Granulomatous inflammation: The overlap of immune deficiency and inflammation

Pediatric granulomatous diseases constitute a heterogenous group of conditions in terms of clinical phenotypes, pathogenic mechanisms, and outcomes. The common link is the presence of multinucleated giant cells in the inflammatory infiltrate. The clinical scenario in which a tissue biopsy shows granulomatous inflammation is not an uncommon one for practicing adult and pediatric rheumatologists. Our role as rheumatologists is to develop a diagnostic plan based on a rational differential diagnostic exercise tailored to the individual patient and based mainly on a detailed clinical assessment. This chapter presents a comprehensive differential diagnosis associated with a classification developed by the authors. We describe with some detail extrapulmonary sarcoidosis, Blau syndrome, and immunodeficiency associated granulomatous inflammation, which in our view are the paradigmatic primary forms of granulomatous diseases in childhood. The other entities are presented only as differential diagnoses listing their most relevant clinical features. This chapter shows that almost all granulomatous diseases seen in adults can be found in children and that there are some entities that are essentially pediatric at onset, namely Blau syndrome and most forms of immunodeficiency associated granulomatous diseases.

Limitations of clinico-histopathological correlation of skin biopsies in leprosy

BACKGROUND

Skin biopsies play an important role in diagnosing and classifying different types of leprosy. The aim of this study was to analyse different histologic types of leprosy, to correlate histopathological diagnosis with clinical diagnosis, to study the uniformity of clinical and histological findings in the diagnosis of leprosy and to evaluate difficulties faced during clinicopathological correlation according to Ridley- Jopling classification due to inadequacy of data provided.

METHODS

This is a retrospective study of all skin biopsies reported from Department of Pathology of Tribhuvan University Teaching Hospital from 14 April 2007 to 13 April 2009, for which leprosy was the diagnosis or was strongly suspected on histopathology.

RESULTS

Out of 40 cases included, 33 were males and seven were females. Tuberculoid leprosy was the most common type comprising 23 /40 cases (57.5%). In 18/ 40 cases (45%), clinical diagnosis was leprosy. Only in three, leprosy was classified according to Ridley-Jopling criteria clinically. Thus clinicopathological correlation according to Ridley-Jopling criteria could not be done. Histopathological reporting lacked uniformity too. In 13/40 reports (32.5%), exact location of granuloma, presence or absence of Grenz zone and enroachment of epidermis by granuloma was not mentioned. None mentioned the number and distribution of lymphocytes or relative proportion of epithelioid cells and foamy histiocytes. Results: Out of 40 cases included, 33 were males and seven were females. Tuberculoid leprosy was the most common type comprising 23 /40 cases (57.5%). In 18/ 40 cases (45%), clinical diagnosis was leprosy. Only in three, leprosy was classified according to Ridley-Jopling criteria clinically. Thus clinicopathological correlation according to Ridley-Jopling criteria could not be done. Histopathological reporting lacked uniformity too. In 13/40 reports (32.5%), exact location of granuloma, presence or absence of Grenz zone and enroachment of epidermis by granuloma was not mentioned. None mentioned the number and distribution of lymphocytes or relative proportion of epithelioid cells and foamy histiocytes.

CONCLUSIONS

Histopathological diagnosis of leprosy did not correlated with clinical diagnosis significantly. Uniformity was not seen in the clinical or histopathological informations provided making it difficult to conduct retrospective clinico pathological correlation.

[Effect of N-acetylcysteine on the egg granuloma in hepatic tissue of mice with Schistosomosis japonica]

OBJECTIVE

To study the effect of N-acetylcysteine (NAC) on the egg granuloma in hepatic tissue of mice infected with Schistosoma japonicum.

METHODS

36 mice were randomly divided into normal group, infected group and NAC group, each with 12 mice. The mice in the latter two groups were each infected with 25+/-2 cercariae of S. japonicum through the skin of abdomen. NAC solution was orally given to the mice of NAC group, 200 mg/kg, 2 times/d from the day of infection through to the 42nd day. Mice in the other 2 groups were given 2 ml normal saline daily. The mice were all sacrificed at the end of the 42nd day and their livers were collected for pathologic observation. Area of the egg granuloma was measured with computer image analysis software. Concentration of nitric oxide (NO) and reduced glutathione hormone (GSH), and the activity of glutathione peroxidase (GSH-PX) in serum and hepatic tissue, and the activity of inducible nitric oxide synthase (iNOS) in the hepatic tissue were all detected.

RESULTS

Number of the single egg granuloma of "+,++,+++" grade were 1.80+/-0.25, 1.37+/-0.23 and 0.53+/-0.15 respectively in NAC treated group, which were less than those of infected group (3.70+/-0.28, 2.77+/-0.25 and 2.00+/-0.14 respectively) (P<0.05). The serum NO and GSH concentration was 0.53+/-0.17 and 229.66+/-9.47 respectively in NAC group, lower than those of infected group (2.64+/-0.31 and 312.47+/-18.55 respectively) (P<0.05), but its GSH-PX activity was 1101.99+/-140.81, higher than that of infected group (663.66+/-25.59) (P<0.05). The concentration of NO and GSH, and the activity of iNOS and GSH-PX in hepatic tissue of NAC group were 6.85+/-0.30, 13.44+/-0.40, 358.40+/-19.15 and 110.84+/-10.93 respectively, lower than those in infected group (8.26+/-1.69, 28.40+/-0.56, 1132.44+/-52.82 and 226.26+/-16.25 respectively) (P<0.05).

CONCLUSION

NAC may have the effect of retarding pathological change of the liver, which may associate with the decrease of NO and GSH in serum and hepatic tissue and iNOS activity in the tissue.

[Examination of granuloma of revised cemented or cementless total hip arthroplasties using inductively coupled plasma atomic emission spectrometry (ICP-OES)]

INTRODUCTION

Aseptic loosening is the most common problem in total hip arthroplasty (THA). One main aspect is inflammatory reaction against wear particles of the prosthesis materials. Analysing failure mechanisms in THA analysis of the particles and their element distribution of revised granulomatous tissue is essential to improve materials used in THA.

MATERIALS AND METHODS

23 granulomas of revised THA due to aseptic loosening, 13 of which with metal on metal bearing (M/M), were analysed using inductively coupled plasma atomic emission spectrometry (ICP-OES).

RESULTS

Elements Cr, Mn, Ni, Al, Cu, Zn, Cd, Ti, V, Zr, Nb and Fe could be detected. The maximum value of Cr was 23.88 ppb (parts per billion), Al 191.02 ppb, Ni 64.95 ppb and Zr 9.96 ppb. The highest value of Al could be found in cementless implants. The maximum value of the elements Cr and Ni could be detected in M/M. In cemented implants the highest value of Zr was found.

DISCUSSION

The origin of Zr was the used bone cement in cemented THA. The elements Cr and Ni were significantly higher in M/M bearings. The highest value of Al was detected in granulomas of revised corund rough blasted cementless implants. The histopathologic findings of the revised M/M bearings have been published recently. Inductively Coupled Plasma Atomic Emission Spectrometry (ICP-OES) could not show any differences of the alloying constituents in cases with or without allergic reactions. ICP-OES analysis seems to be not useful examination of histologic sections using SEM with cryotransfer unit.

[Pulmonary tumors]

Pulmonary nodules may be caused by true neoplasms of the airways, respiratory epithelium, vessels and connective tissue which are mainly malignant or metastatic. They may, however, also represent mainly inflammatory benign pseudotumours. Non-small cell lung cancer (NSCLC) usually presents as an ill-defined soft-tissue pulmonary nodule or mass, often without lymphadenopathy; endobronchial lesions are less common. Small cell lung cancer (SCLC) commonly presents with extensive lymph node and hematogenous metastases. Carcinoid tumors typically manifest as endobronchial lesions with secondary obstruction. Sarcomas are rare and show variable morphology. Metastases most commonly present as basal, peripheral, well-defined nodules. Granulomas often exhibit typical calcifications; hamartoma may also contain popcorn-type calcifications as well as fat. Pulmonary arteriovenous malformation is characterised by feeding artery and draining vein. Inflammatory nodules are well vascularized and may regress spontaneously; their differentiation from malignant lesions, however, is usually difficult.

The spectrum of primary cutaneous elastolytic granulomas and their distinction from granuloma annulare: a clinicopathological analysis

AIMS

Actinic granuloma (AG) and annular elastolytic giant cell granuloma (AEGCG) are terms commonly applied to cutaneous lesions characterized by elastolysis, elastophagocytosis and a multinucleated cell infiltrate. The aim of this study was to clarify the relationship of these lesions to granuloma annulare (GA) which they resemble clinically.

METHODS AND RESULTS

The clinicopathological data of 20 patients whose biopsies showed the histology of elastolytic granuloma as well as those of previously published cases with identical tissue changes were analysed to assess differences between AG, AEGCG and GA. The tissue changes of AG and AEGCG are identical and differ substantially from GA because of the predominant elastolysis and elastophagocytosis in the absence of necrobiosis and palisading granuloma. Actinic and/or thermal injury could be elicited frequently in the patient's history, but not always.

CONCLUSIONS

AG may be considered as an aetiopathological subdivision of AEGCG. Patients with biopsies showing both GA and AEGCG are occasionally encountered. AEGCG is easily differentiated from incidental elastolysis which may be seen in a variety of aetiologically unrelated processes.

Primary nasal tuberculosis: a case report

During the past 2 decades, tuberculosis--both pulmonary and extrapulmonary--has re-emerged as a major health problem worldwide. Nasal tuberculosis--either primary or secondary to pulmonary tuberculosis or facial lupus--is rare, but it should be considered in the differential diagnosis of nasal granulomas. We describe a case of primary nasal tuberculosis in an adult male who presented with a polypoid lesion in one nasal cavity. The diagnosis was based on histopathology and the patient's successful response to antituberculous drug treatment. Given the rising incidence of tuberculosis, it is prudent that otolaryngologists remain cognizant of this infection as a potential cause of unusual lesions in the head and neck.

[Bacterial granulomatous hepatitis]

The liver may react to different infectious and non- infectious agents, developing granulomatous lesions which characterize granulomatous hepatitis. Granulomas of the liver are circumscribed inflammatory lesions (size from 50 to 300 mm) composed of epithelioid cells, varied numbers of mononuclear cells and eosinophils and multinucleated giant cells. They represent a specialized cell-mediated immune response to a wide variety of etiological factors. A broad spectrum of microorganisms may trigger hepatic granulomas. M. tuberculosis is the more frequent agent (~ 44%). Granulomatous hepatitis is characterized by a febrile illness with systemic signs and symptoms such as fatigue, sweating, shivering, hepatomegaly and/or splenomegaly, abnormalities in serum liver tests (aminotransferase, alkaline phosphatase). Liver biopsy provides diagnostic information in approximately 15-30% of cases, identifying directly the microbial agent with special microbial stains and polymerase chain reaction or finding distinctive microscopic features, suggestive of specific microorganisms. In such cases appropriate therapy is possible. Unfortunately in one third of cases is impossible to reach aetiological diagnosis on histological criteria alone. In these cases a therapeutic attempt with steroids, effective in the idiopathic granulomatous hepatitis, may be useful.

[Differentiation of granulomatous lesions in the bone marrow]

Granulomas are an infrequent finding in bone marrow biopsies and may be associated with a broad spectrum of infectious and non-infectious disorders. In this context sarcoidosis generally reveals the highest incidence of such bone marrow lesions. Other granulomas may be encountered in drug-induced secondary changes (toxic myelopathy) and in particular also in HIV myelopathy. In these cases the granulomas are small, ill-defined and difficult to recognize. Special staining methods are required to detect microorganisms. Fibrin ring granulomas (doughnut granulomas) are typical for Q-fever, but may also be seen in reactive conditions, after drug therapy and in the course of other infectious disorders, such as Lyme disease. Therefore a broad serological testing should be performed. In conclusion, in most cases the morphological findings in the bone marrow are not specific so that a synoptical approach regarding histological, clinical and serological data is warranted to reach the correct diagnosis.

Pyelonephritis and interstitial nephritis--clinical-pathological correlations

AIMS

The relation between histological and clinical parameters were studied in 54 consecutive patients with acute interstitial nephritis or pyelonephritis without primary glomerular disorders, in all of whom percutaneous renal core biopsy had been performed.

PATIENTS AND METHODS

Based on clinical criteria and without detailed knowledge of the appearance of the biopsy, the material was divided into 4 main groups: patients with septic and/or tubulotoxic conditions, hypersensitivity reactions (eosinophilic nephritis), ascending infections and other specified conditions.

RESULTS

The overall correlation between the histological and the clinical diagnoses was good, but there were large overlaps between the histological findings in 3 of the groups, making classification of individual cases difficult. The histological and paraclinical findings were poorly correlated. Histologically, ascending infections were characterized by the presence of leukocyte casts and an increased number of neutrophilic granulocytes.

CONCLUSION

The material justifies the present rough classification of the conditions mentioned above. By kidney biopsy, the interstitial conditions can be separated from glomerular and other conditions, but the biopsy offers little information about the clinical severity or the prognosis.

Interstitial granulomatous dermatitis with plaques

BACKGROUND

Interstitial granulomatous dermatitis is a histopathologic pattern with variable clinical appearance associated with autoimmune systemic diseases. The frequency of its different cutaneous expressions and its association with autoimmune diseases are not known.

OBJECTIVE

We describe the clinical, serologic, and histologic features in 17 patients with interstitial granulomatous dermatitis with a clinical presentation consisting of large erythematous plaques.

METHOD

Skin biopsy specimens fulfilling criteria for diagnosis of interstitial granulomatous dermatitis were selected and correlated with the clinical and laboratory findings.

RESULTS

The study included 1 man and 16 women with multiple, asymptomatic, round to oval, erythematous plaques, most often on folds of the skin, in a bilateral and somewhat symmetric distribution. Most of patients had rheumatoid polyarthralgias along with various serologic abnormalities, often connected to collagen vascular diseases. Histologic examination disclosed a distinctive interstitial granulomatous dermatitis characterized by a diffuse infiltration of the interstitium by histiocytes with piecemeal fragmentation of collagen and formation of small granulomas around degenerative areas in concert with variable numbers of polymorphonuclear leukocytes sprinkled within the infiltrate. Churg-Strauss granulomas in miniature and flame figures were occasionally observed and indicated continued or increased activity of the associated autoimmune disease(s).

CONCLUSIONS

Interstitial granulomatous dermatitis with plaques is a distinct entity with highly reproducible clinical and histopathologic features; recognition of these features identifies a patient who may have an underlying systemic autoimmune disorder.

[Hepatic granulomas of infectious origins]

Hepatic granulomas of infectious origin are due to several causes. Bacterial and rickettsial infections are the most frequent (mainly tuberculosis, infections due to atypical mycobacteria, Q fever). However parasitic and fungal infections may also be involved. Histological characteristics of the granuloma are sometimes suggestive of the cause, but the aetiological diagnosis often results from a careful confrontation of clinical, biological, and histological data. One should always have in mind the possibility of tuberculosis, where an effective treatment must be given as early as possible. The cause of granulomas remains unknown in approximately half the cases after careful investigations.

Chemokine receptor 1 knockout abrogates natural killer cell recruitment and impairs type-1 cytokines in lymphoid tissue during pulmonary granuloma formation

Mice with targeted mutation of chemokine receptor 1 (CCR1) were used to assess the contribution of CCR1 agonists to local, regional, and systemic inflammatory-related events during experimental pulmonary granuloma formation. Models of Th1 (type-1) and Th2 (type-2) cell-mediated lung granulomas were induced in wild-type (CCR+/+) and knockout (CCR1-/-) mice by embolizing Sepharose beads coupled to the purified protein derivative of Mycobacterium bovis or soluble antigens derived from Schistosoma mansoni eggs. Morphometric analysis indicated that granuloma sizes were unchanged in CCR1-/- mice, but flow cytometric analyses of dispersed granulomas revealed that natural killer cell recruitment to type-1 lesions was abrogated by 60%. Analysis of cytokine production by draining lymph node cultures showed altered expression in CCR1-/- mice characterized by reduced interleukin-2 and interferon-gamma in the type-1 response, and enhanced interleukin-5 and interleukin-13 in the type-2 response. Peripheral blood leukocytosis was also enhanced in the type-1 but not the type-2 response. These findings suggest that CCR1 agonists contribute to multiple immunoinflammatory events in the type-1 granulomatous response with natural killer cell accumulation being particularly sensitive to CCR1 disruption. Although functional efficacy of granulomas may be altered, chemokine redundancy and cytokine reserve seem to make the bulk of the exudative response resistant to CCR1 disruption.

A clinicopathological classification of granulomatous disorders

Granulomatous disorders comprise a large family sharing the histological denominator of granuloma formation. A granuloma is a focal compact collection of inflammatory cells, mononuclear cells predominating, usually as a result of the persistence of a non-degradable product and of active cell mediated hypersensitivity. There is a complex interplay between invading organism or prolonged antigenaemia, macrophage activity, a Th1 cell response, B cell overactivity and a vast array of biological mediators. Differential diagnosis and management demand a skilful interpretation of clinical findings and pathological evidence. They are classified into infections, vasculitis, immunological aberration, leucocyte oxidase deficiency, hypersensitivity, chemicals, and neoplasia.

Granulomatous gastritis presenting as gastric outlet obstruction: a case report

The clinico-pathologic entity of idiopathic granulomatous gastritis is a form of granulomatous gastritis, distinct from Crohn's disease, sarcoidosis, infections, foreign bodies, malignancy or vasculitis. The case of a 61-year-old female is described who was admitted on account of progressive weight loss, diffuse abdominal pains, post-prandial vomiting. Gastroscopy revealed a pyloric stenosis managed surgically. Pathological examination of the resected stomach showed numerous non-caseating granulomas in the lamina propria. No definite aetiological factor could be detected. A diagnosis of idiopathic granulomatous gastritis was made. She remains well 5 years later and has not developed regional enteritis, sarcoidosis, or any other generalized diseases.

Mycobacterial and schistosomal antigen-elicited granuloma formation in IFN-gamma and IL-4 knockout mice: analysis of local and regional cytokine and chemokine networks

Type 1 (IFN-gamma/TNF-dominant) and 2 (IL-4/IL-5-dominant) granulomatous inflammation were analyzed in mice with knockout of IFN-gamma or IL-4 genes. Lung granulomas were elicited by beads coated with purified protein derivative (PPD) of Mycobacteria bovis or soluble Schistosoma mansoni egg Ags. Parameters included granuloma size, composition, and macrophage function; white blood cell differentials; lymph node cytokine profiles; and cytokine/chemokine mRNA expression by lungs. Type 1 (PPD) and 2 (soluble Schistosoma mansoni egg Ags) responses showed characteristic cytokine and chemokine profiles in control mice. IFN-gamma knockout converted the PPD response to a type 2-like pattern with eosinophil infiltration and decreased TNF and RANTES, but increased IL-4, IL-5, IL-10, IL-13, monocyte chemoattractant protein-3 (MCP-3), and eotaxin expression. IL-4 knockout exacerbated type 1 inflammation with increased IL-2/IFN-gamma production by lymph nodes and IL-1 production by granuloma macrophages, but unexpectedly, IFN-gamma transcripts were reduced in lungs. Regarding the type 2 response, IL-4 was needed for maximal blood eosinophilia, but surprisingly, its absence had a minimal effect on type 2 granuloma size and composition despite regional reductions of IL-5 and IL-10 as well as local reductions of TNF-alpha, MCP-1, MCP-3, and eotaxin. Thus, the type 2 granuloma was not converted to a type 1 composition with IL-4 knockout, but showed persistent expression of IL-13 and some degree of IL-5 and MCP-3, suggesting that these cytokines could potentially support a compensatory type 2 response. IFN-gamma knockout did not augment type 2 granuloma size or Th2 cytokines in lymph nodes and unexpectedly reduced IL-4 transcripts in lungs. This study offers important implications regarding inflammation and its relationship to local and regional cytokine expression.

Correlation of granuloma structure with clinical outcome defines two types of idiopathic disseminated BCG infection

Bacillus Calmette Guérin (BCG) is an attenuated strain of Mycobacterium bovis that is currently used as a live vaccine for human tuberculosis. Disseminated BCG infection may rarely occur following vaccination of children. In half of the cases, regarded as idiopathic, no well-defined immunodeficiency condition can account for the infection. However, the high rates of parental consanguinity and familial forms and the associated opportunistic infections with Salmonella suggest that these idiopathic BCG infections result from one or several new type(s) of inherited immune disorder(s). As an approach to the description and understanding of this newly described condition, the associated lesions were examined. Samples from 14 patients collected from a French national retrospective study were analysed. Pathological data from 22 cases reported in the world literature were also reviewed. Two types of granuloma were found. The first type (type I, tuberculoid) consisted of well-circumscribed and well-differentiated granulomas, with epithelioid and multinucleated giant cells containing very few acid-fast rods, surrounded by lymphocytes and fibrosis and occasionally with central caseous necrosis. The second type (type II, lepromatous-like) consisted of ill-defined and poorly differentiated granulomas, with few if any giant cells and lymphocytes but widespread macrophages loaded with acid-fast bacilli. Most children displayed a single type of granuloma. One half displayed type 1 lesions and the other half displayed type II lesions. There was a strong correlation between the type of granuloma and the clinical outcome. Tuberculoid lesions were associated with survival, whilst lepromatous-like lesions correlated with death. Correlation of granuloma structure with clinical outcome defines two types of idiopathic disseminated BCG infection. The phenotypic heterogeneity of the course of BCG infection reflects distinct pathogenic mechanisms and probably results from a genotypic heterogeneity of the underlying inherited immune disorder.

Granulomatous infections: etiology and classification

Granulomatous disorders are frequently due to a wide variety of infections. Over the past decade advances in molecular diagnostic techniques have allowed identification of organisms involved in granulomatous disorders that previously were of unknown etiology. On the basis of currently available information, granulomatous infections can now be classified in three categories. Group 1 infections are due to a well-recognized organism. Group 2 comprises infections due to organisms that have been recently identified in granulomas by molecular methods but are not readily isolated by conventional microbiological techniques. Group 3 consists of disorders for which the causal organisms have not yet been identified but are strongly suspected; further advances in diagnostic techniques will lead to reclassification of some of these disorders as group 2. This review describes the etiology, histopathologic features, and classification of granulomatous disorders, with an emphasis on those of groups 2 and 3.

Description and classification of different types of lesion associated with natural paratuberculosis infection in sheep

Paratuberculosis lesions in naturally infected sheep were classified histologically. Adult sheep (n = 166) culled for various reasons, from four flocks in which clinical cases of the disease had occurred, were studied. Eight-two sheep (49.4%) showed lesions that could be divided into three main categories. Type 1 lesions, found in 24.1% of these animals, consisted of small granulomata formed by macrophages and were located exclusively in the ileocaecal Peyer's patch. In type 2 lesions, found in 4.8% of the sheep, granulomata were also observed in the mucosa associated with Peyer's patches. Type 3 lesions were characterized by granulomata in areas of the mucosa associated with, and also distinct from, the Peyer's patches. Three subtypes of type 3 lesions were recognized. In subtype 3a, found in 4.2% of the sheep, multifocal granulomata appeared in different areas of the lamina propria; they were not apparently associated with lymphoid tissue, and neither did they modify the morphology of the affected areas. Subtype 3b, found in 13.9% of animals, consisted of large numbers of macrophages, widespread in the lamina propria; in subtype 3c (2.4% of sheep) lymphocytes were the main inflammatory cell, with some macrophages scattered amongst them. In subtypes 3a and b, villi were distended and the mucosa appeared thickened. Mycobacteria could be demonstrated in tissue sections from all the samples with subtype 3b lesions and in almost all of those with type 2 and 3a lesions; these organisms were absent or sparse, however, in type 1 and 3c lesions. Macroscopical lesions were clearly visible only in sheep with type 3b and 3c lesions. Mycobacterium paratuberculosis was cultured from all the animals with type 3 lesions, from 87.5% of those with type 2 lesions, and from 47.5% of those with type 1. Type 3b lesions resembled the "borderline-lepromatous" form of mycobacterial lesions, whereas type 3c lesions resembled the "borderline-tuberculoid" form. The relationship between intestinal lymphoid tissue and paratuberculosis lesions is discussed, and the diagnostic importance of histological examination of the ileocaecal valve emphasized.

Hepatic granulomas following liver transplantation. Clinicopathologic features in 42 patients

Liver granulomas have long been known to pose diagnostic problems for pathologists; however, their prevalence and associated etiologic factors have not been studied in liver transplant patients. We reviewed 3632 liver biopsy specimens from 563 patients at two institutions and identified 42 patients with posttransplant granulomas. A possible or probable etiologic factor was identified in 30 (71%) cases. Most were epithelioid granulomas and microgranulomas located in the parenchyma associated with hepatocyte necrosis (21 cases, 50%). Portal-based granulomas were associated with recurrent primary biliary cirrhosis (5 cases, 12%), acute cellular rejection (2 cases, 4.8%), and a foreign body-type reaction (1 case, 2.4%). One case was associated with tuberculosis (2.4%), 4 cases occurred in a fatty liver (9.5%), and 8 patients had liver granulomas but no other significant abnormality. The granulomas were most frequent in the first 7 months after transplantation when the patients were biopsied more often and underwent episodes of rejection or acute hepatitis. Portal-based granulomas in this period were usually associated with acute cellular rejection. After 7 months, the frequency of granulomas as well as the number of biopsies decreased and portal-based granulomas associated with recurrent primary biliary cirrhosis were most common (5 cases, 12%). Rare, late-appearing parenchymal granulomas were also seen (3 cases) and consisted of 1 lipogranuloma and 2 cases of epithelioid granuloma. The latter were thought, in 1 patient, to be associated with parenchymal hepatocyte necrosis; the others were of unknown etiology.

Reticulohistiocytoma and multicentric reticulohistiocytosis. Histopathologic and immunophenotypic distinct entities

The clinicopathological and immunohistochemical features of four patients with systemic multicentric reticulohistiocytosis (MR) were compared with five cases of solitary and one case of multiple reticulohistiocytoma (RH), which were confined to the skin only. The MR cases mostly affected the limbs of older women, while RH affected young male adults without preference to site. Characteristically, both entities consisted of oncocytic mononuclear histiocytes (with granular eosinophilic cytoplasm similar to oncocytic thyroid cells) and multinucleated histiocytes with a ground-glass appearance, which appeared to be much larger (> 200 microns) and bizarre in cases of RH compared with cases of MR (50-100 microns). In RH a variable number of vacuolated, spindle-shaped, and xanthomatized mononuclear histiocytes were also present. Immunohistochemical profiles showed positivity of mononuclear histiocytes with HHF35, factor XIIIa, and LN3 (HLA-DR), with a variable number of multinucleated histiocytes in RH showing binding with peanut agglutinin. In mono- and multinucleated histiocytes in both entities macrophage markers KP1 (CD68), KiM1P, HAM56, lysozyme, and alpha 1-antitrypsin were positive. However, macrophage markers MAC387 (L1 antigen) and Leu-M1 (CD15) were negative. Vimentin was universally positive in both conditions, with all other markers (S100, desmin, smooth muscle-specific actin, and QBEnd 10 [CD34]) negative. This study shows that histology supplemented by immunocytochemistry delineates MR from RH and immunohistochemical profiles indicate a cell lineage relationship between RH and adult xanthogranuloma.

Contact granulomas of the larynx

Ten cases of intubation granulomas and eight cases of contact granulomas not related to intubation were reviewed for the purpose of clinical analysis and pathological investigation. Granulomas were located primarily at the vocal process of the arytenoid cartilage. Additionally, 58 hemilarynges obtained from 37 cadavers with intubation granulomas were evaluated grossly and histopathologically. The intubation granulomas had no side predilections. All eight contact granulomas occurred in males and had a higher incidence of recurrence (three of eight cases) despite complete removal with laser surgery. In an attempt to explain recurrences of these contact granulomas, all three cases were studied clinically and pathologically. Results indicated that they recurred in singers and vocal abusers, and presumably resulted from the continued hammering of one vocal process against the other. Analysis also demonstrated that vocal rehabilitation was essential prior to or immediately after removal of the granuloma to prevent its recurrence. Pathological evaluation of the contact granulomas revealed focal ulceration and a covering of necrotic tissue with desquamating epithelium. The propria mucosa was edematous and infiltrated by chronic inflammatory cells and neutrophils forming focal granulation tissue in a stroma containing proliferated capillaries. Pathological features around local ulcerations were typical of a secondary granuloma while underlying arytenoid cartilage was partially necrotic.

Chronic granulomatous mastitis: review of 26 cases with special reference to chronic lobular mastitis

Twenty six cases of chronic granulomatous mastitis are reported in a 5 year period and the slides are reviewed. They are sub-classified into Chronic lobular mastitis (CLM), Plasma cell mastitis and subareolar granuloma. There are 10 cases each of CLM and plasma cell mastitis and one of subareolar granuloma. All the three conditions are associated with duct ectasia. Fat necrosis and infective granulomas were 2 each and one of foreign body granuloma. These lesions can be easily differentiated by histology. While most of the CLM occurred in younger age group, plasma cell mastitis is seen in older women. Histologically, there is a florid inflammatory cell reaction of the stroma with dilatation and destruction of some ducts, with microabscess formation. In plasma cell mastitis, the lesion is more chronic with predominance of plasma cells and involutionary changes of the ducts are seen.

Xanthogranulomatous cholecystitis. Histopathological study and classification

Xanthogranulomatous cholecystitis (XC) is a chronic inflammatory lesion of the gallbladder histologically characterized by the presence of varying amounts of foamy histiocytes in the inflammatory infiltrate. In this study a review of 63 cases selected from 1207 surgically removed gallbladder is presented; the percentage found (5.2%) is slightly higher than that of previous reports showing that XC is less uncommon than generally believed. A detailed microscopic study is performed: the authors observed according to the histological features particularly the different patterns of distribution of the inflammatory infiltrate and postulate the existence of three subtypes of XC: multinodular, focal and diffuse XC. Finally, the main etiopathogenetic hypotheses are briefly discussed.

Linear granuloma annulare

Granuloma annulare is a benign dermatosis with multiple clinical presentations and a common histologic picture, which is characterized by areas of degenerated collagen surrounded by palisading histiocytes. A case of granuloma annulare that presented as progressive, asymptomatic, symmetric truncal bands is described. The varied clinical presentations and possible pathogenetic mechanisms of granuloma annulare are reviewed.

A comparative histopathologic study of generalized and localized granuloma annulare

We have reviewed the morphologic findings in 41 histologic slides of granuloma annulare (GA), 15 from localized (LGA) and 26 from generalized granuloma annulare (GGA). The most common pattern was the histiocytic infiltrative type, more so in cases with LGA than with GGA. The palisading granuloma pattern was present in 21.9% of patients and its prevalence was almost equal in both clinical types. The least prevalent histologic type in all patients taken together was the epithelioid nodule type. However, the prevalence of this type in LGA was equal to that of the palisading type, in contrast to that in GGA where it accounted for only 11.5%. In addition, a mixed histologic pattern was found in greater than 25% of sections from GGA and in only one section from LGA. Periodic acid-Schiff stain revealed hyalinized capillary basement membrane in most of GGA and only in approximately 50% of LGA sections. The variation in prevalence of the different histologic patterns between sections from LGA and GGA, and the difference between our findings and those observed in other series, are discussed.

Pulmonary vasculitis

The granulomatous vasculitides frequently involve the lung. These syndromes include Wegener's granulomatosis, allergic angiitis and granulomatosis, and the polyangiitis overlap syndrome. Although not a true systemic vasculitis, necrotizing sarcoid granulomatosis also represents a type of pulmonary vasculitis. It is clear that many infectious agents can cause a picture in the lung that can be confused with granulomatous vasculitis and that an infectious process must be ruled out before a diagnosis of pulmonary vasculitis can be established. Pulmonary vasculitis can be associated with the hypersensitivity vasculitides, and pulmonary hemorrhage can be secondary to pulmonary capillaritis. Therapy of the hypersensitivity vasculitides consists of removing the offending antigen and instituting a limited course of corticosteroids. If the vasculitis is secondary to an underlying disease, such as lymphoma, therapy should be directed at the primary disease. Combination therapy with cyclophosphamide and corticosteroids is effective in the systemic vasculitides and the 5-yr survival rate is approximately 90%.

A new morphological concept and classification of granulomatous inflammation: the polar granulomas

An historical analysis of granulomas and a new morphological concept and classification of granulomatous inflammation, the polar-granulomas, are presented. The historical analysis of the concept of granulomas reveals that the still proclaimed confusion concerning the process was due more to Virchow's comparison of granulomas to ordinary granulation tissue than to tumors and to objections of pathologists to Metchnikoff's theory of phagocytosis. And it is strange to verify that differences between granulomas and granulation tissue, although already established in the end of the 19th Century, were overlooked by the majority of pathologists. In this Century , the knowledge of granulomatous inflammation was greatly improved by Aschoff 's concept of reticulum endothelial system, Mitsuda test for types of leprosy, Jadassohn- Lewandowsky law, South American classification of leprosy into polar forms, and Forbus contribution to histogenesis and morphological classification of granulomas. The best model for the study of granulomatous inflammation is leprosy, because this disease is characterized by two different clinical polar forms, each one having particular types of phagocytosis (complete or incomplete) and of granulomas (tuberculoid or non tuberculoid). Based on the phenomenon of phagocytosis, polar forms of leprosy, Jadassohn- Lewandowsky law, metamorphosis of macrophages and nature of the etiologic agent, granulomas can be defined as a reactional hyperplasia of macrophages towards inanimate agents and towards animate agents of low virulence. Also based in the same data, a morphological classification of granulomas into polar types, tuberculoid and non tuberculoid, is proposed. The polar tuberculoid type follows the Jadassohn- Lewandowsky law, its etiologic agent is absent or scarce (complete phagocytosis) - and comprise two sub-types: tubercle-like and sarcoid-like. The polar non tuberculoid type does not follow the Jadassohn- Lewandowsky law, its etiologic agent is always present or copious (incomplete phagocytosis) and comprises two sub-types: giant cell and persistent macrophage. In the latter case, macrophages behave as a culture medium cell or as a storage cell. When both polar tuberculoid and non tuberculoid structures are found together in the same disease, granuloma can be called interpolar . If both types occur simultaneously in the same disease, granuloma would be bipolar. It seems that the proposed definition of granulomas combines morphology with functional activity of macrophages, easily observed in routine histopathological examination by optical microscopy. This morphological classification into polar granulomas (ABSTRACT TRUNCATED AT 250 WORDS)

Concepts of granulomatous inflammation

Table 8 lists the patterns of the five discrete tissue reaction patterns of granulomatous inflammation and relates them to the predominant microscopic tissue reaction as well as to the dominant cell type present in the infiltrate. The possibility of a sixth group, granulation tissue, was also considered for this classification schema. The term "granulation tissue" was used by Virchow to define granulomatous inflammation. He probably used this term in a broader context than our present definition of granulation tissue (ie, fibrocapillary proliferation). Using the more narrow and perhaps more precise definition, we think that granulation tissue does not constitute a form of granulomatous inflammation.

[Clinical variety of granuloma anulare]

On the basis of over 100 cases of histologically verified granuloma anulare, we made an attempt to classify its many clinical variants. A principal distinction must be made between clinically typical and atypical forms on the one hand, and between localized and disseminated or generalized forms on the other. The various clinical pictures of the atypical forms are systematisized and described.

Granulomatous inflammation--a review

The granulomatous inflammatory response is a special type of chronic inflammation characterised by often focal collections of macrophages, epithelioid cells and multinucleated giant cells. In this review the characteristics of these cells of the mononuclear phagocyte series are considered, with particular reference to the properties of epithelioid cells and the formation of multinucleated giant cells. The initiation and development of granulomatous inflammation is discussed, stressing the importance of persistence of the inciting agent and the complex role of the immune system, not only in the perpetuation of the granulomatous response but also in the development of necrosis and fibrosis.

[The clinical picture of "circumscribed granuloma diseases"]

Characteristic findings, differential diagnosis and clinical course of the so-called "circumscript granulomas" (Granuloma anulare, necrobiosis lipoidica, Miescher's granulomatosis, disciformis, necrobiosis maculosa, granuloma multiforme, actinic granuloma, granuloma faciale and lethal midline granuloma etc.) are represented in a condensed clinical survey.

Granulomatous inflammation of the vulva and penis--a genital counterpart to cheilitis granulomatosa

3 patients are described, in whom chronic swelling of the external genitals occurred after recurrent infections. The histological findings were identical to those seen in cheilitis granulomatosa, the dermal component of Melkersson-Rosenthal syndrome. The authors suppose that the disease of the 3 patients is a genital counterpart to cheilitis granulomatosa, and the name vulvitis or posthitis granulomatosa is suggested.

Endodontic classification

Clinical and histopathologic findings are mixed in current endodontic classifications. A new system, based on symptomatology, may be more useful in clincial practice. The classifications are vital asymptomatic, hypersensitive dentin, inflamed-reversible, inflamed/dengenerating without area-irreversible, inflamed/degenerating with area-irreversible, necrotic without area, and necrotic with area.