Lymphoma-like granuloma
Introduction
Introduction to lymphomatoid granuloma Lymphomatoid granulomatosis (LG) is a rare form of vasculitis and granulomatous reactions. The disease is characterized by vascular nutrition, vascular destructive lesions and granuloma reactions in a variety of tissues, accompanied by a wide range of atypical lymphoproliferative infiltration, mainly involving the lungs, but also involving extrapulmonary tissues. basic knowledge The proportion of illness: 0.002% Susceptible people: no special people Mode of infection: non-infectious Complications: massive hemoptysis, respiratory failure, headache, coma, edema, deafness, facial paralysis
Cause
Cause of lymphomatoid granuloma
(1) Causes of the disease
The cause is unknown, mainly invading the lungs, manifested as necrotizing granuloma and necrotizing vasculitis with atypical lymphoid cell infiltration, and some eventually developed into lymphoma, which is considered to be a deformation of lymphoma. From a histopathological point of view, the disease is There are vasculitis changes and granulomatous reactions. These changes are consistent with allergic reactions. It is speculated that lymphomatoid granuloma may be a neoplastic disease with allergies. The allergic reaction may be directed to an unconfirmed one. Antigen-antibody reaction of tumor antigen, in vivo immune response disorder or injurious diseases such as kidney transplantation, viral hepatitis, Sjogren's syndrome and rheumatoid arthritis, often complicated by lymphomatoid granuloma, this related effect and lymphoma-like granulation Swollen, with atypical lymphatic reticulocyte infiltration, with chronic immunosuppression for certain congenital immunodeficiency states such as Wishkott-Aldrich syndrome, Louis-Bar syndrome, and occasionally with lymphoma-like granulation Swollen, the above clinical observations indicate that lymphomatoid granuloma may be an immune proliferative that occurs following immune disorders or damage Disease, some people have considered the pathogenic effect of autoimmune mechanism on lymphoma-like granuloma, and some patients have T lymphocyte insufficiency, there are cases of LYG after kidney transplantation, and LG and rheumatoid arthritis or Sjogren's syndrome is associated with it, so it may be related to the occurrence of immune abnormalities and the occurrence of LYG.
Some patients have evidence of Epstein-Barr virus infection during the course of the disease, and the heterophilic agglutination test is positive, suggesting that the virus may be involved in the pathogenesis of the disease. In addition, some cases may develop vascular central lymphoma in non-Hodgkin's lymphoma (angiocentric) Lymphoma, AL), therefore some authors believe that LG is a pre-stage of lymphoma, and even classified all LYG into a rare special type of malignant lymphoma.
(two) pathogenesis
The pathogenesis is still not clear. Some people think that it is a deformation of lymphoma, which is characterized by necrotizing granuloma and necrotizing vasculitis with atypical lymphoid cell infiltration. In the experimental model, chronic allogeneic antigen stimulation can activate the chronic part of the host. Immunologically active cells, and induce atypical lymphoid proliferation and lymphoid tissue tumors, the virus may play an important role in the pathogenesis of this disease, it can initiate autoimmune response by altering the membrane antigenicity of the host, or directly through the tumor-causing virus It stimulates the proliferation of the reticuloendothelial system and causes atypical or obvious lymphatic reticulocyte proliferation. So far, it has not been possible to rule out the induction of certain environmental factors on this disease.
Antigen-antibody reactions, immune disorders, viral infections and environmental factors may be a single factor or a combination of factors that may lead to the development of this disease.
Lymphomatoid granuloma mainly invades extranodal organs, and the affected organs are lung (80%), skin (40% to 50%), central nervous system (30%), liver (25%), kidney, bone marrow, and eye. Etc, while superficial lymph nodes are rare.
The pathological feature of the disease is that the infiltrating cells are composed of atypical lymphoid reticulocytes with plasmacytoid features and a small number of neutrophils or eosinophils. The atypical lymphoid reticulocytes are mainly mature lymphocytes. Cell and plasma cells predominate. These cells have larger cell bodies and more cytoplasm than mature lymphocytes. They have many characteristics of immunoblasts, often showing mitotic phase. The vascular inflammatory changes of this disease are more obvious, but Not necessarily several systems of necrotizing vasculitis changes, some typical white blood cell disruption or primary fibrinoid necrotic vasculitis, it is a vascular destructive and vascular nutritional disease, mainly involved Small arteries and veins, vascular lesions are caused by atypical lymphoid reticulocyte infiltration, infiltrating cells can cause vascular endothelial bulging, thickening of the intima, resulting in stenosis, and finally thrombotic occlusion and extensive Vascular necrosis and revascularization, according to the type of infiltrating cells and the extent of necrosis can be divided into III, G1: mainly from small lymphoid, tissue and plasma cells Run, no typical lymphocytes and immunoblasts, generally no necrosis, G2: morphological transition between G1 and G3, G3: infiltrating cells are mainly atypical lymphocytes, inflammatory background of polymorphism often Obviously, necrosis is more prominent. G3 is also called vascular central lymphoma. The above-mentioned hyperplasia of lymphocytes confirmed by immunoelectron microscopy and peripheral blood T cells, mainly T4, usually cannot detect TCR gene recombination.
The cell infiltration in this disease appears to be significantly active hyperplasia in histology, which makes the lesion characterized by malignant transformation, but it is different from lymphoma, and the cell infiltration changes are diverse, mature and immature lymphoid cells. Often mixed, can be associated with extensive necrotizing severe vasculitis, even in the site far away from the infiltrating fossa can also be seen necrotic vasculitis, but the lymphatic tissue near the infiltrating foci is not infringed, these are significantly different from lymphoma However, some cases can also develop into immunoblastoma or atypical lymphosarcoma, suggesting a possible relationship between the disease and lymphoma.
It is currently agreed that LG is a unique vascular central lymphoma formed by pleomorphic cell infiltration. PCR and in situ hybridization strongly suggest that Epstein-Barr virus participates in the pathogenesis of pulmonary vascular central lymphoma. These lesions were thought to be peripheral T cells. Lymphoma, because immunophenotyping studies have confirmed that it is mainly atypical cells expressing T cell-associated antigens. Recently, PCR and immunohistochemistry confirmed large, atypical, EBV-positive B cell monoclonal subpopulations, suggesting many LYGs. Type of vascular central lymphoma is actually EBV-positive B-cell lymphoma with a large number of reactive T cells, however some lesions appear as peripheral T-cell lymphoma, these tumors are EBV-negative, the above pathological changes may involve the trachea, bronchi, lung, Spleen, kidney, brain and lymph nodes.
The lungs are often violated, usually multiple nodular infiltration, the size of the lesion is different, and occasional cavities in the necrotic area of the infarct are the characteristics of the lung infiltration of the disease, sometimes the lesions can be generalized, accompanied by multiple Sexual lung abscess, manifested as suppurative changes or destruction of a lobe or one side of the lung, Saldmm believes that the lung necrosis of this disease is different from Wegener's granuloma, the former is mainly coagulative necrosis, the latter is liquefied necrosis In some cases, complete hyaline degeneration occurred in the functionalized healing area of the lungs. In some cases, in addition to characteristic vascular infiltrates, significant fibroblast proliferation was observed, but no atypical lymphoid network. Cells, and the degree of necrosis is also very light, in addition to extensive vasculitis and necrosis, often seen in the formation of lung parenchymal masses and nodules formed by atypical lymphoid tissue infiltration, has now demonstrated some histology of the disease Characteristics have a certain impact on prognosis. In inflammatory infiltrates, more than half of the infiltrating cells are atypical lymphoblastic cells, suggesting a poor prognosis, while infiltrating cells are mainly small lymphocytes. Or plasma cells greater than 10%, better prognosis, no effect on the extent of necrosis prognosis.
The nervous system is also a common site of involvement in this disease. The necropsy found that the meninges, blood vessels and brain parenchyma are typical and have extensive infiltration of plasmacytoid polymorphic cells. Neuronal loss and white matter fragmentation can be seen in the extensive necrosis area. There is focal cerebral vascular occlusion with wall necrosis, atypical lymphatic reticulocyte infiltration, thrombosis, stenosis and aneurysm formation. Some cases of death can be seen in the brain and spinal cord. The area may be associated with immunoblastic sarcoma. In some cases, the midbrain and pons are extensively necrotic, and the brain tissue is replaced by atypical lymphoid tissue cells.
The histological findings of skin lesions were similar to those seen in the lungs. Light to severe skin vascular central and vascular destructive vasculitis and mixed cell granulomatous infiltration were observed. Atypical lymphatic reticulocytes were also seen, but Acidic cells are rare, and secondary inflammation and destruction of skin accessory structures such as sweat glands and nerves may occur. Once the deep veins are involved, lipitis may be caused by necrosis of adjacent adipose tissue. From the ultrastructural point of view, tissue cell proliferation appears. Certain characteristics, including fluctuations in the edge of the cell membrane, good development of the Golgi apparatus, and aggregation of microfilaments in the cytoplasm, microtubules, etc., when the subcutaneous tissue is involved, typically change to focal fatty necrosis with a foreign body reaction.
The histological changes of the kidney showed typical lymphatic reticulocyte infiltrating nodules. This change was similar to infarction, and there were necrosis and vasculitis, occlusion and venous occlusion. The lesion was only found in the renal parenchyma, but the glomerulus did not change. The pathological features are characterized by scattered focal infiltration in the liver parenchyma, large necrotic lesions, a large amount of collagen deposition in the necrotic area, and dense atypical lymphoid tissue infiltration around the blood vessels.
Prevention
Lymphomatoid granuloma prevention
1. Maintain environmental sanitation, strengthen physical exercise, improve autoimmune function and prevent infection.
2. Pay attention to the law of life, work and rest, comfort, and avoid intense mental stimulation.
3. Strengthen nutrition, fasting and greasy, pay attention to warming.
4. Avoid colds and colds to prevent secondary bacterial infections.
5. Early diagnosis, early treatment.
Complication
Lymphoma-like granuloma complications Complications, massive hemoptysis, respiratory failure, headache, coma, edema, deafness, facial paralysis
The most common complication is dyspnea, especially in patients with lymph nodes in the mediastinum or lung. Patients with clinical conditions similar to lymphoma, about one-third of the patients may have lung cavities, may die from massive hemoptysis, or may have bronchial bronchus Partial obstruction, respiratory failure caused by massive destruction of lung parenchyma is also the main cause of death of the disease. Central nervous system lesions may involve any part of the brain and spinal cord, and may have aphasia, hemiparesis, blindness, movement disorders, paraplegia, oculomotor nerve paralysis, Cranial nerve palsy, headache, paresthesia, confusion, coma, convulsions, quadriplegia, optic nerve edema, deafness, facial paralysis, sensation, cerebral edema, meningoencephalitis, etc., extensive infiltration of the liver, can cause progressive liver failure and death The necropsy found that the liver, spleen, lymph nodes, kidney, heart and gastrointestinal tract can be violated.
Symptom
Symptoms of lymphomatoid granuloma Common symptoms Liver failure, weight loss, fatigue, diplopia, rash, chest pain, body discomfort, rash, ataxia, kidney involvement
The clinical manifestations of LYG overlap with other types of pulmonary lymphoma. The main affected organs are lung (80%), skin (40% to 45%), central nervous system (30%), and liver (25%). Kidney, digestive tract, bone marrow and eye, etc., systemic symptoms include fever, general discomfort, fatigue, weight loss, joint pain and skin damage, usually dying from generalized pulmonary lesions and secondary infections within 14 months of symptoms Because it mainly invades the lungs, the most common complaints are lower respiratory symptoms such as cough, hemoptysis, chest pain and dyspnea. 30% of them have neurological damage, manifested as mental disorder, ataxia, seizures and cranial nerves. Dysfunction, etc., the autopsy found that the liver, spleen, lymph nodes, kidney, heart and gastrointestinal tract can be violated, the main manifestations of extrapulmonary skin in the skin, can be seen in 40% to 45% of cases, the skin lesions are mainly infiltrative red spots Blocks and subcutaneous or dermal nodules can also cause ulcers, maculopapular or erythematous lesions, multiple symmetry occurs in the lower limbs and buttocks, and can also spread the whole body, lesions can occur before the lung damage or at the same time, and often accompanied by the whole body Symptoms such as fever, tiredness , Weight loss, muscle and joint pain, chest symptoms common, because different parts involved and the corresponding clinical manifestations.
Respiratory system
Respiratory symptoms are often the main complaints. Most patients have cough, cough, difficulty breathing or asthma, chest pain, etc. Lung involvement is the most common early manifestation of this disease, often accompanied by varying degrees of fever, weight loss, a few patients can also only have lungs X-ray abnormalities, but no clinical symptoms, some patients have lung involvement at the onset, progressive development, and some patients may also have progressive lung involvement during the course of the disease, the lesions are mainly located in the two lung fields In particular, the two lungs are more common, the tip of the lung is rarely affected, the lesion is almost always bilateral, and the spread is wide, but it can also be asymmetric, although the lung lesion has the characteristics of lymphoma. However, there are few bilateral hilar lymphadenopathy. The lymphadenopathy only occurs in other organ systems, and the performance is not typical. In patients with clinical conditions similar to lymphoma, about 1/3 of the lung cavity may appear. Hemoptysis and death, respiratory failure caused by massive destruction of lung parenchyma is also the main cause of death of this disease. The extent of respiratory involvement in this disease is generally small, but sometimes respiratory lesions are the main clinical features. It is manifested as obstructive bronchiolitis, which is caused by the formation, destruction and occlusion of bronchial ulcer caused by massive inflammatory cell infiltration and fibrous tissue hyperplasia. It can also cause partial obstruction of the bronchus of the lung, which is due to necrotic tissue and inflammatory cells. Widely invaded by the endobronchial membrane.
Infarct-like necrosis in the lung parenchyma, highly invasive nodules, massive lung damage, extensive lung consolidation, and atypical interstitial lung infiltration can occur, atypical lymphoid tissue infiltration invades the pulmonary artery, pulmonary veins Occasionally, these vascular occlusions and extensive lung parenchymal necrosis can be caused, which can cause severe cough and difficulty breathing.
2. The nervous system
There are peripheral neuropathy, cranial nerve palsy and various central nervous system symptoms and signs. When the nervous system is involved, aphasia, headache, paresthesia, hemiplegia, ataxia, confusion, convulsions, etc. can occur before lung disease. In the middle, even when the lung lesions are relieved, the peripheral neuropathy is mostly asymmetrical. The central nervous system lesions may involve any part of the brain and spinal cord. Bell palsy, temporary blindness, diplopia, exophthalmos, vision loss or dizziness may occur. Common symptoms include aphasia, hemiparesis, blindness, movement disorders, paraplegia, oculomotor palsy, cranial nerve palsy, headache, paresthesia, confusion, coma, convulsions, quadriplegia, optic nerve edema, deafness, facial paralysis, feeling dull, Cerebral edema, meningoencephalitis, etc., peripheral nerve involvement, lower limb paresthesia, can occur before other systemic lesions appear, even when the lung lesions are regressive, the central nervous system lesions can still develop, a patient occurs more often One or several of the above symptoms, the occurrence and prognosis of neurological diseases are direct Related, once the nervous system is involved, its mortality rate is as high as 80% or more.
3. Skin
The most common site of involvement outside the lungs is the skin, which is a large invasive erythema, nodules, ulcers, skin lesions account for 40% to 50%, 10% to 25% of patients with first skin lesions; skin lesions can precede lungs 2 to 9 years after the onset, Liebow reported a group of 40 patients, 16 cases (42.5%) developed skin lesions, due to the high incidence of skin lesions, easy biopsy and typical histological findings of the lesion, so in the suspected lymph A dermatological examination should be performed carefully when the tumor-like granuloma is present. The most common typical lesions are red-purple rashes of 1 to 4 cm in size, papules or subcutaneous nodules that are hard and bulging (sometimes ulcers), diameter 2~ 3cm, mostly located in the limb, the lesion can occur in any part, but common in the buttocks, abdomen, thighs and lower extremities, the repair process is often accompanied by scars and pigmentation, other lesions are non-specific changes, such as vesicles, extensive Scales, plaque-like hair loss, local sweatless and ring-shaped plaques, subcutaneous nodules are sometimes large, and occasionally their main clinical manifestations, the main skin damage can also be expressed as red, and finally converted into copper color, induration shape Subcutaneous lesions, skin lesions usually occur simultaneously with lung lesions, but can occur several months or years after the lung lesions, with or without skin lesions and prognosis.
4. Kidney involvement
About half of the patients had renal histological changes, but no clinical symptoms, clinically obvious renal involvement is rare, and LG changes can be found at autopsy.
5. Other
10% of other patients may have hepatomegaly, liver failure, a small number of patients with lymphadenopathy, splenomegaly and ascites, etc., liver enlargement may also be an early manifestation of the disease, due to the extensive infiltration of the liver, can cause progressive liver Death in function failure, lymphadenopathy can occur in most cases, spleen can appear in some cases, accompanied by lymphoma-like granuloma infiltration, can cause leukopenia.
In addition to clinical manifestations, mainly by lung biopsy and skin biopsy confirmed characteristic pathological changes, pathological changes of skin lesions similar to intrapulmonary changes, manifested as atypical lymphocytes and plasma cell infiltration, this change is mainly located around the dermal appendage Some skin biopsy specimens have no vasculitis or are difficult to see typical vascular changes, but other changes are visible.
Examine
Examination of lymphomatoid granuloma
1. Blood routine and a few patients with erythrocyte sedimentation rate have severe anemia, white blood cells can be increased or decreased, lymphocytes can be increased, and erythrocyte sedimentation rate is accelerated.
2. Urine routine is generally normal, sometimes with mild proteinuria and white blood cells.
3. Biochemical examination When the liver parenchyma is widely violated, the transaminase can be elevated.
4. Immunological examination about half of patients may have elevated IgG or IgM, cellular immunoassay is mostly negative, rheumatoid factor, lupus cells, antinuclear antibodies are negative.
5. Peripheral blood tests may have anemia, decreased or increased white blood cells, and increased or decreased lymphocytes.
6. Blood test ESR can be normal or fast, rheumatoid factor can be positive, RF is often positive, ANA is often negative.
7. Immunoglobulin examination Immunoglobulin IgA, IgG can be slightly increased.
8. Pathological examination mainly involves neutrophil infiltration around the deep dermis of the dermis. Lymphocytes, plasma cells and histiocytes are also seen. Occasionally, the lymphoid cells are heterogeneous, with large nuclei, deep staining, irregular shape, and atypical Mitosis, typical infiltration is centered on blood vessels and destroys blood vessels. If subcutaneous tissue is involved, it can cause panniculitis and focal fat necrosis, foreign body giant cell reaction and various inflammatory cell infiltration. Vasculitis is more obvious in inflammatory cell infiltration sparse areas. Mainly invading the arterioles, swelling of the vascular endothelium, thrombosis in the lumen, fibrin-like deposition and inflammatory cell infiltration in the wall, visible lymphoid cells in the infiltration, skin appendages in the infiltrating area are often destroyed, lung infiltration by Small lymphocytes, plasma cells and unequal amount of lymphoid cells, renal damage is mainly renal interstitial infiltration and vasculitis, central nervous system damage is also necrotizing vasculitis and atypical lymphoid cell infiltration, the tumor is blood vessel-centered Necrotic granuloma, blood vessels are infiltrated by a variety of cells, including small lymphocytes, tissue cells, immunoblasts, plasma Cells, mainly involving moderately sized arteries and veins, thickening of the intima, stenosis or occlusion of the lumen, may have thrombosis, according to the type of infiltrating cells and necrosis range can be divided into 3 levels, proliferating lymphocytes are mainly T cells, For CD4 T cells, TCR gene rearrangement is often negative, and lymph node biopsy mostly shows reactive hyperplasia.
9. Immunophenotype EBV positive, B cells often express CD20 and CD79a, CD15 negative; LMP1 positive, some monoclonal cells, cytoplasmic Ig positive, atypical lymphocytes can be CD3 positive, of which CD4 cells are more.
10. X-ray examination of chest X-rays is different depending on the progress of the lesion. Typical manifestations show multiple nodular shadows in the two lungs, and the size of the lower leaves varies from a few millimeters to 10 cm. /3 is accompanied by thick-walled cavities, about 20% of which are only unilateral pulmonary nodule shadows, a few of which show infiltrative shadows of the lungs, 1/3 of pleural effusions, but the hilar lymph nodes are not swollen, occasionally two The lung is diffuse reticular nodular and villous alveolar infiltration, or multiple nodular lesions, similar to metastatic lung cancer, the lesions are mostly bilateral, mainly involving the two lung fields, especially the two lungs The nodule can be rapidly enlarged or reduced, and can even disappear completely. A few patients have mediastinal or hilar lymphadenopathy.
11. According to the condition, clinical manifestations, symptoms, signs, choose to do ECG, B-ultrasound, CT, MRI and other tests.
Diagnosis
Diagnosis and diagnosis of lymphomatoid granuloma
Diagnostic criteria
1. Diagnostic criteria
(1) Age and gender of onset: The disease can be seen in all ages, and the elderly are relatively common. The average age of onset is 50 years, and the ratio of male to female is 1.7:1.
(2) clinical manifestations: the most common respiratory symptoms (80%), may be associated with fever, weight loss, skin lesions are also more common (40% to 50%), manifested as large invasive erythema, nodules, ulcers, etc., central nervous system The system is also often involved (30%), can be manifested as mental disorders, ataxia, hemiplegia, convulsions; brain nerve involvement can occur Bell palsy, temporary blindness, diplopia, exophthalmos, decreased vision or dizziness; peripheral nerve involvement of lower extremity Abnormal sensation, a small number of patients have liver damage (25%), may have liver, splenomegaly, etc., but superficial lymph nodes are rarely involved, which is contrary to lymphoma.
2. Diagnostic steps
Clinically, the above-mentioned lung lesions, or accompanying skin, nervous system lesions, or with liver, spleen, and lymphadenopathy, should take into account the possibility of LG, and further feasible chest X-ray examination, such as multiple nodules with cavity formation It is an important diagnostic clue, but it must be confirmed by pathology before it can be finally diagnosed. The lung disease is extremely common in this disease, and it is often the main complaint of patients who should pay attention to it.
Clinically, the above-mentioned lung lesions, or accompanying skin and nervous system lesions, should take into account the possibility of LG. Chest X-ray examination shows that multiple nodular shadows with cavity formation are important diagnostic clues, but must be confirmed by pathology to be finally diagnosed. .
Differential diagnosis
The diagnosis of this disease is difficult. In order to confirm the diagnosis, a biopsy is needed. It is necessary to distinguish it from Wegener granulomatosis and metastatic tumors:
Lymphoma
The disease is also common in vascular invasion and extensive necrosis. LG patients mainly present with mediastinal enlargement, hilar lymphadenopathy and liver, spleen, superficial lymph node enlargement and malignant lymphoma. Identification or pathology, lymphoma infiltration The cells were relatively homogeneous, and immunohistochemical staining detected monoclonal, while LG mainly showed vascular necrotizing granuloma with various types of cell infiltration. Immunohistochemistry showed that lymphocytes were mainly CD4-positive T cells, TCR gene. Clonal rearrangement (-), the two are clearly different, the following features can be distinguished from LG:
(1) often accompanied by superficial, hilar, mediastinal lymph nodes and hepatosplenomegaly.
(2) Infiltrating cells are often a single cell.
(3) Immunoperoxidase is a monoclonal immunoglobulin, and LYG is a polyclonal immunoglobulin. However, if LG is found to have a focal single-type lymphocyte infiltration, it should be alert to the possibility of developing malignant lymphoma.
2. Wegener granuloma
(Wegener granulomatosis WG) Similar to LG, the most common lung involvement, but the disease is more rare clinically, no gender difference, more common in 40 to 50 years old, patients with fever, joint pain, muscle pain, anemia, Leukocytosis, increased erythrocyte sedimentation rate, early manifestations of respiratory symptoms are nasal, middle ear, sinus inflammation and ulcerative damage of the throat and bronchus. In the middle and late stage, focal glomerulonephritis, extensive hemorrhagic rash of skin and mucous membrane , relaxation heat, mostly due to uremia or systemic death, the average duration of disease is about 6 months, more than 3 months, very dangerous, although the disease and LG have pathological features of vascular necrotic granulation, but WG has Characteristic multinucleated giant cells, granuloma often have more neutrophils and cell debris, while lymphocytes are looser, and coagulative necrosis is rare. In addition, serum anti-neutrophil antibody (ANCA) is positive. An important basis for the diagnosis of WG, its specificity is 86%, sensitivity is 78%, can be distinguished from LG, pathologically infiltrating cells are mainly composed of neutrophils, tissue cells and a small number of eosinophils, and sparsely sparse Dripping In the cell and plasma cell populations, there is no obvious lymphadenoid infiltration in the lymphoma-like granuloma. The Veget's granulomatosis has eosinophils in or near the infiltrating foci. The lymphoma-like granuloma infiltrates do not have this change. In addition, epithelioid-like cells and giant cells are common histological features of Wegener's granulomatosis, but are rarely seen in lymphoma-like granulomas, other pulmonary vasculitis and granuloma. Disease LG and Wegener granuloma are difficult to identify, but the latter infiltrate cells without atypical lymphocytes.
3. Infectious granulomatosis
It is still necessary to exclude granulomatosis caused by infectious diseases such as mycobacteria and fungi before determining LG.
4. Obstructive bronchitis
Because granulomatous lesions destroy the bronchial wall and fibrosis, resulting in stenosis or occlusion, can be misdiagnosed as obstructive bronchitis, lung biopsy must be taken to exclude obstructive bronchitis.
5. Metastatic tumor of the lung
Pulmonary metastatic tumors can also often manifest as multiple nodules in the lungs. When the primary tumor has not been found, it should be differentiated from LG. The nodules of metastatic tumors are often round, with clear edges, smooth, uniform density, and no voids. Generally, there is no large infiltration of the shadow, and LG often shows the formation of nodules with cavities. It can be seen that the infiltrating shadow of the lungs is very different. The pathologically different ones are different. Most of the lung metastases can be found in the primary tumors, such as the liver and prostate. Breast, etc., with the symptoms of the primary lesion can be identified.
