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Background: Xanthogranulomatous osteomyelitis (XO) is a rare disease characterized radiologically by an osteolytic lesion with cortical expansion or disruption. Differentiating this condition from other osteolytic diseases such as primary or metastatic bone neoplasms is imperative. Several case reports have been published on XO, with previous reports predominantly identifying bacteria such as Pseudomonas or Staphylococcus as causative organisms. However, fungal infection-induced XO has not yet been reported., Case Presentation: We present the case of a 23-year-old woman with a tumor-like osteolytic lesion in the pubic bone. The patient had experienced pelvic pain and intermittent febrile episodes for 2 months. Plain radiography revealed an osteolytic lesion in the right pubic tubercle. Magnetic resonance imaging suggested a cystic bone tumor or tubercular infection. Surgical intervention included curettage of the lesion and irrigation with normal saline. Histopathological examination of the specimen revealed abundant foamy histiocytes with inflammatory infiltrates consistent with XO. Culture of the osteolytic lesion confirmed an Aspergillus species infection and antifungal treatment was initiated. At 1-year follow-up, no evidence of local recurrence was observed., Conclusions: Although rare, XO requires differentiation from similar conditions and is treated with surgical intervention and targeted medical therapy based on the identified organisms. Clinicians should be mindful that XO can also be induced by fungal infections and that combination antifungal treatments may be beneficial in such cases., (© 2024. The Author(s).)

Abstract: An 18-year-old man presented with encephalopathy, headache, tremor, and left hemiparesis. 18 F-FDG brain PET/MRI revealed pronounced hypometabolism in the right cerebral hemisphere corresponding to extensive T2/FLAIR signal abnormality, with accompanying miliary enhancement and microhemorrhages in this region. The differential diagnosis favored an autoimmune or inflammatory origin, rather than an infectious or neoplastic etiology. Brain biopsy demonstrated nonnecrotizing granulomatous inflammation affecting the vessel walls, without evidence of glial neoplasm, lymphoma, or infection. Treatment with corticosteroids was subsequently initiated, with favorable clinical response., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Trigeminal neuralgia (TN) is characterized by excruciating facial pain usually caused by neurovascular compression of the trigeminal nerve roots. TN can be treated medically or invasively. Microvascular decompression is the procedure of choice and usually results in complete symptom relief. During surgical decompression, Teflon can be placed between the offending vessel and the nerve root entry zone. In some cases, chronic Teflon-related inflammation can cause recurrent TN, which might lead to additional surgical intervention. We present imaging and histopathological correlation of a patient presenting with intractable recurrent TN approximately 2 years after microvascular decompression with Teflon implant., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Dermoscopy can be an important help for the diagnosis of skin cancers and inflammatory cutaneous diseases. The list of the dermoscopic features reported in granuloma faciale is wide and includes vascular and non-vascular features. We report here three cases of diffuse flat facial and extrafacial granuloma faciale that exhibited elongated linear vessels simulating branching vessels and diffuse structureless orange areas. The differential diagnosis between flat-type granuloma faciale, basal cell carcinoma and cutaneous sarcoidosis can be extremely difficult, making histology mandatory before any treatment., (© 2024 The Authors. Australasian Journal of Dermatology published by John Wiley & Sons Australia, Ltd on behalf of Australasian College of Dermatologists.)

Background: The radiological differentiation of xanthogranulomatous cholecystitis (XGC) and gallbladder cancer (GBC) is challenging yet critical. We aimed at utilizing the deep learning (DL)-based approach for differentiating XGC and GBC on ultrasound (US)., Methods: This single-center study comprised consecutive patients with XGC and GBC from a prospectively acquired database who underwent pre-operative US evaluation of the gallbladder lesions. The performance of state-of-the-art (SOTA) DL models (GBCNet-convolutional neural network [CNN] and RadFormer, transformer) for XGC vs. GBC classification in US images was tested and compared with popular DL models and a radiologist., Results: Twenty-five patients with XGC (mean age, 57 ± 12.3, 17 females) and 55 patients with GBC (mean age, 54.6 ± 11.9, 38 females) were included. The performance of GBCNet and RadFormer was comparable (sensitivity 89.1% vs. 87.3%, p = 0.738; specificity 72% vs. 84%, p = 0.563; and AUC 0.744 vs. 0.751, p = 0.514). The AUCs of DenseNet-121, vision transformer (ViT) and data-efficient image transformer (DeiT) were significantly smaller than of GBCNet (p = 0.015, 0.046, 0.013, respectively) and RadFormer (p = 0.012, 0.027, 0.007, respectively). The radiologist labeled US images of 24 (30%) patients non-diagnostic. In the remaining patients, the sensitivity, specificity and AUC for GBC detection were 92.7%, 35.7% and 0.642, respectively. The specificity of the radiologist was significantly lower than of GBCNet and RadFormer (p = 0.001)., Conclusion: SOTA DL models have a better performance than radiologists in differentiating XGC and GBC on the US., (© 2023. Indian Society of Gastroenterology.)

Background: The diagnosis of solitary pulmonary nodules has always been a difficult and important point in clinical research, especially granulomatous nodules (GNs) with lobulation and spiculation signs, which are easily misdiagnosed as malignant tumors. Therefore, in this study, we utilised a CT deep learning (DL) model to distinguish GNs with lobulation and spiculation signs from solid lung adenocarcinomas (LADCs), to improve the diagnostic accuracy of preoperative diagnosis., Methods: 420 patients with pathologically confirmed GNs and LADCs from three medical institutions were retrospectively enrolled. The regions of interest in non-enhanced CT (NECT) and venous contrast-enhanced CT (VECT) were identified and labeled, and self-supervised labels were constructed. Cases from institution 1 were randomly divided into a training set (TS) and an internal validation set (IVS), and cases from institutions 2 and 3 were treated as an external validation set (EVS). Training and validation were performed using self-supervised transfer learning, and the results were compared with the radiologists' diagnoses., Results: The DL model achieved good performance in distinguishing GNs and LADCs, with area under curve (AUC) values of 0.917, 0.876, and 0.896 in the IVS and 0.889, 0.879, and 0.881 in the EVS for NECT, VECT, and non-enhanced with venous contrast-enhanced CT (NEVECT) images, respectively. The AUCs of radiologists 1, 2, 3, and 4 were, respectively, 0.739, 0.783, 0.883, and 0.901 in the (IVS) and 0.760, 0.760, 0.841, and 0.844 in the EVS., Conclusions: A CT DL model showed great value for preoperative differentiation of GNs with lobulation and spiculation signs from solid LADCs, and its predictive performance was higher than that of radiologists., (© 2024. The Author(s).)

Purpose: Aimed to investigate the role of multiparametric magnetic resonance imaging (mp-MRI) in the diagnosis of granulomatous prostatitis caused by intravesical Bacillus Calmette-Guérin (BCG)., Methods: In this prospective, single-center study, 10 male patients who were given intravesical BCG due to intermediate- and high-risk bladder cancer were included. Before transurethral resection of bladder tumors (TURB), all patients were evaluated by mp-MRI, serum prostate-specific antigen (PSA), and digital rectal examination (DRE). Serum PSA levels and DRE findings were evaluated before and after intravesical BCG treatment. Prostate mp-MRI was performed for patients with elevated levels of serum PSA and/or with abnormal DRE findings. Then, MRI fusion + systematic prostate biopsy was performed. Demographic data of the patients before and after intravesical BCG were compared., Results: The average age of the patients was 66.9 years (55-87 years). While PSA was 1.7 ng/ml before intravesical BCG treatment, it was 4.3 ng/ml after intravesical BCG treatment (p = 0.005). PSA density (PSAD) was 0.04 and 0.10 before and after the treatment, respectively (p = 0.012). DRE findings of all patients were normal before the treatment. However, abnormal findings were detected in 80% of them after the treatment (p = 0.008). PI-RADS ≥ 3 lesions were found to be significantly higher in all patients after intravesical BCG (p = 0.004)., Conclusion: Granulomatous prostatitis is a rare complication of intravesical BCG. High PSA, abnormal DRE, and PI-RADS ≥ 3 lesions detected after intravesical BCG should suggest granulomatous prostatitis and unnecessary biopsies may be avoided., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Xanthogranulomatous inflammation is a chronic inflammatory reaction microscopically characterized by aggregation of foamy histiocytes, fibrous tissue, and infiltration of various inflammatory cells. In contrast to xanthogranulomatous inflammation in the gallbladder or kidney, xanthogranulomatous pancreatitis is rare. We herein present a case of xanthogranulomatous pancreatitis in a patient who underwent distal pancreatectomy with splenectomy under preoperative suspicion of a pancreatic pseudocyst or pancreatic tumor. A 77-year-old woman with a 1 month history of epigastric pain, anorexia, and general fatigue was admitted to our hospital. Contrast-enhanced computed tomography revealed a cystic mass with ill-defined margins at the pancreatic tail together with a splenic abscess. Contrast-enhanced endoscopic ultrasound detected a hyperechoic cystic lesion at the tail of the pancreas with heterogeneous internal echogenicity, and part of the intra-cystic content was enhanced by the contrast agent. Endoscopic retrograde cholangiopancreatography showed a cystic lesion at the tail of the pancreas that continued into the main pancreatic duct, and the main pancreatic duct was slightly narrowed downstream of the cystic lesion. Pancreatic juice cytology revealed suspicious cells, leading to the possibility of intraductal papillary mucinous carcinoma. Distal pancreatectomy with splenectomy was performed, and the histopathological diagnosis was xanthogranulomatous pancreatitis with no malignant findings., (© 2024. Japanese Society of Gastroenterology.)

Background: An accurate and non-invasive approach is urgently needed to distinguish tuberculosis granulomas from lung adenocarcinomas. This study aimed to develop and validate a nomogram based on contrast enhanced-compute tomography (CE-CT) to preoperatively differentiate tuberculosis granuloma from lung adenocarcinoma appearing as solitary pulmonary solid nodules (SPSN)., Methods: This retrospective study analyzed 143 patients with lung adenocarcinoma (mean age: 62.4 ± 6.5 years; 54.5% female) and 137 patients with tuberculosis granulomas (mean age: 54.7 ± 8.2 years; 29.2% female) from two centers between March 2015 and June 2020. The training and internal validation cohorts included 161 and 69 patients (7:3 ratio) from center No.1, respectively. The external testing cohort included 50 patients from center No.2. Clinical factors and conventional radiological characteristics were analyzed to build independent predictors. Radiomics features were extracted from each CT-volume of interest (VOI). Feature selection was performed using univariate and multivariate logistic regression analysis, as well as the least absolute shrinkage and selection operator (LASSO) method. A clinical model was constructed with clinical factors and radiological findings. Individualized radiomics nomograms incorporating clinical data and radiomics signature were established to validate the clinical usefulness. The diagnostic performance was assessed using the receiver operating characteristic (ROC) curve analysis with the area under the receiver operating characteristic curve (AUC)., Results: One clinical factor (CA125), one radiological characteristic (enhanced-CT value) and nine radiomics features were found to be independent predictors, which were used to establish the radiomics nomogram. The nomogram demonstrated better diagnostic efficacy than any single model, with respective AUC, accuracy, sensitivity, and specificity of 0.903, 0.857, 0.901, and 0.807 in the training cohort; 0.933, 0.884, 0.893, and 0.892 in the internal validation cohort; 0.914, 0.800, 0.937, and 0.735 in the external test cohort. The calibration curve showed a good agreement between prediction probability and actual clinical findings., Conclusion: The nomogram incorporating clinical factors, radiological characteristics and radiomics signature provides additional value in distinguishing tuberculosis granuloma from lung adenocarcinoma in patients with a SPSN, potentially serving as a robust diagnostic strategy in clinical practice., (© 2024. The Author(s).)

Abstract: Differentiated thyroid carcinoma constitutes over 90% of all thyroid cancers. The standard treatment approach involves total or near-total thyroidectomy with or without neck dissection followed by 131 I whole-body scintigraphy (WBS) to detect local or distant metastases. Radioiodine offers high sensitivity and specificity for detection of metastatic disease in well differentiated thyroid carcinoma. However, despite its high accuracy, 131 I WBS demonstrates false-positive results, mostly at inflammatory or infective site. These false-positive radioiodine accumulation can lead to misdiagnosis and unwarranted radioiodine treatment. This case presents localization of 131 I to the suture site granuloma leading to false-positive results on 131 I WBS., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Conflict of interest: None declared.

Objective: Cryptococcus, a genus of fungi, primarily includes Cryptococcus neoformans and Cryptococcus gattii, both known to cause human infections. Skeletal infections are rare, and there have been no reported cases of bone cryptococcal infection in conjunction with differentiated thyroid carcinoma., Subject and Methods: A 56-year-old female presented with a one-month history of "cough and throat irritation." Chest CT revealed scattered small nodules in both lungs,suggestive of metastasis.There was minimal inflammation in both lungs, and scattered lymph nodes were observed in the mediastinum and upper pulmonary hilum., Results: The patient was diagnosed with differentiated thyroid carcinoma complicated by cryptococcal infection. Antifungal treatment with itraconazole 200mg/day was initiated, and after 3 months, clinical symptoms disappeared, with a reduction in lung nodules observed in follow-up chest CT., Conclusion: When diagnosing distant metastasis in differentiated thyroid carcinoma, a comprehensive analysis combining imaging studies and serum thyroid globulin plays a complementary role, as illustrated in this case of differentiated thyroid carcinoma concurrent with cryptococcal infection.

Granulomatous orchitis is a relatively rare clinical testicular lesion. The imaging manifestations and clinical symptoms are similar to those of testicular tumors. In order to improve the understanding of this disease, this article reports the ultrasonographic manifestations of a case of granulomatous orchitis and reviews the relevant literature with., (© 2024 Wiley Periodicals LLC.)

Human T-cell lymphotropic virus type-1 (HTLV-1)-associated bronchioloalveolar disorder (HABA) is a pulmonary disorder characterized by lymphocytic infiltration of the peribronchiolar space and interstitium in HTLV-1 carriers and in adult T-cell leukemia/lymphoma (ATLL). We herein report an 85-year-old woman carrying HTLV-1 with HABA who presented with a miliary pattern of micronodules in both lungs on high-resolution computed tomography and a lymphocytic infiltrate with non-necrotizing granulomas on pathology. This rare case of HABA should be differentiated from sarcoidosis, hypersensitivity pneumonitis, or miliary tuberculosis.

Lung granuloma is a very common lung disease, and its specific diagnosis is important for determining the exact cause of the disease as well as the prognosis of the patient. And, an effective lung granuloma detection model based on computer-aided diagnostics (CAD) can help pathologists to localize granulomas, thereby improving the efficiency of the specific diagnosis. However, for lung granuloma detection models based on CAD, the significant size differences between granulomas and how to better utilize the morphological features of granulomas are both critical challenges to be addressed. In this paper, we propose an automatic method CRDet to localize granulomas in histopathological images and deal with these challenges. We first introduce the multi-scale feature extraction network with self-attention to extract features at different scales at the same time. Then, the features will be converted to circle representations of granulomas by circle representation detection heads to achieve the alignment of features and ground truth. In this way, we can also more effectively use the circular morphological features of granulomas. Finally, we propose a center point calibration method at the inference stage to further optimize the circle representation. For model evaluation, we built a lung granuloma circle representation dataset named LGCR, including 288 images from 50 subjects. Our method yielded 0.316 mAP and 0.571 mAR, outperforming the state-of-the-art object detection methods on our proposed LGCR., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Competing Interests: Disclosure Both authors disclosed no financial relationships. CommentaryAeromonas hydrophila is a gram-negative rod bacterium that can be pathologic when located in the GI tract. Symptoms can range from asymptomatic colonization to secretory diarrhea. The endoscopic findings associated with infection are largely unknown but are mostly described as segmental colitis. In this case, a patient underwent colonoscopy for abdominal pain and loose stools. A cecal ulcer over the ileocecal valve was identified, and analysis of biopsy specimens confirmed noncaseating granulomas. Stool cultures from the cecum revealed A. hydrophila. This is an interesting case of an unusual presentation of a colonic bacterial infection, in this case mimicking Crohn disease. Luckily, the symptoms were self-limited, and the patient’s condition improved without further therapy. Amy Tyberg, MD, FASGE, FACG, Associate Editor for Focal Points

Sarcoidosis embodies a complex inflammatory disorder spanning multiple systems, with its origin remaining elusive. It manifests as the infiltration of inflammatory cells that coalesce into distinctive noncaseous granulomas within afflicted organs. Unraveling this disease necessitates the utilization of cellular or tissue-based imaging methods to both visualize and characterize the biochemistry of these sarcoid granulomas. Although hematoxylin and eosin stain, standard in routine use alongside cytological stains have found utility in diagnosis within clinical contexts, special stains such as Masson's trichrome, reticulin, methenamine silver, and Ziehl-Neelsen provide additional varied perspectives of sarcoid granuloma imaging. Immunohistochemistry aids in pinpointing specific proteins and gene expressions further characterizing these granulomas. Finally, recent advances in spatial transcriptomics promise to divulge profound insights into their spatial orientation and three-dimensional (3-D) molecular mapping. This review focuses on a range of preexisting imaging methods employed for visualizing sarcoid granulomas at the cellular level while also exploring the potential of the latest cutting-edge approaches like spatial transcriptomics and matrix-assisted laser desorption ionization mass spectrometry imaging (MALDI-MSI), with the overarching goal of shedding light on the trajectory of sarcoidosis research.

Background: Sarcoidosis affects multiple organs and exhibits diverse clinical manifestations. Although tubulointerstitial nephritis is a known feature of renal involvement, necrotizing vasculitis is rare. Furthermore, prostate involvement with urinary retention is unusual in patients with sarcoidosis. Here, we report a case of systemic sarcoidosis with a rare combination of manifestations and different acute kidney injuries., Case Presentation: A 66-year-old man developed sudden urinary retention and fever. He was diagnosed with prostatitis and admitted to our hospital. An indwelling urethral catheter was inserted, and antimicrobial therapy was initiated; however, the prostatitis was refractory. Computed tomography revealed enlarged mediastinal lymph nodes. Analysis of transbronchoscopic lymph node and prostate biopsies showed epithelioid cell granulomas, suggesting systemic sarcoidosis. During the clinical course, the serum creatinine level rapidly increased to 2.36 mg/dL without oliguria. A kidney biopsy revealed tubulointerstitial injury with moderate lymphohistiocytic infiltration and small-vessel vasculitis in the interstitium. Following oral administration of 60 mg/day prednisolone, the patient's renal function immediately improved, and urinary retention did not recur., Conclusions: To the best of our knowledge, this is the first reported case of sarcoidosis with two unusual complications. Given its clinical course and pathology, this case is clinically valuable., (© 2023. The Author(s).)

Background: The ability of high-definition (HD) videobronchoscopy to detect airway involvement in sarcoidosis has not been evaluated previously., Research Question: What is the role of HD videobronchoscopy in the identification of sarcoidosis-associated airway abnormalities (AAs)? What are the patterns of AAs more commonly observed and more frequently associated with the detection of granulomas in endobronchial biopsy (EBB)?, Study Design and Methods: In this prospective international multicenter cohort study, consecutive patients with suspected sarcoidosis underwent airway inspection with an HD videobronchoscope and EBB using a standardized workflow. AAs were classified according to six patterns defined a priori: nodularity, cobblestoning, thickening, plaque, increased vascularity, and miscellaneous. We assessed diagnostic yield of EBB, prevalence of AAs, and interobserver agreement for different patterns of AAs., Results: AAs were identified in 64 of 134 patients with sarcoidosis (47.8%), with nodularity (n = 23 [17.2%]), plaque (n = 19 [14.2%]), and increased vascularity (n = 19 [14.2%]) being the most prevalent. The diagnostic yield of EBB was 36.6%. AAs were significantly more prevalent in patients with than in those without nonnecrotizing granulomas on EBB (67.4% vs 36.5%; P = .001). Likewise, parenchymal disease on CT scan imaging was significantly more common in patients with than in those without nonnecrotizing granulomas on EBB (79.6% vs 54.1%; P = .003). On a per-lesion analysis, nonnecrotizing granulomas were seen especially in EBB samples obtained from areas of cobblestoning (9/10 [90%]) and nodularity (17/29 [58.6%]). The overall diagnostic yield of random EBB was low (31/134 [23.1%]). The interobserver agreement for the different patterns of AA was fair (Fleiss κ = 0.34)., Interpretation: In a population with a large prevalence of White Europeans, HD videobronchoscopy detected AAs in approximately one-half of patients with sarcoidosis. The diagnostic yield of EBB was higher in patients with parenchymal involvement on CT scan imaging and in those with AAs, especially if manifesting as cobblestoning and nodularity., Trial Registry: ClinicalTrials.gov; No.: NCT4743596; URL: www., Clinicaltrials: gov., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background and Objective: Needle-based confocal laser endomicroscopy (nCLE) allows real-time microscopic imaging at the needle tip. nCLE malignancy criteria are used for tool-in-lesion confirmation during bronchoscopic lung nodule analysis. However, to date, nCLE criteria for granulomas are lacking. The aim was to identify and validate nCLE granuloma criteria and assess if blinded raters can distinguish malignant from granulomatous nCLE videos., Methods: In patients with suspected sarcoidosis, nCLE-imaging of mediastinal lymph nodes was performed during endoscopic ultrasound procedures, followed by needle aspiration. nCLE granuloma criteria were identified by comparison with pathology and final diagnoses. Additionally, nCLE-videos of granulomatous lung nodules part of prospective trials and clinical care were compared to the proposed nCLE granuloma criteria. Blinded raters validated nCLE videos of sarcoid and reactive mediastinal lymph nodes and malignant and granulomatous lung nodules twice., Results: Granuloma criteria were identified (brighter-toned, homogeneous and well-demarcated lesions) based on nCLE-imaging in 14 sarcoidosis patients. Raters evaluated 26 nCLE-videos obtained in lymph nodes (n = 15 sarcoidosis; n = 11 reactive and total of 260 ratings). Granuloma criteria were recognized with 88% accuracy. The inter-observer (κ = 0.63, 95% CI 0.54-0.72) and intra-observer reliability (κ = 0.70 ± 0.06) were substantial. Based on 12 nCLE-videos obtained in lung nodules (n = 4 granulomas, n = 6 malignancy, n = 2 malignancy + granulomas and total of 120 ratings) granuloma and malignancy criteria were recognized with 92% and 75% accuracy., Conclusion: nCLE imaging facilitates real-time granuloma visualization. Blinded raters accurately and consistently recognized granulomas on nCLE-imaging and distinguished nCLE granuloma criteria from malignancy. Our data show the potential of nCLE as a real-time bronchoscopic guidance tool for lung nodule analysis., (© 2023 The Authors. Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.)

Intestinal lipogranulomatous lymphangitis (ILL) is a granulomatous inflammation of the lymphatic vessels of the intestinal wall and mesentery characterized by lipogranulomas. The purpose of this retrospective, multi-center, case series study is to report the ultrasonographic features of canine ILL. Ten dogs with a histologically confirmed ILL undergoing preoperative abdominal ultrasound were retrospectively included. Additional CT was available in two cases. Lesion distribution was focal in eight dogs and multifocal in two. All dogs presented with intestinal wall thickening and two had a concomitant mesenteric mass adjacent to the intestinal lesion. All lesions were in the small intestine. Ultrasonographic features were altered wall layering with predominantly muscular and to a lesser extent submucosal layer thickening. Other findings included hyperechoic nodular tissue within the muscular, serosa/subserosal, and mucosal layers, hyperechoic perilesional mesentery, enlarged submucosal blood/lymphatic vessels, mild peritoneal effusion, intestinal corrugation, and mild lymphadenomegaly. The two intestinal to mesenteric masses presented heterogeneous echostructure, predominantly hyperechoic with multiple hypo/anechoic cavitations filled with mixed fluid and fat attenuation content on CT. Histopathological findings included lymphangiectasia, granulomatous inflammation, and structured lipogranulomas affecting mainly submucosa, muscularis, and serosa. The intestinal to mesenteric cavitary masses revealed severe granulomatous peritonitis with steatonecrosis. In conclusion, ILL should be considered as a differential diagnosis for dogs with this combination of ultrasonographic features., (© 2023 American College of Veterinary Radiology.)

Tattoo-associated sarcoidosis is characterized by granulomas in tattoos with or without the involvement of other organ systems such as the lungs and eyes. 18F-fluorodeoxyglucose (18F-FDG PET is a nuclear medicine imaging study that can differentiate between metabolically over-active areas and normal tissue. Thus, this review finds that 18F-FDG-PET/CT imaging can be used to image inflammatory activity in tattoos and in case of papulonodular tattoo reaction be used to investigate possible systemic sarcoidosis.

Abstract: An 88-year-old man was admitted to our hospital with a recurrent lower urinary tract infection. He had a history of open prostatectomy for benign prostatic hyperplasia 15 years ago and smoking. A mass arising within a bladder diverticula was suspected on the left lateral wall of the bladder on ultrasonography. Although no mass was observed in the bladder lumen on the cystoscopy, abdominal CT detected a left-sided pelvic soft tissue mass. A hypermetabolic mass was detected on 18 F-FDG PET/CT performed because of suspicion of malignancy, and it was excised. Granuloma secondary to chronic vasitis was diagnosed histopathologically., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Caseous granulomas are pathological hallmarks of tuberculosis (TB), and increasing evidence suggests that TB granuloma composition is highly temporally and spatially heterogenous in both animal models and humans. Traditional pathological techniques are limited in their ability to reveal the heterogeneity present in TB granulomas. Multiplex tissue imaging tools combined with powerful, high resolution spatial analysis have enabled the detection of various cell phenotypes, aiding in the visualization of the granuloma complex and revealing the interactions between immune cells and nonimmune cells. This updated understanding of tuberculous granuloma heterogeneity offers vital insights for researchers aiming to uncover the immunoregulatory mechanisms underlying granuloma formation during TB pathogenesis. More detailed granuloma classification systems will also be of use for precision medicine, and for identifying biological targets for host-directed therapeutics in TB patients. This article is categorized under: Infectious Diseases > Genetics/Genomics/Epigenetics Infectious Diseases > Biomedical Engineering Infectious Diseases > Molecular and Cellular Physiology., (© 2023 Wiley Periodicals LLC.)

Cholesterol granulomas of the thymus are extremely rare benign entities. Herein, we describe a case of cholesterol granuloma in a 45-year-old man who presented with multifocal anterior mediastinal lesions on computed tomography (CT). Positron emission tomography (PET)-CT revealed increased fluorodeoxyglucose uptake, with a maximum standardized uptake value of 8.3. Diffusion-weighted magnetic resonance imaging (MRI) revealed extreme hypointensity. He underwent total thymectomy by median sternotomy for presumed multiple thymoma. On histopathological analysis, cholesterol granuloma of the thymus was confirmed, and the patient had an uneventful postoperative course without recurrence for 28 months. Cholesterol granuloma of the thymus is a PET-CT-positive benign tumor with unique histological findings. The MRI findings were indicative of hypocellularity associated with a benign entity, whereas the PET-CT findings corresponded to granulomatous inflammation. Therefore, concurrent use of PET-CT and MRI can be helpful in distinguishing between benign cholesterol granulomas and malignant anterior mediastinal tumors.

Competing Interests: The authors declare that they have no conflict of interest.

Objectives: Limited studies have differentiated radicular cysts and granulomas with MRI. Therefore, we investigated the MRI characteristics of the two lesions and clarified features for distinguishing between them., Methods: We collected data of 27 radicular cysts and 9 granulomas definitively diagnosed by histopathology and reviewed the fat-saturated T 2 weighted, T 1 weighted, and contrast-enhanced fat-saturated T 1 weighted images. We measured the maximum diameter and apparent diffusion coefficient values of the lesions. We employed Fisher's exact test, the Mann-Whitney U test, and independent t -tests to compare the two lesions and created a decision tree for discriminating between them., Results: There were significant differences between radicular cysts and granulomas with respect to five imaging characteristics-signal intensity of the lesion centre on fat-saturated T 2 weighted images; signal intensity, texture, and contrast enhancement of the lesion centre on contrast-enhanced fat-saturated T 1 weighted images; and maximum diameter of the lesion. The cut-off diameter for radicular cysts was 15.9 mm. The area under the receiver operating characteristic curve, sensitivity, and specificity were 0.971, 85.2%, and 100%, respectively., Conclusions: From the decision tree analysis, maximum diameter, lesion centre contrast enhancement on contrast-enhanced fat-saturated T 1 weighted images, and lesion centre signal intensity on fat-saturated T 2 weighted images were important for discriminating between radicular cysts and granulomas.

Abdominal computed tomography revealed a 19×13mm delayed enhancing mass and dilation of the distal pancreatic duct in the head of the pancreas. Magnetic resonance cholangiopancreatography showed pancreatic duct stenosis in the tail of the pancreas. Endoscopic retrograde pancreatography revealed an abrupt interruption of the main pancreatic duct at the tail of the pancreas. We could not assess the distal side of the pancreatic stenosis due to the large extent of obstruction. The pancreatic head mass was diagnosed as adenocarcinoma using endoscopic ultrasound-fine needle aspiration biopsy. However, we could not determine whether the pancreatic duct stenosis in the tail of the pancreas was malignant. Nevertheless, we performed a total pancreatectomy with splenectomy. Histological examination showed poorly differentiated adenocarcinoma in the pancreatic head mass but the pancreatic duct stenosis in the tail of the pancreas was diagnosed as pancreatic granuloma caused by Cryptococcus. Fungal infections may reportedly promote the development of pancreatic cancer, as further suggested by this case of cryptococcal infection.

Sarcoidosis is a granulomatous disorder which presents with pulmonary involvement in >90% of cases. Sinonasal involvement is rare, occurring in 1% of all patients with sarcoidosis. It typically presents in the setting of active pulmonary disease. Here, we present a rare case of sinonasal sarcoidosis (SNS) in a patient with latent pulmonary sarcoidosis. The patient presented to our clinic with several years of nasal obstruction, rhinorrhea and cough unresponsive to medical management. Eventually, radiographic imaging was performed, revealing a large obstructive mass in the left nasal cavity. The mass was resected, and pathology demonstrated epithelioid granulomas, consistent with sarcoidosis. The patient was subsequently placed on systemic therapy with improvement in her symptoms. In summary, SNS is a rare clinical entity that infrequently presents in patients without active pulmonary involvement. Clinicians should have a low threshold to obtain imaging in patients with sarcoidosis who present with sinonasal complaints., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Differentiation of suprasellar xanthogranuloma (XG) from adult craniopharyngioma (CP) can be problematic in endoscopic extended transsphenoidal surgery., Methods: We reviewed the clinical data, preoperative imaging, intraoperative endoscopic findings, and intraoperative frozen section pathology in newly diagnosed adult CPs (19 patients) and XGs (6 patients)., Results: Intracystic signal intensity was often high on T1-weighted magnetic resonance images in the XGs but low in the CPs (P = 0.015). Capsular intensity was low on T2-weighted imaging in XGs but iso to high in CPs (P < 0.001). Capsular gadolinium enhancement was often seen in CPs and not in XGs (P < 0.001). CPs often had a solid component with contrast enhancement but none in XGs (P < 0.001). Intraoperative endoscopic observations frequently found a whitish solid component in the CPs but yellow to brown fibrous granulomatous lesions in XGs (P < 0.001). The tumor capsule was dark grayish and soft in CPs, whereas it was fibrously hard in XGs (P = 0.002). Yellowish hemosiderin deposits were seen in all XGs (P = 0.003). Intraoperative pathologic diagnosis of CP was all verified whereas no evidence of tumor was found in XGs (P < 0.001). Partial removal was performed in 4 patients with XGs. No recurrence was observed in these patients during the follow-up period (1.5-8 years)., Conclusions: Careful interpretation of preoperative magnetic resonance imaging, intraoperative endoscopic findings, and intraoperative frozen section diagnosis may be important for the differential diagnosis between XG and CP. In endoscopic-extended transsphenoidal surgery, intentional partial removal can be effective for XG after careful diagnosis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Abstract: Solitary tuberculoma of periaortic space is extremely rare. We report a case of periaortic tuberculous granuloma revealed by 18 F-FDG PET/CT in a 51-year-old woman without pulmonary or any other organ involvement. Awareness of this rare but possible atypical presentation of tuberculosis is helpful for the differential diagnosis of periaortic mass., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Isolated tuberculous granuloma in the falciform ligament of the liver has never been reported. Here, we report a case of tuberculous granuloma in the falciform ligament of the liver of a 45-year-old woman who complained only of persistent right upper abdominal pain. On abdominal contrast-enhanced CT and MRI, it is difficult to distinguish benign from malignant masses. Imaging on 18 F-FDG PET/CT showed high uptake of 18 F-FDG in the lesion, which was thus considered more likely to be malignant. However, postoperative pathological examination showed granulomatous inflammation with caseous necrosis, which was diagnosed as tuberculosis., (© 2022 John Wiley & Sons A/S . Published by John Wiley & Sons Ltd.)

Introduction: Central nervous system xanthogranulomas are uncommon clinical entities, and symptomatic bilateral choroid plexus xanthogranulomas are rare., Case Presentation: We present the case of a 15-year-old male patient with bilateral choroid plexus xanthogranulomas with symptoms of increased intracranial pressure. Gross total resection of the tumor in the left lateral ventricle was performed. The patient improved, and asymptomatic right-sided tumor was monitored at follow-up., Conclusion: The main treatment objective in these tumors is gross total resection. Asymptomatic tumors can be followed without intervention. However, surgery should be performed for symptomatic tumors that cause hydrocephalus or symptoms of increased intracranial pressure., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: This case report describes the clinical presentation, magnetic resonance imaging (MRI) as well as the histopathological findings in an elderly cat with an intracranial cholesterol granuloma., Case Presentation: An 11.5-year-old, male neutered cat was presented at the emergency service with deteriorating behavioral changes including aggression, and progressive generalized ataxia. Magnetic resonance imaging (MRI) of the brain revealed a large, well demarcated, inhomogeneous and contrast enhancing mass in the lateral ventricles with marked mass effect. Due to a poor clinical prognosis, the cat was euthanized. Histological examination identified the mass as a bilateral cholesterol granuloma in the choroid plexus of the lateral ventricles., Conclusions: Although plexus cholesterol granulomas are rarely seen in cats, they should be considered as a differential diagnosis in elderly patients with neurological signs such as behavioral changes., (© 2022. The Author(s).)

Neuro-sarcoidosis has important ophthalmic and neuro-ophthalmic manifestations. Sarcoidosis most commonly affects the uveal tract (iris, ciliary body, and choroid) however the optic nerve is commonly involved. Sarcoid related optic neuritis is an important differential diagnosis in optic neuritis especially in atypical presentations. The use of multimodal imaging techniques available in the ophthalmic setting can enable the detection of choroidal or optic nerve granulomas and aid the diagnosis. Efferent manifestations of neuro-sarcoidosis are broad and can range from isolated cranial neuropathies or multiple as well as pupil abnormalities. Currently to date there are no diagnostic framework to assist in the diagnosis of ophthalmic manifestations in neuro-sarcoidosis in the absence of a tissue biopsy., (Copyright © 2022 Elsevier B.V. All rights reserved.)

A cholesterol granuloma (CG) is characterized by the presence of cholesterol crystals that cause a chronic granulomatous reaction in an enclosed space. It occurs most commonly in the head and neck region, particularly in the middle ear. Although CGs in the maxilla have also been reported, odontogenic cysts in conjunction with CGs in the maxilla are very rare. We herein present a case of a 72-year-old man who developed a large primordial cyst with a maxillary CG that extended into the maxillary sinus, nasal cavity, and infraorbital region, causing left-sided facial swelling and discomfort. We successfully controlled the symptoms and reduced the size of the lesion using the treatment approach for a common odontogenic cyst: fenestration followed by complete excision. This case suggests that fenestration is an effective technique to treat odontogenic cysts with CGs. Although the mechanisms underlying the pathogenesis and growth of CGs are still unknown, our report highlights a potential therapeutic approach for these lesions.

Xanthogranulomatous salpingo-oophoritis (XGSO) is an exceptionally rare entity. Its clinical manifestations and imaging modalities can mimic benign and malignant adnexal diseases, making it difficult to diagnose. Here we report a case of XGSO in a young woman who was operated with suspicion of a borderline ovarian tumour. Preoperative diagnosis of XGSO should be considered to avoid radical surgical treatment, especially in young patients., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Tuberculosis (TB) is characterized by mycobacteria-harboring centrally necrotizing granulomas. The efficacy of anti-TB drugs depends on their ability to reach the bacteria in the center of these lesions. Therefore, we developed a mass spectrometry (MS) imaging workflow to evaluate drug penetration in tissue. We employed a specific mouse model that─in contrast to regular inbred mice─strongly resembles human TB pathology. Mycobacterium tuberculosis was inactivated in lung sections of these mice by γ-irradiation using a protocol that was optimized to be compatible with high spatial resolution MS imaging. Different distributions in necrotic granulomas could be observed for the anti-TB drugs clofazimine, pyrazinamide, and rifampicin at a pixel size of 30 μm. Clofazimine, imaged here for the first time in necrotic granulomas of mice, showed higher intensities in the surrounding tissue than in necrotic granulomas, confirming data observed in TB patients. Using high spatial resolution drug and lipid imaging (5 μm pixel size) in combination with a newly developed data analysis tool, we found that clofazimine does penetrate to some extent into necrotic granulomas and accumulates in the macrophages inside the granulomas. These results demonstrate that our imaging platform improves the predictive power of preclinical animal models. Our workflow is currently being applied in preclinical studies for novel anti-TB drugs within the German Center for Infection Research (DZIF). It can also be extended to other applications in drug development and beyond. In particular, our data analysis approach can be used to investigate diffusion processes by MS imaging in general.

Competing Interests: Competing interests: None declared.

Purpose: To describe the perfusion patterns of peripheral pulmonary granulomatous lesions (PPGLs) by contrast-enhanced ultrasound (CEUS) and their correlation with vascularization patterns (VPs) represented by immunohistochemical (CD34) endothelial staining., Patients and Methods: From January 2007 until September 2020, 10 consecutive patients with histologically confirmed PPGLs were investigated by CEUS. The time to enhancement, classified as early pulmonary-arterial (PA) pattern of enhancement versus delayed bronchial-arterial (BA) pattern of enhancement, the extent of enhancement, classified as marked or reduced, the homogeneity of enhancement, classified as homogeneous or inhomogeneous, and the decrease of enhancement, classified as rapid washout (<120 seconds) or a late washout (≥120 seconds), were analyzed retrospectively. Furthermore, the tissue samples from the study patients and as a control group, 10 samples of normal lung tissue obtained by autopsy, and 10 samples of lung tissue with acute pneumonia obtained by autopsy were immunohistochemically stained with CD34 antibody. The presence of avascular areas (AAs) and the VPs were evaluated in all tissue samples., Results: On CEUS, all PPGLs showed a reduced inhomogeneous BA pattern of enhancement and a rapid washout (<120 seconds). On CD34 staining, all PPGLs showed central AAs in granulomas and a chaotic VP similar to angiogenesis in lung tumors. The lung tissue in control groups revealed on CD34 staining a regular alveolar VP., Conclusion: The PPGLs on CEUS show an identical perfusion pattern similar to those of malignant lesions. Furthermore, for the first time, neoangiogenesis was demonstrated as a histopathological correlate to BA pattern of enhancement on CEUS., (© 2021 The Authors. Journal of Ultrasound in Medicine published by Wiley Periodicals LLC on behalf of American Institute of Ultrasound in Medicine.)