The pathology of sarcoidosis

Non-negligible ultrasonographic findings in sarcoid myositis: A case series and literature review

Sarcoid myositis is a rare and often debilitating extrapulmonary manifestation of sarcoidosis that can be difficult to recognize without a prior sarcoidosis diagnosis. Sarcoidosis with muscle nodules or masses as the first symptom is the least common form, occurring in approximately 0.5%-2.3% of cases. This article presents four middle-aged female patients who initially sought medical attention for a lower limb mass. Ultrasound examinations revealed consistent characteristic changes indicative of myositis. All patients underwent ultrasound-guided muscle biopsy and were diagnosed with sarcoidosis. Therefore, ultrasonography plays a pivotal role as the primary diagnostic tool for the early detection of sarcoid myositis.

Neuropathological evidence for neurosarcoidosis is more widespread than imaging suggests

We present a single case of a 47 year old male with a relapsing progressive neurological disease characterised by an infiltrative inflammation of the brain and leptomeninges. Investigations revealed the presence of systemic sarcoidosis which was confirmed histologically following a mediastinal lymph node biopsy. The imaging appearances of the brain and spinal canal lesions were compatible with neurological involvement by the same disease. Despite treatment, the patient deteriorated and died. We present the neuropathological findings, correlate these with the imaging features, and find that neuropathological evidence for disease was in this case strikingly more widespread than predicted by imaging ante-mortem.

[Cardiac sarcoidosis as an infrequent cause of sudden death in asymptomatic young patients]

Cardiac involvement in sarcoidosis has been described in both symptomatic and asymptomatic patients. The aim of this report is to further the understanding of sarcoidosis and its clinical presentation. We report the autopsy and toxicology results of two cases of sudden death in young men. A 37-year-old male had generalized sarcoidosis, in mediastinal glands and intramyocardial sarcoid granulomas in the left ventricle, which had caused a 14mm thickening of the ventricular wall and a secondary dilated myocardiopathy causing sudden death. A 27-year-old male had extensive sarcoidosis of the lungs and mediastinum. Granulomas with a fibrotic background were found in the cardiac wall which could have originated an arrhythmogenic mechanism causing sudden death. Post-mortem study including careful examination of cardiac conduction pathways are vital to ascertain the cause of sudden death.

Clinical Features, Histopathology and Differential Diagnosis of Sarcoidosis

Sarcoidosis is a chameleon disease of unknown etiology, characterized by the growth of non-necrotizing and non-caseating granulomas and manifesting with clinical pictures that vary on the basis of the organs that are mainly affected. Lungs and intrathoracic lymph nodes are the sites that are most often involved, but virtually no organ is spared from this disease. Histopathology is distinctive but not pathognomonic, since the findings can be found also in other granulomatous disorders. The knowledge of these findings is important because it could be helpful to differentiate sarcoidosis from the other granulomatous-related diseases. This review aims at illustrating the main clinical and histopathological findings that could help clinicians in their routine clinical practice.

Sarcoidosis during treatment of pulmonary tuberculosis: a rare case report and review of the literature

The coexistence of pulmonary tuberculosis and pulmonary sarcoidosis is rare. Further, the morphological features of pulmonary tuberculosis with comorbid pulmonary sarcoidosis are similar to those of tuberculosis alone. There are obvious clinical, histological, and radiological similarities between sarcoidosis and tuberculosis, which makes differential diagnosis very challenging, particularly in countries with a high burden of tuberculosis. Here, a rare case of computed tomography (CT) findings of sarcoidosis that developed during tuberculosis treatment is reported. The 46-year-old male patient had no significant symptoms and was undergoing treatment for Mycobacterium tuberculosis infection. Chest CT revealed enlargement of multiple lymph nodes, without cystic or necrotic changes, in the mediastinum and both hili, and post-infectious changes consistent with the sequelae of tuberculosis infection in the left upper lobe. Chest radiographic evidence was accompanied by compatible clinical features and noncaseating granulomas on biopsy. As the patient was clinically stable, corticosteroid treatment was not initiated. To date, the patient remains without specific symptoms and outpatient follow-ups continue. Although rare, sarcoidosis may occur during treatment of pulmonary tuberculosis, and requires attention for diagnosis and treatment. The present case draws a radiological picture of how tuberculosis evolved to sarcoidosis.

[Overview: granulomatous diseases of the lung]

The spectrum of pulmonary granulomatoses is wide and includes infectious and noninfectious entities, each with very different therapeutic consequences. The first step of histological examination discriminates between necrotizing and non-necrotizing granulomatosis. After this, an infectious cause of the granulomatosis has to be excluded by special histological stains and molecular-pathologic methods, if necessary. Diagnosis also includes clinical, radiological, and microbiological findings. The process of pathological examination should be standardized as described.

Extensive bony sarcoidosis of the head and neck region: a rare presentation

We present a rare case of sarcoidosis with extensive bony destruction of the maxillofacial and skull base bones. A 65-year-old woman was referred with an asymptomatic, non-healing dental socket. Examination revealed an oroantral fistula that was biopsied and repaired under general anaesthesia. Investigations included plain and cross-sectional imaging. Serological tests, in particular ACE, were normal. Histology showed benign florid granulomatous inflammation. At 6 months, the patient remained asymptomatic. She was re-referred 3 years later with further bony destruction of her maxilla and mandible. Repeat imaging showed intrathoracic lymphadenopathy and skull base involvement. Repeat biopsy confirmed granulomatous inflammation. Given the pulmonary, histological and radiological findings, a sarcoidosis diagnosis was made. Following multidisciplinary team meetings, the patient was treated with methotrexate and arrangements made for close monitoring. This case highlights the need for a consensus in identifying, treating and developing a follow-up protocol in such patients.

Novel protein pathways in development and progression of pulmonary sarcoidosis

Pulmonary involvement occurs in up to 95% of sarcoidosis cases. In this pilot study, we examine lung compartment-specific protein expression to identify pathways linked to development and progression of pulmonary sarcoidosis. We characterized bronchoalveolar lavage (BAL) cells and fluid (BALF) proteins in recently diagnosed sarcoidosis cases. We identified 4,306 proteins in BAL cells, of which 272 proteins were differentially expressed in sarcoidosis compared to controls. These proteins map to novel pathways such as integrin-linked kinase and IL-8 signaling and previously implicated pathways in sarcoidosis, including phagosome maturation, clathrin-mediated endocytic signaling and redox balance. In the BALF, the differentially expressed proteins map to several pathways identified in the BAL cells. The differentially expressed BALF proteins also map to aryl hydrocarbon signaling, communication between innate and adaptive immune response, integrin, PTEN and phospholipase C signaling, serotonin and tryptophan metabolism, autophagy, and B cell receptor signaling. Additional pathways that were different between progressive and non-progressive sarcoidosis in the BALF included CD28 signaling and PFKFB4 signaling. Our studies demonstrate the power of contemporary proteomics to reveal novel mechanisms operational in sarcoidosis. Application of our workflows in well-phenotyped large cohorts maybe beneficial to identify biomarkers for diagnosis and prognosis and therapeutically tenable molecular mechanisms.

[Histological differential diagnosis of granulomatous lung diseases (part I)]

Granulomatous diseases are a heterogeneous group of the diseases of different etiology, which are manifested by a variety of clinical syndromes and variants of tissue changes, by non-uniform sensitivity to therapy, and by the predominance of the common dominant histologic sign - the presence of granulomas that determine the clinical and morphological essence of each disease. Granuloma is a chronic inflammatory response, which involves macrophages and other inflammatory cells. After exposure to an antigen, T-lymphocytes, macrophages, epithelioid cells, and multinucleated giant cells are activated, resulting in the formation of granulomas. Granuloma also includes the extracellular matrix produced by fibroblasts, which can demarcate and isolate the antigen. According to etiology, granulomatous diseases are classified as infectious and non-infectious. However, recent investigations demonstrate that pathogenic microorganisms can cause granulomas in diseases previously considered non-infectious. In some cases, it is very difficult to classify a granulomatous process as infectious and non-infectious. The aim of this paper is to draw the attention of readers to the diversity of granulomatous diseases, to describe the key points of pathological and anatomical manifestations of various non-infectious diseases, as well as to determine an approach to the differential diagnosis of granulomatoses.

Sarcoidosis from Head to Toe: What the Radiologist Needs to Know

Sarcoidosis is a multisystem granulomatous disorder characterized by development of noncaseating granulomas in various organs. Although the etiology of this condition is unclear, environmental and genetic factors may be substantial in its pathogenesis. Clinical features are often nonspecific, and imaging is essential to diagnosis. Abnormalities may be seen on chest radiographs in more than 90% of patients with thoracic sarcoidosis. Symmetric hilar and mediastinal adenopathy and pulmonary micronodules in a perilymphatic distribution are characteristic features of sarcoidosis. Irreversible pulmonary fibrosis may be seen in 25% of patients with the disease. Although sarcoidosis commonly involves the lungs, it can affect virtually any organ in the body. Computed tomography (CT), magnetic resonance imaging, and positron emission tomography/CT are useful in the diagnosis of extrapulmonary sarcoidosis, but imaging features may overlap with those of other conditions. Familiarity with the spectrum of multimodality imaging findings of sarcoidosis can help to suggest the diagnosis and guide appropriate management. ^©RSNA, 2018.

Reprint of: The pathology of pulmonary sarcoidosis: update

Sarcoidosis is a multi-system disease of unknown etiology, usually affecting the respiratory tract and other organs, and is characterized by the formation of nonnecrotizing epithelioid granulomas. The diagnosis depends on a combination of a typical clinicoradiological presentation, the finding of nonnecrotizing epithelioid granulomas in a tissue biopsy, and exclusion of other possible diseases, especially those of infectious etiology. The granulomas contain epithelioid cells, giant cells, CD4+ T cells in their center, and CD8+ T lymphocytes and B lymphocytes at their periphery. The granulomas are present in a lymphatic pattern around bronchovascular structures and, because of this, may show angioinvasion. The bronchial involvement produces a high diagnostic yield for transbronchial and endobronchial biopsies in this disease. Finally, small amounts of fibrinoid necrosis may occur within granulomas of sarcoidosis and do not exclude the diagnosis. Larger amounts suggest either infection or the rare disease necrotizing sarcoid granulomatosis (NSG). A number of cytoplasmic structures/inclusions can be identified within the granulomas of sarcoidosis, including asteroid bodies, Schaumann's bodies, calcium oxalate crystals, and Hamazaki-Wesenberg bodies; the last two of these can cause difficulties in differential diagnosis. Extra-pulmonary sarcoid can be an important factor in prognosis. Involved sites include (in decreasing frequency): skin, endocrine organs, extra-thoracic lymph nodes, neurologic sites, eyes, liver, spleen, bone marrow, cardiac, ear/nose/throat, parotid/salivary, muscles, bones/joint, and kidney. NSG is a controversial variant of sarcoidosis consisting of granulomatous pneumonitis with sarcoid-like granulomas, variable amounts of necrosis, and granulomatous vasculitis. The lesions are most often confined to lung, and they usually appear as multiple nodules or nodular infiltrates, but occasionally as solitary or unilateral nodules ranging up to 5 cm in diameter. Nodular sarcoidosis is rare, varying from 1.6% to 4% of patients with sarcoidosis, and, as the name suggests, it shows radiographic nodules measuring 1 to 5 cm in diameter that typically consist of coalescent granulomas. Lung transplantation can be used in selected patients with fibrotic late-stage sarcoidosis. There is a high reported frequency of recurrence of disease in the pulmonary allograft, ranging from 47% to 67%, but recurrence is usually not clinically significant. Studies of the pathogenesis of sarcoidosis suggest that it is a chronic immunological response produced by a genetic susceptibility and exposure to specific environmental factors.

A Case of Severe Cardiac Sarcoidosis with Minimal Pulmonary Involvement: A Case Report with Literature Review

Sarcoidosis is a granulomatous disease of unknown etiology. Although sarcoidosis is a systemic disease, there appears to be a predilection for involvement of certain organs. The pulmonary system is the most commonly affected system among all racial groups. Cardiac and respiratory complications are the leading causes of death due to sarcoidosis and in certain patient populations about half of these deaths are attributed to cardiac sarcoidosis. There are few autopsy case reports of cardiac sarcoidosis with minimal respiratory involvement making this case report relevant to the importance of the recognition and awareness of this entity. Acad Forensic Pathol. 2018 8(2): 407-415.

Concomitant presentation of sarcoidosis and pulmonary tuberculosis with ARDS: A diagnostic dilemma and therapeutic challenge

Tuberculosis and sarcoidosis are chronic multisystem granulomatous conditions which have different aetiology and management but may mimic each other clinically, radiologically and pathologically. Both these diseases usually have a sub acute or chronic presentation and it is rather uncommon for them to coexist or present with acute respiratory failure. We report a case of a 57-year-old male who presented with pyrexia of unknown origin with chronic cough. He was initially diagnosed to have sarcoidosis based on clinico-radiological and histologic evidence and was started on corticosteroids. However, he presented within two weeks with acute respiratory distress and on further investigation was diagnosed with co-existing pulmonary tuberculosis.

Diagnostic Approach to Advanced Fibrotic Interstitial Lung Disease: Bringing Together Clinical, Radiologic, and Histologic Clues

Context.—

Idiopathic pulmonary fibrosis (IPF) is a distinctive clinicopathologic entity and the most common form of progressive diffuse lung scarring in older adults. Idiopathic pulmonary fibrosis manifests histopathologically as the usual interstitial pneumonia pattern. The usual interstitial pneumonia pattern is distinguished by geographically and temporally heterogeneous fibrosis that is peripherally accentuated, often with honeycombing and traction bronchiectasis. Idiopathic pulmonary fibrosis is not the only disease that leads to end-stage lung fibrosis, however, and several other entities may also cause advanced fibrosis. Surgical lung biopsies often present a diagnostic dilemma when they show clear evidence of advanced fibrosis, but the clinical, imaging, and/or histopathologic subcharacteristics suggest something other than IPF.

Objective.—

To address this dilemma, we review several other fibrotic lung diseases, including connective tissue disease–associated interstitial lung disease, chronic hypersensitivity pneumonitis, advanced pulmonary Langerhans cell histiocytosis, end-stage pulmonary sarcoidosis, Erdheim-Chester disease, Hermansky-Pudlak syndrome, and others, detailing their clinical, radiologic, and histopathologic attributes and emphasizing similarities to and differences from IPF.

Data Sources.—

Data sources comprised published peer-reviewed literature and personal experience of the authors.

Conclusions.—

Often, clues in the lung biopsy may offer the first suggestion of a fibrotic lung disease other than IPF, and accurate classification is important for prognosis, treatment, and the development of future therapies.

Multiple bilateral pulmonary nodules masquerading as pulmonary metastasis; a case of nodular sarcoidosis

Sarcoidosis is a multi-system inflammatory disorder of unknown etiology that is manifested by the presence of non-caseating granulomas. Multiple pulmonary nodules are rare presentations of sarcoidosis. We report a case of nodular sarcoidosis in a young male of Middle-East origin who had initially presented with bilateral painful ankle edema. His chest X-ray showed multiple bilateral pulmonary nodules. A high resolution computed tomography scan of the chest demonstrated multiple pulmonary nodular lesions and also mediastinal and hilar lymphadenopathy. Subsequent biopsies revealed non-necrotizing granuloma with multi-nucleated giant cells indicative of sarcoidosis. An appropriate work-up was done to confirm the true nature of the nodules and facilitate treatment.

Coexistence of pulmonary tuberculosis and sarcoidosis: a diagnostic dilemma

Tuberculosis and sarcoidosis are multisystem diseases having different aetiology and management; however, they have similar clinical and histological characteristics. Very rarely they may coexist. We report a rare case of a 38-year-old woman who presented with chronic cough, low-grade fever and respiratory distress that was initially diagnosed as miliary tuberculosis. Diagnosis was supported by positive mycobacterial culture and initially responded to antitubercular treatment, but later recurrences led to further investigations and the diagnosis of coexisting sarcoidosis.

Positron emission tomography imaging in sarcoidosis

Sarcoidosis is a chronic granulomatous disease of unknown origin. There are several modalities for diagnosis, staging and therapeutic management of patients with sarcoidosis. Among these, whole-body F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography is found to useful in patients with complex and multisystem forms of sarcoidosis. Other modalities include Gallium scanning, assesment of angiotensin converting enzyme levels in blood, chest radiography, mediastinoscopy etcetera.

Case series and literature review of multiple nodular sarcoidosis

Background

Nodular lung disease is a rare presentation of sarcoidosis. Radiologically it can present as multiple pulmonary masses or solitary lung nodule.

Case presentation

We report three cases of nodular sarcoidosis in young females of Asian origin who had initially presented with dry cough and worsening dyspnea non-responsive to initially administered antibiotics. Pulmonary nodules were discovered upon radiographic imaging in all three cases which raised concern for the possibility of neoplastic processes. Subsequent biopsies revealed granulomatous inflammation indicative of sarcoidosis. All cases responded very well to systemic corticosteroids.

Conclusion

Sarcoidosis may present as nodular infiltrates which alerts the treating physician to other neoplastic and infectious diseases of the lungs. Appropriate workup may reveal the true nature of this disease and hence, simplify treatment.

A rheumatoid nodule in an unusual location: mediastinal lymph node

Rheumatoid arthritis (RA) is a multisystem inflammatory disease characterised by destructive synovitis and varied extra-articular involvement. Rheumatoid lung nodules are the most common pulmonary manifestations of RA. Rheumatoid nodules in mediastinal lymph nodes are extremely uncommon. We describe a male patient with long-standing RA and subcutaneous rheumatoid nodules presenting with multiple lung nodules and mediastinal lymphadenopathies. Definite histopathology of a lymph node was consistent with necrobiotic granuloma due to RA. Clinicians should be aware of rheumatoid nodules as a potential cause of mediastinal lymphadenopathies, mainly in advanced rheumatoid arthritis.

Intramedullary spinal sarcoidosis masquerading as cervical stenosis

OBJECTIVE

Intramedullary spinal sarcoidosis is a difficult diagnosis to make because of its nonspecific clinical and imaging features and its imitation of other common spine disorders. We present a patient with intramedullary spinal sarcoidosis that mimicked spinal cord injury from a cervical disk herniation.

METHODS

Relevant information was extracted from the patient's medical and imaging records. A thorough literature review subsequently was performed.

RESULTS

A 59-year-old woman presented to our institution with several months of intermittent parathesias, pain, and subjective weakness in her right upper and lower extremities. Magnetic resonance imaging of the cervical spine demonstrated a large osteophyte-disk complex at C4-5 adjacent to a small area of intramedullary spinal cord enhancement. The patient underwent C4-5 anterior cervical diskectomy and fusion for the osteophyte-disk complex. She initially improved postoperatively but subsequently worsened after a few months. Because of more prominent spinal cord enhancement, a posterior laminectomy and biopsy of the enhancing lesion was performed. Intramedullary spinal sarcoidosis was diagnosed, and she was treated medically with steroids and immunosuppressive agents.

CONCLUSION

Spinal sarcoidosis can mimic more common disease processes, such as cervical spondylosis. It is an important consideration in the diagnosis of intramedullary or intradural lesions of the spinal cord because early medical treatment may improve the course of the disease process. Surgery should be limited to biopsy for diagnostic purposes.

Oral Lesion as the first Clinical Presentation in Sarcoidosis: A Case Report

Sarcoidosis is a common multi-system disease characterized histolopathologically by the formation of non-caseating granulomas in the affected tissues. The oral involvement of sarcoidosis is relatively rare with less than 70 reported cases in literature while an oral lesion as the initial presenting sign is even less common. Oral lesions of sarcoidosis may mimic the lesions of other serious systemic diseases including Crohn's disease and tuberculosis as well as lesions localized to the orofacial region such as orofacial granulomatosis. This report presents a case of non-progressive sarcoidosis where the initial presenting symptom was a lesion in the buccal vestibule attached to the gingivae. A brief review of the pathology and clinical features is also presented.

Imunofenotipagem e remodelamento da matriz extracelular na sarcoidose pulmonar e extrapulmonar

OBJETIVO: Investigar o significado de marcadores de imunidade celular e de componentes elásticos/colágeno da matriz extracelular em estruturas granulomatosas em biópsias de pacientes com sarcoidose pulmonar ou extrapulmonar. MÉTODOS: Determinações qualitativas e quantitativas de células inflamatórias, de fibras de colágeno e de fibras elásticas em estruturas granulomatosas em biópsias cirúrgicas de 40 pacientes com sarcoidose pulmonar e extrapulmonar foram realizadas por histomorfometria, imuno-histoquímica, e técnicas de coloração com picrosirius e resorcina-fucsina de Weigert. RESULTADOS: A densidade de linfócitos, macrófagos e neutrófilos nas biópsias extrapulmonares foi significativamente maior do que nas biópsias pulmonares. Os granulomas pulmonares apresentaram uma quantidade significativamente maior de fibras de colágeno e menor densidade de fibras elásticas que os granulomas extrapulmonares. A quantidade de macrófagos nos granulomas pulmonares correlacionou-se com CVF (p < 0,05), ao passo que as quantidades de linfócitos CD3+, CD4+ e CD8+ correlacionaram-se com a relação VEF1/CVF e com CV. Houve correlações negativas entre CPT e contagem de células CD1a+ (p < 0,05) e entre DLCO e densidade de fibras colágenas/elásticas (r = -0,90; p = 0,04). CONCLUSÕES: A imunofenotipagem e o remodelamento apresentaram características diferentes nas biópsias dos pacientes com sarcoidose pulmonar e extrapulmonar. Essas diferenças correlacionaram-se com os dados clínicos e espirométricos dos pacientes, sugerindo que há duas vias envolvidas no mecanismo de depuração de antígenos, que foi mais eficaz nos pulmões e linfonodos.

[Thoracic sarcoidosis]

Sarcoidosis is a multisystemic granulomatous disease of unknown etiology. It mainly affects the thoracic lymph nodes and the lungs. The staging of sarcoidosis, which classifies patients according to their probability of spontaneous remission, is based on the plain chest film findings. Plain chest films are not as sensitive as high resolution computed tomography (HRCT) at detecting involvement of the lymph nodes, lungs, or bronchi. The high resolution CT findings can be typical, practically pathognomic, or atypical. High resolution CT provides information about the activity of the disease and detects incipient signs of fibrosis and other complications. To reach the diagnosis, it is necessary to correlate the clinical and radiological findings (and often the histological findings). Cardiac involvement can cause sudden death. The diagnosis of cardiac involvement is difficult; it is based on various imaging tests, like magnetic resonance imaging, which is more specific, and positron emission tomography. Diagnostic confirmation by endomyocardial biopsy is obtained in few patients.

Neuro-ophthalmologic Manifestations of Sarcoidosis

The first-line treatment for the neuro-ophthalmologic manifestations of sarcoidosis is corticosteroid therapy. Prednisone, 0.5 to 1 mg/kg/day, is initially prescribed for 2 to 4 weeks, before a slow taper is begun as the patient's symptoms and examination are monitored. Patients frequently require adjunct therapy, which can be in the form of immunomodulatory drugs such as pentoxyfillin, hydroxychloroquine, or thalidomide, or immunosuppressive drugs such as mycophenolate mofetil, azathioprine, methotrexate, and cyclophosphamide. Individuals with profound visual compromise or progressive disease may benefit from high-dose intravenous methylprednisolone or tumor necrosis factor-alpha antagonists such as infliximab. Attention to the overall medical status of the patient is essential to ensure that an optimal clinical status is achieved.

Cardiac sarcoidosis: a pathology-focused review

CONTEXT

Sarcoidosis is a granulomatous disease of unclear etiology. It is not commonly fatal, but when sarcoidosis is fatal, it is most often from cardiac involvement and when sarcoidosis involves the heart, it frequently causes death. The disease presents diagnostic challenges both clinically and histologically.

OBJECTIVES

To review the histology of cardiac sarcoidosis and the histologic differential diagnosis of cardiac granulomatous disease and to review the epidemiology and gross pathology of cardiac sarcoid as well as discuss current controversies, clinical diagnostic criteria, and proposed mechanisms of pathogenesis.

DATA SOURCES

We reviewed the literature searchable on PubMed as well as selected older studies revealed by our review of the recent literature. Photographs were taken from cases on file at the University of Pittsburgh Medical Center (Pittsburgh, Pennsylvania) and Columbia University Medical Center (New York, New York).

CONCLUSIONS

Sarcoidosis is a focal or disseminated granulomatous disease that likely represents the final common pathway of various pathogenic insults in a genetically susceptible host. The type of insult may influence the specific sarcoid phenotype. Controversy still abounds, but many areas of investigation around sarcoidosis are yielding exciting discoveries and bringing us closer to a richer understanding of this puzzling disease.

Granulomatous lung disease: an approach to the differential diagnosis

CONTEXT

Granulomas are among the most commonly encountered abnormalities in pulmonary pathology and often pose a diagnostic challenge. Although most pathologists are aware of the need to exclude an infection in this setting, there is less familiarity with the specific histologic features that aid in the differential diagnosis.

OBJECTIVE

To review the differential diagnosis, suggest a practical diagnostic approach, and emphasize major diagnostically useful histologic features. This review is aimed at surgical pathologists who encounter granulomas in lung specimens.

DATA SOURCES

Pertinent recent and classic peer-reviewed literature retrieved from PubMed (US National Library of Medicine) and primary material from the institutions of both authors.

CONCLUSIONS

Most granulomas in the lung are caused by mycobacterial or fungal infection. The diagnosis requires familiarity with the tissue reaction as well as with the morphologic features of the organisms, including appropriate interpretation of special stains. The major noninfectious causes of granulomatous lung disease are sarcoidosis, Wegener granulomatosis, hypersensitivity pneumonitis, hot tub lung, aspiration pneumonia, and talc granulomatosis.

A rare case of pulmonary tuberculosis with simultaneous pulmonary and skin sarcoidosis: a case report

Background

Tuberculosis and sarcoidosis are chronic diseases that rarely occur concomitantly. Sarcoidosis is a multisystem granulomatous disorder characterized pathologically by the presence of non-caseating granulomas in involved tissues. Tuberculosis is infectious disease caused by Mycobacterium tuberculosis characterized by granulomas with caseous necrosis.

Case presentation

We present a case of 43-year-old female refugee from Kosovo with microbiological confirmation of pulmonary tuberculosis and pulmonary and skin sarcoidosis at the same time. Three weeks after corticosteroid therapy for pulmonary sarcoidosis was introduced, positive finding of mycobacterium culture of bronchial aspirate was observed. Based on these results, corticosteroid therapy was excluded and antituberculous therapy was introduced for six months. In the meantime, new nodes on face and nose appeared and skin sarcoidosis was diagnosed. The patient was given corticosteroids and colchicine according to the skin and pulmonary sarcoidosis therapy recommendation.

Conclusion

The authors of this study suggest that in cases when there is a dilemma in diagnosis between tuberculosis and sarcoidosis we should advance with corticosteroid therapy until we have microbiological confirmation of mycobacterium culture. This case is remarkable because this is a third described case of sarcoidosis and tuberculosis together (the first reported in Asia, the second in South Africa), and to authors knowledge, this is a first case report in Europe.

Neurosarcoidosis with necrotising sarcoid granulomatosis mimicking meningiomatosis cerebri: case report and literature search

A 52-year-old woman presented with headaches, difficulty with word finding and left eye blindness. MRI showed enhancing frontal dural-based masses suggestive of meningiomatosis. Biopsy and debulking revealed necrotising granulomas, without discernible micro-organisms or neoplasia; a thorough clinical work-up was negative for infection and vasculitis. A CT scan showed mild bilateral hilar lymphadenopathy, a tiny pulmonary nodule and cirrhotic liver. Her subsequent alteration of mental status was attributed to hepatic encephalopathy based upon elevated aminotransferase and ammonia levels, biopsy evidence of hepatoportal sclerosis with rare granulomas and response to lactulose. A diagnosis of neurosarcoidosis of the necrotising sarcoid granulomatosis variant (NS-NSG) with atypical systemic involvement was made. This is the fifth case report of NS-NSG clinically mimicking a neoplasm and histologically mimicking a mycobacterial infection. NS-NSG can have an atypical clinical picture including intracranial masses; a thorough work-up to exclude infectious and other non-infectious aetiologies is a prerequisite to its diagnosis.

The clinical and radiologic features of nodular pulmonary sarcoidosis

STUDY OBJECTIVES

Nodular sarcoidosis is an uncommon presentation of sarcoidosis. Our objective was to describe the clinical characteristics of a large cohort of patients with nodular sarcoidosis.

METHODS

We performed a retrospective study of patients with nodular sarcoidosis diagnosed at an urban teaching hospital over a 10-year period.

RESULTS

Thirty-three patients with nodular sarcoidosis were identified. All patients were African-American. The mean age was 35 and the female-to-male ratio was 5:1. Twenty-six patients were current or former smokers. All patients had chest CT scan and/or chest radiograph evidence of pulmonary masses. Twenty-seven patients had multiple pulmonary masses/nodules and six had solitary pulmonary nodules/masses. The upper lobes were involved in 27 patients. Mediastinal lymphadenopathy and pleural-based masses were present in 30 and 20 patients, respectively. Extrapulmonary manifestations were present in 14 patients. All patients had tissue diagnosis of noncaseating granulomas with negative culture. Twenty-two patients underwent bronchoscopy with transbronchial biopsies, which were diagnostic in 19. Follow-up data were available on 27 patients: complete or nearly complete resolution of the pulmonary masses--either spontaneously or with systemic treatment--was documented for 19 patients, no change in the radiologic findings for 7 patients, and progression to pulmonary fibrosis for 1 patient.

CONCLUSIONS

Nodular sarcoidosis is a rare presentation of pulmonary sarcoidosis. It usually presents with multiple pulmonary masses that tend to be peripheral and are associated with mediastinal lymphadenopathy. Bronchoscopy with transbronchial biopsies has high diagnostic yield. Despite its ominous presentation, nodular sarcoidosis has favorable prognosis.

Solitary pituitary sarcoidosis with normal endocrine function

✓ Sarcoidosis is a multisystemic granulomatous disease characterized by noncaseating epithelioid granulomata that affects the lung in over 90% of patients and the central nervous system (CNS) in 5–9%. Neurosarcoidosis often occurs as multifocal meningeal and parenchymal lesions, and its diagnosis is particularly difficult in the absence of concomitant systemic disease. Hypothalamic-pituitary sarcoidosis occurs in fewer than 10% of patients with neurosarcoidosis and has been previously reported in association with profound endocrinological dysfunction. The authors report the case of a patient with isolated pituitary sarcoidosis who was first evaluated for visual symptoms and showed no preoperative endocrinological dysfunction or evidence of multisystemic or other CNS involvement. To the authors' knowledge, only 1 other such presentation is previously reported in the English literature. Such presentations are diagnostically and therapeutically challenging, and definitive diagnosis requires obtaining a biopsy specimen of the lesion with histological proof of noncaseating epithelioid granuloma, as well as the exclusion of other possible entities.

Sarcoidosis in the setting of idiopathic chronic bronchiolitis with airway colonization from P. aeruginosa: treatment with low-dose macrolides

It has long been suggested that infectious agents may trigger sarcoidosis through their infectious or antigenic properties. A patient with airway colonization from P. aeruginosa in the setting of idiopathic bronchiolitis (IB) mimicking diffuse panbronchiolitis (DPB) developed sarcoidosis. Impressive clinical and radiological improvement of both bronchiolitis and sarcoidosis features was achieved with a one-year treatment with low-dose erythromycin, thus suggesting a possible link between the two conditions in this specific case. Pathogenic hypotheses and therapeutic implications are specifically discussed.

Intravascular sarcoidosis presenting as pulmonary vein occlusion: CT and pathologic findings

It is well known that destruction of the distal capillary bed from extensive fibrosis and honeycombing in the setting of sarcoidosis may lead to pulmonary hypertension. However, we report an unusual manifestation of sarcoidosis where pulmonary hypertension resulted from granulomatous involvement of the pulmonary veins and venules. This presented as venous occlusion and intraluminal filling defects that simulated thrombus on chest computed tomography. To our knowledge, this is the first reported imaging case of such a presentation.

The pathology of pulmonary sarcoidosis: update

Sarcoidosis is a multi-system disease of unknown etiology, usually affecting the respiratory tract and other organs, and is characterized by the formation of nonnecrotizing epithelioid granulomas. The diagnosis depends on a combination of a typical clinicoradiological presentation, the finding of nonnecrotizing epithelioid granulomas in a tissue biopsy, and exclusion of other possible diseases, especially those of infectious etiology. The granulomas contain epithelioid cells, giant cells, CD4+ T cells in their center, and CD8 + T lymphocytes and B lymphocytes at their periphery. The granulomas are present in a lymphatic pattern around bronchovascular structures and, because of this, may show angioinvasion. The bronchial involvement produces a high diagnostic yield for transbronchial and endobronchial biopsies in this disease. Finally, small amounts of fibrinoid necrosis may occur within granulomas of sarcoidosis and do not exclude the diagnosis. Larger amounts suggest either infection or the rare disease necrotizing sarcoid granulomatosis (NSG). A number of cytoplasmic structures/inclusions can be identified within the granulomas of sarcoidosis, including asteroid bodies, Schaumann's bodies, calcium oxalate crystals, and Hamazaki-Wesenberg bodies; the last two of these can cause difficulties in differential diagnosis. Extra-pulmonary sarcoid can be an important factor in prognosis. Involved sites include (in decreasing frequency): skin, endocrine organs, extra-thoracic lymph nodes, neurologic sites, eyes, liver, spleen, bone marrow, cardiac, ear/nose/throat, parotid/ salivary, muscles, bones/joint, and kidney. NSG is a controversial variant of sarcoidosis consisting of granulomatous pneumonitis with sarcoid-like granulomas, variable amounts of necrosis, and granulomatous vasculitis. The lesions are most often confined to lung, and they usually appear as multiple nodules or nodular infiltrates, but occasionally as solitary or unilateral nodules ranging up to 5 cm in diameter. Nodular sarcoidosis is rare, varying from 1.6% to 4% of patients with sarcoidosis, and, as the name suggests, it shows radiographic nodules measuring 1 to 5 cm in diameter that typically consist of coalescent granulomas. Lung transplantation can be used in selected patients with fibrotic late-stage sarcoidosis. There is a high reported frequency of recurrence of disease in the pulmonary allograft, ranging from 47% to 67%, but recurrence is usually not clinically significant. Studies of the pathogenesis of sarcoidosis suggest that it is a chronic immunological response produced by a genetic susceptibility and exposure to specific environmental factors.

Acute granulomatous lupus pneumonitis: the first case report

Acute lupus pneumonitis is a rare form of pulmonary involvement in systemic lupus erythematosus (SLE). We present herein a patient with acute lupus pneumonitis who presented with acute onset of fever, cough, dyspnea and a miliary pattern on chest radiographs and computer tomography. Lung histopathology revealed bronchocentric granulomatosis. To our knowledge, this is the first documented case of granulomas in lung parenchyma believed to be caused by SLE. The differential diagnoses of acute lupus pneumonitis and the pertinent literature are discussed.

Neurosarcoidosis which manifested as acute hydrocephalus: diagnosis and treatment

Neurosarcoidosis is generally expressed by various symptoms; it is exceptionally revealed by hydrocephalus. We report a 27-year-old African man hospitalized with acute neurological deterioration due to hydrocephalus. The treatment consisted of ventriculostomy and corticosteroid therapy; however a permanent shunt was not required. After six months of follow-up, the patient had fully recovered. Clinical presentation, neuroimaging findings and treatment modalities are discussed.

[The pseudoalveolar form of sarcoïdosis: a diagnostic pitfall]

BACKGROUND

Sarcoïdosis is a benign systemic granulomatosis whose aetiology remains unknown. Lung is the most frequently involved organ. The pseudoalveolar form of this disease is known to have an acute onset and is quite uncommon. Therefore, diagnosing such a rare variety of sarcoidosis is rather often challenging.

OBSERVATIONS

In the present article, the authors report two cases of pseudoalveolar sarcoidosis. The patients, both young adults, showed no suggestive signs of sarcoidosis at first presentation. This resulted in a considerable delay to diagnosis and to the corticosteroid therapy.

CONCLUSION

The authors emphasize the rarity of the pseudoalveolar form of sarcoidosis. They insist on its roentgenographic characteristics and demonstrate the functional benefits allowed by the precocious medical management. They also propose a current review of the literature.

Concurrent presentations of the sarcoidosis, tuberculosis and lymphoma in a single patient

A 56-year-old female patient, developing ALK-negative anaplastic T cell lymphoma 7 years after the diagnosis of sarcoidosis with clinical and histopathological features of tuberculosis has been presented. We herein present concurrent occurrence of the sarcoidosis, lymphoma and tuberculosis along with the confusing findings during the investigation for the establishing the diagnosis and management that represented a great challenge.

[Cervical lymphodenopathy--a single presentation of sarcoidosis?]

BACKGROUND

Sarcoidosis is a chronic inflammatory disease, commonly found in lungs and hilar lymph nodes, but multiple organs could be involved. The diagnosis is based on specific pathohistology which should be always combined with clinical, radiological and laboratory findings.

CASE REPORT

A patient initially presented with pneumonia, and treated with antibiotics, but with the general symptoms that persisted despite radiological resolution of lung infiltration was reported. The further diagnostic procedures revealed the presence of sarcoid granulomas in cervical lymph nodes. The peripheral lymph nodes are often affected in the early course of the disease, but it is difficult to distinguish if the illness is a sarcoid reaction to lung infection or a acute onset of sarcoidosis.

CONCLUSION

The detection of sarcoid granulomas in cervical lymph nodes should be precisely analyzed for the presence of sarcoidal changes in other tissues, primarily in the lungs tissue. Early diagnosis of lung sarcoidosis is significant, especially in the light of the fact that the latest studies point out that the prednisone therapy, started immediately after the diagnosis has been made, renders positive effects also in asympthomatic patients in II and III phase of the disease.

Pulmonary sarcoidosis with usual interstitial pneumonia distributed predominantly in the lower lung fields

Nodular and reticular opacities were detected in both lower lung fields of a 75-year-old man in 2000. Bronchoscopy revealed pulmonary sarcoidosis. In 2002, nodular and reticular opacities were shown in the right upper lobe, and video-assisted thoracoscopic surgery was performed. The histological findings revealed usual interstitial pneumonia (UIP)-like lesions, whereas non-caseous granulomas were not detected. In the present case of pulmonary sarcoidosis, nodular and reticular opacities were predominantly distributed in both lower lung fields, and the histological findings obtained by video-assisted thoracoscopic surgery showed UIP-like lesions. These findings may enlighten the assist in understanding of the process of development of pulmonary sarcoidosis.

Oral sarcoidosis: a review of literature

Sarcoidosis is a common systemic granulomatous disease affecting multiple organs. Oral involvement is relatively rare and, to our knowledge, there have been only 64 cases reported in the English literature. Most cases of oral sarcoidosis present with mobility of the teeth due to rapid alveolar bone loss. Other oral manifestations include asymptomatic swelling of the involved mucosa, gingivitis and ulcers. Diagnosis of sarcoidosis is by exclusion as no specific test is available. Radiographic, biochemical and histological findings are non-specific, but helpful. All cases of sarcoidosis do not require treatment. Corticosteroids are the treatment of choice in patients requiring treatment. Other drugs such as chloroquine, methotrexate, infliximab and thalidomide are also used in the treatment of sarcoidosis. In most of the oral cases reported, systemic steroids and surgery were the preferred treatment.