GRANULOMATOUS INFLAMMATION

BY:
DR. RITU MATHUR
(POST GRADUATE STUDENT)
(DEPTT. OF PERIODONTICS)

CONTENTS

Definition
Pathogenesis
Causes
Mechanism of granuloma formation
Types of granuloma
Tuberculosis
Leprosy
Sarcoidosis
Conclusion

DEFINITION:

Granulomatous inflammation is a distinctive pattern of

chronic inflammatory reaction.
What is a granuloma ?
A granuloma is a microscopic aggregation of
macrophages that are transformed into epithelium-like
cells surrounded by a collar of mononuclear
leukocytes, principally lymphocytes and occasionally
plasma cells.

Epithelioid cells fuse to form giant

cells containing 20 or more nuclei.
The nuclei arranged either
peripherally (Langhans-type giant
cell) or
haphazardly (foreign body-type
giant cell).
These giant cells can be found either
at the periphery or the center of the
granuloma

CAUSES
Bacterial
Tuberculosis (Mycobacterium tuberculosis)
Leprosy (Mycobacterium leprae)
Syphilitic gumma (Treponema pallidum)
Cat-scratch disease
Berylliosis
Parasitic
Schistosomiasis (Schistosoma mansoni, S. haematobium,
S. japonicum)
Fungal
Histoplasma capsulatum
Blastomycosis
Cryptococcus neoformans
Coccidiodes immitis

Inorganic Metals or Dusts

Silicosis
Berylliosis
Foreign Body
Suture, breast prosthesis, vascular graft
Unknown
Sarcoidosis

MECHANISM OF
GRANULOMA FORMATION

 Granuloma:
bacilli are inhaled by droplets

Bacteria are phagocytosed by

macrophages

After amassing substances that they

cannot digest, macrophages lose
their motility, accumulate at the site
of injury and transform themselves
into nodular collections; the
Granuloma

A localized inflammatory
response recruits more
mononuclear cells

Containment usually
fails when the
immune status of the

The granuloma consists of a

kernel of infected
macrophages surrounded by
foamy macrophages and a ring
of lymphocytes and a fibrous
cuff (containment phase)

patient changes; the

granuloma caseates,
ruptures and spills
into the airway

TYPES

OF

GRANULOMAS:

Foreign body
granulomas form
when material such as
talc, sutures, or other
fibers are large enough to
preclude phagocytosis by
a single macrophage.

Immune granulomas
caused by insoluble particles
that are capable of inducing
a cell-mediated response
Eg: tuberculosis

ORAL CAVITY

SKIN

LUNGS

TUBERCULOSIS

Mycobacterium

2-10micrometer in length.

Structrually gram positive but also contains large amount of lipids in

the cell wall:making them acid fast.

No toxins

No spores

Obligate Aerobic

Elicit granulomatous inflammation

MYCOBACTERIUM TUBERCULOSIS
Tuberculosis is a chronic communicable disease in
which the lungs are the prime target , although any
organ may be Infected
TYPES
Primary TB
SecondaryTB
Progressive pulmonary TB
Miliary TB

PATHOGENESIS

The course of tuberculosis depends on age and immune

competence AND total burden of the organisms
Tuberculous Infection: refers to growth of the organism in a
person,whether there is symptomatic disease or not.
Active Tuberculosis; refers to infection manifested by tissue
destruction-----symptomatic disease.

PRIMARY TUBERCULOSIS
Primary tuberculosis is the form of disease that develops
in a previously unexposed and unsensitized person.
Tuberculosis is a type of delayed tissue hypersensitivity
to the tuberculous bacillus which elicit a cell-mediated
immune response which will resists the growth and
spread of the mycobacterium.
This hypersensitivity reaction produces the pathologic
feature
of
tuberculosis
in
immunocompetent
individuals,
i.e.
granulomas,
caseation,
cavity
formation.

Is characterized by:
Ghon Focus -----

lung lesion of

primary TB,involves upper

segments of the lower lobes or
lower segment of the upper lobe.
Ghon complex----- combination of
a peripheral ghon focus and
involved mediastinal or hilar
lymphnode.
Microscopically the classic lesion of
TB is a caseous granuloma

SECONDARY TUBERCULOSIS
Is the pattern of disease that arises in a previously
sensitized host.
Is usually a reactivation of dormant primary lesions
when the host resistance is lowered.
Or exogenous reinfection by a high dose of virulent
bacilli which occur more commonly in endemic areas.
Only 5% of patients with primary disease develop
secondary tuberculosis.

COMPLICATIONS OF SECONDARY TB

Scarring &calcification
Spread to other areas
Pleural fibrosis&adhesions
Rupture of caseous lesion
Implantation of bacteriain the larynx ---hoarseness

MILIARY TUBERCULOSIS
Occurs when organisms drain through lymphatics into the
lymphatic ducts, which empty into the venous return to
the right side of the heart and hence into the
pulmonary arteries.
Individual lesions are either microscopic or small, visible
(2-mm) foci of yellow-white consolidation scattered
through the lung parenchyma.
Miliary lesions may expand and coalesce to yield almost
total consolidation of large regions or even whole lobes
of the lung.

With progressive pulmonary tuberculosis, the pleural

cavity is invariably involved, and serous pleural
effusions, tuberculous empyema, or obliterative
fibrous pleuritis may develop.
Miliary tuberculosis is most prominent in :
the liver,

bone marrow,

spleen,
adrenals,
meninges, kidneys, fallopian tubes, and epididymis.

TUBERCULIN TEST
It is a classic example of delayed hypersensitivity.
The tuberculin reaction, is produced by the intracutaneous
injection of tuberculin, a protein-lipopolysaccharide component
of the tubercle bacillus.
In a previously sensitized individual, reddening and induration of
the site appear in 8 to 12 hours, reach a peak in 24 to 72
hours, and thereafter slowly subside.
Morphologically, delayed type hypersensitivity is characterized by
the accumulation of mononuclear cells around small veins and
venules, producing a perivascular "cuffing" .

LEPROSY

M. leprae is an acid-fast obligate

intracellular organism that grows
very poorly in culture

Inhaled M. leprae, like M.

tuberculosis, is taken up by alveolar
macrophages and disseminates
through the blood, but grows only in
tissues of the skin and extremities.

Cell-mediated immunity is reflected

by delayed type hypersensitivity
reactions to dermal injections of a
bacterial extract called lepromin

Leprosy is primarily a granulomatous disease of the peripheral nerves and

mucosa of the upper respiratory tract; skin lesions are the primary
external sign
Leprosy may also be divided into the following types
Early and indeterminate leprosy
Tuberculoid leprosy
Borderline tuberculoid leprosy
Borderline leprosy
Borderline lepromatous leprosy
Lepromatous leprosy
Histoid leprosy

SARCOIDOSIS

Sarcoidosis (from sarc meaning "flesh", -oid, "like", and -osis,

"diseased or abnormal condition"), also called sarcoid, BesnierBoeck disease orBesnier-Boeck-Schaumanndisease,

It is a syndrome involving abnormal collections of chronic

inflammatory cells (granulomas) that can form as nodules in
multiple organs.The granulomas that appear are usually not of
the caseating variety and are most often located in the lungs or
thelymph nodes, but virtually any organ can be affected.

CONCLUSION

Chronic inflammation is inflammation of prolonged duration

(weeks to years) in which continuing inflammation, tissue injury,
and healing, often by fibrosis occurs and involves complex
interactions between several cell populations and their secreted
mediators.

Understanding the pathogenesis of chronic inflammatory

reactions requires an appreciation of these cells and their biologic
responses and functions and also treatment modalities which will
differ according to the underlying or systemic cause of the
granulomatosis.

REFERENCES

Textbook of pathology Harshmohan ( 3th edi)

Robbins and cotran pathologic basis of disease

( 7th , 8th edi.)