Necrotising Granulomatous Inflammation

29.06.2023 Chukwudi Eze 0 Comments

A necrotizing granuloma is an area of inflammation in which tissue has died. Necrotizing means dying or decaying. Tuberculosis and granulomatosis with polyangiitis are conditions that cause necrotizing granulomas.

Contents

- 0.0.1 What causes necrotizing granulomatous inflammation?

1 What is the cause of granulomatous inflammation?
- - 1.0.1 What are 4 causes of granulomatous inflammation?
2 What are 5 causes of granulomatous inflammation?
- 2.1 Can you live with granulomatous disease?
  - 2.1.1 What are the stages of granulomatous inflammation?
- 2.2 How do you diagnose granulomatous inflammation?
  - 2.2.1 What is the most common cause of granulomas?
3 What autoimmune disease causes granulomas?
- - 3.0.1 Is granulomatous an autoimmune disease?
4 What happens if granuloma is not treated?
- - 4.0.1 What is the survival rate of granulomatous disease?
- 4.1 Is A granuloma A tumor?
5 What causes necrotizing inflammation?
- - 5.0.1 What is the most common cause of granulomatous disease?
  - 5.0.2 What are 5 causes for granulomatous reaction?
6 What is the most common cause of granulomatous gastritis?

What causes necrotizing granulomatous inflammation?

Introduction – Necrotizing granulomatous inflammation (NGI) is usually caused by Mycobacterium tuberculosis, It usually occurs in the lung. The extrapulmonary sites commonly include lymph node, pleura, and joints, although any organ may be involved, However, its causes still remained unexplained in nearly 20%-40% of cases,,

What is the cause of granulomatous inflammation?

Abstract – Granulomatous inflammation is a histologic pattern of tissue reaction which appears following cell injury. Granulomatous inflammation is caused by a variety of conditions including infection, autoimmune, toxic, allergic, drug, and neoplastic conditions.

The tissue reaction pattern narrows the pathologic and clinical differential diagnosis and subsequent clinical management.
Common reaction patterns include necrotizing granulomas, non necrotizing granulomas, suppurative granulomas, diffuse granulomatous inflammation, and foreign body giant cell reaction.

Prototypical examples of necrotizing granulomas are seen with mycobacterial infections and non-necrotizing granulomas with sarcoidosis. However, broad differential diagnoses exist within each category. Using a pattern based algorithmic approach, identification of the etiology becomes apparent when taken with clinical context.

The pulmonary system is one of the most commonly affected sites to encounter granulomatous inflammation. Infectious causes of granuloma are most prevalent with mycobacteria and dimorphic fungi leading the differential diagnoses. Unlike the lung, skin can be affected by several routes, including direct inoculation, endogenous sources, and hematogenous spread.

This broad basis of involvement introduces a variety of infectious agents, which can present as necrotizing or non-necrotizing granulomatous inflammation. Non-infectious etiologies require a thorough clinicopathologic review to narrow the scope of the pathogenesis which include: foreign body reaction, autoimmune, neoplastic, and drug related etiologies.

Granulomatous inflammation of the kidney, often referred to as granulomatous interstitial nephritis (GIN) is unlike organ systems such as the skin or lungs. The differential diagnosis of GIN is more frequently due to drugs and sarcoidosis as compared to infections (fungal and mycobacterial). Herein we discuss the pathogenesis and histologic patterns seen in a variety of organ systems and clinical conditions.

What are 4 causes of granulomatous inflammation?

The tissue reaction pattern narrows the pathologic and clinical differential diagnosis and subsequent clinical management. Common reaction patterns include necrotizing granulomas, non necrotizing granulomas, suppurative granulomas, diffuse granulomatous inflammation, and foreign body giant cell reaction.

The pulmonary system is one of the most commonly affected sites to encounter granulomatous inflammation. Infectious causes of granuloma are most prevalent with mycobacteria and dimorphic fungi leading the differential diagnoses. Unlike the lung, skin can be affected by several routes, including direct inoculation, endogenous sources, and hematogenous spread.

Granulomatous inflammation of the kidney, often referred to as granulomatous interstitial nephritis (GIN) is unlike organ systems such as the skin or lungs.
The differential diagnosis of GIN is more frequently due to drugs and sarcoidosis as compared to infections (fungal and mycobacterial).
Herein we discuss the pathogenesis and histologic patterns seen in a variety of organ systems and clinical conditions.

Keywords: Foreign-body, Granulomatous inflammation, Granuloma, Mycobacterial, Sarcoidal, Tuberculous

What are 5 causes of granulomatous inflammation?

The tissue reaction pattern narrows the pathologic and clinical differential diagnosis and subsequent clinical management.
Common reaction patterns include necrotizing granulomas, non necrotizing granulomas, suppurative granulomas, diffuse granulomatous inflammation, and foreign body giant cell reaction.

Can you live with granulomatous disease?

What is the prognosis (outlook) for people with chronic granulomatous disease (CGD)? – Doctors can successfully manage many cases of CGD. Treatments may continue indefinitely to keep infections and inflammation from becoming severe. With ongoing treatment and support, many people with CGD live active and fulfilling lives.

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What are the stages of granulomatous inflammation?

GRANULOMA FORMATION AND FUNCTION – Granuloma formation correlates with the development of delayed hypersensitivity revealed by a positive tuberculin test, emergence of activated T-cell subsets, improved macrophage responsiveness in areas of localized infection, and improved phagocytosis and mycobacterial killing.

The granuloma plays a pivotal role in orchestrating the interaction between immune cells leading to an effective response, inhibiting and killing M.
Tuberculosis, containing infection, preventing the spread of the organism, and localizing the inflammatory response and tissue damage.57 Granuloma formation may be divided into four phases: initiation, accumulation, effector, and resolution.

Very little is known about the initiation phase, but macrophages migrate into the site of infection and initiate granuloma formation. Both initiation and accumulation phases involve cellular recruitment.65 Knockout mice experiments have established the importance of both TNF-α and lymphotoxin-α in granuloma formation.

These cytokines achieve their effect by regulating the expression of adhesion molecules and chemokine receptors, and establishing chemokine gradients.49, 57 T-lymphocytes are involved in all four phases.65 A fully formed tuberculous granuloma consists of a central zone of caseating necrosis, surrounded by cellular infiltrate comprising activated macrophages (epithelioid cells), DCs, T-lymphocytes, B-lymphocytes, and fibroblasts.

Macrophages are centrally located and have the ability to differentiate into multinucleated giant cells. The outer layer of the human granuloma structurally resembles secondary lymphoid follicles and contains APCs, CD4+ T-lymphocytes, CD8+ T-lymphoctes, and B-lymphocytes where the host and pathogen probably interact ( Fig.8.5 ).4 T-lymphocyte proliferation is limited in granulomata.

T-cell receptor diversity is determined by cellular migration and possibly T-lymphocyte priming, which is thought to occur in the outer layers of the granuloma.65 In productive granuloma without recognizable caseation very few cells show apoptotic features but large numbers of macrophages and lymphocytes undergoing apoptosis are seen within caseating granulomas.66 Granuloma formation is accompanied by a change in the mycobacterial gene expression pattern as the organisms adapt to the environment of the granuloma.

Loss of acid-fastness during latency suggests that the cell wall structure of dormant M. tuberculosis is altered.67 The location of the latent organisms remains uncertain but one study indicates that they are present in tissue outside the areas of caseating necrosis.14 During the effector phase macrophage–lymphocyte cooperation plays a determining role in reducing the pathogen burden within granulomas.

How do you diagnose granulomatous inflammation?

Symptoms and signs reference –

Flow cytometric oxidative (respiratory) burst assay

Diagnosis of chronic granulomatous disease is by a flow cytometric oxidative (respiratory) burst assay to detect oxygen radical production using dihydrorhodamine 123 (DHR) or nitroblue tetrazolium (NBT). This test can also identify female carriers of the X-linked form and recessive forms.

Prophylactic antibiotics and usually antifungals Usually interferon gamma For severe infections, granulocyte transfusions Hematopoietic stem cell transplantation

Treatment of chronic granulomatous disease is continuous prophylactic antibiotics, particularly sulfamethoxazole/ trimethoprim 800/160 mg orally twice a day. Oral antifungals are given as primary prophylaxis or are added if fungal infections occur even once; most useful are

Itraconazole orally once a day (100 mg capsule for patients 50 kg) Voriconazole orally every 12 hours (9 mg/kg oral suspension for patients 2 to 12 years or weighing < 40 kg; 200 mg tablet for those weighing ≥ 40 kg) Posaconazole 300 mg delayed-release tablet orally twice a day on day 1, then 300 mg once daily; weight-based dosing for patients weighing < 40 kg

Interferon gamma may reduce severity and frequency of infections and is usually included in the treatment regimen. Usual dose is 50 mcg/m 2 subcutaneously 3 times a week. Granulocyte transfusions can be lifesaving when infections are severe. Gene therapy is under study.

Suspect chronic granulomatous disease (CGD) if patients have recurrent abscesses during childhood (sometimes not until the early teens), particularly if the pathogen is a catalase-producing organism (eg, Staphylococcus aureus, Escherichia coli, Serratia, Klebsiella, Pseudomonas, fungi). Use the flow cytometric oxidative burst assay to diagnose CGD and identify carriers. Treat most patients with prophylactic antibiotics, antifungals, and interferon gamma. For severe infections, give granulocyte transfusions. Consider hematopoietic stem cell transplantation.

What is the most common cause of granulomas?

My mother-in-law recently had a chest X-ray and was told she has a granuloma in her lung. What does that mean? – Answer From Pritish K. Tosh, M.D. A granuloma is a small area of inflammation. Granulomas are often found incidentally on an X-ray or other imaging test done for a different reason.

Typically, granulomas are noncancerous (benign). Granulomas frequently occur in the lungs, but can occur in other parts of the body and head as well. Granulomas seem to be a defensive mechanism that triggers the body to “wall off” foreign invaders such as bacteria or fungi to keep them from spreading.

Common causes include an inflammatory condition called sarcoidosis and infections such as histoplasmosis or tuberculosis. Granulomas in people without symptoms almost never require treatment or even follow-up imaging tests. With Pritish K. Tosh, M.D.

What autoimmune disease causes granulomas?

Introduction – Sarcoidosis is a multisystem granulomatous disease of unknown origin with predominant lung involvement, variable clinical course, and no universally accepted treatment algorithm ( 1, 2 ). The disease occurs worldwide, varying in prevalence and clinical course between regions, and populations.

African Americans and Northern Europeans are considered to be the most susceptible to the development of sarcoidosis with the predominance being in women, and incidence peaks from 30 to 60 years of age ( 2 ).
Recently, much attention has been paid to the study of the etiology and pathogenesis of sarcoidosis and the role of autoimmunity in its development and progression.

In addition to genetic predisposition, triggers such as infection, inorganic materials, and environmental factors are likely to play a role, which leads to the possible development of an autoimmune response in the disease ( 2, 3 ). Sarcoidosis has a wide variety of clinical phenotypes wherein many of them remind “classic” autoimmune diseases.

About half of the patients have no symptoms, while in severe clinical cases, sarcoidosis can lead to a failure of the internal organ functions with the development of fibrosis and pulmonary hypertension. The most common clinical symptoms of pulmonary sarcoidosis are a dry cough, shortness of breath, and chest pain, which are described in more than 50% of patients.

Up to 30% of cases include fever, unexplained weight loss, and chronic fatigue ( 1, 2 ). Extrapulmonary manifestations of the disease are described in 15–25% of cases. The most common are arthralgia, arthritis, periarthritis, acute nodular myositis, and chronic myopathy, where differential diagnosis is made with rheumatoid arthritis and other connective tissue disorders.

Two main acute syndromes in sarcoidosis are described: Löfgren’s syndrome manifested by nodular erythema, fever, polyarthritis, and uveitis and Heerfordt syndrome, which is described as a combination of uveitis, parotitis, fever, and facial paralysis ( 2, 4 ).
Pulmonary sarcoidosis may coexist with other autoimmune diseases, which suggests the possibility of a common pathogenesis and genetic predisposition.

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Most often, cases of sarcoidosis associated with Sjogren’s syndrome are described, where patients have signs of both diseases, e.g., epithelioid granulomas in their internal organs as well as anti-Ro and anti-La autoantibodies as well as lacrimal and salivary gland dysfunction.

Sarcoidosis and Sjogren’s syndrome are both associated with the HLA-DR3 genotype and elevated levels of CD4+ lymphocytes ( 5, 6 ).
In some cases, a combination of systemic lupus erythematosus (SLE) and sarcoidosis is observed.
As a rule, SLE debuts as a primary disease where over time non-caseating granulomas in the skin and lungs are detected ( 7 ).

These cases suggest a common pathogenesis of both sarcoidosis and SLE regarding the similarity of some laboratory findings: In both diseases antinuclear antibodies (in sarcoidosis up to 30% of cases), a disturbance of the T and B lymphocytes ratio, and the elevation of immunoglobulin concentration are observed.

The combination of sarcoidosis with Crohn’s disease, antiphospholipid syndrome, idiopathic pulmonary fibrosis, and primary biliary cirrhosis is also described ( 8 ). When sarcoidosis coexists with ankylosing spondylitis, non-caseating granulomas in the lungs, sacroiliitis, and the HLA-B27 genotype typical for spondyloarthritis are described ( 9 ).

One of the most important evidence of the autoimmune inflammation in sarcoidosis is the formation of granulomas, mainly in the lungs and the mediastinal lymph nodes as well as in the skin and liver of patients. The formation of granulomas of both infectious and autoimmune nature is based on the aggregation of hypertrophic macrophages.

In infectious granulomatosis, such as tuberculosis, a pronounced activation of Th1 lymphocytes and M1 macrophages which then progress to the M2 phenotype is described.
In sarcoidosis the opposite situation is observed: the M2 (anti-inflammatory) macrophage phenotype predominates in granulomas, which represents paradoxically reduced immune response.

When studying the molecular mechanisms underlying the dysfunction of macrophages, there is growing evidence of the role of the mTOR pathway in granuloma formation. Linke and Wilson et al. in their studies showed that activation of rapamycin (mTOR) complex 1 (mTORC1) in macrophages in mice leads to the progression and development of granulomas.

It has also been shown in people with a progressive sarcoidosis ( 10, 11 ). After processing of environmental immunogenic antigens by mononuclear antigen-presenting cells, the antigen is presented to T-effector cells. Further activation of immune cells occurs with the help of various chemokines, such as CCL5 (for Tx1) and CCL2 (for Tx2).

Recently, a lot of attention has been paid to the role of T17 lymphocytes in the pathogenesis of sarcoidosis, a subgroup of CD4+ lymphocytes expressing IL-17A, which exhibit pro-inflammatory or anti-inflammatory properties in response to the local inflammatory milieu.

It has been shown that in sarcoidosis granuloma macrophages express CCR20, causing the attraction of Tx17, and the expression of IL-23 causes a significant increase in the concentration of IL-17A ( 11, 12 ).
The ratio between Th17 and Treg cells probably determines the development and clinical course of sarcoidosis and can serve as a prognostic marker.

Its increase indicates active sarcoidosis and correlates with the likelihood of exacerbation when steroid therapy is canceled ( 12 ). Considering the possible autoimmune nature of sarcoidosis, it is necessary to discuss the possibilities of treatment with immunosuppressive therapy.

Corticosteroids for patients with sarcoidosis are considered as the treatment of choice despite many possible contraindications and side effects ( 13, 14 ).
If the corticosteroid therapy is ineffective and the disease progresses, the use of cytostatics (methotrexate, leflunomide, azathioprine) is recommended, but the doses and duration of treatment in patients with sarcoidosis require further study ( 15 ).

In chronic sarcoidosis, especially in patients with extrapulmonary lesions, the use of TNF-α inhibitors (infliximab, adelemaumab, rituximab) is possible, though this question requires further study due to the immunologic abnormalities that accompany this kind of treatment and the uneven role of TNF-α in granuloma formation ( 16 ).

Other biotherapy options for sarcoidosis are also being explored. The efficacy of a therapy based on inhaled vasoactive intestinal peptide (IVIP) has been shown. IVIP increases the activity of regulatory T cells and decreases the activity of effector T cells, thereby providing an immunoregulatory effect ( 17 ).

There are studies on the possible beneficial effect of using IL-6 suppressors. The level of this cytokine is increased in patients with sarcoidosis and correlates with the level of CD3+ lymphocytes (tocilizumab), cytotoxic T-lymphocyte (abetacept), and IL-12/IL-23P40 and Th17 pathways, inducing the production of TNFα (ustekinumab, tildrakizumab, secukinumab) ( 18 ).

The effectiveness of immunosuppressive therapy in the treatment of patients with sarcoidosis alludes to the important role of the autoimmune component in the pathogenesis of this disease.
Despite a large number of studies on sarcoidosis, its etiology is still not fully understood.
To consider the possible autoimmune nature of sarcoidosis, the criteria proposed in 1993 by N.R.

Rose and C. Bona can be used ( 19 ). In accordance with the classification, direct proof, indirect and circumstantial evidence are distinguished. Direct criteria include: the occurrence of the disease in a healthy individual (human or animal) with the injection of purified human antibodies, including during transplacental transfer, or in vitro destruction of cells carrying specific antigen.

Indirect evidence includes detection of the corresponding antigen in humans or its equivalent in animals and reproduction of essential features of the disease by immunization. Circumstantial evidence includes association with other autoimmune diseases, lymphocytic infiltration, statistical association with specific HLA haplotype, and positive response to immunosuppression.

To assess sarcoidosis compliance with autoimmune disease criteria, a detailed study of risk factors, environmental, immunological, and immunogenetic triggers is necessary. Review and original articles from 1960 to 2019 were studied in the international databases (PubMed, Web of Science, SCOPUS, Elsevier, ScienceDirect).

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Is granulomatous an autoimmune disease?

Key points about granulomatosis with polyangiitis –

Granulomatosis with polyangiitis (GPA) is an autoimmune disorder that causes swelling and irritation in blood vessels and other tissues. It is uncommon. Doctors don’t know what causes it. Most people with GPA first report vague symptoms. Biopsy is the only way to know for sure if it’s GPA. Most people with GPA will find relief by taking strong medicines. GGPA may come back even after successful treatment. Ongoing GPA can have serious complications. Continue to follow up with your healthcare provider, even when you are in remission.

: Granulomatosis with Polyangiitis

What happens if granuloma is not treated?

Granulomatosis with polyangiitis – Granulomatosis with polyangiitis is a rare disease. It is a type of vasculitis, or inflammation in the blood vessels. Doctors used to call it Wegener’s granulomatosis, Granulomas develop in the blood vessels, making it difficult for blood to reach vital organs. Common symptoms include:

joint painweakness and fatigue (lack of energy)ongoing cold symptoms, such as a runny nose

Diagnosis will depend on where the granulomas are. Doctors will usually only need to do a physical examination to diagnose skin granulomas. In most cases, they will also ask a few questions about the lumps, such as when they appeared. To diagnose internal granulomas, doctors will need to understand the underlying cause of the problem. To do this, they may:

ask a series of questions about the person’s symptomscarry out a blood testcarry out an imaging test, such as an X-ray or CT scan carry out a genetic testtake a tissue sample by performing a needle biopsy

Treatment will depend on the underlying cause of the granuloma. In most cases, skin granulomas will go away on their own without treatment. Sometimes, though, they might come back. Underlying health conditions can also cause granulomas. When this is the case, doctors will focus on treating the underlying cause of the lumps.

Granulomas are not cancerous. Anyone with a granuloma that does not get better on its own, or that keeps coming back, should speak with a doctor. People who feel they may have an underlying autoimmune disorder should also seek medical attention. Granulomas are small clumps of immune cells. They are usually a normal part of the body’s immune system, working to isolate threats from the rest of the body.

They can develop anywhere on the body, including the skin, lungs, and other organs. They tend to go away on their own. If someone has an autoimmune condition, such as Crohn’s disease or sarcoidosis, granulomas can develop for no reason. Sometimes, they can damage the body and lead to scarring.

What is the survival rate of granulomatous disease?

CGD was initially termed ‘fatal granulomatous disease of childhood’ because patients rarely survived past their first decade in the time before routine use of prophylactic antimicrobial agents. The average patient now survives at least 40 years.

Is A granuloma A tumor?

Pyogenic granulomas are a type of vascular tumor. Also called lobular capillary hemangioma.

What causes necrotizing inflammation?

A granuloma is a clump of cells that forms when the immune system tries to fight off a harmful substance but cannot remove it from the body. A necrotizing granuloma is an area of inflammation in which tissue has died. Necrotizing means dying or decaying.

Tuberculosis and granulomatosis with polyangiitis are conditions that cause necrotizing granulomas. Jones KD, Urisman A. Histopathologic approach to the surgical lung biopsy in interstitial lung disease. In: Collard HR, Richeldi L, eds. Interstitial Lung Disease. Philadelphia, PA: Elsevier; 2018:chap 12.

Updated by: Debra G. Wechter, MD, FACS, General Surgery Practice Specializing in Breast Cancer, Virginia Mason Medical Center, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

What is the most common cause of granulomatous disease?

What infections cause granulomas? – The most common infectious cause of granulomas is tuberculosis. But other bacterial infections, fungal infections, parasites and viruses can also cause granulomas, including:

Aspergillosis, Blastomycosis. Candidiasis, Cat scratch disease, Coccidioidomycosis (Valley fever), Cytomegalovirus, Dirofilariasis. Epstein-Barr virus, Histoplasmosis. Leishmaniasis, Leprosy (Hansen’s disease), Measles, Mycobacterium marinum (fish tank granuloma). Schistosomiasis,

What are 5 causes for granulomatous reaction?

The pulmonary system is one of the most commonly affected sites to encounter granulomatous inflammation. Infectious causes of granuloma are most prevalent with mycobacteria and dimorphic fungi leading the differential diagnoses. Unlike the lung, skin can be affected by several routes, including direct inoculation, endogenous sources, and hematogenous spread.

What is the most common cause of granulomatous gastritis?

Most cases of granulomatous gastritis occur in patients with Crohn disease, sarcoidosis, or infection.

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