Transplantation |

Non-Necrotizing Granulomas: A Retrospective Review of Etiology FREE TO VIEW

Andres Borja Alvarez, MD; Isabel Mira-Avendano, MD; Augustine Lee, MD
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Mayo Clinic, Jacksonville, FL

Chest. 2014;146(4_MeetingAbstracts):971A. doi:10.1378/chest.1987615
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SESSION TITLE: Topics in ILD and Lung Transplantation

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 29, 2014 at 02:45 PM - 04:15 PM

PURPOSE: Sarcoidosis is an idiopathic granulomatous disease characterized by variable organ involvement with non-necrotizing granulomas. As a diagnosis of exclusion with a broad differential, we aimed to determine how often non-necrotizing granulomas were initially attributed to sarcoidosis, how often the diagnosis subsequently changed, and what were the other leading causes of it.

METHODS: We performed a retrospective review of all biopsies performed at a tertiary academic center showing non-necrotizing granulomas from 1996 to 2014. Biopsies done for cancer surveillance (colon, bladder) or for post-transplant surveillance (liver, lung) were excluded.

RESULTS: Of 433 pathologically confirmed biopsies with non-necrotizing granulomas, 308 biopsies in 308 subjects were eligible. The average age was 58.2 years, 60.7% were female. The organs biopsied included lung parenchyma 190 (61%), intra-thoracic lymph nodes 66 (21%), lung nodules 28 (9%), liver 6 (2%), gastrointestinal tract 4 (1.2%), extrathoracic lymph nodes 2 (0.6%), and skin 3 (0.9%). The initial diagnosis was kept in 223 (72.4%): 135 (43.83%) sarcoidosis, 14 (4.5%) hypersensitivity pneumonitis, 8 (2.5%) idiopathic pulmonary fibrosis, and 38 other distinct diagnoses among the remaining 82 cases. The initial diagnoses were eventually altered in 85 (27.6%) patients, though if the initial diagnosis was sarcoidosis, it was changed infrequently: 9 (2.9%). The more common initial diagnoses that were subsequently changed to sarcoidosis were hypersensitivity pneumonitis (20 cases), unspecified granulomatous reaction (9 cases), and mycobacterium avium intracellulare infection (9 cases). The remaining 38 (12.3%) cases in which the diagnoses were altered, the most common initial diagnosis included: lung malignancy, interstitial lung diseases, and metastatic process, being recognized at the end as a hypersensitivity pneumonitis, unspecified granulomatous reaction, and pulmonary nodules. Sarcoidosis was the final diagnosis in 173 (56%).

CONCLUSIONS: Sarcoidosis remains a leading cause of non-necrotizing granulomas, but at least 44% will be due to alternative causes. More than a quarter of the initial diagnoses will be altered based on subsequent clinical course.

CLINICAL IMPLICATIONS: It is important to keep in mind a broad differential for non-necrotizing granulomas, and sarcoidosis should always be considered as a provisional diagnosis, as the clinical course may further clarifies the ultimate diagnosis.

DISCLOSURE: The following authors have nothing to disclose: Andres Borja Alvarez, Isabel Mira-Avendano, Augustine Lee

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