STAT expression and TFH1 cells in CVID granulomatosis and sarcoidosis: immunological and histopathological comparisons

Granulomatous disease is a serious complication of common variable immunodeficiency (CVID-GD) that occurs in 8-22% of these patients and can mimic sarcoidosis, with which it shares certain clinical, biological, and radiological features. However, few studies to date have compared the two pathologies immunologically and histologically. Therefore, we analyzed the immunological-histological findings for different tissue samples from ten patients with CVID-GD and compared them to those of biopsy-proven sarcoidosis. Specifically, we wanted to know whether or not the signaling abnormalities observed in sarcoidosis granulomas are also present in CVID-GD. Morphological differences were found between CVID-GD histology and classical sarcoidosis: mainly, the former's notable lymphoid hyperplasia associated with granulomas not observed in the latter. All CVID-GD involved organs contained several follicular helper-T (TFH) cells within the granulomatosis, while those cells were inconstantly and more weakly expressed in sarcoidosis. Moreover, CVID and sarcoidosis granulomas expressed the phosphorylated-signal transducer and activator of transcription (pSTAT)1 and pSTAT3 factors, regardless of the organ studied and without any significant difference between entities. Our results suggest that the macrophage-activation mechanism in CVID resembles that of sarcoidosis, thereby suggesting that Janus kinase (JAK)-STAT-pathway blockade might be useful in currently difficult-to-treat CVID-GD.

[Paradoxical tuberculosis reaction]

Paradoxical tuberculosis reaction is defined as the aggravation of lesions present at diagnosis or the development of new lesions under anti-tuberculosis treatment, after exclusion of other alternate causes. It affects 5 to 30% of tuberculosis patients, with a variable prevalence depending on the site of infection and the clinical background. The diagnosis of paradoxical reaction is one of elimination, and requires having ruled out therapeutic failure, notably linked to poor compliance and/or to the presence of mycobacterial antibiotic resistance. The severity of paradoxical tuberculosis reaction lies in its neurological impairment. Despite its clinical importance, the mechanisms involved remain poorly understood and its management is not consensual. Corticosteroids are the cornerstone in the medical management. The role of anti-TNF agents, currently proposed in cases of corticodependence or corticoresistance, remains to be properly defined.

Pulmonary Foreign Body Granulomatosis after Cosmetic Injection

INTRODUCTION

We occasionally encounter irregular marginated masses discovered incidentally in young individuals. In most cases, further investigations are conducted to assess the presence of a primary malignancy, as these masses often raise suspicions of malignancy. However, rare exceptional cases leave us perplexed. Granulomas arising from common lung infections and those induced by foreign substances can often pose challenge in distinguishing them from lung cancer. Therefore, we aimed to present a case of multiple pulmonary granulomatosis following cosmetic procedure.

CASE PRESENTATION

A 55-year-old woman visited the hospital after an incidental discovery of an abnormal chest radiograph during a routine health check-up. Subsequent computed tomography (CT) scans showed worrisome lung nodules, leading to biopsies and positron emission tomography CT scans. Histological examination of the biopsied specimens revealed a chronic inflammatory reaction surrounded by multinucleated foreign body giant cells. Upon sharing the biopsy results with the patient and conducting additional history-taking, she had undergone various cosmetic procedures (botox injection, dermal filler treatments, and thread lifts) around the face and neck, approximately 5-6 months ago. It was hypothesized that these cosmetic materials might have led to the observed pulmonary granulomatosis. After 3 months of conservative care, a follow-up CT showed no change in the lesions.

CONCLUSION

We present this case to underscore the importance of considering pulmonary foreign body granulomatosis as a potential differential diagnosis, especially when it closely resembles lung cancer, particularly following cosmetic injections.

Efficacy of Rituximab on Refractory Organ Involvements in Granulomatosis with Polyangiitis: A Systematic Review of Case Reports

INTRODUCTION

Granulomatosis with polyangiitis (GPA) is a type of Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) characterized by necrotizing vasculitis affecting small and medium-sized blood vessels. GPA affects various organs, with respiratory tract, vasculitis and glomerulonephritis being the most common triad. Remission induction and maintenance therapy for GPA traditionally involves corticosteroids and cyclophosphamide. However, treatment with rituximab, a monoclonal antibody that depletes B-cells involved in autoimmune disease, has been successful in inducing remission in several studies. The purpose of this systematic review was to investigate the efficacy of rituximab in treating various clinical manifestations of GPA.

METHODS

In adherence to PRISMA guidelines for systematic reviews and meta-analyses, we carried out a comprehensive review to investigate the effectiveness of rituximab on particular organ involvement in GPA. We searched three databases (PubMed, Scopus, and Embase) up until November 6, 2022, for case reports on the topic. To ensure all relevant studies were included, we manually screened the first 50 pages of Google Scholar's search results.

RESULTS

The review identified a total of 64 case reports and a case series of 113 cases, highlighting the effectiveness of rituximab in treating refractory organ involvement in GPA. The review also analyzed the effectiveness of rituximab in treating ocular, CNS, cardiac, pulmonary, cutaneous, gastrointestinal, renal, and other organ involvements in GPA.

CONCLUSIONS

Our results indicated that rituximab can be a promising therapy for treating specific clinical manifestations of several organ involvements. However, more research is needed to determine the long-term efficacy of rituximab in treating GPA.

A child with polyarthritis and chronic lung disease: a case report of ataxia-telangiectasia

BACKGROUND

Ataxia-telangiectasia (A-T) is a rare autosomal recessive DNA repair disorder, characterized by progressive cerebellar degeneration, telangiectasia, immunodeficiency, recurrent sinopulmonary infections, radiation sensitivity, premature aging and predisposition to cancer. Although the association with autoimmune and chronic inflammatory conditions such as vitiligo, thrombocytopenia and arthritis has occasionally been reported, an onset with articular involvement at presentation is rare.

CASE PRESENTATION

We herein report the case of a 7-year-old Caucasian girl who was admitted to the Rheumatology Department with a history of febrile chough and polyarthritis which led initially to the suspicion of an autoinflammatory disease. She had overt polyarthritis with knees deformities and presented with severe pneumonia. A chest Computed Tomography (CT) scan showed bilateral bronchiectasis, parenchymal consolidation and interstitial lung disease; rheumatoid factor and type I interferon signature resulted negative, therefore excluding COatomer Protein subunit Alpha (COPA) syndrome. A diagnosis of sarcoidosis had been suspected based on histological evidence of granulomatous liver inflammation, but ruled out after detecting normal angiotensin converting enzyme and chitotriosidase blood levels. Based on her past medical history characterized by at least six episodes of pneumonia in the previous 4 years, immunological phenotyping was performed. This showed complete IgA and IgE deficiency with defective antigen-specific antibodies to Pneumococcal, Tetanus toxin and Hemophilus Influenzae B vaccines. Additionally, low numbers of B cells and recent thymic emigrants (RTE) were found (CD4Ra 1.4%), along with a low CD4+/CD8 + T cells ratio (< 1). Finally, based on gait disturbances (wobbly wide-based walking), serum alfa-fetoprotein was dosed, which resulted increased at 276 ng/ml (normal value < 7 ng/ml). A diagnosis of Ataxia-Telangiectasia was made, strengthened by the presence of bulbar telangiectasia, and then confirmed by Whole Exome Sequencing (WES).

CONCLUSIONS

Although rare, A-T should always be ruled out in case of pulmonary bronchiectasis and gait disturbances even in the absence of bulbar or skin telangiectasia. Autoimmune and granulomatous disorders must to be considered as differential diagnosis.

Vasculitis: When to Consider this Diagnosis?

Vasculitis is a diverse group of disorders involving inflammation of the blood vessels. Approaching the diagnosis of vasculitis can be challenging, given the differing clinical presentation and organ manifestations. Often vasculitis is a diagnosis that is considered too late, given the heterogeneous presentation and various mimics. This article aims to provide physicians with a diagnostic approach to vasculitis.

[Peripheral neuropathies during systemic diseases: Part I (connective tissue diseases and granulomatosis)]

Systemic diseases (connective disease, granulomatosis) may be associated with peripheral neuropathies. The diagnosis can be complex when the neuropathy is the presenting manifestation of the disease, requiring close collaboration between neurologists and internists. Conversely, when the systemic disease is already known, the main question remaining is its imputability in the neuropathy. Regardless of the situation, the positive diagnosis of neuropathy is based on a systematic and rigorous electro-clinical investigation, specifying the topography, the evolution and the mechanism of the nerve damage. Certain imaging examinations, such as nerve and/or plexus MRI, or other more invasive examinations (skin biopsy, neuromuscular biopsy) enable to specify the topography and the mechanism of the injury. The imputability of the neuropathy in the course of a known systemic disease is based mainly on its electro-clinical pattern, on which the alternatives diagnoses depend. In the case of an inaugural neuropathy, a set of arguments orients the diagnosis, including the underlying terrain (young subject), possible associated systemic manifestations (inflammatory arthralgias, polyadenopathy), results of first-line laboratory tests (lymphopenia, hyper-gammaglobulinemia, hypocomplementemia), autoantibodies (antinuclear, anti-native DNA, anti-SSA/B) and sometimes invasive examinations (neuromuscular biopsy).

[Sarcoidosis as prime example of a granulomatous disease]

Sarcoidosis is the most frequent immunologically related granulomatous disease and can serve as a model for understanding diseases within this category. The evidence on the diagnostics and treatment is so far limited. It is therefore all the more important that two new and significant guidelines on diagnosis and treatment of sarcoidosis were published during the last 2 years. Additionally, there were more new publications, which were considered for this review article. In this context, this review article provides a current update and overview of sarcoidosis. Pathophysiologically, there is an increasing understanding of the complex processes and interactions involved in the inflammatory processes and granuloma formation. The probability of a diagnosis of sarcoidosis is determined by compatible histology, the exclusion of differential diagnoses and if possible evidence of a multiorgan manifestation. The clinical course is variable and ranges from an asymptomatic manifestation to severe life-threatening organ failure. The most frequently affected organ are the lungs. Pulmonary fibrosis is the most severe form and is also decisive for mortality. An increasing focus is on the extrapulmonary organ manifestations, in particular, cardiac, hepatosplenic, gastrointestinal, renal, ocular and neurological involvement. Treatment, which consists primarily of immunosuppression, should be initiated in cases of organ-threatening or quality of life-impairing activity of the disease. Additional organ-specific management must also be evaluated. In cases of organ failure transplantation should be considered. Due to the limited evidence especially for the treatment of multiorgan sarcoidosis, when possible, patients with this disease should be included in clinical trials.

Pediatric cardiothoracic vasculitis: multimodality imaging review

The pediatric vasculitides are a relatively uncommon and heterogeneous group of disorders characterized by vessel inflammation, often with cardiothoracic involvement. Diagnosis and monitoring are often clinically challenging because of the nonspecific symptoms and laboratory markers. Thus, imaging has assumed increasing importance for early detection of disease activity, extent and complications as well as long-term monitoring pre- and post-treatment. Herein, we review the major pediatric vasculitides with frequent chest manifestations, including Takayasu arteritis, Kawasaki disease, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis, Behçet disease and potential mimics. We highlight key clinical features and management considerations, emphasizing the central role of imaging.

Granulomatosis with polyangiitis and neurofibromatosis type 1: a fortuitous association? (a case report)

Neurofibromatosis type 1 is a common neurocutaneous syndrome, caused by an alteration of the NF-1 gene, which is a tumor suppressor. It has been reported to be associated with different types of benign and malignant tumors but its association to systemic diseases is uncommon and has not been reported previously to be associated with vasculitis particularly granulomatosis with polyangiitis (GPA). We report a case of a 17-year-old male patient, who, during his follow-up for neurofibromatosis type 1, in our outpatient consultation; we objectified hypereosinophilia at 1700 eosinophils/μl without a history of asthma or atopy. He reported a nasal obstruction with epistaxis and no rhinorrhea or pruritus. Physical examination revealed afebrile patient with the lesions of his neurofibromatosis type 1 without cutaneous rash or urticaria. Rhinoscopy didn’t show any lesion. Laboratory tests revealed a normal renal function, negative 24-hour urine protein, and no biological inflammatory syndrome. Immunological tests noted positives cytoplasmic antineutrophil cytoplasmic antibodies, and a slight increase in antinuclear antibodies at 1/180. Extensive infectious research was negative. Computed tomography (CT) of the sinuses revealed a non-obstructive nasal septum deviation with anatomical variations, and a chest scan showed multiple bilateral pulmonary nodules and micronodules. After ruling out the other etiologies, we retained the diagnosis of granulomatosis with polyangiitis according to American College of Rheumatology (ACR) criteria 1990 and we could start early the treatment. To our knowledge, the association between Neurofibromatosis type 1 and vasculitis, particularly GPA, has not been reported previously, which makes our case original and confirms the utility of an extensive lesion assessment during the follow-up.

[Bone involvement in cat scratch disease]

INTRODUCTION

Cat scratch disease caused by Bartonella henselae with bone involvement is a rare presentation.

CASE REPORT

We report a case of disseminated bartonellosis with multifocal osteomyelitis and multiple visceral involvement in an immunocompetent adult. Diagnostic confirmation was obtained by PCR on lymphadenopathy. In addition to our observation, 31 cases of bartonellosis with bone involvement were reported in the literature. Diagnosis is based on a combination of history, serology and PCR performed on tissue. The antibiotic treatment allows recovery in all cases.

CONCLUSION

Cat scratch disease in its systemic form with bone involvement is a rare and difficult diagnosis for the clinician and an invasive approach is often required to obtain the diagnosis.

[Silica causes difficulties]

Silicosis and sarcoidosis are two very distinct entities in the literature. All the additional non-invasive examinations, including the chest CT scan, often do not differentiate them. The history, including occupational exposure to identified silica particles, is a discriminating factor. However, due to the pathogenic power of silica, it would be possible to have the simultaneous development of these two pathologies in the same patient. To illustrate this situation, here is the case of a 62-year-old patient, who presented initially with a picture of dyspnea and productive cough. The chest CT showed micronodular peribronchovascular infiltrates and mediastinal lymphadenopathy. The other additional examinations did not find anything specific. In the diagnostic process, the patient had multiple endoscopic samples which did not make it possible to be conclusive on one or the other of these pathologies. He therefore underwent a surgical lung biopsy which revealed histological lesions compatible with the two pathologies. Recent studies suggest that inhaled particles, especially silica, could be responsible for the pattern of sarcoidosis. However, it is difficult to say whether, in this case, silica was responsible for the development of sarcoidosis.

Granulomatous mastitis caused by Rickettsia species

Granulomatous mastitis is a rare inflammatory disease of varying etiology. Tuberculosis and cystic neutrophilic granulomatous mastitis caused by Corynebacterium are the best-established infectious examples. Despite the increasing incidence of Rickettsia-related diseases worldwide, granulomatous inflammation of breast parenchyma caused by Rickettsia has not yet been reported. We present a unique case of bilateral granulomatous mastitis documented with mammography, magnetic resonance imaging and core-needle biopsy. The rickettsial etiology of the disease was proved with specific immunohistochemistry and confirmed with DNA extraction, PCR and serology. The lesions completely resolved after a full-course tetracycline treatment. This case report widens the knowledge about the possible clinical manifestations of Rickettsia infection and adds a new bacterium to the list of etiological factors causing granulomatous mastitis.

Acute Myocardial Infarction and COVID-19 in a Known Case of Granulomatosis with Polyangiitis

Since the emergence of novel coronavirus and the disease named as COVID-19 in late December of 2019 in Wuhan, Hubei province, China, many aspects of this disease have been reported in the literature (mainly pulmonary manifestations). In patients with COVID-19, rheumatic and cardiovascular manifestations and interactions were reported separately, but they were all very rare. This is the report of a 14-year-old teenager with GPA (previously known as Wegner's granulomatosis) who was in remission with immunosuppressive therapy. Post COVID-19 infection, she developed exacerbation of her disease. Besides the rheumatologic manifestations, she developed epigastric pain found to be acute myocardial infarction (MI) that needed primary percutaneous coronary intervention (PCI).

Healthcare and economic burden of ANCA-associated vasculitis in Italy: an integrated analysis from clinical and administrative databases

ANCA-associated vasculitides (AAV) comprise a group of systemic vasculitides characterized by inflammation of small-sized blood vessels leading to multi-organ involvement. The worldwide annual incidence of AAV ranges from 1.2 to 3.3 cases per 100 000 individuals with a prevalence of 4.6-42.1 cases per 100 000 individuals. The prevalence of AAV is geographically heterogeneous; therefore, regional epidemiological studies can be more informative to improve health care systems. Even though clinicians are aware that the healthcare burden and the risk of hospitalization of AAV appear high, data on hospitalization and cost of illness due to AAV are still scarce or even lacking. This study aims to characterize the economic burden of AAV in Friuli Venezia Giulia (FVG), Italy. Thus, a retrospective study was conducted through the integration of many administrative health databases of the FVG as the source of information. From data integration, we estimated that more than two-thirds of AAV patients showed at least one hospitalization in their medical history, most frequently caused by the disease itself or superimposed infections. Around 10% of patients developed end-stage renal disease. In an 8-year follow-up, the overall healthcare cost was € 1,215,078, corresponding to € 6,168 patient-year. ANCA-positive patients showed much higher costs than ANCA-negative patients did. Overall, AAV are rare diseases, but imply very high healthcare costs. Early diagnosis and optimal treatment probably still remain unmet needs for AAV.

Breast tuberculosis: a case series

BACKGROUND AND AIM

Breast tuberculosis is a rare disease, even in endemic areas. The diagnosis can be challenging, as it can mimic breast cancer. We aim to report our experience and discuss diagnoses and management modalities.

RESULTS

We encountered twelve cases of breast tuberculosis in our institution from 2004 to 2019. The average age of our Caucasian North African patients was 42 years old (22-63). The classic presentation was a breast lump found in half of the cases. On physical examination, we suspected breast carcinoma in seven patients. The average size of the tumors was 39 mm (15-80 mm). Nine patients had a mammogram. In five cases, there was a suspicious breast mass mimicking a malignant tumor with an average size of 33 mm (25-60 mm). A ultrasonography was performed in 6 cases and revealed a suspicious ill-circumscribed nodule in four patients with an average size of 37.5 mm (10-60 mm). Five patients had a lumpectomy, and seven women underwent drainage of the abscess and the biopsy of its hull. The association of epithelioid cell granulomas and caseous necrosis was mandatory for the histological diagnosis of tuberculosis. All of them had an antitubercular therapy. The median period of follow-up was of 43 months (3-156 months). One patient presented with a recurrent abscess of the breast.

CONCLUSION

Our study found that clinical examination and radiological imaging were not specific. Positive cultures for Koch bacillus or histological confirmation are mandatory for the diagnosis. A meta-analysis of the existing cases is needed.

[IgG4-associated lung disease with granulomatous lesions : Coexistence of two entities or the spectrum of one disease?]

A 54-year-old patient with a history of pulmonary tuberculosis and occupational exposure to dust in early adulthood presented with symptoms of coughing with sputum, weight loss, occasional night sweats, and thoracic pain. Non-necrotizing granulomatosis in lung and lymph-node biopsies indicated sarcoidosis. Combined immunosuppressive therapy did not lead to an improvement. An atypical lung resectate with fibroinflammatory changes and obliterative endothelialitis may finally lead to the diagnosis of IgG4-associated lung disease with a bronchovascular pattern of involvement. The question discussed here is whether this is a coexistence of IgG4-associated lung disease with sarcoidosis or the spectrum of one disease.

[Histopathology of pulmonary tuberculosis]

Although typical histological findings of tuberculosis are well known, the diagnosis of nonmicrobiologically proven tuberculosis with the instruments available to pathology is challenging. Indeed, necrotizing epithelioid cell granulomatosis is typical for tuberculosis, but it is also seen in a number of different infectious or noninfectious lung diseases. The tools of microscopy and molecular pathology are suitable for confirming the diagnosis or paving the way to a differential diagnosis, but molecular pathology applied to formalin-fixated and paraffin-embedded material is limited. This should be openly communicated to the referring clinician. After interdisciplinary re-evaluation of the findings, an alternative solution to confirm the diagnosis must therefore be found if the additional examinations are negative.

[Heerfordt's syndrome: about a case and literature review]

Le syndrome de Heerfordt est une manifestation rare de la sarcoïdose associant dans sa forme classique une uvéite, parotidomégalie, paralysie faciale et fièvre. C'est une forme active de la maladie dont le diagnostic est facilité par la biopsie salivaire. Il s'agit d'une observation clinique d'une patiente âgée de 17 ans présentant une uvéite, une parotidomégalie droite et une paralysie faciale droite d'apparition brutale. Après un bilan biologique et une imagerie (échographie parotidienne), une biopsie des glandes salivaires accessoires a conduit au diagnostic de sarcoïdose. Un bilan pré thérapeutique a permis d'instituer une corticothérapie par voie orale avec une évolution favorable et rémission totale. Le syndrome de Heerfordt est une forme clinique rare de sarcoïdose avec un profil évolutif favorable dans la majorité des cas. Il nécessite une approche diagnostique précise (éliminer les diagnostics différentiels surtout les formes incomplètes) en insistant sur les progrès thérapeutiques dans ce domaine.

Parathyroid gland hyperplasia associated with tuberculous granulomatous inflammation manifesting as primary hyperparathyroidism

OBJECTIVES

Inflammatory disorders of the parathyroid gland are poorly defined. Only seven cases of granulomatous infection have been reported in the literature.

PATIENTS AND METHODS

A 68-year-old woman presented with parathyroid hormone level at 277pg/mL and calcium level at 10.8mg/dL, considered as primary hyperparathyroidism. Parathyroidectomy was performed, normalizing analytical values.

RESULTS

Normal-size gland with chief cell hyperplasia, focal pseudofollicular changes, and presence of epithelioid granulomas with Langhans giant cells and caseous necrosis areas, and a positive PCR for M. tuberculosis complex was identified. Chronic granulomatous inflammation could provoke a cascade of immune system activation, resulting in hyperplasia with the consequent increase in parathyroid function, and therefore primary hyperparathyroidism.

CONCLUSIONS

In populations with a high incidence of tuberculosis, the coexistence of these pathologies must be kept in mind. This theory needs further biomolecular studies to be confirmed, but it provides a new perspective within the possible etiologies of hyperparathyroidism.

Strawberry gingivitis - First sign of Wegener's granulomatosis

Wegener's Granulomatosis (WG) is an immunologically mediated rare multisystem disease characterized by necrotizing granulomatous inflammation affecting the upper and lower respiratory tracts, disseminated vasculitis and glomerulonephritis. WG oral lesions are reported to occur in 6%–13% of patients; they were an initial presenting feature in only 2% of cases. A case of strawberry gingivitis as the first sign of WG presented with erythematous and painful localized gingival enlargement affecting the maxillary anterior region of jaw in a 17-year-old boy is reported here. Correlation of histopathology with routine hematoxylin and eosin and special stains such as Grocott-Gomori's methenamine-silver nitrate and periodic acid–Schiff, peripheral blood smear, chest radiographs, Mantoux test and clinical presentation were established in diagnosing this rare entity. By the above-mentioned procedures, we arrived at the diagnosis of WG. The aim of reporting this case was to emphasize that, the dental surgeon often being the first person to examine the oral cavity, should be familiar with the typical appearance of gingiva as “strawberry gingivitis,” its clinical course, diagnostic parameters and adequate management of WG.

[Echo-guided splenic biopsy: An effective diagnostic tool in sarcoidosis?]

BACKGROUND

Histological diagnosis of systemic granulomatosis may be difficult. The question of the best histological target remains unanswered.

CASE

We report here the observation of a patient admitted in intensive care unit for severe hypercalcemia in the context of polylymphadenopathy and constitutional symptoms. Assessment of this hypercalcemia was suggestive of systemic granulomatosis. The CT (computed tomodensitometry) revealed lymphadenopathies of the mediastinum and the hepatic hilus, hepatomegaly and heterogeneous splenomegaly. At this stage, our main hypotheses were: lymphoid hematopathy, sarcoidosis, tuberculosis. An echo-guided biopsy of the spleen allowed the histological diagnosis of systemic granulomatosis suggestive of sarcoidosis, without significant complication in the course.

CONCLUSION

This observation illustrates the efficiency and safety of spleen biopsy for the histological diagnosis of systemic granulomatosis.

Treatment of Peristomal granulomatosis with a Neem and Red Hypericum Oil application: Case studies

BACKGROUND

Peristomal granulomatosis is a chronic inflammatory disease of uncertain aetiology, and a high recurrence rate. It frequently occurs in patients with enterostomy and urostomy. The most frequent type affects the mucocutaneous junction, causing bleeding and painful nodular lesions, which complicate management of the ostomy pouching system. Currently, only invasive treatments are available, consisting in cauterisation or surgical removal of the granuloma. Our objective was to evaluate efficacy of a topic mixture oil, composed by a 1:1 of extracts of Neem and Red Hypericum; amongst its many therapeutical properties, it is proven to inhibit the over-granulation process.

METHOD

Two clinical cases presenting typical peristomal granulomatosis were selected. On first access after recruitment, the patients underwent an accurate nursing anamnesis, a global assessment was carried out according to the Toven Method and an assessment of peristomal sore skin according to SACS 2.0. Granulomatosis wounds were treated with the oil mixture, applied on a hydrofiber pad, secured over the wound site by means of a transparent film. This allowed the release of active ingredients while ensuring the pouching system secure adhesion. The chosen protocol consisted in 2 dressing changes per week, while monitoring the granulomatosis wound evolution by means of a TOR Form validated data form and documenting progress by taking photographs.

RESULTS

Initially a regression of the inflammatory process was observed, with significant decrease of bleeding and pain. Gradually, the proliferating lesions reduced in size (both width and extent), and eventually healed completely. The product was very well tolerated, even when in contact with the stoma mucous membrane. No recurrence signs were observed either at the follow up visit 15 days from end of treatment, and in clinical case N.2 equally none were present two months after treatment.

CONCLUSIONS

Compared to conventional methods which are invasive, not resolving, and not tolerated by patients, the product was demonstrated to be an innovative therapeutical solution, easy to apply, with no side effects and well-liked by patients. The excellent results obtained require further confirmation and validation through new studies on a statistically significant number of cases.

Autoimmune/inflammatory syndrome induced by adjuvants-ASIA-related to biomaterials: analysis of 45 cases and comprehensive review of the literature

Systemic autoimmune or granulomatous disorders related to biomaterials of human use have rarely been described. The aim of this study was to report cases of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) related to biomaterial injections and prostheses, mainly silicone, hyaluronic acid, acrylamides and methacrylate compounds in a Spanish patient cohort. This study is a retrospective analysis of clinical, laboratory, histopathological and follow-up data of 45 cases of patients suffering from late-onset, non-infectious inflammatory/autoimmune disorders related to bioimplants. Late onset was defined as 3 months or more post injection. Data were obtained through a further non-systematic but comprehensive review of the literature. Forty-five cases of late-onset adverse reactions related to biomaterial injections or prostheses were reviewed. All cases had systemic complaints that could be categorised as ASIA. In all but four patients, inflammatory features at the implantation site preceded distant or systemic manifestations. Abnormal blood tests were common. Localised inflammatory nodules and panniculitis in 40/45 (88.88%) evolved into a variety of disorders, viz., primary biliary cirrhosis, Sjögren's syndrome, sarcoidosis, human adjuvant disease, vasculitis, inflammatory bowel syndrome and inflammatory polyradiculopathy. Five (11.11%) cases presented primarily with systemic autoimmune disorders. Biomaterials and prostheses can provoke late-onset systemic autoimmune disorders fulfilling ASIA criteria, or present primarily local/regional inflammatory reactions that may eventually evolve into systemic autoimmune and/or granulomatous disorders which fall under ASIA.

Cerebral granulomatosis as a manifestation of Crohn's disease

BACKGROUND

Crohn's disease (CD) is associated with a variety of extra-intestinal manifestations. Most commonly these involve the eye, skin, joints, coagulation system and liver. Cerebral manifestations of CD have been reported to a far lesser extent. The extensive detrimental impact of neurological symptoms on a patient's quality of life makes an early diagnosis and treatment particularly important. In previous case-reports, diagnosis of cerebral manifestations in CD often relied upon magnetic resonance imaging (MRI) and computed tomography (CT) alone. To our knowledge, only one case-report has documented a histologically confirmed case of cerebral lesions associated with CD so far.

CASE PRESENTATION

A 39-year-old right-handed woman with a history of CD was referred to our hospital with etiologically unexplained Gadolinium (Gd)-enhancing cortical lesions, triggering epileptic seizures. A CT-scan of the thorax and bronchoalveolar lavage found no signs of sarcoidosis. Lumbar punctures and laboratory testing found no underlying infection or coincidental autoimmune disorders and MRI-scans showed progression of lesion load. Consequently, the patient underwent stereotactic biopsy of a cortical lesion. Histological examination revealed a mixed lympho-histiocytic and tuberculoid granulomatous inflammation surrounding small vessels and no signs for infection. After exclusion of other granulomatous diseases and the typical histological findings we diagnosed a cerebral granulomatosis as a manifestation of CD. The patient was initially started on azathioprine, which had to be switched to corticosteroids and methotrexate because of an azathioprine related pancreatitis. The patient has not suffered any further epileptic seizures to date.

CONCLUSION

Cerebral manifestation of CD is a possibly underreported entity that may respond well to immunosuppressive treatment. In contrast to earlier reports of cerebral manifestations in CD, our patient showed no coincident gastrointestinal symptoms indicating an activity of CD during the progression of cortical lesion load, suggesting that similar to other extra-intestinal manifestations in CD, the activity of gastrointestinal symptoms does not necessarily reflect the activity of CD associated cerebral vasculitis. Therefore, diagnosis and therapy of cerebral manifestation may be delayed when focusing on gastrointestinal symptoms alone.

Differentiation of Cocaine-Induced Midline Destructive Lesions from ANCA-Associated Vasculitis

INTRODUCTION

Cocaine-induced midline destructive lesions (CIMDL) are complications of regular nasal cocaine inhalation. CIMDL can mimic systemic diseases with positive anti-neutrophil cytoplasmic antibodies (ANCA), such as granulomatosis with polyangiitis (GPA).

CASE REPORT

In this article, we describe the case of a young woman who presented with nasal perforation induced by cocaine, along with positive perinuclear ANCA test (proteinase 3 antigen), misdiagnosed as limited GPA. The patient was treated with immunosuppressive therapy, which partially improved her symptoms. Admittance of cocaine use aided in the diagnosis of CIMDL. This patient was advised to stop cocaine use. Three-month follow-up revealed no further complications.

CONCLUSION

Considering the seropositivity of ANCA in both CIMDL and GPA, early diagnosis of CIMDL and its differentiation from GPA is crucial, and clinicians play an important role in this regard. Lack of distinct histologic characteristics of vasculitis or unresponsiveness to standard therapeutic regimens may favor the diagnosis of CIMDL syndrome. It is crucial to recognize that these conditions may have similar presentations, so that undesired and potentially toxic treatments can be prevented.

Peripheral Arterial Tonometry in Pulmonary Vasculitis

Vascular wall inflammation in primary vasculitides results in diminished vessel dilation and finally impaired blood flow, causing multiple organs dysfunction and ultimate damage. In granulomatosis with polyangiitis (GPA), the inflammatory process concerns small and medium sized vessels and its pulmonary location is often predominant. The pivotal role in the development of that pathology plays vascular endothelium. Endothelial vasodilatory function strongly depends on the instant production and release of nitrogen oxide (NO), a potent local factor controlling vascular tonus. NO output is triggered by a variety of stimuli, especially by ischemia. The endothelial vasodilatory ability can be measured indirectly by a few of methods, one of them is peripheral arterial tonometry (PAT). The method assesses reactive hyperemia, mediated mostly by NO release, as a response to vessel occlusion. The vasodilatory reaction depends on the quality of the endothelium which deteriorates with time of GPA disease progression. The aim of the present study was to estimate a correlation between the clinical status, reflected by the disease extent index (DEI), and the vasodilatory endothelial function reflected by the index of arterial reactive hyperemia (RHI), measured by PAT in 27 patients with GPA, having a significant pulmonary involvement. We found a moderate inverse correlation between DEI and log-transformed RHI (r = -0.46, p < 0.05). The conclusion is that impaired endothelial function, as assessed by RHI-PAT, might predict the GPA progression.

Extensive pulmonary sarcoid reaction in a patient with BMPR-2 associated idiopathic pulmonary arterial hypertension

Pulmonary arterial hypertension is a progressive life-threatening disease characterized by vascular remodeling. There is evidence that varied immune mechanism play an important role in progression of pulmonary hypertension.  We describe a case of a 35-year-old woman with idiopathic pulmonary arterial hypertension (IPAH) and a novel BMPR2 mutation, who underwent a successful lung transplantation.  Extensive granulomatous inflammation was seen in the resected lungs. The granulomatous inflammation found in the histology supports  a sarcoid-like reaction due to pulmonary hypertension in the context of the BMPR2 mutation.

A case of Granulomatosis with Polyangiitis presenting with significant ocular cicatricial scarring and symblepharon formation

Purpose

To report a case of Granulomatosis with Polyangiitis presenting with rare findings of cicatricial entropion progressing to significant symblepharon and fornix obliteration.

Observations

An otherwise healthy patient with initial presentation findings of lower lid entropion with minimal cicatricial changes and a corneal ulcer. Management with an entropion Jones procedure repair produced good early postoperative results. 2 months post entropion repair, this patient represented with rapid progression to severe corneal ulceration, symblepharon formation and total obliteration of lower fornix and near complete obliteration of upper fornix of the left eye with concurrent acute kidney injury. He fulfilled diagnostic criteria for Granulomatosis with Polyangiitis (GPA). Systemic immunosuppressive treatment with prednisone and cyclophosphamide allowed acute kidney injury to recover however progressive cicatricial scarring ensued.

Conclusions and importance

Cicatricial entropion is a very rare presentation of GPA which can take years to progress however with surgical intervention, rapid recurrence and severe tarsal-conjunctival disease progression can ensue despite systemic immunosuppressive therapy. To prevent such unexpected surgical complication, we recommend a thorough systemic evaluation prior to consideration of lid surgery in any cases of cicatrising conjunctivitis presentation.

Elemental analysis of occupational granulomatous lung disease by electron probe microanalyzer with wavelength dispersive spectrometer: Two case reports

The parenchymal lung diseases caused by metal inhalation include interstitial fibrosis, giant cell interstitial pneumonitis, chemical pneumonitis, and granulomatous disease, among others. We reported two cases of granulomatous lung disease with occupational exposure to metal dusts other than beryllium. They had worked in the battery manufacturing industry for 7 years and in an aluminum-processing factory for 6 years, respectively. Chest high-resolution computed tomography showed diffuse micronodules, and histology of video-assisted lung biopsy specimens revealed granulomatous lesions in the pulmonary interstitium. Results of microscopic examination of the tissue with special stains for mycobacteria and fungi were negative. Analysis by an electron probe microanalyzer with a wavelength-dispersive spectrometer (EPMA-WDS) confirmed the presence of silicon, iron, aluminum, and titanium in the granulomas. In particular, aluminum was distributed in a relatively high concentration in the granulomatous lesions. Although chronic beryllium disease is well known as an occupational granulomatous lung disease, much less is known about the other metals that cause granulomatous reactions in humans. Our report pointed out manifestations similar to beryllium disease after other metal dust exposures, in particular aluminum exposure. To our knowledge, this is the first report showing two-dimensional images of elemental mapping in granulomatous lesions associated with metal inhalation using EPMA-WDS.

Successful cataract surgery in a patient with refractory Wegener's granulomatosis effectively treated with rituximab: A case report

Wegener’s granulomatosis is a granulomatous disorder associated with systemic necrotizing vasculitis. Eye involvement occurs in approximately 50% of Wegener’s granulomatosis patients and is an important cause of morbidity. Conventional treatment-related morbidity and failure have led to studies of alternative treatment modalities. In this case of a 35-year-old man with severe Wegener’s granulomatosis, conventional therapy failed to induce remission. Despite the standard immunosuppressive therapy, progression of the disease was observed, mainly with ocular manifestations and renal impairment. Rituximab was given intravenously and led to remission of both systemic and ocular manifestations of the disease. After 1 year of disease quiescence, he was admitted one week after his third regularly-scheduled rituximab treatment and was started on intravenous methylprednisolone, 500 mg/day for 3 days, before cataract surgery. Subsequently, the patient underwent phacoemulsification cataract surgery in his left eye. Six months later, in the same manner he underwent uneventful phacoemulsification cataract surgery in the right eye with a favorable outcome in both eyes. Conclusion: In this patient, rituximab was a well-tolerated and effective remission induction agent for severe refractory Wegener’s granulomatosis and led to successful cataract surgery.

Asthma Control and Airway Inflammation in Patients with Eosinophilic Granulomatosis with Polyangiitis

BACKGROUND

Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic necrotizing vasculitis that occurs in patients with asthma, nasal disease, blood and tissue eosinophilia, and extrapulmonary manifestations.

OBJECTIVE

The aim of our study was to assess the clinical, functional, and inflammatory status of upper and lower airways in 37 patients with EGPA, examined 6.4 ± 4.7 years after diagnosis, when they were in partial or complete remission from systemic involvement while on treatment with low-dose oral corticosteroids as maintenance therapy.

METHODS

All patients performed spirometry and were assessed for bronchial hyperreactivity, sputum eosinophilia, and fractional exhaled nitric oxide; asthma control was evaluated according to the Global Initiative for Asthma (GINA) guidelines and the Asthma Control Test. Markers of systemic disease were compared with the data available at diagnosis. Nasal involvement was evaluated by using the Sino-Nasal Outcome Test, nasal endoscopy, and nasal cytology. The impact on the quality of life was evaluated by using generic (36-item short form health survey) and organ-specific questionnaires.

RESULTS

At the time of the study visit, almost all patients were receiving low-dose oral corticosteroids and immunomodulating drugs, but only 50% were being treated with inhaled corticosteroids. Although low systemic disease activity was documented in the large majority of patients, poorly controlled asthma and rhinosinusitis with eosinophilic airway inflammation were demonstrated in almost all patients. A significant correlation was found between sputum and blood eosinophilia and between fractional exhaled nitric oxide and asthma control. The 36-item short form health survey questionnaire results significantly correlated with the Sino-Nasal Outcome Test but not with the Asthma Control Test.

CONCLUSIONS

Systemic treatment controls systemic involvement in EGPA, but not asthma and nasal diseases, which negatively affects patients' quality of life.

[Association of lymphoma and granulomatosis: A case series]

PURPOSE

The sarcoidosis-lymphoma syndrome is a recognised entity. However, the presence of granulomas in patients with a haematological disease should not lead too easily to a diagnosis of sarcoidosis. The presence of granulomatous lesions during the follow-up of these patients raises diagnostic and therapeutic issues.

METHODS

We included 25 patients followed by the department of haematology in a French hospital (Centre Léon-Bérard). These patients presented with granulomatous lesions. Patients with a history of sarcoidosis were excluded. We report the type of haematological disease, the time of onset of the granulomatous disease compared to that of lymphoma, associated symptoms, aetiology and outcome. Patients were divided into three groups according to the time of onset of the granulomatous lesions.

RESULTS

Granulomatous lesions appeared before the haematological disease in 4 cases, was concomitant in 8 cases and appeared later in 13 remaining cases. The two main subtypes of lymphoma encountered were: diffuse large cell lymphoma (36%) and Hodgkin's lymphoma (28%). Granulomatous lesions were related to the progression of the hematological disease in 11 cases, to sarcoidosis in 4 cases, to infection in 3 cases, to drug allergy in one case, to inflammatory bowel disease in one case, to granuloma annulare in one case and was isolated in 4 cases (no identified etiology). In the group where granulomas appeared after the haematological disease, mean SUV was 11 for the haematological disease versus 6.4 for granulomas.

CONCLUSION

Granulomatous diseases in lymphomas can be due to various aetiologies: infection, reaction to the haematological disease, or systemic sarcoidosis. It is an important challenge for clinicians, who can miss the diagnosis of lymphoma and or conclude to a treatment failure or a relapse. Computed tomography scan (CT-scan) or (18)F-deoxyglucose-positron emission tomography scan can help establish a diagnosis but do not replace biopsy.

Rituximab in refractory sarcoidosis: a single centre experience

Sarcoidosis is a granulomatous disease whose outcome varies from spontaneous remission to chronic refractory disease. Provided that steroids represent the gold standard as a first line treatment, many immune suppressants drugs are currently used in the disease management. However, refractory disease is still a great challenge. Rituximab is an anti-CD20 chimeric monoclonal antibody, currently used for the treatment of B cell malignancies and systemic autoimmune diseases. There are few case reports describing the successful use of Rituximab in refractory sarcoidosis with lung, eye, lymph nodes and skin involvement. In this paper we described three different case reports in which Rituximab has been used to treat refractory sarcoidosis and we reviewed the existing literature.

[Prevalence of granulomatous lesions in minor salivary gland biopsy in a case series of 65 patients with tuberculosis]

PURPOSE

The distinction between tuberculosis (TB), a worldwide infectious granulomatosis requiring specific antibiotic therapy, and sarcoidosis, a rare granulomatous disease that may require corticosteroids is not straightforward and may result in diagnostic and therapeutic delay.

METHODS

We prospectively and consecutively evaluated the presence of epithelioid granulomas in minor salivary gland biopsy of 65 consecutive patients with TB.

RESULTS

In our study, 10.8 % of our TB patients had epithelioid granulomas without caseous necrosis identified in their minor salivary gland biopsy, regardless of the location of TB, HIV status and whether or not the sputum examination was positive for tuberculous bacilli.

CONCLUSION

The presence of epithelioid granulomas in minor salivary gland biopsy may not be helpful to the clinician to rule out TB in a patient with suspected sarcoidosis.

[Granulomatosis with polyangiitis in the elderly: report of two cases and review of literature]

La granulomatose avec polyangéite (GPA) est une vascularite nécrosante des vaisseaux de petit calibre. L’âge moyen d'entrée dans la GPA est entre 35 et 55 ans, les formes gériatriques sont cependant rares, Nous rapportons deux cas de GPA révélés après 60 ans, le mode de révélation était inhabituel, ophtalmologique dans le premier cas et cutané dans le deuxième cas.

[An unusual case of duodenal sarcoidosis]

INTRODUCTION

Sarcoidosis is a systemic granulomatous disorder of unknown aetiology. It may rarely affect the gastrointestinal tract.

CASE REPORT

We reported a 54-year-old woman with a delayed diagnosis of duodenal sarcoidosis. She presented with gastric and right upper abdominal pain associated with vomiting and marked weight loss. Abdominal computed tomographic scan showed non-compressive retroperitoneal lymph nodes and histological examination revealed non-caseating epithelioid granulomas typical of sarcoidosis. Diagnosis of duodenal sarcoidosis was obtained at the third gastroscopy. The patient's condition improved quickly with corticosteroid therapy.

CONCLUSION

Gastrointestinal sarcoidosis should be looked for in patients with digestive symptoms and another sarcoid localisation. Furthermore, it is important to repeat gastroscopy to confirm diagnosis because treatment improved most patients.

Positron emission tomography imaging in sarcoidosis

Sarcoidosis is a chronic granulomatous disease of unknown origin. There are several modalities for diagnosis, staging and therapeutic management of patients with sarcoidosis. Among these, whole-body F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography is found to useful in patients with complex and multisystem forms of sarcoidosis. Other modalities include Gallium scanning, assesment of angiotensin converting enzyme levels in blood, chest radiography, mediastinoscopy etcetera.

Isolation of Mycobacterium fortuitum from fish tanks in Alborz, Iran

INTRODUCTION

Fish mycobacteriosis is caused by the non-tuberculous mycobacteria. Infected fish are normally the primary source of infection, although non-tuberculous Mycobacteria can be found in the environment. The present study was designed to investigate the few recently found suspected cases of mycobacteriosis in Iranian ornamental fish tanks.

MATERIALS AND METHODS

Pathological specimens including granolumas from autopsied fish were used to inoculate Lowenstein-Jensen medium. Genomic material was extracted from all acid-fast positive cultures. The mycobacterial identity of bacterial isolates was authenticated using a PCR assessment targeting a 543 bp-long stretch of 16Sr RNA gene. Further more, a PCR assessment targeting a 294 bp-long stretch of heat shock protein hsp65 was performed and the amplicons were sequenced to identify the isolates.

RESULTS

Characteristic mycobacterial bacilli were identified both in light and fluorescent microscopy of bacterial culture from all the suspected specimens. PCR-amplification of DNA templates from all isolates successfully resulted in production of the expected products. Existence of Mycobacterium fortuitum was confirmed by comparison analysis of nucleotide sequencing at hsp65 gene.

CONCLUSION

The present work clearly shows mycobacteria are important in pathology of ornamental fish diseases. People who are keeping fish as pet in their homes should be cantioned about the bacterial contamination risks arise from close contact with exotic ornamental species of fish.

Primary labial tuberculosis: a rare presentation

Tuberculosis is one of the oldest scorches of mankind that has not left this world even today. The disease is more common in the developing countries. Oral tuberculosis has been considered in 0.1-5% of all tuberculous infections. Mostly, the oral tuberculous lesions are secondary to pulmonary tuberculosis, but rarely primary lesions may occur. Primary lesions occur due to direct inoculation of the microorganism into the oral mucosa and mainly seen in the young individuals. Tongue is the most common oral site involved. Of all the sites involved, labial involvement is extremely rare. This case report intends to throw light on one such unique case, where a young male patient presented with a primary tubercular lesion of the lip. The lesion resolved immediately after anti tubercular therapy.

[Combined variable immunodeficiency with unusal features. A case report]

INTRODUCTION

The association granulomatosis - combined variable immunodeficiency (CVID) - is well known from the clinicians. However, the association with a large granular lymphocyte (LGL) leukemia has not been yet reported.

CASE REPORT

We report a 50-year-old woman, followed for CVID associated with a granulomatous disease. During the follow-up, the patient developed a granulomatous lymphocytic interstitiel lung disease (GLILD). Secondarily, she presented a LGL leukemia.

CONCLUSION

To our knowledge, this is the first reported case of an association between CVID and LGL leukemia.

Diagnosis and classification of granulomatosis with polyangiitis (aka Wegener's granulomatosis)

Granulomatosis with polyangiitis (GPA, formerly known as Wegener's Granulomatosis) is an autoimmune small vessel vasculitis which is highly associated with anti-neutrophil cytoplasmic antibodies (ANCA). The hallmarks of this condition are systemic necrotising vasculitis, necrotising granulomatous inflammation, and necrotising glomerulonephritis. The aetiology of granulomatosis with polyangiitis is linked to environmental and infectious triggers inciting onset of disease in genetically predisposed individuals. Anti-neutrophil cytoplasmic antibodies are pathogenic and play an important role in the pathogenesis of this disease, although ANCA positivity is not essential for a clinical diagnosis of granulomatosis with polyangiitis. Granulomatosis with polyangiitis is diagnosed based on clinical manifestations of systemic vasculitis and histological evidence of necrotising vasculitis or granulomatous inflammation. This small vessel vasculitis may present as limited disease of the ears, nose and upper airways or mild, moderate or severe systemic disease. Immunosuppression and adjuvant therapies have contributed to the improved prognosis of granulomatosis with polyangiitis over the past decades. Treatment strategies are tailored to the severity of the disease. They are based on published evidence of the efficacy and safety of the immunosuppressive drugs indicated to manage active vasculitis and maintain clinical remission. This review will summarise the history, aetiology, pathogenesis, classification, diagnosis and management of granulomatosis with polyangiitis.

Granulomatosis with polyangiitis (Wegener's) presenting as the right ventricular masses: A case report and review of the literature

BACKGROUND

Granulomatosis with polyangiitis (Wegener's) is a systemic necrotizing vasculitis. Cardiac involvement in Wegener's has rarely been reported. In this study the echocardiographic findings of granulomatosis with polyangiitis (GPA) in a patient is described.

CASE PRESENTATION

The case was a 45 years old man admitted to the hospital with a 3 months history of persistent fever and sinusitis. Mild left and right ventricular enlargements as well as three small masses in the right ventricular cavity were identified in echocardiography. One mass was attached to the tricuspid valve and the other two masses were attached to the right septum. Pulmonary artery hypertension (45mmHg) was also reported. The masses responded dramatically to plasma exchanges in combination with steroid therapy, followed by oral cyclophosphamid and low-dose steroid therapy. In the kidney biopsy, 8 out of 11 golomeruli contained fibrous crescents along with sclerotic lesions. Spleen has 140 mm diameter with multiple echo-free lesions and coarse parenchyma in abdominal ultrasound. Serum C-ANCA=671, P-ANCA=1.7 (normal= up to 15U/mL). The diagnosis of granulomatosis with polyangiitis (Wegener's) was established.

CONCLUSIONS

Presence of three small masses in right ventricular cavity and pulmonary artery hypertension in association with the spleen lesions were an uncommon presentation of GPA. GPA should be considered in the differential diagnosis of any nonspecific illnesses with cardiac involvement.

Testicular masses in a man with a plausible sarcoidosis

Genitourinary involvement with sarcoidosis is very rare. The objective of this report was to present a case of a patient with testicular swelling. The patient was an infertile 42-year-old man with bilateral testicular swelling. Semen analysis in the past 10 years revealed no abnormality; however, gradually he became azoospermic in 3 years. A diagnosis of sarcoidosis made on the basis of hilar and mediastinal lymphadenopathy in chest CT scan was confirmed through testicular and epididymal biopsy. Testicular masses vanished after administering steroids, and azoospermia recovered. To conclude, although genitourinary sarcoidosis is rare, it must be kept in mind in patients with confirmed sarcoidosis.