Necrotizing Sarcoid Granulomatosis: Clinico-Radio-Pathologic Diagnosis

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Presentation transcript:

Necrotizing Sarcoid Granulomatosis: Clinico-Radio-Pathologic Diagnosis David John Tobias McArdle, BA (Hons), MPsych (Clin Neuro), MBBS, John Patrick McArdle, MBBS, MD, Peter Jessup, MBBS (Hons), Robin A. Harle, MBBS, Serena Parker, MBBS, FRACP The American Journal of Medicine Volume 130, Issue 7, Pages e283-e286 (July 2017) DOI: 10.1016/j.amjmed.2017.03.015 Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 1 Axial (A), coronal (C), and parasagittal (D) computed tomography chest maximal intensity projections revealed innumerable spiculated soft-tissue nodules throughout the lungs, varying in size from 1 to 20 mm. Although the majority are centrilobular, there are some based on the pleura and within fissures, highlighted in the parasagittal slice (D). They are well defined and not typical of hypersensitivity pneumonitis. The nodules were variably avid on positron emission tomography scan (B). The American Journal of Medicine 2017 130, e283-e286DOI: (10.1016/j.amjmed.2017.03.015) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 2 Histopathology from the video-assisted thoracoscopic surgery wedge biopsies. Multiple single and confluent granulomata are seen scattered through the alveolar parenchyma (A; hematoxylin and eosin [HE], ×100). If sectioned in the appropriate plane, many are related to a small, often eccentrically placed, vessel (B; orcein-Giemsa/HE, ×200). In other areas, multiple confluent granulomata surround vessels showing severe luminal narrowing (C; orcein-Giemsa/HE, ×200). The American Journal of Medicine 2017 130, e283-e286DOI: (10.1016/j.amjmed.2017.03.015) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 3 Histopathology from the video-assisted thoracoscopic surgery wedge biopsies. (A) Scanning magnification reveals scattered foci of coagulative necrosis (orcein-Giemsa/hematoxylin and eosin [HE], ×40). The focus is centred on an obliterated vessel (V1), recognized only by the elastic in its wall. The focus of necrosis lies adjacent to a narrowed bronchiole (“B” in image), and another vessel showing granulomatous vasculitis (V2) is seen on the other side of the bronchiole. (B, C) Closer examination reveals a virtually occluded vessel (left) immediately adjacent to an area (right) of coagulative necrosis (B; orcein-Giemsa/HE, ×200). In the center of this area of coagulative necrosis, elastic stains show the outline of a necrotic narrowed vessel (C; orcein-Giemsa/HE, ×200, arrows). The American Journal of Medicine 2017 130, e283-e286DOI: (10.1016/j.amjmed.2017.03.015) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 4 Chest x-ray obtained after the initial lung biopsy showed multiple pulmonary nodules bilaterally (A). Marked improvement was seen after 1 month of treatment with prednisolone (B). The American Journal of Medicine 2017 130, e283-e286DOI: (10.1016/j.amjmed.2017.03.015) Copyright © 2017 Elsevier Inc. Terms and Conditions