1
|
Mironova M, Gopalakrishna H, Rodriguez Franco G, Holland SM, Koh C, Kleiner DE, Heller T. Granulomatous liver diseases. Hepatol Commun 2024; 8:e0392. [PMID: 38497932 PMCID: PMC10948139 DOI: 10.1097/hc9.0000000000000392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/18/2023] [Indexed: 03/19/2024] Open
Abstract
A granuloma is a discrete collection of activated macrophages and other inflammatory cells. Hepatic granulomas can be a manifestation of localized liver disease or be a part of a systemic process, usually infectious or autoimmune. A liver biopsy is required for the detection and evaluation of granulomatous liver diseases. The prevalence of granulomas on liver biopsy varies from 1% to 15%. They may be an incidental finding in an asymptomatic individual, or they may represent granulomatous hepatitis with potential to progress to liver failure, or in chronic disease, to cirrhosis. This review focuses on pathogenesis, histological features of granulomatous liver diseases, and most common etiologies, knowledge that is essential for timely diagnosis and intervention.
Collapse
Affiliation(s)
- Maria Mironova
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Harish Gopalakrishna
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Gian Rodriguez Franco
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Steven M. Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Christopher Koh
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David E. Kleiner
- Department of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Theo Heller
- Translational Hepatology Section, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| |
Collapse
|
2
|
Abstract
Hepatic granulomas are encountered in approximately 2% to 10% of liver biopsies. There are many potential infectious and noninfectious causes; granulomas can be generally classified by their morphology, which may be helpful in refining the differential diagnosis. This article provides a review of hepatic granulomas with an emphasis on infectious causes.
Collapse
Affiliation(s)
- Eun-Young Karen Choi
- Department of Pathology, University of Michigan, University of Michigan, 5231B Medical Science I, 1301 Catherine Street, SPC 5602, Ann Arbor, MI 48109, USA.
| | - Laura W Lamps
- Department of Pathology, University of Michigan, University of Michigan, 5231B Medical Science I, 1301 Catherine Street, SPC 5602, Ann Arbor, MI 48109, USA
| |
Collapse
|
3
|
|
4
|
Abstract
Fibrin ring granulomas are an uncommon finding in liver biopsies although they have been described in liver injury secondary to several infectious and noninfectious entities, most notably Q fever. Immune checkpoint inhibitors are recent advances in cancer therapy, and stimulate the immune system to cause antitumoral effects but may also lead to adverse immune events such as hepatitis and colitis. We report 2 patients on combination ipilimumab/nivolumab who developed hepatitis and had fibrin ring granulomas in their liver biopsies.
Collapse
|
5
|
A Case of Acute Q Fever Hepatitis Diagnosed by F-18 FDG PET/CT. Nucl Med Mol Imaging 2012; 46:125-8. [PMID: 24900046 DOI: 10.1007/s13139-012-0130-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 02/10/2012] [Indexed: 10/28/2022] Open
Abstract
A 53-year-old man with fever of unknown origin underwent F-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT) as a workup for a fever of unknown origin. On presentation, he complained of fever, chills, and myalgia. The F-18 FDG PET/CT scan showed diffusely increased uptake of the liver with mild hepatomegaly. A liver biopsy then revealed fibrin-ring granulomas typically seen in Q fever. The patient was later serologically diagnosed as having acute Q fever as the titers for C. burnetii IgM and IgG were 64:1 and 16:1, respectively. He recovered completely following administration of doxycycline. This indicates that F-18 FDG PET/CT may be helpful for identifying hepatic involvement in Q fever as a cause of fever of unknown origin.
Collapse
|
6
|
Struthers K, Okhandiar A, Goodlad JR. Bone marrow fibrin ring granulomas in Epstein-Barr virus infection. Histopathology 2011; 59:150-2. [PMID: 21771034 DOI: 10.1111/j.1365-2559.2011.03866.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
7
|
Restrepo MI, Vasquez EM, Echeverri C, Fiebelkorn KR, Anstead GM. Fibrin ring granulomas in Rickettsia typhi infection. Diagn Microbiol Infect Dis 2010; 66:322-5. [DOI: 10.1016/j.diagmicrobio.2009.10.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Revised: 10/18/2009] [Accepted: 10/27/2009] [Indexed: 11/28/2022]
|
8
|
|
9
|
Soulard R, Souraud JB, Landais C, Le Hemon A, Gaillard T, Fouet B. Histopathology of a granulomatous lobular panniculitis in acute Q fever: a case report. J Cutan Pathol 2009; 37:870-6. [DOI: 10.1111/j.1600-0560.2009.01423.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
10
|
Choi HC, Lee SH, Kim J, Kim SH, Hwang JH, Kim JW, Jeong SH, Kim H. A case of acute q Fever with severe acute cholestatic hepatitis. Gut Liver 2009; 3:141-4. [PMID: 20431739 PMCID: PMC2852695 DOI: 10.5009/gnl.2009.3.2.141] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2008] [Accepted: 04/04/2009] [Indexed: 01/29/2023] Open
Abstract
Minimal hepatic dysfunction can be common in acute Q fever, but severe acute cholestatic hepatitis is rarely reported. We report on a 55-year-old male with acute Q fever and severe acute cholestatic hepatitis. He complained of fever, jaundice, ascites, and restlessness on admission. A liver biopsy revealed the presence of compact fibrin-ring granulomas. Serologic titers for C. burnetii IgM and IgG were 2048:1 and 1024:1, respectively. C. burnetii DNA was detected by a nested polymerase chain reaction on the liver tissue.
Collapse
Affiliation(s)
- Hyun Cheul Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Chung HJ, Chi HS, Cho YU, Jang S, Park CJ. Bone Marrow Fibrin-Ring Granuloma: Review of 24 Cases. Ann Lab Med 2007; 27:182-7. [DOI: 10.3343/kjlm.2007.27.3.182] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Hee-Jung Chung
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Hyun-sook Chi
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Young-Uk Cho
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Chan-Jeoung Park
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| |
Collapse
|
12
|
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.
Collapse
Affiliation(s)
- David E Kleiner
- Laboratory of Pathology, National Cancer Institute, Building 10, Room 2N212, 10 Center Drive, MSC 1516, Bethesda, MD 20892, USA.
| |
Collapse
|
13
|
Galache C, Santos-Juanes J, Blanco S, Rodríguez E, Martínez A, Soto J. Q fever: a new cause of 'doughnut' granulomatous lobular panniculitis. Br J Dermatol 2004; 151:685-7. [PMID: 15377359 DOI: 10.1111/j.1365-2133.2004.06125.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Q fever is an uncommon zoonotic rickettsial disease with no exanthem or specific cutaneous lesions. Only nonspecific cutaneous involvement has been reported to date. A 69-year-old Spanish woman with chronic myelogenous leukaemia developed fever and two subcutaneous nodules. The patient complained of extreme pain. Biopsy revealed a granulomatous lobular panniculitis with a characteristic 'fibrin ring' or 'doughnut' appearance: fibrin and inflammatory cells arranged around a central clear space. Changes of membranous lipodystrophy were also found. Q fever serological studies were positive. Our patient had panniculitis with singular histopathological features. These histopathological changes have been described in liver and bone marrow of patients with Q fever. To the best of our knowledge, this cutaneous involvement due to Q fever has not previously been described in the literature.
Collapse
Affiliation(s)
- C Galache
- Department of Dermatology, Hospital de Cabueñes, Gijón, Asturias, Spain.
| | | | | | | | | | | |
Collapse
|
14
|
Tjwa M, De Hertogh G, Neuville B, Roskams T, Nevens F, Van Steenbergen W. Hepatic fibrin-ring granulomas in granulomatous hepatitis: report of four cases and review of the literature. Acta Clin Belg 2001; 56:341-8. [PMID: 11881318 DOI: 10.1179/acb.2001.051] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The differential diagnosis of hepatic fibrin-ring granulomas includes infective agents (Coxiella burneti, CMV, EBV,....), hypersensitivity to medication (allopurinol) and malignancy. METHODS During a period of 6 months, four patients presented at our university hospital with a similar clinical picture of fever and abnormal liver tests, and fibrin-ring granulomas on liver biopsy. Clinical course, laboratory and imaging findings, and histopathological features were compared. RESULTS Clinical manifestations, and laboratory and imaging findings were similar. Histopathological assessment of the hepatic fibrin-ring granulomas appeared not to be helpful in identifying the causative agent. Other histopathological features (e.g. sinusoidal rows of lymphocytes, eosinophilic polymorphonuclear infiltrate) were suggestive for the causative agent, yet conclusive identification was obtained by either serology (Q fever, CMV, EBV), or by exclusion with concomitant stop of medication (allopurinol). CONCLUSIONS In the differential diagnosis of hepatic fibrin-ring granulomas, serologic titers remain the determining factor, since an infective agent is the most common cause. When hepatic fibrin-ring granulomas are present, other histopathological features may be helpful in making the differential diagnosis.
Collapse
Affiliation(s)
- M Tjwa
- Dienst Lever, Galwegen- en Pancreasaandoeningen, Universitair Ziekenhuis Gasthuisberg, UZ GHB Herestraat 49 3000, Leuven, België Katholieke Universiteit Leuven
| | | | | | | | | | | |
Collapse
|
15
|
Collins MH, Jiang B, Croffie JM, Chong SK, Lee CH. Hepatic granulomas in children. A clinicopathologic analysis of 23 cases including polymerase chain reaction for histoplasma. Am J Surg Pathol 1996; 20:332-8. [PMID: 8772787 DOI: 10.1097/00000478-199603000-00010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In a 15-year period at the Riley Hospital for Children, granulomas were found in 23 (4%) of a total of 521 liver biopsies. An etiology was identified in 87%: Histoplasma was diagnosed in 15 cases (65%) by polymerase chain reaction (PCR) on paraffin-embedded tissue, serology, and special stains; sarcoidosis was diagnosed in four cases; and schistosomiasis was diagnosed in one case. Serial liver biopsies were available from five patients; granulomas occurred in only one biopsy of the series from each patient. Extrahepatic tissue from six patients contained granulomas, and an etiology for the liver granulomas was identified in all six patients (four histoplasmosis, two sarcoidosis). The extrahepatic tissue from two patients with Histoplasma was diagnostic. We made the following conclusions: that PCR is applicable to archival material and greatly increases the yield of specific infectious diagnoses of liver granulomas compared with conventional diagnostic methods (65 versus 22%); that the infections causing liver granulomas are those that are endemic in a community (e.g., Histoplasma in Indiana); that Histoplasma can coexist with a wide variety of systemic and primary liver diseases; that the likelihood of identifying a cause of liver granulomas is increased if there are extrahepatic granulomas; and that hepatic granulomas may have a limited life span. Treatment of liver granulomas should be determined by the clinical setting and directed at the underlying cause.
Collapse
Affiliation(s)
- M H Collins
- Department of Pathology and Laboratory Medicine, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana, USA
| | | | | | | | | |
Collapse
|
16
|
Yamamoto T, Ishii M, Nagura H, Miyazaki Y, Miura M, Igarashi T, Toyota T. Transient hepatic fibrin-ring granulomas in a patient with acute hepatitis A. LIVER 1995; 15:276-9. [PMID: 8531599 DOI: 10.1111/j.1600-0676.1995.tb00685.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A case of acute hepatitis A associated with fibrin-ring granulomas in the liver is presented. Because a relationship between acute hepatitis A infection and granuloma formation had not previously been established, liver specimens were examined from both the hepatitic and recovery phases. Numerous fibrin-ring granulomas were observed in the parenchyma during the hepatitic phase. The cellular components of the granulomas were largely macrophages and CD4-positive T-cells. Granulomas had disappeared completely by the recovery phase. These results suggest that fibrin-ring granulomas were caused by hepatitis A virus infection. This virus may activate macrophages and CD4-positive T-cells through an as-yet undetermined mechanism.
Collapse
Affiliation(s)
- T Yamamoto
- Third Department of Internal Medicine, Tohoku University School of Medicine, Miyagi, Japan
| | | | | | | | | | | | | |
Collapse
|
17
|
Ruel M, Sevestre H, Henry-Biabaud E, Courouce AM, Capron JP, Erlinger S. Fibrin ring granulomas in hepatitis A. Dig Dis Sci 1992; 37:1915-7. [PMID: 1473440 DOI: 10.1007/bf01308088] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Fibrin ring granuloma is characterized by a fibrinous ring surrounding a central fat vacuole. It has been found in the liver and bone marrow of patients with Q fever, and occasionally with visceral leishmaniasis, cytomegalovirus, Epstein-Barr virus, Staphylococcus epidermidis infections, Hodgkin's lymphoma, and hypersensitivity to allopurinol. We describe a case of serologically confirmed viral hepatitis A with this lesion in the liver biopsy. A false positive anti-hepatitis A virus IgM result has been excluded. This is, to our knowledge, the second reported case of type A hepatitis with hepatic fibrin ring granulomas. It confirms that hepatitis A should be included in the differential diagnosis of this lesion.
Collapse
Affiliation(s)
- M Ruel
- Médecine interne et gastro-entérologie, Hôpital de Senlis, Senlis, France
| | | | | | | | | | | |
Collapse
|