Diagnosis Of Granulomatous Lung Disease Research Articles

Pathology of Granulomatous Pulmonary Diseases.

Because granulomas are represented in almost every disease category, the number of clinically and pathologically important granulomatous pulmonary diseases is large. Their diagnosis by pathologists is particularly challenging because of their nonspecificity. A specific diagnosis can be achieved only when a granuloma-inciting agent(s) (eg, acid-fast bacilli, fungi, foreign bodies, etc) are identified microscopically or by culture; this does not occur in most cases. Furthermore, a specific diagnosis cannot be reached in a high percentage of cases. Although sarcoidosis and infectious diseases account for approximately half of pulmonary granulomatous diseases worldwide, there is significant geographic variation in their prevalence. To present updated information to serve as a guide to pathologic diagnosis of pulmonary granulomatous diseases, to address some commonly held misconceptions and to stress the importance of multidisciplinary coordination. Presentation of basic aspects of granulomas is followed by discussion of specific disease entities, such as tuberculous and nontuberculous Mycobacterial infections, fungal, bacterial, and parasitic infections, sarcoidosis, necrotizing sarcoid granulomatosis, berylliosis, hypersensitivity pneumonitis, hot tub lung, rheumatoid nodule, bronchocentric granulomatosis, aspirated, inhaled, and embolized foreign bodies, drug-induced granulomas, chronic granulomatous disease, common variable immunodeficiency, and granulomatous lesions associated with various types of cancer. Review of pertinent medical literature using the PubMed search engine and the author's practical experience. Although the diagnosis of granulomatous lung diseases continues to present significant challenges to pathologists, the information presented in this review can be helpful in overcoming them. The importance of multidisciplinary coordination in cases where morphologic diagnosis is not possible cannot be overstated.

Pay attention to the diagnosis of granulomatous lung disease

Pay attention to the diagnosis of granulomatous lung disease

BRONCHOCENTRIC GRANULOMATOSIS: THE MALIGNANCY MIMICKER

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bronchocentric Granulomatosis (BG) is a rare disorder with a wide variety of clinical presentations. It can be subdivided into two epidemiological categories: asthmatic and non-asthmatic. Here, we describe a non-asthmatic with BG whose presentation was concerning for malignancy. CASE PRESENTATION: A 46 year-old male never smoker with a history of bronchiectasis and seizures was referred for abnormal computed tomography (CT) scans of the chest, performed in the context of a 2 year history of dry cough. He had no associated symptoms including wheezing, dyspnea, nasal congestion, acid reflux, and weight loss. Serial CT scans revealed a spiculated nodule in the left upper lobe that had decreased in size but persisted across 2 years. Notably, he had a biological sister who passed away from a biopsy proven small cell lung carcinoma at age 27. Physical examination was unremarkable, as well as pulmonary function testing and serological testing, including a normal eosinophil count. A positron emission tomography (PET) scan showed that the nodule was PET avid with an SUV of 5.74 g/mL. The patient ultimately underwent a left upper lobe trisegmentectomy for the nodule. Pathology revealed necrotizing granulomatous inflammation with destruction of adjacent bronchiolar walls, consistent with BG. Surgical specimen bacterial and fungal cultures were negative. Serum aspergillus antibodies, galactomannan, antineutrophil cytoplasmic antibodies, and rheumatoid factor were also negative. His cough improved after his surgery, and a CT scan done 2 months postoperatively showed no abnormalities other than post-surgical changes. DISCUSSION: Patients with BG commonly present with constitutional symptoms such as fatigue and fever. Respiratory symptoms are reportedly rare, but tend to be seen more commonly in the asthmatic type. A chronic indolent presentation is more common for non-asthmatic patients. Associated etiologies include allergic bronchopulmonary aspergillosis, rheumatoid arthritis, vasculitides, and mycobacterial infections. In the context of such associated diseases, treatment of the underlying cause is imperative. In idiopathic disease, most patients recover without therapy but steroids can also be used. Radiographically BG can present as pulmonary nodules or consolidation, often in the upper lobes. Diagnosis of BG is made based on histopathology of a surgical lung biopsy specimen. It is characterized by peribronchiolar necrotizing granulomatous inflammation, limited to the airway and parenchyma without vascular involvement. CONCLUSIONS: In our case, the pulmonary nodule decreased in size prior to resection, which could represent the spontaneous resolution previously described in idiopathic non-asthmatic patients. This case illustrates that BG should be in the differential diagnosis for patients with a suspected malignant nodule in the absence of clinical symptoms or comorbidities concerning for malignancy. Reference #1: Ohshimo, S., et al. (2017). “Differential diagnosis of granulomatous lung disease: clues and pitfalls: Number 4 in the Series “Pathology for the clinician” Eur Respir Rev 26(145). Reference #2: Mimur, K., et al. (2011). “A case of bronchocentric granulomatosis resembling lung cancer on diagnostic imaging.” Nihon Kokyuki Gakkai Zasshi 49(12): 970-975 Reference #3: Granada, M. and A. C. Theodore (2010). A Case Of Bronchocentric Granulomatosis Following Treatment For Non Hodgkin Lymphoma. C43. Case Reports In Interstitial Lung Disease and More II, American Thoracic Society: A4505-A4505. DISCLOSURES: No relevant relationships by Johanna Ben-Ami, source=Web Response No relevant relationships by Oki Ishikawa, source=Web Response No relevant relationships by Bushra Mina, source=Web Response No relevant relationships by Doaa Morrar, source=Web Response

Histological differential diagnosis of granulomatous lung diseases (part I)

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

Histological differential diagnosis of granulomatous lung diseases (Part II)

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

Differential diagnosis of granulomatous lung disease: clues and pitfalls: Number 4 in the Series "Pathology for the clinician" Edited by Peter Dorfmüller and Alberto Cavazza.

Granulomatous lung diseases are a heterogeneous group of disorders that have a wide spectrum of pathologies with variable clinical manifestations and outcomes. Precise clinical evaluation, laboratory testing, pulmonary function testing, radiological imaging including high-resolution computed tomography and often histopathological assessment contribute to make a confident diagnosis of granulomatous lung diseases. Differential diagnosis is challenging, and includes both infectious (mycobacteria and fungi) and noninfectious lung diseases (sarcoidosis, necrotising sarcoid granulomatosis, hypersensitivity pneumonitis, hot tub lung, berylliosis, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, rheumatoid nodules, talc granulomatosis, Langerhans cell histiocytosis and bronchocentric granulomatosis). Bronchoalveolar lavage, endobronchial ultrasound-guided transbronchial needle aspiration, transbronchial cryobiopsy, positron emission tomography and genetic evaluation are potential candidates to improve the diagnostic accuracy for granulomatous lung diseases. As granuloma alone is a nonspecific histopathological finding, the multidisciplinary approach is important for a confident diagnosis.

Challenges in the differential diagnosis of granulomatous lung disease

Introduction. Granulomatous lung diseases comprise a large family sharing the histological denominator of granuloma formation. Review of literature. From a diagnostic standpoint, epithelioid granulomas, are considered to be nonspecific lesions, they can be associated with infection, immunological conditions or they may be idiopathic. The precise diagnosis of granulomatous disorders can be readily apparent on clinical and radiological ground alone in some cases or extremely difficult even after histological examination of large surgical samples in a limited number of conditions. No single and specific diagnostic test has been developed so far. To achieve a timely diagnosis and help reduce associated morbidity and mortality, it is essential to recognize both the typical and the atypical manifestations of the disease. Differential diagnosis and management demand a skilful interpretation of clinical findings and pathological evidence. Conclusion. A clinicopathological synthesis provides the strongest foundation.

Case of pulmonary Mycobacterium mageritense infection: the difficulty of differential diagnosis of granulomatous lung diseases

A 36 year-old female was pointed out of pulmonary abnormal shadows in the annual chest survey. Chest radiograph and computed tomography (CT) disclosed bilateral diffuse infiltrative shadows and tree-in-bud appearance in the right upper lung field and the left lingula. A sputum smear for acid-fast bacilli was negative. Histopathologically, the transbronchial lung biopsy specimen revealed non-caseous epithelioid granulomas with numerous giant cells. Acid-fast bacilli were cultured from her sputum, however, nontuberculous mycobacteria was not detected by DNA-DNA hybridization method. Mycobacterium mageritense was identified by 16S ribosomal RNA sequencing with 100% matching. The isolated colony of M. mageritense was resistant to nine anti-tuberculous drugs. Follow-up chest CT scan showed a gradual decrease of infiltrative shadows without therapy. To the best of our knowledge, M. mageritense infections are rare, and this is the first case report of pulmonary infection in the literature. We conclude that the pulmonary infection of M. mageritense is one of causes of granuloma formation, and in some case it is difficult to differentiate clinically from sarcoidosis.

Pathological diagnosis of granulomatous lung disease: a review

Granulomas in the lung are common diagnostic problems encountered by pathologists. They occur in a wide range of pulmonary conditions, ranging from common entities to uncommon ones and including both infections and non-infectious diseases. This review summarizes the main histological features that help distinguish various granulomatous lung diseases. It concentrates on the most important and common entities that may be encountered and emphasizes helpful features in the differential diagnosis.