Interstitial granulomatous drug reaction related to hydrochlorothiazide

Interstitial granulomatous drug reaction is a rare condition presenting as erythematous-to-violaceous plaques on the lateral trunk, axillae, buttocks, and thighs. Calcium-channel blockers, angiotensin converting enzyme inhibitors, beta-blockers, and statins have been described as drugs that can trigger interstitial granulomatous drug reaction. We present a case of interstitial granulomatous drug reaction related to hydrochlorothiazide and our approach to management of this condition. The diagnosis was confirmed with a skin biopsy and a rechallenge of hydrochlorothiazide, which exacerbated the patient's symptoms. The patient improved significantly with rigorous photoprotection, combination dapsone-alitretinoin therapy, and discontinuation of hydrochlorothiazide.

Abatacept induced granulomatous hepatitis with a sarcoidosis- like reaction: a blinded trial in mice

BACKGROUND

Abatacept is increasingly used for rheumatoid arthritis (RA) and juvenile idiophathic arthritis (JIA) treatment. However little is known about the risk of hepatotoxicity. The aim of this study was to determine whether the inhibition of the T cell CD28 receptor by abatacept results in acute hepatitis in BALB/c mice.

METHODS

Twenty BALB/c mice were studied. Ten mice received subcutaneous (SC) injection of abatacept (0.25mg per 25g body weight per 0.03 ml normal saline) at 0, 2, 4 and 8 weeks. For the control group, 10 mice received a SC injection of normal saline (NS) (0.03 ml). At the 10th week post injection, the mice were sacrificed, and histopathological studies were conducted.

RESULTS

Of the abatacept-treated group, 3/10 mice died. Liver histology for the abatacept-treated group showed that 6/7 displayed histopathological changes in the lobular cellular infiltrates of eosinophils, lymphocytes and histiocytes, in addition to granuloma formation. In contrast, only minimal inflammation was observed in 3/10 mice in the control group (p=0.036).

CONCLUSION

Abatacept may play a role in inducing granulomatous hepatitis with a sarcoidosis-like reaction. Additional data including transaminases, antinuclear antibodies (ANA), Antimitochondrial antibodies (AMA) and other auto antibodies should be tested.

Correlations between the Levels of the Main Extracellular Matrix Components in Mouse Liver in Chronic BCG-Induced Granulomatosis

Correlations between extracellular matrix components in mouse liver revealed the pathogenetically determined dynamic structure of these interrelations (some correlations appeared while others disappeared) at various terms of BCG-induced granulomatosis. The correlations between the studied parameters were strong during the first (postinfection days 3-10) and the second (postinfection days 60-90) periods but became moderate during the third period manifested by chronic inflammation (postinjection day 180). The greatest number of correlations was observed at the beginning of the stabilization period (postinjection day 60). At this period, the content of all structural components of hepatic proteoglycans closely correlated with that of hydroxyproline. These findings attested to systemic changes in metabolism of extracellular matrix components and interrelation between some structural units of proteoglycans in the liver and the components of extracellular matrix in the lungs. The common and typical organ-specific correlations in the liver and lungs suggest the existence of correlations between different organs during progression of BCG-induced granulomatosis.

Etanercept-induced granulomatous hepatitis as a rare cause of abnormal liver tests

The authors report the case of a 76 year-old man with rheumatoid arthritis treated with prednisolone and etanercept. The patient was seen for persistent changes in liver tests lasting for six months, with a mixed pattern. The patient denied intake of new drugs or dietary/herbal supplements. Imaging studies showed mild steatosis. Additional study for chronic liver diseases only revealed positivity for anti-nuclear antibodies. Liver biopsy revealed noncaseating granulomas in some portal tracts. Consequent etiologic study for granulomatous diseases showed negative or normal results. So it was decided to suspend etanercept, with a subsequent gradual improvement on analytical parameters that normalized three months later. To date, only one case of granulomatous liver disease associated with an anti-TNF agent was described in the literature. This case also raises the question whether the development of granulomatous processes associated with anti-TNF agents has been underdiagnosed due to the presence of other concomitant immunosuppressant therapies.

An Expandable Mechanopharmaceutical Device (2): Drug Induced Granulomas Maximize the Cargo Sequestering Capacity of Macrophages in the Liver

PURPOSE

Drug-induced liver injuries (DILI) comprise a significant proportion of adverse drug reactions leading to hospitalizations and death. One frequent DILI is granulomatous inflammation from exposure to harmful metabolites that activate inflammatory pathways of immune cells of the liver, which may act as a barrier to isolate the irritating stimulus and limit tissue damage.

METHODS

Paralleling the accumulation of CFZ precipitates in the liver, granulomatous inflammation was studied to gain insight into its effect on liver structure and function. A structural analog that does not precipitate within macrophages was also studied using micro-analytical approaches. Depleting macrophages was used to inhibit granuloma formation and assess its effect on drug bioaccumulation and toxicity.

RESULTS

Granuloma-associated macrophages showed a distinct phenotype, differentiating them from non-granuloma macrophages. Granulomas were induced by insoluble CFZ cargo, but not by the more soluble analog, pointing to precipitation being a factor driving granulomatous inflammation. Granuloma-associated macrophages showed increased activation of lysosomal master-regulator transcription factor EB (TFEB). Inhibiting granuloma formation increased hepatic necrosis and systemic toxicity in CFZ-treated animals.

CONCLUSIONS

Granuloma-associated macrophages are a specialized cell population equipped to actively sequester and stabilize cytotoxic chemotherapeutic agents. Thus, drug-induced granulomas may function as drug sequestering "organoids" -an induced, specialized sub-compartment- to limit tissue damage.

The distribution of BCG prostatitis: A clue for pathogenetic processes?

BACKGROUND

We observed in cystoprostatectomy specimens that Bacillus Calmette-Guérin (BCG) granulomatous prostatitis tended preferentially to affect the peripheral zone (PZ) and aimed to study the matter, postulating that assessment of its distribution might contribute to understanding pathogenetic processes.

METHODS

Entire prostate glands from 27 men (47-83 years; mean = 69 years), who had previously received intravesical BCG therapy for non-muscle-invasive urothelial carcinoma of the bladder, were studied as whole-mount sections to determine the anatomical distribution and histopathological characteristics of BCG prostatitis.

RESULTS

Twenty-two (81.5%) showed BCG-type granulomatous inflammation. It often radiated from close to the prostatic urethra toward to the gland periphery as a wedge-shaped area related to one or more duct systems. Twenty-one of these prostate glands (95.5%) showed predominantly or exclusively PZ involvement. Eighteen (81.8%) involved only the PZ, while three cases (13.6%) also showed involvement of the transitional zone (TZ). One case (4.5%) involved only the TZ. No granulomas were seen in the central zone or anterior fibromuscular septum.

CONCLUSIONS

Our observations imply the microanatomical arrangement of prostatic ducts is a factor in the pathogenesis of BCG prostatitis. PZ ducts enter the urethra at less obtuse angles than those from other zones and are likely to be more prone to urine reflux and damage from suspended BCG. We speculate that prostatic duct microanatomy could also play a role in the pathogenesis of other prostatic diseases, including conventional prostatitis and adenocarcinoma.

Xanthogranulomatous reaction to trametinib for metastatic malignant melanoma

Trametinib, a mitogen-activated extracellular signal-regulated kinase (MEK) inhibitor, has demonstrated great promise in treating metastatic melanoma associated with BRAF V600E and V600K mutations; however, it also is highly associated with cutaneous adverse events (AEs). As both BRAF and MEK inhibitors become increasingly used to treat malignant melanoma, it is important to better characterize these AEs so that we can manage them. Herein, we present a case of a 66-year-old man who developed erythematous scaly papules on the face and bilateral upper extremities after beginning therapy with trametinib. The severity of the reaction worsened on trametinib monotherapy compared to combination therapy with a BRAF inhibitor. Biopsy revealed a xanthogranulomatous reaction.

Granulomatous Tumoral Melanosis Associated With Pembrolizumab Therapy: A Mimicker of Disease Progression in Metastatic Melanoma

Immune checkpoint inhibitor therapy has revolutionized the treatment of advanced melanoma, with these agents significantly improving survival for patients with metastatic disease. With the increasing use of these agents, the number of adverse reactions secondary to their use has also increased. Sarcoidosis and sarcoid-like reactions are one such immune checkpoint inhibitor-related adverse event. We report a case of sarcoid-like granulomatous tumoral melanosis in a patient on the programmed cell death-1 (PD-1) receptor inhibitor pembrolizumab for metastatic melanoma. This is, to our knowledge, the first reported case of a sarcoidal form of tumoral melanosis in a patient on anti-PD-1 therapy. We postulate that this reflects tumor regression in response to pembrolizumab-induced immune activation, with concomitant therapy-triggered induction of a sarcoid-like reaction. These findings and the literature review presented herein should alert clinicians and pathologists to the possibility of regressed lesions with sarcoid-like features presenting as mimickers of disease progression in patients undergoing immunotherapy for advanced melanoma.

Short-Term Pulmonary Toxicity Assessment of Pre- and Post-incinerated Organomodified Nanoclay in Mice

Organomodified nanoclays (ONCs) are increasingly used as filler materials to improve nanocomposite strength, wettability, flammability, and durability. However, pulmonary risks associated with exposure along their chemical lifecycle are unknown. This study's objective was to compare pre- and post-incinerated forms of uncoated and organomodified nanoclays for potential pulmonary inflammation, toxicity, and systemic blood response. Mice were exposed via aspiration to low (30 μg) and high (300 μg) doses of preincinerated uncoated montmorillonite nanoclay (CloisNa), ONC (Clois30B), their respective incinerated forms (I-CloisNa and I-Clois30B), and crystalline silica (CS). Lung and blood tissues were collected at days 1, 7, and 28 to compare toxicity and inflammation indices. Well-dispersed CloisNa caused a robust inflammatory response characterized by neutrophils, macrophages, and particle-laden granulomas. Alternatively, Clois30B, I-Clois30B, and CS high-dose exposures elicited a low grade, persistent inflammatory response. High-dose Clois30B exposure exhibited moderate increases in lung damage markers and a delayed macrophage recruitment cytokine signature peaking at day 7 followed by a fibrotic tissue signature at day 28, similar to CloisNa. I-CloisNa exhibited acute, transient inflammation with quick recovery. Conversely, high-dose I-Clois30B caused a weak initial inflammatory signal but showed comparable pro-inflammatory signaling to CS at day 28. The data demonstrate that ONC pulmonary toxicity and inflammatory potential relies on coating presence and incineration status in that coated and incinerated nanoclay exhibited less inflammation and granuloma formation than pristine montmorillonite. High doses of both pre- and post-incinerated ONC, with different surface morphologies, may harbor potential pulmonary health hazards over long-term occupational exposures.

[Not Available]

La práctica de tatuajes tienen más de 8000 años de antigüedad, existiendo un incremento continuo en la sociedad occidental en las últimos 3 décadas La introducción de una sustancia exógena en la pielpuede provocar una respuesta inmunológica en su contra, estando descritas reacciones cutáneas por hipersensibilidad a una variedad de pigmentos, las que se limitan al área de un determinado color,atribuyéndose a los materiales inyectados. El color más reportado en la literatura es el rojo, que tradicionalmente se confeccionaban a base dederivados del mercurio (cinabrio). Diversos patrones histológicos de reacción están descritos, siendo el más frecuente el liquenoide. Presentamos una serie de 10 pacientes con reacción de hipersensibilidad a tatuaje rojo, con patrón histológico predominante dereacción granulomatosa y con moderada respuesta a tratamiento. Es importante cuando se está ante un patrón granulomatoso de reacción descartar sarcoidosis sistémica e infecciones por micobacterias.

Methanolic Extract of Leathery Murdah, Terminalia coriacea (Roxb.) Wight and Arn. Leaves Exhibits Anti-Inflammatory Activity in Acute and Chronic Models

OBJECTIVE

The aim of the present study was to evaluate anti-inflammatory activity of methanolic extract of Terminalia coriacea.

MATERIALS AND METHODS

A methanolic extract of T. coriacea leaves was studied in albino Wistar rats with carrageenan-induced paw edema, an acute model, and cotton pellet-induced granuloma, a chronic model, at 3 oral test doses (125, 250, and 500 mg/kg). Aspirin 100 mg/kg was used as a positive control. Paw volume and wet and dry weights of cotton pellets were determined. The data were analyzed by one-way ANOVA followed by Dunnett's multiple comparison test.

RESULTS

The test extract at doses of 125 and 250 mg/kg decreased paw volume and wet and dry weights of cotton pellets. The highest test dose (500 mg/kg) displayed a response comparable to that of the standard drug (p < 0.01) on paw volume. The extract produced similar (p < 0.05) decrease in wet weight of the cotton pellet at 125 and 250 mg/kg, whereas the effect of 500 mg/kg of the extract was comparable to that of aspirin 100 mg/kg (p < 0.01). The extract of T. coriacea at 500 mg/kg induced the most significant (p < 0.01) effect on wet weight of granulomatous tissue.

CONCLUSION

The methanolic extract of T. coriacea leaves successfully decreased paw edema as well as dry and wet weights of granulomatous tissue in both acute and chronic inflammatory models thus confirming the anti- edematogenic, antitransudative, and antiproliferative properties of T. coriacea.

Chronic granulomatous dermatitis induced by talimogene laherparepvec therapy of melanoma metastases

Talimogene laherparepvec (TVEC) is the first oncolytic viral immunotherapy approved by the FDA, for advanced melanoma consisting of genetically modified herpes simplex type 1 virus which selectively replicates causing tumor lysis, expressing granulocyte macrophage-colony stimulating factor (GM-CSF) and activating dendritic cells. Intratumoral injection of TVEC produces objective response in 41% of stage IIB-IV M1a melanoma. However, clinical response assessment can be problematic due to immune-related inflammation at established tumor sites. Herein, we report 5 cases of granulomatous dermatitis developing at sites of TVEC injection associated with pathologic complete response in 4 of 5 patients. Over 5 months, TVEC injections were administrated in a median of 20 tumors per patient for 9 median doses prior to biopsy of persistent, indurated nodules. Granulomatous dermatitis with melanophages and melanin pigment incontinence was observed in all samples without evidence of melanoma cells in 4 patients. The fifth patient was rendered melanoma-free by resection of the 1 nodule out of 4 with persistent tumor. Repetitive administration of TVEC or other oncolytic viral immunotherapies mimicking unresolved infection can produce granulomatous inflammation confounding assessment of the degree of tumor response and need for additional TVEC therapy. Tumor biopsies are encouraged after 4 to 6 months of TVEC administration to differentiate melanoma from granulomatous inflammation. Patients with confirmed granulomatous dermatitis replace continued with remained in remission after treatment discontinuation. Inflammatory nodules typically regress spontaneously.

Management of Late-Onset, Recurrent Facial Nodular Reaction After Poly-L-Lactic (PLLA) Injections

Despite a well-established safety profile for poly-L-lactic acid (PLLA), known complications of nodules, papules and granulomas can occur. The author presents a case of late-onset facial nodules after treatment with PLLA dermal filler for facial volumization. The late-onset nodules appeared 16 months post-initial injection and were initially treated with intralesional steroids followed by 5-fluorouracil, and oral corticosteroids. It took over a year of treatment with oral corticosteroids and periodic intralesional steroid injections for the nodules to resolve. The author describes in detail the course of the nodules as well as the clinical management.

Granulomatous Interstitial Nephritis: A Clinicopathologic Study of 46 Cases from a Single Institution

Acute interstitial nephritis is commonly seen in kidney biopsies of patients with acute renal failure; however, granulomatous interstitial nephritis (GIN) is rare. We identified 46 cases of GIN in a 17-year period in this institution and we investigated their most probable etiologies. Complete clinical information was available in 38 patients. Seventeen of 38 patients (44.7%) were classified as drug-induced. Renal sarcoidosis was responsible for 28.9% of cases, and the remaining 15.9% of cases included Wegeners granulomatosis, foreign body giant cell reaction, GIN secondary to intravesical bacillus Calmette-Guerin therapy for bladder cancer, and xanthogranulomatous pyelonephritis. Clinical investigation failed to reveal possible etiology in 4 patients (10.5%), classified as idiopathic. We concluded that three quarters of our cases were either drug-induced or due to sarcoidosis; only a small proportion of our cases occurred secondary to any other cause or to unknown factors.

Epididymal Sperm Granuloma Induced by Chronic Administration of 2-Methylimidazole in B6C3F1 Mice

Two-year mouse and rat bioassay studies of 2-methylimidazole (2-MI) conducted by the National Toxicology Program revealed that epididymal sperm granuloma(SG)s occurred only in male B6C3F1 mice in a dose-related manner. The present study characterized 2-MI-induced SGs in these epididymides. Groups of 50 male B6C3F1 mice were fed diets containing 0, 625, 1250, or 2500 ppm 2-MI for 105 weeks; the doses were equivalent to average daily doses of approximately 13, 40, or 130 mg/kg. Testes and epididymides were histopathologically reexamined. 2-Methylimidazole increased the incidence of epididymal SGs (0%, 0%, 6%, 12%, respectively). Histologically, most of the SGs exhibited rupture of epididymal ducts with focal aggregations of macrophages in interstitia. Lesions occurred in the proximal caput of the epididymis and/or efferent ducts, not in the corpus and cauda. In the testis, incidences of germinal epithelial atrophy (GEA) increased dose-relatedly (2%, 8%, 16%, 28%, respectively). All mice with epididymal SG developed testicular GEA. The grading scores of testicular GEA tended to be more severe in mice with SGs than those without. No epididymal SG or testicular GEA was observed in 6-month-interim-sacrificed mice. The results imply that 2-year treatment of B6C3F1 mice with 2-MI can induce epididymal SGs, primarily followed by more severe testicular GEA. The potential mechanism of SG induction by 2-MI is discussed.

[Sarcoid-like granulomatosis in patients treated with anti-TNFα]

Over recent years, anti-TNFα have been used to treat rheumatoid arthritis. The principal secondary effect of anti-TNFα is tuberculosis infections. Another paradoxical effect, previously less well understood, is the development of sarcoid-like granulomatous reactions. We report the case of a 36 year old woman who had been treated for 9 years with anti-TNF alpha. She developed a pulmonary sarcoid-like gra-nulomatosis, complication that is rare but not exceptional in patients treated with TNF-blockers. Discontinuation of anti TNF usually led to recovery. It has been suggested that these reactions mainly occur with etanercept, but this requires further confirmation.

Postoperative Granulomas at Liposuction Incision Sites

Since most liposuction incisions heal uneventfully, difficult healing in such incisions must be investigated. In the cases of two gynecomastia liposuction patients in which a water-based lubricating gel was used on the liposuction incisions, the incisions failed to heal. For both patients, workup uncovered palisading granulomas at the lateral inframammary fold incision sites several months after otherwise successful surgeries. These two cases are presented and the previous literature is reviewed, with consideration given to the etiology and prevention of such granulomas. LEVEL OF EVIDENCE 5: Risk.

A Case Report of Majocchi's Granuloma Associated with Combined Therapy of Topical Steroids and Adalimumab

Currently, tumor necrosis factor alpha (TNF-alpha) inhibitors are widely used for many autoimmune disorders. However, they cause an immunocompromised status that sometimes leads to many cutaneous side effects including atypical infections. Herein, we report the first case of adalimumab-related Majocchi's granuloma.A 43-year-old Taiwanese male patient with chronic plaque-type psoriasis developed numerous tender nodules 1 month after adalimumab injection. The nodules responded poorly to bacterial folliculitis treatment. After repeated skin biopsies for pathology and tissue fungal culture, Majocchi's granuloma was confirmed. Adalimumab was withheld, and 12 weeks of terbinafine treatment was given. On completion of treatment, the nodular skin lesions and dystrophic nail lesions improved dramatically.The information, including time span, clinical features, histological findings, and improvement following withdrawal of adalimumab and treatment with an oral antifungal agent, indicates that Majocchi's granuloma was adalimumab-related. Psoriasis patients are more susceptible to dermatophyte infection due to local and systemic immunosuppressant therapy. It is important to perform a thorough examination for latent dermatophyte infection, including skin and nail lesions, before treatment with TNF-alpha inhibitors and during traditional psoriasis treatment. When atypical presentation together with treatment failure is noted in psoriasis patients prescribed biologics, clinicians should investigate evidence of dermatophyte infection and provide proper treatment. Sometimes, multiple skin biopsies and tissue fungal cultures are required to establish a correct diagnosis.

The effects of Nano titanium dioxide (TiO2NPs) on lung tissue

OBJECTIVES

The application of nanoparticles is widely spread in all aspects of modern life because of their unique features such as small size and high surface area. High surface area can be very reactive and produce reactive oxygen species (ROS). These nanoparticles can damage human and animal cells by increasing oxidative stress mechanism. Titanium dioxide nanoparticles (TiO2NPs) are among the top five nanoparticles used in consumer products, paints, and pharmaceutical preparations.TiO2 NPs have various capabilities such as robust oxidation, biocompatibility and photocatalytic properties. They are frequently used in a wide range of sciences, including pharmaceuticals, cosmetics, medicine and engineering. The ever increasing industrial and consumer applications of TiO2NPs raise concern over the possible risk association with their environmental exposure.

METHODS

This study investigates the effects of TiO2NP on lung tissue by intraperitoneal injection to rats at different doses (15, 30, 60 and 70 mg/kg).

RESULTS

Our results showed that intraperitoneal injection of TiO2NP creates capillary congestion and hemorrhage in alveolar wall, granulomas in lung parenchyma, and hemosiderin depositions in blood vessels adjacent to bronchioles without any inflammation. The pulmonary side effects could be due to the production of ROS post TiO2NP exposure (Tab. 1, Fig. 5, Ref. 27). Text in PDF www.elis.sk.

[Aluminium allergy and granulomas induced by vaccinations for children]

Vaccination with aluminium-adsorbed vaccines can induce aluminium allergy with persistent itching subcutaneous nodules at the injection site – vaccination granulomas. In this article we give an overview of childhood aluminium-adsorbed vaccines available in Denmark. Through literature studies we examine the incidence, the symptoms and the prognosis for the vaccination granulomas and the allergy. Finally we discuss the status in Denmark.

[Investigation of incidence and risk factors of subcutaneous granulomas induced by injection of leuprorelin acetate]

We investigated the incidence of granuloma and its related factors in 180 patients with prostate cancer who showed subcutaneous granuloma formation during androgen deprivation therapy with subcutaneously administered leuprorelin acetate. A granuloma was defined as a persistent induration over 30 mm in diameter in the injected portion. Small indurations which often developed and disappeared after every injection were excluded. The survey was performed using a questionnaire after receiving written informed consent. Among the 180 patients with prostate cancer, 21 (11.7%) developed a granuloma at the injection portion, and subsequently the injection of leuprorelin acetate had to be discontinued. Eighteen of the 21 patients alternatively received goserelin acetate. Three patients had high-grade granulomas with ulcer and abscess formation, and were successfully treated with oral antibiotics. The average duration between the first injection of leuprorelin acetate and granuloma formation was 20.2 months (range : 4 to 62 months). There was no association between granuloma formation and patient backgrounds, such as allergic predisposition and past history. Twenty-one of the 180 prostatic cancer patients developed subcutaneous granuloma induced by the injection of leuprorelin acetate. The investigation showed an unexpectedly high incidence of granuloma formation. We must explain the risk of developing subcutaneous granuloma to the patients before introducing leuprorelin acetate.

Airbag lung: an unusual case of sarcoid-like granulomatous lung disease after a rollover motor vehicle accident

Sarcoid-like granulomatous lung disease (SLGLD) is a condition associated with the formation of noncaseating, nonnecrotizing granulomas. The final by-product of airbag deployment is alkaline silicates or glass. Silicates trapped and sequestered in the lung parenchyma are a potential mediator for immune system activation and development of sarcoid-like granulomatous lung disease.