Granulomatous Inflammatory Process Research Articles

Cardiac Sarcoidosis Presenting as Sustained Ventricular Tachycardia.

Sarcoidosis has many possible clinical presentations since it can affect any organ, most commonly the lungs. The hallmark of the disease consists of the formation of non-necrotising granulomas. Pathogenesis is thought to rely on the interplay of genetic, environmental and epigenetic factors. This case highlights the importance of a thorough clinical history and physical examination, and the correlation with imaging findings in the diagnostic work-up of the non-ischaemic cardiomyopathy. A 57-year-old woman was admitted due to the sudden onset of malaise, dizziness, and chest discomfort. Sustained monomorphic ventricular tachycardia was evidenced and the patient rapidly evolved with haemodynamic instability; she underwent successful electrical cardioversion. The electrocardiogram afterwards showed a high-risk electrocardiographic pattern. Invasive coronary angiography excluded obstructive epicardial coronary lesions. Physical examination revealed skin lesions on the lower limbs which raised suspicion for erythema nodosum and therefore a biopsy was performed. Transthoracic echocardiography and cardiac magnetic resonance imaging revealed features consistent with an inflammatory cardiomyopathy, and an implantable cardioverter-defibrillator was placed. The histologic examination of the cutaneous lesions showed a non-necrotising granulomatous inflammatory process. Radionuclide imaging was inconclusive. The patient underwent an endomyocardial biopsy, which confirmed the diagnosis of systemic sarcoidosis with cardiac involvement. Systemic sarcoidosis with cardiac involvement is a challenging diagnosis. The role of imaging techniques such as transthoracic echocardiography, cardiac magnetic resonance imaging and radionuclide imaging is essential in raising suspicion and diagnosing this pathology. Endomyocardial biopsy is the 'gold standard' for its diagnosis; however, it has a low diagnostic yield. Systemic sarcoidosis with cardiac involvement is a challenging diagnosis as it may present in many different ways.The case presented highlights the importance of a thorough clinical history and physical examination, and the correlation with imaging findings.Imaging techniques such as transthoracic echocardiogram, cardiac magnetic resonance and radionuclide imaging are essential in raising suspicion and diagnosing cardiac sarcoidosis.

A novel entity of massive multifocal osteolyses in the elderly

Osteolyses are common findings in elderly patients and most frequently represent malignant or locally aggressive bone tumors, infection, inflammatory and endocrine disorders, histiocytoses, and rare diseases such as Gorham-Stout syndrome. We here report on a novel entity of massive multifocal osteolyses in both shoulders, the right hip and left knee joint and the dens of an 83-year-old patient not relatable to any previously known etiopathology of bone disorders. The soft tissue mass is of myxoid stroma with an unspecific granulomatous inflammatory process, aggressively destroying extensive cortical and cancellous bone segments and encroaching on articulating bones in diarthrodial large joints. Radiological, nuclear medical, serological, histological, and immunohistochemical analyses were incapable of further classifying the disease pattern within the existing scheme of pathology. Quantitative polymerase chain reaction and next generation sequencing revealed that mutations are not suggestive of any known hereditary or acquired bone disease. Possible treatment options include radionuclide therapy for pain palliation and percutaneous radiation to arrest bone resorption while surgical treatment is inevitable for pathological fractures. This case study shall increase the awareness of the musculoskeletal community and motivate to collect further information on this rare but mutilating disorder.

Infectious Lesion Simulating Malignant Neoplasm. Clinical Case and Literature Review

The extrapulmonary manifestations of tuberculosis (TBC) that affect the Central Nervous System (CNS), by hematogenous dissemination, are an infrequent entity. Intracranial tuberculomas are the least common form of tuberculosis in CNS. Represent a granulomatous inflammatory process with cerebral involvement. The prognosis is related to the early diagnosis, the degree of surgical resection and the complemen-tary treatment with antituberculous drugs. We describe an infrequent clinical case of cerebral tuberculoma that simulated a malignant neoplasm, and also performed a literature review. A clinical case about a 31-year-old female with no relevant medical history. She described a sud-denly diplopia, without previous trauma. The patient was evaluated by Ophthalmology, which iden-tified papillary edema, with no other alterations. In this context was performed a Brain CT/MRI, which showed an intra-axial, left frontobasal lesion with perilesional edema, ring contrast enhancement and a hypodense/hypointense central area. Spectroscopy showed a reduction in n-acetylaspartate (NAA) with a peak in creatine and choline, suggestive of a malignant tumor. The patient underwent surgery, having performed a frontal left craniotomy and complete excision of a nodular, capsulated, avascular lesion with a spongy consistency. Subsequently, the histological diagnosis of tuberculoma was confirmed. We describe an infrequent clinical case of cerebral tuberculoma which, due to the characteristics presented in the preoperative studies, was suggestive of a malignant tumor that was not confirmed, which is the particularity of this case. The patient presents a good clinical and imaging evolution during the follow-up period.

TOLOSAHUNT SYNDROME: A RARE CAUSE OF OCULOMOTORPARALYSIS

Tolosa-Hunt syndrome is related to an idiopathic granulomatous inflammatory process. Its clinical manifestation is painful ophthalmoplegia. We report the case of a young patient who presented with oculomotor paralysis, and whose diagnosis of Tolosa-Hunt syndrome was accepted, given the negativity of all the complementary examinations carried out. Treatment with corticosteroids led to a rapid regression of symptoms.

HISTOPLASMOSIS IN A MAN WITH AIDS: CASE REPORT

Histoplasmosis is a systemic infectious disease caused by Histoplasma capsulatum. Patient, male, 40 years old, melanoderma, with AIDS, referred from a Reference Center for Tropical Diseases for stomatological care, complaining of a "tongue lesion". Nothing noteworthy was seen in the extra-oral examination. Intra-oral, a nodular lesion disseminated in a red tongue, papillary and ulcerated surface with sessile base. The clinical diagnosis was Histoplasmosis and Paracoccidioidomycosis. An incisional biopsy was performed and the histopathological sections were stained with hematoxylin and eosin (HE) revealing a granulomatous inflammatory process associated with pseudoepitheliomatous hyperplasia compatible with histoplasmosis. Positive PAS reaction and Grocott staining; and negative in the Ziehl-Neelsen staining. The patient died before starting the treatment. This case reinforces the importance of the stomatologist and oral pathologist in the elucidation of cases of systemic diseases when it is shown exclusively in the mouth and the diagnostic challenge. Histoplasmosis is a systemic infectious disease caused by Histoplasma capsulatum. Patient, male, 40 years old, melanoderma, with AIDS, referred from a Reference Center for Tropical Diseases for stomatological care, complaining of a "tongue lesion". Nothing noteworthy was seen in the extra-oral examination. Intra-oral, a nodular lesion disseminated in a red tongue, papillary and ulcerated surface with sessile base. The clinical diagnosis was Histoplasmosis and Paracoccidioidomycosis. An incisional biopsy was performed and the histopathological sections were stained with hematoxylin and eosin (HE) revealing a granulomatous inflammatory process associated with pseudoepitheliomatous hyperplasia compatible with histoplasmosis. Positive PAS reaction and Grocott staining; and negative in the Ziehl-Neelsen staining. The patient died before starting the treatment. This case reinforces the importance of the stomatologist and oral pathologist in the elucidation of cases of systemic diseases when it is shown exclusively in the mouth and the diagnostic challenge.

ORAL CRYPTOCOCOSIS IN AN IMMUNOSUPPRESSED PATIENT: A CASE REPORT

A 57-year-old male patient, immunosuppressed after heart transplantation, was hospitalized for suspected disseminated opportunistic infection. The patient complained of pain due to lesions in the mouth, fever, and diarrhea starting 15 days ago. Upon physical examination, crateriform erythematous ulcers covered by a purulent membrane were observed in the anterior region of the hard palate and upper labial mucosa, in addition to erythematous plaques on the upper attached gingiva. Ulcers were also observed in the nose wing and mentual region. Chest tomography revealed irregular reticular opacities in both lungs and ground-glass infiltrate. Biopsies from lung oral lesions were performed, which revealed a granulomatous inflammatory process and small rounded structures. Special Grocott-Gomori staining allowed confirmation of the fungal structure of Cryptococcus, and a final diagnosis of Cryptococcosis was reached. Treatment was conducted with Amphotericin B associated with Fluconazole, and after seven months of follow-up, complete remission of the lesions was observed. Support: CAPES, CNPq. A 57-year-old male patient, immunosuppressed after heart transplantation, was hospitalized for suspected disseminated opportunistic infection. The patient complained of pain due to lesions in the mouth, fever, and diarrhea starting 15 days ago. Upon physical examination, crateriform erythematous ulcers covered by a purulent membrane were observed in the anterior region of the hard palate and upper labial mucosa, in addition to erythematous plaques on the upper attached gingiva. Ulcers were also observed in the nose wing and mentual region. Chest tomography revealed irregular reticular opacities in both lungs and ground-glass infiltrate. Biopsies from lung oral lesions were performed, which revealed a granulomatous inflammatory process and small rounded structures. Special Grocott-Gomori staining allowed confirmation of the fungal structure of Cryptococcus, and a final diagnosis of Cryptococcosis was reached. Treatment was conducted with Amphotericin B associated with Fluconazole, and after seven months of follow-up, complete remission of the lesions was observed. Support: CAPES, CNPq.

Serious lesions in Green turtles (Chelonia mydas) afflicted by fatal Spirorchiidiasis found stranded in south and southeastern Brazil.

Several diseases have been reported as affecting endangered wild sea turtle population worldwide, including spirorchiidiasis. This parasitic infection results in serious circulatory disorders in sea turtles, as well as tissue damage due to the presence of spirorchiids eggs. However, few reports of organs severely affected by tissue replacement caused by granulomatous inflammatory processes due to spirorchiidiasis in sea turtles are available. In this regard, this study describes massive lesions in 16 juvenile green turtles from southeastern Brazil presenting no other detectable diseases or injuries, associated to parasitic compression of air spaces, parasitic thyroid atrophy, parasitic encephalic compression and parasitic splenic lymphoid depletion. These rare injuries were categorized as extremely severe, affecting most spirorchiidiasis-infected organs. Spirorchiidiasis was, thus, noted herein as capable of causing a variety of lethal injuries to vital or extremely important organs in sea turtles. Spirorchiidiasis should, therefore, also be considered a potential cause of death in stranded green sea turtle monitoring efforts.

Histopathological and molecular methods as complementary diagnostic in case of lymphadenopathies suggestive of bovine tuberculosis.

Bovine tuberculosis (TB) is a chronically evolving zoonotic infectious disease caused by Mycobacterium bovis. Anatomopathological examination during post mortem inspection in bovines is the main resource engaged in sanitary slaughter; however, it is very troublesome since many granulomatous inflammatory processes have similar morphological characteristics. Thus, this study aims to use complementary diagnosis methods (histopathological and polymerase chain reaction - PCR assays) to confirm the macroscopic assessment of lymphadenopathies indicative of tuberculosis in bovines slaughtered in a refrigerated slaughterhouse in Tailândia city, PA, Brazil. Fifty‑one samples were collected from lesions indicative of tuberculosis in pre‑scapular and pre‑pectoral lymph nodes (or different lymphadenitis) in condemned carcasses. Histological processing employed routine techniques carried out at the Laboratory of Animal Pathology of the Federal Rural University of the Amazon, while the PCR assay was performed at the Bacteriology Laboratory of the Evandro Chagas Institute. Results showed that 1.96% of the histopathology samples corresponded to inflammatory processes typical of TB and that, in PCR, 4.25% of the samples had the amplification profile of the M. bovis species. These results indicate the importance of adding complementary methods to assist the sanitary inspection line and make inspection more efficient in its decisions.

DRUG-INDUCED SARCOIDOSIS-LIKE REACTION IN THE ORAL CAVITY: A CASE REPORT

Drug-induced sarcoidosis-like reaction (DISR) is almost indistinguishable from sarcoidosis, and it manifests as a systemic granulomatous tissue reaction occurring in a temporal association with initiation of an offending drug. This study presents a rare case of DISR with oral involvement. A 63-year-old woman with a history of rheumatoid arthritis who has been treated with adalimumab presented with multiple ulcerative nodules on the hard palate, with 15 days of duration. Imaging exams did not exhibit any alteration. Blood tests and serological investigations were negative. An incisional biopsy was performed. Microscopic examination demonstrated a granulomatous inflammatory process in the connective tissue, consisting of multiple granulomas, without evidence of caseating necrosis or microorganisms. Histochemical reactions were negative for acid-fast bacilli and fungi, and immunohistochemical assessment for CD3, CD20, and CD68 highlighted the presence of normal lymphocytes and histiocytes. Adalimumab was ceased and after 17 months complete resolution of the lesions was observed.

PRIMARY ORAL TUBERCULOSIS PRESENTING AS A TONGUE ULCER

Primary tuberculosis of the oral cavity is an extremely rare condition accounting for less than 1% of the extrapulmonary cases. A 36-year-old male patient was referred for consultation complaining of dysphonia and dysphagia associated with a painful nonhealing lesion in the tongue for approximately 60 days. Physical examination revealed a well-defined ulcer affecting the tongue apex. The patient reported the use of topic corticosteroids for over 30 days without any improvement. Hematologic exams were within normal limits and serologic tests for HIV, syphilis, and hepatitis were negative. Incisional biopsy was performed, and histopathologic examination revealed a granulomatous inflammatory process composed of multinucleated giant cells, epithelioid histiocytes, and lymphocytes. A Ziehl-Neelsen stain showed the presence of acid-fast bacilli, compatible with mycobacteria. No chest imaging alterations nor previous respiratory symptoms were present. Sixty days after starting antituberculous treatment, the patient showed complete healing of the lesion.

Vertebral destruction in an 11-month-old child with spinal tuberculosis: a case report and review of literature

BackgroundThe incidence of tuberculosis is increasing especially in endemic countries. Spinal tuberculosis represents nearly the 50% of reported cases of skeletal tuberculosis. This is the youngest case of spinal tubercular disease that has been reported. The objective of this report is to describe a spinal tuberculosis case in an infant in thoracic spine, in order to show the importance of early diagnosis in this population, to limit the progression of this highly destructive disease and reduce the severe sequelae that this disease is associated.Case presentationAn 11-month-old infant previously healthy born in the northeast Mexico. Physical examination revealed a mass lesion in the dorsal region, fixed to deep planes, indurated. Neurological examination found Frankel C paraparesis showing muscle strength 2/5 on the Lovett scale in both lower extremities, anal reflex present, and preserved sensitivity.In the magnetic resonance of the spine, hyperintensities in the vertebral bodies of D6-D9 were observed in the T2 with destruction of the D7 and D8 bodies. A thoracotomy was performed with total mass resection with corpectomy of vertebrae D7 and D8, medullary decompression, and placement of fibula allograft between vertebrae D6 and D9. In the histopathological sample, a chronic granulomatous inflammatory process associated with acid-fast bacilli was observed, in addition to presenting a positive result in quantitative real-time PCR GeneXpert MTB/RIF sensitive to rifampicin. Twelve months later, he presented 5/5 muscular strength, without alterations in sensitivity, in addition to presenting ambulation onset at 18 months of age.ConclusionThe spinal tuberculosis is a disease that occurs in endemic countries. A prompt diagnosis is necessary to limit the progression of a highly destructive disease. In addition, the fact of presenting at an early age produces hard making decisions for the adequate treatment of the disease and reduces the adverse effects of these procedures.

Структурные изменения в печени мышей при БЦЖ-гранулематозе и применении окисленного декстрана в возрастной динамике

Introduction. Tubercular granulomatosis in newborns and children is much less common than in adults, and especially its visceral forms, including hepatic lesion. Oxidized dextran enhances the production of oxygen radicals, cytotoxic and bactericidal potential of phagocytes, accelerates the process of phagolysosomal fusion and elimination of the pathogen, reducing the granulomatous inflammatory process in organs. Aim. To study morphological changes in the liver of mice from the neonatal period to adulthood with the BCG vaccine administration and use of oxidized dextran. Materials and methods. Mice of the C57B1/6 line (200 animals in total) were divided into 4 groups: mice from the 1st (intact) group were injected with 0.02 ml/kg of 0.9% sodium chloride solution on the first day after birth. Mice from the 2nd group on the 2nd day after birth were injected with a solution of oxidized dextran with a molecular mass of 40 kDa. Mice from the 3rd group were injected with a solution of the BCG vaccine of 0.02 ml/kg on the first day after birth. Mice of the 4th group were injected with a solution of the BCG vaccine of 0.02 ml/kg, on the second day after birth – a solution of oxidized dextran with a molecular mass of 40 kDa. Results. The numerical density (Nai) of granulomas in the liver progressively increased from 28th to 56th day of the experiment in mice of the 3rd and 4th groups by 13.5 times. However, in mice of the 4th group, the number of granulomas was 1.4 times less than in mice of the 3rd group. The diameter of granulomas in the liver in mice of the 4th group was smaller on the 28th and 56th days in comparison with the same indicator in mice of the 3rd group by 2 times and 1.3 times, respectively. In mice of the 4th group, the volume density (Vv) of degenerated hepatocytes from 3rd to 5th day was 8 times lower compared to the same indicator in mice of the 3rd group, on the 10th and 28th days – 1.7 and 1.2 times, respectively. Vv of foci of hepatocyte necrosis in mice of the 4th group did not differ from that in mice of the 1st (intact) and 2nd (control) groups in all periods of observation, and was less on the 3rd and 56th days in comparison with the same indicator in mice of the 3rd (BCG) group by 3 times. On the 28th and 56th days of the experiment, mice from the 3rd and 4th groups showed an increase in the Nai of binuclear hepatocytes and hepatocytes with mitoses in comparison with the same indicator in mice of the 1st and 2nd groups. In mice of the 4th group, the number of binuclear hepatocytes, reflecting the reparative regeneration of hepatocytes, was 1.8 times greater than in mice of the 3rd group on the 28th and 56th days. Conclusion. Granulomas formation (the number and diameter of granulomas) in the liver of mice with the administration of the BCG vaccine and use of oxidized dextran was less marked in comparison with animals not treated with oxidized dextran, which indicates the effective elimination of the pathogen in phagocytes. Destructive changes (degeneration and necrosis of hepatocytes) in the liver parenchyma of mice with the injection of the BCG vaccine and subsequent use of oxidized dextran are significantly reduced, while the processes of reparative regeneration in the liver parenchyma of mice are activated, which is due to the hepatotropic action of oxidized dextran.

Disseminated Phaeohyphomycotic Lymphadenitis with Cladophialophora Species

Objective: This study describes a case of disseminated phaeohyphomycotic lymphadenitis in a young female with delayed diagnosis and good clinical response after appropriate treatment. Methods: A 32-year-old female presented with erythematous to violaceous papules with oozing discharge bilaterally in her inguinal region for a few months. History revealed tuberculous meningitis 4 years earlier treated with first line anti-tuberculous therapy for 18 months, and 2 years previously she developed pigmented discharging lymph nodes bilaterally in her axillae. The histopathology of the biopsy of the axillary nodes showed chronic granulomatous inflammation with multiple branching septate fungal hyphae. She received amphotericin B for 21 days but without improvement. Biopsy from the inguinal lesions was sent for histopathology and culture. Results: Histopathology of the biopsy material showed chronic granulomatous inflammatory process with multinucleate giant cells, epithelioid cells, histiocytes, and lymphocytes with multiple branching septate fungal hyphae. Gram stain revealed moderate septate hyphae with numerous pus cells. Culture on Sabouraud dextrose agar yielded velvety olive–black colonies in the fourth week. Microscopic slide examination of culture material was suggestive of Cladophialophora species. The patient was started on voriconazole, which was continued for 6 months, and showed clinical improvement. Conclusion: Incomplete investigation of infectious lesions may delay diagnosis. Furthermore, clinical presentations are greatly influenced by the immune status of the host. Both histopathological and microbiological assessments are equally important for making a conclusive diagnosis. Anti-fungal therapy may delay the growth of fungi that normally grow within a week; thus, a longer incubation time may be warranted for fungal smear-positive samples.

Genes associated as risk factor Morbus Hansen’s disease: A review article

Introduction: Morbus Hansen is a chronic infectious disease caused by the bacteria Mycobacterium leprae and Mycobacterium lepromatosis. Morbus Hansen is still a health problem in endemic areas, such as Africa, Southeast Asia and Latin America. Morbus Hansen (MH) is named after the founder of this disease in the 19th century, a doctor from Norway named Gerhard Henrik Armauer Hansen. An increase in the incidence of Morbus Hansen occurs in people with household contacts with Morbus Hansen sufferers. This manuscript review which gene had a role in morbus Hansen disease. Discussion: Morbus Hansen disease is characterized by a granulomatous inflammatory process in the peripheral nerves and mucosa of the upper respiratory tract and lesions on the skin are the main clinical signs that can be seen. Mycobacterium leprae is intracellular, namely in reticuloendothelial cells, for example macrophages and on peripheral nerves, namely on the Schwan cell. Mycobacterium leprae infection can also attack the eye and testes. Risk factors for the occurrence of Morbus Hansen disease include: living in an endemic area of Morbus Hansen, low socio-economic conditions, such as poor living facilities, contaminated water, poor nutrition, other diseases that can reduce the body’s immune system, contact with morbus Hansen patient’s and gene risk. Several genes have been studied and are associated with individual susceptibility to infection with the bacteria Mycobacterium leprae. Conclusion: Several genes are associated with individual susceptibility to infection with Morbus Hansen Disease. Recent studies have this gene could defects in the cellular immune response more vulrenerable to infection with bacteria Mycobacterium leprae. These defect came from genes that are thought to be associated with Morbus Hansen disease. Furthermore, research studies must confirm these genes.

Tubercúlide papulonecrótica

As tubercúlides são reações de hipersensibilidade cutânea aos antígenos do Mycobacterium tuberculosis. Este é o caso de uma mulher de 45 anos que procurou a Unidade Básica de Saúde (UBS) com um quadro de eritema nodoso com mais de 10 anos de evolução, de etiologia desconhecida, e que evoluía como nódulos em pescoço e membros, que se tornavam úlceras necróticas, cicatrizavam e recidivavam periodicamente. Biópsias das lesões evidenciavam um processo inflamatório granulomatoso com extensa necrose, sugestivo de tuberculose, mas sem a presença do bacilo. Após anos sem tratamento adequado, finalmente levantou-se a hipótese de tubercúlide papulonecrótica. A paciente iniciou tratamento com o esquema básico (2RHZE/4RH) e dessensibilização vacinal, recebendo alta por cura.

New opportunities of computer tomography in diagnostics of pleural lesion in sarcoidosis

Introduction. According to the literature, involvement in the granulomatous inflammatory process of the pleura in thoracic sarcoidosis is an unusual occurrence. The range of occurrence is from 0.08 to 10%, the median is 3%. Most often (70%) pleural sarcoidosis manifests itself as a pleural effusion. For comparison, in the publications of pathologists, pleural involvement in sarcoidosis is observed much more often – in 35% of cases. Computed tomography and, above all, multispiral computed tomography (MSCT), with a wide range of tomographic image post-processing, offers great opportunities for improving the diagnosis of sarcoidosis. Aim . The desire to acquaint with new, diverse, not known to a wide range of radiologists and pulmonologists, a set of symptoms of pleural lesions in sarcoidosis, based on 3D-reformation of tomographic images. Materials and methods .A retrospective study analysis was carried out according to a special protocol to identify pleural pathology in 140 initially verified patients with thoracic sarcoidosis. As a tool for scientific research, the DICOM archive of the Far Eastern Scientific Center of Physiology and Pathology of Respiration from 2013 to 2020 was used, containing the results of MSCT examinations of 490 patients with sarcoidosis (85% morphologically verified), which a total of 1148 studies were performed in dynamics. Results. Pleural changes were detected in 48 of 140 (34.3%) retrospectively analyzed patients. Focal and plaque granulomatous changes in the pleura are predominantly registered. Pleural effusion was found in only two patients. It has been established that the main morphological elements, as is commonly believed (WASOG, Federal Clinical Guidelines for the Diagnosis and Treatment of Sarcoidosis), are not lymphadenopathy without pulmonary pleural changes (50% at stage I), but a combination of enlarged bronchopulmonary lymph nodes, granulomatous changes in the lung parenchyma and pleura (79% in stage II). According to our data, an increase in intrathoracic lymph nodes without pulmonary lesions (stage I) and granulomatous changes without an increase in intrathoracic lymph nodes (stage III) are a rather rare condition (6 and 7%, respectively), which is confirmed by the results of X-ray morphological studies with the maximum use of post-processing. Conclusion . The results of the completed assessment of the prevalence of the combined pulmonary-pleural form of sarcoidosis are more than 10 times (34.3%) higher than the data presented in the scientific literature, and to a greater extent correspond to the results of published pathological studies (35%). A significant correction of the staging of sarcoidosis, reflecting the dominance of the X-ray morphological basic structural elements characterizing thoracic sarcoidosis, was carried out.

ORAL MANIFESTATIONS OF SARCOIDOSIS: A CASE REPORT

Sarcoidosis is a relatively rare, acquired systemic granulomatous disease, affecting multiple organs and tissues. Head and neck lesions of sarcoidosis are manifested in 10% to 15% of patients. Lesions that occur in the soft tissues of the oral cavity and/or in the jaws are rare. We report a case of an 83-year-old female patient with main complaint of an ulcerated lesion located in palate. A biopsy was taken and histopathological sections showed granulomatous inflammatory process. Special stains for Ziehl-Neelsen and Periodic Acid-Schiff and immunohistochemical stain to leishmaniasis were also negative. Patient underwent tuberculosis test, which was negative. A hypothesis of oral sarcoidosis (OS) was defined and the patient is under investigation of laboratory tests to confirm the diagnosis, with erythrocyte sedimentation rate, serum angiotensin converting enzyme, blood calcium, and urine calcium. This case illustrates the importance of a stomatologist to elaborate the correct diagnosis of OS. Sarcoidosis is a relatively rare, acquired systemic granulomatous disease, affecting multiple organs and tissues. Head and neck lesions of sarcoidosis are manifested in 10% to 15% of patients. Lesions that occur in the soft tissues of the oral cavity and/or in the jaws are rare. We report a case of an 83-year-old female patient with main complaint of an ulcerated lesion located in palate. A biopsy was taken and histopathological sections showed granulomatous inflammatory process. Special stains for Ziehl-Neelsen and Periodic Acid-Schiff and immunohistochemical stain to leishmaniasis were also negative. Patient underwent tuberculosis test, which was negative. A hypothesis of oral sarcoidosis (OS) was defined and the patient is under investigation of laboratory tests to confirm the diagnosis, with erythrocyte sedimentation rate, serum angiotensin converting enzyme, blood calcium, and urine calcium. This case illustrates the importance of a stomatologist to elaborate the correct diagnosis of OS.

Necrobiosis Lipoidica Affecting the Leg: What Is the Best Treatment in a Patient with Very High Aesthetic Demand?

Summary:Necrobiosis Lipoidica (NL) is a rare necrotising disorder of the skin characterized by collagen degeneration, thickening of blood vessels, and granulomatous inflammatory process. Its main clinical features are brownish-red papules and yellowish plaques with atrophic central areas. NL affects 0.3% -1.2% of the diabetic population, mostly women (female/male ratio is 3:1). Management of NL is challenging, especially for large lesions refractory to medical therapy, thus requiring surgical excision as an alternative option. Due to the rare occurrence of this condition no treatment guidelines exist and individualized treatment mostly depends on the severity of the lesion, location and patient's expectations. A case of a 30-year-old diabetic woman with very high aesthetic expectations was succesfully treated with staged resections of a giant NL to the leg and reconstruction with dermal template and full thickness skin grafts. Grafts were taken from the groin region bilaterally and from the lower abdomen after a cosmetic mini-abdominoplasty procedure. This approach allowed for a stable and very satisfactory aesthetic result with no donor site exposed scars.

Tuberculous Empyema: VATS Findings

A 58-year-old male patient was admitted with suspected tuberculous empyema. Due to an unfavorable clinical evolution, a thoracoscopic pleural biopsy was performed to achieve an etiological diagnosis after 6 days of hospitalization. VATS findings showing the bride’s veil or Mya’s sign helped to confirm the diagnosis, ruling out other causes. Although all the cultures were negative, the pathological study of the pleural biopsy confirmed the presence of a tuberculoid granulomatous inflammatory process. Hospital discharge occurred 4 days later. Thoracoscopic pleural biopsy is useful in the diagnosis of tuberculosis, especially when the clinical manifestations are uncertain. VATS improves drainage of the pleural space when tuberculous empyema is suspected.

Chylothorax with Transudate: An Unusual Presentation of Tuberculosis.

IntroductionTwenty-five per cent of tuberculosis patients have pleural tuberculosis, which is the third most common form of presentation. Most cases present as an exudative pleural effusion with just few cases reported as chylothorax in the literature. All pleural effusions from confirmed cases, including tuberculous chylothorax, had exudate features.AimTo describe a patient with Mycobacterium tuberculosis affecting the lungs and pleura, which laboratory testing demonstrated had features of transudate chylothorax.Patient and methodsA 70-year-old man presented with constitutional symptoms, progressive exertional dyspnoea and right pleural effusion with fibrocavitary changes on chest imaging. Thoracentesis and pleural fluid analysis revealed chylous fluid with transudate features, high triglycerides, low cholesterol content and mononuclear cell predominance. Acid-fast sputum stains and pleural fluid were negative for Mycobacterium tuberculosis as was an adenosine deaminase test for pleural effusion. Tomography-directed lung biopsy sampling of a lung nodule revealed a chronic granulomatous inflammatory process associated with the presence of acid-fast bacilli.DiscussionTuberculosis-associated chylothorax is an uncommon presentation of the disease. A recent review found only 37 cases of confirmed tuberculous chylothorax had been reported in the literature. All cases had exudate characteristics. The diagnosis of pleural tuberculosis was made through culture or testing of sputum, pleural fluid or biopsy samples in 72.2% of cases, with the rest identified by histopathology.LEARNING POINTSThe main cause of non-traumatic chylothorax is malignancy, which is found in 39–72% of cases.Few cases of transudative chylothorax have been reported in the literature; the main aetiology is chronic hepatopathy.Tuberculosis-associated chylothorax is a rare presentation of infection caused by Mycobacterium tuberculosis, an uncommon aetiology.