*2.7.1.4 Blastomycosis*

*Sarcoidosis and Granulomatosis - Diagnosis and Management*

*2.7.1.2 Cryptococcosis (European blastomycosis)*

(**Figure 11**).

*2.7.1.3 Coccidiosis*

examination [15].

matosis is more often described in *H. capsulatum* infection [15].

cause the formation of epithelioid cell granulomas; however, necrotizing granulo-

*Cryptococcus neoformans* is ubiquitous; it is found in soil and pigeon excrements. The fungal cell is of 4–7 μm in size, replicates by budding, and is stained with H&E, mucicarmin, and PAS. Cryptococci cause a spectrum of various changes in the lungs. A typical granulomatous reaction presents with confluent non-necrotizing granulomas, many multinucleated giant cells, and a mild inflammatory reaction; giant cells are located mainly outside the granulomas and contain cryptococcal cells

These fungi can also be located inside necrotizing granulomas (cryptococcomas) resembling those with mycobacterial and other types of fungal infections (**Figure 12**). In immunocompromised individuals, cryptococcal cells are found inside the alveoli, in their walls, and in the interstitium, without marked inflamma-

*Coccidia* most often lead to necrotizing granuloma formation; the eosinophilic reaction may be marked or absent; numerous neutrophils may be observed. Like in other infections, granulomas are located peribronchiolar or with destroyed bronchioles. This process is accompanied by the formation of small non-necrotizing granulomas at the periphery. *Coccidia* are usually found in the center of necrotizing granulomas, they consist of large spherical structures (spherules) containing yeast-like structures (endospores). Endospores of various sizes can be located in necrosis or cellular debris, resembling other fungal infections. The detection of spherules and endospores favor the diagnosis of coccidiosis. Like *Histoplasma, Coccidia* do not grow in vitro; thus, the diagnosis can only be made by histological

*Cryptococci cells and multinucleated giant cells in a granuloma. Combined stain of alcian blue and PAS.*

tory reaction; some scattered multinucleated giant cells can be found [9].

**56**

**Figure 11.**

Blastomycosis is a rare disease, and this diagnosis may be suspected when granulomatosis or giant cell lesion in combination with severe acute inflammation is detected. Blastomycosis is characterized by basophilic necrosis rich in cellular debris in contrast to eosinophilic or slightly "dirty" infectious necrotizing granulomas. Blastomycosis is often a bronchiolocentric process. Large, thickwalled, yeast-like *Blastomyces* cells can be detected in H&E and also mucicarmin staining. Active budding is a distinctive feature of the microorganism; nuclear material (multiple nucleoli) can also be found inside the cells, but these signs are not always observed. In this regard, compared to *Histoplasma* and *Cryptococci* cells and *coccidial* endospores, *Blastomyces* cells are larger but still smaller than *coccidial* spherules [15]*.*
