Are pulmonary granulomas a concern?

From the Guidelines

Granulomas on the lungs can be a significant issue, particularly if they are caused by conditions like sarcoidosis, which can lead to pulmonary hypertension, reduced lung function, and pulmonary fibrosis, ultimately affecting morbidity, mortality, and quality of life. The presence of granulomas on the lungs should be evaluated by a healthcare provider to determine their underlying cause, as they can result from various conditions including infections, inflammatory disorders, or exposure to certain substances 1. According to the European Respiratory Journal, about 5% of patients with sarcoidosis die from the disease, with pulmonary and cardiac disease being the most common reasons for death from sarcoidosis 1.

Key Considerations

• The decision to treat granulomas on the lungs depends on two major factors: risk for death or organ failure and impairment of quality of life (QoL) 1.
• Recent studies have identified features associated with increased risk for death from pulmonary disease, including pulmonary hypertension, reduced lung function, and pulmonary fibrosis 1.
• Anti-inflammatory therapy for less severe but impaired patients may prevent progression to irreversible disease 1.
• Regular follow-up imaging is often recommended to monitor granulomas for changes in size or appearance.

Management

• If granulomas are due to an active infection, medications such as antibiotics for bacterial infections or antifungal drugs like itraconazole or fluconazole may be needed.
• For inflammatory conditions like sarcoidosis, corticosteroids such as prednisone (typically starting at 20-40mg daily) might be prescribed, as recommended by the European Respiratory Society (ERS) clinical practice guidelines on treatment of sarcoidosis 1.
• Identifying the trigger is an important part of management, as the body forms granulomas as a way to wall off foreign substances or infection that it cannot eliminate.

Prognosis

• Granulomas can potentially cause problems if they grow large enough to obstruct airways, affect lung function, or indicate an underlying disease process that needs treatment.
• The overall prognosis depends on the underlying cause of the granulomas and the effectiveness of treatment.
• In some cases, such as granulomatous and lymphocytic interstitial lung disease (GLILD) associated with common variable immunodeficiency (CVID), lung transplantation may be considered as a treatment option 1.

From the Research

Granulomas on Lungs: An Issue

• Granulomas in the lung are a common finding in pulmonary pathology and can pose a diagnostic challenge 2.
• The majority of granulomas in the lung are caused by mycobacterial or fungal infections, but non-infectious causes such as sarcoidosis, Wegener granulomatosis, and hypersensitivity pneumonitis can also occur 2, 3.
• A specific diagnosis of granulomatous lung disease can be achieved only when a granuloma-inciting agent is identified microscopically or by culture, which does not occur in most cases 3.
• The diagnosis of granulomatous lung diseases requires a multidisciplinary approach, including clinical, radiologic, and laboratory data, as well as histologic features of the lung tissue 3, 4.

Causes of Granulomatous Lung Disease

• Infectious causes:
  • Mycobacterial infections (e.g. tuberculosis) 2, 3
  • Fungal infections 2, 3
• Non-infectious causes:
  • Sarcoidosis 2, 3, 5
  • Wegener granulomatosis 2
  • Hypersensitivity pneumonitis 2, 4
  • Vasculitis 4

Diagnosis and Treatment

• Diagnosis requires a combination of clinical, radiologic, and laboratory data, as well as histologic features of the lung tissue 3, 4.
• Treatment options vary depending on the underlying cause of the granulomatous lung disease, and may include glucocorticoids, immunosuppressive drugs, and biological therapies 5, 6.