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Nasal Granulomas






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Nasal Granulomas. Dr. Vishal Sharma. Definition of granuloma. Granulomas result from chronic inflammation & consist of: a. macrophages b. epithelioid cells (active macrophages resembling epithelial cells)
Nasal Granulomas

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Nasal granulomas l.jpgSlide 1

Nasal Granulomas

Dr. Vishal Sharma

Definition of granuloma l.jpgSlide 2

Definition of granuloma

Granulomas result from chronic inflammation &

consist of:a. macrophages

b. epithelioid cells (active macrophages

resembling epithelial cells)

c. multi-nucleated giant cells

+ d. vasculitis

+e. necrosis

Classification of nasal granulomas l.jpgSlide 3

Classification of nasal granulomas

Slide4 l.jpgSlide 4

A. BacterialC. Fungal

1. Rhinoscleroma1. Mucormycosis

2. Tuberculosis2. Aspergillosis

3. Syphilis D. Non-specific:

4. Leprosy1.Sarcoidosis

B. Aquatic parasite2.Wegener’s granuloma

1.Rhinosporidiosis3.Allergic granuloma

4. Sinonasal lymphoma ?

Rhinoscleroma or respiratory scleroma l.jpgSlide 5

Rhinoscleroma or Respiratory Scleroma

Definition l.jpgSlide 6

Definition

Rhinoscleroma or scleroma is progressive granulomatous disease caused by gram negative Klebsiella rhinoscleromatis [von Frisch bacillus]

Commences in nose  nasopharynx, para nasal sinus, oropharynx, larynx, trachea & bronchi

Nasal involvement staging l.jpgSlide 7

Nasal involvement staging

1. Catarrhal Stage: foul smelling purulent nasal discharge (carpenter’s glue), not responding to conventional antibiotics2. Atrophic stage:foul smelling, honey-comb coloured crusting in stenosed nasal cavity (in contrast to roomy nasal cavity of atrophic rhinitis)

Nasal involvement staging8 l.jpgSlide 8

Nasal involvement staging

3. Nodular/ granulation stage: Non-ulcerative,

painless nodules (soft & bluish–red  pale & hard)which widen lower nose (Hebra nose)

4. Cicatrizing stage:Adhesions & stenosis  coarse & distorted external nose (Tapir nose). Lower external nose & upper lip have woody feel.

Rhinoscleroma nodules l.jpgSlide 9

Rhinoscleroma nodules

Lesion in nose palate l.jpgSlide 10

Lesion in nose & palate

Hebra nose l.jpgSlide 11

Hebra nose

Tapir hebra l.jpgSlide 12

Tapir Hebra

Involvement of other sites l.jpgSlide 13

Involvement of other sites

Nasopharynx:Ear block & ed hearing (fibrosis of eustachian tube orifice). Nasal intonation & nasal regurgitation (fibrosis of soft palate).Oropharynx: Sore throatLarynx & tracheo-bronchial tree:Dry cough, hoarseness, respiratory distress

Investigations l.jpgSlide 14

Investigations

  • X-ray PNS: sinusitis + bone destruction

  • Nasopharyngoscopy:obliteration of nasopharynx due to adhesions b/w deformed V-shaped soft palate & posterior pharyngeal wall (Gothic sign)

  • Flexible laryngoscopy: subglottic stenosis

  • Biopsy & H.P.E.:Mikulicz cell & Russel body

  • Complement fixation test: b/w pt’s serum & Frisch bacillus suspension. Done if biopsy is inadequate.

Histopathology l.jpgSlide 15

Histopathology

Granulomatous tissue characterized by:1. Mikulicz (foam) cells:histiocytes with foamy vacuolated cytoplasm + central nucleus & containing Frisch bacilli

2. Russel (Hyaline) body: degenerated plasma cells with large round eosinophilic material

Histopathology16 l.jpgSlide 16

Histopathology

Histopathology magnified l.jpgSlide 17

Histopathology (magnified)

Warthin starry stain mikulicz cell l.jpgSlide 18

Warthin-Starry stain: Mikulicz cell

Medical treatment l.jpgSlide 19

Medical treatment

  • Total duration= 6 wk to 6 months (or negative cultures from 2 consecutive biopsy materials)

  • Streptomycin: 1g OD intramuscularly + Tetracycline: 500 mg QID orally

  • Rifampicin: 450 mg OD orally

  • 2% Acriflavine solution: applied locally OD

Radiotherapy surgery l.jpgSlide 20

Radiotherapy & Surgery

  • R.T.: 3500 cGy over 3 wk along with antibiotics halts progress of resistant cases

  • Removal of granulations & nodular lesions with cautery or laser

  • Dilatation of airway combined with insertion of Polythene tubes for 6 – 8 wk

  • Plastic reconstructive surgery: after 3 negative cultures from biopsies

Tuberculosis l.jpgSlide 21

Tuberculosis

Sino nasal tuberculosis l.jpgSlide 22

Sino-nasal Tuberculosis

  • Rare. Usually due to spread from pulmonary TB

  • Ulcers, nodules, polypoid masses in cartilaginous part of septum, lateral wall & inferior turbinate

  • H.P.E.: epithelioid granulomas with Langhan’s multi-nucleate giant cells, caseating necrosis

  • AFB may be found on nasal smears

  • Treatment: INH + Rmp + Etb + Pzn X 6 – 9 mth

Acid fast bacillus l.jpgSlide 23

Acid Fast Bacillus

Histopathology24 l.jpgSlide 24

Histopathology

Histopathology magnified25 l.jpgSlide 25

Histopathology magnified

Lupus vulgaris l.jpgSlide 26

Lupus Vulgaris

  • Tuberculosis of skin (of nose & face)

  • Can mimic a squamous cell carcinoma

  • Rapid course / indolent chronic form

  • Nodules have apple jelly appearanceon diascopy

  • Nodules ulcerate & crust  scarring + distortion of nasal alae, nasal tip & vestibule

  • Tx: A.T.T.  surgical reconstruction if required

Lupus vulgaris27 l.jpgSlide 27

Lupus vulgaris

Apple jelly nodule l.jpgSlide 28

Apple jelly nodule

Syphilis l.jpgSlide 29

Syphilis

Primary syphilis l.jpgSlide 30

Primary syphilis

  • Lesions develop 3-4 wks after contact

  • Chancre on external nose / vestibule

  • Hard, painful, ulcerated papule

  • Enlarged, rubbery, non-tender node

  • Spontaneous regression in 6-10 wks

Primary syphilis chancre l.jpgSlide 31

Primary syphilis chancre

Secondary syphilis l.jpgSlide 32

Secondary syphilis

  • Most infectious stage

  • Symptoms appear 6-10 wks after inoculation

  • Persistent, catarrhal rhinitis

  • Crusting / fissuring of nasal vestibules

  • Mucous patches in nose/pharynx

  • Roseolar, papular rashes on skin

  • Pyrexia, shotty enlargement of lymph nodes

Secondary syphilis rashes l.jpgSlide 33

Secondary syphilis rashes

Rash of secondary syphilis l.jpgSlide 34

Rash of secondary syphilis

Congenital syphilis l.jpgSlide 35

Congenital syphilis

  • Infants: snuffles, 3 wks to 3 mth after birth

  • Fissuring / excoriation of upper lip / vestibule

  • Mucosal rashes, atrophic rhinitis, saddle nose deformity, palatal perforation

  • Prenatal h/o syphilis, stillbirths, miscarriages

  • Hutchinson’s incisors, Moon’s mulberry molars, interstitial keratitis, corneal opacities, SNHL

Congenital syphilis palatal rash perforation l.jpgSlide 36

Congenital syphilis: palatal rash & perforation

Tertiary syphilis l.jpgSlide 37

Tertiary syphilis

  • Commonest manifestation of nasal syphilis

  • Gumma: red, nodular, submucous swelling with infiltration. Ulcerates with putrid discharge / crusting. Ulcer margins irregular, overhanging, indurated, bare bone underneath.

  • Sites: mucosa, periosteum, bony septum, lateral wall, floor of nose, nasal dorsum, nasal bones

Tertiary syphilis gumma l.jpgSlide 38

Tertiary syphilis gumma

Investigations39 l.jpgSlide 39

Investigations

  • Dark-ground illumination examn of nasal smear

  • Venereal Disease Research Laboratory test

  • Rapid Plasma Reagin

  • Fluorescent Treponemal Antibody Absorption

  • Treponema Pallidum Haem-agglutination Assay

  • H.P.E.: peri-vascular cuffing by lymphocytes &

    plasma cells. Endarteritis: narrowing of

    vascular lumen, necrosis, ulceration.

Sensitivity of serological tests l.jpgSlide 40

Sensitivity of serological tests

Treatment l.jpgSlide 41

Treatment

1. Benzathine penicillin G, IM, 2.4 MU single dose

2. If penicillin allergic: Doxycycline or Tetracycline

 Doxycycline: 100 mg orally BD for 2 weeks

 Tetracycline: 500 mg orally QID for 2 weeks

3. Sequestrectomy

4.Augmentation Rhinoplastyfor nasal deformity

Complications of untreated syphilis l.jpgSlide 42

Complications of untreated syphilis

  • Secondary infection with pyogenic organisms

  • Sequestration of bone

  • Perforation & collapse of bony nasal septum

  • Perforation of hard palate

  • Scarring / stenosis of choanae

  • Atrophic rhinitis

  • Meningitis

Leprosy l.jpgSlide 43

Leprosy

Leprosy44 l.jpgSlide 44

Leprosy

  • Etiology: Mycobacterium leprae

  • Types:a. tuberculous

    b. lepromatous

    c. borderline

  • C/F: nodules, inflammation of nasal mucosa, nasal obstruction, septal cartilage perforation

  • X-ray:erosion of anterior nasal spine

  • Sequelae: saddle nose, atrophic rhinitis, stenosis

Tuberculous lepromatous l.jpgSlide 45

Tuberculous Lepromatous

Saddle nose in leprosy l.jpgSlide 46

Saddle nose in leprosy

Erosion of anterior nasal spine l.jpgSlide 47

Erosion of anterior nasal spine

W h o treatment regimen l.jpgSlide 48

W.H.O. treatment regimen

A. Tuberculoid (pauci-bacillary) leprosy: for 6 mth

Dapsone: 100 mg daily, unsupervised

+ Rifampicin: 600 mg monthly, supervised

B. Lepromatous (multi-bacillary) leprosy: for 1–2 yr

Dapsone: 100 mg daily unsupervised

+ Clofazimine: 50 mg daily unsupervised

+ Rifampicin: 600 mg monthly supervised

+ Clofazimine: 300 mg monthly supervised

Rhinosporidiosis l.jpgSlide 49

Rhinosporidiosis

Definition50 l.jpgSlide 50

Definition

Chronic granulomatous infection by Rhinosporidium seeberi, mainly affecting mucous membranes of nose & nasopharynx; characterized by formation of friable, bleeding or polypoidal lesions

  • Other sites: lips, palate, antrum, conjunctiva, lacrimal sac, larynx, trachea, bronchus, ear, scalp, skin, penis, vulva, vagina, hand & feet.

What is rhinosporidium seeberi l.jpgSlide 51

What is Rhinosporidium seeberi?

  • Bizarre fungus: obsolete theory

  • Microcystis aeruginosa:a unicellular prokaryotic cyanobacterium (Karwitha Aluwalia)

  • Aquatic parasite (Protoctistan Mesomycetozoa) according to recent 18S ribosomal ribonucleic acid (rRNA) gene analysis

Epidemiology l.jpgSlide 52

Epidemiology

  • 88 – 95% cases are found in India & Sri Lanka

  • Common in Kerala, Karnataka & Tamil Nadu

  • Age : 20 – 40 yrs.

  • Male: Female ratio = 4 : 1

  • People with blood group “O” more susceptible

Classification l.jpgSlide 53

Classification

Benign

a. Nasal---------------------------------------------------- 78%

b. Nasopharyngeal-------------------------------------- 16%

c. Mixed (naso-nasopharyngeal, nasolacrimal) -- 05%

d. Bizarre (Conjunctival / Tarsal / Cutaneous) --- rare

Malignant------------------------------------------------- rare

Generalized, deep seated & difficult to eradicate

Clinical presentation l.jpgSlide 54

Clinical Presentation

Epistaxis + viscid nasal discharge + nose block

Nasal mass:papillomatous or polypoid, granular, friable, bleeds on touch, pedunculated or sessile, pink surface studded with white dots [Strawberry apperance], involves septum & turbinates

Nasal mucosa:edematous, hyperemic, covered with copious viscid secretions containing spores

Lymph nodes:not affected

Nasal mass l.jpgSlide 55

Nasal mass

Bleeding nasal mass l.jpgSlide 56

Bleeding nasal mass

Nasal nasopharynx l.jpgSlide 57

Nasal + Nasopharynx

Nasal nasopharynx58 l.jpgSlide 58

Nasal + Nasopharynx

Oropharyngeal mass l.jpgSlide 59

Oropharyngeal mass

Mass in uvula l.jpgSlide 60

Mass in uvula

Cutaneous granulomas l.jpgSlide 61

Cutaneous granulomas

Mode of transmission l.jpgSlide 62

Mode of transmission

1. Bathing (head dipping) in infected water: infective

spores enter via breached nasal mucosa

2. Droplet infection by cattle dung dust

3. Contact transmission:contaminated fingernails

are responsible for cutaneous lesions

4. Haematogenous: to other sites in infected pt

Life cycle l.jpgSlide 63

Life cycle

Slide64 l.jpgSlide 64

Life cycle begins as oval / spherical Trophocyte

[8 μm] with single nucleus. Nuclear + cytoplasmic

division of Trophocyte results in intermediate

Sporangium. This enlarges into a mature

Sporangium [120 – 300 μm] with chitinous wall &

contains 16,000 Endospores. Mature sporangium

ruptures during sporulation & releases infective

endospores via its Germinal pore. Endospores

enter another host & grow into trophocyte.

Differential diagnosis l.jpgSlide 66

Differential diagnosis

  • Infected antrochoanal polyp

  • Inverted papilloma

  • Other granulomas:

     Rhinoscleroma

     Tuberculosis

     Leprosy

     Fungal (aspergillosis, mucormycosis)

  • Malignancy of nose / paranasal sinus

Investigations67 l.jpgSlide 67

Investigations

  • Biopsy & Histo-pathological examination

  • Microscopic examination of nasal discharge for spores

Haematoxylin eosin stain l.jpgSlide 68

Haematoxylin & Eosin stain

Periodic acid schiff stain l.jpgSlide 69

Periodic Acid Schiff stain

Gomori methenamine silver stain l.jpgSlide 70

Gomori Methenamine Silver stain

Medical treatment71 l.jpgSlide 71

Medical Treatment

  • Dapsone: arrests maturation of spores (inhibits folic acid synthesis) & increases granulomatous response with fibrosis

  • Dose: 100 mg OD orally (with meals) for one year

  • Give Iron & Vitamin supplements

  • Side effects:Methemoglobinemia & anemia

Surgical management l.jpgSlide 72

Surgical management

  • At least 2 pints blood to be kept ready

  • General anesthesia with Oro-tracheal intubation

  • 2% Xylocaine (with 1:2 lakh adrenaline) infiltrated till surrounding mucosa appears blanched

  • Mass avulsed using Luc’s forceps & suction

  • After removal of mass, its base cauterized

  • Avoid traumatic implantation during surgery

  • Laser excision: minimal bleeding, no implantation

Fungal granulomas l.jpgSlide 73

Fungal granulomas

Fungal sinusitis l.jpgSlide 74

Fungal Sinusitis

A. Invasive (hyphae present in submucosa)

1. Acute invasive or fulminant (< 4 weeks)

2. Chronic invasive or indolent (> 4 weeks)

 Granulomatous  Non - granulomatous

B. Non-invasive

1. Allergic 2. Fungal ball 3. Saprophytic

Aspergillosis & Mucormycosis are common

Predisposing factors for invasive fungal infection l.jpgSlide 75

Predisposing factors for invasive fungal infection

  • Uncontrolled diabetes mellitus

  • Profound dehydration

  • Severe malnutrition

  • Severe burns

  • Leukemia, lymphoma

  • Chronic renal disease, septicemia

  • Long term tx with (steroids, anti-metabolites, broad spectrum antibiotics)

Clinical features l.jpgSlide 76

Clinical Features

  • Acute invasive fungal sinusitis by Mucormycosis

  • Unilateral nasal discharge + black crusts due to ischaemic necrosis, proptosis, ophthalmoplegia

  • Cerebral & vascular invasion may be present

  • Significant inflammation with fibrosis & granuloma formation seen in chronic invasive fungal sinusitis

  • Locally destructive with minimal bone erosion

Black crusting l.jpgSlide 77

Black crusting

Treatment78 l.jpgSlide 78

Treatment

  • Remove precipitating factors

  • Surgical debridement of necrotic debris

  • Amphotericin B infusion:1 mg / kg / day IV daily / on alternate days (total dose of 3 g). Liposomal Amphotericin B less toxic & more effective

  • Itraconazole:100 mg BD for 6-12 months

  • Hyperbaric oxygen:fungistatic +  tissue survival

Surgical debridement l.jpgSlide 79

Surgical debridement

Allergic fungal sinusitis l.jpgSlide 80

Allergic fungal sinusitis

  • Associated with ethmoid polyps & asthma

  • Unilateral thick yellow nasal discharge with mucin, eosinophils & Charcot Leyden crystals

  • C.T. scan: radio-opaque mass with central area of hyper density (due to hyphae)

  • Tx:Surgical debridement + anti-histamines + steroids (oral & topical)

Allergic fungal sinusitis81 l.jpgSlide 81

Allergic fungal sinusitis

Allergic fungal sinusitis82 l.jpgSlide 82

Allergic fungal sinusitis

C t scan coronal cuts l.jpgSlide 83

C.T. scan coronal cuts

C t scan axial cuts l.jpgSlide 84

C.T. scan axial cuts

Slide85 l.jpgSlide 85

Fungal ball (Mycetoma)

Refractory sinusitis with foul smelling cheesy material in maxillary sinus

Tx:Surgical removal. No anti-fungal drugs.

Saprophytic fungal sinusitis

Seen after sino-nasal surgery due to proliferation of fungal spores on mucous crusts

Tx:Surgical removal. No anti-fungal drugs.

Investigations86 l.jpgSlide 86

Investigations

  • Biopsy & HPE: Tissue invasion by broad, non-septate, 900 branching hyphae. Fungal penetration of arterial walls with thrombosis & infarction. Staining by Periodic Acid Schiff or Grocott – Gomori Methenamine Silver nitrate stain.

  • X-ray PNS:Sinusitis + focal bone destruction

  • CT scan: rule out orbital & intracranial extension

  • MRI:for vascular invasion & intracranial extension

Aspergillosis mucormycosis l.jpgSlide 87

Aspergillosis Mucormycosis

Immuno fluorescent staining l.jpgSlide 89

Immuno-fluorescent staining

Sarcoidosis l.jpgSlide 90

Sarcoidosis

Definition etiology l.jpgSlide 91

Definition & etiology

  • Synonym:Boeck’s sarcoid or Besnier – Boeck –

    Schaumann syndrome

  • Definition:chronic systemic disease of unknown

    etiology which may involve any organ with non-

    caseating (hard) granulomatous inflammation

  • Etiology: 1. Special form of Tuberculosis (?) 2. Unidentified organism

Clinical features92 l.jpgSlide 92

Clinical features

  • Nasal discharge, nasal obstruction, epistaxis

  • Mucosal: reveals yellow nodules surrounded by hyperaemic mucosa on anterior septum & turbinates

  • Skin (Lupus Pernio or Mortimer’s malady):nasal tip shows symmetrical, bulbous, glistening violaceous lesion (resembling perniosis or cold induced injury) Similar lesions on cheeks, lips & ears [Turkey ears]. Diascopy reveals yellowish – brown appearance.

Lupus pernio l.jpgSlide 93

Lupus Pernio

Heerfordt s syndrome l.jpgSlide 94

Heerfordt’s syndrome

Synonym:Waldenström’s uveo-parotid fever

Special form of sarcoidosis with:

1. Transient B/L Facial palsy

2. Parotid enlargement

3. Uveitis

4. Fever

Probe test l.jpgSlide 95

Probe test

  • Probing of nodular lesion to look for penetration

  • Negative in sarcoidosis: probe does not penetrate nodular swelling because of hard granulomas

  • Positive in Lupus vulgaris:probe penetrates up to soft granulation tissue in centre of nodule

Investigations96 l.jpgSlide 96

Investigations

  • Biopsy of nodule & HPE:Non-caseating hard granuloma with ill-defined rim of surrounding lymphoid cells (naked tubercle). Giant cells contain asteroid inclusion or Schaumann bodies

  • Kveim Siltzbach Test:Intradermal injection of spleen extract from case of sarcoidosis followed 6 wks later by skin biopsy shows development of non-caseating nodules

Non caseating granuloma l.jpgSlide 97

Non-caseating granuloma

Non caseating granuloma98 l.jpgSlide 98

Non-caseating granuloma

Asteroid inclusion bodies l.jpgSlide 99

Asteroid inclusion bodies

Chest x ray findings l.jpgSlide 100

Chest X-ray findings

  • Stage I= B/L Hilar lymph node enlargement

  • Stage II=B/L Hilar lymph node enlargement +

    diffuse parenchymal infiltrates

  • Stage III= Diffuse parenchymal infiltrates without

    Hilar lymph node enlargement

  • Stage IV =Diffuse parenchymal infiltrates +

    fibrosis with cor pulmonale

Hilar lymphadenopathy l.jpgSlide 101

Hilar lymphadenopathy

Treatment102 l.jpgSlide 102

Treatment

1. Prednisolone: 1 mg/kg/d x 6 wk, taper over 3 mth.

Good response in mucosal disease only.

2. Chloroquine / Methotrexate + Prednisolone:

in pt not responding to steroids

Chloroquine =250 mg PO on alternate days x 9 mth

Methotrexate =5mg PO weekly x 3mth

3. Cutaneous lesions: excised & skin grafted

Wegener s granuloma l.jpgSlide 103

Wegener’s granuloma

Definition104 l.jpgSlide 104

Definition

Autoimmune (?) condition characterized by necrotizing granulomas within nasal cavity & lower respiratory tract,

generalised vasculitis &

focal glomerulonephritis

Clinical features105 l.jpgSlide 105

Clinical Features

Nose & paranasal sinus:epistaxis, nasal block, extensive crusts, septal destruction & nasal collapse. Rule out nasal substance abuse.

Pulmonary:Cough, haemoptysis

Renal: Hematuria & oliguria

Otological:Otalgia, deafness, facial nerve palsy

Oral & pharyngeal: Hyperplastic, granular lesions

Clinical features106 l.jpgSlide 106

Clinical Features

Laryngo-tracheal: laryngitis, subglottic stenosis

Ophthalmological:scleritis, conjunctivitis, corneal ulceration, dacryocystitis, proptosis, optic neuritis, blindness

Others: Skin ulceration, polymyalgia, polyarthritis

If untreated:death within 6 mth due to renal failure

Crusting in nasal cavity l.jpgSlide 107

Crusting in nasal cavity

External nasal deformity l.jpgSlide 108

External nasal deformity

Destruction of orbit nose l.jpgSlide 109

Destruction of orbit & nose

Differential diagnosis110 l.jpgSlide 110

Differential diagnosis

VASCULITISGRANULOMAS + VASCULITIS Polyarteritis nodosa  Allergic granulomatosis S.L.E.  Loeffler’s syndrome Rheumatoid arthritis PULMONARY + RENAL Sjogren’s syndrome  Goodpasture’s syndromeOTHER GRANULOMASNEOPLASMSpecific Sinonasal lymphoma T.B. Metastatic bronchial cancer SyphilisOTHERSNon-specific Nasal substance abuse Sarcoidosis  Systemic myiasis

Investigations111 l.jpgSlide 111

Investigations

E.S.R.: raised

Urine microscopic examn:RBC casts & RBCs

CT PNS: bone destruction in nasal cavity

Chest X-ray & CT scan:pulmonary nodules

Serum urea & creatine: ed renal function

Biopsy of lesion & HPE:Granulomas + Vasculitis + Fibrinoid vascular necrosis

Ct scan pns nasal destruction l.jpgSlide 112

CT scan PNS: nasal destruction

Cxr nodular lesion with cavity l.jpgSlide 113

CXR: nodular lesion with cavity

C t scan lungs l.jpgSlide 114

C.T. scan lungs

nodular lung infiltrate with cavitation

Hpe granulomatous vasculitis l.jpgSlide 115

HPE: Granulomatous vasculitis

L = small pulmonary artery lumen surrounded by inflammatory infiltrate including a giant cell (black arrow)

Segmental glomerular necrosis l.jpgSlide 116

Segmental glomerular necrosis

early crescent formation (black arrows)

C a n c a l.jpgSlide 117

c-A.N.C.A.

  • Anti-Neutrophil Cytoplasmic Antibody (ANCA) titre by immuno-fluorescence.

  • c-ANCA = cytoplasmic fluorescence

  • Raised c-ANCA titres = 65-96% sensitive in WG

  • Becomes -ve when disease is controlled

  • p-ANCA = peri-nuclear fluorescence

  • p-ANCA titres raised in Polyangitis

C anca by indirect immuno fluorescence l.jpgSlide 118

C – ANCA by indirect immuno-fluorescence

Medical treatment119 l.jpgSlide 119

Medical Treatment

1. Triple therapy:

Prednisolone: 1 mg/kg/d x 1 mth  Taper over 3 mth

+ Cyclophosphamide: 2mg/kg / day x 6-12 mth

+ Cotrimoxazole: 960 mg OD X indefinitely

2. Plasma exchange & intravenous immunoglobulin

3. Alkaline nasal douche for crusts

Sinonasal lymphoma not a granuloma l.jpgSlide 120

Sinonasal lymphoma (not a granuloma)

Synonyms l.jpgSlide 121

Synonyms

  • Stewart’s granuloma

  • Lethal midline granuloma

  • Non-healing midline granuloma

  • Idiopathic midline destructive disease (IMDD)

  • Sinonasal T-cell lymphoma

  • Necrosis with atypical cellular exudate (NACE)

  • Midline malignant reticulosis

Clinical features122 l.jpgSlide 122

Clinical Features

  • Prodromal stage: Blood-stained nasal discharge

  • Active stage:Nasal crusting, ulceration, septal perforation

  • Terminal stage: Tumour sloughing, mid-face mutilation

  • D/D:Wegener’s granuloma, Basal cell carcinoma

  • Rx: Radiotherapy (5000 cGy) + chemotherapy

Mid face mutilation l.jpgSlide 123

Mid-face mutilation

Churg strauss syndrome l.jpgSlide 126

Churg & Strauss Syndrome

  • Synonym:allergic granulomatosis

  • C/F:nasal polyps + bronchial asthma

  • Chest X-ray: pulmonary lesions

  • HPE of nasal polyp:necrotizing granulomas with abundant eosinophils without vasculitis

  • Tx: 1. Corticosteroids (topical & systemic)

    2. Nasal polypectomy

Thank you l.jpgSlide 127

Thank You


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