Necrotizing sarcoid granulomatosis: a case report of gastric involvement

Necrotizing sarcoid granulomatosis: A distinctive form of pulmonary granulomatous disease

OBJECTIVES

To define the characteristics of necrotizing sarcoid granulomatosis (NGS) a very rare pulmonary disease hardly recognised by pulmonologists and pathologists.

DATA SOURCE

PubMed was searched for the term necrotising or necrotizing sarcoid granulomatosis.

STUDY SELECTION

All cases reported in the English literature were included.

RESULTS

NGS is presented at all ages (range 8-68 years) with a median age of 42 years old. It shows female (62%) and Caucasian (80%) predominance. The most frequent symptoms are cough, fever, dyspnoea and chest pain. Extra-pulmonary involvement is found in one third of the cases, with ocular being the most common (12.5%). At imaging, multiple nodules (64.75%) or a solitary mass (20.49%) are found accompanied by mediastinal lymphadenopathy at one third of the cases. It can be clinically mistaken for malignancy as it is tumour-like, increases rapidly in size and it is hyperfixating in PET-SCAN. Histologically, NGS is defined by large areas of necrosis, well-formed granulomas and vascularitis.

CONCLUSION

NGS is a disease often confounded clinically with malignancy or with sarcoidosis even histologically when all criteria are not strictly applied. This review provides NGS' characteristics and discusses its differential diagnosis form sarcoidosis, Wegener granulomatosis and tuberculosis.

Four decades of necrotizing sarcoid granulomatosis: what do we know now?

CONTEXT

In the 4 decades since Dr Averill A. Liebow introduced necrotizing sarcoid granulomatosis, there have been publications of numerous cases, but its nature and possible relationship to classical and nodular sarcoidosis have been and remain controversial. Liebow introduced necrotizing sarcoid granulomatosis as a provisional diagnostic term and stated that "the problem is whether the disease represents necrotizing angiitis with sarcoid reaction, or sarcoidosis with necrosis of the granulomas and of the vessels." There has, as yet, been no definitive answer to the questions that he raised.

OBJECTIVE

To determine whether there is a relationship between necrotizing sarcoid granulomatosis and nodular sarcoidosis in order to ascertain whether the current prevailing opinion that they are related is correct.

DATA SOURCES

The world's literature on necrotizing sarcoid granulomatosis from 1973 to 2013 and nodular sarcoidosis from 1952 to 2013 was critically reviewed. One hundred three cases of necrotizing sarcoid granulomatosis and 111 cases of nodular sarcoidosis were found suitable for individual case analysis.

CONCLUSIONS

The data showed a striking overlap in the clinical, radiologic, and pathologic features of both entities, strongly supporting the conclusion that necrotizing sarcoid granulomatosis is a previously unrecognized manifestation of sarcoidosis and is essentially the same as nodular sarcoidosis. It is proposed that use of necrotizing sarcoid granulomatosis as a diagnostic term be discontinued and replaced by sarcoidosis with necrotizing sarcoid granulomatosis pattern provided that an infectious etiology can be reasonably excluded. Our concept of sarcoidosis should now be expanded to recognize that there is a continuous spectrum of necrosis ranging from minimal to extensive.

Necrotizing sarcoid granulomatosis with hemoptysis: a case report and literature review

Virtual Slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1955868163936338

We present a case of 39-year-old male with the symptoms of fever, cough, chest pain and bloody phlegm, whose chest CT showed multiple subpleural nodules and inflammatory infiltration. Video-Assisted Thoracic Surgery ( VATS ) for right subplural nodule was performed and confirmed the diagnosis of necrotizing sarcoid granulomatosis. Prednisolone was administered and the symptoms were under control untill the occurrence of intermittent hemoptysis after 10 months. Chest CT and bronchoscope revealed the right lower lobe nodule with intraluminal necrotic tissue in the right lower lobe posterior basal segment respectively. Fatal hemoptysis happened during endobronchial biopsy by flexible bronchoscope forcep. Based on this case, we reviewed the relevant literature and discussed the clinical features, pathological changes and prognosis of the disease.