Typical Granulomas Research Articles

Clinical Features and Prognostic Factors in Northern Chinese Patients with Peripheral Granuloma Type of Ocular Toxocariasis: A Retrospective Cohort Study

ABSTRACT Purpose To summarize the clinical features and probable factors associated with recurrence within 6 months in northern Chinese ocular toxocariasis (OT) patients. Methods A retrospective cohort study (38 OT eyes) was conducted. Clinical features, aqueous inflammatory cytokines, complications, and parameters associated with recurrence after treatment were analyzed. Results The initial best-corrected visual acuity (BCVA) was related to the anterior inflammation grade at the onset (P = .028). The mean BCVA and anterior inflammation improved significantly (P < .05) after treatment. The OT eyes had higher aqueous humor cytokine levels (IL-6, IL-8, and IL-10) compared with the normal eyes (P < .001). More severe anterior inflammation grade or longer duration of uveitis were more likely to increase the probability of recurrence (P = .008 and P = .025), TA injection during/after vitreous surgery can reduce the probability of recurrence (P = .031). Conclusions The combination therapy of vitreoretinal surgery, steroids, and albendazole therapy may reduce inflammation and recurrence of OT effectively. Abbreviations: BCVA: best-corrected visual acuity; BFGF: basic fibroblast growth factor; CFT: central foveal thickness; CI: confidence interval; ELISA: Enzyme-linked immunosorbent assay; ERM: epiretinal membrane; IOP: intraocular pressure; IQR: interquartile range; IL: interleukin; LFM: laser flare meter; MH: macular hole; OCT: optical coherence tomography; OR: odds ratio; OT: ocular toxocariasis; RD: retinal detachment; TA: triamcinolone acetonide; TCLA: Toxocara canis larva crude antigen; TGF: transforming growth factor; VCAM: vascular cell adhesion molecule; VEGF: vascular endothelial growth factor

Propionibacterium acnes-associated sarcoidosis complicated by acute bird-related hypersensitivity pneumonitis

BackgroundThe number of reports on sarcoidosis complicated by hypersensitivity pneumonitis (HP) is limited, and most describe cases complicated by chronic bird-related HP. Here, we present for the first time a case with Propionibacterium acnes-associated sarcoidosis complicated by acute bird-related HP.Case presentationA 62-year-old man with a past medical history of sarcoidosis was admitted to our department, and chest computed tomography showed diffuse ground-glass opacities, which appeared as he rapidly increased the number of pigeons he kept for a competition. Random transbronchial lung biopsy revealed well-formed non-caseating epithelioid granulomas, which contained positively stained substances on immunohistochemistry using the PAB antibody, a specific monoclonal antibody against P. acnes lipoteichoic acid. Poorly formed non-caseating granulomas without positively stained substances were also detected.ConclusionWe describe the successful identification of this exceptionally rare case of sarcoidosis complicated by acute bird-related HP in which two morphologically and immunohistologically different types of granulomas were present in the same lung.

The immunological architecture of granulomatous inflammation in central nervous system tuberculosis

Of all tuberculosis (TB) cases, 1% affects the central nervous system (CNS), with a mortality rate of up to 60%. Our aim is to fill the ‘key gap’ in TBM research by analyzing brain specimens in a unique historical cohort of 84 patients, focusing on granuloma formation. We describe three different types: non-necrotizing, necrotizing gummatous, and necrotizing abscess type granuloma. Our hypothesis is that these different types of granuloma are developmental stages of the same pathological process. All types were present in each patient and were mainly localized in the leptomeninges. Intra-parenchymal granulomas were less abundant than the leptomeningeal ones and mainly located close to the cerebrospinal fluid (subpial and subependymal). We found that most of the intraparenchymal granulomas are an extension of leptomeningeal lesions which is the opposite of the classical Rich focus theory. We present a 3D-model to facilitate further understanding of the topographic relation of granulomas with leptomeninges, brain parenchyma and blood vessels. We describe innate and adaptive immune responses during granuloma formation including the cytokine profiles. We emphasize the presence of leptomeningeal B-cell aggregates as tertiary lymphoid structures. Our study forms a basis for further research in neuroinflammation and infectious diseases of the CNS, especially TB.

Case series of cutaneous Langerhans cell histiocytosis in Indonesian children; The clinicopathological spectrum.

Langerhans Cell Histiocytosis (LCH) is a rare disease characterized by the clonal proliferation of Langerhans cells, which are immunoreactive to S-100 and CD-1a/ CD207 (Langerin). Cutaneous involvement is the most common presentation of LCH in children. It is suggested that the patients with single-system LCH limited to the skin have a better prognosis than those with systemic involvement. Three histologic reactions of cutaneous LCH have been reported and are associated with the clinical types of LCH. These histological reactions include: proliferative, granulomatous, and xanthomatous. This study presents the clinicopathological features of ten cutaneous LCH cases collected from Dr. Sardjito General Hospital Yogyakarta Indonesia between 2014-2018. The ten cases showed various clinical features, in which some features mimic other diseases. The microscopic features of skin biopsies showed granulomatous reaction in 80% of cases and proliferative reaction in the other 20%. Five patients (50% of cases) who died had systemic manifestation of thrombocytopenia, anemia, icterus, hepatosplenomegaly, and revealed the granulomatous type from their skin biopsy specimens. The clinical recognition of LCH and subsequent histological reaction determination are important since some cases may develop multisystem disease and have a poor prognosis.

The Pathogenesis of Tuberculosis-The Koch Phenomenon Reinstated.

Research on the pathogenesis of tuberculosis (TB) has been hamstrung for half a century by the paradigm that granulomas are the hallmark of active disease. Human TB, in fact, produces two types of granulomas, neither of which is involved in the development of adult type or post-primary TB. This disease begins as the early lesion; a prolonged subclinical stockpiling of secreted mycobacterial antigens in foamy alveolar macrophages and nearby highly sensitized T cells in preparation for a massive necrotizing hypersensitivity reaction, the Koch Phenomenon, that produces caseous pneumonia that is either coughed out to form cavities or retained to become the focus of post-primary granulomas and fibrocaseous disease. Post-primary TB progresses if the antigens are continuously released and regresses when they are depleted. This revised paradigm is supported by nearly 200 years of research and suggests new approaches and animal models to investigate long standing mysteries of human TB and vaccines that inhibit the early lesion to finally end its transmission.

The induction of Mitsuda type of late response by tuberculin in patients with pulmonary tuberculosis and its significance

Traditionally, the kinetics of tuberculin testing has been studied up to 72 hours. In this study, we have studied the Mitsuda type of late response, usually seen in patients with leprosy after three weeks and also evaluated its significance in patients with pulmonary tuberculosis. Thirty patients of pulmonary tuberculosis were divided into two groups based on sputum Acid-fast bacilli (AFB) examination. Group I patients were sputum AFB positive relapse (n=13). Group II patients were previously treated for pulmonary tuberculosis with negative sputum AFB (n=17). The induration was measured on day 3 and day 21, after tuberculin test with Purified protein derivative (PPD). A punch biopsy was taken from the site of induration on day 21 to study the histo-pathological characteristics. Four patients (23.5%) of Group 2 had an induration of more than 10 mm on day 21, while none from Group I had more than 10 mm size of induration. Granulomas, typical feature of ‘Mitsuda’ type of late response were seen in 92% and 100% in Group I and II respectively. The incidence of a granulomatous type of late response is 96.7% in patients with pulmonary tuberculosis. The Mitsuda type of late response can be induced by the PPD, which we are using for conventional tuberculin testing. The late response appears to offer no protection in preventing relapse in previously treated patients for pulmonary tuberculosis

Clinical Significance of M1/M2 Macrophages and Related Cytokines in Patients with Spinal Tuberculosis

Background Macrophages are important immune cells involved in Mycobacterium tuberculosis (M.tb) infection. To further investigate the degree of disease development in patients with spinal tuberculosis (TB), we conducted research on macrophage polarization. Methods Thirty-six patients with spinal TB and twenty-five healthy controls were enrolled in this study. The specific morphology of tuberculous granuloma in spinal tissue was observed by hematoxylin-eosin (H&E) staining. The presence and distribution of bacilli were observed by Ziehl-Neelsen (ZN) staining. Macrophage-specific molecule CD68 was detected by immunohistochemistry (IHC). M1 macrophages play a proinflammatory role, including the specific molecule nitric oxide synthase (iNOS) and the related cytokine tumor necrosis factor-α (TNF-α) and interferon-γ (IFN-γ). M2 macrophages exert anti-inflammatory effects, including the specific molecule CD163 and related cytokine interleukin-10 (IL-10). The above markers were all detected by quantitative real-time PCR (RT-PCR), enzyme-linked immunosorbent assay (ELISA), and IHC. Results Typical tuberculous granuloma was observed in the HE staining of patients with spinal TB. ZN staining showed positive expression of Ag85B around the caseous necrosis tissue and Langerhans multinucleated giant cells. At the same time, IHC results indicated that CD68, iNOS, CD163, IL-10, TNF-α, and IFN-γ were expressed around the tuberculous granuloma, and their levels were obviously higher in close tissue than in the distant tissue. RT-PCR and ELISA results indicated that IL-10, TNF-α, and IFN-γ levels of TB patients were also higher than those of the healthy controls. Conclusion The report here highlights that two types of macrophage polarization (M1 and M2) are present in the tissues and peripheral blood of patients with spinal TB. Macrophages also play proinflammatory and anti-inflammatory roles. Macrophage polarization is involved in spinal TB infection.

Brucellar spondylodiscitis: A case series with focus on histopathological features

Brucellar spondylodiscitis (BS) is the most common form of musculoskeletal brucellosis. The isolation of Brucella spp from blood, other body fluids or tissue cultures is the gold standard for definitive diagnosis of BS. BS shows a large histopathological spectrum of lesions with non-specific and granulomatous forms, and its histopathological features are not widely reported. This case series study reported the histopathological features of a series of 21 BS. Ten cases revealed nonspecific forms of BS. Lymphocytes were the predominant inflammatory cells in this group. In one case neutrophils were predominant. The eleven remaining were granulomatous. The 11 exhibited histiocytic type granulomas. Ten were non-necrotizing. One case, taken from abscess wall, contained minimal deposition of caseous like necrotic material. This case and 2 others corresponding to abscess wall biopsies, showed histiocytic granulomas mixed with small aggregates of epithelioid cells without well-formed epithelioid granuloma nor giant cell.The histopathological diagnosis of BS is challenging. Nonspecific forms of BS, mimiking pyogenic spondylodiscitis, are observed in about half of the cases. Although nonspecific forms of BS are characterized by the predominance of lymphocytes and plasmocytes, BS forms with predominant neutrophil cell infiltration do exist. Histiocytic granuloma is highly suggestive of BS. Purely epithelioid forms of BS were not observed in the present series. Caseous like necrosis suggestive of tuberculosis is a possible feature of BS.

MON-482 Thyroid Tuberculosis - An Unlikely Diagnosis

Background: Mycobacterium tuberculosis (MTB) is an aerobic bacillus responsible for the most cases of tuberculous infection. Approximately one-third of the world’s population is infected. Tuberculosis (TB) of the thyroid gland is an unusual diagnosis with an estimated prevalence of 0.1 to 0.6%. The thyroid TB can mimic different pathologies (thyroid neoplasms, lymphoma, infectious or granulomatous thyroiditis, Graves’ disease or bacterial abscess) and the diagnosis can be easily disregarded, especially in non-endemic countries and if the patient doesn’t have systemic symptoms. The fine needle aspiration and histopathological examination, with acid-fast bacilli staining and TB culture, are the gold standard exams.Clinical Case: A 71-year-old female was referred to our Endocrinology department after a diagnosis of nodular thyroid disease. She had complaints of slight cervical discomfort, with 6 months of duration. She hadn’t personal or familiar relevant antecedents. At observation, a movable, elastic and non-tender nodule of 15mm at the right superior thyroid lobe was identified. Blood tests including a thyroid profile were normal. The neck ultrasound showed, at the right lobe of the thyroid, multiple solid nodules; the dominant had 18mm, was heterogeneous and had multiple calcifications. Moreover, lymph nodes with suspicious ultrasonographic features along the right internal jugular chain were reported. The patient underwent fine-needle aspiration (FNA) of the suspicious thyroid nodule and one lymph node. Results were respectively: non-diagnostic (Bethesda I) and reactive pattern. FNA was repeated on a different occasion and results were similar. Due to ultrasound suspicious of malignancy, a total thyroidectomy was performed and a lymph node from level IV was sampled for extemporaneous examination. Necrotizing granulomas were documented; the Ziehl-Neelson staining (ZNS) was negative; material was sent to microbiology. Following this finding, ganglion emptying was not performed. The thyroid histology showed tuberculoid type granulomas with lymphoid border and central necrosis. However, the ZNS was negative. The diagnosis was definitely established by a positive culture of the lymph node tissue and molecular detection, by polymerase chain reaction (PCR), of MTB. Pulmonary involvement was excluded and she started antituberculous agents planned for 9 months (rifampicin and isoniazid during 9 months and ethambutol and pyrazinamide for 2 months).Conclusion: Thyroid TB is a rare presentation of extrapulmonary tuberculosis. In presence of systemic or specific complaints or history of exposition the diagnosis may be suspected and confirmatory tests requested in order to ensure an adequate treatment. However, sometimes, histopathology remains a key step and the use of cultures improves the sensitivity and specificity of TB tests.

Non-healing Wounds: A Delayed Wound Infection by Mycobacterium Tuberculosis.

Non-healing wound causes significant morbidity and mortality of patients. One of the rare causes behind non-healing wound infection is M. tuberculosis which often remains undiagnosed. The aim of this study was to determine the tuberculosis as one of the causes of non-healing wound. Wounds that did not heal even after secondary suturing and tissue biopsies were sent for histopathological examination. The cases diagnosed with tuberculosis received anti-tubercular treatment. Follow-up was done after 7 and 14days of treatment, and response was seen in terms of reduction in inflammation and discharge. Of the 36 patients, five patients had tubercular infection out of which one patient revealed tubercular granuloma, two revealed epitheloid cells, Langhans cells, whereas two revealed non-specific chronic inflammation in histopathology. A high degree of suspicion and tissue biopsy is required in case of delayed or non-healing wounds to diagnose tuberculosis as a cause. Even if typical tubercular granuloma is not visible in histopathology, the presence of epitheloid cells, giant cells, Langhans cells or predominant lymphocytic infiltrate equally suggests tubercular tissue infection.

Granulomatous Skin Diseases in a Tertiary Care Portuguese Hospital: A 10-Year Retrospective Study.

Granulomatous skin diseases comprise an extensive group of pathologies whose diagnosis usually requires a histopathological examination. At this level, various types of granulomas can be distinguished, namely tuberculoid, sarcoid, necrobiotic, suppurative, xanthogranuloma, and foreign-body granulomas. This study aimed to determine the frequency and pattern of different granulomatous skin lesions in the Dermatopathology Department of Hospital de Santa Maria (Lisboa, Portugal). A retrospective study of all skin biopsies with granulomatous lesions received during a period of 10 years (2008-2017) was performed. Clinical and histopathological characteristics of the selected cases were analyzed, and the lesions were categorized according to histological type of granuloma and etiology. Foreign-body granulomas secondary to ruptured cyst, folliculitis, or suture material were excluded. From a total of 48,253 cutaneous biopsies performed in this period, 461 (1%) granulomatous lesions were included in our study. In the analysis according to type of granuloma, necrobiotic granulomas were the most frequent (N = 111; 27.0%), followed by sarcoidal (N = 72; 17.5%), tuberculoid (N = 51; 12.4%), suppurative (N = 45; 10.9%), foreign body (N = 40; 9.7%), and xanthogranulomas (N = 26; 6.3%). The remaining 20% corresponded to granulomas of other types. During these 10 years, the most frequent etiology was granuloma annulare (N = 98; 88.3%), followed by sarcoidosis (N = 47; 65.3%). Histopathology is a fundamental tool in the diagnosis of granulomatous skin diseases, allowing for the categorization of various types of granulomas and often guiding further investigation of these patients. The geographical area has an influence on the types of granulomas observed, as evidenced by comparing this study with others previously published.

The histopathological approach to granulomatous skin lesions

Granulomatous inflammation of skin and subcutaneous tissue are common in India. An identical histological picture is produced by several causes. Present study aims at classifying infectious granulomas based on histomorphology and special staining and developing a proper approach for making a specific etiological diagnosis. To classify the granulomatous dermatitis and a simple diagnostic histological approach has been worked out based on morphology of granuloma, presence of caseous necrosis, palisading necrosis, location of the granuloma and use of special stains. A prospective study of skin biopsies with granulomatous inflammation over a period of 2 years is done. Histologically lesions were divided into six subtypes:-Tuberculoid, foreign body type, histoid, necrobiotic, suppurative and sarcoidal type. On basis of morphological features and special staining each type was further subclassified and a specific diagnosis was given. Among 580 skin biopsies, 175 cases (30.17%) were of granulomatous skin lesions. On histopathological typing Tuberculoid type of granuloma was the most common type (62/175 cases, 35.43%) of which leprosy (40/62 cases, 64.52%) was the commonest etiology identified. Infections form an important etiology of granulomatous skin inflammation (120/175 cases, 68.57%) of which leprosy (82/120 cases, 68.33%) is the leading etiology in our study. Adequate clinical work-up in combination with pathological resources help in correctly approaching a granulomatous skin lesion and reaching a specific etiologic diagnosis.

Datia Langhans cells as tuberculous lymphadenitis diagnose parameter based on chemical reaction

The incidence of tuberculosis in Indonesia increases every year, resulted in increased cases of tuberculous lymphadenitis. The histopathological picture is often similar to other types of lymphadenitis. This study was an in-depth exploration of the anatomical pathology of Langhans datia cells and necrosis in tuberculous lymphadenitis. This research used secondary data from medical record of the lymph node paraffin blocks in the Anatomical Pathology Department of Sadikin Hasan General Hospital Bandung from January to December 2017. There are 322 medical records of tuberculosis lymphadenitis patients, consisting of 179 types of tuberculous lymphadenitis, 144 types of non-lymphadenitis specific, and nine types of granulomatous lymphadenitis. In all kinds of lymphadenitis, necrosis shows a general picture, whereas datia Langhans are more dominant in the tuberculous and granulomatous lymphadenitis type. The description of necrosing in lymphadenitis is tuberculous type 176(98.3%), non-specific type 120(83.3%), and granulomatous type 7(77.8%), while datia Langhans cells are more common in 132(73.7%) tuberculosis lymphadenitis, and granulomatous lymphadenitis 7(77.8%), compared with non-specific lymphadenitis 42(29.2%). This study concludes that there is necrosis in almost every type of lymphadenitis, whereas datia Langhans cells are lower in the tuberculous and granulomatous lymphadenitis.

Progressive necrosis of lipid: A case report

A 61-year-old woman was referred to our department with a 11-year-erythra. In the anterior tibia of both lower extremities, we could see large dark red infiltrating erythema, waxy luster, clear boundary, slight central atrophy, depression and capillary dilatation. He was diagnosed with dermatitis contusiformis in local hospitals, but the treatment of traditional Chinese medicine and external drugs was not effective. She had normal laboratory findings for blood routine test, biochemical indexes, C reactive protein(CRP) and erythrocyte sedimentation rate(ESR)．Furthermore, autoimmune antibodies were all negative. The skin pathology showed degeneration and necrosis of collagen fibers, chronic granulomatous inflammation in the dermis, and there were more acute and chronic inflammatory cell infiltration around the small vessels and in the wall of the tube. We eventually diagnosed it as necrobiosis lipoidica (NL) according to the history, erythra morphology and skin pathology. After treatment of low dose hormone and thalidomide for 1 year, the color and range of skin lesions gradually alleviated. NL was a rare chronic granulomatous inflammatory disease. There appeared to be a predominance in females. The incidence of NL was higher in patients with diabetes mellitus, although this asscoiation was currently questioned. NL might also be connected with autoimmune diseases, such as rheumatoid arthritis, sarcoidosis, ulcerative colitis and Crohn's disease. The pathological changes of the tissue were mainly in the dermis, including necrotic type, granulomatous type or mixed type. NL typically presented on the pretibial surface of lower extremities. Less typical locations included the face, scalp, vulva and upper limbs. Leisions usually began with small papules and nodules that gradually infiltrated into brownyellow patches and developed central wax-like atrophy. The diagnosis is often based on clinical examination and skin biopsy. NL is rare and easy to be misdiagnosed. For rheumatologists, we should carefully compare with the nodular erythema, the microscopic polyangitis and allergic purpura. It is significant for differential diagnosis to perform skin biopsy. Lacking of randomized controlled trials, no specific treatment has proven to be the gold standard. First-line therapy mainly consists of intralesional and systemic corticosteriods. Additionally, other reported treatment options include immunomodulator, biological agent, antiplatelet aggregation drug and plateletrich plasma. These patients need long term follow up continuously for progression of the disease, ulcerations, and possibility of malignant tranformation.

LARGE IRREGULAR PIGMENTED MACULE IN THE POSTERIOR EDENTULOUS MANDIBULAR ALVEOLAR RIDGE

We report an unusual case of a 1.5-cm dark macule on the edentulous posterior mandibular alveolar ridge. The lesion affected a 62-year-old woman referred by a clinician to the oral medicine service with suspect of melanoma. Clinical investigation found no signs of pain and discomfort. The patient stated she had not noticed the lesion previously. An excisional biopsy was performed and during the excision a loose brownish granular material within the submucosa and over the mandibular bone surface was seen. This material was curetted and submitted for microscopic evaluation. The histopathologic report described a loosely organized connective tissue with blackened granular agglomerates that also stained the elastic collagen fibers dispersed in the matrix and in the vessel wall leading to a foreign body–type granuloma with focal argyrosis (amalgam tattoo). Postsurgical follow-up of 11 months was uneventful. We report an unusual case of a 1.5-cm dark macule on the edentulous posterior mandibular alveolar ridge. The lesion affected a 62-year-old woman referred by a clinician to the oral medicine service with suspect of melanoma. Clinical investigation found no signs of pain and discomfort. The patient stated she had not noticed the lesion previously. An excisional biopsy was performed and during the excision a loose brownish granular material within the submucosa and over the mandibular bone surface was seen. This material was curetted and submitted for microscopic evaluation. The histopathologic report described a loosely organized connective tissue with blackened granular agglomerates that also stained the elastic collagen fibers dispersed in the matrix and in the vessel wall leading to a foreign body–type granuloma with focal argyrosis (amalgam tattoo). Postsurgical follow-up of 11 months was uneventful.

Predicting the artificial immunity induced by RUTI\xae vaccine against tuberculosis using universal immune system simulator (UISS)

BackgroundTuberculosis (TB) represents a worldwide cause of mortality (it infects one third of the world’s population) affecting mostly developing countries, including India, and recently also developed ones due to the increased mobility of the world population and the evolution of different new bacterial strains capable to provoke multi-drug resistance phenomena. Currently, antitubercular drugs are unable to eradicate subpopulations of Mycobacterium tuberculosis (MTB) bacilli and therapeutic vaccinations have been postulated to overcome some of the critical issues related to the increase of drug-resistant forms and the difficult clinical and public health management of tuberculosis patients. The Horizon 2020 EC funded project “In Silico Trial for Tuberculosis Vaccine Development” (STriTuVaD) to support the identification of new therapeutic interventions against tuberculosis through novel in silico modelling of human immune responses to disease and vaccines, thereby drastically reduce the cost of clinical trials in this critical sector of public healthcare.ResultsWe present the application of the Universal Immune System Simulator (UISS) computational modeling infrastructure as a disease model for TB. The model is capable to simulate the main features and dynamics of the immune system activities i.e., the artificial immunity induced by RUTI® vaccine, a polyantigenic liposomal therapeutic vaccine made of fragments of Mycobacterium tuberculosis cells (FCMtb). Based on the available data coming from phase II Clinical Trial in subjects with latent tuberculosis infection treated with RUTI® and isoniazid, we generated simulation scenarios through validated data in order to tune UISS accordingly to STriTuVaD objectives. The first case simulates the establishment of MTB latent chronic infection with some typical granuloma formation; the second scenario deals with a reactivation phase during latent chronic infection; the third represents the latent chronic disease infection scenario during RUTI® vaccine administration.ConclusionsThe application of this computational modeling strategy helpfully contributes to simulate those mechanisms involved in the early stages and in the progression of tuberculosis infection and to predict how specific therapeutical strategies will act in this scenario. In view of these results, UISS owns the capacity to open the door for a prompt integration of in silico methods within the pipeline of clinical trials, supporting and guiding the testing of treatments in patients affected by tuberculosis.

Histopathological study of dermal granuloma

Introduction: The objectives of this study were to confirm the diagnosis of clinically suspected dermal granuloma- tous diseases by histopathological examination and by routine and special stains as well as to study the incidence of various types of dermal granulomas. Materials And Methods: This study was conducted at the Department of Pathology in collaboration with De- partment of Skin and Venereal disease. A total of 90 cases from outdoor patient department of skin and venereal disease, which were clinically diagnosed as suspected dermal granulomatous diseases, were taken as the study population. Results: In our study, we found that leprosy had the highest incidence (50%), followed by cutaneous tuberculosis (30%) among all dermal granulomatous diseases like syphilis, fungal, granuloma annulare, foreign body, actino- mycosis, and sarcoidosis. Dermal granulomas were most common in middle age between 21 and 40 years of age. Conclusion: Histopathology played an important role in the final diagnosis of dermal granulomatous lesions. Most common dermal granulomatous disease was leprosy, followed by cutaneous tuberculosis.

Choroidal granuloma caused by Mycobacterium Fortuitum

BackgroundTo report a case of a chronic steroid user male patient who developed local abscesses caused by M. fortuitum and concomitant asymptomatic choroidal granuloma.Case presentationA 37-year-old african-american male with history of use of anabolic drugs and intramuscular mineral oil injections in the upper and lower limbs for 15 years for muscular hypertrophy. He developed intramuscular abscesses with systemic infection, sub-retinal lesions in both eyes and alterations in cerebrospinal fluid suggestive of mycobacteria. Considering these findings, empirical treatment for tuberculosis was started, without success. After several negative cultures of the material drained from the abscesses, finally one of the cultures isolated the agent Mycobacterium Fortuitum. Proper treatment for atypical mycobacteria was initiated with clinical and laboratory improvement. After 6 months the sub-retinal lesions regressed.ConclusionsA typical choroidal granuloma caused by M. Fortuitum is a rare presentation of the infection and our report showed a good outcome with proper treatment.

A rare case of shoulder swelling: epithelioid sarcoma- case report

Epitheloid sarcoma is a rare soft tissue sarcoma classified under tumor of uncertain histogenesis. Incidence being 0.4/million/year, it is divided into proximal variant-where in the proximal parts of the body are more involved and distal variant which is commoner and less aggressive of the two predominantly involving distal parts of upper limb followed by distal lower extremities and proximal upper limb. It has a male preponderance (1.8:1), although females have better prognosis comparatively, also it has a tendency of lymphatic spread with 13% metastasis. Recurrence of 77% is reported. Definitive diagnosis is made only on tissue biopsy. Most common variant is pseudo granulomatous type. This case report is based on a case which presented with a single right anterior shoulder swelling and was found to be of epitheloid sarcoma on biopsy. A 60 years old female patient came to OPD of D. Y. Patil Medical College, Pune, with complaints of swelling over her right shoulder since 1 month, initially small and gradually increasing in size of swelling. No history of pain and loss of appetite or weight. On examination, a 4 3 cms firm to hard swelling present over anterior part of right shoulder. It was observed to be non-tender, well defined and mobile. Patient has been investigated with x-ray, FNAC, and ultrasound of the swelling. FNAC was significant other giant cell lesion of soft tissue hence taken up for excision biopsy which showed epitheloid sarcoma on histopathology with faint focal positivity for pancytokeratin and EMA and negative for LCA, CK-3 and S-100.

Neumonitis de hipersensibilidad asociada con exposición a ácido oxálico: partiendo de un caso

INTRODUCCIÓN: la neumonitis de hipersensibilidad (NH; alveolitis alérgica extrínse- ca) es una enfermedad inmunológica pulmonar causada por una respuesta inmunitaria exage- rada a la inhalación de partículas químicas u orgánicas que afectan los alvéolos, bronquiolos terminales e intersticio alveolar. No existen casos reportados de asociación acido oxálico- neumonitis de hipersensibilidad; además, el infradiagnóstico contribuye al mal pronóstico de la enfermedad, lo que motivó a la presentación del caso.DESCRIPCIÓN DEL CASO: se trata de una paciente de 35 años de edad con cuadro de disnea y tos seca crónica después de la exposición no laboral a ácido oxálico, pruebas de función pulmonar con patrón restrictivo, tomografía axial computarizada de alta resolución (TACAR) de tórax con patrón sugestivo de NH y biopsia pulmonar de un granuloma tipo colesterol. Se inició el tratamiento sin respuesta, se solicitó trasplante de pulmón actualmente en lista de espera.DISCUSIÓN: la paciente cumplió criterios para NH sugeridos por Semin y colaborado- res (2012), una vez se retiró de noxa no hubo mejoría de los síntomas, así como tampoco presentó mejoría con el uso de corticosteroides, se considera que el diagnóstico y tratamiento tardíos son elementos que modificaron la respuesta al mismo y finalmente alteraron el pro- nóstico. El trasplante mejora la supervivencia de los pacientes a corto y mediano plazo.