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Chapter 14 : Granulomatous Reactions

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Abstract:

Granulomatous reactions are cellular responses to irritating, persistent, and poorly soluble substances. Many diseases demonstrate both granulomatous reactions and vasculitis, varying from essentially pure granulomatous lesions to pure vasculitis. “Allergic granulomatosis,” or Churg-Strauss syndrome, includes necrotizing vasculitis, extravascular granulomas, and tissue infiltration with eosinophils, which occur in a setting of bronchial asthma. A common feature of granulomas, such as Wegener’s granulomatosis and Churg-Strauss syndrome, is the presence of anti-neutrophil cytoplasmic antibodies (ANCA), which reflect disease activity. Granulomatous diseases include infectious diseases, such as tuberculosis, leprosy, and parasitic infestations; responses to known antigens, such as zirconium granuloma, berylliosis, and extrinsic alveolitis; and other diseases of unknown etiology in which epithelioid granulomas are the primary lesion. Epithelioid granulomas occur in other diseases such as tertiary syphilis, fungus infections, and some foreign body reactions. The immune characteristics of various clinical classifications of leprosy are presented in this chapter. Granulomatous reactions occur in response to many parasitic infections, particularly those of fungi and certain helminths, and may be responsible for the pathogenesis of the chronic forms of the diseases. It is not possible to include the many different infections here. Histoplasmosis, schistosomiasis, and filariasis are mentioned briefly. Granulomatous disease of children consists of chronic pulmonary disease, recurrent suppurative lymphadenitis, and chronic dermatitis with scattered granulomas in many organs.

Citation: Sell S. 2001. Granulomatous Reactions, p 452-477. In Immunology, Immunopathology, and Immunity, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818012.ch14
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Figures

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Figure 14.1

Granulomatous hypersensitivity reactions. Granulomatous reactions can be identified morphologically by the appearance of reticuloendothelial cells, including histiocytes, epithelioid cells, giant cells, and lymphocytes, arranged in a characteristic round or oval laminated structure called a granuloma. Hypersensitivity granulomas form as a variation of DTH or antibody reactions. Sensitized lymphocytes react with antigens, releasing lymphokines that attract and activate macrophages. The activated macrophages are unable to “clear” the poorly degradable antigens, accumulate in the tissues, form epithelioid and giant cells, and organize into granulomas. Granulomas may also form in response to poorly degradable antibody-antigen complexes in tissue, where complement-mediated inflammation results in accumulation of macrophages unable to degrade the antigen.

Citation: Sell S. 2001. Granulomatous Reactions, p 452-477. In Immunology, Immunopathology, and Immunity, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818012.ch14
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Figure 14.2

Progression of granulomas. (1) Granulomas begin as small collections of lymphocytes and macrophages that form around poorly degradable antigens. (2) Macrophages change to epithelioid cells and become organized into a cluster of cells. (3) Further progression results in ball-like clusters of cells and fusion of macrophages into giant cells. Further progression may include the following: (4) development of necrosis in the center as characteristic of chronic tuberculosis, (5) continued enlargement and replacement of normal tissue (progressive disease), or (6) fibrosis with scar formation, characteristic of “healed” sarcoidosis.

Citation: Sell S. 2001. Granulomatous Reactions, p 452-477. In Immunology, Immunopathology, and Immunity, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818012.ch14
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Figure 14.3

Spectrum of association of granulomatous reactions and vasculitis. The lesions of Loeffler's syndrome and eosinophilic granuloma are essentially granulomas; those of the vasculitis found with polyarteritis nodosa and collagen diseases are almost pure arteritis. On the other hand, a number of diseases, such as some connective tissue diseases (see chapter 10) and Wegener's granulomatosis, demonstrate a mixture of granulomatous reactions and vasculitis. In these lesions, which are difficult to classify, it is possible that the granulomatous reactions are secondary to tissue damage initiated by another mechanism.

Citation: Sell S. 2001. Granulomatous Reactions, p 452-477. In Immunology, Immunopathology, and Immunity, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818012.ch14
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Figure 14.4

Postulated role of cell-mediated immunity to tuberculosis.

Citation: Sell S. 2001. Granulomatous Reactions, p 452-477. In Immunology, Immunopathology, and Immunity, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818012.ch14
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Figure 14.5

Sequence of tissue changes in evolution of granulomas in regional enteritis. Lesions begin with pericryptal mononuclear cell infiltration. This is followed by destruction of the epithelial cells (crypt abscess). Macrophage reaction converts the lesion to a granuloma. (Modified from P. Schmitz-Moorman and H. Becker, p. 76, in A. S. Pera, et al., ed., Recent Advances in Crohn's Disease, Martinus Nijhoff Publishers, The Hague, The Netherlands, 1981.)

Citation: Sell S. 2001. Granulomatous Reactions, p 452-477. In Immunology, Immunopathology, and Immunity, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818012.ch14
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Tables

Generic image for table
Table 14.1

Koch's postulates: a statement of the experimental evidence required to establish the etiologic relationships of a given microorganism to a given disease

Citation: Sell S. 2001. Granulomatous Reactions, p 452-477. In Immunology, Immunopathology, and Immunity, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818012.ch14
Generic image for table
Table 14.2

Immunologic characteristics of leprosy a

Citation: Sell S. 2001. Granulomatous Reactions, p 452-477. In Immunology, Immunopathology, and Immunity, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818012.ch14
Generic image for table
Table 14.3

Human filarial infections

Citation: Sell S. 2001. Granulomatous Reactions, p 452-477. In Immunology, Immunopathology, and Immunity, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818012.ch14
Generic image for table
Table 14.4

Classification and immunopathologic mechanisms in filariasis

Citation: Sell S. 2001. Granulomatous Reactions, p 452-477. In Immunology, Immunopathology, and Immunity, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818012.ch14
Generic image for table
Table 14.5

Source and type of antigen-producing extrinsic allergic alveolitis a

Citation: Sell S. 2001. Granulomatous Reactions, p 452-477. In Immunology, Immunopathology, and Immunity, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818012.ch14

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