Multiple Epithelioid Granulomas Research Articles

Bacillus Calmette-Guérin Adenitis: An Intriguing Series of Four Cases

Bacille Calmette-Guérin (BCG) vaccine is part of the immunisation schedule in India. It is a live-attenuated vaccine with very few adverse reactions, one of which is BCG adenitis. The intriguing fact is that there has been a sudden upsurge in the number of BCG adenitis cases (two males and two female children), with four reported cases within three months (March 2023-June 2023). There were two male and two female children, aged between 2-8 months. All of them presented with left axillary swelling, and all but one had low grade fever only in the initial days. They all had a healed BCG vaccination scar on their left arm. Fine Needle Aspiration Cytology (FNAC) showed multiple epithelioid granulomas and, in some cases, frank caseation necrosis with the demonstration of tubercle bacilli using either Ziehl-Neelsen (Z-N) stain or Cartridge-based Nucleic Acid Amplification Test (CBNAAT). These cases mostly benefited from pus aspiration from the swelling site, with no definite role for oral antibiotics. Proper training of nursing or paramedical staff regarding vaccination technique and dosage, proper maternal and child healthcare, early detection of these cases with a high index of suspicion, as well as adequate knowledge of the treating doctors and parents/caregivers, may help in prompt management of these cases in future occurrences.

An interesting case of tonsillar tuberculosis in a 10-year-old boy

Tuberculosis of the tonsils is a rare type of extra pulmonary tuberculosis. The secondary form is more common than the primary, usually caused by the contact with the infected sputum or saliva from a sputum smear positive case of tuberculosis. We report a primary form of tonsillar tuberculosis in 10-year-old boy, with no remote history suggestive of documented pulmonary tuberculosis. Local examination revealed Grade IV tonsillar hypertrophy and congestion of posterior pharyngeal wall. Management included, Coblation assisted adenotonsillectomy under general anaesthesia. Histopathological examination revealed features suggestive of chronic adenotonsillitis, multiple epithelioid granulomas with caseous necrosis, langhans type of giant cells with scant inflammatory infiltrate in the background.

An unusual pseudoneoplasm: mass-forming tuberculosis infection mimicking rectal carcinoma

A rare case of primary rectal tuberculosis presented as a rectal mass, indistinguishable clinically and radiologically from advanced rectal carcinoma . Histology failed at first to identify granulomas, acid fast bacilli, or malignancy, but subsequent biopsies showed multiple epithelioid granulomas with caseating necrosis and Langhans giant cells. Given these findings and the high regional incidence of tuberculosis, presumptive diagnosis was given and anti-tubercular drugs were initiated followed by resolution of the mass and symptoms.

Erythema induratum: a rare case with unusual presentation

Tuberculosis, still one of the most common infectious diseases globally, manifests primarily as pulmonary tuberculosis. Extra-pulmonary tuberculosis can occur in other sites including skin. Cutaneous tuberculosis, comprising merely 1-2% of all forms of tuberculosis, has been classified into various morphological variants. One of the morphological variants of cutaneous tuberculosis is erythema induratum, a tuberculid, which is caused by hematogenous spread of tuberculosis, the pathogenesis of which is due to hypersensitive reaction against the mycobacterial antigens. The skin biopsy findings of erythema induratum are characterized by panniculitis with formation of non-caseating epithelioid granulomas with no mycobacteria detected in the lesions, though mycobacterial antigens or DNA could be detected by polymerase chain reaction (PCR). In this context, being presented here is a case of erythema induratum which is rare and unusual in its presentation inasmuch as caseating epithelioid granulomas were seen in the lesional skin biopsy along with detection of acid-fast bacilli. In our study a 57-year-old male presented to the Dermatology OPD with multiple erythematous lesions bilaterally over the groin and thigh regions. Clinically the lesions were considered to be equivocally suggestive of migratory erythema or erythema marginatum. The skin biopsy taken from the lesions revealed multiple epithelioid granulomas in the dermis with central areas of caseation necrosis. Sections stained with Ziehl-Neelsen stain showed the presence of occasional acid-fast bacilli. Erythema induratum, a rare tuberculid form of cutaneous tuberculosis, which is pathogenetically considered to be occurring as a result of hypersensitivity reaction against mycobacterial antigens with characteristic absence of tubercle bacilli. In the case presented here erythema induratum presents in a rare unusual manner as a caseating granulomatous lesion with presence of demonstrable acid-fast bacilli.

Isolated muscular tuberculosis: unusual location of the Koch bacillus.

A 23-year-old female patient with a family history of pulmonary tuberculosis and tuberculous spondylodiscitis was hospitalized for swelling of the left anterior-external surface of the left thigh, (A) with altered general status. Biology has shown a biological inflammatory syndrome. The ultrasound showed a collection opposite the great trochanter fusing towards the lodge of the gluteus muscle and forward towards the terminal part of the common chief ischio-psoas. MRI of the hips revealed an intra-muscular collection of the antero-lateral side of the thigh root, taking contrast in the periphery, involving the quadriceps muscle and tensor of facia lata, (B and C). The biopsy of the collection under ultrasound guidance brought back 30 cc of casein. The diagnosis of tuberculosis of the quadriceps muscle and tensor of the facia lata was based on the positivity of the tuberculin skin test, (D), the positivity of the PCR for Mycobacterium tuberculosis in the puncture fluid and histology showing multiple epithelioid granulomas centered by caseous necrosis. There were no other tuberculous sites. The patient was treated with antituberculosis drugs for 12 months with good progress. Muscular tuberculosis (MT) is a rare localization of the disease (0.01 to 2%). Its occurrence without associated bone involvement is exceptional. MT often simulates a muscular tumor. MRI contributes to the improvement of the sensitivity of the diagnosis of MT because it allows to specify the extent of the muscular lesions and to orient the site of the muscular biopsy. The diagnosis is essentially based on histology.

Anatomopatologia de bursite cervical (oncocercose) encontrada em bovinos abatidos sob inspeção estadual no estado do Rio de Janeiro

A patologia descritiva das lesões em animais domésticos de açougue permite enriquecer a literatura médica veterinária especializada em inspeção sanitária de carnes, assim como subsidiar tecnicamente os profissionais inspetores. A oncocercose é uma parasitose causada pelo nematódeo Onchocerca sp,, sendo que a espécie O. gutturosa é a que mais acomete bovinos na América do Sul. Foram avaliados, pelo exame anatomopatológico, dois casos de lesões localizadas no ligamento nucal de bovinos abatidos para o consumo. A macroscopia de um caso revelou bursite crônica, representada por grande quantidade de líquido citrino e viscoso e, ainda, muitos corpúsculos livres, elípticos e achatados desprovidos de raiz (arrizo). A microscopia dessas estruturas evidenciou moldes de fibrinas amorfos e eosinofílicos. O segundo caso foi caracterizado por bursite aguda, e a microscopia das lesões ligamentar e periligamentar revelou granulomas epitelioides com reação gigantocitária, centralizados por formações semelhantes ao Onchocerca sp.

Ognisko gruźlicy w obrębie guza Warthina ślinianki przyusznej

Summary Introduction Warthin's tumor is the second most common neoplasm of major salivary glands, whereas tuberculosis is a rare entity within parotid gland. Mycobacteria may reach stroma of the gland from saliva (through lymphatic vessels and salivary ducts). The infection might spread from primary origin in lungs as well. Inflammatory changes within adenolymphoma are well documented. Patey and Thackray suggested that fluid component of cysts within Warthin's tumor may be the culture medium for pathogens. There are very few documented cases of coexistence of adenolymphoma and tuberculosis within parotid gland. Case presentation 74-year-old female with a tumor of left mandibular angle was admitted to ENT Clinic of Medical University of Silesia. The patient underwent superficial parotidectomy. Tissue specimens revealed features of adenolymphoma and multiple epithelioid granulomas with caseation. She received antimycobacterial treatment. Conclusions The case of coexistence of adenolymphoma and tuberculosis within parotid gland mentioned in this work is the first documented in Poland.

5q Minus Myelodysplasia Associated with Multiple Epithelioid Granulomas within Conventional Renal Cell Carcinoma

A 69-year-old Caucasian female, with a previous diagnosis of 5q minus myelodysplastic syndrome, presented with conventional renal cell carcinoma (RCC) associated with multiple-epithelioid nonnecrotizing granulomas. Two previous reports of sarcoidosis, primarily involving the lung and skin, have been described in patients with 5q minus myelodysplasia. A cluster of closely linked genes encoding for cytokines such as IL-4, IL-5, and IL-3 are present on chromosome 5q. Hence, in sarcoidosis, cytokine imbalances associated with the deletion of these cytokine genes have been postulated. However, an occurrence of epithelioid granulomas within a carcinoma, in preexisting clonal myelodysplastic syndrome, has not been described. The patient, in the current study, had long standing 5q minus deletion, clinically characterized by refractory anemia associated with hypolobated megakaryocytes. However, the patient's history was negative for sarcoidosis and the extensive nonnecrotizing epithelioid granulomas were confined within RCC. Due to the absence of Th-2 cytokines, such as IL-4 and IL-5, in a subset of 5q minus myelodysplastic syndrome, proinflammatory Th-1 cytokines such as IFN-γ and TNF-α may be exaggerated in an environment conducive to antigen expression. Hence, we propose a greater susceptibility for the development of granulomas, at least in a subset of patients with 5q minus myelodysplasia.

Granulomatous gall bladder: A surgico-pathological challenge

Granulomatous gall bladder: A surgico-pathological challenge

MCQs

Warthin's tumor is the second most common neoplasm of major salivary glands, whereas tuberculosis is a rare entity within parotid gland. Mycobacteria may reach stroma of the gland from saliva (through lymphatic vessels and salivary ducts). The infection might spread from primary origin in lungs as well. Inflammatory changes within adenolymphoma are well documented. Patey and Thackray suggested that fluid component of cysts within Warthin's tumor may be the culture medium for pathogens. There are very few documented cases of coexistence of adenolymphoma and tuberculosis within parotid gland.74-year-old female with a tumor of left mandibular angle was admitted to ENT Clinic of Medical University of Silesia. The patient underwent superficial parotidectomy. Tissue specimens revealed features of adenolymphoma and multiple epithelioid granulomas with caseation. She received antimycobacterial treatment.The case of coexistence of adenolymphoma and tuberculosis within parotid gland mentioned in this work is the first documented in Poland.

Kimura's disease with unusual eosinophilic epithelioid granulomatous reaction: A finding possibly related to eosinophil apoptosis

We report and discuss a case of Kimura's disease with an unusual eosinophilic epithelioid granulomatous reaction. A 3-year-old Japanese boy with eosinophilia and a high concentration of IgE developed lymphadenopathy and multiple cervical masses. A lymph node biopsy demonstrated the infiltration of eosinophils in the stroma, which is consistent with the findings of Kimura's disease. Interestingly, a number of apoptotic eosinophils was detected in the infiltrating eosinophils. Multiple epithelioid granulomas with central eosinophilic abscesses and necrosis were also observed. Macrophages and giant cells had phagocytosed the apoptotic eosinophils at the edge of the granulomas. In situ terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) assay showed that the TUNEL-positive eosinophils were both in the macrophages and in the central eosinophilic abscesses of the granulomas. These findings suggest that the eosinophils had undergone an accelerated apoptosis in this case of Kimura's disease, and that the epithelioid granulomas were produced by phagocytosis of the apoptotic eosinophils by macrophages. HUM PATHOL 33:561-564. Copyright 2002, Elsevier Science (USA). All rights reserved.

Structural Similarities between Hematoidin Crystals and Asteroid Bodies: Evidence of Lipid Composition

Hematoidin crystals (HC) are found in tissues where extravasated erythrocytes undergo degradation. Previous studies have determined that hematoidin is composed, in part, of a bilirubin-like pigment. In a previous study (Papadimitriou and Drachenberg, Ultrastruct. Pathol.16, 413–421, 1992), we demonstrated that giant cell asteroid bodies (AB) are formed by membrane lipid bilayers. We evaluated three cases in which HC developed within splenic infarcts. The crystals were analyzed by light microscopy (LM), electron microscopy (EM), and X-ray microanalysis. A case of sarcoidosis with multiple epithelioid granulomas containing AB was studied for comparison. By LM the HC demonstrated intense, golden-color, fine threads, both intracellularly and extracellularly, in small and large clusters, and in radiating, star-shape patterns ranging in size from 2 to 200 μm. By EM the HC were composed of a core of empty clefts, consistent with dissolved lipids, suggestive of cholesterol crystals, and were surrounded by myelinoid membrane aggregates. The AB showed by LM significant morphological similarities with the intracellular HC. By EM, the AB were composed of a core of dense phospholipid bilayer tubes surrounded by a halo of myelinoid membranes. No accumulation of specific elements was found in either HC or AB by X-ray microanalysis. HC and AB show a similar star-shape morphology by both LM and EM. We postulate that this shape is due to the physicochemical properties of the accumulated lipids which originate from superfluous cell membranes created during cell fusion in the case of AB and after cellular (predominantly red cell) breakdown in the case of HC. The golden color of the HC likely results from adsorption of hydrophobic bilirubin-like pigments left over from erythrocyte breakdown into the accumulated lipids. Thus, this study shows two different (patho)physiological processes that lead to a markedly similar morphological end-product and provides further support to our proposed mechanism for AB formation.

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.

Sarcoidosis with Nasal Obstruction and Septal Perforation

Although sarcoidosis is predominantly a pulmonary disorder, it often produces disease in the head and neck. For this reason, otolaryngologists should be comfortable in evaluating and treating the disease. The diagnosis of sarcoidosis often can be made with a biopsy of conjunctival or oral mucosa, even when disease manifestations are not apparent in those parts of the body. In a case of sarcoidosis involving the nose, a 54-year-old black man had a proliferation of small lumps on the tip of his nose. For many years, he had had daily epistaxis, anosmia and severe difficulty breathing through this nose. The bridge of his nose was deformed, and he had a large anterior septal perforation. Physical examination revealed palpable bilateral cervical lymphadenopathy. Laboratory test results were, for the most part, normal; however, fine-needle aspiration of one of the cervical lymph nodes showed multiple epithelioid granulomas with interspersed lymphocyte, and an incisional biopsy of the nasal tissue was highly suggestive of sarcoidosis. Unenhanced computed tomography also revealed widespread nasal inflammation and an abnormal soft tissue mass anterior to the maxilla consistent with chronic osteomyelitis. The patient's condition dramatically improved following treatment with oral prednisone; however, he considered undergoing reconstructive surgery for the noticeable nasal septal deformity.