Peroxisome Proliferator-activated Receptor-γ Deficiency Exacerbates Fibrotic Response to Mycobacteria Peptide in Murine Sarcoidosis Model

We established a murine model of multiwall carbon nanotube (MWCNT)-elicited chronic granulomatous disease that bears similarities to human sarcoidosis pathology, including alveolar macrophage deficiency of peroxisome proliferator-activated receptor γ (PPARγ). Because lymphocyte reactivity to mycobacterial antigens has been reported in sarcoidosis, we hypothesized that addition of mycobacterial ESAT-6 (early secreted antigenic target protein 6) to MWCNT might exacerbate pulmonary granulomatous pathology. MWCNTs with or without ESAT-6 peptide 14 were instilled by the oropharyngeal route into macrophage-specific PPARγ-knockout (KO) or wild-type mice. Control animals received PBS or ESAT-6. Lung tissues, BAL cells, and BAL fluid were evaluated 60 days after instillation. PPARγ-KO mice receiving MWCNT + ESAT-6 had increased granulomas and significantly elevated fibrosis (trichrome staining) compared with wild-type mice or PPARγ-KO mice that received only MWCNT. Immunostaining of lung tissues revealed elevated fibronectin and Siglec F expression on CD11c⁺ infiltrating alveolar macrophages in the presence of MWCNT + ESAT-6 compared with MWCNT alone. Analyses of BAL fluid proteins indicated increased levels of transforming growth factor (TGF)-β and the TGF-β pathway mediator IL-13 in PPARγ-KO mice that received MWCNT + ESAT-6 compared with wild-type or PPARγ-KO mice that received MWCNT. Similarly, mRNA levels of matrix metalloproteinase 9, another requisite factor for TGF-β production, was elevated in PPARγ-KO mice by MWCNT + ESAT-6. Analysis of ESAT-6 in lung tissues by mass spectrometry revealed ESAT-6 retention in lung tissues of PPARγ-KO but not wild-type mice. These data indicate that PPARγ deficiency promotes pulmonary ESAT-6 retention, exacerbates macrophage responses to MWCNT + ESAT-6, and intensifies pulmonary fibrosis. The present findings suggest that the model may facilitate understanding of the effects of environmental factors on sarcoidosis-associated pulmonary fibrosis.

Sarcoidosis with small syringotropic granulomas presenting clinically as a pigmented purpuric dermatosis: Inconspicuous clinical and histopathological clues to systemic illness

Sarcoidosis is a multisystem granulomatous disease with a myriad of clinical manifestations and a predilection to involve the lungs, eyes, lymph nodes, and skin. A 38-year-old man presented to dermatology with a history of progressive dyspnea, pulmonary consolidations on chest X-ray, and hilar adenopathy on computed tomography scan. Skin exam revealed asymptomatic, yellow to brown macules on the right lower extremity. Biopsy of a lesion showed diminutive syringotropic granulomas and perivascular hemosiderin; stains for bacteria, mycobacteria, and fungi were negative. Subsequent fine needle aspiration of a hilar mass revealed non-necrotizing epithelioid granulomas further supporting a diagnosis of sarcoidosis. The patient was placed on systemic steroids and had improvement of his pulmonary symptoms and stabilization of his hilar lymphadenopathy without resolution of his pigmented purpuric dermatosis (PPD) like lesions. Only three prior cases of syringotropic sarcoidosis have been reported; however, the biopsies had revealed conspicuously large granulomas in contrast with the small granulomas in our case, and none of the prior patients had clinical examination findings that mimicked PPD. Recognition of rare dermatologic and histopathological appearances of sarcoidosis is paramount as cutaneous sarcoidosis may be the harbinger of a systemic illness, which requires a timely diagnosis.

Silver Nanoparticles for the Therapy of Tuberculosis

Rapid emergence of aggressive, multidrug-resistant Mycobacteria strain represents the main cause of the current antimycobacterial-drug crisis and status of tuberculosis (TB) as a major global health problem. The relatively low-output of newly approved antibiotics contributes to the current orientation of research towards alternative antibacterial molecules such as advanced materials. Nanotechnology and nanoparticle research offers several exciting new-concepts and strategies which may prove to be valuable tools in improving the TB therapy. A new paradigm in antituberculous therapy using silver nanoparticles has the potential to overcome the medical limitations imposed in TB treatment by the drug resistance which is commonly reported for most of the current organic antibiotics. There is no doubt that AgNPs are promising future therapeutics for the medication of mycobacterial-induced diseases but the viability of this complementary strategy depends on overcoming several critical therapeutic issues as, poor delivery, variable intramacrophagic antimycobacterial efficiency, and residual toxicity. In this paper, we provide an overview of the pathology of mycobacterial-induced diseases, andhighlight the advantages and limitations of silver nanoparticles (AgNPs) in TB treatment.

Alveolar Macrophage ABCG1 Deficiency Promotes Pulmonary Granulomatous Inflammation

Pulmonary granuloma formation is a complex and poorly understood response to inhaled pathogens and particulate matter. To explore the mechanisms of pulmonary granuloma formation and maintenance, our laboratory has developed a multiwall carbon nanotube (MWCNT)-induced murine model of chronic granulomatous inflammation. We have demonstrated that the MWCNT model closely mimics pulmonary sarcoidosis pathophysiology, including the deficiency of alveolar macrophage ATP-binding cassette (ABC) lipid transporters ABCA1 and ABCG1. We hypothesized that deficiency of alveolar macrophage ABCA1 and ABCG1 would promote pulmonary granuloma formation and inflammation. To test this hypothesis, the effects of MWCNT instillation were evaluated in ABCA1, ABCG1, and ABCA1/ABCG1 myeloid-specific knockout (KO) mice. Histological examination revealed significantly larger pulmonary granulomas in ABCG1-KO and ABCA1/ABCG1 double-KO animals when compared with wild-type animals. Evaluation of BAL cells indicated increased expression of CCL2 and osteopontin, genes shown to be involved in the formation and maintenance of pulmonary granulomas. Single deficiency of alveolar macrophage ABCA1 did not affect MWCNT-induced granuloma formation or proinflammatory gene expression. These observations indicate that the deficiency of alveolar macrophage ABCG1 promotes pulmonary granulomatous inflammation and that this is augmented by additional deletion of ABCA1.

Presence of Antibodies Binding to Negative Elongation Factor E in Sarcoidosis

Sarcoidosis is characterized by multiorgan involvement and granulomatous inflammation. Its origin is unknown and the potential role of autoimmunity has not been sufficiently determined. We investigated the presence of autoantibodies in sarcoidosis using protein array technology. The derivation cohort consisted of patients with sarcoidosis (n = 25) and controls including autoimmune disease and blood donors (n = 246). In addition, we tested a validation cohort including pulmonary sarcoidosis patients (n = 58) and healthy controls (n = 13). Initially, sera of three patients with sarcoidosis were screened using a protein array with 28.000 proteins against controls. Thereby we identified the Negative Elongation Factor E (NELF-E) as an autoantigen. With confirmatory Enzyme-linked Immunosorbent Assay (ELISA)testing, 29/82 patients (35%) with sarcoidosis had antibodies against NELF-E of the Immunoglobulin (Ig) G type, whereas 18/253 (7%) sera of the controls were positive for NELF-E. Clinically, there was an association of the frequency of NELF-E antibody detection with lung parenchymal involvement and corresponding x-ray types. NELF-E autoantibodies are associated with sarcoidosis and should be further investigated.

Pathogenetic mechanism of oral granulomatous diseases: An update

Oral granulomatous diseases are an intriguing group of lesions characterized by granuloma formation. Mechanisms of granuloma formation differ from disease-to-disease. This article provides an insight into common granulomatous pathogenic mechanisms involving these lesions including immunodeficient states. Understanding various pathogenic mechanisms underlying various granulomatous conditions affecting oral tissues which mainly revolve around inflammatory cells such as macrophages, T lymphocytes, and genetic mutations might aid in devising treatment modalities without having significant side-effects or morbidity in affected subjects.

Cutaneous nontuberculous mycobacterial infection in Thailand: A 7-year retrospective review

A remarkable increase in the prevalence of cutaneous nontuberculous mycobacterial (NTM) infection has occurred worldwide. However, updated data regarding cutaneous NTM infection in Thailand is limited.This study aim to describe the clinical manifestations, pathogenic organism, and prognostic factors of cutaneous NTM infections among patients living in Thailand.The electronic medical records of all patients with confirmatory diagnosis of cutaneous NTM infection from either positive cultures or polymerase chain reaction were retrospectively reviewed at a university-based hospital.From 2011 to 2017, a total of 88 patients with a confirmed diagnosis of cutaneous NTM infection were included. Mycobacterium abscessus was the most common pathogens followed by M haemophilum and M marinum (61.4%, 10.2%, and 8.1%, respectively). Nodule and plaque were 2 most common lesions (26.4% and 25.5%, respectively) and lower leg is the most common site of involvement (50.9%). The majority of patients presented with single lesion (67%). Seven patients (7.9%) had history of surgical procedure and/or cosmetic injection before the development of lesion and all pathogenic organisms in this group were rapidly growing mycobacteria. Sweet's syndrome and erythema nodosum were the 2 most common reactive dermatoses, presented in 3.4% and 2.3%, respectively. The majority of patients infected with cutaneous M haemophilum infections were immunocompromised and lacked history of preceding trauma (77.8%). Patients with cutaneous NTM that receiving less than 3 medications was associated with higher disease relapse (odds ratio 65.86; P = .02).M abscessus is the most common pathogen of cutaneous NTM infection in Thailand. The prevalence of M haemophilum is increasing and should be particularly cautious in immunocompromised patients. Rapidly growing mycobacteria should be suspected in all cases of procedure-related cutaneous NTM. We recommend at least 3 antibiotics should be considered for cutaneous NTM infection to reduce the rate of relapse.

Dermal fillers do not induce upregulation of NLRP3 inflammasomes or expression of inflammatory cytokines in granulomas

BACKGROUND

Filling materials have increasingly been used in aesthetics over the last decades. Understanding the pathophysiology of granuloma formation as a very relevant unwanted side effect of filler application may be essential to help avoid these adverse events.

AIMS

Our aim was to investigate the role of the inflammasome in the formation of filler granuloma, as a central column of the innate immune response.

METHODS

RPMI 1640 medium was used for growth of THP-1 cells and the induction of THP-1 macrophages. Sonication was applied in order to crush the acrylic particles of the filler. ELISA was the method of analysis for the specific cytokines. Biopsy specimens of filler granuloma were analyzed by various immunohistochemical methods. GraphPad Prism 5 software was used for the statistical data analysis.

RESULTS

Neither was the sensor NALP3 overexpressed, nor could an elevated expression of cleaved IL-1β, IL-18, or IFN-γ be detected. Furthermore, no increased expression of IL-8 or IL-1β was detectable in vitro.

CONCLUSION

No increased inflammasome activation could be observed; however, filler granulomas were infiltrated with granulocytes and macrophages. Therefore, we speculate that an unspecific immune response might be the key player in the formation of filler granuloma.

Sarcoidosis and the mTOR, Rac1, and Autophagy Triad

Sarcoidosis is an enigmatic multisystem disease characterized by the development and accumulation of granulomas: a compact collection of macrophages that have differentiated into epithelioid cells and which are associated with T helper (Th)1 and Th17 cells. Although no single causative factor has been shown to underlie sarcoidosis in humans, its etiology has been related to microbial, environmental, and genetic factors. We examine how these factors play a role in sarcoidosis pathogenesis. Specifically, we propose that dysfunction of mTOR, Rac1, and autophagy-related pathways not only hampers pathogen or nonorganic particle clearance but also participates in T cell and macrophage dysfunction, driving granuloma formation. This concept opens new avenues for potentially treating sarcoidosis and may serve as a blueprint for other granulomatous disorders.

Granuloma in the explanted lungs: Infectious causes and impact on post-lung transplant mycobacterial infection

INTRODUCTION

The significance of granuloma in explanted lungs of lung transplant recipients (LTR) on the development of post-transplant mycobacterial infection is unclear.

METHODS

A retrospective review comparing LTRs and heart-lung transplant (H-LTR) recipients with granuloma in the explanted lungs between 2000 and 2012 (excluding those LTRs with granuloma due to sarcoidosis) and LTRs or H-LTRs without granuloma. Patients were followed for 2 years post-transplant.

RESULTS

A total of 144 LTRs and 4 H-LTRs with granulomas (75 necrotizing and 73 non-necrotizing) and a comparator cohort of 144 LTRs and 4 H-LTRs without granuloma were analyzed. In LTRs with granulomas, identification of infectious organisms was more common by histopathology (35 AFB and 22 fungal) compared to cultures (six NTM and seven fungal) taken around time of the transplant. LTRs with granulomas were more likely to have pre-transplant non-tuberculous mycobacteria (NTM) infection compared to LTRs without granuloma; P < .01. In the multivariate analysis, having granuloma or positive mycobacterial cultures at time of transplant were associated with increased risk of post-transplant mycobacterial infection (HR = 1.8 95% CI [1.024-3.154]; P = .041 and HR = 2.083 95% CI [1.011-4.292]; P = .047). Although there was a trend toward increase mycobacterial disease in those with granulomas P = .056, there was no difference in survival post-transplantation between those with or without granuloma in the explanted lung; P = .886.

CONCLUSION

The presence of granuloma in the explanted lungs of LTRs or positive mycobacterial cultures at time of transplant is associated with an increased risk of mycobacterial infection post-transplant.

Sterile traumatic panniculitis in a captive Brent goose

A captive, adult female Brent goose (Branta bernicla) with a history of severe feather picking by its mate, was presented with 0.5-2.5 cm skin nodules on the head and neck. Histologic examination revealed a well-delineated dermal mass that surrounded an intact feather follicle and was composed of lakes of proteinaceous fluid and fibrin with scattered foamy macrophages and multinucleate giant cells. No bacteria or fungi were identified with histology, microbial culture, or PCR. Sterile panniculitis is an infrequent finding in animals and traumatic panniculitis is rarely sterile.

In Vitro Granuloma Models of Tuberculosis: Potential and Challenges

Despite intensive research efforts, several fundamental disease processes for tuberculosis (TB) remain poorly understood. A central enigma is that host immunity is necessary to control disease yet promotes transmission by causing lung immunopathology. Our inability to distinguish these processes makes it challenging to design rational novel interventions. Elucidating basic immune mechanisms likely requires both in vivo and in vitro analyses, since Mycobacterium tuberculosis is a highly specialized human pathogen. The classic immune response is the TB granuloma organized in three dimensions within extracellular matrix. Several groups are developing cell culture granuloma models. In January 2018, NIAID convened a workshop, entitled "3-D Human in vitro TB Granuloma Model" to advance the field. Here, we summarize the arguments for developing advanced TB cell culture models and critically review those currently available. We discuss how integrating complementary approaches, specifically organoids and mathematical modeling, can maximize progress, and conclude by discussing future challenges and opportunities.

Granulomatous reaction following bacillus Calmette-Guérin vaccination: Successful response to clarithromycin

We report a 3-year-old girl with a delayed nontuberculous granulomatous reaction on a bacillus Calmette-Guérin injection site with dissemination to distant sites who showed a favorable response to clarithromycin used for 12 weeks with no recurrence on a follow-up of more than 2 years.

Sarcoid-Like Granulomatosis in a Patient With Breast Cancer Mimicking Refractory Metastatic Disease

Sarcoid-like granulomatosis is a known but rare adverse reaction to immune checkpoint inhibitors and chemotherapy in the treatment of advanced solid tumors. We present a case of a 29-year-old female with a pathologically confirmed poorly differentiated invasive ductal carcinoma of the breast with presumed metastases to the lungs, hilar lymph nodes, liver, and spleen. Despite appropriate chemotherapy, the patient developed pulmonary lesions that were interpreted on imaging studies as progression of malignancy. Autopsy revealed disseminated sarcoid-like granulomatosis with multiple noncaseating granulomata with associated fibrosis in the lungs, liver, and spleen. No residual invasive carcinoma or metastatic disease was identified. This case illustrates the difficulty in differentiating this nonneoplastic process from progressive disease in the clinical setting.

The Mtb-HIV syndemic interaction: why treating M. tuberculosis infection may be crucial for HIV-1 eradication

Accelerated tuberculosis and AIDS progression seen in HIV-1 and Mycobacterium tuberculosis (Mtb)-coinfected individuals indicates the important interaction between these syndemic pathogens. The immunological interaction between HIV-1 and Mtb has been largely defined by how the virus exacerbates tuberculosis disease pathogenesis. Understanding of the mechanisms by which pre-existing or subsequent Mtb infection may favor the replication, persistence and progression of HIV, is less characterized. We present a rationale for the critical consideration of ‘latent’ Mtb infection in HIV-1 prevention and cure strategies. In support of this position, we review evidence of the effect of Mtb infection on HIV-1 acquisition, replication and persistence. We propose that ‘latent’ Mtb infection may have considerable impact on HIV-1 pathogenesis and the continuing HIV-1 epidemic in sub-Saharan Africa.

Blastomycosis Misdiagnosed as Tuberculosis, India

Chronic pulmonary blastomycosis is often misdiagnosed and treated as tuberculosis in disease-endemic and non–disease-endemic areas. We report the case of a 32-year-old man who after visiting Chicago, Illinois, USA, returned to India and received treatment for tuberculosis for 12 months before receiving the correct diagnosis of blastomycosis.

Identification of Novel Genetic Variants in CVID Patients With Autoimmunity, Autoinflammation, or Malignancy

Common variable immunodeficiency (CVID) is a primary immunodeficiency characterized by recurrent bacterial infections and defined by reduced levels of IgG, IgA, and/or IgM, insufficient response to polysaccharide vaccination, and an abnormal B-cell immunophenotype with a significantly reduced fraction of isotype-switched memory B cells. In addition to this infectious phenotype, at least one third of the patients experience autoimmune, autoinflammatory, granulomatous, and/or malignant complications. The very heterogeneous presentation strongly suggests a collection of different disease entities with somewhat different pathogeneses and most likely diverse genetic etiologies. Major progress has been made during recent years with the advent and introduction of next-generation sequencing, initially for research purposes, but more recently in clinical practice. In the present study, we performed whole exome sequencing on 20 CVID patients with autoimmunity, autoinflammation, and/or malignancy from the Danish CVID cohort with the aim to identify gene variants with a certain, possible, or potential disease-causing role in CVID. Through bioinformatics analyses, we identified variants with possible/probable disease-causing potential in nine of the patients. Of these, three patients had four variants in three different genes classified as likely pathogenic (NFKB1, TNFAIP3, and TTC37), whereas in six patients, we identified seven variants of possible pathogenic potential classified as variants of unknown significance (STAT3, IL17F, IRAK4, DDX41, NLRC3, TNFRSF1A, and PLCG2). In the remaining 11 patients, we did not identify possible genetic causes. Genetic findings were correlated to clinical disease presentation, clinical immunological phenotype, and disease complications. We suggest that the variants identified in the present work should lay the ground for future studies to functionally validate their disease-causing potential and to investigate at the mechanistic and molecular level their precise role in CVID pathogenesis. Overall, we believe that the present work contributes important new insights into the genetic basis of CVID and particular in the subset of CVID patients with a complex phenotype involving not only infection, but also autoimmunity, autoinflammation, and malignancy.

Proteomic Profiling Reveals the Architecture of Granulomatous Lesions Caused by Tuberculosis and Mycobacterium avium Complex Lung Disease

Tuberculosis (TB) and Mycobacterium avium complex lung disease (MAC-LD) are both characterized pathologically by granuloma lesions, which are typically composed of a necrotic caseum at the center surrounded by fibrotic cells and lymphocytes. Although the histological characterization of TB and MAC-LD granulomas has been well-documented, their molecular signatures have not been fully evaluated. In this research we applied mass spectrometry-based proteomics combined with laser microdissection to investigate the unique protein markers in human mycobacterial granulomatous lesions. Comparing the protein abundance between caseous and cellular sub-compartments of mycobacterial granulomas, we found distinct differences. Proteins involved in cellular metabolism in transcription and translation were abundant in cellular regions, while in caseous regions proteins related to antimicrobial response accumulated. To investigate the determinants of their heterogeneity, we compared the protein abundance in caseous regions between TB and MAC-LD granulomas. We found that several proteins were significantly abundant in the MAC-LD caseum of which proteomic profiles were different from those of the TB caseum. Immunohistochemistry demonstrated that one of these proteins, Angiogenin, specifically localized to the caseous regions of selected MAC-LD granulomas. We also detected peptides derived from mycobacterial proteins in the granulomas of both diseases. This study provides new insights into the architecture of granulomatous lesions in TB and MAC-LD.

Mineral oil in food, cosmetic products, and in products regulated by other legislations

For a few years, mineral oils and their potential adverse health effects have been a constant issue of concern in many regulatory areas such as food, cosmetics, other consumer products, and industrial chemicals. Analytically, two fractions can be distinguished: mineral oil saturated hydrocarbons (MOSH) and mineral oil aromatic hydrocarbons (MOAH). This paper aims at assessing the bioaccumulative potential and associated histopathological effects of MOSH as well as the carcinogenic potential of MOAH for consumer-relevant mineral oils. It also covers the absorption, distribution, metabolism, and excretion of MOSH and MOAH upon oral and dermal exposures. The use and occurrence of consumer-relevant, highly refined mineral oils in food, cosmetics and medicinal products are summarized, and estimates for the exposure of consumers are provided. Also addressed are the challenges in characterizing the substance identity of mineral oil products under REACH. Evidence from more recent autopsy and biopsy studies, along with information on decreasing food contamination levels, indicates a low risk for adverse hepatic lesions that may arise from the retention of MOSH in the liver. With respect to MOAH, at present there is no indication of any carcinogenic effects in animals dermally or orally exposed to highly refined mineral oils and waxes. Such products are used not only in cosmetics but also in medicinal products and as additives in food contact materials. The safety of these mineral oil-containing products is thus indirectly documented by their prevalent and long-term use, with a simultaneous lack of clinical and epidemiological evidence for adverse health effects.

Suspected ocular toxocariasis and macular heterotopia

We report a case of an asymptomatic Caucasian male who attended our clinic for a routine check-up and macular heterotopia associated with lesions compatible with ocular toxocariasis were found.

Current diagnosis and therapy in sarcoidosis

Sarcoidosis is a disorder of unknown etiology, that may affect any organ in human body, most often lungs and lymph nodes. New diagnostic guidelines and new treatment recommendations were recently published. Since differential diagnosis of sarcoidosis is broad, diagnostic algorithm has to be complex. Diagnosis needs to be confirmed before initiation of any any treatment regimen - it is a severe mistake to start treatment before confirmation of diagnosis  (histologic pattern of epitheloid non necrotising granuloma, exclusion of other possible causes of granulomatous diseases, exclusive situations mentioned in the article body). Not every patient with sarcoidosis needs pharmacologic treatment. Treatment decision should involve extent of involvement, risk of damage of affected organs and patient symptoms. While in patients with Löfgren syndrome both histologic verification and systemic corticotherapy is not needed (systemic corticotherapy should be avoided), pharmacologic treatment is necessary in patients with myocardial involvement.

A guide to crystal-related and nano- or microparticle-related tissue responses

Crystals and nano- and microparticles form inside the human body from intrinsic proteins, minerals, or metabolites or enter the body as particulate matter from occupational and environmental sources. Associated tissue injuries and diseases mostly develop from cellular responses to such crystal deposits and include inflammation, cell necrosis, granuloma formation, tissue fibrosis, and stone-related obstruction of excretory organs. But how do crystals and nano- and microparticles trigger these biological processes? Which pathomechanisms are identical across different particle types, sizes, and shapes? In addition, which mechanisms are specific to the atomic or molecular structure of crystals or to specific sizes or shapes? Do specific cellular or molecular mechanisms qualify as target for therapeutic interventions? Here, we provide a guide to approach this diverse and multidisciplinary research domain. We give an overview about the clinical spectrum of crystallopathies, about shared and specific pathomechanisms as a conceptual overview before digging deeper into the specialty field of interest.

The Outcome of Salt Treatment for Umbilical Granuloma: A Systematic Review

BACKGROUND

An umbilical granuloma is one of the common umbilical masses in young children which appears after the cords fall off, mainly due to an inflammatory reaction to subclinical infections. Though there are different recommendations of treatment modalities, which management modality is the best is not clear yet.

OBJECTIVE

This systematic review aimed to assess the effectiveness of salt treatment in terms of complete resolution of the granuloma, any adverse effect, and any recurrence risk in those patients treated as inpatient or outpatient care.

METHODOLOGY

The literature search was done using search engines including Google scholar, PubMed, and Medlin. Articles published since 1990 and written in the English language with a target population of young children (less than 24 months) were included. To retrieve the articles, umbilical granuloma, treatment of umbilical granuloma, salt treatment, and neonatal umbilical disorder were used as keywords.

RESULTS

This systematic review indicated that the majority of the studies done on salt treatment for umbilical granuloma show excellent response (complete resolution of the granuloma/discharge) with no adverse effect and no recurrence in the subsequent follow-up of the patients in almost all cases of the treatment group. Salt inside the occluded hyperosmolar chamber causes shrinkage of granuloma by a desiccant effect.

CONCLUSION

Cooking salt treatment for umbilical granuloma is effective, cheap, available, and easy to apply by non-health professionals. No side effects have been reported yet and a recurrence of the granuloma after treatment seems to be null.

[Malignant syphilis in a patient with HIV infection]

Malignant syphilis occurs frequently in patients infected with human immunodeficiency virus (HIV) and presents with cutaneous nodular lesions that tend to ulcerate. Non caseating granulomas are among the most conspicuous histopathological findings and require differential diagnosis with other infectious and non-infectious granulomatous conditions. The evolution of the disease is usually favourable with penicillin treatment. We present the case of an HIV-positive patient who meets diagnostic criteria for malignant syphilis and alert on this infrequent granulomatous entity.