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146
Granulomatous Infections: Etiology and Classification
Alimuddin Zumla and D. Geraint James
From the Academic Infectious Diseases Unit, Department of Medicine,
University College London Medical School; and the Royal Free
Hospital School of Medicine, London, United Kingdom
Granulomatous disorders are frequently due to a wide variety of infections. Over the past decade
advances in molecular diagnostic techniques have allowed identification of organisms involved in
granulomatous disorders that previously were of unknown etiol~gy. ~n the basis of cu~ently available information, granulomatous infections can now be classified m three categones. Group 1
infections are due to a well-recognized organism. Group 2 comprises infections due to organisms
that have been recently identified in granulomas by molecular methods but are not readily isolated
by conventional microbiological techniques. Group 3 consists of disorders for which the causal
organisms have not yet been identified but are strongly suspected; further a~van~es in di~gnostic
techniques will lead to reclassification of some of these disorders as grou~ 2. ThIs r~vlew descnbe~ the
etiology,histopathologic features, and classification of granulomatous disorders, with an emphasis on
those of groups 2 and 3.
Granuloma Formation
A granuloma can be defined as a focal, compact collection
of inflammatory cells in which mononuclear cells predominate.
Granulomas usually form as a result of the persistence of a
nondegradable product or as the result of hypersensitivity responses [1]. An overlap of the two mechanisms occurs in most
infectious diseases since microorganisms can serve both as
foreign bodies and as antigens for immunologic responses.
Normally granulomas are the result of protective mechanisms
and form when acute inflammatory processes cannot destroy
invading agents.
The granuloma forms by a stepwise series of events and is
the end result ofa complex interplay among invading organism,
antigen, chemical, drug or other irritant, prolonged antigenemia, macrophage activity, T cell responses, B cell overactivity,
circulating immune complexes, and a vast array of biological
mediators [2]. Areas ofinflammation or immunologic reactivity
attract monocyte-macrophages, which may fuse to form multinucleated giant cells [3]. Further cellular transformation of
macrophages to epithelioid cells may occur.
The granuloma is an active site of numerous enzymes and
cytokines and, with aging, fibronectin and progression factors
such as platelet-derived growth factor, transforming growth
factor-,B, insulin-like growth factor, and TNF-a. There is a
close relationship between CD4 + T lymphocytes and activated
macrophages showing increased expression of major histocom-
Received 21 August 1995; revised 23 February 1996.
Financial support: Camden and Islington Community Health Services NHS
Trust.
Reprints or correspondence: Professor D. Geraint James, Visiting ~rofessor
of Medicine, Royal Free Hospital School of Medicine, Rowland HIll Street,
London NW3 2PF, United Kingdom
Clinical Infectious Diseases
1996;23:146-58
© 1996 by The University of Chicago. All rights reserved.
1058-4838/96/2301-0020$02.00
patibility (MHC) class II molecules. The T helper cells recognize protein peptides presented to it by antigen-presenting cells
bearing MHC class II molecules.
The T cell induces IL-l on the macrophage, and thereafter
a cavalcade of chemotactic factors promote granuloma genesis
[2, 4]. IFN-'}' increases the expression of MHC class II molecules on macrophages, and activated macrophage receptors
carry a crystallizable fraction of IgG to potentiate their ability
to phagocytose [4]. The end result is the epithelioid granuloma,
which progresses toward fibrosis under the impact of transforming growth factor and platelet-derived growth factor.
T cell subsets, macrophages, and other immune cells produce
several cytokines, the amounts and types of which determine
further subclassifications of granulomas. CD4 + T helper (Th)
lymphocytes are necessary for the development of granulomas
and are broadly classified into two functional types, Thl and
Th2 [5]. Thl-type cells produce IL-2, IFN-'}', and TNF-,B upon
stimulation with antigen and also participate in delayed-type
hypersensitivity responses, while Th2-type cells make IL-4,
IL-5, IL-6, IL-9, IL-I0, and IL-13, cytokines which are important for development of B cells and eosinophilia.
There appears to be a complex relationship between Thltype and Th2-type responses and infectious granulomas. Granulomas that synthesize predominantly Th2-type cytokines, such
as those that form in response to parasite ova, make only small
quantities of Thl-type cytokines chronically [6], whereas granulomas such as those of tuberculoid leprosy make large quantities of Thl-type cytokines and less of Th2-type lymphokines
[7]. Granulomas of various infections may have different immunoregulatory mechanisms governing their formation and
resolution [I, 2, 7].
Classification of Granulomatous Infections
Granulomatous disorders are frequently due to a wide variety
of infections. Over the past decade advances in molecular diag-
em 1996;23
(July)
Granulomatous Infections
147
Table 1. Classification of granulomatous infections and associated
pathogens.
Group 1 Granulomatous Infections (Causal Agents
Well Defined)
Group number,
type of causal agents
A wide range of infectious organisms cause the granulomatous diseases that fall into this category (table 1). These diseases
share similar histologic features and have identifiable and distinct etiologic agents.
Group I
Well recognized
Mycobacteria
Bacteria
Spirochetes
Fungi
Protozoa
Nematodes
Trematodes
Chlamydia species
Rickettsia
Viruses
Group 2
Recently recognized
Bacterium
Actinomyces
Group 3
Suspected but not established
Measles virus
Mycobacterium
? (see table 4)
Viral
?
Granulomatous disorders
Tuberculosis, leprosy, Buruli ulcer,
swimming pool (fish tank)
granuloma
Brucellosis, melioidosis, actinomycosis,
nocardiosis, granuloma inguinale,
listeriosis, tularemia
Syphilis, pinta, yaws
Mycoses (see table 3)
Leishmaniasis, toxoplasmosis
Visceral larva migrans (toxocariasis)
Schistosomiasis, paragonimiasis,
fascioliasis, clonorchiasis
Lymphogranuloma venereum, trachoma
Q fever (Coxiella burnetii infection)
Infectious mononucleosis,
cytomegalovirus infection, measles,
mumps
Cat-scratch disease (Bartonella
henselae infection)
Whipple's disease (Tropheryma
whippelii infection)
Crohn's disease
Primary biliary cirrhosis
Sarcoidosis
Kikuchi's disease
Chronic granulomatous disease of
childhood
Langerhans granulomatosis
nostic techniques have allowed identification of organisms
involved in granulomatous disorders that previously were of
unknown etiology. On the basis of currently available information, granulomas associated with infections can be categorized
in three groups, as listed in table 1.
Group 1 granulomatous disorders are caused by well-recognized agents. In group 2, the causal agents have been suspected
over the years but have only recently been recognized by newer
diagnostic molecular techniques such as PCR. These agents are
not readily isolated by conventional bacteriologic techniques.
Group 3 comprises granulomatous disorders that may be associated with particular infectious agents but for which the causal
organisms have not yet been determined. Future advances in
diagnostic techniques may provide strong evidence of the
causal agents, in which case the disorders may be reclassified
as group 2; any such advancements will allow better management of these idiopathic granulomatoses.
Mycobacterial Infections
Mycobacteria are a large group comprising Mycobacterium
tuberculosis, Mycobacterium leprae, Mycobacterium avium
complex, Mycobacterium ulcerans, Mycobacterium marinum.
several opportunistic mycobacteria, and the mycobacteria from
which BCG vaccine is produced. The nontuberculous mycobacteria produce a wide clinical spectrum of granulomatous
disorders, summarized in table 2. Mycobacteria have been implicated in the etiopathogenesis of sarcoidosis and Crohn' s
disease, and this is discussed in the section on group 3 disorders.
Tuberculosis. The etiologic agent of tuberculosis, M. tuberculosis, is clinically one of the most common microbial
causes of granulomas [2, 8]. The M. tuberculosis granuloma,
classically characterized by the presence of central caseous
necrosis, is referred to as a tubercle. Typically, there is a central
area of amorphous caseating granular debris and loss of cellular
detail, and acid-fast bacilli are present. This area is encircled
by epithelioid cells, lymphocytes, histiocytes, fibroblasts, and
occasionally Langhans' giant cells. These histologic features
of the granuloma are sufficiently characteristic to allow reasonably accurate diagnosis of tuberculosis [8].
While caseating granulomas are the classic finding in cases
of tuberculosis, they are not always present; noncaseating granulomas may occur. When acid-fast bacilli are not identifiable
in the granuloma, culture of the biopsy specimen may yield
M. tuberculosis. PCR with use of primers specific for M. tuberculosis is currently under evaluation for the identification of
this species [9] and may develop into an important tool for
distinguishing it from other (nontuberculous) mycobacteria.
Immunosuppression may alter the classic histopathologic
features of tuberculosis. A spectrum of histopathologic granulomatous tissue reactions are seen in patients infected with HIV
[10]. Classic well-formed granulomas have been observed in
individuals with early HIV disease whose CD4 cell counts have
remained adequate. In patients with advanced HIV disease, the
granulomas are less well formed, are more necrotic, and may
contain abundant bacilli, which may be demonstrated by appropriate staining techniques as well as by culture of biopsy specimens [9-11].
Leprosy. Leprosy, or Hansen's disease, is a chronic granulomatous disorder caused by M. leprae, an obligate intracellular
bacterium that predominantly affects the skin and nerves [12].
First identified over a century ago by Armauer Hansen, the
bacterium has defied all attempts to grow it in culture. Leprosy
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Zumla and James
Table 2.
1996;23 (July)
Granulomatous diseases caused by nontuberculous mycobacteria.
Site
Clinical manifestation
or type of disease
Mycobacterial species
Lung
Bronchopulmonary disease
Lymph node
Lymphadenitis
Bones and joints
Osteomyelitis
Skin and soft tissue
Abscesses
Buruli ulcer
Swimming pool granuloma
Tuberculoid leprosy
Lepromatous leprosy
M. avium complex, M. kansasii, M. xenopi,
M. simiae, M scrofulaceum, M. chelonae,
M. malmoense
M. avium-M. intracellulare, M kansas ii,
M fortuitum, M. scrofulaceum,
M. chelonae
M. avium-M. intracellulare, M. kansasii,
M fortuitum, M scrofulaceum,
M. marinum
M chelonae, M. fortuitum
M. ulcerans
M. marinum
M. leprae
M. leprae
Meningitis, diarrhea, pneumonia,
lymphadenitis
M. avium-M. intracellulare, M. kansasii,
M. chelonae
Multisystem
involvement
manifests as a spectrum of well-described clinical, pathological, and immunologic features [12].
At one end of the spectrum is lepromatous leprosy, the low
resistance form with multiple lesions, extensive skin and visceral involvement, and diffuse infiltration of lesions with numerous leprotic baccilli. At the other end of the spectrum,
tuberculoid leprosy, the highly resistant form, is characterized
by one or few skin lesions and involvement of the nerve at the
site of the lesion. Skin biopsies of patients with tuberculoid
leprosy reveal a few acid-fast and alcohol-fast leprotic bacilli
and a well-defined giant cell granuloma. Actual granulomatous
invasion and destruction of dermal nerves, occasionally with
caseous necrosis, sometimes occurs.
Within the dermis of patients with lepromatous leprosy, increased levels of Th2-type cytokines (lL-4, IL-5, and IL-IO)
and decreased levels of IL-2 and IFN-y have been noted. In
contrast, Th I-type cytokines predominate in tuberculoid lesions
[7]. The diagnosis of leprosy is based on a combination of
clinical and histologic findings. The paucity of acid-fast bacilli
in the lesions of tuberculoid leprosy may sometimes make it
difficult to distinguish them from other infectious and noninfectious granulomas, especially those of sarcoidosis and syphilis
[12]. Pt.R for the detection of M leprae in tissue lesions is
being developed, and this may in the future allow more accurate
diagnosis in such circumstances [13].
Buruli ulcer. M. ulcerans is the cause of chronic, relatively
painless, cutaneous Buruli ulcers. The disease is most prevalent
in Africa and Australia. The organism causes extensive undermined ulcers on the extensor surface of the extremities. The
centers of the ulcers are necrotic, and the edges are undermined;
the organisms are usually found at the periphery, where granulation tissue is most extensive [14]. While it is relatively easy
to diagnose Buruli skin ulcers on the basis of clinical features
and histologic findings, microbiological identification of the
causal mycobacteria may sometimes be quite difficult, requiring long periods of culture.
Newer techniques such as gas-phase chromatography are
becoming useful for identification of the acid-fast bacilli in
low-count subcultures [15]. A report from West Africa [16] of
a case of disseminated M. ulcerans infection that followed a
snakebite and caused multifocal osteomyelitis illustrates the
difficulties that are associated with identifying the organism
by conventional microbiological techniques. Although repeated
cultures were negative, the organism was identified as M. ulcerans by peR amplification of the genes coding for 168 rRNA
from biopsy specimens.
Swimming pool (fish tank) granuloma. M marinum causes
swimming pool (fish tank) granuloma [17]. Although the primary skin infection may be inconspicuous, the draining lymph
nodes are extensively involved and caseous. A similar microscopic picture, with conspicuous plasma cell infiltration, is associated with granulomas due to other opportunistic mycobacteria. Fish tank granulomas develop in persons with minor
abrasions who dip their hands in tropical fish tanks. Usually a
solitary granuloma, nodule, or pustule forms, which may ulcerate or suppurate; however, multiple lesions may extend along
the line of lymphatic vessels (in sporotrichotic infections).
Biopsy specimens that are cultured on Lowenstein-Jensen
medium at room temperature yield pigmented mycobacterial
colonies in 2~4 weeks. The response to treatment is variable
and not dramatic. Antituberculous drugs, cotrimoxazole, and
high doses of minocycline have been advocated.
A wide range of mycobacterial diseases occur in humans
(table 2), and in some cases the clinical features and results of
staining for acid-fast bacilli in granulomas may not reveal the
identity of the causal organisms, which may also be difficult
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Granulomatous Infections
to isolate in culture. The development and application of molecular techniques such as PCR may in the future allow fairly
accurate diagnosis [18].
Bacterial Infections
Brucellosis. Brucellosis (Malta fever) is a multisystem
granulomatous disorder caused by small gram-negative, intracellular coccobacilli of the Brucella species [19]. The United
Kingdom is one of 17 Brucella-free countries. It is more prevalent than its reported incidence in the United States, France,
Spain, and Ireland [20]. Unpasteurized dairy products remain
a common mode of transmission of this chronic granulomatous
disorder among travelers to areas of endemicity. Raw camel's
and goat's milk, raw sheep's and goat's liver, and reindeer
bone marrow have all been associated with transmission.
Diagnosis, which may be difficult by means of culture, is
usually based on clinical features and serological and histopathologic findings [20]. Delayed-type hypersensitivity is believed
to be important in the formation of the tissue granuloma, which
limits the spread of the organism [21]. Epithelioid-cell granulomas may be found in the reticuloendothelial system, lung, brain,
bone, joints, and soft tissue and are difficult to distinguish from
granulomas due to other causes.
Necrotizing hepatic granulomas due to brucellosis have been
described. In these cases, bacteriologic diagnosis may be difficult on the basis of blood or abscess pus cultures, although
serology may be useful [22]. PCR tests for the identification
of Brucella species are being developed [23, 24], and these
may be useful tools for the diagnosis of brucellar granulomas.
Melioidosis. Melioidosis is caused by a gram-negative bacillus, Burkholderia pseudomallei. Acute melioidosis presents
with protean clinical manifestations during which septicemia
may occur, causing septic shock and multiorgan involvement.
This may progress to a chronic suppurative phase, in which
lung involvement, subcutaneous abscesses, lymphadenitis, and
suppurative parotitis are common [25, 26]. Granulomatous osteomyelitis has also been described [27].
The lesions vary histologically from acute, chronic inflammation with a focal granulomatous component to a predominantly granulomatous picture. Caseous or purulent central necrosis is surrounded by epithelioid and giant cells and by
fibrosis in lungs, lymph nodes, and bone. The presence of
intracellular gram-negative bacteria within macrophages or giant cells and of similar extracellular bacilli may provide a clue
to the diagnosis [28].
More-specific enzyme immunoassays are being developed
for the detection of circulating antibody [29] or of B. pseudomallei antigen in the urine [30] of patients with melioidosis.
PCR tests for the identification of B. pseudomallei have recently been described [31, 32], but these require field testing
in areas of endemicity.
149
Treponemal Infections
The spirochetes include Treponema pallidum subspecies pallidum (the cause of syphilis), T. pallidum subspecies pertenue
(responsible for yaws), and Treponema carateum (the causal
agent of nonvenereal pinta in Latin America). All three are
chronic granulomatous disorders that may cause diagnostic
confusion with other granulomatous disorders [33]. Mucocutaneous lesions of secondary syphilis show a spectrum of
histopathologic changes, ranging from minimal infiltration to
granulomatous infiltration throughout the dermis [34]; granulomatous infiltrates show endothelial proliferation, with mononuclear cell infiltration.
The syphilitic gumma may present as a microscopic to
grossly visible lesion, with an enclosing wall of histiocytes,
plasma cell infiltrate, and necrotic center cells with intact cellular outlines. peR to detect T. pallidum subspecies pallidum
DNA in clinical specimens, including gumma biopsy material,
appears to be highly sensitive and specific [35, 36].
Protozoan Infections
Leishmaniasis. Leishmaniasis refers to the spectrum of
clinical disease caused by the protozoan Leishmania [37]. This
parasite is transmitted by phlebotomine sandflies, and the disease presents in three clinical forms: cutaneous, mucocutaneous, and visceral. Amastigotes of Leishmania species live
within macrophages and are usually seen as single or focal
collections within macrophages in blood, aspirates of sternal
marrow, liver or spleen specimens, or special culture medium.
Leishmaniasis has been extensively studied as a model infection for analysis of cell-mediated immunity. Granulomatous
responses are a feature of cutaneous and mucocutaneous leishmaniasis. Cutaneous ulceration is characterized by a mononuclear cell infiltrate, with Th l-type responses emerging after
weeks of infection. Resolution of the infection depends on an
increase in the number of leishmania-specific CD4 + T cells of
the Thl subset [38], following which a granulomatous response
with epithelioid and giant cells emerges.
The nodular stage of post-kala-azar dermal leishmaniasis is
characterized by massive granulomas consisting of lymphocytes, plasma cells, and histiocytes, with numerous amastigotes
of the species Leishmania donovani [39]. A preponderance of
CD8+ T cells occurs in the lesion, in contrast to normal levels
in the peripheral blood. A recent report described the use of
PCR for identifying Leishmania aethiopica DNA in formalinfixed and paraffin-embedded tissue specimens [40]: seven of
the 40 skin biopsy specimens in which parasites were not found
histopathologically were subsequently found to contain parasite DNA.
Toxoplasmosis. Toxoplasmosis refers to the clinical disease caused by the protozoan Toxoplasma gondii. Neonatal
infection occurs during acute maternal infection in pregnancy.
Acquired toxoplasmosis presents as a glandular, fever-like syn-
150
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Zumla and James
Table 3.
1996;23 (July)
Causes and immunopathologic features of granulomatous mycoses.
Fungal species
Clinical condition
Immunopathologic feature(s)
Cryptococcus neoformans
Cryptococcosis
Candida species
Candidiasis
Sporothrix schenckii
Histoplasma capsulatum
varieties
Aspergillus species
Paracoccidioides brasiliensis
Coccidioides immitis
Sporotrichosis
Histoplasmosis
Aspergillosis
South American blastomycosis
Coccidioidomycosis
Blastomyces dermatitidis
Blastomycosis
Phialophora species
Pseudallescheria boydii,
Madurella species
Chromoblastomycosis
Mycetoma
drome that rapidly resolves. The T. gondii trophozoites encyst
and persist in nucleated cells as the cause of chronic, latent
infection that can reactivate with immunosuppression and produce multisystem disease.
The histopathologic changes characteristically occur with a
triad of features [41]: reactive follicular hyperplasia, epithelioid
histiocytes, and monocytoid cells. Langhans' giant cells are
not typically seen. Accurate diagnosis may be difficult in many
cases. PCR is increasingly being used to detect T. gondii DNA
in various clinical samples [42], and its application to identification of T. gondii DNA in tissue biopsy specimens is under
investigation.
Fungal Infections
Fungal infections are common causes of granulomas worldwide. Granulomatous fungal infections can present as localized
conditions or systemic illnesses (table 3). A wide range of
medically important fungi can now be diagnosed by PCR [43].
Histoplasmosis and coccidioidomycosis are caused by dimorphic fungi that produce clinical disease resembling tuberculosis
[44-46].
Histoplasma infections in the lungs of immunocompetent
persons cause epithelioid-cell granulomas that undergo coagulative necrosis. Histologic differentiation from tuberculosis,
sarcoidosis, and coccidioidomycosis may be possible by identification of thin-walled yeast forms in Grocott-Gomori methenamine-silver nitrate stains. In immunodeficient persons, histoplasmosis may be fulminant and is not associated with
formation of epithelioid-cell granulomas: focal collections of
mononuclear phagocytes containing yeasts are seen throughout
tissues of the body, and the reticuloendothelial system becomes
full of macrophages containing yeasts [46, 47].
Pneumonia, infarction, abscess,
meningitis, granuloma, fibrosis
Abscess, necrosis, granulomas
(mucocutaneous or multisystem)
Granuloma (cutaneous, skeletal)
Pneumonia, cavitation, granuloma
Necrotizing multisystem granulomas
Pneumonia, cavitation, granuloma
Pneumonia, cavitation, granuloma,
cutaneous plaques, nodules
Granuloma, microabscess, pneumonia,
chronic pulmonary or extrapulmonary
disease
Granuloma (cutaneous)
Granuloma (skin and subcutaneous tissue)
Coccidioides immitis spores inhaled by immunocompetent
persons induce a delayed-type hypersensitivity reaction. Most
primary cases of coccidioidomycosis involving such patients
are asymptomatic. Lung lesions may develop in some patients,
in association with fever, chest symptoms, and erythema nodosum. A minority of cases progress to disseminated infection.
The primary and secondary granulomatous lung lesions due
to C. immitis are similar to those due to Histoplasma species.
C. immitis organisms are thick-walled, nonbudding spherules
often filled with endopores. A neutrophil infiltrate may occur
around the area of granulomatous reaction when the spherules
rupture to release the endospores. In disseminated disease, the
inflammatory response may be purely granulomatous, pyogenic, or mixed. Pyogenic lesions may dominate in immunosuppressed patients [46, 47].
Helminthic Infections
Several helminthic parasites can cause granulomas with
pathological consequences. Of particular interest are schistosomiasis and visceral larva migrans.
Schistosomiasis. Schistosomiasis is caused by five main
human-blood flukes of the genus Schistosoma: S. haematobium, S. mansoni, S. japonicum, S. intercalatum, and S. mekongi.
These currently infect more than 200 million people. Diagnosis
is made by identification of the species-specific characteristic
ova in feces, urine, or tissues (usually rectal and liver biopsy
specimens). During the chronic phase of the infection, the mature worms produce large numbers of ova, which become
trapped in tissues and induce formation of granulomas [48],
with chronic fibro-obstructive sequelae.
Granuloma formation is the result of a combination of factors: a foreign-body reaction to the deposited ova (which may
em 1996;23
(July)
Granulomatous Infections
or may not be identifiable within the granuloma) and a cellmediated delayed-type hypersensitivity reaction to antigenic
determinants of the parasite [49]. The giant cells are of the
multinucleate type, and the eosinophils are conspicuous. The
ova contain living larvae that release a variety of toxic and
antigenic substances through the egg wall, which itself is antigenic.
These substances induce and maintain the granulomatous
response. The granulomatous response appears to be tightly
regulated and involves development of Th l-type and Th2-type
cytokine responses [50, 51].
Toxocariasis (visceral larva migrans). Dog and cat larval
nematodes, especially Toxocara canis and Toxocara cati, may
infect children and lead to the syndrome of visceral larva migrans [52]. Swallowed infected eggs emerge as larvae in the
intestine, whence they pass to the liver, lungs, brain, and eye,
producing eosinophilic granulomas in these different organs.
This infection should be particularly suspected in children with
hepatomegaly or miliary granulomas in liver biopsy specimens,
miliary lung mottling, eosinophilia, and focal posterior uveitis
or endophthalmitis. Liver granulomas may reveal part of the
larvae with surrounding eosinophilia.
Viral Infections
Measles. The paramyxovirus family is a group of RNA
viruses that includes the measles virus, which has been implicated in the etiology of idiopathic granulomatous disorders,
sarcoidosis, and Crohn's disease. The measles (rubeola) virus
is spread by respiratory droplets and it multiplies within the
upper respiratory tract epithelial cells, mononuclear cells, B
and T lymphocytes, and macrophages. Viremia follows, which
disseminates the virus throughout the body. T cell-mediated
immunity that controls the infection develops and produces the
measles rash.
The blotchy rash of measles consists of dilated skin vessels,
edema, and a nonspecific mononuclear perivascular infiltrate
[47,53]. Lymphoid organs have marked follicular hyperplasia,
large germinal centers, and randomly distributed multinucleate
giant cells (Warthin-Finkeldey cells), which have eosinophilic
nuclear and cytoplasmic inclusion bodies. In the lung, peribronchial and interstitial mononuclear infiltration occurs. The measles virus has been implicated in the etiopathogenesis of sarcoidosis and Crohn's disease and is discussed in the section
on group 3 disorders.
Herpesviruses. The herpes group of viruses are doublestranded DNA viruses that cause a spectrum of human disease.
The Epstein-Barr virus is the etiologic agent of the clinical
condition infectious mononucleosis and is transmitted by close
contact, especially via saliva during kissing. It has also been
implicated in the pathogenesis of several disorders such as
Burkitt's lymphoma, nasopharyngeal carcinoma, B cell
lymphomas, and sarcoidosis.
151
Infectious mononucleosis in its benign form is characterized
by fever, sore throat, lymphadenopathy, splenomegaly, and the
appearance of atypical activated T cells in the peripheral blood.
Further multisystem involvement may occur, leading to hepatitis, meningoencephalitis, and pneumonitis. Atypical lymphocytes are seen in the portal areas and sinusoids of liver biopsy
specimens, and scattered isolated areas of focal parenchymal
necrosis filled with lymphocytes may occur [47].
This histologic picture is difficult to distinguish from that of
other types of viral hepatitis, such as hepatitis B, and from that
of cytomegalovirus [54] infections. Specific diagnosis can be
made by culture of the virus or identification of virus-specific
DNA by PCR [55].
Group 2 Granulomatous Disorders (Recently Recognized
Causal Agents)
Cat-Scratch Disease
Cat-scratch disease or fever is also known as benign lymphoreticulosis or regional granulomatous lymphadenitis [56]. It
only occurs in humans, especially those who are scratched
or bitten by kittens and then develop regional lymphadenitis
proximal to the site of injury. Primary involvement is that of
the lymph nodes, which first show lymphoid hyperplasia. Later,
scattered granulomas with central areas of necrosis coalesce to
form abscesses.
The histopathologic features of cat-scratch disease are not
diagnostic and may be mistaken for tularemia, lymphogranuloma venereum, syphilis, brucellosis, atypical mycobacterial
infections, fungal infections, and toxoplasmosis [47]. WarthinStarry silver staining is used to detect Bartonella henselae,
which may be present in the early phase of the disease. A skin
test antigen has been made from lymph node pus. It is inoculated intradermally, and the degree of induration and erythema
is measured at 48 hours.
The cat-scratch antigen skin test is positive for about 90%
of patients who are clinically suspected of having the disease.
This test will become redundant when techniques for amplifying specific nucleotide sequences with peR come into general use. There is no well-recognized response to antibiotics,
and recovery usually occurs without treatment.
Until recently, the causal agent remained controversial. Two
organisms, Afipia felis and B. henselae, have been identified
as potential candidates [57]. Substantial evidence is now accumulating that B. henselae, a small pleomorphic gram-negative
bacillus, is the etiologic agent [58-60].
A PCR hybridization assay designed to amplify DNA from
B. henselae and A. felis was used on pus aspirates from 89
skin test-positive patients with cat-scratch disease. B. henselae
DNA was found in 96% of samples, while no samples containedA.felis DNA [58]. An indirect fluorescent antibody assay
for B. henselae-specific antibody has been described that
appears to be sensitive for the diagnosis of cat-scratch disease [61].
152
Zumla and James
Whipple's Disease
George Hoyt Whipple of Johns Hopkins Hospital initially
described a 37-year-old missionary who presented with fever,
polyarthritis, and steatorrhea. His report was entitled "A Hitherto Undescribed Disease Characterized Anatomically by Deposits of Fat and Fatty Acids in the Intestinal and Mesenteric
Lymphatic Tissues" [62]. Whipple's disease is a chronic
multisystem granulomatous disorder that affects middle-aged
white males. It presents, as did Whipple's patient, with fever,
polyarthritis, weight loss, and diarrhea progressing to malabsorption.
Hepatosplenomegaly and generalized lymphadenopathy may
be present, and biopsy of the lymph node, liver, or small intestine will reveal sarcoid granulomas, of which PAS stains will
reveal foamy macrophages. The PAS-positive material corresponds with lysosomes containing bacilliform bodies. Electron
microscopy reveals rod-shaped bacilli, termed Whipple bacilli
[63], Whipple's associated bacterial organisms, or (more correctly) Tropheryma whippelii [64-66].
The nucleic acids extracted from an endoscopic biopsy specimen of the proximal small bowel of a patient with Whipple's
disease were subjected to amplification and nucleotide sequencing by PCR. The resulting PCR product from the bacterial 16S
rRNA was then the subject of a computer database search for
the rRNA sequences most similar to it.
T. whippelii is an actinomycete that behaves like an intracellular pathogen and responds particularly well to antibiotics that
enter cells easily. It is an erythrocyte-associated organism (like
Bartonella bacilliformis, Babesia species, and Plasmodium
species, which are also hemotropic). T. whippelii DNA has
been detected by PCR examination of peripheral blood, pleural
effusion cells [66, 67], biopsy tissue from the intestine [68],
heart [69], or vitrectomy specimen of the eye [70].
The PCR primers that have been developed are specific for
T. whippelii, and this technique is now one of the standard
methods for establishing the diagnosis of Whipple's disease
[66, 67, 70]. The technique ensures a more specific diagnosis
since the organism cannot be cultivated. Other data show that
there may be a closely related second causative agent of Whipple's disease [71, 72].
Group 3 Granulomatous Disorders (Infective Agent
Strongly Suspected)
Primary Biliary Cirrhosis
This condition of progressive, nonsuppurative, granulomatous destruction of intrahepatic bile ducts has also been termed
xanthomatous biliary cirrhosis, but its most accurate description
is chronic nonsuppurative destructive cholangitis [73]. Liver
cell necrosis may become superadded, later progressing to cirrhosis. Epithelioid granulomas associated with the bile ducts
are found in about one-third of the cases of primary biliary
cirrhosis (PBC). The condition has been likened to chronic
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1996;23 (July)
graft-versus-host rejection, with similar structural changes in
the bile, lacrimal, and pancreatic ducts, which have a high
concentration of human leukocyte class II antigens on the epithelial surface.
PBC is distinguished by the fact that it predominates in
women in the reproductive years of age and by the presence
of serum mitochondrial antibodies. It is classified as an autoimmune disorder and is associated with other autoimmune conditions, including rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Sjogren's syndrome, and the CREST
syndrome.
The etiology of PBC remains unknown. Two infectious
agents have been postulated as possible trigger cofactors [74,
75]. The antigen specific for PBC serum is M2, a component
of the pyruvate dehydrogenase complex of mitochondrial enzymes. There are similarities between mitochondrial components and Escherichia coli, and cross-reactivity between bile
duct mitochondria and bacteria may be conceivable [73]. Mitochondrial antibodies cross-react with subcellular constituents
or gram-negative intestinal or urinary tract organisms.
An increased incidence of gram-negative urinary tract infections in patients with PBC has been reported. Another infective
association was suggested in a report from Barcelona that incriminated Mycobacterium gordonae. This ubiquitous organism causes granuloma formation, and serum antibodies are evident in PBC serum. Furthermore, there is cross-reactivity
between this organism and the important PBC-defining M2
antigen. PCR has disclosed the presence of this mycobacterium
in the tissues and bile of patients with PBC [75].
Sarcoidosis
Sarcoidosis is a multisystem disorder of unknown etiology
[76]. An antigen (chemical or infectious organism)-driven,
cell-mediated immune response leads to a cytokine cascade, to
sarcoid granuloma formation, and eventually to sarcoid fibrosis.
An intense search for an infectious cause has yielded many
theories, yet none is conclusive (table 4).
In 1961, Edith Mankiewicz [77], of Montreal, reported that
bacteriophages, lytic for mycobacteria, can be isolated with
higher frequency from stool and resection specimens from patients with tuberculosis and sarcoidosis. Raised titers of phageneutralizing antibodies were found in tuberculous patients infected with mycobacteria harboring mycobacteriophages but
not in cases of sarcoidosis.
While mycobacteriophages are common to both diseases
the persistence of phages without antibody was the explanation
given for the absence of M. tuberculosis in sarcoid tissue [78].
This observation led to further experiments in which guinea
pigs were infected with tubercle bacilli alone or together with
mycobacteriophages, and the histological responses (analyzed
blindly) were of two dissimilar types. The first was caseous
necrosis with the presence of acid-fast bacilli, and the second
was a different response modified by the mycobacteriophages:
cm
1996; 23 (July)
Granulomatous Infections
Table 4. Causal agents implicated in cases of sarcoidosis.
Causal agents implicated
Bacteria
Mycobacteria
Streptococci
Propionibacterium acnes
Borrelia burgdorferi
Mycoplasma species
Nocardia species
Viruses
Epstein-Barr
Herpesvirus
Rubella
Measles
Cytomegalovirus
Coxsackievirus B
Retrovirus
Others
Beryllium
Zirconium
Pine pollen
Peanut dust
Clay (ingestion)
Reference( s)
[76-92]
[94]
[88,93]
[95,96]
[97]
[98]
[99]
[100, 101]
[102]
[102]
[102]
[102,103]
[104]
[lOS]
[105]
[106,107]
[107]
[108]
the phage-infected animals showed a granulomatous sarcoidlike picture with very few atypical lysogenic mycobacteria.
The conclusion reached was that phages of different antigenic composition determined a shift in the antigen-antibody
response toward either caseation or noncaseating granuloma
formation. It seemed at that time that sarcoidosis resulted from
unrestrained lytic phage activity against mycobacteria [77, 78].
At about the same time, Chapman and Speight [79] reported
a high incidence of serum antibodies to mycobacteria in patients with sarcoidosis. Serum antibody levels were particularly
high against photochromogen and scotochromogen antigens.
The patients' antibody status changed from negative to positive
as sarcoidosis manifested itself, and in many cases antibodies
appeared 2 months following the onset of erythema nodosum.
Ghosts of mycobacteria have been reported to be detected
by fluorescent microscopy of scalene lymph node biopsy specimens from patients with sarcoidosis and from controls. Auramine-rhodamine stains disclosed shining golden rods resembling mycobacteria in specimens from patients with sarcoidosis
but not in those from controls [80]. Recent advances in molecular biology have resurrected these observations; PCR has detected mycobacterial DNA in clinical samples from patients
with sarcoidosis [81, 82].
Bronchoalveolar lavage samples, bronchial washings, and
tissue specimens have been assayed by PCR for mycobacterial
DNA. M. tuberculosis DNA has been found in 50% of patients
with sarcoidosis, and nontuberculous mycobacterial DNA has
been found in 70% of them. Another study extracted RNA
from five sarcoid and five normal spleens [81]. Extracts were
assayed by liquid-phase DNA/RNA hybridization with a DNA
probe specific for the rRNA of the M. tuberculosis complex.
153
The number of hybrids obtained with the sarcoid spleens (from
which mycobacteria were neither seen on microscopy nor cultured) was 4.8 times higher than that obtained with normal
spleens.
However, the results obtained by PCR are being fiercely
contested by German [83], Scottish [84], and French [85] investigators. The findings of the German group contradict those of
Saboor et a1. [81], and the group concludes that mycobacterial
DNA cannot be detected in tissues or bronchoalveolar lavage
cells in cases of sarcoidosis. They use the technique to distinguish tuberculosis (which produces a positive result) from sarcoidosis. The Glasgow investigators [84] also failed to detect
mycobacterial DNA in sarcoid lymph nodes. The French investigators [85], using PCR, rarely found DNA from M. tuberculosis in cases of sarcoidosis.
The literature for and against a mycobacterial cause of sarcoidosis is summarized in table 5. The existence ofmycobacterial sarcoidosis would validate several claims of infective or
chemical causes of sarcoidosis: Scadding's long-held views on
tuberculous causation [86], a Swedish suggestion [87] of an
interaction between mycobacteria and a virus, a Japanese theory [88] regarding Propionibacterium as the causal agent, and
that of investigators in Houston [89] who isolated cell walldefective spheroplasts of acid-fast mycobacteria from sarcoid
skin biopsy specimens.
The controversy continues [90-93] and many different antigens have come under suspicion, including other bacteria [9497], fungi [98], viruses [99-104], and chemicals [105-- 108].
Many attempts have been made but tissue culture has failed to
uncover a virus. Elevated antibody responses to several viruses
have been reported, but such responses may only reflect B-cell
hyperreactivity rather than a causal relationship.
Crohn's Disease
Crohn's disease is a chronic granulomatous disorder affecting predominantly the gut, but it has multisystem involvement
and variable clinical manifestations. The pathological changes
may involve any parts and any layer of the alimentary tract.
Transmural inflammation consists of chronic inflammatory
cells with lymphoid aggregates scattered throughout. Noncaseating sarcoid-like granulomas may be present in all layers of
diseased and unaffected tissue throughout the alimentary
tract [109].
As with sarcoidosis, controversy prevails concerning a causal
agent. Clinicopathologic studies at the Royal Free Hospital
(London) demonstrated the presence of granulomatous vasculitis and vessel thrombosis, giving rise to focal microulcers. The
investigations have shown early superficial mucosal changes
and disruption of the capillary basement membrane preceding
the formation of the microulcer [I 10]. These inflammatory
changes may extend beyond the alimentary tract to the lung,
causing pulmonary vasculitis, granulomatous interstitial lymphocyte infiltration, and interstitial fibrosis [II I, 112].
154
ern 1996;23
Zumla and James
(July)
Table 5. Summary of the literature for and against a mycobacterial cause of sarcoidosis.
Reference( s)
Year(s) of study
Location of study
[77,78]
[79]
1961-1964
1964
Montreal
Dallas
[80]
1971
Prague
[87]
[93]
1972
1984
Stockholm
Tokyo
[89]
1988
Houston
[81]
[82]
1992
1992
London
London
[83]
[84]
[85]
[90]
[91]
1992
1992
1992
1993
1993
Borstel, Germany
Glasgow
Paris
London
Ohio
[92]
1993
Copenhagen
Laboratory method used or feature
analyzed (finding)
Reaction to mycobacteriophage infection
Presence of mycobacterial antibodies in
serum (positive)
Auramine-rhodamine staining,
fluorescent microscopy (positive)
Mycobacteria-virus interaction
Culture of lymph nodes (positive for
Propionibacterium acnes)
Skin biopsy (cell-wall-defective, acidfast bacilli noted)
PCR (positive for mycobacterial DNA)
Liquid-phase hybridization (positive for
mycobacterial rRNA)
PCR (negative for mycobacterial DNA)
PCR (negative for mycobacterial DNA)
PCR (negative for mycobacterial DNA)
PCR (positive for mycobacterial DNA)
ELISA (positive for antibodies to
Mycobacterium paratuberculosis)
Against this background is the conflict about whether the
causal agent is Mycobacterium paratuberculosis [113], other
mycobacteria [114], or the measles virus [115, 116]. Measles
virus nucleocapsids have been detected in foci of granulomatous inflammation of the intestine in cases of Crohn's disease
[117]. It has been postulated that Crohn' s disease may be a
result of chronic granulomatous vasculitis that develops in reaction to a persistent infection with measles virus within the
vascular endothelium [118].
Langerhans' Cell Granulomatosis
The term Langerhans' cell granulomatosis refers to proliferative disorders of histiocytes, previously referred to as histiocytosis X [119]. It encompasses a group of disorders of unknown etiology characterized by granulomatous infiltration of
the lungs, bone, skin, lymph nodes, and brain. The clinical
conditions have been known by several names, based on the
type of presentation, sites of involvement, rate of progression,
and degree of associated immune dysfunction. They include
eosinophilic granuloma, Letterer-Siwe disease, and HandSchuller-Christian disease. These are now considered to be
different expressions for the same basic disorder, in which the
proliferation of Langerhans' cells results from disturbances in
immunoregu1ation.
Langerhans' histiocytes are bone marrow-derived monocyte-macrophage cells; they include Langerhans' epidermal
cells, Kupffer's cells in the liver, osteoclasts, and alveolar macrophages. They are human leukocyte antigen-DR-positive
Western blotting (positive for antibodies
to Mycobacterium tuberculosis)
functioning macrophages that present antigen to T cells and
play a role in cell-mediated immunity. Unlike histiocytes,
Langerhans' cells can be stained immunohistochemically for
S-100 protein and OKT-6.
Lung biopsy reveals a mixed celullar exudate, foam cells,
eosinophils, and characteristic X bodies (Birbeck granules) in
macrophages. Langerhans' or X bodies are an ultrastructural
feature in 90% of patients [120]. They are identical to the
granules in Langerhans' epidermal cells and consist of intracytoplasmic rod-, plate-, or cup-like pentalaminar structures.
The presence of these tennis racket-shaped ultrastructural
Birbeck granules is diagnostic of the disorder. They have surface adenosine triphosphate activity identifiable by gold fluorescence. These diagnostic cells are readily found by bronchoalveolar lavage, and this technique may make lung biopsy
unnecessary. It may also be a likely means of detecting a
possible causal agent.
Chronic Granulomatous Disease of Childhood (CGD)
CGD comprises a genetically heterogeneous group of diseases that have in common the functional disorder of a multicomponent enzyme system, NADPH oxidase, found in phagocytic cells [121-124]. This defect leads to severe infections,
particularly with Staphyloccocus aureus, Serratia marcescens,
Burkholderia cepacia, and Aspergillus species. Organisms that
lack catalase supply the neutrophil with the hydrogen peroxide
for their own destruction. Thus, catalase-negative organisms
such as pneumococci or streptococci present no problem because they are normally destroyed.
em
1996;23 (July)
Granulomatous Infections
There are three autosomal recessive types, corresponding to
mutations in p22p h0X, p47p h0X, and p67p hox . The classic X-linked
disorder (found in ,....,60% of cases), which affects the gene
encoding gp91phox, occurs in boys and is diagnosed in infancy,
usually on the basis of an infection with a catalase-producing
bacterium or fungus. The diagnosis is confirmed on the basis
of a nitroblue tetrazolium test or other test showing defective
superoxide production.
Hepatosplenomegaly is common and does not reflect active
infection per se. Lymphadenopathy is often undetected, but
when it is significant it usually reflects an active infection.
Severe granulomatous problems can occur in association with
CGD, such as obstruction of the gut and the genitourinary
system. Weeping granulomatous skin lesions occur in the setting of an active wound, typically post-surgically. The histological appearance is marked by lipid-laden macrophages. While
the etiology of CGD is genetic, there may be undetected pathogens responsible for some of the granulomatous complications
of the disease.
Orofacial Granulomatosis (Melkersson-Rosenthal Syndrome)
This is a rare granulomatous disorder of the mouth and
adjacent tissues, involving the oral mucosa, gum, lips, tongue,
pharynx, eyelids, and skin of the face. Melkersson [125] described an association between facial edema and facial paralysis. Rosenthal [126] added the features of lingua plicata or
scrotal tongue. Other clinical features include granulomatous
cheilitis, edema of the gums and scalp, salivary gland dysfunction, granulomatous blepharitis, trigeminal neuralgia, Raynaud's phenomenon, and chronic hypertrophic granulomatous
vulvitis [127-129].
Biopsy of an involved area reveals a noncaseating granuloma. Unlike the findings in cases of sarcoidosis, there are no
chest radiographic changes or uveitis, and the Kveim-Siltzbach
skin test is negative. The etiology remains unknown.
Kikuchi's Disease
This disorder was described in 1972 by a Japanese pathologist and is characterized by lymphadenitis with focal reticulumcell hyperplasia, nuclear debris, and phagocytosis [130]. The
lymphadenitis may be proliferative, necrotizing, or xanthomatous. Immunohistologic analysis shows that the predominant
cells involved in the lymphadenitis are various types of histiocytes, plasmacytoid monocytes, and T cells; B cells are absent
[131]. Clinically there is localized, tender, cervicallymphadenopathy with an upper respiratory tract prodrome.
Kikuchi's disease was initially thought to occur mostly in
women under the age of 30 years, although a recent study of
79 cases showed that the preponderance of cases involving
females is not striking [131]. The disease runs a self-limiting
course and is associated with a recurrence rate of3%. Kikuchi's
disease has been recognized as a presenting feature of mixed
155
connective-tissue disease and has been noted in association
with adult Still's disease and systemic lupus erythematosus, a
finding leading to the hypothesis that Kikuchi's disease and
autoimmune rheumatic disorders may share a common etiology [132].
The disease occurs worldwide and has often been confused
with toxoplasmosis, cat-scratch disease, tuberculosis, infectious
mononucleosis, and non-Hodgkin's lymphoma. The cause of
the disease is not known. A viral etiology is strongly suspected
on the basis of clinical features, although serological and
ultrastructural studies have not yet identified an infectious
agent [133].
Conclusions
Classification schemes are most useful when they provide
insight into the purpose of events and the etiologic mechanisms
that govern them. Granulomas are remarkably complex inflammatory foci that sequester organisms or other substances
resistant to degradation. While a large number of granulomatous disorders are recognized, infections are clearly the most
common underlying causes of granulomas in general.
It is apparent that granulomatous conditions ofdiverse etiologies share common histologic features, although the etiologic
agent is not always identifiable. Although the histopathologic
patterns in various infectious granulomas may be sufficiently
different to prevent an accurate diagnosis, atypical presentations may necessitate identification of the specific etiologic
agent by direct microscopic examination, culture, serology, or
molecular detection.
In several granulomatous diseases the etiologic agent is difficult to identify by microscopic examination, culture, or serological means. The availability of PCR for the diagnosis of
several infectious conditions has been of major importance in
detecting the etiologic agents of granulomatous disease conditions that previously were considered to be of unknown etiology. In particular, PCR has been used successfully for detecting
the bacteriologic causes of Whipple's disease and cat-scratch
disease.
Further applications of molecular techniques may pin down
the microbiological etiology (if any) of several granulomatous
disorders of group 3 (table I), of which the etiology remains
elusive.
References
1. Warren KS. Granulomatous inflammation. In: Lepow IH, Ward PW, eds.
Inflammation: mechanisms and control. New York: Academic Press,
1972:203 -18.
2. Williams GT, Williams WJ. Granulomatous inflammation-a review. J
Clin Pathol 1983; 36:723 - 33.
3. Silverman L, Shorter RG. Histogenesis of the multinucleated giant cell.
Lab Invest 1963; 12:985-90.
4. James DG. What makes granulomas tick'? Thorax 1991;46:734-6.
156
Zumla and James
5. Heinzel FP. Th I and Th2 cells in the cure and pathogenesis of infectious
diseases. Curr Opin Infect Dis 1995; 8:151-5.
6. Weinstock JV. Function and regulation of granulomatous responses (experimental granulomatosis). In: James DG, ed. Sarcoidosis and other
granulomatous disorders. New York: Marcel-Dekker, 1994:99-133.
7. Yamamura M, Uyemura K, Deans RJ, et al. Defining protective responses
to pathogens: cytokine profiles in leprosy lesions. Science 1991;254:
277-9.
8. Cucin RL, Coleman M, Eckardt JJ, Silver RT. The diagnosis of miliary
tuberculosis: utility of peripheral blood abnormalities, bone marrow
and liver needle biopsy. J Chronic Dis 1973;26:355-61.
9. Schluger NW, Kinney D, Harkin TJ, Rom WN. Clinical utility of the
polymerase chain reaction in the diagnosis of infections due to Mycobacterium tuberculosis. Chest 1994; 105:1116-21.
10. Zumla A, James DG. Lung immunology in the tropics. In: Sharma OP,
ed. Lung disease in the tropics. New York: Marcel-Dekker, 1991:164.
11. Lucas S, Nelson AM. Pathogenesis of tuberculosis in human immunodeficiency virus-infected people. In: Bloom BR, ed. Tuberculosis: pathogenesis, protection and control. Washington, DC: American Society
for Microbiology, 1994:503-16.
12. Zumla A. Sarcoidosis and leprosy: a comparative perspective. In: James
DG, ed. Sarcoidosis and other granulomatous disorders. New York:
Marcel-Dekker, 1994:681-705.
13. Santos AR, Goes Filho JT, Nery JA, et al. Evaluation of PCR mediated
DNA amplification in non-invasive biological specimens for subclinical detection of Mycobacterium leprae. FEMS Immunol Med Microbiol 1995;11:113-20.
14. Dodge OG. Mycobacterial skin ulcers in Uganda: histopathological and
experimental aspects. J Pathol Bacteriol 1964; 88:167- 74.
15. Delaporte E, Savage C, Alfandari S, Piette F, Leclerc H, Bergoend H.
Ulcere de Buruli chez une malade Zairoise infectee par le virus de
l'immunodeficience humaine. Ann Dermatol Venereol 1994; 121:
557-60.
16. Hofer M, Hirschel B, Kirschner P, et al. Brief report: disseminated osteomyelitis from Mycobacterium ulcerans after a snakebite. N Engl J
Med 1993; 328:1007-9.
17. Gray SF, Smith RS, Reynolds NJ, Williams EW. Fish tank granuloma.
Brit Med J 1990;300: 1069-1070.
18. Shinnick TM, Jonas V. Molecular approaches to the diagnosis oftuberculosis. In: Bloom BR, ed. Tuberculosis: pathogenesis, protection and
control. Washington, DC: American Society for Microbiology, 1994:
511-31.
19. Bruce D. Malta fever. BMJ 1889; 1:1101-7.
20. Trujillo IZ, Zavala AN, Caceres JG, Miranda CQ. Brucellosis. Infect Dis
Clin North Am 1994;8:225-41.
21. Adams DO. The biology of the granuloma. In: Ioachim HL, ed. Pathology
of granulomas. New York: Raven Press, 1983:1-20.
22. Debat-Zoguereh D, Badiaga S, Uzan E, Le Treut YP, Lebreuil G, Bourgeade A. Granulome necrosant hepatique d'origine brucellienne. A
propos d'un cas. Rev Med Interne 1995; 16:63-6.
23. Romero C, Gamazo C, Pardo M, Lopez-Goff I. Specific detection of
Brucella DNA by PCR. J Clin Microbiol 1995; 33:615- 7.
24. Bricker BJ, Halling SM. Differentiation of Brucella abortus bv. 1, 2, and
4, Brucella melitensis, Brucella ovis, and Brucella suis bv. 1 by PCR.
J Clin Microbiol 1994;32:2660-6.
25. Leelarasamee A, Bovomkitti S. Melioidosis: review and update. Rev
Infect Dis 1989; 11:413- 25.
26. Lumbiganon P, Viengnondha S. Clinical manifestations of melioidosis
in children. Pediatr Infect Dis J 1995; 14:136-40.
27. SirikuIchayanonta V, Subhadrabandhu 1. Melioidosis: another etiology
of granulomatous osteomyelitis. Report of 2 cases. Clin Orthop 1994;
308:183-6.
28. Wong KT, Puthucheary SD, Vadivelu J. The histopathology of human
melioidosis. Histopathology 1995; 26:51- 5.
ern
1996;23 (July)
29. Rugdech P, Anuntagool N, Sirisinha S. Monoclonal antibodies to Pseudomonas pseudomallei and their potential for diagnosis of melioidosis.
Am J Trop Med Hyg 1995;52:231-5.
30. Desakom V, Smith MD, Wuthiekanun V, et al. Detection of Pseudomonas pseudomallei antigen in urine for the diagnosis of meiloidosis.
Am J Trop Med Hyg 1994;51:627-33.
31. Kunakom M, Markham RB. Clinically practical seminested PCR for
Burkholderia pseudo mallei quantitated by enzyme immunoassay with
and without solution hybridization. J Clin Microbiol 1995;33:
2131-5.
32. Lew AE, Desmarchelier PM. Detection of Pseudomonas pseudomallei
by PCR and hybridization. J Clin MicrobioI1994;32:1326-32.
33. Tramont EC. Treponema pallidium (syphilis). In: Mandell GL, Bennett
JE, Dolin R, eds. Mandell, Douglas and Bennett's principles and practice of infectious diseases. 4th ed. Vol. 2. New York: Churchill Livingstone, 1995:2117-33.
34. Pandhi RK, Singh N, Ramam M. Secondary syphilis: a clinicopathologic
study. Int J Dermatol 1995;34:240-3.
35. Burstain JM, Grimprel E, Lukehart SA, Norgard MV, Radolf JD. Sensitive detection of Treponema pallidum by using the polymerase chain
reaction. J Clin Microbiol 1991;29:62-9.
36. Horowitz HW, Valsamis MP, Wicher V, et al. Brief report: cerebral
syphilitic gumma confirmed by the polymerase chain reaction in a
man with human immunodeficiency virus infection. N Engl J Med
1994;331: 1488-91.
37. Peters W, Killick-Kendrick R, eds. The leishmaniases in biology and
medicine. London: Academic Press, 1987.
38. Locksley RM, Louis JA. Immunology ofleishmaniasis. Curr Opin Immunol 1992;4:413-8.
39. Ghosh MK, Nandy A, Addy M, Maitra TK, Ghose AC. Subpopulations
of T lymphocytes in the peripheral blood, dermal lesions and lymph
nodes of post kala-azar dermal leishmaniasis patients. Scand J ImmunoI1995;41:1l-7.
40. Laskay T, Miko TL, Negesse Y, Solbach W, Rollinghoff M, Frommel
D. Detection of cutaneous Leishmania infection in paraffin-embedded
skin biopsies using the polymerase chain reaction. Trans Roy Soc Trop
Med Hyg 1995;89:273-5.
41. Dorfman RF, Remington JS. Value oflymph-node biopsy in the diagnosis
of acute acquired toxoplasmosis. N Engl J Med 1973;289:878-81.
42. Novati R, Castagna A, Morsica G, et al. Polymerase chain reaction for
Toxoplasma gondii DNA in the cerebrospinal fluid of AIDS patients
with focal brain lesions. AIDS 1994;8:1691-4.
43. Makimura K, Murayama SY, Yamaguchi H. Detection of a wide range
of medically important fungi by the polymerase chain reaction. J Med
Microbiol 1994;40:358-64.
44. Davies SF. Fungal pneumonia. Med Clin North Am 1994;78:1049-65.
45. Wong JS, Herman SJ, de Hoyos A, Weisbrod GL. Pulmonary manifestations of coccidioidomycosis. Can Assoc Radiol J 1994;45:87-92.
46. Wheat J. Histoplasmosis and coccidioidomycosis in individuals with
AIDS: a clinical review. Infect Dis Clin North Am 1994; 8:467-82.
47. Samuelson J, Von Lichtenberg F. Infectious diseases. In: Cotran RS,
Kumar V, Robbins SL, eds. Robbins pathologic basis of disease. Philadelphia: WB Saunders, 1994:305-77.
48. Warren KS. The pathology, pathobiology and pathogenesis of schistosomiasis. Nature 1978;273:609-12.
49. Warren KS, Domingo EO, Cowan RBT. Granuloma formation around
schistosome eggs as a manifestation of delayed hypersensitivity. Am
J PathoI1967;51:735-56.
50. Chikunguwo SM, Quinn JJ, Ham DA, Stadecker MJ. The cell-mediated
response to schistosomal antigens at the clonal level. III. Identification
of soluble egg antigens recognized by cloned specific granulomagenic
murine CD4+ Thl-type lymphocytes. J Immunoll993; 150:1413-21.
51. Wynn TA, Cheever AW, Jankovic D, et al. An IL-12 based vaccination
method for preventing fibrosis induced by schistosome infection. Nature 1995;376:594-6.
em 1996;23
(July)
Granulomatous Infections
52. Huntley CC, Costas MC, Lyerly A. Visceral larva migrans syndrome:
clinical characteristics and immunologic studies in 51 patients. Pediatrics 1965; 36:523-36.
53. Halsey NA, Job JS. Measles. In: Warren KS, Mahmoud AAF, eds. Tropical geographic medicine. New York: McGraw-Hill, 1994.
54. Heyries L, Perreard M, Monges 0, Chrestian MA, Gerolami A. Hepatic
granulomatosis associated with mononucleosis syndrome secondary to
cytomegalovirus infection: apropos of 2 cases in healthy adults. Rev
Med Interne 1994; 15:744-6.
55. Nahass GT, Penneys NS, Leonardi CL. Analysis of the polymerase chain
reaction in the detection of herpesvirus DNA from fixed and stained
tissue sections. Arch Dermatol 1995; 131:805-8.
56. Daniels WB, MacMurray FG. Cat scratch disease: report of one hundred
sixty cases. JAMA 1954; 154:1247-51.
57. Drancourt M, Raoult D. La maladie des griffes du chat et la pathologie
a Bartonella (Rochalimaea). Presse Med 1995;24:183-8.
58. Bergmans AMC, Groothedde J-W, Schellekens JFP, van Embden IDA,
Ossewaarde JM, Schouls LM. Etiology of cat scratch disease: comparison of polymerase chain reaction detection of Bartonella (formerly
Rochalimaea) and Afipia felis DNA with serology and skin tests. J
Infect Dis 1995; 171:916-23.
59. Anderson B, Sims K, Regnery T, et a1. Detection of Rochalimaea
henselae DNA in specimens from cat scratch disease patients by PCR.
J Clin Microbiol 1994; 32:942-8.
60. Goral S, Anderson B, Hager C, Edwards KM. Detection of Rochalimaea
henselae DNA by polymerase chain reaction from suppurative nodes
of children with cat-scratch disease. Pediatr Infect Dis J 1994; 13:
994-7.
61. Dalton MJ, Robinson LE, Cooper J, Regnery RL, Olson JG, Childs JE.
Use of Bartonella antigens for serologic diagnosis of cat-scratch disease at a national referral center. Arch Intern Med 1995; 155:1670-6.
62. Whipple GH. A hitherto undescribed disease characterized anatomically
by deposits of fat and fatty acids in the intestinal and mesenteric
lymphatic tissues. Johns Hopkins Hospital Bulletin 1907; 18:382-91.
63. Spapen HOM, Segers 0, De Wit N. Electron microscopic detection of
Whipple's bacillus in sarcoidlike periodic acid-Schiff-negative granulomas. Digest Dis Sci 1989;34:640-3.
64. Reiman DA, Schmidt TM, Mac Dermott RP, Falkow S. Identification of
the uncultured bacillus of Whipple's disease. N Engl J Med 1992;327:
293-301.
65. Donaldson RM Jr. Whipple's disease-s-rare malady with uncommon
potential [editorial]. N Engl J Med 1992;327:346-8.
66. Dobbins WO III. The diagnosis of Whipple's disease [editorial]. N Engl
J Med 1995;332:390-2.
67. Lowsky R, Archer GL, Gyles G, et al. Brief report: diagnosis of Whipple's disease by molecular analysis of peripheral blood. New Engl J
Med 1994;331:1343-6.
68. Maiwald M, Meier-Willersen HJ, Hartmann M, von Herbay A. Detection
of Tropheryma whippelii DNA in a patient with AIDS. J Clin Microbiol
1995;33:1354-6.
69. Wendler 0, Mendoza E, Schleiffer T, Zander M, Maier M. Tropheryma
whippelii endocarditis confirmed by polymerase chain reaction. Eur
Heart J 1995; 16:424-5.
70. Rickman LS, Freeman WR, Green WR, et al. Brief report: uveitis caused
by Tropheryma whippelii (Whipple's bacillus). N Engl J Med 1995;
332:363-6.
71. Wilson KH, Blitchington R, Frothingham R, Wilson JAP. Phylogeny of
the Whipple's disease-associated bacterium. Lancet 1991;338:474475.
72. Harmsen 0, Heesemann J, Brabletz T, Kirchner T, Muller-Hermelink
HK. Heterogeneity among Whipple's-disease-associated bacteria [letter]. Lancet 1994;343:1288.
73. Sherlock SO. Diseases of the liver and biliary system. 9th ed. Oxford:
Blackwell, 1993:461.
157
74. Hopf U, Moller B, Stemerowicz R, et al. Relation between Escherichia
coli R (rough)-forms in gut, lipid A in liver, and primary biliary cirrhosis. Lancet 1989;2:1419-22.
75. Vilagut L, Vila J, Vinas 0, et al. Cross-reactivity of anti -Mycobacterium
gordonae antibodies with the major mitochondrial autoantigens in primary biliary cirrhosis. J HepatoI1994;21:673- 7.
76. James DG, ed. Sarcoidosis and other granulomatous disorders. New York:
Marcel-Dekker, 1994.
77. Mankiewicz E. Mycobacteriophages isolated from persons with tuberculous and nontuberculous conditions. Nature, London, 1961: 191:1416
1417.
78. Mankiewicz E. The relationship of sarcoidosis to anonymous bacteria.
Acta Med Scand Suppl 1964;425:68- 73.
79. Chapman JS, Speight M. Further studies of mycobacterial antibodies in
the sera of sarcoidosis patients. Acta Med Scand Suppl 1964;425:
61-7.
80. Richter J, Bartak F, Halova R. Detection of mycobacteria by fluorescent
microscopy in sarcoidosis. In: Proceedings of the 5th International
Conference on Sarcoidosis. Prague: Universita Karlova, 1971:83-4.
81. Saboor SA, Johnson NM, McFadden J. Detection of mycobacterial DNA
in sarcoidosis and tuberculosis with polymerase chain reaction. Lancet
1992; 339: 1012-5.
82. Mitchell IC, Turk JL, Mitchell DN. Detection of mycobacterial rRNA in
sarcoidosis with liquid-phase hybridisation. Lancet 1992: 339:
1015-7.
83. Gerdes J, Richter E, Rusch-Gerdes S, et al. Mycobacterial nucleic acids
in sarcoid lesions [letter]. Lancet 1992; 339: 1536- 7.
84. Thakker B, Black M, Foulis AK. Mycobacterial nucleic acids in sarcoid
lesions [letter]. Lancet 1992;339:1537.
85. Bocart D, Lecossier 0, De Lassence A. Valeyre D, Battesti J-P, Hance
AJ. A search for mycobacterial DNA in granulomatous tissues from
patients with sarcoidosis using the polymerase chain reaction. Am Rev
Respir Dis 1992; 145:1142--8.
86. Scadding JG. Further observations on sarcoidosis associated with M.
tuberculosis infection. In: Proceedings of the 5th International Conference on Sarcoidosis. Prague: University Karlova, 1971:89-92.
87. Hanngren A, Biberfeldt G, Carlens E, et al. Is sarcoidosis due to an
infectious interaction between virus and mycobacterium? In: Proceedings of the 6th International Conference on Sarcoidosis. Tokyo: University of Tokyo Press, 1974:8-11.
88. Nakata Y, Kataoka M, Kimura 1. Sarcoidosis and Proprionibacterium
acnes [in Japanese]. Nippon Rinsho 1994;52:1492-7.
89. Graham DY, Markesich DC, Kalter DC. Yoshimura HH. Isolation of
cell-wall defective acid-fast bacteria from skin lesions of patients with
sarcoidosis. In: Proceedings of the 11th World Congress on Sarcoidosis
and Other Granulomatous Disorders. Amsterdam: Excerpta Medica.
Elsevier, 1988: 1614.
90. Fidler HM, Rook GA, Johnson NM, McFadden J. Mvcobacterium tuberculosis DNA in tissue affected by sarcoidosis. BM.I 1993; 306:546- 9.
91. Reid .ID, Chiodini RJ. Serologic reactivity against Mvcobacterium paratuberculosis antigens in patients with sarcoidosis. Sarcoidosis 1993:
10:32-5.
92. Milman N, Andersen AB. Detection of antibodies in serum against M
tuberculosis using western blot technique. Comparison between sarcoidosis patients and healthy subjects. Sarcoidosis 1993; 10:29 3 I.
93. Abe C, Iwai K, Mikami R. Hosoda Y. Frequent isolation of Propionibacterium acnes from sarcoidosis lymph nodes. Zentralbl Bakteriol Mikrobiol Hyg (B) 1984;256:541-7.
94. Miyagawa Y, Asoh H, Nakanishi M, Shigematsu N. Epithelioid cell
granuloma formation in Lewis rats induced by streptococcal cell wall
(SCW). In: Abstracts of the 12th World Congress on Sarcoidosis and
Other Granulomatous Disorders. Kyoto, Japan: University of Tokyo
Press, 1989: I07.
95. Montemurro L, Rizzato G. Is sarcoidosis a borreliosis? Sarcoidosis 1991;
8:134-5.
158
Zumla and James
96. Bing H, Quing L, Wang F, Cheng A, Wei 1. Borrelia burgdorferi infection may be the cause of sarcoidosis. Chin Med J 1992;195:560-3.
97. HannukselaM, JannsonE. Isolationof a mycoplasmafrom sarcoidtissue.
In: Iwai K, HosodaY, eds. Proceedingsof the 6th InternationalConference on Sarcoidosis. Tokyo: Tokyo University Press, 1974:4.
98. Uesake E, Izumi T, Tsuki S. Nocardia-like organisms isolated from lesions of sarcoidosis. In: Iwai K, Hosoda Y, eds. Proceedings of the
6th InternationalConferenceon Sarcoidosis. Tokyo: TokyoUniversity
Press, 1974:3.
99. RottoliP, BianchiBandinelliML, Rottoli L, Zazzi M, PanzardiG, Valensin PE. Sarcoidosis and infections by human lymphotropic viruses.
Sarcoidosis 1990;7:31-3.
100. Hirshaut Y, Glade P, Vieira LO, Ainbender E, Dvorak B, Siltzbach LE.
Sarcoidosis, another disease associated with serologic evidence for
herpes-like virus infection. N Engl J Med 1970;283:502-6.
101. Ablashi D, SalahuddinZ, Imam P, et al. Serologicalassociationof a new
herpes virus (HBLV) with sarcoidosis. In: Proceedings of the II th
Congresson Sarcoidosisand Other Granulomatous Disorders.Amsterdam: Excerpta Medica, 1988:68.
102. RottoliP, ValensinPE, Bianchi BandinelliM, BracialeP, FortelioniGM,
Vagliasindi M. Antibody responses to viral antigens in sarcoidosis
[letter]. Sarcoidosis 1993;10:73-4.
103. HillerdalG, Frisk G, Nettelbadt 0, DiderholmH. High frequencyofIgM
antibodies to coxsackie B virus in sarcoidosis patients and patients
with asbestos-related lesions. Sarcoidosis 1992;9:39-42.
104. Petterson HB, Iversen OJ, Eklung A. Retrovirus: a possible etiological
agent of sarcoidosis. In: Abstracts of the 12th World Congress on
Sarcoidosis and Other Granulomatous Disorders. Kyoto, Japan: University of Tokyo Press, 1989:120.
105. Shelley WB, Hurley HJ. The allergic origin of zirconium deodorant
granulomas. Br J Dermatoll958; 70:75.
106. CummingsMM,DunnerE, SchmidtBH, Barnwell JB. Conceptsof epidemiology of sarcoidosis. Postgrad Med J 1956;19:437.
107. Cummings MM, Dunner E, Williams JH Jr. Epidemiologic and clinical
observations in sarcoidosis. Ann Intern Med 1959;50:879-90.
108. Comstock GW, Keltz H, Sencer DJ. Clay eating and sarcoidosis: a controlled study in the state of Georgia. Am Rev Respir Dis 1961;84(5
part 2)(suppl):130-4.
109. Rubin E, Farber JL. The gastrointestinal tract. In: Rubin E, Farber JL,
eds. Essential pathology. Philadelphia: Lippincott, 1988.
110. WakefieldAJ, Sawyerr AM, Dhillon AP, et al. Pathogenesisof Crohn's
disease: multifocal gastrointestinal infarction. Lancet 1989;2:105762.
Ill. Kayser K, Probst F, Gabius HJ, MOller KM. Are there characteristic
alterations of lung tissue associated with Crohn's disease? Pathol Res
Pract 1990;186:485-90.
112. Wakefield AJ, Pittilo RM, Sim R, Cosby SL, Stephenson JR, Dhillon
AP, Pounder RE. Evidence of persistent measles virus infection in
Crohn's disease. J Med ViroI1993;39:345-53.
113. SandersonJD. Mycobacteria in Crohn's disease [letter]. BMJ 1993;306:
1131.
ern 1996;23 (July)
114. Ciclitira PI. Does Crohn's diseasehave a mycobacterialbasis? [editorial].
BMJ 1993;306:733-4.
115. Smith MSH, WakefieldAJ. Viral association with Crohn's disease. Ann
Med 1993;25:557-61.
116. EkbomA, WakefieldAJ, Zack M, Adami HO. Perinatalmeaslesinfection
and subsequent Crohn's disease. Lancet 1994;344:508-10.
117. Lewin J, Dhillon AP, Sim R, Mazure G, Pounder RE, Wakefield AI.
Persistent measles virus infection of the intestine: confirmation by
immunogold electron microscopy. Gut 1995;36:564-9.
118. WakefieldAJ, Ekbom A, Dhillon AP, Pittilo RM, Pounder RE. Crohn's
disease: pathogenesis and persistent measles virus infection. Gasteroenterology 1995; 108:911-6.
119. James DG. Definition and classification. In: James DG, ed. Sarcoidosis
and other granulomatous disorders. New York: Marcel-Dekker, 1994:
33-5.
120. Hance AJ, CandranelJ, Soler P, Basset F. Pulmonaryand extrapulmonary
Langerhans' cell granulomatosis (Histiocytosis X). Semin Respir Med
1988;9:349-68.
121. Smith RM, Curnutte JT. Molecular basis of chronic granulomatousdisease. Blood 1991;77:673-86.
122. Curnutte JT. Chronic granulomatous disease: the solving of a clinical
riddle at the molecular level. Clin Immunol Immunopathol 1993;
67(3)(suppl):S2-15.
123. Thrasher AJ, Keep NH, Wientjes F, Segal AW. Chronic granulomatous
disease. Biochim Biophys Acta 1994;1227:1-24.
124. SchapiroBL, NewburgerPE, KlempnerMS, DinauerMe. Chronicgranulomatous disease presenting in a 69-year-old man. New Engl J Med
1991;325:1786-90.
125. Melkersson E. Case of recurrent facial paralysis with angioneurotic
edema. Hygiea 1928;90:737-41.
126. RosenthalC. Facialislahmungund lingua plicata.Z Neurol Psycholl990;
131:475-501.
127. Larsson E, Westermark P. Chronic hypertrophic vulvitis-a condition
with similarities to cheilitis granulomatosa (Melkersson-Rosenthal
syndrome). Acta Dermatovenereol (Stockholm) 1978;58:92-3.
128. Klaus SN, Brunsting LA. Melkersson's syndrome(persistentswelling of
the face, recurrent facial paralysis and lingua plicata): report of case.
Proc Mayo Clin 1959;34:365- 70.
129. WiesenfeldD, FergusonMM, MitchellDN, et al. Oro-facialgranulomatosis: a clinical and pathological analysis. Q J Med 1985;54:101-113.
130. Kikuchi M. Lymphadenitis showing focal reticulumcell hyperplasiawith
nuclear debris and phagocytosis. Nipon Ketsueki Gakkai Zassi 1972;
35:379-80.
131. Kuo T-t. Kikuchi's disease (histiocyticnecrotizinglymphadenitis): a clinicopathologic study of79 cases with an analysis of histologicsubtypes,
immunohistology, and DNA ploidy. Am J Surg Patho11995;19:798809.
132. Gourley I, Bell AL, Biggart D. Kikuchi's disease as a presenting feature
of mixed connective tissue disease. Clin Rheumatoll995; 14:104-7.
133. Fred HL. Kikuchi-Fujimoto disease. Houston Med 1991;7:115-7.