Multiple Granulomas Research Articles

Rare paradoxical adverse event in Crohn’s disease: a case report

An 18-year-old male adolescent diagnosed with ileocolitis-type Crohn's disease received therapy involving an anti-tumor necrosis factor-α (TNF-α) blocker, which resulted in remission for 2 years. The patient presented with fever, stomatitis, and cough with respiratory distress. Chest radiography revealed bilateral hilar lymphadenopathy; bronchoalveolar lavage showed high lymphocyte level: 40.8% and CD4/8 value: 3.9. Transbronchial lung biopsy identified multiple non-caseating granulomas fused to each other with connective tissue septa, leading to the diagnosis of sarcoidosis. The sarcoidosis was defined as a paradoxical adverse event (PAE) due to the use of TNF-α blocker; therefore, cessation of TNF-α blocker administration was sufficient to induce remission. We report a rare case of PAE on Crohn's disease. The characteristics and distinguishing histologies of PAE and Crohn's disease are described. Biological agent therapy has been reported to cause several PAEs during the treatment of immune-mediated inflammatory disorders. PAEs are defined as pathological conditions that occur during biological agent therapy usually effective in treatment. The laboratory, radiography, and histological findings shown in this case are useful for differential diagnosis and management of PAE.

The effect of dietary vitamin D3, minerals (Ca, P) and plant-protein sources in the development of systemic granulomatosis in meagre (Argyrosomus regius, Asso, 1801)

Systemic Granulomatosis (SG) affects the majority of cultured meagre (Argyrosomus regius). This pathological condition, whose aetiology is still not known, is identified by multiple granulomas in a variety of organs that become calcified and necrotic with time. The available evidence supports the hypothesis that SG is a metabolic disorder associated with nutritional imbalances, and the present study examined the role of dietary vitamin D3, minerals (Ca, P) and plant-protein sources in the development of the disease. The use of plant-protein in the diet formulation exacerbated the progression of SG, while vitamin D3 did not prevent its occurrence. On the other hand, the severity of SG was improved by increasing the P content in the feed. However, the exact irritant that causes this inflammatory response in meagre is still unknown and more research needs to examine other nutritional factors.

Multiple Large Pyogenic Granulomas Overlying a Burn: Case Report and Literature Review

Pyogenic granuloma is a vascular lesion of the skin commonly found in children and young adults. It is known to erupt following skin laceration or penetrating injury, but is only rarely reported in children after a burn injury.

Subcutaneous phycomycosis involving the anterior abdominal wall in an immunocompetent boy successfully treated with potassium iodide

Subcutaneous phycomycosis is a chronic deep fungal infection caused by Basidiobolus ranarum, which usually occurs in children, predominantly affecting males. Herein, we report subcutaneous phycomycosis in a 3-year-old boy who presented with a gradually progressive painless swelling over the anterior abdomen of 20-day duration. Lesional biopsy confirmed the diagnosis of subcutaneous phycomycosis which revealed multiple well-defined granulomas composed of histiocytes, epithelioid cells, and multinucleate giant cells with broad nonseptate hyphae stained with Gomori methenamine silver stain. The child was managed with a saturated solution of potassium iodide which completely melted the swelling.

Outbreak of francisellosis (Francisella noatunensis subsp. orientalis) in cultured neon jewel cichlids Hemichromis bimaculatus from Morelos, Mexico

Francisellosis is a disease caused by different species of the bacterial genus Francisella and has been diagnosed in a wide variety of animals, including fish. Francisellosis in fish is characterized by the development of non-specific clinical signs as well as the presence of numerous granulomas in several organs (mainly spleen and kidney). Ten neon jewel cichlids Hemichromis bimaculatus were submitted for diagnosis from a farm located in Morelos, Mexico. Gross examination, wet preparations, cytology, histopathology and PCR were performed. Affected fish showed lethargy, erratic swimming, imbalance and gasping. At the post mortem examination, multiple granulomas were observed in the kidney and spleen. Microscopically, granulomatous inflammation was observed in several organs. Species-specific PCR assay using DNA from the affected tissues of H. bimaculatus as a template demonstrated the presence of F. noatunensis subsp. orientalis (Fno) by amplifying a hypothetical protein gene of the Fno species. The end diagnosis of francisellosis is important for Mexican ornamental aquaculture, since it is necessary to implement measures for treatment, prevention, control and diagnosis. This is the first report of francisellosis in the neon jewel cichlid.

PRIMARY CONJUNCTIVAL TUBERCULOSIS: A RARE MASQUERADING ENTITY

Primary conjunctival tuberculosis is a rare entity in India. Here, we report a rare case of bilateral primary conjunctival tuberculosis in a 20-years-old female. She had multiple granular lesions in both the eyes for one year and was not responding to topical antibiotic or steroids. Slit-lamp examination showed multiple small subconjunctival granulomas. Conjunctival excision-biopsy revealed granulomatous inflammation with caseous necrosis. A diagnosis of primary conjunctival tuberculosis was made and anti-tubercular therapy was startedto which the patient responded rapidly with complete resolution of the lesions by 2 months. Histopathological examination of chronic non-resolving inflammatory conjunctival lesions is important as it may be a rare presentation of a disease like tuberculosis.

Granuloma whorls.

What is the significance of bone marrow examination in presence of peripheral cytopenias? It is still regarded as a mandatory investigation to diagnose hematological disorders. In this case, bone marrow trephine was initially done as a diagnosis of exclusion for ITP, whereas it revealed multiple granulomas suggesting mycobacterium tuberculosis infection.

3200 A Rare Case of Hepatitis B Association With Sarcoidosis and Treatment Challenge With Immunosuppressive as Resulting in Colonic Histoplasmosis

INTRODUCTION: There have been documented cases reflecting association between Hepatitis C virus (HCV) and sarcoidosis but it is very interesting as in this case that we discussed about association of Hepatitis B virus (HBV) and sarcoidosis, presenting with vague symptoms and confirmed with liver biopsy and immunologic markers. Further challenging is treatment with immunosuppressive medication leading to colonic histoplasmosis. CASE DESCRIPTION/METHODS: 58 year old Indian female with past medical history of cirrhosis secondary to HBV diagnosed six months ago, hypertension and diabetes mellitus 2 presented with bilateral pedal edema, anorexia and mild epigastric discomfort. She has been started on Entecavir since diagnosis six months ago. Patient denied any significant surgical, social and family history. Ultrasonography Liver revealed hepatosplenomegaly and mesenteric lymphadenopathy. 21.3kPa liver stiffness on elastography and HBV level 83. Liver biopsy showed multiple non caseating granulomas consist of Langerhans cell in parenchyma and portal tract, associated with moderate inflammation. Chest CT scan showed upper and middle lobe fibrosis of lung, diagnosis further confirmed with elevated Angiotensin converting enzyme. She was started on prednisone; within 3 months she experienced weight loss, diarrhea and fever. Colonoscopy was done after CT abdomen showed mural thickening of ascending colon and terminal ileum, which on biopsy confirmed Histoplasmosis as described in Figure 1. Prednisone stopped and patient treated with Hydroxychloroquine, amphotericin followed by itraconazole. Patient improved symptomatically and repeated colonoscopy was normal. DISCUSSION: As in this report, studies are scarce to prove association. However; reasonably assumed that the alterations in the pool of cytokines and immune cells caused by HBV infection may have a vicious influence on the immune regulation and can be a trigger for granuloma. Further studies can impact future era for better understanding in pathophysiology of sarcoidosis and HBV correlation and treatment options.

PULMONARY AND SPLENIC SARCOIDOSIS MASQUERADING AS LYMPHOMA

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Sarcoidosis is a systemic inflammatory disease characterized by granuloma formation with a prevelance of 10-20 per 100,000 people, more commonly found in blacks. Sarcoidosis most frequently involves the lung but can manifest in any organ system to a varying degree(1,2). Here we present a patient with a history of Gilbert’s found to have new splenic lesions initially thought to have malignancy. CASE PRESENTATION: A 38-year-old male, never smoker, with a history of Gilbert’s disease and hepatitis as an infant was referred to our pulmonary clinic for suspected sarcoid. The patient is polish in origin and lived in southern Poland during the Chernobyl event then moved to the United States (US) shortly after, has remained in the US since. He had an outpatient MRI with and without contrast of the abdomen for elevated liver function tests showing splenomegaly with multiple scattered lesions in the spleen concerning for lymphoma for which he was referred to hematology. At his hematology visit he reported some weight loss, nocturnal fevers and night sweats, laboratory results at that time revealed an elevated ACE level of 222, ESR 28, no anemia or leukopenia, marked elevation of polyclonal IgG as well as elevation of kappa and lambda chains but normal ratio. He was deemed to not have lymphoma and was referred to pulmonary for sarcoid work up. In our clinic pulmonary function testing was normal. PET/CT scan revealed multiple active lymph nodes (LNs) both above and below the diaphragm, most of which are not abnormally enlarged on CT. The most active lesion was a left external iliac node (SUVmax 16). Biopsy of the left external iliac LN showed no evidence of sarcoid. Bronchoscopy was then pursued with transbronchial biopsies of right upper lobe which showed multiple noncaseating epithelioid granulomas, Langhans giant cells, lymphocytes and Asteroid bodies, with no sign of malignancy. The patient also had an ophthalmic evaluation with no findings of sarcoid and negative infectious work up. The patient was diagnosed with sarcoidosis with pulmonary and splenic involvement. DISCUSSION: Sarcoid is usually expected to present with pulmonary involvement but multiple splenic lesions can be the initial presentation. Systemic symptoms of fatigue, malaise, weight loss, and fever are nonspecific and can easily be confused with symptoms of malignancy(3). Approximately 6% of sarcoid patients have splenomegaly on physical exam with 15% of patients having hypodense splenic nodules on CT(1,4). Other signs to look for are hypersplenism resulting in anemia, leukopenia, thrombocytopenia, or pancytopenia which our patient did not have(5). CONCLUSIONS: It is important to have a broad deferential when approaching a patient with splenic lesions. Assessment for signs suggestive of systemic sarcoid is necessary to avoid missed or delayed diagnosis. Reference #1: Warshauer DM, Dumbleton SA, Molina PL, Yankaskas BC, Parker LA, Woosley JT. Abdominal CT findings in sarcoidosis and clinical correlation. Radiology 1994; 192: 93-9 Reference #2: Thomas KW, Hunninghake GW. Sarcoidosis. JAMA. 2003;289(24):3300–3303. https://doi.org/10.1001/jama.289.24.3300 Reference #3: Raber EL, Haba J, Beck P. Splenic sarcoidosis: a case report and review of the imaging findings of multiple incidental splenic lesions as the initial presentation of sarcoidosis. Can J Gastroenterol. 2011;25(9):477-8. DISCLOSURES: No relevant relationships by Ajay Adial, source=Web Response No relevant relationships by Asma Iftikhar, source=Web Response No relevant relationships by Tereza Izakovich, source=Web Response no disclosure on file for Stephen Karbowitz

2478 Approach to a Foreign Body (Fish Bone) Resulting in a Liver Abscess With Antibiotic-Evading Filamentation of Bacterial Organisms Resembling Fungal Hyphae

INTRODUCTION: Foreign bodies that are ingested may migrate from the gastrointestinal (GI) tract into different organs of the body and cause a variety of clinical manifestations including fever of unknown origin. In this vignette we describe the case of a transmural fish bone migration from the stomach to the liver causing a recurrent liver abscess. CASE DESCRIPTION/METHODS: A 76 year old Caucasian male with a past medical history of hypertension presented to the hospital with a left liver lobe abscess that was aspirated six years ago. All cultures at that time were negative and apparently resolved with antibiotics. About two months prior to his hospital admission, he started developing subjective fevers and malaise, with CT Scan of the abdomen showing a possible liver mass in the left lobe. He underwent a liver biopsy of this lesion that showed multiple caseating granulomas. Infectious work up was negative. Despite broad spectrum antibiotics, the patient continued with low grade fevers. Pancultures were negative and a left liver lobectomy and cholecystectomy was pefomed. CT imaging of the liver showed a multiloculated 7.2 cm lesion in the left lobe of the liver consistent with an abscess, with a linear foreign body which extended from the stomach into the left lobe liver lesion (Figure 1). During surgery, the foreign body was identified and removed. Surgical histology of the foreign body showed bone fragments lined by osteocytes and calcifications, which was identified as a “fish bone.” Furthermore, the left liver lobe showed prominent granulomatous inflammation with necrosis and microabscesses with no evidence of malignancy. Special stain GMS-F was positive for filamentous organisms that most closely resembled nocardia or streptomyces (Figure 2). DISCUSSION: This is the first case report showing filamentation of bacteria resembling a fungal infection causing a liver abscess due to a fish bone that penetrated the left lobe of the liver. Filamentation is a bacterial defense mechanism against eradication by antibiotics, which explains failure of resolution of the infection with antimicrobials. Studies have reported incomplete bacterial replication leading to the appearance of filamentation resembling fungal species. This phenomenon should be considered by clinicians when treating challenging liver foreign body abscesses.

A CASE OF TATTOO SARCOIDOSIS

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Sarcoidosis is a multisystem granulomatous disease that commonly affects the lungs and intrathoracic lymph nodes. In rare cases, it can present as localized hypersensitive reaction to a pre-existing chemical irritant with symptoms limited to areas of granuloma formation. When it affects the lungs and mediastinal lymph nodes, as seen in over 90% of patients, it causes lymphadenopathy associated with cough, dyspnea, and interstitial lung disease. Here we present a case of Sarcoidosis diagnosed in the setting of hypersensitive reaction to a pre-existing tattoo. CASE PRESENTATION: A 61-year-old Caucasian woman presented to dermatologist for evaluation of gradually worsening eyebrow redness, swelling, and pruritus. On physical exam, she was noted to have small, scattered <1 cm areas of raised non-blanching macules limited to where she had received a cosmetic eyebrow tattoo about four years prior to presentation. A skin biopsy of the affected area showed mixed inflammatory infiltrate with numerous epithelloid histiocytes, multinucleated foreign body giant cells, lymphocytes, plasma cells, and a few eosinophils intermixed with tattoo particulate deposition. Skin biopsy was negative for fungal and acid fast bacilli. She was referred to Pulmonology, who she saw four months later, with complaints of fatigue, dry cough and dyspnea on exertion. She denied any chest tightness, wheezing, palpitations, fever, chills or unexpected weight loss. Chest X-ray and CT Chest w/o contrast showed mediastinal bilateral hilar lymphadenopathy and peribronchovascular bundle nodules. She had ACE level 85 IU/L and ESR 25 mm/h. PFTs showed moderate obstructive defect with FEV-1 of 68%. She had no history of COPD or asthma. She was started on long course of Prednisone with taper. At one-month follow-up visit, the patient reported improvement with resolution of shortness of breath and skin changes including eyebrow redness and swelling. DISCUSSION: As this case illustrates, sarcoidal reaction within a pre-existing tattoo can be the sole presenting symptom leading to the diagnosis of systemic sarcoidosis. Other associated findings of dyspnea, hilar lymphadenopathy on CT were seen later in time. It has been proposed that exposure to foreign antigens triggers dysregulated TH-1 inflammatory response activating the CD4 T-helper cells and macrophages. The latent period can range anywhere from months to ten years and it is unknown if tattoo removal affects the progression of the disease. CONCLUSIONS: Sarcoidosis is a diagnosis of exclusion and requires clinical and radiographic findings compatible with histological confirmation of noncaseating granulomas. With the increasing popularity of cosmetic tattoos and techniques to enhance the appearance of eyebrows via addition of pigment to skin, a simple hypersensitivity reaction with supporting pathological and radiologic evidence can lead to the diagnosis of this multisystem disease. Reference #1: Marcoval J, Mañá J, Moreno A, Gallego I, Fortuño Y, Peyrí J. Foreign Bodies in Granulomatous Cutaneous Lesions of Patients With Systemic Sarcoidosis. Arch Dermatol. 2001;137(4):427–430. doi: 10-1001/pubs.Arch Dermatol.-ISSN-0003-987x-137-4-dst0038 Reference #2: Antonovich D.D., Callen J.P. Development of sarcoidosis in cosmetic tattoos. Arch Dermatol. 2005;141:869–872 Reference #3: P. P. Papageorgiou, W. Hongcharu, A. C. Chu. Systemic sarcoidosis presenting with multiple tattoo granulomas and an extra-tattoo cutaneous granuloma. J Eur Acad Dermatol Venereol. 1999 Jan; 12(1): 51–53 DISCLOSURES: No relevant relationships by Mudher Al Shathir, source=Web Response No relevant relationships by Himani Bhasin, source=Web Response No relevant relationships by Kenneth DSouza, source=Web Response

Hypertrophic pachymeningitis: Is it really idiopathic?

Hypertrophic pachymeningitis is a disorder characterized by localized or diffuse enlargement of the dura mater. To elucidate the various characteristics of patients presenting with hypertrophic pachymeningitis. To determine the various aetiologies of pachymeningitis, the clinical profile, the various treatment strategies, patient outcome. 27 patients with clinical & radiological diagnosis of pachymeningitis were included in the study from Jan 2014 – April 2019. They were followed up over 1-2 yrs. Thorough work up for secondary causes was done. Treatment of underlying cause was done and immunosuppression was given. Outcome was analysed on follow up. MRI of a patient with idiopathic hypertrophic pachymeningits with 8,9,10,11,12 cranial nerve palsy. Meningeal biopsy showing multiple non-caseating granulomas in a patient with neurosarcoid. Idiopathic pachymeningitis is diagnosis of exclusion. Hence thorough work up required to rule out secondary causes. Highly responsive to steroids. In our study headache was the universal symptom, responded to immunotherapy. We found secondary causes in 13 cases. Etiological workup is of utmost importance as treatment changes. Recurrence is high, long term immunotherapy is required. The disease is treatable.

2106 Granulomatous Lung Disease in a Patient With IBD: What Is It?

INTRODUCTION: When a patient with inflammatory bowel disease (IBD) presents with respiratory complaints the differential diagnosis includes many conditions unrelated to IBD. Extra-intestinal manifestations (EIM) involving the lungs are relatively uncommon. Biologics for IBD can also have secondary effects including pulmonary toxicity and infectious complications. CASE DESCRIPTION/METHODS: A 48 y/o female nurse with history of bronchial asthma and hypertension was diagnosed with ulcerative pancolitis in 2005. In 2017, she was started on adalilumab (ADA) after repeated use of steroids and intolerance to azathioprine. ADA was discontinued after one year due to multiple subcutaneous nodules and fever that cleared on drug discontinuation. Differential diagnosis included erythema nodosum and hidradenitis. She was found with (+) quantiferon despite negative tuberculin (TB) skin test and chest x ray and was treated for latent TB with isoniazid for one year (04/18-04/19). Four months later (08/18), she was started on infliximab (IFX) with good response. On 01/19, an incidental left pleural effusion was found and she underwent thoracentesis. In 03/19, she developed night sweats and pleuritic chest pain. Chest x-ray demonstrated a large right pleural effusion. Bronchoscopy and pleural biopsy showed necrotizing granulomas negative for AFB and GMS. IFX was discontinued and she was started on high dose steroids with little improvement. Chest CT preformed on 05/19 demonstrated bilateral effusions and multiple upper lobe and centrilobar noncalcified opacities with tree in bud appearance. Bronchoscopy with lung biopsy showed multiple noncaseating granulomas negative for AFB and GMS. DISCUSSION: The differential diagnosis in this patient includes lung involvement of IBD, vasculitis, infections, drug reaction and concurrent primary sarcoidosis among others. Vasculitis and infections have been excluded, and the lack of improvement after IFX discontinuation and steroids suggests IFX is not the cause. However, several cases of sarcoidosis associated to anti-TNF drugs have been reported and drug-induced sarcoidosis remains a high probability. Pulmonary EIM is also still a possibility in spite of clinical remission of UC.This case report demonstrates the importance of remaining aware of possible rare EIM of IBD and also of other rarer complications in this new age of biologics. Early diagnosis and effective treatment are important to prevent complications and improve outcomes for these patients.

Multiple eosinophilic granulomas after vaccination and antiparasitic treatment in a 2-month-old Turkish Angora cat

Multiple eosinophilic granulomas after vaccination and antiparasitic treatment in a 2-month-old Turkish Angora cat

Mycobacterium chimaera Infection: A Case Report and Review of Literature

Abstract Mycobacterium chimaera (MCH) is a non-tuberculous mycobacterium commonly found in the environment. It is a member of the M. avium complex (MAC), and rarely causes infections in humans. However, invasive MCH infections have been reported associated with heater-cooler devices during cardiac surgery. Detection of MCH infections in this setting has been impeded by inadequate clinical awareness and laboratory tests. A 77-year-old man had aorta valve replacement 3 years ago. He recently presented with constitutional symptoms, including fatigue, night sweats, and 50 pounds of weight loss. PET CT showed ground-glass and nodular opacities in the lungs. Bone marrow biopsy demonstrated noncaseating granulomas. Transesophageal echocardiogram revealed severe stenosis and regurgitation of aortic valves. Despite antibiotics and heart surgery to relieve stenosis, the patient succumbed. Autopsy showed multiple small granulomas in the lung and multifocal chronic inflammation in the heart. Premortem mycobacterial cultures of aortic valves were performed, which grew MAC by DNA probe in 1 week. Subsequently, it was identified as MCH by sequencing of the ITS1/ITS2 region. The cause of death was heart failure due to MCH endocarditis. MCH infection is rare but potentially fatal if not promptly treated. Therefore, it is critical to identify patients at risk for infection. Since 2013, over 100 cases of MCH endocarditis have been reported worldwide, specifically associated with contaminated heater-cooler units during heart surgery. Characteristically, MCH infection has a long incubation period after exposure (median 17 months, range 3-72 months). Signs and symptoms are generally nonspecific and often include fatigue, fever, and weight loss. The risk of MCH infection in patients undergoing open heart surgery is low, but clinicians should be aware of the risks especially when heater-cooler units are utilized. A close follow-up over a long period may be necessary due to the long incubation period of this infection.

A Case of Immune-Mediated Necrotizing Myopathy With Associated Skeletal Muscle Involvement by Sarcoid Granulomata: A Rare Association

Abstract Skeletal muscle involvement by noncaseating granulomata occurs in a variety of conditions, including sarcoidosis, infections, and rarely in association with primary inflammatory myopathies such as inclusion body myositis (IBM) and dermatomyositis (DM). Sarcoid myopathy is typically asymptomatic; however, a picture of acute myositis with proximal muscle weakness has been described. Immune-mediated necrotizing myopathy (IMNM) is a subgroup of inflammatory myopathies typically presenting with proximal muscle weakness and markedly elevated muscle enzymes, mostly occurring in the setting of statin treatment. IMNM is associated with positive autoantibodies, but a subset of cases is antibody negative. Here we describe a case of myopathy occurring in association with sarcoidosis with combined features of granulomatous and necrotizing myopathy. The patient was a 54-year-old African American male with medical history significant for statin use 3 years ago, which was discontinued due to myalgia and elevated muscle enzymes and biopsy-proven sarcoidosis diagnosed on a pulmonary lymph node biopsy. He presented with progressive worsening of bilateral proximal weakness involving the upper and lower extremities. Electromyogram showed features of active myopathy with no evidence of peripheral neuropathy. Myositis panel was negative for the following antibodies: anti-Jo1, Mi-2, anti-Ku, PL-7, PL-12, OJ, EJ, and SRP. However, there was elevation of aldolase, CRP, and CK-MB. Biopsy of thigh and deltoid muscle showed necrotic muscle fibers, myophagocytosis with associated minimal inflammation, and multiple well-formed nonnecrotizing granulomas with multinucleated giant cells. Myopathic features include increased internalized nuclei, round atrophic fibers, and scattered split fibers. Specific features of IBM or DM were not present. Conclusion Myopathies developing or worsening after discontinuation of statin are rare. The association of necrotizing myopathy with sarcoidosis is not well described in the literature. Additional studies are warranted to elucidate this association.

A Case of Localized Multiple Subcutaneous Granuloma Annulare on the Fingers of a Patient with Mixed Connective Tissue Disease Manifesting Raynaud's Phenomenon

A Case of Localized Multiple Subcutaneous Granuloma Annulare on the Fingers of a Patient with Mixed Connective Tissue Disease Manifesting Raynaud's Phenomenon

Isotretinoin induced nail fold pyogenic granuloma resolution with combination therapy: A case report and review of the literature

Pyogenic granulomas are vascular hyperplasias presenting as red papules, polyps, or nodules on the gingiva, fingers, lips, face and tongue of children and young adults. Most commonly they are associated with trauma, but systemic retinoids have rarely been implicated as a causative factor in their appearance. We present a case of spontaneous eruption of multiple pyogenic granulomas of the bilateral periungal fingers in an otherwise healthy adolescent male undergoing isotretinoin therapy for severe nodulocystic acne. These pyogenic granulomas did not resolve spontaneously with discontinuation of isotretinoin, or first line therapeutic modalities. Their resolution did occur with administration of intralesional steroids and ablation with silver nitrate.

Chromoblastomycosis in two giant ditch frogs also known as mountain chicken frogs (Leptodactylus fallax)

Because of sudden death of several frogs following the renewal of a terrarium, two giant ditch frogs (Leptodactylus fallax) were submitted for post-mortem examination. The animals displayed extensive erythematous to...

Microbial exposure and autoimmunity in the etiopathogenesis of Sarcoidosis

Abstract Sarcoidosis is an enigmatic inflammatory disease affecting multiple organs such as the lungs, lymph nodes, brain, heart, and skin. It is characterized by the occurrence of multiple non-caseating granulomas comprised of macrophages, giant cells, and CD4 T cells. Although genetic and environmental factors increase the risk for sarcoidosis, the etiology remains unknown. Recent studies have shown that HLA-DR3+ sarcoidosis patients harbor CD4+ T cells reactive with a vimentin peptide 424–443. However, whether autoimmunity is a cause or consequence of the disease is not known. This study was undertaken to investigate the mechanisms responsible for activation of vimentin reactive T cells and determine their pathogenic role in sarcoidosis. For this purpose, we immunized the NOD-DR3 mice with the vimentin peptide 424–443 and induced a robust T cell response against the peptide. Fine epitope mapping using T cell hybridomas reactive with the peptide showed that both N-terminal and C-terminal amino acids were critical for T cell activation. Homology searches of microbial protein database identified a 100% homologous sequence in a protein from Klebsiella pneumoniae. Immunization of mice with this peptide, followed by intravenous transfer of peptide-coupled agarose beads induced granulomatous lesions in the lungs. Immunohistochemical analysis of these lesions showed the presence of CD4+ T cells, macrophages, and an upregulated MHC-II expression. In summary, our data demonstrate for the first time that autoimmunity is involved in the pathogenesis of sarcoidosis. Furthermore, the demonstration of molecular mimicry between a lung infecting microbe and vimentin might explain the role of microbial exposures as a risk factor for sarcoidosis.