Well-formed Granulomas Research Articles

Gastrointestinal Tuberculosis: 8-year Experience from a Tertiary Care Hospital in North India.

Introduction: Tuberculosis (TB) represents a significant communicable disease on a global scale. The clinical manifestations of abdominal TB frequently resemble those of various gastrointestinal disorders, potentially leading to delays in accurate diagnosis. Materials and methods: From January 2012 to December 2019, consecutive patients aged 12 years and older, diagnosed with gastrointestinal TB at a tertiary care center in North India, were enrolled. Demographic and clinical data, radiological imaging findings, gastrointestinal endoscopy results, and histopathological findings were meticulously recorded. Antitubercular treatment was administered, and gastrointestinal endoscopy was performed upon the completion of treatment. Results: During the study period, 234 patients with gastrointestinal tuberculosis were enrolled, of which 151 (64.5%) were male and 83 (35.5%) were female. The most common presenting symptoms included weight loss (94.9%), abdominal pain (85.9%), fever (51.7%), and diarrhea (30.8%). The ileocecal region was the most frequently affected site (76.1%), followed by segmental colonic TB (17.1%). The most common finding on computed tomography (CT) of abdomen was thickening of the bowel wall with/without local or mesenteric lymphadenopathy. The most common endoscopic lesions were ulcerations (82.0%) followed by nodularity (73.9%), deformed cecum and ileocecal valve (41.9%) and strictures (11.1%). Histopathological examination of endoscopic biopsy revealed, well-formed granulomas in 94 (40.2%), collection of epithelioid cells with Langhans giant cells in 66 (28.2%), and chronic nonspecific inflammatory changes in 74 (31.6%). All patients responded to the antitubercular treatment. Follow-up colonoscopy in 171 (73.1%) patients showed regression of lesions. Conclusion: Gastrointestinal tuberculosis (GiTb) presents with nonspecific symptoms such as weight loss, fever, and abdominal pain, with ileocecal region being most commonly involved. Gastrointestinal endoscopy shows ulceration, nodularity, and strictures as prominent findings. Histopathology and culture were helpful for making diagnosis in almost half of the patients with GiTb. Majority of the patients responded well to antitubercular treatment.

Diagnosis of pulmonary sarcoidosis comorbid with non-specific interstitial pneumonia: a case report

BackgroundAlthough the imaging manifestations of pulmonary sarcoidosis have been described in detail in previous studies, a consensus has not been reached on the imaging presentation of non-specific interstitial pneumonia (NSIP) lookalike pattern as a distinct pattern in the diagnosis of pulmonary sarcoidosis in high-resolution computed tomography (HRCT). No cases of pulmonary sarcoidosis comorbid with NSIP have been reported.Case presentationA 53-year-old male presented to the hospital with a five-year history of recurrent coughing up sputum and a four-year history of shortness of breath. In addition to the typical features of pulmonary sarcoidosis, the patient’s HRCT also showed unexpected interstitial changes in the lower lobes of both lungs, suggesting an NSIP pattern. Histopathology of the lung tissue in this region confirmed well-formed noncaseating epithelioid granulomas and pathological modifications of NSIP. After a rigorous exclusion diagnosis combining the patient’s clinical features, radiological and pathological findings, we diagnosed this patient with pulmonary sarcoidosis comorbid with NSIP.ConclusionsThis suggests that NSIP may act as a rare comorbidity of pulmonary sarcoidosis thereby resulting in the patient’s HRCT presenting differently from routine sarcoidosis imaging.

ISOLATED TUBERCULOSIS OF PAROTID GLAND:A COMMON DISEASE AT AN UNCOMMON LOCATION WITH REVIEW OF LITERATURE

Tuberculosis infection is a common health problem in developing countries like India which is caused by Mycobacterium tuberculosis (MTB). It commonly affects the pulmonary system. Although it can affect any organ of the body but salivary glands especially the parotid gland arethe rarest entity that is involved in tuberculosis. Less than 200 cases have been reported in literature till now and mostly diagnosed in post-parotidectomy specimens. Generally, it presents with a painless growing mass and hence, its clinical diagnosis is challenging and may be misdiagnosed as it can mimic parotid gland neoplasm on physical examination. Radiological investigations such as ultrasonography (USG) and computed tomography (CT) are not much beneficial. In such cases, fine needle aspiration cytology (FNAC) is the preliminary step for the workup of the patients. Histologically diagnosis is confirmed by the presence of well-formed epithelioid cell granuloma and acid-fast bacilli (AFB) stain is positive for tubercular bacilli. Here we report a case of tubercular parotitis in a 50-year-old female diagnosed on histopathological examination and patient treated with anti-tubercular therapy (ATT) successfully.

Relative Value of Immunohistochemistry in Detection of Mycobacterial Antigen in Suspected Cases of Tuberculosis in Tissue Section.

Due to its infectious nature, complex immunological response, chronic progression, and the necessity for long-term treatment, tuberculosis has always been a major health burden. Immunohistochemistry (IHC) has the capacity to highlight the occurrence of mycobacterial antigens for tissue diagnosis. This study was conducted to understand the advantage of immunostaining over culture of Mycobacterium tuberculosis. A cross-sectional study was conducted on 30 samples of suspected cases of tuberculosis. Specimens received were fixed in 10% formalin and processed; 3-5 µm thick sections were made from paraffin block, stained with hematoxylin and eosin, Ziehl-Neelsen stain, and immunohistochemistry. Culture was done using Lowenstein-Jensen medium. Immunohistochemistry was interpreted as fine granular brownish cytoplasmic, coarse granular brownish cytoplasmic, and bacillus staining. Out of the 30 samples studied, 12 (40.0%) were culture positive while 20 (66.7%) of them were IHC positive. Immunohistochemistry showed 17 granulomatous lesions of which 11 (55.0%) were well-formed granulomas. The sensitivity and negative predictive value were found to be high with immunohistochemistry, while specificity and positive predictive value were found to be on the lower side. Among the 20 positive IHC cases, the degree of staining was fine granular cytoplasmic staining in 13 cases (65.0%) and coarse granular staining in 7 cases (35.0%). Immunohistochemistry is a reliable test with high sensitivity as well as high negative predictive value which can be done rapidly for establishing an etiological diagnosis of tuberculosis in histologic specimens.

Histopathological Review of Granuloma in Diagnosis of Tuberculosis Lymphadenitis (TBL)

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis and is the second leading cause of death from an infectious disease. Indonesia has the highest TB cases in West Java, East Java, and Central Java. Tuberculosis lymphadenitis (TBL) represents about 30–40% of cases of extrapulmonary tuberculosis. The study aimed to study the clinical and histopathological characteristics of TBL patients. The research design in this study used an exploratory, descriptive method. Data was taken from Al Islam Hospital Bandung as medical records from January 2019 to December 2020. The result showed that TBL primarily affects patients aged 6–11 years (28%), male gender (57%), patients not working (25%), and those residing in the East Bandung area (34%). Histopathological appearance showed granulomas of caseous necrosis, epithelioid cells, and Langhan's cells, indicated by types 1, 2, and 3. The most common type was type 1 (47%), which was more widely distributed in the right neck (46%) with size 1–3 cm. In conclusion, the frequency of TBL is higher in boys aged 6–11 years, residents of the East Bandung area, and patients who did not work. Well-formed granuloma of enlarged lymph nodes in the right neck with size 1–3 cm is most commonly found in TBL.

Histological findings associated with treatment response in cutaneous leishmaniasis: a clinicopathological correlation study.

Treatment responses to cutaneous leishmaniasis (CL) observed in Sri Lanka show variability, ranging from quick healing to delayed or failed responses to routine medication. The determinants of these differences in treatment response are not well defined. This study aimed to identify predictive features of treatment response and outcome in localized CL caused by Leishmania donovani, focusing on both clinical and histopathological findings in the patients. Tissue sections (n = 103) derived from 3 mm punch biopsies of parasitologically confirmed patients were assessed. Patients were followed up weekly until complete healing of skin lesions and were reviewed at the end of 6 months and 1 year. Healing required 7-21 weekly doses of intralesional sodium stibogluconate (IL-SSG) (mean = 12.2 ± 0.622). Twenty-nine (28.1%) patients were identified as delayed responders. None had recurred at the end of 1 year. The demographic or clinical features (age, gender, lesion type, size, location, and lesion duration) did not significantly influence the treatment response. A heavy parasite load and acanthosis were significant predictors of a delayed response to treatment (P < 0.001). Higher parasite loads were associated with inflammation of the entire dermis (P = 0.008), more intense infiltration of macrophages (p = 0.001), and epidermal atrophy (P = 0.033). Well-formed granulomas were inversely proportional to parasite loads. Histology findings proved to be better prognostic markers than clinical features for delayed responders to treatment and will aid in targeted patient management when tissue biopsies are performed in the initial diagnosis of CL.

Pituitary Tuberculosis - A Rare Case Report

Tuberculosis is an infectious disease primarily affecting lungs and also involves any body organ. Intracranial tuberculosis constitutes about 0.15-5% of all intracranial space-occupying lesions. Pituitary gland as primary site for tuberculosis is very rare. Delayed diagnosis and treatment can result in permanent endocrine dysfunction. Here we present a case in a 44-year-old female presented to the hospital with complaints of progressive worsening headache, left eye pain, and blurred vision for 6 months. Patient was evaluated and radiological workup was done. MRI brain with contrast showed enhancing mass lesion of 1.7x1.4 cm arising from Sella with mass effect on optic chiasma and it was radiologically diagnosed as pituitary adenoma. A biopsy from the pituitary region was obtained and histopathological examination was done. Microscopic examination revealed pituitary gland parenchyma showing well-formed epithelioid granulomas consisting of epithelioid cells, Langhans type of giant cells, and chronic inflammatory cells along with foci of caseous necrosis. The case was finally diagnosed as pituitary tuberculoma. Keywords: Tuberculosis, granuloma, space-occupying lesion, pituitary gland.

Cytomorphological findings in drug defaulters of tuberculous lymphadenitis.

Tuberculosis (TB) is an important health problem specially in the developing countries. Although effective chemotherapy is available, compliance of patient is a major challenge. The aim of this study was to describe cytomorphological features of drug defaulters on lymph node on fine-needle aspiration cytology (FNAC) and compare it with newly diagnosed cases. A cross-sectional study was done for a period of 18 months, in which all patients having tuberculous lymphadenitis were included after taking detailed history regarding previous anti-TB drug intake. Cytomorphological findings in drug defaulters were evaluated and compared with newly diagnosed cases. There were a total of 150 cases with 120 newly diagnosed and 30 drug defaulters. Splintered epithelioid cell granuloma was seen in 40% of drug defaulters, while it was absent in case of newly diagnosed cases (P < 0.0001). Well-formed epithelioid cell granuloma was most commonly seen in newly diagnosed cases (65.83%) followed by poorly formed granuloma (26.67%). Another significant finding was distribution of eosinophils which were significantly high in case of drug defaulters (56.67%) (P < 0.0001). Cytomorphological findings can help in identification of the drug defaulters on FNAC and thus plan further line of treatment.

A Complex Case of Pulmonary Silico-Tuberculosis and Review of Literature.

Silicosis caused by the inhalation/deposition of free silica particles is characterized by pulmonary inflammation/fibrosis. Among the clinical disorders associated with silicosis, tuberculosis is by far the most prominent. A 66-year-old male non-smoker, originally from North Africa, reported a dry cough and significant weight loss. He was a foundry worker. He had a medical history of bladder carcinoma associated with schistosomiasis. Computed tomography (CT) and positron emission tomography (PET)/CT showed bilateral multiple hypermetabolic lung nodules, some with cavitation. The patient underwent surgical resection of the largest nodule, which was highly suspicious of lung metastasis. The histological examination revealed multiple nodular formations. Several lesions showed the characteristic features of silicotic nodules. There were also adjacent well-formed granulomas, some with central caseous necrosis. A real-time polymerase chain reaction, performed for the identification and quantification of the DNA of the Mycobacterium tuberculosis complex, was positive. Pulmonary silico-tuberculosis is often encountered in patients with a history of silica exposure in tuberculosis-endemic areas. This case serves as a reminder to never underestimate patient occupational exposure and geographic origin. A careful histological diagnosis and molecular investigation are mandatory when approaching difficult cases, especially patients with a prior cancer history and clinical/radiological features suggestive of tumour recurrence/metastasis.

Unusual features of neurosarcoidosis: A 18-year retrospective

BackgroundNeurosarcoidosis (NS) is a challenging diagnosis for clinicians and pathologists. NS most often presents with leptomeningeal involvement where it mimics infectious or neoplastic meningitis, and in up to half of cases, systemic signs of sarcoidosis are lacking. Rare presentations include dural-based mass(es) (mimicking meningioma), hypothalamic/sellar-based lesions (mimicking pituitary adenoma), or as myelopathy (mimicking tumor or neurodegenerative condition). For pathologists, the morphological effects of prior therapy are not well documented. NS as an unsuspected cause of demise today is even less well known. MethodsSearch of departmental databases and personal files, 2004–2022, for NS cases, with focus on the subset with features of interest to pathologists. Results22 cases were identified (8 M: 14F, 13–66 years), in 11 of which the CNS specimen represented first diagnosis of sarcoidosis. 20 were surgical and 2 were autopsy cases. Focus of the study revolved around 2 surgical cases with NS granulomas intimately admixed with tumor (1 meningoma, 1 gonadotroph pituitary adenoma/pituitary neuroendocrine tumor (PitNET). One surgical and one autopsy case each had decrease in lymphocytes and well-formed granulomas, with increased fibrosis and hemosiderin in post-treatment tissues. We speculate, but cannot prove, that this may be due to prior steroid therapy. Both autopsy cases were women (38, 43-years), both with cauda equina syndrome/ progressive weakness as first presentation, and extensive spinal cord/nerve root sarcoidosis at demise. First diagnosis of NS/sarcoidosis was at autopsy in the 38-year-old. ConclusionsUnusual features for pathologists are that NS can co-exist within benign tumors, prior therapy alters histological features, and even in the modern era, may be first diagnosed at autopsy.

P11 Acrodermatitis chronica atrophicans: a sign of late lyme disease

Abstract Borrelia infection manifests a variety of signs and symptoms, and its insidiousness and heterogeneity mean that its diagnosis can be delayed. We describe two patients from south-east Scotland who presented with unilateral asymptomatic atrophic areas of skin discoloration. The first was a 71-year-old woman, who presented with a 4-month history of a nonprogressive, mottled, erythematous rash involving her right thigh, buttock and calf. Case 2 was a 56-year-old woman with a 2-year history of an erythematous area of atrophic skin involving the medial aspect of her left thigh and shin. Histology from case 1 showed a normal epidermis with a largely ‘top-heavy’ superficial and deep, predominantly interstitial and focally perivascular, lymphohistiocytic infiltrate, with a predominance of mononuclear histiocytes and with focal extension to deep reticular dermis. Scattered plasma cells were identified, but eosinophils were not a prominent feature. Well-formed granulomas were absent, as were interface dermatitic activity and vasculitic changes. On close questioning, each patient remembered ‘insect’ bites in the vicinity of the cutaneous changes, although neither recalled rashes that could have been consistent with erythema chronicum migrans. In both cases, serology confirmed infection with Borrelia burgdorferi (sensu lato) and diagnoses of acrodermatitis chronica atrophicans (ACA) were made. Both patients responded well to oral treatment with doxycycline. ACA is a cutaneous sign of late-stage Lyme disease and is caused by ongoing active skin infection by tick-borne bacteria of the Lyme disease group of Borrelia species. The tick bite has usually occurred months or years before symptom onset. Typically, there is an early, unilateral inflammatory stage with bluish-red discoloration of the skin and an oedematous appearance. This is followed by an atrophic stage where the skin becomes thin and wrinkled (‘cigarette paper’-like), with the loss of epidermal and dermal structures. Histological features usually include marked atrophy of the epidermis and dermis, loss of adnexal structures and an absence of elastic tissue. A band-like lymphocytic infiltration with plasma cells and mast cells is seen in the dermis, especially in the early stage of disease. Laboratory-confirmed cases of Lyme borreliosis in the UK have risen steadily since reporting began in 1986. ACA is likely to be underdiagnosed and, if there is a clinical suspicion, a detailed history, careful skin examination, Borrelia serology and skin biopsy should be undertaken. Early recognition and treatment reduce the risk of irreversible skin changes and systemic symptoms.

Clinical and Histopathologic Characteristics of Recurrent Sarcoidosis in Posttransplant Lungs: 25 Years of Experience.

Lung transplantation is the definitive therapy for end-stage pulmonary sarcoidosis. While recurrent sarcoidosis in allografts has been described in several case reports, the incidence and clinicopathologic characteristics remain unclear. In this study, we characterize the clinical and histopathologic features of recurrent sarcoidosis diagnosed in posttransplant lung surveillance transbronchial biopsies (TBBx). We identified 35 patients who underwent lung transplant for pulmonary sarcoidosis during the study period. Among them, 18 patients (51%) experienced recurrent sarcoidosis posttransplant. These included 7 females and 11 males with mean age at recurrence of 51.6 years. The average time interval from transplant to recurrence was 252 days (22 to 984d). All TBBx contained >4 pieces of alveolated lung tissue with no evidence of International Society for Heart and Lung Transplantation (ISHLT) grade A2, A3, or A4 acute cellular rejection; chronic rejection; or antibody-mediated rejection. There were 33 surveillance TBBx that contained granulomatous inflammation with a mean of 3.6 well-formed granulomas per TBBx (range: 1 to >20). Multinucleated giant cells were identified in 11 TBBx (33.3%), with 1 case containing asteroid bodies. While most of the granulomas were "naked granulomas," 5 cases (15.2%) showed prominent lymphoid cuffing. Two cases showed evidence of fibrosis. One of the granulomas had focal necrosis; however, no infectious organisms were identified by special stains and clinical correlation suggested this case represented recurrent sarcoidosis. Biopsies of recurrent sarcoidosis usually show multiple well-formed granulomas with giant cells in more than half of the cases, while lymphoid cuffing, fibrosis, asteroid bodies, and necrotizing granulomas are uncommon findings. Pathologists should be aware of these features, as recurrence of sarcoidosis following lung transplant occurs in more than half of patients.

Primary extranodal soft tissue Lennert lymphoma (lymphoepithelioid variant of peripheral T-cell lymphoma, unspecified): a case report and review of the literature

Lennert lymphoma (LeL) is a rare variant of peripheral T-cell lymphoma, not otherwise specified (PTCL/NOS) that is rich in epithelioid histiocytes. LeL may pose great diagnostic and therapeutic challenges to the pathologist and clinician. Primary extranodal soft tissue LeL is even rarer and has not been reported. Herein, we report a case of LeL arising from soft tissue.A 65-year-old male presented for evaluation of a painless mass in the subcutaneous soft tissue of the left forehead. There was no invasion of the bone and no ulceration on the surface of the skin. The surrounding skin was erythematous and swollen. Grossly, the tumor was gray-red and 30 mm × 20 mm × 10 mm in size.Microscopically, the demarcation between the lesion and surrounding tissues was unclear without a capsule. The tumor invaded the surrounding striated muscle and adipose tissue. The tumor had a diffuse proliferation of small-sized atypical lymphocytes and numerous large clusters of epithelioid histiocytes. Plasma cells, eosinophils, and Hodgkin-Reed-Sternberg (HRS) cells were not identified. Rare multinucleated histiocytes were noted, and well-formed granulomas were not present. Rare mitotic figures were noted, but no necrosis. The immunophenotypic features in this case were as follows: CD2+/CD3+/CD5low+/CD7+/CD4low+/ CD8+/CD30−/CD56− in neoplastic lymphocytes; CD163+/CD31+/CK(pan)− in epithelioid histiocytes; and CD20−/CD30−/TdT−/CD5−/ALK−/S-100−/CD1α−/CD21 + 23−/SSTR2− in neoplastic lymphocytes and epithelioid histiocytes. Epstein-Barr virus (EBV)-encoded RNA in situ hybridization (EBER-ISH) was negative. The Ki-67 index was elevated to 60%. PCR showed a polyclonal pattern for IgH and a monoclonal TCR γ-chain rearrangement.The final diagnosis was PTCL/NOS, lymphoepithelioid cell variant (LeL), which arose from soft tissue and had a rare double-positive CD4low+/CD8+ immunophenotype. The patient received four cycles of cyclophosphamide, doxorubicin liposomes, vincristine, and prednisone tablets (CHOP) and was followed for 20 months. Overall treatment efficacy was achieved without lymphadenopathy, and no other discomfort or illnesses were reported.

Cutaneous Sarcoidosis Masquerading as Papular Amyloidosis Revealed Post--Hair Removal.

Cutaneous Sarcoidosis Masquerading as Papular Amyloidosis Revealed Post--Hair Removal.

Reporting of mycetoma cases from skin and soft tissue biopsies over a period of ten years: A single center report and literature review from Pakistan

Mycetoma is an important neglected tropical disease associated with debilitation, disfigurement and death if not diagnosed and treated adequately. In Pakistan, mycetoma cases have frequently been diagnosed in histopathology and microbiology laboratories. However, there is scarcity of published data from this country. Therefore, the objectives of this study were to evaluate the frequency and type of mycetoma reported in skin and soft tissue biopsies from a single center over 10 years and review of published literature from Pakistan. This descriptive observational retrospective study was conducted at the Aga Khan University Hospital laboratory, Karachi, Pakistan. Laboratory data from 2009-2018 of skin and soft tissue biopsies with positive findings of mycetoma were retrieved from hospital information system. The variables for statistical analysis were age and gender of patient, anatomical site of lesion, residence of patient (geographical location) in the country, etiologic agents of mycetoma and significant gross and microscopic histopathological findings. The data was entered, and descriptive epidemiologic assessment was carried out using MS excel 2013. Geographical information system was used for mapping the location. Literature review of mycetoma cases reported from Pakistan was done on PubMed, Google search and PakMediNet from 1980 till April 2019. During ten years of study period, 89 skin and soft tissue biopsies were reported as mycetoma, majority were eumycetoma [n = 66/89 (74%)] followed by actinomycetoma [n = 23/89 (26%)]. Involvement of lower limb was predominantly observed [n = 74/89 (83%)] in which foot had significant contribution [n = 65/74 (88%)]. Only 18 specimens were submitted for microbiological assessment and six grew agents of mycetoma, with Madurella mycetomatis reported in only three. Well-formed granuloma formation was observed in only 26%[n = 23/89] of cases. Specific geographical location was not identified, and cases were reported from across the country. From Pakistan, only two original papers and 7 case reports were available in published literature. This single center study reports a handful of cases of mycetoma from Pakistan. We conclude that the index of suspicion should remain high among treating surgeons and physicians and clinical laboratories should improve their diagnostic capacity and skills. This will have a great impact on disease outcome and patient's life.

Microgranulomas at Diagnosis Are Associated With Need for Antitumor Necrosis Factor Escalation in Pediatric Crohn Disease.

Granulomas are a pathologic hallmark of Crohn disease (CD) although they are found in only a subset of patients. Well-formed granulomas are associated with an aggressive phenotype although it is unknown if microgranulomas confer a similar phenotype. This study sought to define the incidence of microgranulomas in pediatric CD and compare the clinical course with cases with granulomas and those without granulomatous inflammation. We performed a single-center, retrospective study of pediatric CD patients who had at least 3 years of follow-up. initial diagnostic biopsies were systematically re-examined by a gastrointestinal pathologist. A priori definitions of granuloma (10+ histiocytes) and microgranuloma (4-9 histiocytes) were used. Disease outcomes of hospitalization, development of complicated disease behavior, perianal disease, and the use of anti-tumor necrosis factor (anti-TNF) therapy were assessed by Kaplan-Meier survival plots. This study included 138 subjects with an average follow-up of 4.6 years. Granulomas were seen in 38 of 138 subjects (27.5%) and an additional 38 subjects (27.5%) had at least 1 microgranuloma (in the absence of granulomas). Escalation to anti-TNF therapy was higher in CD with granulomas (P = 0.001) and microgranulomas (P = 0.0001) compared with those without granulomatous inflammation. A significant subset of pediatric CD patients have microgranulomas (in the absence of well-defined granulomas). Children with CD who have microgranulomas are escalated to anti-TNF therapy more frequently than those without granulomatous inflammation (and at a similar rate to those with granulomas). Pathologists should have a low threshold to report microgranulomas as they may help to predict disease behavior.

Can infections trigger sarcoidosis?

Can infections trigger sarcoidosis?

Refractory feline sporotrichosis: a comparative analysis on the clinical, histopathological, and cytopathological aspects

ABSTRACT: Sporotrichosis is a chronic fungal infection caused by Sporothrix species. The occurrence of cases that are resistant to long-term treatment, especially in the nasal planum of cats, emphasizes the importance of studying its pathogenesis. The purpose of this study was to analyze and compare the inflammatory process of cutaneous lesions of feline refractory sporotrichosis to clinical aspects through cytopathological and histopathological examination. Moreover, the study included 13 cats with cutaneous lesions that had been resistant to itraconazole treatment for more than a year. Cutaneous lesions samples were collected for cytopathological, histopathological, and fungal culture analyses. Tissue fragments were processed and stained with hematoxylin-eosin (HE) and Grocott methenamine silver (GMS). Further, two clinical presentations had the highest occurrence: the localized cutaneous form in animals with good general condition and stable disease (n=9, 69.2%) and the disseminated cutaneous form in cats with poor general condition (n=4, 30.8%). In cats with refractory sporotrichosis, the nasal planum (84.6%) was the most common location of lesions. In the cytopathological study, cats with fewer than two lesions and in good general condition (n=9, 69.2%) showed absence or mild yeast intensity (up to 5 yeasts per field), lower intensity of macrophages and neutrophils, and higher intensity of epithelioid cells, lymphocytes, plasma cells, and eosinophils. On the other hand, (n=4, 30.8%) of the cats with disseminated sporotrichosis and a poor general condition had a marked intensity of yeasts, which were mostly phagocytosed by an increased number of macrophages and neutrophils. Of those animals with good general condition, the majority (n=6, 66.7%) had higher eosinophil intensity. In histopathology, malformed suppurative granuloma was the predominant type (n=9, 69.2%) in feline sporotrichosis lesions, followed by well-formed granulomas (n=4, 30.8%). Malformed granulomas showed mild to moderate fungal intensity (55.6%) in animals with good general condition and localized lesions while marked fungal intensity (44.4%) in cats with the disseminated form of the disease and poor general condition. Well-formed granulomas (n=4, 30.7%) had mild to moderate intensity of fungal load, and 75% of the animals with this type of granuloma had only one lesion and were in good general condition. Long-term itraconazole treatment in these cats with refractory sporotrichosis can keep the infection under control and localized lesions stable; however, fungus reactivation can occur, resulting in an exuberant and inefficient immune response.

MUSCULAR TUBERCULOSIS: RARE PRESENTATION OF A COMMON ENTITY

Tuberculosis is a global health problem mainly affecting people in developing countries although muscular involvement is rarely seen. Authors hereby, describe a case of tuberculosis of triceps muscle in a 35-year-old immunocompetent female who presented with swelling in right upper arm. Radiological examination ruled out involvement of underlying bones. Excision biopsy was performed and on histopathological examination cyst wall showed presence of foamy macrophages in sheets, inammatory cells and few scattered epithelioid cells but no well-formed granulomas or giant cells were seen. ZN stain for acid fast bacilli was positive. Based on the above ndings a diagnosis of tuberculosis of triceps muscle was made. The patient responded well to antituberculosis therapy and is currently on follow up.

A SOLITARY ENDOBRONCHIAL BRONCHOLITH AS AN UNCOMMON PRESENTATION OF HISTOPLASMOSIS

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Broncholithiasis refers to calcified material within the airway lumen, often resulting from granulomatous reaction to endemic pathogens such as M. tuberculosis or Histoplasma, or aspiration of foreign material. Histoplasma broncholiths are thought to originate from adjacent lymph nodes that erode into the airway lumen. Here we present a case of a large isolated endobronchial broncholith secondary to Histoplasma without associated lymphadenopathy or parenchymal lung lesions. CASE PRESENTATION: A 69 year-old female with GERD presented with one month of dyspnea, cough, and wheezing thought to occur after a popcorn kernel aspiration. She was treated twice for bronchitis without improvement and was diagnosed with COPD based on obstruction on spirometry. The patient denied smoking or other inhalational exposures. Vital signs and oxygenation were normal on our evaluation. A CT pulmonary angiogram showed a 1.3 cm calcified foreign body (FB) consistent with an aspirated tooth in the left mainstem bronchus without significant lymphadenopathy. Bronchoscopy showed a white-yellow multilobulated FB partially embedded in and nearly occluding the left mainstem bronchus. Removal of the FB revealed a deep but not transmural ulceration of the mucosa. Though it grossly resembled a popcorn kernel, histologic examination of the broncholith showed well-formed granulomas and yeast forms consistent with Histoplasma capsulatum. The patient felt immediate relief of dyspnea post-removal and on follow up denied any symptoms. She was discharged and scheduled for repeat testing to ensure no further evidence of fungal disease. DISCUSSION: Although broncholithiasis from Histoplasma granulomata is common, to our knowledge this is the first report of the disease presenting as a solitary endobronchial broncholith. Given that no adjacent lymphadenopathy and/or calcifications were noted on CT, this case was likely secondary to calcification of a primary endobronchial inoculum. Patients with symptomatic or obstructing broncholithiasis should undergo attempted removal either with bronchoscopy or surgical intervention. Bronchoscopic removal should be undertaken with great caution since the extraluminal origin of many broncholiths can result in airway perforation or major hemorrhage with manipulation. Large broncholiths such as this sometimes require laser lithotripsy to facilitate extraction. CONCLUSIONS: Broncholithiasis is a condition often associated with pulmonary and mediastinal histoplasmosis and can present with transmural bronchial invasion. Isolated endobronchial lesions are uncommon. Prompt imaging and endoscopic evaluation is key to accurate diagnosis. Careful consideration of transmural extension and involvement of extrabronchial structures is crucial. REFERENCE #1: Alshabani K, Ghosh S, Arrossi AV, Mehta AC. Broncholithiasis: A Review. Chest. 2019 Sep;156(3):445-455. REFERENCE #2: Krishnan S, Kniese CM, Mankins M, Heitkamp DE, Sheski FD, Kesler KA. Management of broncholithiasis. J Thorac Dis. 2018;10(Suppl 28):S3419-S3427. REFERENCE #3: Olson EJ, Utz JP, Prakash UB. Therapeutic bronchoscopy in broncholithiasis. Am J Respir Crit Care Med. 1999 Sep;160(3):766-70. DISCLOSURES: No relevant relationships by Gregory Eisinger, source=Web Response No relevant relationships by Molly Howsare, source=Web Response No relevant relationships by Meghana Moodabagil, source=Web Response No relevant relationships by Alberto Revelo, source=Web Response No relevant relationships by Konstantin Shilo, source=Web Response