what is granuloma?

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WHAT IS GRANULOMA?

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What is granuloma? Mechanism? Why? Differential diagnosis?

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Granuloma

A granuloma is a focal area of granulomatous inflammation.

Macrophages that are transformed into epithelium like cells

Mononuclear leukocytes (principally lymphocytes and plasma cells)

Giant cells Two types- pathogenetically

Foreign body type Immune granulomas

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Epitheloid cells

Pale pink granular cytoplasm Indistinct cell boundaries The nucleus is oval or elongate, folding of the

nuclear membrane

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Giant cells

Fusion of the epitheloid cells Located at the center or periphery of

granulomas 40-50 milimicron 20 or more small nuclei Location of nuclei

Peripherically in Langhans-type Haphazardly in foreign-body type

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Foreign body granuloma

Material large enough to preclude phagocytosis, and do not incite either an inflammatory or an immune response

Talc, sutures ec. The foreign body can be identified

(with polarized light)

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Immune granuloma

Insolubl particles Cell- mediated ımmun response Macrophages T cells

cytokines (IL-2)

IFN-gamma Granuloma

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GRANULOMATOUS LESIONS OF THE LUNG

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GRANULOMATOUS LESIONS OF THE LUNG- CLASSIFICATION

1) INFECTIOUS

2) NON-INFECTIOUS

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Infectious granulomatous diseases Bacterial

Actinomycosis, botryomycosis, nocardiosis, Mycobacterial Fungal

Pnömosistis Protozoal

Dirofilaria Parasitic Aspiration pneumonitis

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NON-INFECTİOUSgranulomatous disease Wegener granulomatosis Rheumatoid nodule Bronchocentric granulomatosis Churg- Strauss Syndrome Sarcoidosis Necrotizing sarcoid granulomatosis Pulmonary hyalinizing granuloma Extrinsik allergic alveolitis Drug reaction

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Non infectious granulomatous diseases Eosinophilic pneumonitis Nodular amyloidosis Giant cell reaction Exogen lipoid pneumonia Intravenous drug reaction Pneuomoconiosis (Berylliosis) Localised bronchiectasis Lymphoma (Hodgkins’)

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Diagnostic approach

Clinical information Anamnesis Clinical findings

Acute, subacute, chronic

Radiologic findings Histopathological pattern analysis

Pattern analysis Components of granuloma

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Histopathological pattern analysis Angiosentrik Bronchocentric-bronchiolocentric Pleural-subpleural Lymphatic disttribution Peripheral acinar Septal changes Random distribution Airspace consolidation Diffuse interstitial infiltration

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Components of granuloma

Epitheloid histiocytes Giant cells Lymhoid cells Neutrophils Necrosis Abscess. Foreign body, cyrstal, infectious agent,

deposition of material

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Infectıous granulomas

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Tuberculoid granuloma

Peribronchioler, interstitial, perivascular Cellular, necrotic Langhans type giant cell Lymphocytes, few neutrophiles No foreign body!

Clinical and microbiological investigation

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Fungal granuloma

Interstitial, perivascular Cellular, necrotic Foreign body type giant cell Lymhoid cells,neutrophils Grocott, PAS vs special stains

Microbiological investigation

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Non infectious granulomas

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Granuloma of immune response

Rective to tumor Draniage lymph nodes Lymphoproliferative diseases Underlying disease

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Sarcodosis

Interstitial, pleural, Lymphatic distribution perivacular

Cellular, small fibrinoid – coagulative necrosis Giant cells- asteroid body Schaumann body Lymphocytes Large necrosis-in necrotizing sarcoidosis

neutrophiles

Clinical information

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Bronchocentric granulomatosis Bronchiolocentric Necrotising Giant cell Lymphocytes- neutrophiles-eosinophiles Grocott, PAS

Asthma and aspergillosis

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Pneumoconiosis

Interstitial, lymphatic distribution Cellular, necrotic. Foreign body type giant cells Lymphocytes Crystal

Clinical story

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Wegener granuloma

Interstitial, vascular (rarely pleural, septal,bronchocentrically)

Cellular, necrotic (rarely fibrinoid) Giant cells İnflammatory backgroud, neutrophiles,

abscesses formation, geographic necrosis Absence of sarcoid type granuloma. Vascular dyes CLINICAL INFORMATION

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Churg-Strauss

Interstitial, vascular (small sized vessels) Cellular, necrotic Small granulomas Giant cells Eosinophils Vascular dyes

CLINICAL INFORMATION

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Collagen vascular diseases

Pleural, septal. Cellular, necrotic (Fibrinoid necrosis) Palisaded histiocytes-fibrosis- lymphocytes No inflammatory background

CLINICAL INFORMATION

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Interstitial diseases with granuloma Peribronchioler, interstitial, perivascular Cellular, necrotic Langhans type or foreign body type giant

cells

Additional features- Clinical information

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DIFFERENTIAL DIAGNOSIS

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PATTERN ANALYSIS

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GRANULOMA

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sarkoidoz

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NECROSIS

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tbc

Br

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Kollagen doku has

tbc

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wegener

tbc

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INFLAMMATORY CELLS

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wegener

Eozinofil pnömoni

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Eks al

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GIANT CELLS

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Last words

Granuloma is a part of granulomatous inflammation Foreign type and immune granuloma Several reasons

Infectious Non-infectious

Two main group With necrosis Without necrosis

Clinical+ Radiological+Pathological

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