Langhans Giant Cells Research Articles

Disseminated intraparenchymal microgranulomas in the brainstem in central nervous system sarcoidosis

We report a 70-year-old woman with sarcoidosis and multiple cranial nerve palsy. The patient suffered from dysarthria, dysphagia and weakness of the upper and lower extremities and died of sepsis. No abnormalities were noted in brain MRI. At autopsy, numerous epithelioid granulomas with Langhans giant cells were present in the bilateral lungs, including the hilar lymph nodes. The brain had a normal external appearance. Histologically, there were brainstem parenchymal lesions consisting of many microgranulomas, lymphocytic infiltration, activated microglias and astrocytosis. Perivascular lympocytic cuffing was also seen. Neither granulomas nor lymphocytic infiltration were seen in the leptomeninges. The present case was considered to be a peculiar type of neurosarcoidosis, that is, "sarcoid brainstem encephalitis".

OP17. PATHOLOGIC FEATURES OF TAKAYASU'S ARTERITIS (NON SPECIFIC AORTOARTERITIS)

Takayasu's arteritis or Non-specific aortoarteritis (NSAA) is an uncommon form of large vessel vasculitis and has been known by various names. The morbid anatomical features of NSAA described here are based on the autopsy findings of 80 cases seen in a 30-year period. These autopsies were carried out at Seth GS Medical College & KEM hospital, Mumbai. With an active autopsy service, the incidence of NSAA is about 0.15%. 46.25% of these cases were in the pediatric age group. In the aorta the disease had 2 patterns of involvement: (a) Segmental lesions either single or multiple, with skip areas in between. (b) Diffuse extensive disease. Marked periadventitial and adventitial fibrous thickening with adhesions to neighboring structures with enlarged lymph nodes is often noted around the involved segments. The aorta is stiff and rigid, sometimes with dilated segments and aneurysms. Localised stenotic lesions is fairly common (37.5%), seen particularly in children and is noted in the descending thoracic (DTA) and abdominal aorta. In our material the DTA is the segment maximally affected. The lesion starts at the level of L subclavian or just beyond it to involve variable lengths of DTA. Abdominal aorta (renal artery segment) disease is more common in adults. This is often associated with renal artery stenosis. In diffuse disease the thoracic abdominal aorta is affected, sparing the ascending aorta. In autopsy material, isolated arch vessel disease is rare. When arch vessel is diseased, it involves mainly the L Subclavian and there is always associated aortic arch disease. Arch vessel disease is in the form of complete block or osteal narrowing with occlusive luminal thrombi. Coronary osteal stenosis is not uncommon. The intimal surface of the aorta is covered with gelatinous or whitish plaques or is diffusely thickened. Mural thrombi are sometimes present in the constricted segment. Histopathological features: Inflammation may be in the active or more commonly in the chronic healed phase. In the active phase, diffuse or granulomatous inflammation is seen consisting of Langhans giant cells, foreign body giant cells, mixed inflammatory cells and sometimes-fibrinoid necrosis. Inflammatory reaction is maximal at the junction of the media and adventitia and is marked around vasavasorum though there is no vasculitis. Adventitia shows increase in ground substance with acid mucopolysaccharides. Media shows neovascularization and inflammatory cells. Intima is thickened with increase in ground substance. There is no intimitis. In chronic phase there is sparse inflammation around vasavasorum, adventitial thickening, fibrosis, scarring in the media, disruption of elastic fibres and hyaline intimal thickening. Pulmonary artery and coronary artery involvement is infrequent. The commonest associated pathology noted at autopsy is tuberculous lymphadenitis (55%). Matted enlarged Para aortic and mediastinal lymph nodes are particularly present around the involved segments of aorta. It is not easy to reconstruct the natural course of the disease. Symptoms are related to well establish lesions in the aorta or its branches. The inflammatory process may be self limiting in most cases. Regression of lesions has been documented in a few case reports. Prognosis is influenced by clinical course, age of onset and complications like hypertension, rapid development of congestive cardiac failure, and left ventricular failure. As of today there is no specific disease activity marker and treatment should be aimed at preventing vital organ ischemia and cardiac failure.

Scar sarcoidosis after hyaluronic acid injection

A 54-year-old woman presented with a 5-month history of tender nodules in both nasolabial folds that had developed 4 months after the injection of hyaluronic acid (HA) (Restylane) for wrinkles. The patient was treated with 1.5 mg/day betamethasone for 6 days and her lesions disappeared within 1 week. About 8 days after stopping therapy, however, new nodules developed at the same site, on previously healthy buttocks, and on old scars. On examination, nodules of about 0.5-1 cm in size were palpable at the nasolabial folds, and red nodules were present on the buttocks (Fig. 1) and on two old scars. Laboratory tests disclosed an increased protein C reaction (7.9 mg/L; normal value, < 5 mg/L) and acetyl-converting enzyme test (14.5 U/L; normal value, < 9 U/L). A chest X-ray was normal. Lung function tests showed a decreased lung CO diffusion, and chest axial tomography disclosed fibrosis, increased parenchyma density, and calcifications, findings suggestive of a diagnosis of lung sarcoidosis. An X-ray of the hands showed some bone cysts. Interestingly, two granulomatous lesions were observed at the sites of venipuncture. Histology of a gluteal lesion biopsy showed a deep granuloma with epithelioid and Langhans cells in the absence of necrobiosis. Sarcoidosis was diagnosed and the patient was given 50 mg/day prednisone with clear clinical improvement of cutaneous lesions in about 6 months. Decreased parenchyma density was also observed by chest axial tomography.

子宮内膜細胞診が診断の手掛かりとなった結核性子宮内膜炎の１例

We report a case of a 77-year-old woman with endometrial tuberculosis who had to abnormal changes in cervical or endocervical cytology. Endometrial cytological findings showed a number of epithelioid cell clusters with a few Langhans giant cells. A histological examination of the endometrium indicated chronic granulomatous inflammatory disease involving epithelioid cells, Langhans giant cellsand lymphocytes suggestive of tuberculosis. Culture and mycobacterium tuberculosis DNA tests (PCR assay) were positive. Endometrial cytology is thus a useful tool for diagnosing endometrial tuberculosis.

Leprous osteitis presenting as bone cyst and erosions

A 30-year-old man presented to the Hansen outpatient department with swelling and ulceration of toes for 2 months and swelling of the right fifth and fourth fingers and the left second finger for 1 month. In addition to skin lesions of lepromatous leprosy (subpolar type), there was nontender, non-fluctuant swelling of the right fifth and fourth fingers and left second finger. Skin over the right fifth finger showed sinus-like openings with associated purulent discharge. He also had swelling and ulceration of second left toe. Slit-skin smear (SSS) showed a bacterial index of 6+ from the ear lobes and cutaneous nodules, 4+ from the patch, and 3+ from normal skin. Modified Ziehl-Neelsen staining of the discharge extruding from the sinuses on the right fifth finger also showed abundant acid-fast bacilli. Radiography of the hands and feet showed lytic lesions in the distal epimetaphyseal region o proximal phalanx of the right fifth finger and left second finger and erosion of distal end of proximal phalanges of both second toes. Histopathological examination of biopsy specimen from the patch (back) showed features of lepromatous leprosy, and Fite-Faraco stain for tissue acid-fast bacteria (AFB) was strongly positive. Fine-needle-aspiration cytology (FNAC) from the lytic lesion in the bone also showed predominantly foamy macrophages with strongly positive staining for AFB with a few interspersed lymphocytes, epithelioid cells and Langhans giant cells. On the basis of these features, a clinical diagnosis of subpolar lepromatous leprosy with leprous osteitis was made. In today's clinical era of improved case detection and prompt treatment with effective multidrug regimens, advanced bone changes are rarely encountered. We describe this case of lepromatous leprosy that developed cavitating lesions of the phalanges of the hand, seen on x-ray as well-defined bone cyst and erosions.

Nasopharyngeal granulomatous inflammation and tuberculosis complicating undifferentiated carcinoma

Objective Four cases of nasopharyngeal granulomatous inflammation after radiotherapy for undifferentiated carcinoma were analyzed for tuberculosis, and the histologic features were compared. Study design and setting We conducted a retrospective study with analysis of tuberculosis by Ziehl Neelsen staining and polymerase chain reaction analysis for Mycobacterium tuberculosis DNA on histologic materials. Results Three patients had previous nasopharyngeal undifferentiated carcinoma, one had previous metastatic undifferentiated carcinoma to cervical lymph nodes, and all patients received similar radiotherapy regimen. The light microscopic features were similar with epithelioid histiocytes and granulomas with Langhan's giant cells. In 3 cases, acid-fast bacilli were identified by Ziehl Neelsen stain, and 1 was negative. The results of 2 cases were confirmed by polymerase chain reaction analysis for Myocbacterium tuberculosis DNA. Conclusion Granulomatous reaction after radiotherapy of nasopharyngeal undifferentiated carcinoma can be caused by tuberculosis. Significance Diligent search for organisms in postirradiation granulomatous inflammation is warranted to avoid missing an occult tuberculosis infection.

Clinical and epidemiological observations of cutaneous tuberculosis in Larkana, Pakistan.

Cutaneous tuberculosis is widespread in Pakistan but has not been fully documented. This study was conducted to determine the clinical pattern, nature and existence of the disease in Larkana, Sindh province, Pakistan. We are reporting 153 cases of patients with cutaneous tuberculosis who visited our department from 1996 to 1999. All cases were diagnosed at the clinic, and the biopsies were examined for histopathological evidence. The patients received three antituberculous treatments during a 9 month course. Clinically, 63 (41.2%) cases of lupus vulgaris, 54 (35.3%) of scrofuloderma, 29 (19.59%) of lupus verrucosa cutis, six (3.92%) of tuberculosis cutis orificialis and one (0.64%) case of disseminated cutaneous tuberculosis were observed in our department from 1996 to 1999. All patients were aged between 3 and 50 years and had experienced the present complaints for 1 to 12 years. Sixty-nine (45.1%) cases were children aged under 10 years, 50 cases (37.25%) were aged between 10 and 20 years, and 27 cases (17.65%) were aged over 20 years. There was no considerable ratio difference of the disease between male and female patients. Histopathologically, all the specimens showed chronic granulomatous changes; the majority was infiltrated with epitheloid cells, langhans giant cells, plasma cells and other inflammatory cells, such as lymphocytes, eosinophils and neutrophils in ulcerated lesions. Increased numbers of mast cells were seen in upper and lower dermis in two-thirds of the specimens. Caseating necrosis was visible in half of the specimens while Ziehl-Neelsen stain was negative in all the sections. The observed number of patients was moderately large, thus indicating a high incidence of cutaneous tuberculosis in Larkana. Lupus vulgaris, a form of cutaneous tuberculosis, was widespread in this area and prevalent in adults, while scrofuloderma was prevalent in children. Moreover, the existing rate of the disease was higher in children aged under 10 years and lower in adults. This indicates that children are more prone to this disease than adults.

Mycobacterium bovis Infection in a Farmed Elk in Korea

A case of tuberculosis is reported in an eight-year-old, male, elk (Cervus elaphus nelsoni). The elk showed severe coughing, respiratory distress, abdominal breathing, anorexia, and severe progressive emaciation in the elk farm. At necropsy, the elk appeared in poor body condition. Mild enlargement of retropharyngeal and submandibular lymph node was observed in the head. Diffuse fibrinous pleuritis and purple red lobar pneumonia were found in the thorax. Well demarcated numerous dark yellow discrete or confluent nodules from 0.3 to 2 cm in diameter were scattered in the whole lung. Bronchial and mediastinal lymph nodes were also enlarged. Histopathologically, lungs had typical classical tuberculous granulomas, multiple abscesses, and numerous macrophages and Langhans giant cells infiltration in alveolar lumen. In the lymph nodes, there were small clusters of necrosis and infiltration of numerous macrophages, epithelioid cells, and Langhans giant cells. With the acid-fast staining, numerous mycobacteria were revealed in the lung and lymph nodes. According to this study, there are differences of the histopathologic lesions and the numbers of acid-fast bacilli in the lesions between this elk and cattle. Mycobacterium bovis was confirmed as a causative agent in this elk using bacterial isolation, biochemical characteristics, and PCR technique. The isolate was negative for niacin test, nitrate reductase, and pyrazinamidase. This is a first report for bovine tuberculosis of farmed elk in Asia.

High-level expression of NRAMP1 in peripheral blood cells and tuberculous granulomas from Mycobacterium bovis-infected bovines.

By Western blotting, we demonstrate high-level expression of NRAMP1 proteins in peripheral blood cells and granulomas of Mycobacterium bovis-infected bovines. Immunohistochemistry of granulomatous lesions showed heavily labeled epithelioid macrophages and Langhans cells. These data suggest that M. bovis infection enhances NRAMP1 expression and that active tuberculosis can occur despite this response.

A critical examination of adrenal tuberculosis and a 28-year autopsy experience of active tuberculosis.

Tuberculosis is potentially fatal and adrenal gland involvement is uncommonly reported. The aims of the current study were to define the characteristics of tuberculosis in hospitalized patients and to analyse the features of adrenal tuberculosis. Retrospective analysis of autopsies and adrenalectomies. 13,762 patients (13492 at autopsies and 270 at adrenalectomy). The presence of active tuberculosis, the predisposing factors, the pathological features and organs of involvement were examined. Active tuberculosis was present in 871 patients (6.5% of all 13492 autopsies). It was first diagnosed in 70% of these patients during autopsy. Cancers and a history of recent major operations were the 2 main concomitant factors in the patients with tuberculosis. Extra-pulmonary tuberculosis was seen in 261 patients (30%). The five most common extra-pulmonary sites of tuberculosis were the liver, spleen, kidney, bone and adrenal gland. Adrenal tuberculosis was seen in 52 of the 871 patients (6%) with active tuberculosis at autopsy and in 3 patients at adrenalectomy. The adrenal gland was the only organ involved by active tuberculosis in 14 of these 55 patients (25%; 35 men, 20 women). Tuberculosis was evident on macroscopic examination of the adrenal glands in 46% of the patients. On histological examination, caseous necrosis and granulomatous inflammation with Langhan's giant cells were seen in 71% and 40% of patients, respectively. Seven patients presented with signs and symptoms of Addison's disease due to bilateral adrenal involvement. Langhan's giant cells were frequently seen in histological sections and bilateral enlargement of the adrenal glands was often noted. Fine needle aspiration cytology was not useful for diagnosing adrenal tuberculosis. Unexpected and extra-pulmonary tuberculosis such as adrenal tuberculosis has been a common problem. A high index of suspicion, correct diagnosis and proper treatment are essential for the management of tuberculosis.

A Clinical Study of Malignant Head and Neck Tumors in Juvenile Patients

Twenty patients under 20 years old age with malignant head and neck tumors were treated at Kurume University Hospital between 1979 and 1998. There were eight males and twelve females and the mean age was 14 years old. Histologically, rhabdomyosarcoma and papillary carcinoma were observed in 5 patients, squamous cell carcinoma in 4 patients, neuroblastoma and malignant lymphoma in 2 patients, and Langhans cell histiocytoma and leiomyosarcoma in 1 patient. Their 5-year survival rate was 82.6%. Team practice is required to treat juvenile patients with malignant head and neck tumors.

A Case of Tuberculous Uveitis Complicated by Myelodysplastic Syndrome

Background: Recently, the incidence of tuberculosis in compromised hosts has increased. Case: A 52-year-old man suffering from myelodysplastic syndrome (MDS) had pulmonary tuberculosis. On June 22, 1996, we found a disc-sized choroidal lesion with milky appearance on the paramacular in his right eye. After 1 month, a similar choroidal lesion was found near the disc in the same eye. In spite of chemotherapy for MDS and antituberculosis medications, those choroidal lesions gradually enlarged. In November, satellite lesions were found around them. Some retinal exudates and hemorrhage were also detected in both eyes. He died on April 6, 1997. We found Langhan's giant cells in the choroid on the specimen of his eyes. So we judged the choroidal lesions to be tuberculous uveitis. Conclusion: This case showed choroidal tuberculosis and choroidal miliary tuberculosis in the same eye that were resistant to medications. We thought resistance to medication was due to destruction of the immune system by MDS.

Generalized tuberculosis in the acquired immune deficiency syndrome: A clinicopathologic analysis based on autopsy findings

○ Objective.-Generalized, or hematogenously disseminated, tuberculosis (TB) in patients with the acquired immune deficiency syndrome (AIDS) has been associated with a high incidence of cases remaining undiagnosed until postmortem. To better characterize generalized TB in the setting of AIDS, this report describes the clinical, laboratory, radiologic, and pathologic features of 20 fatal cases. Design.-The medical records, autopsy protocols, and histologic material from patients with AIDS and concomitant TB were reviewed. All patients were autopsied at a tertiary care medical center during the years 1985-1997. Results.-In 50% of our 20 cases, diagnosis was not made until postmortem. Signs and symptoms were few, including the absence of fever (temperature ≥38°C) in 55% of patients. Consistent laboratory abnormalities of a nonspecific nature were limited to hyponatremia (sodium <135 mmol/L) in 60%. Both peripheral and deep (thoracic and abdominal) lymphadenopathy, unusual in adults with TB, occurred in 45% and 95% of cases, respectively. In contrast to previous reports, all of the 6 cases of tuberculous meningitis presented as acute meningitis with a predominance of neutrophils in cerebrospinal fluid. Necrotizing encephalitis with extension of the acute inflammation into the superficial cortex was seen in all cases and tuberculous brain abscesses occurred in 50% of cases, a higher frequency than previously reported. Despite lung involvement in 90% of the cases, 33% of chest radiographs were interpreted as normal and disseminated mycobacterial disease was not suggested in the radiograph report in any of the other cases. Soft tissue abscesses in uncharacteristic locations such as the neck, mediastinum, and perirectal area occurred in these patients. Histologically, 95% of organs sampled showed inflammatory foci characterized by extensive necrosis with numerous neutrophils and/or karyorrhectic debris, numerous acid-fast bacilli, few or no ep. ithelioid histiocytes, and no Langhans giant cells. Conclusion.-Clinically and pathologically, generalized TB in the setting of AIDS is characterized by either unusual features or a lack of the typical features described for generalized TB in patients who do not have AIDS. This absence of classic features contributes to the high incidence of cases that remain undiagnosed until postmortem examination.

Generalized Tuberculosis in the Acquired Immune Deficiency Syndrome

Generalized, or hematogenously disseminated, tuberculosis (TB) in patients with the acquired immune deficiency syndrome (AIDS) has been associated with a high incidence of cases remaining undiagnosed until postmortem. To better characterize generalized TB in the setting of AIDS, this report describes the clinical, laboratory, radiologic, and pathologic features of 20 fatal cases. The medical records, autopsy protocols, and histologic material from patients with AIDS and concomitant TB were reviewed. All patients were autopsied at a tertiary care medical center during the years 1985-1997. In 50% of our 20 cases, diagnosis was not made until postmortem. Signs and symptoms were few, including the absence of fever (temperature > or = 38 degrees C) in 55% of patients. Consistent laboratory abnormalities of a nonspecific nature were limited to hyponatremia (sodium <135 mmol/L) in 60%. Both peripheral and deep (thoracic and abdominal) lymphadenopathy, unusual in adults with TB, occurred in 45% and 95% of cases, respectively. In contrast to previous reports, all of the 6 cases of tuberculous meningitis presented as acute meningitis with a predominance of neutrophils in cerebrospinal fluid. Necrotizing encephalitis with extension of the acute inflammation into the superficial cortex was seen in all cases and tuberculous brain abscesses occurred in 50% of cases, a higher frequency than previously reported. Despite lung involvement in 90% of the cases, 33% of chest radiographs were interpreted as normal and disseminated mycobacterial disease was not suggested in the radiograph report in any of the other cases. Soft tissue abscesses in uncharacteristic locations such as the neck, mediastinum, and perirectal area occurred in these patients. Histologically, 95% of organs sampled showed inflammatory foci characterized by extensive necrosis with numerous neutrophils and/or karyorrhectic debris, numerous acid-fast bacilli, few or no epithelioid histiocytes, and no Langhans giant cells. Clinically and pathologically, generalized TB in the setting of AIDS is characterized by either unusual features or a lack of the typical features described for generalized TB in patients who do not have AIDS. This absence of classic features contributes to the high incidence of cases that remain undiagnosed until postmortem examination.

Sarcoidosis presenting with facial palsy and uveitis

A 43-year-old woman presented with peripheral facial palsy and bilateral anterior uveitis. The diagnosis of sarcoidosis was established by an elevated serum angiotensin-converting enzyme level, hilar adenopathy on chest x-ray film, restrictive ventilatory impairment on pulmonary function testing, and a transbronchial biopsy specimen showing noncaseating epithelioid granulomas with Langhans giant cells. A complete ophthalmic examination is important in patients with peripheral facial palsies to search for signs of systemic disease.

Inoculation of Lacazia loboi into the subcutaneous tissue of the hamster cheek pouch

The subcutaneous tissue of the hamster cheek pouch, a site of immunologic privilege, has been used to investigate the potential infectivity of different types of parasites. It has been demonstrated that the implantation of fragments of lesions induced by the fungus Lacazia loboi, the etiologic agent of Jorge Lobo's disease, into the subcutaneous tissue of the hamster cheek pouch resulted in parasite multiplication and dissemination to satellite lymph nodes16. Here we describe the evolution of lesions induced by the inoculation of the isolated fungus into this immunologically privileged site. The morphology of the inflammatory response and fungal viability and proliferation were evaluated. Inoculation of the fungus into the cheek pouch induced histiocytic granulomas with rare lymphocytes. Although fungal cells were detected for a period of up to 180 days in these lesions, the fungi lost viability after the first day of inoculation. In contrast, when the parasite was inoculated into the footpad, non-organized histiocytic lesions were observed. Langhan's giant cells, lymphocytes and fungal particles were observed in these lesions. Fungal viability was observed up to 60 days after inoculation and non-viable parasites were present in the persistent lesions up to 180 days post-inoculation. These data indicate that the subcutaneous tissue of the hamster cheek pouch is not a suitable site for the proliferation of Lacazia loboi when the fungus isolated from human tissues is tested.

Pathologic findings for bacille Calmette-Guérin infections in immunocompetent and immunocompromised patients.

The pathologic findings from biopsy specimens from 9 patients with postvaccination bacille Calmette-Guérin (BCG) infection are presented. The patients were vaccinated with BCG during the first 2 days of life. Four patients had normal immunity and 5 patients were immunocompromised. The pathologic findings in both groups were different. Biopsy specimens from patients with normal immunity showed multiple epithelioid granulomas and Langhans giant cells with or without suppuration. Caseous necrosis was minimal. Ziehl-Neelsen stain for acid-fast bacilli showed a few bacilli in 2 cases and was negative in the remaining 2 cases. Biopsy specimens from the second group of patients, who were immunosuppressed, consisted mainly of skin and subcutaneous tissue. These revealed diffuse infiltrates of histiocytes with plump nuclei and abundant "dirty" grayish cytoplasm, which was full of numerous acid-fast bacilli. The clinical course for the 2 groups also was different. Patients with normal immunity generally recover completely, spontaneously or after excision of the suppurative lymph node and usually do not require antibiotic chemotherapy. In immunosuppressed patients, disseminated BCG infection, which may prove fatal, may develop. These patients should receive a full course of antituberculous chemotherapy and, in addition, treatment of the underlying immunologic disorder.

Fatty acid synthase is expressed mainly in adult hormone-sensitive cells or cells with high lipid metabolism and in proliferating fetal cells.

Animal fatty acid synthase (FAS) is a homodimer protein which synthesizes long-chain fatty acids and is rich in liver, brain, breast, and lung. However, the precise cellular localization of FAS in human tissues has not been elucidated. Immunohistochemistry with a new antibody to human FAS revealed that in adult human tissues FAS is distributed mainly in cells with high lipid metabolism (adipocytes, corpus luteum, hepatocytes, sebaceous glands, and Type II alveolar cells), in hormone-sensitive cells (anterior pituitary, apocrine gland, breast, endometrium, prostate, seminal vesicle, and adrenal cortex), and in a subset of epithelial cells of duodenum and stomach, colon absorptive cells, cerebral neurons, basket cells of cerebellum, decidua, uroepithelium, and epidymis. In fetal cells at 20 weeks of gestation, FAS was mainly present in proliferative epithelial cells of the digestive and respiratory systems, proximal renal tubules, adrenocortical cells, and mesenchymal and hematolymphoid cells. Staining was significant in nonproliferating cells, as observed in adult, and in sympathetic ganglion cells, Leidig cells of testis, and Langhans cells of chorionic villi. FAS is maintained in hormone-sensitive cells and/or cells active in lipid metabolism in the adult and is expressed in proliferating cells in the fetus, suggesting active fatty acid synthesis for energy utilization or membrane lipids.

A CASE OF COLD ABSCESS OF THE BREAST DUE TO BONE TUBERCULOSIS

A 69-year-old woman was admitted to our hospital because of a tumor in her right breast measuring 8.0×8.0cm without enlargement of axillary lymph nodes. A homogeneous tumor shadow was seen on the mammogram and an ultrasonogram showed a mosaic pattern, thickened walls and high back echo of the tumor. Chest roentgenogram revealed pleural effusion in the right lung and a CT of the chest showed destruction of the ribs. Since malignancy was present, partial mastectomy of the right breast including resection of the 6th and 7th ribs was performed. The pathology of the biopsy reported tuberculosis, based on the observation of epithelioid granulation, Langhans giant cells and tuberculous necrotic tissues. Oral antituberculosis regimen with isonicotinic acid hydrazide, rifanpicin and etambtol was started. It is important that physicians bear in mind the possible presence of tuberculosis when checking for breast tumors.

Lupus vulgaris complicated by metastatic squamous cell carcinoma

A 47-year-old Bedouin man presented with an ulcerated nodule of several months' duration on the nape of the neck. The nodule developed on an asymptomatic, slowly growing plaque which appeared during childhood. Physical examination revealed two erythematous plaques covering the posterior and right lateral aspects of the neck. The border of the plaques was soft, circinate, with a reddish-brown color, while the center was slightly erythematous and atrophic. An ulcerated nodule measuring 2 cm was seen on one of the plaques. Physical examination was unremarkable with no lymphadenopathy. Laboratory tests, including complete blood cell count, erythrocyte sedimentation rate (ESR), and routine chemistry tests, were all within normal limits. Chest X-ray showed a small calcified perihilar lymph node. The Mantoux test was positive with erythema and induration of 15 mm after 48 h. Biopsy from a plaque showed extensive diffuse granulomatous infiltration throughout the dermis with epithelioid and Langhans giant cells surrounded by mononuclear inflammatory cells. No caseation necrosis was present. Ziehl-Neelsen, periodic acid-Schiff (PAS), and Giemsa stains were negative. Polymerase chain reaction (PCR) for the detection of Mycobacterium tuberculosis and atypical mycobacteria from a skin sample was also negative. Fresh tissue cultures yielded M. tuberculosis after 6 weeks. A biopsy specimen from the ulcerated nodule demonstrated islands of atypical malignant squamous cells invading the dermis, which were compatible with moderately differentiated squamous cell carcinoma (SCC). The ulcerated nodule was completely excised, and treatment for tuberculosis was initiated with a combination of isoniazid, rifampicin, and pyrazinamide. Within 3 months of therapy, the patient's lesions resolved, leaving only slightly atrophic hypopigmented scars. A month after the treatment's initiation, an enlarged cervical lymph node was noted showing metastatic SCC on histologic examination. The patient underwent neck dissection and radiation therapy without evidence of any further metastases.