*2.7.1 Fungi*

*Sarcoidosis and Granulomatosis - Diagnosis and Management*

Necrotizing granulomatosis is also seen in (previously, Churg-Strauss syndrome), in combination with necrotizing vasculitis and eosinophilic pneumonia. Granulomas in allergic angiitis with granulomatosis are well formed; with central necrosis containing many eosinophils, there is also eosinophilic infiltration of the blood vessel walls and bronchioles, necrotizing vasculitis with eosinophils, and giant multinucleated cells present. However, additional clinical and laboratory data are necessary to determine the diagnosis, because the classical triad (granulomatosis, necrotizing vasculitis, and eosinophilic pneumonia) is rarely found in lungs.

Furthermore, necrotizing pulmonary granulomas may form in rheumatoid arthritis; however, the diagnosis in this case should be made with caution. First of all, one should take into account clinical data, since nodular forms of rheumatoid arthritis develop only in the active phase in seropositive patients with severe articular syndrome. As a rule, necrosis is eosinophilic, cell debris is usually located between the necrosis and the surrounding rim of histiocytes; it may be combined with vasculitis, but necrotizing vasculitis is not characteristic for this disease (**Figure 9**) [12]. The described histological features are practically indistinguishable from infectious granulomatosis; moreover, rare clinical cases of rheumatoid arthritis and tuberculosis combination have been described, and therefore, the infection

Infectious granulomatosis should also be differentiated from NSG. Some characteristics of the latter are likened to those seen in polyangiitis with granulomatosis. NSG is characterized by the interstitial necrosis, which is often eosinophilic, but

*Rheumatoid arthritis: Extensive necrosis with rims of histiocytes at the periphery and lymphoid infiltration of* 

**2.4 Allergic angiitis with granulomatosis**

**2.5 Rheumatoid arthritis**

must be thoroughly excluded.

**2.6 Necrotizing sarcoid granulomatosis (NSG)**

**54**

**Figure 9.**

*vessel wall. H&E.*

Fungi that cause deep mycoses, as a rule, do not form granulomas in the lungs. In most cases, fungi such as *Aspergillus, Candida*, and some others cause local mycetoma, diffuse invasive mycosis, or allergic reactions (allergic bronchopulmonary aspergillosis/mycosis). The granulomatous response in these fungi infections is rare [14].
