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Geri G, Saadoun D, Cacoub P. Manifestations hépatiques des maladies systémiques. Rev Med Interne 2011; 32:486-93. [DOI: 10.1016/j.revmed.2010.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2009] [Revised: 04/24/2010] [Accepted: 07/19/2010] [Indexed: 12/20/2022]
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Turhan N, Kurt M, Ozderin YO, Kurt OK. Hepatic granulomas: a clinicopathologic analysis of 86 cases. Pathol Res Pract 2011; 207:359-65. [PMID: 21531083 DOI: 10.1016/j.prp.2011.03.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 01/17/2011] [Accepted: 03/22/2011] [Indexed: 02/03/2023]
Abstract
The aim of this study was to determine the prevalence and histopathological characteristics of hepatic granulomas. All records of liver biopsies/resections evaluated in our pathology department between 2002 and 2009 were retrospectively reviewed. Specimens with hepatic granulomas were reexamined by a designated pathologist. Type and localization of granulomas, size of granulomas and epithelioid histiocytes, and the morphological findings of surrounding liver tissue were recorded in an attempt to establish a correlation with relevant clinical, laboratory and radiological findings. Out of 1420 liver biopsy/resected specimens evaluated at our institution during the study period, 86 cases of epithelioid cell granulomas (6.05%) were observed. Of the 86 cases, 23 were men and 63 were women. The most common underlying etiology was PBC in 38 patients, infections in 34, malignancies in five, sarcoidosis in four, and foreign bodies in three patients. One case (1.2%) of a drug-induced hepatic granuloma was encountered, while another case was deemed idiopathic (of unknown etiology). Contrary to common belief, granulomas were observed not only in early stage PBC but also in cases with stage 3 disease. Out of all the PBC cases with granulomas, 55.6% had stage 3 disease, and besides periductal granulomas, intraacinar granulomas were also seen. For sarcoidosis, intra- and peri-granulomatous fibrosis was observed in as many as 75% of cases. A large majority of granulomas (82.4%) associated with infections were of the necrotizing type. Extensive evaluation of the morphological characteristics of hepatic granulomas and surrounding liver tissue along with clinical, radiological, and other laboratory findings may help arrive at an accurate diagnosis in a majority of cases. Rather than being a final diagnosis, the presence of hepatic granulomas entails the need for further investigations towards identifying the underlying etiology, with a pathologist being at the center of the diagnostic process.
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Affiliation(s)
- Nesrin Turhan
- Department of Pathology, Turkiye Yuksek Ihtisas Teaching and Research Hospital, Kizilay Sk. No: 2, 06100, Sihhiye, Ankara, Turkey.
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Kaklamanos M, Hardavella G, Trigidou R, Dionellis G, Paissios N, Koulouris N, Goritsas C. Multi-organ failure with atypical liver granulomas following intravesical Bacillus Calmette-Guerin instillation. World J Hepatol 2011; 3:79-82. [PMID: 21487539 PMCID: PMC3074089 DOI: 10.4254/wjh.v3.i3.79] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 02/22/2011] [Accepted: 03/01/2011] [Indexed: 02/06/2023] Open
Abstract
Bacillus Calmette-Guerin (BCG) intravesical instillation has been adopted in the treatment of patients with superficial bladder cancer. BCG-induced disseminated infection, though rare, has been associated with the histological finding of epithelioid granulomas in different organs, including the liver. We report the case of an adult patient with multi-organ failure, who developed sepsis, acute respiratory failure and acute hepatic failure with encephalopathy whose liver biopsy confirmed the presence of atypical, granulomatous-like lesions. Recovery was observed only after empirical therapy for Mycobacterium bovis with isoniazid, rifampicin, ethambutol and steroids was introduced. This case highlights the importance of a thorough patient assessment in order to exclude other more common causes of hepatic granulomas and to confirm diagnosis. Histological findings may be non-specific when the liver is involved in BCG-induced disseminated infection.
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Affiliation(s)
- Michail Kaklamanos
- Michail Kaklamanos, Nikolaos Paissios, Constantin Goritsas, Department of Internal Medicine, "Sotiria" Hospital of Chest Diseases, Athens 11527, Greece
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Lagana SM, Moreira RK, Lefkowitch JH. Hepatic granulomas: pathogenesis and differential diagnosis. Clin Liver Dis 2010; 14:605-17. [PMID: 21055685 DOI: 10.1016/j.cld.2010.07.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Granulomatous liver disease constitutes a category of hepatic disorders and is at present diagnosed in approximately 4% of liver biopsies. Hepatic granulomas develop through the interactions of T lymphocytes and macrophages, with the integral involvement of T-helper (T(H)) 1 or T(H)2 pathways or both, depending on the specific granulomatous disease. Hepatic granulomas may be manifested clinically by elevated levels of serum alkaline phosphatase and g-glutamyltransferase enzymes, damage to specific structures (eg, intrahepatic bile ducts in primary biliary cirrhosis), or infrequently, progressive liver disease with portal hypertension and cirrhosis (eg, sarcoidosis). Systemic immunologic disorders, infectious diseases, drug hepatotoxicity, and reaction to neoplastic disease are the major causative factors responsible for granulomas in the liver. These causes and recent epidemiologic trends are covered in this discussion.
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Affiliation(s)
- Stephen M Lagana
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY 10032, USA.
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55
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Tumor necrosis factor-alpha (TNF-α)-blockade-induced hepatic sarcoidosis in psoriatic arthritis (PsA): case report and review of the literature. Clin Rheumatol 2010; 30:133-7. [PMID: 20886249 DOI: 10.1007/s10067-010-1577-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2010] [Accepted: 09/13/2010] [Indexed: 12/11/2022]
Abstract
To study the cytokine profile in a 52 year old woman with psoriasis, PsA, and HCV who developed hepatic sarcoidosis following Etanercept therapy for 7 months. 11 PsA patients on TNF blockers mean disease duration 158.4 (SD 114.5), mean treatment duration 72.1 (SD 42.14) months, 8/11 PsA were on Etanercept and 5 healthy controls were studied. TNF-α, sTNF RI/RII, IFN-α/β/γ, IL-1 α, IL-15, IL-6, VEGF, s IL-1 R, sIL-6 R, IL-12, IL-23, IL-17, Adiponectin, Leptin and EGF were assessed. All PsA and controls tested negative for Quantiferon TB Gold, hepatitis B/C, HIV, ACE level, chest x-ray, liver function test (LFTs). Serologic biomarkers of the subject in comparison to the controls indicate that sTNF RI value was significantly higher; and IL-1 alpha level has a high outlier compared to the 11 PsA patients on TNF blockers. The clinical course, histologic findings, increased levels of s TNF R I and IL-1 α in the subject as compared to the other PsA on TNF blockade and controls, suggest that most likely Etanercept induced inflammatory cytokine imbalance was responsible for inducing hepatic sarcoidosis.
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56
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Geri G, Cacoub P. [Hepatic granulomas]. Rev Med Interne 2010; 32:560-6. [PMID: 20832918 DOI: 10.1016/j.revmed.2010.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Revised: 05/29/2010] [Accepted: 06/24/2010] [Indexed: 10/19/2022]
Abstract
Liver granulomas are histopathologically defined and associated with various liver and non-livers disorders. There are five main causes of liver granulomatosis: primary biliary cirrhosis, tuberculosis, sarcoidosis, B and C viral hepatitis, and drug related. In the other cases, not associated with an underlying systemic granulomatous disease, a systematic diagnostic approach should be used to identify less common etiologies. After a careful diagnostic work-up, a long-term follow-up of patients with undetermined liver granulomatosis is mandatory as it may be a presenting feature of liver lymphoma.
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Affiliation(s)
- G Geri
- Service de Médecine Interne II, Université Pierre-et-Marie-Curie-Paris 6, CNRS, UMR 7087, Hôpital Pitié-Salpêtrière, AP-HP, 47-83, Boulevard de l'Hôpital, 75013 Paris cedex 13, France
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57
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Martin-Blondel G, Camara B, Selves J, Robic MA, Thebault S, Bonnet D, Alric L. Étiologies et évolution des hépatites granulomateuses : étude rétrospective de 21 cas consécutifs. Rev Med Interne 2010; 31:97-106. [DOI: 10.1016/j.revmed.2009.10.430] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Revised: 09/19/2009] [Accepted: 10/12/2009] [Indexed: 11/24/2022]
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Abstract
Three months after diagnosis of Wegener granulomatosis, an 84-year-old woman who was treated with cyclophosphamide (CPY) and prednisone developed deranged liver function tests (LFTs). Treatment with CPY was held, which led to normalization of LFTs, but after reinitiating of CPY, LFTs started increasing. Liver biopsy showed noncaseating epithelioid granulomas within liver lobules consistent with granulomatous hepatitis. Patient died within 2 months secondary to liver failure. This elevation of transaminases was considered to be secondary to CPY-induced hepatotoxicity. Involvement of liver in patients with Wegener granulomatosis is seen but it presents with necrotizing granulomatous vasculitis. CPY-induced hepatitis is an extremely rare phenomenon with only 1 case reported in literature. Clinicians and hepatologists should be aware of this potentially serious complication when CPY therapy is initiated. Baseline LFTs and periodic assessment are recommended before and during treatment with CPY.
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60
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Kapoor SR, Snowden N. The use of infliximab in a patient with idiopathic granulomatous hepatitis. BMJ Case Rep 2009; 2009:bcr06.2008.0319. [PMID: 21686858 DOI: 10.1136/bcr.06.2008.0319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a therapeutic response to infliximab in a patient with idiopathic granulomatous hepatitis resistant to treatment with methotrexate and corticosteroids. A 41-year-old woman presented with a 12-month history of fever, night sweat, gross hepatomegaly and 13 kg weight loss. Infection and malignancy were carefully excluded and a liver biopsy showed changes consistent with idiopathic granulomatous hepatitis. The patient was treated with high dose steroids and methotrexate, but her clinical symptoms and biochemical and radiological signs did not settle. Introduction of infliximab led to rapid and sustained resolution of symptoms, hepatomegaly and liver function tests (LFTs) after 1 year of follow-up. To our knowledge this is the first successful use of infliximab in idiopathic granulomatous hepatitis.
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Affiliation(s)
- Sabrina Reenu Kapoor
- North Manchester General, Rheumatology, Delaunays Road, Crumpsall, Manchester M8 5RB, UK
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61
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Granulomatous hepatitis, perihepatic lymphadenopathies, and autoantibody positivity: an unusual association in a child with hepatitis C. Eur J Pediatr 2009; 168:275-9. [PMID: 18509673 DOI: 10.1007/s00431-008-0749-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Accepted: 04/22/2008] [Indexed: 10/22/2022]
Abstract
A 10-year-old boy with hepatitis C had granulomatous hepatitis (GH) at initial liver biopsy. He also had enlarged perihepatic lymph nodes and smooth muscle antibody (SMA) positivity. GH is a rare finding in hepatitis C virus (HCV) infection. Our patient is special since GH secondary to HCV infection was associated with both autoantibodies and multiple intraabdominal lymphadenopathies. After interferon (IFN) and ribavirin therapy, HCV RNA became negative, along with the resolution of hepatic granulomas (HG), lymphadenopathies, and SMA positivity. Although early virologic response was not achieved under IFN treatment, the therapy period was extended, contrary to routine practice, and resulted in a delayed response. We conclude that the usage of IFN for longer periods in GH-associated HCV infection might be promising.
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Abstract
Hepatic granulomas are often encountered on liver biopsy and may represent a primary hepatic process, a manifestation of a systemic illness, or an innocent finding of no clinical relevance. Hepatic granulomas are a unique inflammatory response that may be idiopathic or may be a response to a bacterial, fungal, viral, or parasitic infection; a manifestation of drug-induced liver injury; or a manifestation of underlying malignancy. When granulomas are found on liver biopsy, clinicians must correlate the histologic findings with historical and clinical data to help provide an accurate diagnosis and guide management. Therapy may be warranted, either directly for the granulomatous inflammation of the liver or for a systemic process. For some patients, observation may be the most appropriate form of management.
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Affiliation(s)
- Sidharth S Bhardwaj
- Division of Gastroenterology/Hepatology, 975 West Walnut Street, IB 327, Indianapolis, IN 46202-5121, USA.
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63
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Abstract
AIM: To determine the most frequent etiologies of hepatic epithelioid granulomas, and whether there was an association with chronic hepatitis C virus (HCV).
METHODS: Both a retrospective review of the pathology database of liver biopsies at our institution from 1996 through 2006 as well as data from a prospective study of hepatic fibrosis markers and liver biopsies from 2003 to 2006 were reviewed to identify cases of hepatic epithelioid granulomas. Appropriate charts, liver biopsy slides, and laboratory data were reviewed to determine all possible associations. The diagnosis of HCV was based on a positive HCV RNA.
RESULTS: There were 4578 liver biopsies and 36 (0.79%) had at least one epithelioid granuloma. HCV was the most common association. Fourteen patients had HCV, and in nine, there were no concurrent conditions known to be associated with hepatic granulomas. Prior interferon therapy and crystalloid substances from illicit intravenous injections did not account for the finding. There were hepatic epithelioid granulomas in 3 of 241 patients (1.24%) with known chronic HCV enrolled in the prospective study of hepatic fibrosis markers.
CONCLUSION: Although uncommon, hepatic granulomas may be part of the histological spectrum of chronic HCV. When epithelioid granulomas are found on the liver biopsy of someone with HCV, other clinically appropriate studies should be done, but if nothing else is found, the clinician can be comfortable with an HCV association.
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64
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Onal IK, Ersoy O, Aydinli M, Yonem O, Harmanci O, Sokmensuer C, Bayraktar Y. Hepatic granuloma in Turkish adults: a report of 13 cases. Eur J Intern Med 2008; 19:527-30. [PMID: 19013382 DOI: 10.1016/j.ejim.2008.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Accepted: 01/20/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatic granuloma (HG) is a well defined histopathological finding with an heterogenous clinical presentation. Diagnosis of a specific clinical entity is not possible every time. Descriptive studies may shed light on the various etiologies also common and distinctive findings among these patients. METHODS We reviewed the results of the liver biopsies of 592 patients. Characteristics of the patients with HG were extracted from the hospital charts. Laboratory studies included biochemical tests, hepatitis C virus (HCV) antibody, Brucella agglutination tests, tuberculin skin test. According to the diagnostic clues further tests (thoracic computed tomography (CT), ultrasonography, organ biopsy in addition to liver, antimitochondrial antibody, hepatitis B surface (HBs) antigen, venereal disease research laboratory (VDRL)) were performed. RESULTS HG was found in 13 of the 592 patients (2.2%). Primary biliary cirrhosis (three cases) was the most frequent cause followed by sarcoidosis, miliary tuberculosis and BCGitis (Bacillus Calmette Guerin) (two cases each). Two patients with HG could not be diagnosed. Only three patients had remarkable physical examination findings. Alkaline phosphatase and gamma-glutamyl transpeptidase were the most frequently elevated enzymes. Abdominal ultrasonography provided no specific diagnostic clue in any patient. Localization of the HGs was portal in 6 patients, parenchymal in 5 patients and both portal and parenchymal in 2 patients. Three exitus were due to BCGitis, miliary tuberculosis and fungal infection. CONCLUSIONS Tuberculosis is still among the most common etiologic factors. BCGitis has a fulminant rather than an indolent course. Abdominal ultrasonography could be used to rule out obstructive jaundice rather than to reach a specific diagnosis. Involvement of portal area by HG in most of the cases might cause obstruction of the biliary canaliculi and elevation of the cholestatic enzymes. Follow up of the difficult cases may be the best approach since the presence of HG was not proved as a bad prognostic factor for any disease.
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Affiliation(s)
- Ibrahim Koral Onal
- Department of Internal Medicine, Hacettepe University Medical School, Turkey.
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65
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Abstract
Granulomas are aggregates of macrophages, often admixed with other inflammatory cells, which usually result from chronic antigen presentation. Many diseases that produce granulomas involve the liver. Some are intrinsic hepatic diseases, whereas others are disseminated systemic diseases that involve the liver and other organs. Hepatic granulomas are reportedly present in 2% to 10% of all liver biopsy specimens examined in general practice, and of those supposedly as many as 36% have no discoverable etiology even after extensive evaluation of the specimen. This review focuses on the diagnosis of granulomas in infectious diseases affecting the liver, including use of special stains, serologic studies, and molecular diagnostic techniques, and discusses pertinent noninfectious causes of hepatic granulomas that are in the differential diagnosis.
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66
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Abstract
Sarcoid affecting the skin, eye, or liver can be symptomatic of or cause significant morbidity. When disease is sever, alternative therapies may be needed.
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Affiliation(s)
- Anthony S Rose
- Division of Pulmonary and Critical Care Medicine, Indiana University, Richard L. Roudebush VA Medical Center, 1481 W. 10th Street, Indianapolis, IN 46202, USA
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67
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Seixas Duarte MI, Tuon FF, Pagliari C, Kauffman MR, Brasil RA. Human visceral leishmaniasis expresses Th1 pattern in situ liver lesions. J Infect 2008; 57:332-7. [PMID: 18722018 DOI: 10.1016/j.jinf.2008.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Revised: 06/28/2008] [Accepted: 07/04/2008] [Indexed: 10/21/2022]
Abstract
The architectural and infiltrate pattern of liver human visceral leishmaniasis (HVL) have been systematically classified as typical, fibrogenic or nodular. Despite this histopathological classification, the immune response based on cytokines and cellular phenotypes have never been performed. The aim of this study was to determine the immunophenotypic pattern and cytokine profile of the nodular involvement of the liver in HVL. We evaluated nine cases of the nodular form of HVL. In situ immune response was studied through cytokine analysis and immunohistochemical study for phenotype markers: IL-1, IL-4, IL-10, TNF-alpha, IFN-gamma, CD4+ T cells, CD8+ T cells, CD20, CD68, CD57 and macrophage activation was determined by evaluation of iNOS activity. HVL seems to be related to a better immune response. Amastigotes were rarely found on liver sections. Leishmania antigen expression was also rare and located in the inflammatory nodules. The lower expression of IL-4 and IL-10, moderate expression of TNF-alpha and IFN-gamma demonstrate a panorama of Th1 phenotype. The increased expression of NK cells could help in sustaining this model of response. This pattern of immune response is probably responsible for improvement in the parasite's clearance from liver tissue and it is a prognostic marker of human visceral leishmaniasis.
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Affiliation(s)
- Maria Irma Seixas Duarte
- Laboratory of Infectious Diseases Pathology, Pathology Department, Faculty of Medical Sciences, University of Sao Paulo, Sao Paulo, Brazil.
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Papo T. Granulomatoses systémiques. Mise en perspective. Rev Med Interne 2008; 29:3-4. [PMID: 17689838 DOI: 10.1016/j.revmed.2007.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Accepted: 07/16/2007] [Indexed: 10/23/2022]
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69
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Vital Durand D, Durieu I, Rousset H. Granulomatoses d’origine médicamenteuse ou toxique. Rev Med Interne 2008; 29:33-8. [DOI: 10.1016/j.revmed.2007.09.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Accepted: 09/22/2007] [Indexed: 10/22/2022]
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70
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Abstract
The liver has a double blood supply and plays a central role in the metabolism of proteins, carbohydrates, and many medications. In addition, it has a role in the induction of immune tolerance and may also be a target for immune-mediated damage. For these reasons, the liver may be involved in many systemic diseases. In this review, we discuss the involvement of the liver in granulomatous, rheumatologic, malignant, and circulatory diseases. An understanding of the wide spectrum of liver involvement in systemic diseases will aid in both diagnosis and treatment of patients with a wide range of medical conditions.
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71
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Gousseff M, Mechaï F, Lecuit M, Lortholary O. [Systemic granulomatosis of infectious origin]. Rev Med Interne 2007; 29:15-27. [PMID: 18054122 DOI: 10.1016/j.revmed.2007.09.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Accepted: 09/22/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE Granulomatous diseases are defined by specific histological features, following the local recruitment of macrophages and lymphocytes. Many infections can lead to the development of granuloma. CURRENT KNOWLEDGE AND KEY POINTS Microorganisms responsible for granuloma include mainly mycobacteria, many viral and fungal species, as well as schistosoma in endemic areas. Nevertheless, almost all microorganisms can lead to granuloma, especially if their clearance needs macrophages pathway. New immunosuppressive drugs such as tumor necrosis factor antagonists are associated with a high risk of infectious granulomatous complications. All patients with granuloma must be carefully screened to find a potential underlying infection, since an immunosuppressive therapy could be otherwise considered. We here review the general diagnostic process with a specific glance to the main organs. FUTURE PROSPECTS AND PROJECTS Without clinical or epidemiological clue, diagnosis can be very tedious. New molecular tools now assist classical microbiological and histological techniques. Their specificity and sensitivity have recently been better characterized, and their use will probably increase in the near future for the diagnosis of infectious granuloma. They may also lead to discover new infectious aetiologies of granulomatous diseases formerly considered as idiopathic. We describe here the main microorganisms that can be responsible for granuloma, with a specific focus on the use of new diagnostic tools.
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Affiliation(s)
- M Gousseff
- Service des maladies infectieuses et tropicales, université René-Descartes-Paris-5, hôpital Necker-Enfants-Malades, centre d'infectiologie Necker-Pasteur, 149 rue de Sèvres, Paris cedex 15, France
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72
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Fiel MI, Shukla D, Saraf N, Xu R, Schiano TD. Development of hepatic granulomas in patients receiving pegylated interferon therapy for recurrent hepatitis C virus post liver transplantation. Transpl Infect Dis 2007; 10:184-9. [PMID: 17916116 DOI: 10.1111/j.1399-3062.2007.00258.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Infrequently, hepatitis C (HCV) appears to be the cause of hepatic granulomas. Interferon therapy for HCV has been increasingly associated with the development of sarcoidosis. AIMS We sought to determine the incidence of hepatic granulomas in patients with recurrent HCV post liver transplantation (LT). METHODS Between 1994 and 2005, 820 patients were transplanted for HCV at our institution. The pathology database was searched for patients having recurrent HCV and granulomas. At Mount Sinai Medical Center, protocol biopsies have been performed for the last 2 years in patients receiving pegylated interferon-alpha2b and ribavirin (PEG) for recurrent HCV. Review of slides from explanted livers, pre- and post-perfusion biopsies, and all allograft biopsies were evaluated. Lipogranulomas were excluded because of their frequent association with steatosis. RESULTS A total of 10,225 liver biopsies were performed on HCV patients, and 25 (0.24%) showed non-caseating epithelioid granulomas. Hepatic granulomas were detected in 14 post-LT HCV patients; 9 patients received PEG. Typically, only 1 lobular granuloma was found. None of these patients had granulomas in the native liver or in any biopsy before interferon therapy; 6/9 patients had undetectable HCV-RNA levels, and 4 had sustained viral response. No other cause for granuloma formation was identified in the 6 patients. CONCLUSIONS Hepatic granulomas are infrequently found in HCV liver biopsies and rarely found in post-LT biopsies with recurrent HCV. When present, they occur more commonly in patients receiving and virologically responding to PEG therapy. The presence of granulomas in patients with HCV being treated with PEG may not warrant an extensive etiologic work-up for granulomatous hepatitis unless otherwise clinically indicated.
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Affiliation(s)
- M I Fiel
- The Lillian and Henry M. Stratton-Hans Popper Department of Pathology, The Mount Sinai Medical Center, New York, New York 10029, USA.
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73
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Abstract
Granulomatous diseases of the liver span a huge range of infectious, drug-related, and immunologic disorders. Familiarity with the different types of granulomas as well as how they present in different diseases can be helpful in narrowing the pathologic differential diagnosis. This review surveys both common and unusual granulomatous diseases with emphasis on practical diagnosis.
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Affiliation(s)
- David E Kleiner
- Laboratory of Pathology, National Cancer Institute, Building 10, Room 2N212, 10 Center Drive, MSC 1516, Bethesda, MD 20892, USA.
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74
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Demirkok SS. Relationship between the pathogenesis of sarcoidosis and hepatitis C. World J Gastroenterol 2007; 13:1883-4. [PMID: 17465488 PMCID: PMC4149974 DOI: 10.3748/wjg.v13.i12.1883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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75
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Abstract
Hepatic granulomas were present in 3.7% of liver biopsies from a 6-year Greek study. The majority of cases were due to autoimmune disease (primary biliary cirrhosis), followed by sarcoidosis and idiopathic causes. Infections were infrequent. This profile is similar to series from the USA, Ireland and Scotland. It contrasts dramatically with series from Turkey and Saudi Arabia where infectious aetiologies form the majority of cases, and autoimmune cases are not reported. Tuberculosis and schistosomiasis are the most prevalent infections. The patient sex and age differ strikingly in some series. The series were tabulated for easy comparison.
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Affiliation(s)
- Helen Wainwright
- Department of Pathology, UCT Medical School, Observatory 2905, South Africa.
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76
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Dourakis SP, Saramadou R, Alexopoulou A, Kafiri G, Deutsch M, Koskinas J, Archimandritis AJ. Hepatic granulomas: a 6-year experience in a single center in Greece. Eur J Gastroenterol Hepatol 2007; 19:101-4. [PMID: 17272993 DOI: 10.1097/01.meg.0000243882.09820.d2] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Hepatic granulomas have been reported in 2-15% of unselected liver biopsies, with a wide clinical profile responsible for their presence. To date, no series concerning the prevalence and the etiology of granulomas from Greece has been reported. OBJECTIVES To evaluate the prevalence and the etiology of hepatic granulomas and to investigate whether there has been an alteration in distribution of diagnoses in our series compared with those published so far in the literature. STUDY The results of liver biopsy specimens performed in a Department of Medicine, between 1999 and 2004, were retrospectively reviewed and the cases revealing hepatic granulomas had their medical notes and the liver biopsies recorded. RESULTS Over the study period, 1768 liver biopsies were performed. Hepatic granulomas were identified in 66 (3.7%). Of those, 51 were female with a mean age of 57 years (range 34-74 years) and 15 were male with a mean age of 42 years (range 18-78 years). Autoimmune liver diseases including primary biliary cirrhosis, overlap syndrome and autoimmune hepatitis accounted for the majority of cases (68%), followed by sarcoidosis (7.5%), chronic hepatitis B virus and hepatitis C virus infection (7.5%), idiopathic (6%), drugs (3%) and other miscellaneous causes (7.5%). CONCLUSIONS Our series showed that autoimmune liver diseases, mainly primary biliary cirrhosis was the most common cause of granuloma formation, a finding rather similar to that stated in the studies from Western countries. A rather small number of idiopathic cases were recorded. Chronic viral hepatitis and sarcoidosis rates were equal, a finding possibly reflecting a fairly high proportion of viral hepatitis in our sample.
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Kawashita Y, Kamohara Y, Furui J, Fujita F, Miyamoto S, Takatsuki M, Abe K, Hayashi T, Ohno Y, Kanematsu T. Destructive granuloma derived from a liver cyst: A case report. World J Gastroenterol 2006; 12:1798-801. [PMID: 16586558 PMCID: PMC4124364 DOI: 10.3748/wjg.v12.i11.1798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We herein report the case of an idiopathic liver cystic mass which aggressively infiltrated the thoraco-abdominal wall. A 74-year-old woman who had a huge cystic lesion in her right hepatic lobe was transferred to our hospital for further examinations. Imaging studies revealed a simple liver cyst, and the cytological findings of intracystic fluid were negative. She was followed up periodically by computed tomography (CT) scans. Seven years later, she complained of a prominence and dull pain in her right thoraco-abdominal region. CT revealed an enlargement of the cystic lesion and infiltration into the intercostal subcutaneous tissue. We suspected the development of a malignancy inside the liver cyst such as cystadenocarcinoma, and she therefore underwent surgery. A tumor extirpation was performed, including the chest wall, from the 7th to the 10th rib, as well as a right hepatic lobectomy. Pathologically, the lesion consisted of severe inflammatory change with epithelioid cell granuloma and bone destruction without any malignant neoplasm. No specific pathogens were evident based on further histological and molecular examinations. Therefore the lesion was diagnosed to be a destructive granuloma associated with a long-standing hepatic cyst. Since undergoing surgery, the patient has been doing well without any signs of recurrence.
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Affiliation(s)
- Yujo Kawashita
- Department of Transplantation and Digestive Surgery, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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Agard C, Pottier P, Hamidou M, Papo T, Généreau T, de Faucal P, Boutoille D, Ponge T, Connault J, Brisseau JM, Planchon B, Barrier JH. [Empirical treatment of granulomatous hepatitis of unknown origin: practice investigation in the French National Society of Internal Medicine]. Rev Med Interne 2006; 27:276-84. [PMID: 16530889 DOI: 10.1016/j.revmed.2006.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2005] [Accepted: 01/06/2006] [Indexed: 10/25/2022]
Abstract
PURPOSES Ten to fifteen percent of granulomatous hepatitis are idiopathic. If symptoms like prolonged fever are present, empirical treatment is discussed. The goal of this study is to describe the empirical treatment proposed in this situation by French specialists of internal medicine. METHODS We conducted a practice investigation among the French national society of internal medicine (SNFMI), using an anonymous questionnaire that related a case of idiopathic granulomatous hepatitis. This questionnaire was proposed to all French internists present at the SNFMI congress in June and December 2004. French specialists of internal medicine had to answer if they would prescribe an empirical treatment and if so, to specify this treatment. RESULTS Thirty-six French specialists of internal medicine answered to the questionnaire. In the proposed situation, 89% of them initiate an empirical treatment. In 18/36 cases (50%), a first-line anti-tuberculosis empirical treatment is proposed (quadritherapy in 11 cases). In 7 cases (19%), an empirical treatment with prednisone, 0.4 mg/kg/d (N=1) and 1 mg/kg/d (N=6), would be prescribed. Seven internists (19%) would prescribe an empirical treatment with cyclins at the dose of 100 to 400 mg/d. Median duration of the empirical treatment would be 28 days (range: 8-252d). The evaluation parameters mentionned are: fever (69%), weight (59%), seric level of C-reactive protein (59%), and liver biology (53%). In case of failure of first-line empirical treatments, 69% of all questionned internists prescribe a second-line treatments: prednisone at the dose of 0.4 to 2 mg/kg/d (72%), anti-tuberculosis treatments (16%), cyclins 200 mg/d (12%), with a median duration of 28 days. Seven internists (19%) propose to combine two empirical treatments. DISCUSSION Faced with a problem of idiopathic granulomatous hepatitis, French internists questionned propose four therapeutics options: no treatment, anti-tuberculosis treatment, cyclins or steroids treatment. First-line anti-tuberculosis treatment is a coherent proposition regarding to the high prevalence of tuberculosis. There are only few data available concerning empirical treatment with steroids or cyclins. Specific proposition of such empirical treatments should be defined. CONCLUSIONS The management of idiopathic granulomatous hepatitis is difficult. Our study shows that therapeutics practices of French internists are heterogenous. The main proposition consists in a first-line anti-tuberculosis empirical treatment, that has to be evaluated after four weeks, and switched with steroids (prednisone, 1 mg/Kg/d) in case of failure. This study is not an expert proposition but contributes to suggest clinical practice guidelines for a rare, complex, heterogenous, and typically internist situation.
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Affiliation(s)
- C Agard
- Service de Médecine Interne, CHU Hôtel-Dieu, place Alexis-Ricordeau, 44093 Nantes cedex 01, France.
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Verma S, Bhakta H, Nowain A, Pais S, Kanel G, Squires K. Severe cholestatic liver injury days after initiating antiretroviral therapy in a patient with AIDS: drug toxicity or immune reconstitution inflammatory syndrome? Dig Dis Sci 2005; 50:1813-7. [PMID: 16187179 DOI: 10.1007/s10620-005-2943-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2004] [Accepted: 10/22/2004] [Indexed: 12/09/2022]
Affiliation(s)
- Sumita Verma
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California 90033, USA.
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81
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Selmi C, Invernizzi P, Miozzo M, Podda M, Gershwin ME. Primary biliary cirrhosis: does X mark the spot? Autoimmun Rev 2004; 3:493-9. [PMID: 15546796 DOI: 10.1016/j.autrev.2004.05.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2004] [Accepted: 05/20/2004] [Indexed: 01/12/2023]
Abstract
Primary biliary cirrhosis (PBC) is an autoimmune disease of unknown etiology leading to progressive destruction of intrahepatic bile duct, with cholestasis, cirrhosis, and eventually liver failure. Epidemiological data indicate that environmental factors trigger autoimmunity in genetically susceptible individuals, although no definitive association of PBC with specific genes has been found. Further, no convincing explanation has been provided for the strong female predominance observed in the prevalence of PBC. However, we recently suggested that the enhanced monosomy X in peripheral white blood cells, and particularly in lymphocytes, of affected women might play a role in the induction of PBC. Such observations appear independent from the degree of cholestasis and specific for PBC. In this review we discuss the implications of these findings and their immunological implications.
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Affiliation(s)
- Carlo Selmi
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, TB 192 One Shields Ave., Davis, CA 95616, USA
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82
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Abstract
PURPOSE OF REVIEW Primary biliary cirrhosis is a chronic inflammatory disease of the intrahepatic bile ducts that eventually leads to liver cirrhosis and organ failure, in which several observations suggest an autoimmune origin. Similarly to other autoimmune diseases, microbial mediated molecular mimicry is the most widely studied trigger that may break immunologic tolerance in primary biliary cirrhosis. RECENT FINDINGS The hypothesis of a bacterial role in the cause of primary biliary cirrhosis has received recent attention, based on in vitro data and the identification of a unique xenobiotic-metabolizing bacterium that modulates naturally occurring environmental estrogens, namely, Novosphingobium aromaticivorans. SUMMARY The evidence indicates that bacteria, through different mechanisms, may precipitate autoimmunity in primary biliary cirrhosis and other autoimmune diseases. These data have several implications.
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Affiliation(s)
- Carlo Selmi
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California at Davis, Davis, California 95616, USA
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Tahan V, Ozaras R, Lacevic N, Ozden E, Yemisen M, Ozdogan O, Mert A, Tabak F, Avsar E, Celikel CA, Ozbay G, Kalayci C, Senturk H, Tozun N. Prevalence of hepatic granulomas in chronic hepatitis B. Dig Dis Sci 2004; 49:1575-7. [PMID: 15573907 DOI: 10.1023/b:ddas.0000043366.18578.15] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
An increasing frequency of hepatic granulomas, up to 10%, in chronic hepatitis C patients is reported, and their presence is considered to be a predictor of treatment success. However, there is only one prevalence study on granuloma in chronic hepatitis B, and its significance for treatment outcome is unknown. We aimed to determine the prevalence of hepatic granulomas in a larger group of chronic hepatitis B patients and to compare their presence with the response to interferon therapy. Biopsy specimens of chronic hepatitis B patients were reevaluated for the presence of hepatic granulomas. All patients with hepatic granuloma were screened for other granulomatous diseases by tuberculin skin test, chest X-ray and computed tomography, venereal disease research laboratory, Brucella agglutination tests, and exposure to hepatotoxic agents. We screened 663 cases of chronic hepatitis B. Hepatic granulomas were found in 10 cases (1.5%). The granulomas could not be ascribed to any other reason. Of the 10 patients with hepatic granulomas, 4 responded to interferon therapy, 2 dropped out, and 4 were nonresponders. We conclude that hepatic granuloma is a rare finding in chronic hepatitis B and its presence does not seem to predict the response to interferon therapy.
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Affiliation(s)
- Veysel Tahan
- Department of Gastroenterology, Marmara University, Medical Faculty.
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Cardellach F, Miró O, Cirera I, Arguis P, Miquel R. Mujer de 66 años con astenia y eosinofilia. Med Clin (Barc) 2004. [DOI: 10.1016/s0025-7753(04)74401-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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