Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On 30 Nov 2018




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National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




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An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
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Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2011 | Month : April | Volume : 5 | Issue : 2 | Page : 301 - 306

A Histopathological study of Granulomatous Inflammations with an attemptto find the Aetiology

JAYASHREE PAWALE, REKHA PURANIK, MH KULKARNI

Dept of pathology, SN medical college, Bagalkot. Dept of pathology, Karnataka institute of medical sciences,Hubli.

Correspondence Address :
Dr Jayashree Pawale, C-14 staff quarters, SN Medical College
Bagalkot.587101. Karnataka.
Email address:jaishree_pawale@yahoo.co.in
ashutosh_pawale@yahoo.co.in, Phone: 09538161007

Abstract

Granulomas are the commonest lesions that the pathologists come across in routine practice. In order to treat these lesions, definitive diagnosis by the demonstration of the aetiological agent is essential, which will bear an impact on the patient management and outcome.

Our aim was to find the aetiology in all the granulomatous lesions, on histopathologically evaluated biopsies.

A two year prospective study was done in KIMS; Hubli.The biopsies of the cases which were diagnosed as granulomas on H and E stained sections from all the sites were selected. Special stains like Ziehl-Neelsen stain, Gomori’s Methenamine silver, Fite Faraco and Auramine Rhodamine stain were done wherever required.
A total of 170 granulomatous lesions were studied. Granulomas with different aetiologies were seen. The commonest were the granulomas due to tuberculosis with 84 (49.41%) cases, followed by those with leprosy, rhinoscleroma, actinomycosis andfungal infections and foreign body granulomas and granulomas with unknown aetiology.

An attempt has to be made to put these granulomas into specific aetiological categories for specific treatment.

The morphology of the lesions and the use of special stains helped us to diagnose 159 out of the 170 cases.

Keywords

Granulomas, Tuberculosis, fungal

How to cite this article :

JAYASHREE PAWALE, REKHA PURANIK, MH KULKARNI. A HISTOPATHOLOGICAL STUDY OF GRANULOMATOUS INFLAMMATIONS WITH AN ATTEMPTTO FIND THE AETIOLOGY. Journal of Clinical and Diagnostic Research [serial online] 2011 April [cited: 2019 Apr 21 ]; 5:301-306. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2011&month=April&volume=5&issue=2&page=301-306&id=1230

IntroductionThe term, ‘Granulomatous inflammation’ defines a pattern of reaction to a wide range of aetiological agents, organic and inorganic, with certain morphological correlates (1).
Granuloma is “a focal chronic inflammatory response to a tissue injury, which is evoked by a poorly soluble substance which is characterized by the accumulation and proliferation of leukocytes, principally of the mononuclear type” (1). The provocative agents of granulomatous inflammation appear to be non-degradable by both neutrophils and non-active macrophages. The actions of polymorphonuclear leucocytes, non-activated macrophages and chemical mediators which are associated with the tissue injury are insufficient to completely digest and eradicate the offending agents. For such a degradation, the action of transformed macrophages which are formed with the help of the CD4+T cells, is required. The CD4+T cells secrete various mediators such as IL2, IFγ, TNF and lymphotoxin for the transformation of the macrophages into epithelioid cells and giant cells, which are the components of granulomas (2). Classification of granulomas based on the aetiology: 1. Bacterial 2. Metal induced 3. Fungal 4. Viral / Chlamydial a. Cat scratch fever b. Lymphogranuloma venerum 5. Helminthic 6. Foreign body type 7. Unknown cause (3). Classification based on the morphological criteria: 1. Epithelioid 2. Histiocytic 3. Foreign body 4. Necrobiotic / Palisading 5. Mixed inflammatory (1). Granulomatous inflammations are a common and intriguing problem. The arrival at a proper diagnosis is mandatory, so that the appropriate treatment can be meted out. Histopathology is a tool which can be used for establishing a correct diagnosis like in many other diseases, pertaining to the various organ systems of the body (4). Good clinical history, a close histological examination and a clinicopathological correlation are essential in making a final diagnosis. By combining all the available information, one should be able to arrive at a reasonable differential diagnosis on which to proceed. However in a minority of the cases, it will not be possible to make a definitive diagnosis, even with all the clinical information being available. A rational histological diagnostic approach to granulomatous inflammation is also not present without its problems. Special stains may also be required to reach a diagnosis. In a small percentage of cases, no definitive diagnosis can be given, other than that of granulomatous inflammation (5). However, no comparative study, to our knowledge, has been carried out to determine the frequency and the types of different gran-ulomatous lesions in India and hence this study was carried out.

Material and Methods

The present study was undertaken from October 2004 to April 2006 in the Department of Pathology, Karnataka Institute of Medical Sciences, Hubli. The biopsies were received from various departments of the KIMS hospital, Hubli and a few were received from other hospitals in and around Hubli. A histopathological study of 170 granulomatous lesions was done. A majority of the granulomas were seen in skin and sub cutaneous tissues with 53 cases, followed by the involvement of lymph node in 31, the respiratory system in 29, bones and joints in 13, the gastrointestinal tract in 11, the breast in 10, the female reproductive system in 07, the male reproductive system in 05, the ear in 4, the gall bladder in 2 and 1 case each in the oral cavity, the liver, omentum, the brain and the urinary tract. The biopsies of the cases which were diagnosed as granulomas from all the sites, on haemotoxyline and eosin stained sections were selected. Special stains like ZN, GMS, PAS, Fite Faraco and the Auramine Rhodamine stain were used whenever required. The relevant clinical findings and lab investigation details were collected by a personal interview and the examination of the patient, or fromthe hospital case sheets.

Results

The ages of the patients with the 170 granulomatous lesions ranged from 2 to 70 yrs, with a mean age of 31.26±14.64 years. A majority of patients were in the age group of 20-29 years. A majority of them were males. Males accounted for 92 (54.12%) cases of the total 170 cases with male to female ratio of 1.18:1(Table/Fig 1)Granulomas of different aetiologies were seen. Tuberculosis was the most common cause of granulomas with 84 (49.41%) cases, followed by leprosy with 30 cases (17.65%) and rhinoscleroma with 20 cases (11.76%), foreign body granulomas -13 (7.65%), granulomas with unknown aetiology- 11(6.47%) and those with fungal infections- 10 (5.88%) and actinomycosis -2 (1.18%). (Table/Fig 2)One (7.69%) case each of seminoma with granuloma, squamous cell carcinoma with granuloma and benign cystic teratoma of the ovary with granuloma were seen. Eleven cases of granulomas of unknown aetiology were noted. Granulomatous mastitis was seen in a majority of the cases [with 5(45.45%) cases], followed by granuloma annulare in 2(18.18%). One case (9.09%) each of sarcoidosis, granulomatous orchitis, granuloma in the pleura and in the mastoid antrum were also noted. The aetiology was not identified in these cases, even on special staining like ZN and GMS. So, they were just grouped as granulomatous lesions. Different morphological patterns of the granulomaous lesions were seen. The commonest was the tuberculoid type with 98(57.65) cases, followed by histiocytic granulomas in 29(17.06%), foreign body granulomas in 17(10.00%), ill defined granulomas in 13(7.65%), mixed inflammatory granulomas in 11(6.47%) and necrobiotic granulomas in 2(1.18%)In tuberculosis, the ZN stain was done for all the 84 cases, out of which 19 (22.62%) cases were ZN positive and 65 (77.38%) were negative. Twenty five cases were randomly selected for the Auramine Rhodamine staining. Out of these, 19 cases which were negative for the ZN stain, were positive for Auramine Rhodamine and 5 cases which were negative for the ZN stain, were negative for Auramine and Rhodamine also. One case, which was positive for the ZN stain, was also positive for Auramine Rhodamine. (Table/Fig 3)Though ZN stain and Auramine Rhodamine was negative in 46 cases, due to the presence of caseous necrosis, raised ESR and other relevant clinical findings, they were classified as tuberculous lesions. In the present study, all the 30 cases of leprosy were stained with the Fite Faraco staining. Seventeen cases (56.66%) were positive for the Fite faraco stain and 13 cases (43.33%) were negative. All the 20 (100%) cases of rhinoscleroma showed histiocytic granulomas, with the predominance of histiocytes. Epithelioid cells and giant cells were absent in all the cases. The Rhinoscleroma cases were confirmed by their typical histology. In two cases, actinomycotic colonies were seen on H and E staining and these were confirmed by Grams staining. Ten cases of fungal lesions were identified either by histology or with the help of special stains like GMS, with a majority being maduramycosis. The interesting cases were P.Boydii and histoplasmosis involving the skin and subcutaneous tissues. One case of cerebral aspergillosis infection was also seen. (Table/Fig 4) Thirteen cases of foreign body granulomas were encountered, where the aetiology was identified. The most common among them were xanthomas with 6 (46.15%) cases, followed by bile induced granulomas of the gall bladder in 2 (15.38%) and epidermal cysts with granulomas in 2 (15.38%). In all these cases, foreign bodies could be identified in the giant cells. (Table/Fig 4)

Discussion

Out of the 170 cases, a) Special staining was not done in 33 cases 1. 20 cases were Rhinoscleromas 2. 11 cases were Foreign body granulomas 06 were Xanthomas - 02 were Bile induced - 03 were Keratin induced- 3. 2 cases were Granuloma annulare - b) Special stains were done in 137 cases In the present study, the ZN stain was positive in19 (22.62%) out of 84 cases, whereas it was positive in 91(71%) out of 128 cases in the study of Krishnaswamy H et al (6). (Table/Fig 5)Twenty five cases were randomly selected for the Auramine Rhodamine staining. Out of the 25 cases, the ZN stain was positive in 1(4%) case and it was negative in the rest of the 24 cases. The Auramine Rhodamine staining was positive in 20(80%) cases, whereas in Krishna Swamy H et al’s study, out of 128 cases, the ZN stain was positive in 91 (71.1%) cases and the Auramine Rhodamine stain was positive in 102(79.69%) cases (6). (Table/Fig 6)Out of the 30 cases of leprosy, the Fite Faraco stain was positive in 17(56.66%) cases and negative in 13(43.33%) cases, whereas in the study which was done by Nayak SV et al, it was positive inIn a case of Actinomycosis, the histopathology revealed skin and subcutaneous tissues with a number of suppurative granulomas having central actinomycotic colonies, which was comparable to that seen in Mirza M et al’s study(7)(8) (9).(Table/Fig 8)(Table/Fig 9) The commonest fungal lesion which was observed in our study was maduramycosis, which constituted 3(30%) cases, followed by rhinosporidiosis in 2(20%) cases, whereas in the study done by Chavan SS et al, there was a predominance of rhinosporidiosis [34(68%)] cases, followed by maduramycosis [8(16%)] cases (10). [Table/Fig 20]In the present study, one case of sarcoidosis of the lymph node was identified. It showed dense, discrete, small, uniform, noncaseating, back to back granulomas. No giant cells or necrosis was seen. The ZN stain for AFB was negative. The diagnosis was made by a typical histopathological examination. However, serum calcium levels25(44.64%) cases and negative in 31(55.35%) cases (7). There was a predominance of histiocytes and plasma cells in a majority of the rhinoscleroma cases. This was similar to the observation which was made by Meyer PR et al in their study on 9 rhinoscleroma cases (8). (Table/Fig 7)Fibrosis was seen in 5 (25%) cases and Russel bodies in 2(10%), which were comparable to Meyer PR et al’s study showing fibrosis in 2(22.22%) cases and Russel bodies in 2 (22.22%) (8). (Table/Fig 10)Two (20%) cases of P.boydii and one (10%) case each of histoplasmosis and mucormycosis were seen. However; granulomas caused by these three fungi were not reported in the study which was done by Chavan SS et al (10). In our study, 5 cases of granulomas were seen in the breast, where the aetiology was not identified. Out of these, 3 were epithelioid cell granulomas and 2 were foreign body granulomas. In a study by Fletcher A et al, 7 cases of granulomas were seen and all were epithelioid granulomas (11). [Table/Fig 23]Two cases of granuloma annulare were identified. Both cases revealed several small granulomatous lesions in the upper and mid dermis which were composed of small foci of necrobiotic collagen, surrounded by histiocytes in a pallisading arrangement and intermingled with the lymphoid cells. All these findings were similar to the observation which was made by Khatri ML et al in his case study on generalized granuloma annulare (12). [Table/Fig 26]and the angiotensin converting enzyme were not contributory. Subsequently, a careful search for other causes of granuloma by using clinical data and laboratory tests showed no positive results. All these above findings were comparable to the results of Manonukul J et al’s study (13).

Conclusion

Our study shows that granulomatous lesions are more common in males. Tuberculosis is one of the most commonest cause of granulomas. Granulomatous lesions accounted for 2.1% of the non-neoplastic biopsies which were received in our department. Out of the 170 cases, a definite aetiological diagnosis could be made only in 159 cases. Even after relevant special stains, the aetiological diagnosis could be confirmed in only 93.52% cases. Cooperation between the clinician and the pathologist is more important in the field of dermatology than in any other field, if the patient is to derive the greatest benefit from the biopsy. This percentage can be further consolidated, if culturing, serological investigations and PCR are done.

Key Message

(1). Granulomas are the commonest lesions that the pathologists come across in routine practice. (2). Tuberculosis is the commonest cause of granuloma. (3). The morphology of the lesions and special stains helped us to identify the aetiology.

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