A Case of Pulmonary Hyalinizing Granuloma Associated with Posterior Uveitis

Pulmonary hyalinizing granuloma: a multicenter study of 5 new cases and review of the 135 cases of the literature

Pulmonary hyalinizing granuloma (PHG) is a rare disease characterized by single or multiple benign lung nodules mimicking lung neoplasma. Histologic analysis reveals homogenous hyaline lamellae, usually surrounded by collection of plasma cells, lymphocytes and histiocytes in a perivascular distribution. The clinical and radiological findings have been described in small series, but the long-term outcomes have rarely been reported. The objectives were to describe the clinical, radiological and outcomes of PHG in new cases and through a literature review. Patients with PHG were found by a multicenter search among French departments of internal medicine, pulmonology and anatomo-pathology. Review of the literature was made through the National Library of Medicine's MEDLINE database using keywords "hyalinizing granuloma." Five news cases and 135 cases of the literature were found. There were 82 men and 57 women, mean age at the diagnosis 44.6 years (15-83). Patients were frequently asymptomatic (n = 39, 27.4 %). The nodule was unique in 37 cases (28.9 %) and multiple in 91 cases (71.1 %). 18FDG PET scan revealed hypermetabolism of the nodule in 9/15 cases (60 %). A systemic disease was associated in 65 cases (mainly mediastinal and retroperitoneal fibrosis, autoimmune, tumoral or infectious disease or thromboembolism). The outcomes were evaluated in 73 patients when follow-up was available: 14 patients had a surgical resection of the nodule. Forty-five patients did not receive any immunosuppressive drug. Among these patients, 2 improved, 29 were stable and 14 worsened. Corticosteroids were used as a monotherapy in 19 patients and led to radiological improvement in 8 cases, stabilization in 8 cases and worsening in 3 cases. Five patients were treated with corticosteroids and at least one immunosuppressive drug and 4 patients improved. PHG is a rare benign disease, mimicking lung neoplasma, frequently associated with systemic diseases.

Pulmonary Hyalinizing Granuloma Mimicking Metastatic Lung Cancer

Pulmonary hyalinizing granuloma is a very rare benign condition, which usually manifests as solitary and sometimes as multiple pulmonary nodules. Deposition of immune complexes in the lung parenchyma due to hypersensitivity reactions is implicated in the etiology of pulmonary hyalinizing granuloma. A 59-year-old female patient who presented to our clinic with complaints of chest pain and cough had bilateral, multiple, and rounded lesions with regular margins suggesting metastatic lung disease. A transthoracic needle biopsy of the nodule was performed in the left pulmonary anterior segment. Biopsy showed no malignancy. Since no diagnosis was made by the biopsy, the patient underwent a video-assisted thoracic surgery. The wedge biopsy reported pulmonary hyalinizing granuloma. We aimed to present the diagnosis and treatment stages of our patient who was diagnosed with pulmonary hyalinizing granuloma in the light of literature review.

A 40-year-old woman with multiple pulmonary nodules. Pulmonary hyalinizing granuloma

A 40-year-old woman (a nonsmoker) with history of idiopathic thrombocytopenic purpura and a platelet count > 90,000 cells/μL without specific medication was referred to pulmonary clinic for evaluation of multiple pulmonary nodules. The patient presented to an outside hospital with fatigue, lack of energy, and dyspnea on exertion for 2 years. She denied fever, cough, chest pain, or weight loss. An initial chest radiograph showed bilateral multiple pulmonary nodules. A chest CT scan revealed multiple nodular lesions, varying in size, in all lobes of both lungs. There was no mediastinal lymphadenopathy or pleural effusion. There was no significant hypermetabolic activity on a subsequent fluorodeoxyglucose PET scan/CT scan, and there had been no significant change. She underwent CT scan-guided percutaneous transthoracic biopsy and bronchoscopy with transbronchial biopsies, all of which were inconclusive. An open lung biopsy was considered.

Pulmonary hyalinizing granuloma detected in a family member after confirmation of tuberculosis in his father

Pulmonary hyalinizing granuloma (PHG) is an uncommon lung disease that usually presents as bilateral multiple nodules, and more rarely as a solitary nodule. An exaggerated immune response to antigenic stimuli resulting from infection or an autoimmune process has been suggested as the cause of PHG. Here, we describe a rare case of solitary PHG that was detected in a family member after tuberculosis had been confirmed in his father, without any background of infectious disease or autoimmune abnormality.

Recurrent pulmonary hyalinizing granuloma

We report the case of a 61-year-old male patient who underwent surgical excision of a lung mass for anatomopathological study. The patient had previously presented with fever, dry cough, and chest pain, together with lung masses detected by chest X-ray, and had undergone thoracotomy for diagnostic investigation on two occasions (1976 and 1981), although a conclusive diagnosis had not been made. A CT scan of the chest revealed large masses with areas of calcification in both lung fields. The anatomopathological study was consistent with pulmonary hyalinizing granuloma. In the postoperative period, the patient experienced several episodes of bronchospasm, which was reversible with the use of symptomatic medication. At this writing, the patient was receiving maintenance therapy with prednisone (40 mg/day) and had shown clinical improvement.

Pulmonary hyalinizing granuloma in HIV/AIDS

A 55-year-old man who was recently diagnosed with HIV/AIDS developed multiple bilateral pulmonary nodules after starting highly active antiretroviral therapy. Workup confirmed the diagnosis of pulmonary hyalinizing granuloma. This is the first described case of pulmonary hyalinizing granuloma in HIV/AIDS, and may represent a rare form of immune reconstitution inflammatory syndrome.

Non-diagnosed pulmonary hyalinizing granuloma (PHG) as a cause of sudden unexpected death

Pulmonary hyalinizing granuloma (PHG), a very rare benign tumour of the lungs, was first reported in 1977. We present a PHG of a 32-year-old woman from Yemen who collapsed 1 day after her arrival in Germany. Tuberculosis was suspected and the health authorities nearly closed part of one of the major international airports in Europe. However, this drastic measure was avoided by autopsy and a correct interpretation of the solid-elastic and well-circumscribed lung tumour as not characteristic for tuberculosis. Although the final diagnosis of PHG was only achieved after histology, this case strongly illustrates the necessity of a profound morphological training of forensic physicians.

Subpleural pulmonary hyalinizing granuloma presenting as a solitary pulmonary nodule

We introduce a case of pulmonary hyalinizing granuloma presented as a solitary pulmonary nodule located subpleurally. The patient was a 57-year-old man who had abnormal chest roentgenograms showing a solitary pulmonary nodule in the right lower lung field. The nodule was resected for definitive diagnosis and histopathologically proved to be pulmonary hyalinizing granuloma. In previously reported cases, most patients had ill-defined margins and usually bilateral, multiple lesions radiographically. In our case, the subpleural location is an uncommon location of this rare entity.

Radiology–Pathology Conference: pulmonary hyalinizing granuloma associated with lupus-like anticoagulant and Morvan's Syndrome

Pulmonary hyalinizing granulomata are rare, noninfectious, fibrosing lesions of the lung, which can mimic metastatic disease radiographically. Their etiology is unknown, but they may be caused by an exaggerated immune response. We report the radiology, long clinical course, and pathology of a patient with pulmonary hyalinizing granuloma who presented with initially asymptomatic pulmonary nodules. Over a 10-year period, the patient developed multiple insidious autoimmune phenomena, including lupus anticoagulant, neuromyotonia, demyelinating sensorimotor polyneuropathy, and eventually, Morvan's syndrome. Such an association has not been previously published to our knowledge.

Pulmonary hyalinizing granuloma and retroperitoneal fibrosis in an adolescent

We describe a 15-year-old boy who developed pulmonary hyalinizing granuloma (PHG) and retroperitoneal fibrosis (RPF). His PHG and RPF were not associated with histoplasmosis or tuberculosis and appeared to represent idiopathic autoimmune phenomena. This is the first reported case of PHG in a pediatric patient and the fourth reported co-occurrence of PHG and RPF. The use of F-18 fluorodeoxyglucose positron emission tomography in the diagnostic and follow-up evaluation of PHG is reported.

Serum Interleukin-2 and Neopterin Levels as Useful Markers for Treatment of Active Pulmonary Tuberculosis

Macrophages and T cells are responsible for the main immune response to tuberculosis by secreting many cytokines and other substances. The aim of this study was to determine the effects of multidrug treatment on serum levels of interleukin-2 (IL-2), secreted by activated T cells, and of neopterin, secreted by macrophages and monocytes, in patients with pulmonary tuberculosis. The study included 30 patients with active pulmonary tuberculosis, confirmed by the detection of acid-fast bacilli in direct sputum smears and/or sputum cultures. The serum levels of IL-2 and neopterin were measured before and during the treatment and compared with 15 patients with inactive pulmonary tuberculosis and 15 healthy controls. Serum IL-2 and neopterin levels were higher in patients with active tuberculosis (164.53 +/- 58.91 pg/ml and 69.54 +/- 29.42 nmol/l, respectively) than those in inactive tuberculosis (95.43 +/- 31.17 pg/ml and 10.71 +/- 1.78 nmol/l) or controls (79.20 +/- 14.81 pg/ml and 9.50 +/- 2.27 nmol/l) (p < 0.001 for each parameter). No significant differences were found in IL-2 and neopterin levels between inactive tuberculosis and control subjects. The IL-2 levels remained elevated in active tuberculosis at 2nd month of treatment (p < 0.001) and decreased to the control levels after 4th month. Neopterin levels were significantly higher in active tuberculosis than those in inactive tuberculosis or controls at the 2nd and 4th months of treatment. These findings indicate that measurements of serum IL-2 and neopterin levels are useful in following up the treatment and immune response to tuberculosis.

Miliary Tuberculosis Associated with Multiple Intracranial Tuberculomas

In this study we have reported a 12-year old girl patient who visited out-patient clinic with the history of headache and convulsion. The patient was diagnosed as miliary tuberculosis and multiple brain tuberculomas. Miliary infiltration was observed in chest x-ray and high-resolution thorax computed tomography (CT), and multiple tuberculomas surrounded with wide edema was observed in Magnetic Resonance Imaging (MRI). Acid-fast bacilli were detected in inducted sputum and gastric fluid. Focal epileptiform activity was seen in electroencephalography (EEG). The patient was administered antitubercular, anti-edema and antiepileptic therapy. The patient had not experienced convulsion for the second time and EEG had been normal; therefore her treatment was completed within 12 months. Chest x-ray and high-resolution thorax CT findings turned to normal and brain MRI findings improved significantly. As a conclusion, tuberculosis disease has very different clinical pattern depending on the organs it involves. The significance of our case is due to the presence of both the miliary tuberculosis and intracranial tuberculomas. The patient was admitted to the hospital due to central nervous system symtoms rather than pulmonary symptoms.