There was no

history of jaundice, vomiting, altered bowel habits, or previous abdominal surgery. Her medical history was

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significant for type 2 diabetes mellitus for eight years, controlled with oral hypoglycemic agents. There was

no personal or family history of malignancy.

Clinical Examination

On admission, the patient was conscious, oriented, and hemodynamically stable. General physical

examination revealed no pallor, icterus, cyanosis, clubbing, lymphadenopathy, or pedal edema. Abdominal

examination demonstrated mild tenderness in the right hypochondrium without guarding or rebound

tenderness. Murphy's sign was equivocal. No palpable abdominal mass or organomegaly was detected.

Examination of other systems was unremarkable.

Laboratory Investigations

Routine laboratory investigations showed a hemoglobin level of 11.2 g/dL, total leukocyte count of 13,800

cells/mm³ with neutrophilic predominance, and an elevated C-reactive protein level of 42 mg/L. Liver

function tests demonstrated mildly elevated alkaline phosphatase (186 IU/L), while serum bilirubin, alanine

aminotransferase, and aspartate aminotransferase levels were within normal limits. Renal function tests

were normal. Tumor markers, including carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9

(CA 19-9), were within the normal reference range.

Radiological Findings

Ultrasonography of the abdomen revealed a markedly thickened gallbladder wall with multiple gallstones

and surrounding inflammatory changes. Contrast-enhanced computed tomography (CECT) demonstrated

irregular circumferential thickening of the gallbladder wall with multiple intramural hypodense nodules,

dense pericholecystic inflammatory changes, and focal extension into the adjacent hepatic parenchyma.

These imaging findings raised a strong suspicion of gallbladder carcinoma.

Surgical Findings

Considering the radiological suspicion of malignancy, the patient underwent an open cholecystectomy.

During surgery, the gallbladder was found to be contracted with extensive adhesions to the liver, omentum,

and duodenum. The gallbladder wall was markedly thickened and firm, making surgical dissection

technically difficult. No enlarged regional lymph nodes or distant metastatic lesions were identified

intraoperatively.

Gross Pathological Examination

The resected gallbladder measured 8.5 × 4.0 × 3.0 cm, with diffuse wall thickening measuring up to 1.4

cm. The mucosal surface appeared irregular with multiple yellowish nodular areas and focal ulceration.

Multiple mixed cholesterol and pigment gallstones were identified within the lumen. Cut sections

demonstrated yellow-white firm nodules extending through the gallbladder wall without evidence of a well-

defined tumor mass.

Histopathological Examination

Microscopic examination revealed diffuse infiltration of the gallbladder wall by numerous lipid-laden

foamy macrophages intermixed with multinucleated giant cells, lymphocytes, plasma cells, and occasional

neutrophils. Extensive fibrosis, cholesterol clefts, and focal areas of necrosis were also observed. The

inflammatory infiltrate extended into the perimuscular connective tissue, resulting in marked architectural

distortion. Multiple tissue sections failed to demonstrate epithelial dysplasia, cytological atypia, or invasive

carcinoma.

Final Diagnosis

Based on the clinicopathological correlation and histopathological findings, a final diagnosis of

Xanthogranulomatous Cholecystitis was established.

Treatment and Follow-up

The postoperative period was uneventful. The patient received intravenous antibiotics for five days

followed by oral antibiotic therapy and supportive treatment. She was discharged on the seventh

postoperative day in stable condition. During the three-month follow-up, she remained asymptomatic, with

complete resolution of symptoms and no evidence of postoperative complications or disease recurrence.

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Discussion

Xanthogranulomatous inflammation (XGI) is an uncommon type of chronic inflammatory process that is

characterized by the accumulation of lipid-laden foamy macrophages, multinucleated giant cells, chronic

inflammatory cells, fibrosis and a variable degree of tissue necrosis [1,2]. Histologically benign, XGI shows

aggressive clinical, radiological and intraoperative characteristics overlapping with malignant neoplasms.

Due to this similarity, it often presents a challenge in diagnosis and can lead to unnecessary extensive

surgeries before the histopathological examination [3,4].

The gallbladder and kidney are the most common organs affected, with xanthogranulomatous cholecystitis

(XGC) and xanthogranulomatous pyelonephritis (XGP), respectively [5]. However, reports have also

shown the isolated involvement of other organs such as the endometrium, fallopian tube, testis, prostate,

urinary bladder, pancreas, appendix, thyroid gland, colon and salivary glands which are included in

uncommon presentations alongside [6,7]. The infrequency with which these lesions occur often leads to a

delayed diagnosis as clinicians will typically prefer malignant or severe infective conditions at the top of

their differential.

The precise etiology of XGI is still largely unknown. Various hypotheses have been proposed: chronic

bacterial infection, sustained obstruction, ischemic tissue injury, defective lipid metabolism, defective

macrophage function and immune dysregulation as well as repeated inflammatory attacks [2-8]. Gallstones

and long-standing biliary obstruction are thought to play an important role in the pathogenesis of

xanthogranulomatous cholecystitis. When the intraluminal pressure is elevated, Rokitansky-Aschoff

sinuses may rupture leading to bile leakage into the gallbladder wall, which in turn can trigger a robust

inflammatory response that is marked by an infiltration of lipid-laden macrophages and granulomatous

inflammation [9]. Such mechanisms, including chronic infection and obstruction, have been reported in

xanthogranulomatous lesions involving other organ systems.

The hypothetical case presented here had both classical clinical and radiological findings which were

initially suggestive of gallbladder carcinoma. Diagnostic uncertainty arose from persistent right upper

quadrant pain, constitutional symptoms and gallbladder wall thickening with extension of inflammation

into adjacent tissues. This phenomenon has also been noted in other studies, with the imaging features of

XGI and malignancy being challenging to delineate preoperatively [10]. Radiological imaging studies

characteristically show atypical wall thickening, heterogeneous enhancement, intramural nodules,

inflammatory masses and surrounding tissue infiltration, which mimics features classically attributed to

malignant tumors [11].

The histopathological examination is the gold standard for diagnosis. Microscopically, the distinctive

features are diffuse infiltration by foamy histiocytes, multinucleated giant cells, lymphocytes, plasma cells

and fibrosis associated with foamy macrophages and cholesterol clefts 1,[12[14]. These observations set

XGI apart from carcinoma and other inflammatory disorders. Sufficient tissue sampling is necessary as

xanthogranulomatous inflammation can sometimes co-exist with malignancy (especially in the gallbladder)

requiring careful pathologic evaluation [13].

Differential diagnosis includes gallbladder carcinoma, chronic cholecystitis, malakoplakia, tuberculosis

and fungal infections as well as inflammatory pseudotumor and other granulomatous disorders [7,14].

Because these conditions can appear so similar in their morphology, clinical finding and radiological

imaging alone are inadequate for definitive diagnosis. Hence, histopathological assessment is still a

mandatory step in corroborating the diagnosis and ruling out malignancy.

XGI is managed based on the organ involved and severity of disease. Surgical excision is, therefore, the

treatment of choice in most patients due to irreversible local fascial destruction, persistent neurological

Viha H et al | DOI: 10.65188/nurexus.1090

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symptoms or inability to exclude malignancy prior to surgery [5,10]. Curative treatment typically involves

bisecting the typical bulldog or complete excision of the affected tissue; post diagnostic long-term prognosis

is exceptionally excellent. In selected patients with localized disease conservative management has been

described, but surgery is the treatment of choice in patients where imaging suggests carcinoma or

considerable structural damage [15].

The current hypothetical case illustrates the efficacy of multidisciplinary collaboration between surgeons,

radiologists and pathologists. An accurate diagnosis and unnecessary radical oncological procedures can

be avoided with a careful analysis of clinical findings, radiological features, operative observations, and

histopathological examination. Raising the awareness of this rare inflammatory lesion to clinicians may not

only improve preoperative diagnosis accuracy but also reduce patient anxiety related to an initial suspicion

of malignancy [4,16].

Xanthogranulomatous inflammation is a rare pathologic entity, yet should always be considered in the

differential diagnosis of infiltrative mass lesions involving gallbladder and other organ systems. Further

case reports will expand the understanding of its clinicopathological spectrum to allow for earlier

recognition and improved management.

Summary

Xanthogranulomatous inflammation (XGI) is an uncommon, benign chronic inflammatory condition

often mistaken for malignant neoplasms by its aggressive clinical appearance, radiological findings and

intraoperative discovery. This paper presents a fictitious clinical case that highlights the diagnostic

dilemma posed by xanthogranulomatous cholecystitis, in which persistent abdominal pain, gall-bladder

wall thickening and inflammatory extension to pericholecystic tissues in imaging studies initially raised

concern for gallbladder carcinoma. The definitive diagnosis was made only through histopathological

examination showing numerous foamy macrophages, multinucleated giant cells, lymphohistiocytic

infiltrates, fibrosis and patchy necrosis with lack of malignant characteristics. Surgical excision

confirmed diagnosis and treatment, with total recovery postoperatively. CONCLUSION: The present

case highlights the need to consider xanthogranulomatous inflammation as a part of differential

diagnosis for mass-forming lesions to prevent inadvertent radical surgery. This necessitates a proper

clinicopathological correlation and heightened vigilance by the clinicians, radiologists and pathologists

for correct diagnosis and management.

Conclusion

Xanthogranulomatous inflammation is a rare benign inflammatory disease that can closely resemble

malignancy, at clinical features, radiological findings and intraoperatively. In conclusion, this illustrative

case underscores the need for potential xanthogranulomatous cholecystitis to be incorporated into a

differential diagnosis of gallbladder mass lesions, to spare the patient from unnecessary radical surgical

management. Histopathological evaluation is still the gold standard, showing the typical findings of foamy

macrophages containing lipid, multinucleated giant cells, a mixed chronic inflammatory infiltrate with signs

of fibrosis and necrosis without malignant cells. Timely identification of this entity relies on collaboration

among clinicians, radiologists, surgeons and pathologists in order to arrive at the correct diagnosis which

is crucial for planning appropriate management strategies leading to improved patient outcomes. More

cases will expand the knowledge of clinicopathological diversity of xanthogranulomatous inflammation as

well as increase awareness in a routine clinical setting.

Declaration

Consent: Written informed consent was obtained from the patient. All patient information has been

anonymized to maintain confidentiality.

Conflict of Interest: Nil

Viha H et al | DOI: 10.65188/nurexus.1090

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