Granuloma

A granuloma is a small, organized collection of immune cells that forms when the body attempts to isolate and contain something it can’t easily remove, such as certain infections, foreign materials, or other irritants. The primary type of cell found in a granuloma is the histiocyte, a kind of immune cell that helps protect the body. In granulomas, histiocytes often group closely together and resemble epithelial cells (the cells that line the surfaces of your body), so pathologists refer to them as epithelioid histiocytes. Other immune cells, like lymphocytes and multinucleated giant cells (large cells formed by the fusion of multiple histiocytes), are also frequently found in granulomas.

Why do granulomas form?

Granulomas form when your immune system detects something unusual that it cannot easily remove or destroy. To protect the body, your immune cells surround and “wall off” these substances.

Common causes include:

• Infections, for example, can be caused by bacteria (such as Mycobacterium tuberculosis, the bacterium that causes tuberculosis), fungi (such as Histoplasma, which causes histoplasmosis), or parasites.

• Foreign objects, such as splinters, silica, or other materials, that accidentally enter the body.

• Cellular debris, including fragments of bone, hair, or connective tissue.

What medical conditions are associated with granulomas?

Granulomas can appear in various conditions, including:

• Infectious diseases like tuberculosis, leprosy, or histoplasmosis.

• Chronic inflammatory diseases such as sarcoidosis and Crohn’s disease.

• Exposure to certain substances, like beryllium (which causes berylliosis), silica, or talc.

What is the difference between necrotizing and non-necrotizing granulomas?

Granulomas can be classified as necrotizing or non-necrotizing, depending on whether they contain dead cells (necrosis) at their center.

• Necrotizing granulomas have a central area of dead cells. They are typically linked to certain chronic infections, especially tuberculosis. When viewed with the naked eye, these granulomas often have a cheese-like appearance, which pathologists refer to as “caseating.”

• Non-necrotizing granulomas do not have a center of dead cells. They commonly occur in conditions such as sarcoidosis or reactions to foreign materials. These granulomas usually indicate an immune response that causes less tissue damage.

Why is it important to distinguish between necrotizing and non-necrotizing granulomas?

Distinguishing between these two types helps your doctor determine the cause and select the most effective treatment. Necrotizing granulomas often indicate infections that require antibiotics or other antimicrobial treatments. Non-necrotizing granulomas, on the other hand, may indicate chronic inflammatory conditions or reactions to foreign substances, leading your doctor to manage inflammation or modulate your immune response.

How is the diagnosis made?

Granulomas are typically diagnosed when a tissue sample is examined under a microscope by a pathologist. The appearance, size, and presence or absence of necrosis in the granuloma help your medical team understand the underlying cause. Based on these findings, your doctor may recommend further tests or treatments.

What happens next?

If granulomas are identified in your tissue, your doctor will likely recommend additional tests, such as blood tests, imaging, or specialized cultures, to determine their exact cause. Treatment will depend on the underlying condition but could include medications to manage infections, inflammation, or autoimmune responses. Regular follow-up is important to monitor your condition and ensure the appropriate treatment is effective.

Questions to ask your doctor

• What is likely causing the granulomas in my tissue sample?

• Will I need any additional tests to determine the exact cause?

• Are my granulomas necrotizing or non-necrotizing, and why is this important?

• Do these granulomas suggest a chronic condition, infection, or exposure to something specific?

• What treatment options do you recommend, and how long will treatment likely last?

• Are there potential complications if granulomas are left untreated?

• How often should I follow up with you for monitoring or additional testing?

• Should my family members be tested for any related conditions?