Histopathology: granulomatous inflammation, including tuberculosis

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1 Histopathology: granulomatous inflammation, including tuberculosis These presentations are to help you identify basic histopathological features. They do not contain the additional factual information that you need to learn about these topics, or all the images from resource sessions. This presentation contains images of basic histopathological features of granulomatous inflammation, including in tuberculosis. Before viewing this presentation you are advised to review relevant sections of a pathology textbook, histopathology atlas, relevant lecture notes and the histopathology power point presentation on chronic inflammation. Copyright University of Adelaide 2011

2 Granulomatous inflammation is a particular form of chronic inflammation characterized by the presence of epithelioid (resembling epithelial cells) macrophages +/- multinucleate giant cells +/- necrosis. This type of inflammation is driven by CD4 T lymphocytes (delayed type hypersensitivity) in response to certain persistent or non-degradable antigens. There are many causes. A granuloma is a small discrete welldefined aggregate of these modified macrophages seen histologically. The specific histopathologic features of granulomatous inflammation can vary depending on the cause e.g. there is no necrosis in sarcoidosis. Recognition of this pattern of inflammation in a biopsy is important diagnostically. Granulomatous inflammation is initiated by a variety of infectious (e.g. TB, leprosy, certain fungal and parasitic infections) and non-infectious stimuli (e.g. in sarcoidosis, Crohn s disease, reactions to endogenous or exogenous irritants (e.g. suture material, keratin, urate crystals) and certain malignancies (e.g. lymphoma). When a pathologist sees granulomatous inflammation in a histopathological section, in order to determine a cause they will need to consider its location, specific features, presence of foreign material and do a number of special histochemical stains in an attempt to identify infective organisms. Specific diagnosis will often require clinicopathological correlation. Students do not need to know details of the various diseases given in the following examples, unless they have been covered in PBL/CBL.

3 Multinucleate giant cell of Langhans type (outlined in black) in tuberculosis with nuclei dispersed around the edge of the cell, with background lymphocytes (small dark nuclei, minimal cytoplasm e.g. black arrows) and epithelioid macrophages (e.g. yellow arrows). The visible differences between normal and epithelioid macrophages are subtle (and students needn t concern themselves with them).

4 Necrotizing granulomatous inflammation in tuberculosis (medium power). Grey star: area of caseous necrosis. Black arrows: multinucleate giant cells of Langhans type with nuclei dispersed around the edge of the cell. Background lymphocytes (small dark nuclei, minimal cytoplasm) and epithelioid macrophages (larger paler nuclei).

5 Granulomatous inflammation in tuberculosis. Black arrows: multinucleate giant cell of Langhans type with nuclei dispersed around the edge of the cell. Background lymphocytes (small dark nuclei) and epithelioid macrophages (larger paler nuclei).

6 Ziehl Nielson stain showing acid fast bacilli.

7 Miliary tuberculosis (low power view), here in the lung: small foci of necrotising granulomatous inflammation.

8 Granulomatous inflammation: Well circumscribed granuloma (outlined in black) with many epithelioid macrophages (some indicated by yellow arrows) and a multinucleate giant cell (outlined in red). The granuloma is surrounded by fibrous tissue and macrophages and lymphocytes. There is no necrosis here.

9 Birefringent (shiny) suture material (yellow arrows) that has been phagocytosed by giant multinucleate macrophages (outlined in black).

10 Gouty tophus. Aggregates of urate crystals (black stars) are surrounded by epithelioid macrophages and multinucleate giant cells. Some crystals have been phagocytosed by a giant cell (black arrow).

11 Pilonidal sinus. Hair from a pilonidal sinus has caused a granulomatous inflammatory response. Shafts of hair (black arrows) are seen within multinucleate giant cells. Numerous plasma cells (yellow arrows) and lymphocytes (blue arrows) are also present and there is surrounding fibrosis.

12 Granulomatous inflammation: Multinucleate giant cells (black arrows) and numerous epithelioid macrophages (yellow stars) in the dermis of skin, the collagen of which is staining deeply eosinophilic. This is an example of an uncommon condition called actinic granuloma, where it is postulated that in certain persons, solar-damaged elastic fibers are weakly antigenic and cause a cell-mediated immune response.

13 Non-necrotizing granulomatous inflammation in an appendix. The causes include tuberculosis, sarcoidosis and idiopathic granulomatous appendicitis.

14 Granulomatous inflammation with multinucleate giant cells (black arrows) and a few neutrophils in erythema nodosum, an inflammatory disorder of skin involving deep dermis and subcutaneous tissue (see inset) often associated with various antecedent infections (at other sites), inflammatory bowel disease and certain drugs.

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