Regression course of ostium granulomas under topical intranasal steroids coverage after endoscopic dacryocystorhinostomy.

This study aimed to elucidate the regression process of ostium granulomas under the usage of intranasal steroid after primary endoscopic dacryocystorhinostomy (DCR). The authors retrospectively reviewed 57 patients (a total of 72 ostia) who had ostium granulomas after primary endoscopic DCR between 2011 and 2015. Topical intranasal steroid spray was applied in all the patients since postoperative day 1. Adjunctive intralesional triamcinolone acetonide injections were administered for extensive and large-sized granulomas that caused impending ostium blockage. Sequential regression of the ostium granulomas and success rates of DCR were assessed using endoscopic photos. The granulomas completely disappeared in 69 (95.8%) ostia, and the average time interval from the surgery to the disappearance was 6.9 ± 2.8 months. Anatomical and functional surgical success rates were 90.3% and 84.7%, respectively. Intralesional steroid injections for ostium granulomas did not alter the outcomes compared to topical intranasal steroid usage significantly (p = 0.445). In conclusion, we observed that, by continuing the usage of intranasal steroids, ostium granulomas disappear gradually at postoperative 6 months. The intranasal surgical manipulation of granulomas, which results in more mucosal cicatricial change and impedes patient satisfaction, can be successfully avoided.

Rare manifestations of sarcoidosis in a young boy.

Sarcoidosis is a chronic multisystem granulomatous disease of unknown etiology. It is rare in young children. A 9-year-old boy presented with failure to thrive, skin rashes, persistent fever, and respiratory symptoms since 5 years of age. Blood investigations done showed elevated serum calcium and angiotensin converting enzyme levels and biopsy of the rashes on the left shin revealed non-caseating granulomatous lesion. Computed tomography of chest revealed interstitial lung disease and examination of eyes showed bilateral uveitis. He also had sensorineural hearing impairment, nephrocalcinosis, and short stature. The patient was treated with oral steroids and mycophenolate mofetil. At follow up, there was improvement in his systemic features including rashes and arthritis. Early detection, diagnosis, and appropriate treatment of sarcoidosis are vital for disease control and to avoid morbidity.

Cytomorphological findings in confirmed cases of tubercular lymphadenitis.

Objective: Tuberculosis (TB) remains a major health problem, especially in the developing countries. Fine-needle aspiration cytology is the first line of investigation for tubercular lymphadenitis as it is easy to perform, less invasive, quick, and economical. The typical cytopathological features of tuberculosis TB include epithelioid cell granulomas with Langhans giant cells and caseous necrosis. The present study aimed to evaluate the cytomorphological features of newly diagnosed cases of tubercular lymphadenitis confirmed by GeneXpert. Material and Methods: This was a retrospective study in which all fine-needle aspirates from newly diagnosed cases of tubercular lymphadenitis confirmed by GeneXpert over a 1-year period from July 2022 to July 2023 were included in the study. The May-Grunwald-Giemsa stained smears from these aspirates were categorized into three patterns-epithelioid cell granulomas with necrosis, epithelioid granulomas without necrosis, and necrosis only. The granulomas were further categorized into well-formed, ill--formed, and splintered. The background of the aspirate which included a reactive lymphoid background, lymphocytes, eosinophils, and neutrophils was tabulated for all the cases. Results: Out of the three cytomorphological patterns, epithelioid granulomas with necrosis were the most predominant (67.5%), followed by necrosis only (20.8%) and granulomas without necrosis (11.6%). An acid-fast bacilli (AFB) positivity of 53.3% (64 cases) was seen on the Ziehl-Neelsen stain. Well-composed, poorly formed, and splintered granulomas were seen in 55 (57.9%), 42 (44.2%), and 21 (22.1%) cases, respectively. Neutrophils were the most common background population (42, 35%) followed by lymphocytes (36, 30%). Reactive lymphoid cells and eosinophils were seen in 12 (10%) and 3 (2.5%) cases, respectively. Conclusion: Fine-needle aspiration cytology is a rapid inexpensive minimally invasive test for tubercular lymphadenitis as epithelioid cell granulomas along with caseous necrosis are highly suggestive of TB. However, manual acid-fast AFB detection has a low sensitivity as is illustrated in the present study where only AFBwas demonstrated in only 53.3% of cases.

Granuloma Annulare Exhibits Mixed Immune and Macrophage Polarization Profiles with Spatial Transcriptomics.

Granuloma annulare (GA) is an idiopathic condition characterized by granulomatous inflammation in the skin. Prior studies have suggested that GA develops from various triggers, leading to a complex interplay involving innate and adaptive immunity, tissue remodeling, and fibrosis. Macrophages are the major immune cells comprising GA granulomas; however, the molecular drivers and inflammatory signaling cascade behind macrophage activation are poorly understood. Histologically, GA exhibits both palisaded and interstitial patterns on histology; however, the molecular composition of GA at the spatial level remains unexplored. GA is a condition without Food and Drug Administration-approved therapies despite the significant impact of GA on QOL. Spatial transcriptomics is a valuable tool for profiling localized, genome-wide gene expression changes across tissues, with emerging applications in clinical medicine. To improve our understanding of the spatially localized gene expression patterns underlying GA, we profiled the spatial gene expression landscape from 6 patients with GA. Our findings revealed mixed T helper 1 and T helper 2 signals comprising the GA microenvironment and spatially distinct M1 and M2 macrophage polarization characteristics. IFN-γ and TNF signals emerged as important regulators of GA granulomatous inflammation, and IL-32 emerged as a key driver of granulomatous inflammation. Overall, our spatial transcriptomics data indicate that GA exhibits mixed immune and macrophage polarization.

Pulmonary granulomas confirmed in Blau syndrome using TBLC specimens: Case report.

Blau syndrome (BS), is an autoinflammatory granulomatosis disease characterized by a distinct triad of skin, joint, and eye disorders similar to those of sarcoidosis, but the lung involvement frequently observed in sarcoidosis are rare. Granulomas from patients with BS displayed a distinct morphology indicating an exuberant chronic inflammatory response. Patients with BS may have granulomatous lung lesions, which require early diagnosis. To determine whether therapeutic intervention is needed for lung lesions, examining transbronchial lung cryobiopsy specimens and accumulating cases of BS with lung involvement could be contributed to improving BS management in the future.

Tuberculosis extrapulmonar en paciente embarazada. Reporte de caso / Extrapulmonary Tuberculosis in Pregnant Patient. Case Report

Introducción: La tuberculosis (TB) extrapulmonar es la afectación de cualquier órgano, sin compromiso pulmonar demostrado, como consecuencia de la diseminación hematógena/linfática del bacilo de Koch. Presentación de caso: Paciente en puerperio inmediato cursando cuadro clínico de gonalgia que se estudió con resonancia magnética que mostró lesión endomedular en región distal del fémur izquierdo. Se estudió con tomografía de tórax, abdomen y pelvis que evidenciaron otras lesiones a nivel esplénico, sin compromiso hepático ni pulmonar. Se realizó punción diagnóstica femoral con evidencia de granulomas con necrosis central. Se interpretó tuberculosis extrapulmonar y se inició tratamiento antifímico con mejora sintomática. Discusión: La TB extrapulmonar puede impactar a nivel de pleura, ganglios linfáticos, vías urinarias, sistema osteoarticular, sistema nervioso central y abdomen. En el embarazo, la prevalencia de TB extrapulmonar es baja. Conclusión: La TB femoral y esplénica concomitante en pacientes embarazadas es un hallazgo infrecuente por lo que su análisis resulta de gran importancia. Arribar al diagnóstico requiere un elevado índice de sospecha. El retraso diagnóstico conlleva a un aumento de la morbimortalidad

Introduction: Extrapulmonary tuberculosis (TB) is the involvement of any organ, without demonstrated pulmonary involvement, as a consequence of the hematogenous/lymphatic dissemination of the Koch bacillus. Case presentation: Patient in the immediate postpartum period with clinical symptoms of gonalgia that was studied with magnetic resonance imaging showing intramedullary lesion in the distal region of the left femur. A CT scan of the chest, abdomen and pelvis showed other lesions at the splenic level, without liver or lung involvement. A femoral diagnostic puncture was performed with evidence of granulomas with central necrosis. Extrapulmonary tuberculosis was interpreted and antifimic treatment was started with symptomatic improvement. Discussion: Extrapulmonary TB can impact the pleura, lymph nodes, urinary tract, osteoarticular system, central nervous system and abdomen. During pregnancy, the prevalence of extrapulmonary TB is low. Conclusion: Concomitant femoral and splenic TB in pregnant patients is a rare finding, which is why its analysis is of great importance. Arriving at a diagnosis requires a high index of suspicion. Delayed diagnosis leads to an increase in morbidity and mortalit

Bilateral swelling of the lacrimal glands as first manifestation of systemic sarcoidosis in a patient with breast cancer.

Sarcoidosis, a multifaceted granulomatous disease primarily affecting the lungs, occasionally presents in atypical locations. Lacrimal gland involvement, though rare, poses distinct diagnostic challenges. This case report details a 52-year-old female with bilateral lacrimal gland swelling initially suggestive of metastatic tumor due to a history of breast cancer. Subsequent investigations, including CT and MRI, unveiled pulmonary sarcoidosis. Discussion emphasizes the diverse ocular manifestations of sarcoidosis, with lacrimal gland participation potentially indicating early stages. Diagnostic complexities involve differentiation from other lacrimal pathologies, including neoplasms, lymphoproliferative disorders, Sjögren's syndrome, Wegener's granulomatosis, tuberculosis, and IgG4-related disease. In summary, while lacrimal gland involvement in sarcoidosis is infrequent, it should be considered in orbital masses, necessitating a comprehensive approach for accurate diagnostic orientation in such cases.

Idiopathic Granulomatous Vulvitis: A Case Report on a Rare Disease.

Idiopathic granulomatous vulvitis is an uncommon anogenital area disease described in the last few decades. It causes an inflammatory reaction that culminates in swelling and possibly distortion of the female anogenital area. Many reported cases consider this non-infectious entity the genital counterpart to granulomatous cheilitis. We here present a 64 years old female patient with idiopathic granulomatous vulvitis co-existing with lipodermatosclerosis, with the excellent response of the former condition to hydroxychloroquine and potent topical steroids.

Lung Cancer Screening: All That Glitters Is Not Gold.

Lung cancer screening with low-dose computed tomography (LDCT) can significantly improve survival rates with early detection. With the increased amount of imaging studies being performed for screening, there are more incidental lesions found. Malignancy and pulmonary infections are two of the major differentials when a lesion is found on CT. Neither a CT scan nor a positron emission tomography can reliably differentiate between malignancy and infectious lesions. Here, we present an unexpected case of multiple nodules detected on LDCT that was performed for lung cancer screening and the workup that was done to lead to a diagnosis.

Sex-dependent vulnerability for Wistar rats model following intranasal instillation with Klebsiella pneumoniae ATCC 43816 causing lobar pneumonia.

BACKGROUND: Klebsiella pneumoniae has become one of the major threats to public health as it causes nosocomial and community-acquired infections like lobar pneumonia. This infection causes acute inflammation in the lung, characterized by the recruitment of polymorphonuclear cells, generating free radicals, and decreasing the endogenous antioxidant balance system. Many experimental studies have focused on the induction, progression and resolution of infection up to its peak, but these documented processes remain highly random and their sex dependence un-elicited. These fluctuations of physiopathological parameters would impact disease progression depending on the animal's model and bacterial strain used. The present study investigated the sex-dependent vulnerability of Wistar rats to K. pneumoniae ATCC 43816 lobar pneumonia induced by the intranasal instillation method. METHODS: Experimental pneumonia was induced by K. pneumoniae ATCC 43816 in male and female Wistar rats following intranasal instillation. The physiopathogenesis of the disease was studied by bacteriological and histopathological exams, histomorphometric analysis of the blood and/or lung tissue, and body weight loss in infected animals. In addition, the overall severity of lesions was determined by the total score obtained by averaging the individual scores from the same group of animals. RESULTS: The K. pneumoniae ATCC 43816 strain showed inoculation dose-, incubation time of the disease- and sex-dependent- differences in its ability to induce lobar pneumonia. Evaluation of different parameters showed that the disease peaked on day 15 post-inoculation, with more pathogenic effects on female rats. This observed sex-dependence difference in Wistar rats was mainly highlighted by the determined lethal dose 50 (LD50), bacterial load count in whole blood and lung tissues, body weight loss, inflammatory granulomas forming and diffuse alveolar damages. The pathogenicity was confirmed by scoring the severity of pathologic lesions of lung tissues. CONCLUSIONS: The results obtained highlighted the gender-dependency in the physiopathogenesis processes of K. pneumoniae ATCC 43816 induced-lobar pneumonia, in Wistar rats. Female Wistar rats' susceptibility is useful in studying pathology and in preclinical trial investigations of new treatments for infectious pneumonia.

Fluvastatin Converts Human Macrophages into Foam Cells with Increased Inflammatory Response to Inactivated Mycobacterium tuberculosis H37Ra.

Cholesterol biosynthesis inhibitors (statins) protect hypercholesterolemic patients against developing active tuberculosis, suggesting that these drugs could help the host to control the pathogen at the initial stages of the disease. This work studies the effect of fluvastatin on the early response of healthy peripheral blood mononuclear cells (PBMCs) to inactivated Mycobacterium tuberculosis (Mtb) H37Ra. We found that in fluvastatin-treated PBMCs, most monocytes/macrophages became foamy cells that overproduced NLRP3 inflammasome components in the absence of immune stimulation, evidencing important cholesterol metabolism/immunity connections. When both fluvastatin-treated and untreated PBMCs were exposed to Mtb H37Ra, a small subset of macrophages captured large amounts of bacilli and died, concentrating the bacteria in necrotic areas. In fluvastatin-untreated cultures, most of the remaining macrophages became epithelioid cells that isolated these areas of cell death in granulomatous structures that barely produced IFNγ. By contrast, in fluvastatin-treated cultures, foamy macrophages surrounded the accumulated bacteria, degraded them, markedly activated caspase-1 and elicited a potent IFNγ/cytotoxic response. In rabbits immunized with the same bacteria, fluvastatin increased the tuberculin test response. We conclude that statins may enhance macrophage efficacy to control Mtb, with the help of adaptive immunity, offering a promising tool in the design of alternative therapies to fight tuberculosis.

CRDet: A circle representation detector for lung granulomas based on multi-scale attention features with center point calibration.

Lung granuloma is a very common lung disease, and its specific diagnosis is important for determining the exact cause of the disease as well as the prognosis of the patient. And, an effective lung granuloma detection model based on computer-aided diagnostics (CAD) can help pathologists to localize granulomas, thereby improving the efficiency of the specific diagnosis. However, for lung granuloma detection models based on CAD, the significant size differences between granulomas and how to better utilize the morphological features of granulomas are both critical challenges to be addressed. In this paper, we propose an automatic method CRDet to localize granulomas in histopathological images and deal with these challenges. We first introduce the multi-scale feature extraction network with self-attention to extract features at different scales at the same time. Then, the features will be converted to circle representations of granulomas by circle representation detection heads to achieve the alignment of features and ground truth. In this way, we can also more effectively use the circular morphological features of granulomas. Finally, we propose a center point calibration method at the inference stage to further optimize the circle representation. For model evaluation, we built a lung granuloma circle representation dataset named LGCR, including 288 images from 50 subjects. Our method yielded 0.316 mAP and 0.571 mAR, outperforming the state-of-the-art object detection methods on our proposed LGCR.

Clinical efficacy of intense pulsed light combined with low-dose intralesional corticosteroids in treating noninfectious granulomas after mesotherapy: A case series analysis.

BACKGROUND: Mesotherapy is a popular cosmetic procedure for localized delivery of substances. However, due to the lack of standardized processes, there are potential risks of adverse reactions. Granulomas formation is one of the chronic reactions which impose significant physical and mental burdens on patients. OBJECTIVES: The aim of this analysis is to evaluate the safety and feasibility of combining intense pulsed light (IPL) with intralesional corticosteroids for treating noninfectious granulomas after mesotherapy. METHODS: This retrospective observational case series included patients who suffer from noninfectious granulomas after mesotherapy and received combination of IPL and intralesional corticosteroids treatment between October 2021 and December 2022 at Peking University Shenzhen Hospital, Shenzhen, China. The process and effect were analyzed and summarized. RESULTS: Among the seven patients, five expressed extreme satisfaction with the efficacy, while two was slightly satisfied. The physicians believed that all patients had shown significant improvement. No adverse reactions or recurrences were observed during follow-up. CONCLUSION: Based on this analysis, the application of the combined treatment in patients suffering from noninfectious granuloma due to mesotherapy demonstrates good clinical efficacy and safety, making it worth considering as a treatment option.

Bilateral Cryptococcal Choroiditis in a Human Immunodeficiency Virus-Infected Patient: A Case Report.

Introduction: In this case report, we present a rare case of bilateral cryptococcal choroiditis following a diagnosis of meningitis in a 38-year-old woman with HIV. Case Presentation: A Colombian woman, newly diagnosed with HIV, presented with respiratory distress followed by meningeal syndrome. Further evaluation revealed cryptococcal meningitis caused by Cryptococcus neoformans, confirmed through cerebrospinal fluid analysis and brain magnetic resonance imaging. The patient reported mild blurred vision, prompting an ophthalmic examination that included indocyanine green angiography. The findings revealed signs of HIV retinopathy and multifocal choroidal lesions in both eyes, suggestive of choroidal cryptococcosis. Treatment involved intravenous administration of amphotericin B and flucytosine, followed by oral fluconazole. Subsequently, the choroidal lesions gradually regressed, and regular monitoring demonstrated no signs of recurrence. Conclusion: Cryptococcal choroiditis, though exceptionally rare, can occur in HIV-positive patients with disseminated cryptococcosis. Ophthalmologists should maintain a high index of suspicion for opportunistic infections, even in the absence of pronounced ocular symptoms, particularly in immunocompromised individuals. Early diagnosis and appropriate treatment are crucial for achieving favorable outcomes in such cases.

Neurosarcoidosis and Transverse Myelitis: Life-Threatening Manifestations of Sarcoidosis.

Sarcoidosis, a systemic granulomatous disorder, typically involves the lungs, skin, and lymph nodes. Neurological manifestations are diverse and may include longitudinally extensive transverse myelitis (LETM), an uncommon inflammatory disorder of the spinal cord. We present a case of a 62-year-old female with LETM as the initial manifestation of sarcoidosis. The patient exhibited progressive bilateral lower extremity weakness, urinary retention, and sensory disturbances. Diagnostic workup revealed characteristic findings on spinal magnetic resonance imaging (MRI), cerebrospinal fluid analysis, and thoracic biopsy. Treatment with high-dose corticosteroids and subsequent immunomodulatory therapy resulted in significant improvement. Our case highlights the importance of including sarcoidosis in the differentials of LETM, particularly in patients with no respiratory manifestations.

The Pattern of Granuloma Formation in the Liver of Rats as a Reflection of the Mechanism of Internalization of Submicron Silicon Particles.

A morphological analysis of the liver of Wistar rats was performed 2 months after a single intravenous injection of porous silicon particles of different sizes (60-80, 250-300, and 500-600 nm; 2 mg/ml, 1 ml). Histological, immunohistochemical, and electron microscopic methods showed the development of CD68+ granulomas in all experimental groups. Injection of 60-80-nm porous silicon particles led to the formation of single large granulomas (>2000 µm2), while 500-600-nm nanoparticles caused the formation of numerous smaller granulomas. The mechanism of involution of granulomas by apoptosis of Kupffer cells and the absence of subsequent connective tissue remodeling of the organ tissue is shown.

Epstein-Barr virus-positive inflammatory follicular dendritic cell sarcoma with significant granuloma: case report and literature review.

BACKGROUND: Epstein-Barr virus-positive inflammatory follicular dendritic cell sarcoma (EBV+IFDCS) is a rare disease characterized by mild clinical symptoms and non-specific imaging findings. The diagnosis of the disease depends on pathological diagnosis. However, EBV+IFDCS has a very broad spectrum of histological morphology and immune phenotypes, and its histopathological features have not been fully described by pathologists. CASE PRESENTATION: A 59-year-old female, with no significant discomfort, was found to have a splenic mass during a routine physical examination. Microscopic examination at low magnification revealed numerous epithelioid granulomas, amidst which a substantial inflammatory response was observed. Interspersed among the dense inflammatory cells were spindle or oval-shaped cells, distributed sporadically with indistinct boundaries. Under high magnification, these spindle cells had subtle features: smooth and clear nuclear membranes, inconspicuous small nucleoli, and infrequent mitotic figures. Immunophenotypically, the spindle cells expressed CD21 and CD23, and Epstein-Barr encoding region (EBER) in situ hybridization yielded positive results. The inflammatory milieu predominantly consisted of T cells, with a minority of plasma cells expressing IgG4. The confluence of morphological and immunohistochemical findings led to the final pathological diagnosis of EBV+IFDCS in this case. CONCLUSIONS: The presentation of EBV+IFDCS with pronounced granulomatous changes is rare. This morphological variant poses a high risk of misdiagnosis, frequently leading to confusion with other granulomatous diseases. Accurate diagnosis necessitates a comprehensive analysis, integrating immunohistochemistry and in situ hybridization. The case presented here is instrumental in raising awareness and understanding of EBV+IFDCS, with the goal of reducing misdiagnoses and unrecognized cases.