Nonspecific simple eosinophilic granulomatous prostatitis with eosinophilia in peripheral blood. A case report

Nonspecific simple eosinophilic granulomatous prostatitis is extremely rare and in the present paper, the first case showing eosinophilia in the peripheral blood is reported. The patient was a 55-year-old Japanese man who was admitted because of difficulty in urination over a period of several years. The laboratory findings revealed marked eosinophilia (36%) in the peripheral blood, but the patient's past history showed neither bronchial asthma nor any allergic tendency. Transurethral resection of the prostate was performed and the histopathologic findings revealed a picture of non-caseating granulomatous prostatitis with massive eosinophilic infiltration without fibrinoid necrosis or vasculitis. Fragments of the prostatic urethra also showed the same findings. No fungus, bacterium or parasite was found. Although remnants of smooth muscle fibers were noted in the granulomas, neither immunoglobulins nor complement components could be demonstrated, and the etiology remained undetermined.     

NONSPECIFIC SIMPLE EOSINOPHILIC GRANULOMATOUS PROSTATITIS WITH EOSINOPHILIA IN PERIPHERAL BLOOD: A Case Report

Nonspecific simple eosinophilic granulomatous prostatitis is extremely rare and in the present paper, the first case showing eosinophilia in the peripheral blood is reported. The patient was a 55-y-ear-old Japanese man who was admitted because of difficulty in urination over a period of several years. The laboratory findings revealed marked eosinophilia (36%) in the peripheral blood, but the patient's past history showed neither bronchial asthma nor any allergic tendency. Transurethral resection of the prostate was performed and the histopathologic findings revealed a picture of non-caseating granulomatous prostatitis with massive eosinophilic infiltration without fibrinold necrosis or vasculitis. Fragments of the prostatic urethra also showed the same findings. No fungus, bacterium or parasite was found. Although remnants of smooth muscle fibers were noted in the granulomas, neither immunoglobulins nor complement components could be demonstrated, and the etiology remained undetermined.     

Granulomatous prostatitis: a spectrum including nonspecific, infectious, and spindle cell lesions

Most granulomas of the prostate are nonspecific; infectious, post-operative, and allergic lesions are much less common. Fine-needle aspiration findings in the typical case are distinctive and easily recognized. Several series have been reported, but few have included histologic follow-up. We describe three cases of granulomatous prostatitis (GP) which showed a spectrum of findings confirmed by histologic sections. In all cases, carcinoma was suspected clinically. Case 1 represents typical nonspecific GP with epithelioid and multinucleated histiocytes. In case 2, aggregates of epithelioid histiocytes alternated with areas of necrosis and neutrophils. Histologically, the granulomas showed purulent centers. Silver stains revealed budding yeast in smears and sections. Cultures of FNA material subsequently revealed Cryptococcus. In case 3, the histiocytes were predominantly spindled and occurred singly and in groups. The differential diagnosis included reactive and neoplastic spindle cell lesions. Histologic sections showed GP with spindled histiocytes. Appreciation of the broad cytologic spectrum of GP will facilitate accurate cytologic diagnosis.     

Iatrogenic granulomas of the prostate and the urinary bladder

In 1059 patients who had transurethral resections (TUR) of the prostate 8 cases (0.8%) with nonspecific granulomas were found. In another group of 280 patients treated by TUR for tumours of the urinary bladder 5 cases (1.8%) had granulomatous lesions in the resectates. The granulomas were observed only in patients with prior surgical trauma of the prostate and the bladder with an incidence of 14% and 6.5%, respectively. None of the patients had systemic diseases. Morphologically, two types of granulomas were observed, foreign-body-type and necrotizing. Carbonization rests were frequently noticed in the granulomatous lesions and the configurations and anatomical distribution of the granulomas suggest a common pathogenesis by electrocauterization. Immunohistochemically, histiocytic cells were stained by antibodies against lysozyme. In the prostate, no reaction by antibodies against prostate specific antigen was observed in the granulomas. The findings are compared to previously reported cases of iatrogenic granulomas in the prostate, the urinary bladder and other organs. It is concluded that the granulomas arise as a local reaction to previous surgery, maybe involving hypersensitivity to locally altered collagen.     

Necrotising prostatic granulomas following transurethral resection--a case report

Necrotising post surgical granulomatous prostatitis following transurethral resection of the prostate is a poorly recognized entity. It is often mistaken for other conditions like tuberculosis, allergic granulomatous prostatitis, etc. This case is being reported in order to increase the awareness of this condition. The relevant literature has also been reviewed.     

Eosinophil infiltration in posttransurethral resection prostatitis and cystitis with special reference to sequential changes of eosinophilia

Posttransurethral resection (TUR) status in the prostate and urinary bladder has been infrequently documented. Furthermore, sequential changes in eosinophil count in peripheral blood (PB) after TUR have not been investigated in detail. In the present study, eosinophil counts and changes in eosinophils in PB were examined before to after TUR of the prostate (P) in 20 patients with benign prostatic hyperplasia. Among them, 14 patients exhibited increased numbers of eosinophils, the greatest increase being 17%. After TUR to treat bladder tumor (BT), massive infiltration of eosinophils into the resected areas, peaking 1 month later, was also detected in 8 of 15 cases of post-TUR cystitis. The PB eosinophil counts increased by more than 5% in two of five cases of post-TUR cystitis in which eosinophil counts were obtained before and after surgery. Most infiltrating eosinophils reacted positively to antibodies to eosinophil cationic proteins. These results indicated that, in patients with post-TUR prostatitis, the number of eosinophils in PB increased, and peaked 1 month later, with infiltration by eosinophils observed. Pathologists and urologists should be aware of the potential for increase in eosinophils not only in regions of TUR but also in PB.     

Granulomatous prostatitis and poorly differentiated prostate carcinoma. Their distinction with the use of immunohistochemical methods

Granulomatous prostatitis and poorly differentiated prostate carcinoma can mimic each other both clinically and histologically. To develop criteria useful in resolving problem cases, the authors compared the reactivities of these conditions (nine cases of granulomatous prostatitis and six cases of poorly differentiated carcinoma) with a panel of antibodies to cytokeratin (AE1/3), prostate-specific antigen (PSA), prostatic acid phosphatase (PAP), lysozyme, antimacrophage M, and leukocyte common antigen (LCA). In granulomatous prostatitis, histiocytes were not immunoreactive for PAP, PSA, or cytokeratin; however, histiocytes reacted to lysozyme in nine of nine cases, antimacrophage M in seven of nine cases, and LCA in one of nine cases. Tumor cells from all six carcinoma cases reacted with PAP, PSA, and cytokeratin; all failed to react with lysozyme, LCA, and antimacrophage M. The authors conclude that granulomatous prostatitis and poorly differentiated carcinoma can be reliably distinguished with immunohistochemical methods.     

Kimura's disease with unusual eosinophilic epithelioid granulomatous reaction: a finding possibly related to eosinophil apoptosis

We report and discuss a case of Kimura's disease with an unusual eosinophilic epithelioid granulomatous reaction. A 3-year-old Japanese boy with eosinophilia and a high concentration of IgE developed lymphadenopathy and multiple cervical masses. A lymph node biopsy demonstrated the infiltration of eosinophils in the stroma, which is consistent with the findings of Kimura's disease. Interestingly, a number of apoptotic eosinophils was detected in the infiltrating eosinophils. Multiple epithelioid granulomas with central eosinophilic abscesses and necrosis were also observed. Macrophages and giant cells had phagocytosed the apoptotic eosinophils at the edge of the granulomas. In situ terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) assay showed that the TUNEL-positive eosinophils were both in the macrophages and in the central eosinophilic abscesses of the granulomas. These findings suggest that the eosinophils had undergone an accelerated apoptosis in this case of Kimura's disease, and that the epithelioid granulomas were produced by phagocytosis of the apoptotic eosinophils by macrophages.     

Granulomatous prostatitis with vasculitis. A sequel to transurethral prostatic resection

An 80-year-old patient suffering from prostatism underwent repeated transurethral prostatic resection. Histologic examination of the prostatic tissue that was removed at the time of the second operation disclosed a granuloma with fibrinoid necrosis combined with necrotizing vasculitis. Only four cases of granulomatous prostatitis and vasculitis have been reported in the literature:two were generalized vasculitis, while in the two other instances, the vasculitis was confined to the prostate. We report an additional case of granulomatous prostatitis combined with vasculitis localized in the prostate.     

Granulomatous prostatitis: a clinicopathological study

In a clinicopathological study of granulomatous prostatitis, we have found two distinct histological patterns. Approximately one third of cases consisted of localized, often elongated or stellate lesions, resembling rheumatoid nodules. Where clinical details were available, most of these cases had a history of previous transurethral resection. The remaining cases showed more diffuse involvement of the prostate, with lesions centred on ducts and glands, and were not associated with previous prostatic surgery or systemic illness. Immunohistochemical studies of the associated inflammatory infiltrate showed an apparently random distribution of T- and B-lymphocytes in the former group, while in the latter group there was a concentration of T-cells in and around damaged ducts and glands, suggesting a possible immune-mediated destruction of these structures.     

Hepatic changes in congenital Schistosoma japonicum infections in pigs

The inflammatory response in liver tissue from piglets congenitally infected with Schistosoma japonicum was examined at two different timepoints after infection. The piglets, which were the offspring of three sows infected with 9000 S. japonicum cercariae in the 10th week of gestation, were allocated into two groups (n=9 and 17) killed 5 or 11 weeks after birth, respectively. All piglets developed a low level infection,with no significant difference between the groups. Inflammatory lesions in the liver consisted mainly of granulomas in portal areas, often obliterating the portal veins, and frequently with central eggs or egg remnants. The granulomatous reaction consisted of epithelioid cells and occasional giant cells surrounded by layers of lymphocytes, eosinophils, plasma cells, and various amounts of collagen and fibroblasts. Mild to moderate infiltration of portal and septal connective tissue with eosinophils and lymphocytes was common, but the connective tissue was generally not increased. At the two timepoints, slight differences were observed in the numbers of eosinophils and lymphocytes in the granulomas and in the size of the granulomatous reaction. The same pattern of immunohistochemical labelling was seen in both groups. CD79alpha(+) B cells were scarce except in granuloma-associated lymphoid follicles;the majority of lymphocytes in granulomas and at other sites were CD3epsilon(+) T cells. The granulomatous reaction in the livers of piglets to schistosoma eggs from prenatal S. japonicum infection was similar to that seen in postnatal infection. Signs of immunomodulation of granulomas between the two timepoints of infection were not demonstrable.     

ALLERGIC GRANULOMATOSIS AND ANGIITIS (CHURG-STRAUSS SYNDROME)

A 54-year-old nonasthmatic man was found to have allergic granulomatosis and angiitis (AGA) (Churg-Strauss syndrome) with pulmonary lesions suggestive of diffuse panbronchiolitis (DPB) at autopsy. The patient, with initial symptoms of cough and sputum, developed progressive dyspnea, eosinophilia, emaciation, fever, mononeuritis multiplex and myocardial infarction. The hypereosinophilic syndrome (HES) and DPB were suspected clinically. Corticosteroid therapy was not given at any time during the course. Autopsy revealed necrotizing, granulomatous angiitis affecting medium-sized arteries in many organs, extravascular granulomas in the interstitium of the heart and tissue infiltration by eosinophils. The heart showed widespread myocardial fibrosis and small foci of muscle fiber coagulation necrosis, which seemed to be the cause of death. In the lungs, the walls of respiratory bronchioles showed marked thickening with lymphocytic infiltration, lymph follicle formation and fibrosis. Accumulation of xanthoma cells was also observed. On the basis of the findings of clinical and pathological examinations, the patient was considered to have had DPB before the development of AGA.     

FOCAL PALISADING GRANULOMA IN THE PROSTATE AND BLADDER: A Clinicopathologic Study of 88 Total Cystectomy Specimens

In close inspection of 88 total cystectomy specimens, 20 were found to have rheumatoid nodule-like lesions known as "focal palisading granulomas". Nineteen of these nodules were from patients with a history of previous transurethral resection (TUR). Such granulomas were identified in the prostate in 3, in the bladder in 13, and in both prostate and bladder in another 3. The remaining one patient had undergone a cold cup biopsy followed by electric coagulation. The granulomas were characterized microscopically by the presence of central necrosis surrounded by palisading histiocytes and fibroblasts, and were situated in areas of the previous TUR. There were no granulomas in 20 other patients with no history of previous TUR and other surgical procedures. The lesions were commonly seen in the superficial zone of the bladder wall and in the prostate and, as proved by serial sections, opened onto the mucosal surface of the bladder and urethra, respectively. The observation confirmed that the focal palisading granulomas occurred not only in the prostate but also in the bladder, and seemed to be closely related to surgical procedures, especially to the electrocauterizing process, in both the bladder and prostate.     

Focal palisading granuloma in the prostate and bladder. A clinicopathologic study of 88 total cystectomy specimens

In close inspection of 88 total cystectomy specimens, 20 were found to have rheumatoid nodule-like lesions known as "focal palisading granulomas". Nineteen of these nodules were from patients with a history of previous transurethral resection (TUR). Such granulomas were identified in the prostate in 3, in the bladder in 13, and in both prostate and bladder in another 3. The remaining one patient had undergone a cold cup biopsy followed by electric coagulation. The granulomas were characterized microscopically by the presence of central necrosis surrounded by palisading histiocytes and fibroblasts, and were situated in areas of the previous TUR. There were no granulomas in 20 other patients with no history of previous TUR and other surgical procedures. The lesions were commonly seen in the superficial zone of the bladder wall and in the prostate and, as proved by serial sections, opened onto the mucosal surface of the bladder and urethra, respectively. The observation confirmed that the focal palisading granulomas occurred not only in the prostate but also in the bladder, and seemed to be closely related to surgical procedures, especially to the electrocauterizing process, in both the bladder and prostate.     

Tissue localization of human eosinophil cationic proteins in allergic diseases

Mouse monoclonal antibodies were raised to the storage and secreted forms of eosinophil cationic protein (ECP), and were used to study the presence of activated eosinophils and secreted ECP in the tissues of patients with a variety of allergic diseases. Immunocytochemical localization was shown with alkaline phosphatase-linked second antibodies, and fast-red substrate. Deposition of a red reaction product indicated sites in tissues where eosinophils had become activated, and where secreted ECP was present. Activated eosinophils and secreted ECP were found together in (1) skin lesions of patients with chronic urticaria, (2) gut lesions of patients with eosinophilic gastroenteritis and ulcerative colitis, and (3) tissues containing granulomas in patients with allergic granulomatosis and vasculitis - the Churg and Strauss syndrome. These results show the value of these techniques for determining the sites of eosinophil activation and secretion in allergic diseases. They support the suggestion that ECP may be involved in the development of these tissue lesions.     

An immunohistological study of granulomatous prostatitis

Granulomatous prostatitis may result from tuberculosis and fungal infection and has been described following prostatic surgery. In most cases, however, the aetiology is unknown, although it may be due to a reaction to extravasated or altered prostatic secretions. We have investigated cells (macrophages, lymphocytes), serum proteins (fibrinogen, alpha 1-antitrypsin) and prostatic epithelial products (prostatic-specific antigen and prostatic acid phosphatase) in diffuse granulomatous prostatitis (3 cases), focal periacinar prostatic granulomas (9) and focal prostatic infarcts (5), using an immunohistological technique. T-lymphocytes and macrophages are present in diffuse and focal granulomatous prostatitis, but few B-lymphocytes occur. Fibrinogen-related antigen is absent from granulomas, but a small amount is present within infarcts, whereas plentiful alpha 1-antitrypsin was detected both in granulomas and infarcts. Significant reduction in prostatic-specific antigen and acid phosphatase reactivity occurs in granulomatous prostatitis. This suggests that cytokines derived from activated macrophages and T-lymphocytes may be exerting a cell regulatory effect and altering cell secretions, as well as causing destruction of the prostatic epithelium.     

Identification of group 1 coronavirus antigen in multisystemic granulomatous lesions in ferrets (Mustela putorius furo)

Tissues from nine ferrets with granulomatous lesions similar to those seen in feline infectious peritonitis were examined histopathologically and immunohistochemically. Four main types of lesions were observed: diffuse granulomatous inflammation on serosal surfaces; granulomas with areas of necrosis; granulomas without necrosis; and granulomas with neutrophils. Other less commonly seen lesions were granulomatous necrotizing vasculitis and endogenous lipid pneumonia. FCV3-70 monoclonal antibody produced immunolabelling of group 1 coronavirus antigen in tissue samples from eight animals, the antigen being present in the cytoplasm of macrophages in the different types of granulomatous lesions.     

Measurement of extent of spread of oesophageal squamous carcinoma by serial sectioning.

OBJECTIVES: (1) To examine the prevalence and extent of intramural metastasis in squamous cell carcinomas of the oesophagus so as to delineate the resection margins for these tumours; (2) to devise an appropriate method for measurement of these lesions which takes into account of the contraction of the specimens after resection. METHODS: Oesophagectomy specimens were prospectively collected from 96 patients (87 males, nine females) with primary oesophageal squamous cell carcinoma over a two year period. The sizes of the tumours were measured in situ, after resection and after application of muscle relaxant (to regain their in situ length). The specimens were then serially sectioned for histological examination. RESULTS: The sizes of the tumours measured after application of muscle relaxant roughly corresponded to those measured in situ. Intramural metastasis was observed in 26% of the cases. Sixty four per cent (16 cases) of these were on the oral side, 72% (18 cases) on the gastric side, and 25% (nine cases) on both sides of the tumours. The most distant extent of intramural metastasis from the primary tumour was from 0.5 cm to 7.7 cm (mean = 3.4 cm) on the oral side, and 0.5 to 9.5 cm (mean 4 cm) on the gastric aspect of the tumour. Intramural metastasis was seen only in patients in whom the primary cancer had deep muscle infiltration. Multiple neoplastic lesions could be detected in 33% of the patients. Both intramural metastasis and multiple neoplastic lesions were associated with extensive lymph node infiltration. However, they had different histological features and extent of infiltration. CONCLUSIONS: Intramural metastasis was frequently observed in oesophageal squamous cell carcinoma. This implies that excision with wide margins should be considered for local control of the disease.     

Recent advances in the diagnosis of Churg-Strauss syndrome.

Most pathologists assume that a diagnosis of Churg-Strauss syndrome (CSS) requires the finding of necrotizing vasculitis accompanied by granulomas with eosinophilic necrosis in the setting of asthma and eosinophilia. However, recent data indicate that this definition is too narrow and that adherence to it leads to cases of CSS being missed. CSS has an early, prevasculitic phase that is characterized by tissue infiltration by eosinophils without overt vasculitis. Tissue infiltration may take the form of a simple eosinophilia in any organ, and a fine-needle aspirate showing only eosinophils may suffice for the diagnosis in this situation. The prevasculitic phase appears to respond particularly well to steroids. Even in the vasculitic phase of CSS, many cases do not show a necrotizing vasculitis but often only an apparently nondestructive infiltration of vessel walls by eosinophils. In modern biopsy materials, granulomas frequently cannot be found. In the postvasculitic phase of CSS, healed vascular lesions resemble organized thrombi but typically show very extensive destruction of elastica and, often, an absence of eosinophils. The widespread use of steroids as therapy for asthma has led to the peculiar and confusing situation in which the steroid therapy accidentally suppresses CSS and changes in steroid treatment uncover the disease; this type of "formes frustes" CSS is now well recognized with leukotriene receptor antagonist treatment and will be seen with increasing frequency as other steroid-sparing therapies for asthma are introduced.     

The histopathologic spectrum in Mycobacterium marinum infection

Review of nine culture-positive cases of Mycobacterium marinum infection revealed a broad range in the histopathologic features of lesions produced by this organism. Four synovial lesions and five cutaneous infections were observed. A range of inflammatory changes were seen in both synovial and skin lesions, varying from mostly acute inflammation with suppuration to a more chronic process with numerous, well-formed granulomas. Organisms were observed in the biopsy sections of only one of the nine cases. Therefore, culture of the biopsy tissue at 30 degrees C is crucial in establishing the diagnosis. These cases emphasize the importance of considering mycobacterial infection and performing cultures even when granulomatous changes in the synovium or skin are subtle.