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Differential diagnosis of granulomatous lung disease: clues and pitfalls

Shinichiro Ohshimo, Josune Guzman, Ulrich Costabel, Francesco Bonella
European Respiratory Review 2017 26: 170012; DOI: 10.1183/16000617.0012-2017
Shinichiro Ohshimo
1Dept of Emergency and Critical Care Medicine, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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Josune Guzman
2General and Experimental Pathology, Ruhr-University Bochum, Bochum, Germany
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Ulrich Costabel
3Interstitial and Rare Lung Disease Unit, Ruhrlandklinik, University of Duisburg-Essen, Essen, Germany
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Francesco Bonella
3Interstitial and Rare Lung Disease Unit, Ruhrlandklinik, University of Duisburg-Essen, Essen, Germany
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  • For correspondence: francesco.bonella@ruhrlandklinik.uk-essen.de
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  • FIGURE 1
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    FIGURE 1

    Chest high-resolution computed tomography (HRCT) of a–c) acute hypersensitivity pneumonitis and d–f) chronic hypersensitivity pneumonitis. Chest HRCT of acute hypersensitivity pneumonitis shows bilateral ground-glass densities with centrilobular micronodular accentuation and minor consolidation. Chest HRCT of chronic hypersensitivity pneumonitis shows bilateral reticular shadowing, traction bronchiectasis and minor mosaic perfusion along with some micronodules.

  • FIGURE 2
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    FIGURE 2

    Diagnostic algorithm of granulomatous lung diseases. OP: organising pneumonia; EGPA: eosinophilic granulomatosis with polyangiitis; NSG: necrotising sarcoid granulomatosis; GPA: granulomatosis with polyangiitis; GLILD: granulomatous–lymphocytic interstitial lung disease; HP: hypersensitivity pneumonitis; PLCH: pulmonary Langerhans cell histiocytosis.

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  • TABLE 1

    Differential diagnosis of granulomatous lung diseases

    Infectious lung diseases
     MycobacteriaTuberculosis and nontuberculous mycobacteriosis
     Fungal infectionCryptococcus, Coccidioides, Histoplasma, Blastomyces and Aspergillus
     Aspiration pneumonia
     OthersSyphilis, Hansen's disease (leprosy), tularaemia, cat scratch disease, parasitic infections and Whipple's disease
    Noninfectious lung diseases
     InflammatorySarcoidosis
    Necrotising sarcoid granulomatosis
    Bronchocentric granulomatosis
    Inflammatory bowel disease
     Exposure/toxinsHypersensitivity pneumonitis
    Drugs (methotrexate, interferon, Bacillus Calmette-Guérin, infliximab, etanercept, leflunomide, mesalamine and sirolimus)
    Hot tub lung
    Berylliosis
    Talc
    Metals (aluminium and zirconium)
    Foreign body reaction
     VasculitisGranulomatosis with polyangiitis
    Eosinophilic granulomatosis with polyangiitis
     Autoimmune diseasesRheumatoid nodule
     MalignancySarcoid-like lesions
    Lymphomatoid granulomatosis
     OthersPulmonary Langerhans cell histiocytosis Granulomatous–lymphocytic interstitial lung disease
  • TABLE 2

    Predictors of hypersensitivity pneumonitis

    VariableOR (95% CI)
    Exposure to a known offending antigen38.8 (11.6–129.6)
    Positive precipitating antibodies5.3 (2.7–10.4)
    Recurrent episodes of symptoms3.3 (1.5–7.5)
    Inspiratory crackles4.5 (1.8–11.7)
    Symptoms 4–8 h after exposure7.2 (1.8–28.6)
    Weight loss2.0 (1.8–28.6)

    Reproduced and modified from [89] with permission from the publisher.

    Supplementary Materials

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    • Supplementary Material

      F. Bonella ERR-0012-2017_Bonella

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    Differential diagnosis of granulomatous lung disease: clues and pitfalls
    Shinichiro Ohshimo, Josune Guzman, Ulrich Costabel, Francesco Bonella
    European Respiratory Review Sep 2017, 26 (145) 170012; DOI: 10.1183/16000617.0012-2017

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    Differential diagnosis of granulomatous lung disease: clues and pitfalls
    Shinichiro Ohshimo, Josune Guzman, Ulrich Costabel, Francesco Bonella
    European Respiratory Review Sep 2017, 26 (145) 170012; DOI: 10.1183/16000617.0012-2017
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    • Article
      • Abstract
      • Abstract
      • Introduction
      • Definition of granuloma
      • Basic diagnostic procedure and difficulties
      • Infectious lung diseases
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