Granulomatous Inflammation

What is Granulomatous Inflammation?

A granuloma refers to a benign inflammatory condition that is composed of small, organized collections of activated macrophages or histiocytes and multinucleated giant cells which take on a squamous cell-like manifestation. This distinctive pattern is so organized in a tight, ball-like structure that the margins of the individual cells are hard to outline. It is not a granuloma when macrophages are slackly diffused. This massing of macrophages bordered by the lymphocytes looks like epithelial cells, thus the term epitheloid cells.

This characteristic lesion is formed the moment the immune system tries to isolate an infectious or non-infectious substance which is distinguished as foreign but is not capable of getting rid of it. There are situations in which the macrophages gather together to develop into a defined mass, thus, lesions of a granulomatous disease become space-occupying.

The distinction of granulomas from other types of inflammation is the concept that the former is formed because the causative agents are impervious to the first line of special defense cells including the neutrophils and eosinophils. Most frequently, the inciting antigen involved in the development of granulomas is an infectious microorganism or an inorganic material extraneous to the body. In some cases however, such as in sarcoidosis, the main culprit which stimulates the antibody production is not yet recognized.

Characteristically, a granuloma takes in merely a trivial segment of the body tissue. On the whole, affected individuals are asymptomatic. In point of fact, most of the granuloma cases are identified by chance via an x-ray performed for a different purpose. Oftentimes, when discovered in an x-ray, these inflammations are being confused with cancer.

The potential offending agents may be bacterial, fungal or idiopathic in origin. Others include unwelcomed exogenous substances, endogenous substances that have changed like lipids and keratin debris.

On the whole, the type of granuloma that develops from the above problems is a calcified granuloma. This type involves calcium deposition and commonly takes a longer time to surface.

One of the important things that must be established early on is whether these granulomas involve necrosis or not. Necrosis is the death of cells which, upon magnification, appears as a collection of amorphous fragments without the presence of nuclei. Another term, caseation, describes a form of necrosis, which, to the unaided eye seems to bear a similarity to a cheese and is classically a characteristic of granulomas in TB. Quite the opposite of TB granuloma is sarcoidosis with granulomatous lesions that are classically non-caseating. The recognition of the presence of necrosis in granulomatous inflammation is significant since when a granuloma contains necrosis, this means the cause of the inflammation is an infectious agent. More than a few cases may be exempted to the rule; however, it continues all the same to be valuable in everyday diagnostic pathology.

Symptoms

In general;

• The mass of granulation tissue is classically small, 1 to 2-millimeter-lesion.
• The amount of pain is influenced by the location of the granulomatous inflammation. In a few instances, affected individuals do not experience pain at all or even any physical indications of inflammation.

Below are some of the familiar causes of granulomatous inflammation. The lesions are typically detected in infected organs which the inciting agent has caused reactions in that organ’s cells.

Tuberculosis

A tubercle is the granulomatous inflammatory reaction to Mycobacterium tuberculosis infection. Distinctive to this type of granuloma is the occurrence of a cheesy necrotic middle. Though not exclusive for TB infection, there are multinucleated giant cells with nuclei organized in a way that is similar to a horseshoe.

As soon as the disease becomes active, the individual experiences chest pain, coughing up of blood and a insistent productive cough for more than 3 weeks. Other systemic manifestations include hyperthermia, chills, shortness of breath, night sweats, loss of appetite, weight loss, paleness and tiredness.

Leprosy

In this condition, the granulomatous inflammations become superficially conspicuous. The granulomas appear on the skin and are likely to include the underlying nerves.

Schistosomiasis

A few of the schistosome eggs laid in the intestinal and urinary venules are pushed backward into the liver through the portal vein resulting to the formation of granulomatous lesions in this organ.

Causes

Granulomatous inflammation describes a distinct subclass of chronic inflammatory mechanism which predictably arises when the normal inflammatory response involving the neutrophil cannot eliminate the provoking agent. Once these common white blood cells fail to remove the causative agent, the second line of defense comprising the macrophages take over.

Most of these inflammations are the effects of tissue injury, predominantly as a consequence of infection. For a number of instances, granulomas may emerge in the lungs too. Besides, the most familiar cause of these inflammations is histoplasmosis, a serious fungal lung disease caused by Histoplasma capsulatum. Other diseases that are accompanied with the formation of granulomas are infections such as TB, syphilis, schistosomiasis and leprosy; systemic conditions including sarcoidosis, regional enteritis, and Wegener’s granulomatosis; inorganic material poisoning such as beryllium, silica, asbestos and zirconium.

These inciting agents share one thing in mutual; that is, they are poorly digested and frequently aren’t simply influenced by the first line of the inflammatory mechanism. The epitheloid cells cannot disintegrate the phagocytosed particles the way it should be.

Treatment

For orofacial granulomatosis

The treatment modality will differ according to the underlying or systemic cause of the granulomatosis. For localized inflammation with no systemic association, lesions can be dealt by applying conservative surgical removal and reconstruction. Before the operation, the patient is given with a number of drugs with unpredictable outcomes. Some of these include intralesional and systemic steroidal medications, radiotherapy in low dose, and sulfasalazine.

For Tuberculosis

In the present day, BCG vaccine is extensively used all over the globe as it supports in the risk reduction of serious tuberculosis in younger population. Pharmacological treatment is available and is aimed at destroying the intracellular and extracellular microorganisms and in preventing the development of multi-drug resistance.

Therapy includes the combination of four antibiotics with medical direction namely isoniazid, rifampin, pyrazinamide and ethambutol which is usually recommended for 6 to 9 months. These four anti-TB drugs are classified into first-line and second-line agents, depending on the level of effectiveness and toxicity. Under the first line drugs are isoniazid, rifampicin and pyrazinamide. Supplementary therapeutic processes are sufficient rest and sleep, hospitalization in isolation rooms and surgical treatment to eliminate the damaged lung.

For Aspergillosis

To successfully manage the granulomatous disease, the mainstay of the disease management consists of aggressive neurosurgical measures to surgically eliminate Aspergillus abscesses and granulomatous inflammations, modification to decrease the effect of predisposing and precipitating factors, administration of amphotericin B in conjunction with flucytosine, and treatment of the cause of infection.