Histologic changes: In other areas, there were foci of consolidated lung that appeared as below.

What types of cells are present, and what type of inflammatory response is this? Answer

A mild chronic bronchiolitis is present. Scattered inflammatory cells including lymphocytes and plasma cells surround small airways. Eosinophils are present here and there, but there is no collagenosis of the basement membrane as would be expected in asthma. The epithelium is intact, and the smooth muscle is more prominent than normal. Goblet cells, also expected in asthma, are not seen.

Clinical summary Image 3





























Answer: The inflammatory cells are a mixture of lymphoid cells and a few PMNs and eosinophils mixed with some histiocytes. At least 3 multinucleated giant cells are present--one at the left with a rim of nuclei at the edge (Langhans' type), one in the center (arrow), and one at the lower right with nuclei spread throughout the cytoplasm (foreign body type). This pattern is not one of discrete granulomas, and no granulomas were found in the biopsy, but when this pattern of giant cells and chronic inflammation--a granulomatosis--is seen, diseases with discrete granulomas should be considered. Some of these are listed below.

Differential Diagnosis of Granulomas

Infectious granulomas--fungal, mycobacterial

Reaction to tumor

Hypersensitivity pneumonia

Drug reaction--methotrexate, chlorambucil


Eosinophilic pneumonia

Talc/cellulose granulomas

Churg-Strauss syndrome

Foreign body aspiration--lipoid, organic, inorganic material

Wegener's granulomatosis (discrete granulomas very rare)

Clinical summary Image 3

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