The changing pattern of granulomas of the upper respiratory tract

Primary nasal tuberculosis-a rare clinical entity

Primary tuberculosis of the nose is very rare. We report a case of a 35-year-old woman who presented with bilateral nasal obstruction and epistaxis of 3 months' duration but who was otherwise healthy. She was diagnosed with primary nasal septal tuberculosis and was treated with antituberculosis DOTS (directly observed treatment, short course) therapy for 6 months with complete recovery. Given the resurgence of tuberculosis in recent times, it is important that clinicians remain aware of this rare and treatable clinical entity.

Eight cases of nasal tuberculosis

OBJECTIVE

To elucidate the clinical characteristics of nasal tuberculosis and to discuss its diagnostic difficulties.

STUDY DESIGN

Retrospective clinical analysis.

RESULTS

A total of eight patients presented with nasal tuberculosis during the study period (from January 1989 through December 2006). Six were female and two were male. The patient age varied from 17 to 51 years, with a mean of 31 years. The most commonly involved site was the nasal septum (7 of 8). Perforation of the nasal septum was observed in three cases. Sinus invasion was observed in two cases and required sinus surgery. Six of the cases were a result of primary infections, while two were secondary disease manifestations. All patients were treated with anti-tuberculosis medications, with subsequent improvement with regard to clinical symptoms and physical signs.

CONCLUSIONS

We present the largest number of nasal tuberculosis cases reported in the medical literature from a single institute. Diagnosing nasal tuberculosis requires a high index of suspicion and occasionally the use of experimental drug treatment options.

An Unusual Case of Primary Nasal Tuberculosis with Epistaxis and Epilepsy

Primary nasal tuberculosis is rare. We report a case that was all the more extraordinary because of the age and sex of the patient (an 11-year-old boy), the unusual associated symptoms (epistaxis and grand mal seizures), and the presence of intracranial extension. Clinical and radiologic finding s on our initial evaluation suggested that the patient had a large sinonasal malignancy. The patient manifested no evidence of pulmonary tuberculosis. The diagnosis of primary nasal tuberculosis was established only after we obtained the results of histopathology of the excised mass and a subsequent tuberculin skin test; the diagnosis was confirmed by the patient's rapid response to antituberculosis drug therapy. We also review the relevant literature on this rare condition.

Laryngeal tuberculosis in renal transplant recipients

BACKGROUND

Tuberculosis is the most common non-pyogenic infection encountered among renal transplant recipients in India. Although the lung is the most common site of involvement, a number of extrapulmonary organs can be involved. There is often a delay in diagnosis and institution of effective chemotherapy when there is an unusual site of involvement.

METHODS AND RESULTS

We report two renal transplant recipients with laryngeal tuberculosis who presented with prolonged hoarseness of voice and painful dysphagia. Acid-fast bacilli were demonstrated on laryngeal biopsy and smear. Fever and pulmonary involvement were seen in only one patient. This is the first report of laryngeal tuberculosis in renal transplant recipients.

CONCLUSIONS

Laryngeal tuberculosis should be suspected in renal transplant recipients who develop hoarseness of voice and odynophagia. Demonstration of acid-fast bacilli on biopsy or smear obtained by direct laryngoscopy helps in determining the diagnosis.

Nasal tuberculosis in the 20th century

During the last decade, tuberculosis has reemerged as a major health problem in the United States. Much of the blame for this resurgence has been attributed to human immunodeficiency virus infection, although homelessness and deterioration of the social infrastructure have also been implicated. Extrapulmonary tuberculosis is uncommon, and nasal tuberculosis is rare. The latter usually manifests as nasal obstruction or discharge. Only 35 cases of nasal tuberculosis were identified in a search of the English-language medical literature from the last 95 years. They are reviewed here. In addition, we describe a new manifestation of nasal tuberculosis, exemplifying the variety of ways in which this may occur.

Nasal tuberculosis--an increasing problem?

Nasal tuberculosis represents a rare manifestation of infection by Mycobacterium tuberculosis: a case is presented together with a review of the literature. The correct management is documented, especially the need to treat the patients as if there was a generalized condition, and the problems concerning drug resistance are also considered. The incidence of this disease is rising and its importance must once again be highlighted.

Primary nasal tuberculosis masquerading as a malignant tumour

Primary nasal tuberculosis is rare. We report a case of primary nasal tuberculosis in an elderly lady who presented with symptoms and signs suggestive of a nasal fossa tumour. Histological examination of the lesion revealed the diagnosis. Treatment was with standard anti-tuberculous chemotherapy. The implications of primary nasal tuberculosis are discussed.

Malignant histiocytosis (histiocytic sarcoma). A (the?) major cause of the 'midline granuloma syndrome'

Five out of eight consecutive cases with initial symptoms of a 'midline granuloma' were identified as malignant histiocytosis (histiocytic sarcoma) which within 5 months to 4 years led to generalization and death. The three remaining cases also fulfilled the morphological criteria of this type of neoplasia, though these patients are still alive 1/2 to 8 years after diagnosis, possibly as a result of local radiotherapy. The age of the individuals ranged from 18 to 71 years and there was a male preponderance of 7:1. The histiocytic nature of the atypical cells was primarily documented by intense activity of NaF-inhibitable non-specific esterase, of acid phosphatase and of beta-glucuronidase as demonstrated in cryostat sections of formaldehyde-saccharose-fixed fresh biopsy specimens and by the detection of alpha-1-antichymotrypsin, alpha-1-antitrypsin, and lysozyme antigens, in that order of constancy (immunohistochemical examination of formaldehyde-fixed paraffin sections, using the avidin-biotin-peroxidase complex method). There was among the reported cases a considerable heterogeneity with regard to these 'markers'. We conclude that malignant histiocytosis is a (the?) major cause of the 'midline granuloma syndrome'.

Cholesterol metabolism in cholesteatoma and cholesterol granuloma

Based on biochemical and morphological studies, the significance of cholesterol in cholesteatoma and cholesterol granuloma is discussed. In cholesteatoma, cholesterol is synthesized through desmosterol and delta 7-cholestenol (lathosterol), possibly in the matrix. Cholesterol crystal might have educed from keratin layers or a cell-disintegrated layer adjacent to the matrix by a physicochemical rather than by a biochemical process. Production of cholesterol in the matrix may differ depending on the cell cycle. In cholesterol granuloma, cholesterol may be derived from blood with some other compositions such as albumin and cholestanol, although other sources cannot be denied. Crystallized cholesterol is treated by the surrounding tissue as a foreign body; this results in formation of granuloma. The delta 7-cholestenol is not involved in the biosynthesis of cholesterol in cholesterol granuloma.

The ultrastructure of cholesterol granuloma of the middle ear: an electron microscope study

The ultrastructure of giant cells in cholesterol granuloma is described, with particular reference to their role in the absorption of cholesterol needles. Cholesterol is a highly resistant substance in its crystalline form and it is confirmed that the giant cells are endowed with endoplasmic structures and organelles and are partly crowded with lysosomes, as evidence of the active role of the giant cells in the absorption and removal of cholesterol formed in the granuloma from blood, mucus or necrotic material.

Idiopathic pleomorphic midfacial granuloma (Stewart's type)

Idiopathic mid-facial granuloma is an unusual highly destructive disease which was virtually unknown prior to 1955. Great confusion exists, due in large part to the terminology applied to this entity as well as the clinical similarity of the process to other destructive mid-facial lesions. A classical case of idiopathic mid-facial granuloma of Stewart's type is presented, with characteristic lesions limited to the mid-face. Definitive histopathological features consist of pleomorphic inflammatory granulation tissue with patchy necrosis and no system lesions or neoplasia in the autopsy tissues.

Idiopathic cholesterol pneumonitis

The fiftieth case of idiopathic cholesterol pneumonitis (ICP) is presented and the 49 previously reported cases have been reviewed. This review draws attention to certain features which have not previously been emphasized, including marked male predominance, single lobe involvement, the distribution of the lesions, dense pleural fibrosis, smoking history and the close histological association between giant cells and disrupted elastic fibres of the alveolar walls. The clinical and radiological similarity between ICP and primary bronchogenic carcinoma is described. Various aetiology theories are discussed, and the similarity between ICP and spontaneous lipid pneumonia in the mongoose is noted; the hypothesis is put forward that ICP, like the mongoose pneumonia, is an expression of disordered production or disposal of excessive surfactant.

Lethal midline granuloma: a pathological spectrum

Lethal midline granuloma is a non-specific clinical term used for different pathological entities often exhibiting some semblance to each other as they lie along a histological spectrum. Nevertheless, each entity has a specific diagnostic pattern. The histological picture with distinguishing features of each specific type is pointed out. Stress is made on the use of repeated biopsy until the specific histological diagnosis can be made so that specific treatment as breifly outlined, can be carried out to insure the best prognosis.

Non-healing granulomata of the upper respiratory tract

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