Abstract
Inflammatory granulomas represent a defense mechanism in case of damage, for example in elimination a foreign body. In pathological conditions they should be associated with a large number of infective or noninfective (immunopathological) inflammatory disorders, in rheumatic diseases, espec. with rheumatoid arthritis (RA), granulomatosis with polyangiitis (Wegener) (GPA) and eosinophilic granulomatosis with polyangiitis (Churg-Strauss) (EGPA).
Prognostic importance of inflammatory granulomas (nodules) is usually associated with noncutaneous location. For elucidation the probleme an algorithmic approach should be used: a) differential diagnostic confirmation (espec. versus malignancy) using microscopic analysis of biopsy or OP specimen in any case if possible, and b) successive approximate evaluation using a scale "multiplicity - size - location - cavitation".
Inflammatory granulomas in RA may be present elsewhere, but prognostic importance is usually associated with pulmonary, laryngeal and cardiac location. Lung malignancy mimicking pulmonary rheumatoid nodules was demonstrated in RA as twice frequent than pulmonary rheumatoid nodules.
On the contrary, isolated pulmonary granuloma in GPA may be evaluated as malignancy. Inflammatory lung granuloma itself should be dangerous after cavitation with a risk of pneumothorax with acute respiratory insuficiency, or infection (bacterial abscess, mycetoma).
Nonbacterial valvular damage in RA (GPA, EGPA, SLE, ect.) is usually the most important cardiac involvement, because is associated with a risk of embolism, incl. CNS, but infective endocarditis should be always excluded.
Pharmacotherapy (MTX, LFM, TNFi, ect.) may accelerate not only digital, but also systemic rheumatoid nodulosis. Histopathology with detection of microscopic nodules may be useful also for confirmation the diagnosis under suspection (giant cell arteritis, ect.).
In general, it is important to emphasize, that inflammatory granulomas in rheumatic diseases may represent an ambiguous probleme of clinical rheumatology, requiring urgent elucidation and subsequently an adequate therapy.