Case report: Rubella virus-associated cutaneous granuloma in an adult with TAP1 deficiency

Rubella virus-associated granulomas commonly occur in immunocompromised individuals, exhibiting a diverse range of clinical presentations. These manifestations can vary from predominantly superficial cutaneous plaques or nonulcerative nodules to more severe deep ulcerative lesions, often accompanied by extensive necrosis and significant tissue destruction. TAP1 deficiency, an exceedingly rare primary immune-deficiency disorder, presents with severe chronic sino-pulmonary infection and cutaneous granulomas. This report highlights the occurrence of rubella virus-associated cutaneous granulomas in patients with TAP1 deficiency. Notably, the pathogenic mutation responsible for TAP1 deficiency stems from a novel genetic alteration that has not been previously reported. This novel observation holds potential significance for the field of diagnosis and investigative efforts in the context of immunodeficiency disorders.

Replication of Small Ruminant Lentiviruses in Aluminum Hydroxide-Induced Granulomas in Sheep: a Potential New Factor for Viral Dissemination

Aluminum (Al)-based salts are widely used adjuvants in ruminants and other species to strengthen the immune response elicited against vaccine antigen(s). However, they can lead to the formation of long-lasting granulomas composed of abundant activated macrophages. Small ruminant lentiviruses (SRLV) are widely distributed macrophage-tropic retroviruses that cause persistent infections in sheep and goats. Infected monocytes/macrophages and dendritic cells establish an inflammatory microenvironment that eventually leads to clinical manifestations. The aim of this work was to study the effect of Al-induced granulomas in the replication and pathogenesis of SRLV. Eleven adult, naturally SRLV-infected sheep showing clinical arthritis were distributed in vaccine (n = 6), adjuvant-only (n = 3), and control (n = 2) groups and inoculated with commercial Al-based vaccines, Al hydroxide adjuvant alone, or phosphate-buffered saline, respectively. In vitro studies demonstrated viral replication in Al-induced granulomas in 5 out of 10 sheep. Immunohistochemistry (IHC) evinced granular, intracytoplasmic SRLV presence in macrophages within granulomas. Viral sequences obtained from granulomas, blood monocytes, and other tissues were highly similar in most animals, suggesting virus circulation among body compartments. However, notable differences between isolated strains in granulomas and other tissues in specific animals were also noted. Interestingly, the B2 subtype was the most commonly found SRLV genotype, reaching a wider body distribution than previously described. Recombination events between genotypes B2 and A3 along the gag region were identified in two sheep. Our results indicate that Al-hydroxide-derived granulomas may represent an ideal compartment for SRLV replication, perhaps altering natural SRLV infection by providing a new, suitable target tissue.IMPORTANCE Granulomas are inflammation-derived structures elicited by foreign bodies or certain infections. Aluminum adjuvants included in vaccines induce granulomas in many species. In sheep, these are persistent and consist of activated macrophages. Small ruminant lentiviruses (SRLV), which are macrophage-tropic lentiviruses, cause a chronic wasting disease affecting animal welfare and production. Here, we studied the occurrence of SRLV in postvaccination granulomas retrieved from naturally infected ewes after vaccination or inoculation with aluminum only. SRLV infection was confirmed in granulomas by identification of viral proteins, genomic fragments, and enzymatic activity. The infecting SRLV strain, previously found exclusively in carpal joints, reached the central nervous system, suggesting that occurrence of SRLV in postvaccination granulomas may broaden tissue tropism. SRLV recombination was detected in inoculated animals, a rare event in sheep lentiviruses. Potentially, virus-host interactions within granulomas may modify viral pathogenesis and lead to more widespread infection.

SIV and Mycobacterium tuberculosis synergy within the granuloma accelerates the reactivation pattern of latent tuberculosis

Human immunodeficiency virus infection is the most common risk factor for severe forms of tuberculosis (TB), regardless of CD4 T cell count. Using a well-characterized cynomolgus macaque model of human TB, we compared radiographic, immunologic and microbiologic characteristics of early (subclinical) reactivation of latent M. tuberculosis (Mtb) infection among animals subsequently infected with simian immunodeficiency virus (SIV) or who underwent anti-CD4 depletion by a depletion antibody. CD4 depleted animals had significantly fewer CD4 T cells within granulomas compared to Mtb/SIV co-infected and Mtb-only control animals. After 2 months of treatment, subclinical reactivation occurred at similar rates among CD4 depleted (5 of 7 animals) and SIV infected animals (4 of 8 animals). However, SIV-induced reactivation was associated with more dissemination of lung granulomas that were permissive to Mtb growth resulting in greater bacterial burden within granulomas compared to CD4 depleted reactivators. Granulomas from Mtb/SIV animals displayed a more robust T cell activation profile (IFN-α, IFN-γ, TNF, IL-17, IL-2, IL-10, IL-4 and granzyme B) compared to CD4 depleted animals and controls though these effectors did not protect against reactivation or dissemination, but instead may be related to increased viral and/or Mtb antigens. SIV replication within the granuloma was associated with reactivation, greater overall Mtb growth and reduced Mtb killing resulting in greater overall Mtb burden. These data support that SIV disrupts protective immune responses against latent Mtb infection beyond the loss of CD4 T cells, and that synergy between SIV and Mtb occurs within granulomas.

Infectious vaccine-derived rubella viruses emerge, persist, and evolve in cutaneous granulomas of children with primary immunodeficiencies

Rubella viruses (RV) have been found in an association with granulomas in children with primary immune deficiencies (PID). Here, we report the recovery and characterization of infectious immunodeficiency-related vaccine-derived rubella viruses (iVDRV) from diagnostic skin biopsies of four patients. Sequence evolution within PID hosts was studied by comparison of the complete genomic sequences of the iVDRVs with the genome of the vaccine virus RA27/3. The degree of divergence of each iVDRV correlated with the duration of persistence indicating continuous intrahost evolution. The evolution rates for synonymous and nonsynonymous substitutions were estimated to be 5.7 x 10-3 subs/site/year and 8.9 x 10-4 subs/site/year, respectively. Mutational spectra and signatures indicated a major role for APOBEC cytidine deaminases and a secondary role for ADAR adenosine deaminases in generating diversity of iVDRVs. The distributions of mutations across the genes and 3D hotspots for amino acid substitutions in the E1 glycoprotein identified regions that may be under positive selective pressure. Quasispecies diversity was higher in granulomas than in recovered infectious iVDRVs. Growth properties of iVDRVs were assessed in WI-38 fibroblast cultures. None of the iVDRV isolates showed complete reversion to wild type phenotype but the replicative and persistence characteristics of iVDRVs were different from those of the RA27/3 vaccine strain, making predictions of iVDRV transmissibility and teratogenicity difficult. However, detection of iVDRV RNA in nasopharyngeal specimen and poor neutralization of some iVDRV strains by sera from vaccinated persons suggests possible public health risks associated with iVDRV carriers. Detection of IgM antibody to RV in sera of two out of three patients may be a marker of virus persistence, potentially useful for identifying patients with iVDRV before development of lesions. Studies of the evolutionary dynamics of iVDRV during persistence will contribute to development of infection control strategies and antiviral therapies.

Varicella-zoster Virus Related Pulmonary Granulomas in Which Varicella-zoster Virus DNA Was Demonstrated in a Thoracoscopic Lung Biopsy Specimen

A 43-year-old man with malignant lymphoma who had been treated with the cyclosphamide, vincrstine, procarbazine, and prednisolone (C-MOPP) regimen was admitted to our hospital with skin eruption. He was diagnosed to have varicella, and treatment with acyclovir and immune globulin was started. Chest computed tomography revealed multiple nodules in the both lung fields. Diagnostic thoracoscopic lung biopsy specimens revealed granuloma formation, and polymerase chain reaction testing revealed the presence of varicella-zoster virus DNA in the granulomatous tissue. It was unusual for the lung nodule in varicella pneumonia to increase in size over time in a patient who had undergone antiviral therapy, while also demonstrating multiple granulomas.

Rubella Virus-Associated Cutaneous Granulomatous Disease: a Unique Complication in Immune-Deficient Patients, Not Limited to DNA Repair Disorders

The association of immunodeficiency-related vaccine-derived rubella virus (iVDRV) with cutaneous and visceral granulomatous disease has been reported in patients with primary immunodeficiency disorders (PIDs). The majority of these PID patients with rubella-positive granulomas had DNA repair disorders. To support this line of inquiry, we provide additional descriptive data on seven previously reported patients with Nijmegen breakage syndrome (NBS) (n = 3) and ataxia telangiectasia (AT) (n = 4) as well as eight previously unreported patients with iVDRV-induced cutaneous granulomas and DNA repair disorders including NBS (n = 1), AT (n = 5), DNA ligase 4 deficiency (n = 1), and Artemis deficiency (n = 1). We also provide descriptive data on several previously unreported PID patients with iVDRV-induced cutaneous granulomas including cartilage hair hypoplasia (n = 1), warts, hypogammaglobulinemia, immunodeficiency, myelokathexis (WHIM) syndrome (n = 1), MHC class II deficiency (n = 1), Coronin-1A deficiency (n = 1), X-linked severe combined immunodeficiency (X-SCID) (n = 1), and combined immunodeficiency without a molecular diagnosis (n = 1). At the time of this report, the median age of the patients with skin granulomas and DNA repair disorders was 9 years (range 3-18). Cutaneous granulomas have been documented in all, while visceral granulomas were observed in six cases (40%). All patients had received rubella virus vaccine. The median duration of time elapsed from vaccination to the development of cutaneous granulomas was 48 months (range 2-152). Hematopoietic cell transplantation was reported to result in scarring resolution of cutaneous granulomas in two patients with NBS, one patient with AT, one patient with Artemis deficiency, one patient with DNA Ligase 4 deficiency, one patient with MHC class II deficiency, and one patient with combined immunodeficiency without a known molecular etiology. Of the previously reported and unreported cases, the majority share the diagnosis of a DNA repair disorder. Analysis of additional patients with this complication may clarify determinants of rubella pathogenesis, identify specific immune defects resulting in chronic infection, and may lead to defect-specific therapies.

Concomitant Epstein-Barr Virus-associated smooth muscle tumor and granulomatous inflammation of the liver

Epstein-Barr Virus-associated smooth muscle tumor (EBV-SMT) is a rare mesenchymal tumor typically seen in immunocompromised patients. Here, we report a case of EBV-SMT and associated granulomatous inflammation in the liver of a 32-year-old man with history of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). To our knowledge, an association of these two lesions has not been previously reported. We review the literature and discuss pathogenesis, differential diagnosis and immunohistochemical (IHC) stains helpful for the diagnosis of this rare entity. Finally, we consider possible explanations for the concomitant presence of these lesions.

Relationship Between HIV Coinfection, Interleukin 10 Production, and Mycobacterium tuberculosis in Human Lymph Node Granulomas

BACKGROUND

 Human immunodeficiency virus type 1 (HIV)-infected persons are more susceptible to tuberculosis than HIV-uninfected persons. Low peripheral CD4+ T-cell count is not the sole cause of higher susceptibility, because HIV-infected persons with a high peripheral CD4+ T-cell count and those prescribed successful antiretroviral therapy (ART) remain more prone to active tuberculosis than HIV-uninfected persons. We hypothesized that the increase in susceptibility is caused by the ability of HIV to manipulate Mycobacterium tuberculosis-associated granulomas.

METHODS

 We examined 71 excised cervical lymph nodes (LNs) from persons with HIV and M. tuberculosis coinfection, those with HIV monoinfection, and those with M. tuberculosis monoinfection with a spectrum of peripheral CD4+ T-cell counts and ART statuses. We quantified differences in M. tuberculosis levels, HIV p24 levels, cellular response, and cytokine presence within granulomas.

RESULTS

 HIV increased M. tuberculosis numbers and reduced CD4+ T-cell counts within granulomas. Peripheral CD4+ T-cell depletion correlated with granulomas that contained fewer CD4+ and CD8+ T cells, less interferon γ, more neutrophils, more interleukin 10 (IL-10), and increased M. tuberculosis numbers. M. tuberculosis numbers correlated positively with IL-10 and interferon α levels and fewer CD4+ and CD8+ T cells. ART reduced IL-10 production.

CONCLUSIONS

 Peripheral CD4+ T-cell depletion correlated with increased M. tuberculosis presence, increased IL-10 production, and other phenotypic changes within granulomas, demonstrating the HIV infection progressively changes these granulomas.

Coronavirus Infection in Ferrets: Antigen Distribution and Inflammatory Response

Multisystemic granulomatous lesions are the most common finding in ferrets infected by ferret systemic coronavirus (FRSCV). To characterize the inflammatory response developed against this virus, lesions from 4 naturally infected ferrets were examined. Lesions were classified into the 4 known types of granulomas (granulomas without necrosis [G], granulomas with necrosis [G-N], granulomas with neutrophils [G-NL], and diffuse granulomatous inflammation [DG]). The cellular composition of the lesions was characterized on the basis of cellular morphology and immunohistochemistry using markers for T and B-lymphocytes, plasma cells, macrophages, and neutrophils. The extent and distribution of viral antigen expression was also assessed. In G lesions, macrophages were mainly located in the center of the granuloma, with a moderate number of T-lymphocytes scattered among the macrophages, plasma cells, and B-lymphocytes. G-N lesions exhibited a necrotic center surrounded by abundant macrophages, some T-lymphocytes, plasma cells, and a few B-lymphocytes. In G-NL lesions, there was a central area dominated by neutrophils with low numbers of macrophages, plasma cells, and lymphocytes. DG presented similar cell proportions, but distributed evenly throughout the lesions. FRSCV was expressed in G, G-NL, G-N, and DG, with decreasing numbers of immunoreactive cells. This study reveals the important role of macrophages in the inflammatory response of ferrets against the virus and the variable proportions of leukocytes among different types of lesions, indicating their variable age. The results also confirm the similarities of the disease in ferrets to feline infectious peritonitis.

Tuberculosis and hepatic steatosis are prevalent liver pathology findings among HIV-infected patients in South Africa

Liver disease epidemiology in sub-Saharan Africa has shifted as a result of HIV and the increased use of antiretroviral therapy leading to a need for updated data on common causes of liver disease. We retrospectively reviewed records from all hospitalized patients who had liver biopsy at a single hospital in South Africa from 2001 to 2009 and compared diagnosis by HIV status. During the period of study 262 patients had liver biopsy, 108 (41%) were HIV-infected, 25 (10%) were HIV-sero-negative, and 129 (49%) had unknown or unrecorded HIV status. Overall 81% of biopsies provided additional diagnostic data. Malignancy was the most common finding reported on 56 (21%) biopsies followed by granuloma or TB, hepatic steatosis, and fibrosis or cirrhosis. HIV-infected patients were more likely to have granulomas and steatosis. Half of patients with granulomas were already on TB treatment, suggesting paradoxical reactions or drug induced liver injury may have been important causes of liver inflammation among these patients. We note that TB, paradoxical reactions during TB treatment, possible drug induced liver injury, and hepatic steatosis are important causes of liver pathology among HIV-infected hospitalized patients with unclear etiology of liver disease after initial assessment. Among HIV sero-negative patients, malignancy was the major cause of liver disease. Our findings re-enforce the importance of TB as a diagnosis among HIV-infected individuals.

HIV-related Burkitt lymphoma with florid granulomatous reaction: an unusual case with good outcome

Burkitt lymphoma (BL) is a highly aggressive subtype of non-Hodgkin lymphomas (NHL). Lymphoma related granulomatous reaction rarely occurs in sporadic BL. Herein, we describe the first case of HIV related Burkitt lymphoma with florid granulomatous reaction. A 41-year-old HIV-positive Chinese male presented lymphadenopathy in the right cervical region for 3 months. The enlarged lymph node biopsies revealed the presence of prominent granulomas of varying size with Langhans giant cells, leading to the misdiagnosis of tuberculous lymphadenitis in other hospital. Subsequently, the case was sent to us for consultation. The morphology, immunophenotype, special staining, interphase FISH analysis and blood tests confirmed a diagnosis of HIV related Burkitt lymphoma with granulomatous reaction. Without radiotherapy and chemotherapy, the patient was alive and well with no evidence of lymphoma during the observation period of 24 months. The case suggested that lymphoma with florid granulomatous reaction can easily be misdiagnosed as benign lesions since the large number of epithelioid granulomas could obscure the primary lesion. Moreover, the granulomatous reaction may be an indicator for favorable prognosis in HIV related Burkitt lymphoma.

[Sarcoidosis--granulomatosis: the modern view of the etiology and pathogenesis with clinical cases review]

Diagnostic criteria of sarcoidosis were offered in the 60-ies of XX century, however today the problem of sarcoidosis is difficult for understanding the different specialists and early detection. The development of laboratory diagnostic of viral infections and introduction of polymerase chain reaction (PCR) has greatly improved the level of diagnosis of herpes infections, reveal the previously unknown etiology of many diseases: sarcoidosis (granulomatosis), migraine, multiple sclerosis, cystic prenatal brain damage, convulsions, Hodgkin's disease and others. Sarcoidosis is the set of clinical symptoms (fatigue, shortness of breath, coughing, heaviness in the chest), laboratory, radiological and histopathological data that allow the doctor to diagnose, predict prognosis and treatment policy. Most often, sarcoidosis affects the lungs and thoracic lymph nodes. In the last period for 2011-2013 in 2930 immunologically tested patients the sarcoidosis was confirmed in 146. Primarily these patients were exposed to different diagnosis--COPD, pneumonia, tuberculosis, lung cancer. Among patients with sarcoidosis on the first place in frequency of detection were EBV and HHV-6. We were the first in 2000, described the Epstein-Barr virus as the causative factor of sarcoidosis, and has been hypothesized the immunopathology of sarcoidosis and principles of individual immunotherapy with a resolution of the granulomatous process in 92 % of cases. Subsequently, this association has been and illustrates the relationship to other viruses (HHV-6, HHV-8) demonstrated by other authors.

Post-varicella-zoster virus granulomatous dermatitis: a report of 2 cases

Granulomatous dermatitis (GD) is known to occur following varicella-zoster virus (VZV) infection. Lesions may appear at varying times after the acute eruption in both immunosuppressed and immunocompetent hosts. The etiology of GD is unclear, and findings of VZV in the lesions often are inconsistent. We describe 2 immunocompromised patients who presented with GD following VZV infection; their lesions were examined for the presence of VZV. We also review the literature on postzoster GD.

Tolosa-hunt syndrome associated with cytomegalovirus infection

We herein present the case of a 38-year-old woman with left-sided oculomotor paralysis with ocular pain that developed after a respiratory infection. Her serum was positive for IgM against GM2 and GalNAc-GD1a gangliosides and cytomegalovirus. Thin-slice magnetic resonance imaging revealed enhanced abnormal tissue located primarily in the superolateral part of the left-sided cavernous sinus, which corticosteroids subsequently obscured with immediate resolution of the patient's ocular symptoms. These clinical features were consistent with those of Tolosa-Hunt syndrome (THS). Our findings in the present patient suggest that cytomegalovirus may provoke granuloma formation in the cavernous sinus, as reported in other various organs, thereby leading to the development of THS.

[Cycloferon in complex therapy management of chronic laryngitis]

The clinical course of various forms of chronic laryngitis, including contact granulomas not only persistant and relapsing, but also inclined to oncologic pathology due to hyperplastic changes in the larynx resulting in malignization was described. Inhibition of the leukocyte interferon-synthesizing activity was observed in more than 88.1% of the subjects. Pathogenic viruses were isolated from 48.2% of the patients, EBV and mycoplasma prevailing. High direct correlation between chronic laryngitis and Herpes viruses was shown. The presence of three-component virus associations in the larynx mucosa was likely indicative of the bening process malignancy. The use of the interferon inductor cycloferon in the complex surgical and medicamentous management of chronic laryngitis was shown valid. The rate of the relapses lowered to 1.7 episodes a year.

Neutrophil survival factors (TNF-alpha, GM-CSF, and G-CSF) produced by macrophages in cats infected with feline infectious peritonitis virus contribute to the pathogenesis of granulomatous lesions

Feline infectious peritonitis (FIP) is a feline coronavirus (FCoV)-induced fatal disease of domestic and wild cats. The infiltration of neutrophils into granulomatous lesions is unusual for a viral disease, but it is a typical finding of FIP. This study aimed to investigate the reason for the lesions containing neutrophils in cats with FIP. Neutrophils of cats with FIP were cultured, and changes in the cell survival rate were assessed. In addition, the presence or absence of neutrophil survival factors was investigated in specimens collected from cats with FIP. Furthermore, it was investigated whether macrophages, one of the target cells of FIPV infection, produce neutrophil survival factors (TNF-alpha, GM-CSF, and G-CSF). We showed that virus-infected macrophages overproduce neutrophil survival factors, and these factors act on neutrophils and up-regulate their survival. These observations suggest that sustained production of neutrophil survival factors by macrophages during FCoV infection is sufficient for neutrophil survival and contributes to development of granulomatous lesions.

Identification of group 1 coronavirus antigen in multisystemic granulomatous lesions in ferrets (Mustela putorius furo)

Tissues from nine ferrets with granulomatous lesions similar to those seen in feline infectious peritonitis were examined histopathologically and immunohistochemically. Four main types of lesions were observed: diffuse granulomatous inflammation on serosal surfaces; granulomas with areas of necrosis; granulomas without necrosis; and granulomas with neutrophils. Other less commonly seen lesions were granulomatous necrotizing vasculitis and endogenous lipid pneumonia. FCV3-70 monoclonal antibody produced immunolabelling of group 1 coronavirus antigen in tissue samples from eight animals, the antigen being present in the cytoplasm of macrophages in the different types of granulomatous lesions.

Fibrin ring granuloma in chronic hepatitis C: virus-related vasculitis and/or immune complex disease?

Fibrin ring granulomas are rare lesions whose pathophysiology has remained somewhat elusive. It has been suggested that these peculiar lesions are related to focal vasculitis with endothelial injury and deposition of immune complexes. Fibrin ring granulomas have been described in Q fever; in viral infections such as cytomegalovirus, Epstein-Barr virus, and hepatitis A virus; and in other conditions. We submit the first reported case of fibrin ring granuloma in a patient with chronic hepatitis C infection, in whom other potential etiologies have been excluded, and offer a brief review of available literature on the pathogenesis of both conditions.

Respiratory syncytial virus replication is prolonged by a concomitant allergic response

Epidemiological studies show an association between early exposure to respiratory syncytial virus (RSV) and the development or exacerbation of asthma. This idea is supported by studies in mice that demonstrate worsened airway hyper-reactivity (AHR) when RSV-infected animals are exposed to allergen. The effect of allergen on RSV disease, however, has not been reported. Cotton rats (Sigmodon hispidus) that have been used as a model to study RSV pathogenesis were sensitized to extracts of Aspergillus fumigatus (Af), a common household mould. The allergic response to Af included eosinophilia, formation of granulomas and induction of Th2 type cytokines. RSV infection prior to allergen challenge resulted in exacerbation of the inflammatory response as well as increased airway responsiveness to methacholine. The exacerbated response was indeed dependent on virus replication. Virus replication in turn was influenced by the allergic response, with persistence in the noses for 2 days longer in animals challenged with allergen. This diminished clearance corresponded to decreased induction of mRNA for IFN-gamma, a Th1-type cytokine that is characteristic of viral infection. Treatment of RSV-infected Af-challenged animals with recombinant IFN-gamma reduced the allergic inflammatory response as well as the relative levels of Th1 and Th2 cytokine mRNA. However, this treatment did not reduce airway reactivity, showing that these pathologic and physiologic measures of exacerbated disease are independent. We speculate that the reciprocal effect of the allergic response on viral immunity may benefit the host by limiting exacerbation of physiologic responses that are IFN-gamma-dependent.

Hepatitis C-associated granulomas after liver transplantation: morphologic spectrum and clinical implications

Liver granulomas have been described in biopsy specimens from people with de novo chronic hepatitis C virus (HCV) infection and in allograft biopsy specimens from recipients of transplants for HCV-related liver disease. The latter have not been well studied, and there are no data regarding the prevalence, morphologic spectrum, and clinical significance of HCV-associated granulomas after liver transplantation. We observed granulomas in allograft liver biopsy specimens of 4 (8%) of 53 recipients of transplants for HCV-related end-stage liver disease during a 3-year period. Initial appearance of granulomas ranged from 4 to 41 weeks after transplantation. Lobular and portal nonnecrotizing, epithelioid granulomas and lobular microgranulomas were observed, with the latter predominating. Serum transaminase and alkaline phosphatase levels were significantly higher in patients with granulomas than in age- and sex-matched control subjects, but histologic disease activity, cellular rejection scores, HCV genotypes, viral titers, and retransplantation rate owing to recurrent disease were not significantly different. Our study suggests that a granulomatous response to HCV infection occurs in a subset of patients after transplantation; however, this histologic finding does not portend a worse clinical outcome.

Virally activated CD8 T cells home to Mycobacterium bovis BCG-induced granulomas but enhance antimycobacterial protection only in immunodeficient mice

The effect of secondary infections on CD4 T-cell-regulated chronic granulomatous inflammation is not well understood. Here, we have investigated the effect of an acute viral infection on the cellular composition and bacterial protection in Mycobacterium bovis strain bacille Calmette-Guérin (BCG)-induced granulomas using an immunocompetent and a partially immunodeficient murine model. Acute lymphocytic choriomeningitis virus (LCMV) coinfection of C57BL/6 mice led to substantial accumulation of gamma interferon (IFN-gamma)-producing LCMV-specific T cells in liver granulomas and increased local IFN-gamma. Despite traffic of activated T cells that resulted in a CD8 T-cell-dominated granuloma, the BCG liver organ load was unaltered from control levels. In OT-1 T-cell-receptor (TCR) transgenic mice, ovalbumin (OVA) immunization or LCMV coinfection of BCG-infected mice induced CD8 T-cell-dominated granulomas containing large numbers of non-BCG-specific activated T cells. The higher baseline BCG organ load in this CD8 TCR transgenic animal allowed us to demonstrate that OVA immunization and LCMV coinfection increased anti-BCG protection. The bacterial load remained substantially higher than in mice with a more complete TCR repertoire. Overall, the present study suggests that peripherally activated CD8 T cells can be recruited to chronic inflammatory sites, but their contribution to protective immunity is limited to conditions of underlying immunodeficiency.

Absence of surface expression of feline infectious peritonitis virus (FIPV) antigens on infected cells isolated from cats with FIP

Feline infectious peritonitis virus (FIPV) positive cells are present in pyogranulomas and exudates from cats with FIP. These cells belong mainly to the monocyte/macrophage lineage. How these cells survive in immune cats is not known. In this study, FIPV positive cells were isolated from pyogranulomas and exudates of 12 naturally FIPV-infected cats and the presence of two immunologic targets, viral antigens and MHC I, on their surface was determined. The majority of the infected cells were confirmed to be cells from the monocyte/macrophage lineage. No surface expression of viral antigens was detected on FIPV positive cells. MHC I molecules were present on all the FIPV positive cells. After cultivation of the isolated infected cells, 52 ± 10% of the infected cells re-expressed viral antigens on the plasma membrane.

In conclusion, it can be stated that in FIP cats, FIPV replicates in cells of the monocyte/macrophage lineage without carrying viral antigens in their plasma membrane, which could allow them to escape from antibody-dependent cell lysis.

Investigation of a broad-spectrum PCR assay for human papillomaviruses in screening benign lesions of the upper aerodigestive tract

BACKGROUND

A variety of different human papillomavirus (HPV) types can be found in benign and malignant lesions of the upper aerodigestive tract. Therefore a broad-spectrum assay is needed for screening reasons.

METHODS

A PCR system with degenerate consensus primers originating from a very conserved region (e.g. L1) of the HPV genome was applied. The sensitivity level was improved by combining PCR and nested PCR.

RESULTS

A total of 27 biopsies from laryngeal papillomas (9), exophytic (3) and inverted (6) papillomas of the nasal cavity or paranasal sinuses, papillomas of the uvula or soft palate (5), leukoplakias of the larynx (2), seborrheic keratosis (1) and granulation tumor of the tongue (1) were analyzed by the broad-spectrum PCR system. Sixteen cases showed a positive result in either PCR or nested PCR or both.

CONCLUSIONS

It was shown that the applied broad-spectrum PCR system is a reliable tool in the detection of HPV DNA in benign lesions of the upper aerodigestive tract.

Bronchocentric granulomatosis associated with influenza-A virus infection

Bronchocentric granulomatosis is an unusual pathologic entity that is characterized by a necrotizing granulomatous inflammation surrounding the airways. The diagnosis is usually made retrospectively, after histopathologic examination of an open-lung biopsy or resection of a pulmonary lesion. Although the aetiology has not been fully elucidated, the current pathogenetic mechanism is considered to be an immunologic reaction against endobronchial antigens, since most patients exhibit signs of bronchial asthma, eosinophilia and allergic bronchopulmonary aspergillosis. However, non-asthmatic patients may develop bronchocentric granulomatosis without signs for endobronchial fungal infections, but probably as a consequence of other pulmonary infections. An 80-year-old female patient presented with high fever and bilateral pulmonary infiltrates and nodules. After extensive investigations and open-lung biopsy, the diagnosis bronchocentric granulomatosis was established that was possibly associated with an influenza-A virus infection. Treatment consisted of immunosuppressive drugs (prednisone and cyclophosphamide), which led to complete clinical and radiological recovery.

Hepatic granuloma in chronic hepatitis C

We report the findings in a 54-year-old male with chronic hepatitis C with granulomas liver biopsy. Unfortunately, this patient died before treatment could be started.

Florid Granulomatous Reaction in Epstein-Barr Virus-positive Nonendemic Burkitt Lymphomas

Epithelioid cell granulomas have been reported in association with a wide range of neoplasms including malignant lymphomas. In lymphoma, this refers mainly to Hodgkin disease and T-cell-derived non-Hodgkin lymphomas where a granulomatous reaction is probably evoked by aberrant cytokine production in the tumor cells or other cells composing the tumor background. Here we report on four cases of sporadic Burkitt lymphoma with unusual florid granulomatous reaction. In all samples, the tumor cells were admixed with numerous epithelioid cells that formed clusters and granulomatous lesions. No microorganisms could be detected at the tissue level, and there were no clinical or laboratory indications of an underlying immunodeficiency. The lymphomas harbored a specific morphology and immunophenotype of Burkitt lymphoma, and the presence of translocation breakpoint in MYC gene was confirmed by interphase fluorescence in situ hybridization. In all four patients, the lymphoma was associated with Epstein-Barr virus infection, detected by EBER in situ hybridization and the latency I phenotype as defined by lack of expression of LMP1. All four patients were treated with polychemotherapy, achieved a complete remission, and are alive without evidence of disease. We draw attention to this unusual phenomenon as it caused difficulties in interpretation and delayed diagnosis and hypothesize on the possible role of Epstein-Barr virus products.

Hepatic granulomas: a 10 year single centre experience

BACKGROUND

Epithelioid granulomas have been reported in 2-15% of unselected liver biopsies, with numerous underlying aetiologies described. However, all UK series were reported before identification of hepatitis C virus (HCV).

AIM

To evaluate the current aetiologies of hepatic granulomas and to assess the prognosis for the "idiopathic" group, in which all investigations for a recognised cause were negative or normal.

METHODS

A retrospective review of patient case notes between 1991 and 2001; all patients who had a liver biopsy at Glasgow Royal Infirmary revealing epithelioid granulomas had their case notes and liver biopsies reviewed and a standard proforma completed.

RESULTS

Over the study period, 1662 liver biopsies were performed. Hepatic granulomas were found in 63. Of those identified, 47 were female, with a mean age of 42 years (range, 17-81). Underlying aetiologies were as follows: primary biliary cirrhosis (PBC; 23.8%), sarcoidosis (11.1%), idiopathic (11.1%), drug induced (9.5%), HCV (9.5%), PBC/autoimmune hepatitis (AIH) overlap (6.3%), Hodgkin lymphoma (6.3%), AIH (4.8%), tuberculosis (4.8%), resolving biliary obstruction (3.2%), and other single miscellaneous causes (9.5%). Of the seven patients with idiopathic hepatic granulomas, one was lost to follow up, one died of stroke, and the remaining five were well with no liver related morbidity at a mean follow up of 6.2 years.

CONCLUSIONS

The aetiology of hepatic granulomas is broad ranging, with HCV an important cause in this population. Despite extensive investigations, a 10-15% of patients still had "idiopathic" hepatic granulomas. However, the prognosis for this last group appears to be excellent.

Expression of monocyte chemoattractant protein-1 but not interleukin-8 in granulomatous lesions in lymph nodes from pigs with naturally occurring postweaning multisystemic wasting syndrome

Monocyte chemoattractant protein-1 (MCP-1) but not interleukin-8 (IL-8) was detected by in situ hybridization using a nonradioactive digoxigenin-labeled complementary DNA probe in granulomatous lesions of lymph nodes from 20 pigs with naturally occurring postweaning multisystemic wasting syndrome (PMWS). Complementary DNA probes of 375 and 266 base pairs for MCP-1 and IL-8, respectively, were generated by reverse transcription-polymerase chain reaction. The 20 pigs with PMWS had distinct positive hybridization signals for MCP-1 but not for IL-8. The hybridization signals for MCP-1 were strictly confined to the cells with granulomatous lesions, including macrophages and multinucleated giant cells. A very close cell-to-cell correlation between MCP-1 and porcine circovirus 2 was seen in serial sections of lymph nodes. Results of this study indicate that MCP-1 expression may play a role in the pathogenesis of granulomatous inflammation in pigs with PMWS.

A comparison of lymphatic tissues from cats with spontaneous feline infectious peritonitis (FIP), cats with FIP virus infection but no FIP, and cats with no infection

Lymphatic tissues (spleen, mesenteric lymph nodes, thymus) from 24 cats with spontaneous feline infectious peritonitis (FIP) were examined by light microscopy and immunohistochemistry for cellularity, cellular composition, and degree of cellular turnover. Additionally, the formation of granulomatous lesions in lymphatic tissues in cats with FIP was examined. For comparison, tissues from 14 specific pathogen-free (SPF) cats and seven cats infected with FIP virus (FIPV; as the result of long-term exposure) but free from FIP were examined. In cats with FIP, the precardial mediastinum (including site of the thymus) and mesenteric lymph node parenchyma were often affected by granulomatous-necrotizing processes. In general, lymphoid tissues showed T- and B-cell depletion, often including massive to complete thymic involution or atrophy. In some cases, the number of apoptotic lymphocytes was increased in lymphoid follicles as well as in T-cell zones. The number of macrophages was increased in the splenic red pulp. In contrast, the FIPV-exposed cats without FIP generally showed a distinct lymphoid hyperplasia. The findings indicated that the major difference in lymphatic tissues between FIPV-infected cats with FIP and those without FIP was the development of lymphocyte depletion in the first group and lymphocyte proliferation in the second.

Inhibitory and enhancing effects of IFN-gamma and IL-4 on SHIV(KU) replication in rhesus macaque macrophages: correlation between Th2 cytokines and productive infection in tissue macrophages during late-stage infection

HIV-1 is dual-tropic for CD4+ T lymphocytes and macrophages, but virus production in the macrophages becomes manifest only during late-stage infection, after CD4+ T cell functions are lost, and when opportunistic pathogens begin to flourish. In this study, the SHIV/macaque model of HIV pathogenesis was used to assess the role of cytokines in regulating virus replication in the two cell types. We injected complete Freund's adjuvant (CFA) intradermally into SHIV(KU)-infected macaques, and infused Schistosoma mansoni eggs into the liver and lungs of others. Tissues examined from these animals demonstrated that macrophages induced by CFA did not support viral replication while those induced by S. mansoni eggs had evidence of productive infection. RT-PCR analysis showed that both Th1 (IL-2 and IFN-gamma) and Th2 cytokines (IL-4 and IL-10) were present in the CFA lesions but only the Th2 cytokines were found in the S. mansoni lesions. Follow-up studies in macaque cell cultures showed that whereas IFN-gamma caused enhancement of virus replication in CD4+ T cells, it curtailed viral replication in infected macrophages. In contrast, IL-4 enhanced viral replication in infected macrophages. These studies strongly suggest that cytokines regulate the sequential phases of HIV replication in CD4 T cells and macrophages.

HTLV-I-associated granulomatous T-cell lymphoma in a child

Adult T-cell leukemia/lymphoma (ATLL) is a T-cell malignancy closely associated with human T-cell lymphotropic virus-1 (HTLV-I). Because of its long latency period, ATLL occurs almost exclusively in adults. We report a case of a 13-year-old boy with an 8-year history of skin eruptions. After complete evaluation, a diagnosis of HTLV-I-associated lymphoma/leukemia was made. The T-cell lymphoma exhibited a granulomatous histomorphology. There have been very few reports of ATLL presenting in childhood and none, to our knowledge, demonstrating granulomatous histology. We conclude that ATLL may rarely present as a chronic granulomatous eruption in a child.

Virulence-associated protein characterisation of Rhodococcus equi isolated from bovine lymph nodes

Rhodococcus equi has a low pathogenicity in cattle, but it occasionally causes lymph node granulomas, which are detected at abattoir post mortem inspection, and must be distinguished from tuberculous granulomas. Lymph node lesions were detected in 6719 cattle, from a total of 3,263,622 cattle examined post mortem in abattoirs, in the Republic of Ireland, during 1997 and 1998. Histological examination was performed on all lesions, principally for the purpose of identifying animals with tuberculosis. A total of 1122 of the lesions were cultured on blood agar and on Stonebrinks and Lowenstein-Jensen medium containing pyruvate, because the histological findings were difficult to interpret or were suggestive of R. equi infection. R. equi was isolated from 264 lesions. Almost all of the R. equi granulomas were confined to a single lymph node, and were present predominantly in the retropharyngeal, bronchial and mediastinal lymph nodes. R. equi granulomas were present in a significantly higher proportion of the lesions detected in steers and heifers compared to cows. The prevalence in the total population of 3.3 million cattle examined post mortem was 0.008%. The 15-17kDa antigens, associated with virulence in this organism, and the 20kDa antigen, associated with intermediate virulence, were not detected in isolates from 146 cattle, analysed by immunoblot assays. A PCR assay to detect the plasmid gene encoding the 15-17kDa antigens was also negative for isolates from these 146 animals. Plasmids were not detected in 30 isolates which were examined.

Diseases of the eye of farmed shrimp Penaeus monodon

Lesions were found in the eyes of cultured shrimp Penaeus monodon that displayed non-specific signs of disease, including lethargy, dark pigmentation, brown gills, empty midgut, anorexia, white tail muscle, necrosis of uropods and fouled cuticle. Eye lesions were associated with sexual development in moribund shrimp in at least 1 disease event. Suppurative inflammation, granuloma and malacia were observed in histological examination of the eye and the causative agents of lesions appear to be Vibrio spp. and a rod-shaped virus (similar to Lymphoid Organ Virus, Gill-Associated Virus [GAV] and Yellow-Head Virus). Suppurative inflammation was characterised by edema, infiltration of haemocytes and local sites of abscesses. Eyes with granuloma usually appeared white in pond-side examinations, and histology showed that fibrous tissue replaced ommatidia, ganglia and internal structures of the eye. Malacia of the eye was characterised by necrosis of nervous tissue, vacuolation and vascular proliferation in the medulla ganglia. Levels of presumptive Vibrionaceace were high in moribund specimens and Gram-negative rods were observed in some specimens as free particles in the interstitial fluid and haemolymph in the eye. Transmission electron microscopy showed that nerve cells in the fasciculated zone (near the basement membrane) contained cytoplasmic vesicles (1 to 3 microm in diameter) with particles (15 to 26 nm in diameter) and rod-shaped nucleocapsids. The rods were similar to those of GAV and were 130 to 260 nm long, 10 to 16 nm in diameter and had helical symmetry with a screw-like thread (2.4 to 3.5 nm pitch). Also, unidentified enveloped virions, averaging 74 nm in diameter, were observed in cytoplasmic vesicles in the fasciculated zone. In conclusion, it is suggested that bacterial and viral infections of the eye could result in impaired neuroendocrine functions, which may cause a range of clinical signs of disease.

Lymphohistiocytic and granulomatous phlebitis in penile lichen sclerosus

Lichen sclerosus (LS) is a chronic inflammatory disease of unknown etiology that may affect the genital and/or extragenital skin of individuals of either sex at all ages. In boys, the prepuce is the most common site of involvement. The diagnostic criteria of LS include the presence of inflammatory infiltrates mainly composed of T lymphocytes. We report on two cases of LS of the prepuce because of the unusual feature of lymphocytic (CD45RO+ and CD20+), histiocytic (CD68+), and granulomatous phlebitis. This lesion was not present in a group of another 18 cases of childhood penile LS. We have not been able to find any references describing and illustrating inflammatory involvement of the dermal vein walls in LS. Unlike the data reported in the literature, the dermal inflammatory infiltrates of these two cases showed a similar proportion of B and T lymphocytes in addition to frequent CD68+ histiocytes.

[Lung and bone marrow granulomas associated with human parvovirus B19 infection]

A 56-year-old man was admitted with flu-like symptoms, and his platelet count abruptly decreased. A chest X-ray film showed granular shadows, and lung and bone marrow specimens disclosed non-caseating epithelioid cell granulomas. The patient's serum IgM titer for human parvovirus (HPV) B19 was elevated. Our conclusion was that HPV B19 must be kept in mind as a possible pathogenic agent of granuloma formation.

Systemic granulomatous arteritis associated with Epstein-Barr virus infection

A 61-year-old woman initially presented with symptoms and findings reminiscent of infectious mononucleosis, and her illness then took a rapidly fatal course. Autopsy revealed widespread granulomatous arteritis, with multinucleated giant cells but without eosinophils and fibrinoid necrosis, affecting small arteries and arterioles and infiltration of haemophagocytic histiocytes into many organs. In situ hybridization with Epstein-Barr virus (EBV)-specific oligonucleotide probes showed positive signals in the infiltrating immune cells and epithelial and endothelial cells of the affected organs. EBV-associated haemophagocytic syndrome (EBV-AHS) with systemic granulomatous arteritis was diagnosed. From the immunophenotypes of the infiltrating immune cells, a possible role of CD4+ T-cells in the pathogenesis of this haemophagocytic syndrome and granulomatous vasculitis was suggested.

Posttransplant liver granulomatosis associated with hepatitis C?

BACKGROUND

Liver granulomatosis is an occasional finding in posttransplant liver biopsies. Its diagnosis is made more difficult by the variety of conditions that can lead to it. In the nontransplant setting, the association of liver granulomatosis and hepatitis C virus (HCV) infection has occasionally been described.

METHODS

We describe the case of a patient with a liver transplantation for an HCV-associated cirrhosis who developed an alteration of liver tests. Granulomatosis was detected on the liver biopsy.

RESULTS

Other causes of granulomatosis were satisfactorily excluded. The development of the lesions coincided with a viral flare-up.

CONCLUSION

We think that HCV can be listed among the possible causes of liver granulomas in the posttransplant setting and that it must be considered in the differential diagnosis of this condition.

Cutaneous reactions at sites of herpes zoster scars: an expanded spectrum

Several types of cutaneous lesions have previously been described at the sites of herpes zoster scars. We describe 16 patients with cutaneous lesions which had developed on herpes zoster scars. Biopsies were taken from these lesions, and a polymerase chain reaction assay was used to detect the viral genome in paraffin-embedded specimens. Histopathological findings enabled diagnosis of nonspecific granulomatous dermatitis in five patients, granulomatous vasculitis in two patients, lichen sclerosus in two patients, and pseudolymphoma, keloid, sarcoidal granuloma, granuloma annulare, granulomatous folliculitis, lichen planus and cutaneous Rosai-Dorfman disease, each in one patient. Varicella-zoster virus DNA was not identified in any of the patients. Granulomatous folliculitis, lichen sclerosus and cutaneous Rosai-Dorfman disease have not previously been described in herpes zoster scars, but they are three new cutaneous reaction patterns that may have developed within these scars. Our investigations indicate that the cutaneous reactions appearing in herpes zoster scars are not due to the persistence of varicella-zoster virus DNA within the lesions.

Herpes zoster sine herpete. A potential cause of iridoplegic granulomatous iridocyclitis

OBJECTIVE

Herpes zoster ophthalmicus (HZO) is a recurrence of varicella zoster virus involving cranial nerve V-1, but does not always have skin manifestations. The objective of this work is to study iridoplegic granulomatous iridocyclitis as an acute, fulminant iridocyclitis that probably is caused by the recurrence of varicella zoster virus without skin eruptions.

PARTICIPANTS

The author reports 15 cases of iridoplegia granulomatous iridocyclitis with involvement of the anterior uveal tract without known skin eruptions.

RESULTS

All patients have had a clinical course of iridocyclitis closely resembling those cases of herpes zoster with skin eruptions. Nine of the 15 are documented to have had a recurrence of varicella zoster virus with an appropriate rise and fall of systemic titers. The remaining six patients had clinical findings, including loss of accommodation, iridoplegia, and sectoral iris atrophy that were more typical for HZO than other infectious agents.

CONCLUSIONS

Iridoplegic granulomatous iridocyclitis is a newly described, acute, fulminant uveitis probably caused by a herpes virus and most probably by varicella zoster virus. Herpes zoster sine herpete (erupticum) should be suspected as a potential diagnosis in patients with appropriate anterior segment manifestations. Further study is necessary to discern if any of such cases could be caused by herpes simplex.

Rationale for the use of contrast media in MR imaging

Understanding the rationale of contrast media use in MR imaging is based on knowledge of the blood brain barrier (BBB) and the pathophysiology of infectious agents attacking the central nervous system. This article focuses on the relationship between BBB structures and functions in healthy and unhealthy conditions and contrast media in patients with acquired immunodeficiency syndrome.

Detection and comparative analysis of persistent measles virus infection in Crohn's disease by immunogold electron microscopy

AIMS

To determine the specificity of persistent measles virus infection in intestinal samples from Crohn's disease patients using quantitative immunogold electron microscopy. To compare the results with samples from ulcerative colitis, a granulomatous inflammatory control (tuberculous lymphadenitis), and a positive control.

METHODS

Formalin fixed, paraffin embedded intestinal tissue from patients with Crohn's disease was reprocessed and stained with antimeasles nucleocaspid protein primary antibody followed by 10 nm gold conjugated secondary antibody. Tissue samples were taken from granulomatous and non-granulomatous areas of the intestine. Intestinal samples from patients with ulcerative colitis, tuberculous lymphadenitis, or acute mesenteric ischaemia were similarly processed. Brain tissue from a patient with subacute sclerosing panencephalitis (SSPE) was used as the positive control. Duplicate sections of all tissues were processed without the primary antibody. Stained specimens were examined by electron microscopy.

RESULTS

In Crohn's disease patients, 8/9 foci of granulomatous inflammation and 0/4 foci of non-specific inflammation were positive for measles virus. Of controls, 0/5 non-inflamed intestinal tissues, 1/8 tuberculous tissues, 1/5 ulcerative colitis tissues, and 1/1 SSPE tissues were positive. Gold grain counts per nuclear field-of-view in both Crohn's disease granulomas (43.29) and SSPE (36.94) were significantly higher than in tissues from patients with ulcerative colitis (13.52) or tuberculous lymphadenitis (15.875), and nongranulomatous areas of Crohn's disease (4.89) (p < 0.001, p < 0.001, p = 0.0006, respectively), with no significant difference between Crohn's disease and SSPE (p > 0.1). In both SSPE and Crohn's disease staining was confined to a small population of cells exhibiting characteristic cytopathology.

CONCLUSION

These data support a role for measles virus in the aetiology of Crohn's disease.

Granulomas and hepatitis C

Hepatitis C (HCV) is associated with a number of characteristic histological features. A recent paper has identified an increased frequency of granulomas in resection specimens from cases of HCV. We have carried out a retrospective study of 155 cases of HCV to assess the frequency of granulomas in biopsy specimens. We had two control groups: 151 cases of hepatitis B (HBV) and 129 cases of alcohol induced liver disease. Granulomas were found in 14 cases of HCV (10%), three cases of HBV (2%) and three cases of alcohol induced liver disease (2%). Granulomas were significantly commoner in cases of HCV than in the other two groups. Of the 14 cases of HCV, the granulomas could be ascribed to another cause in seven cases. When the analysis was carried out, excluding those granulomas which could be ascribed to another cause, they were still significantly commoner in cases of HCV. We conclude that granulomas are more frequent in HCV but that in half of cases in which they are found another cause can be identified. This means that if granulomas are seen in association with hepatitis C another aetiology should be sought before ascribing them to HCV.

Cutaneous reactions following herpes zoster infections: report of three cases and a review of the literature

Three patients, one healthy and two immunocompromised, developed cutaneous reactions that histologically mimicked granuloma annulare at sites of resolved varicella-zoster virus (VZV) reactivation infections. Variable latency periods between the infection and the granulomatous reaction were noted. As in other case reports, the presence of VZV DNA in these lesions was inconsistently demonstrated by the polymerase chain reaction (PCR) and appears more common in early, as opposed to late, post-zoster granulomas. In addition to various granulomatous reactions, vasculitic and neoplastic eruptions following resolved VZV infections have been described and are reviewed here. Therapeutically, topical, intralesional and systemic corticosteroids, as well as acyclovir, have been tried with inconsistent results. Although the pathogenesis remains unclear, the presence of VZV DNA in early lesions that histologically do not display viral cytopathic changes, suggests the virus induces an atypical delayed hypersensitivity reaction not affected by antiviral therapy.