RESIDENT CASE STUDIES

Week 7 June 2 - June 6, 2003: Case 3 

Table of Contents | List of Diagnoses | Case 1 | Case 2 | Case 3 | Case 4

32 year old African American male with asymptomatic right lung mass by chest X-ray. 

Discussion: 
Pulmonary hyalinizing granuloma (PHG) is a rare fibrosing nodular lung disease characterized by its histological appearance which includes, at the center of the lesion, a dense network of concentric hyalinized collagen lamella surrounded by perivascular lymphoplasmacytic infiltrate. It may present as solitary or multiple nodules.^{1, 2, 3} Presentation as a solitary nodule is rare.³   

Pulmonary hyalinizing granuloma is likely a process of an inflammatory reaction by an unknown stimulus. Inflammatory agents such as tubercle bacilli, or fungal organisms (e.g., Histoplasma, aspegillus), or a collagen, or autoimmune disease may act as trigger mechanisms for the induction of; PHG. ^4,5,6 It is usually seen in adult patients, with equal incidence in male and female. The lesion varies in size from a millimeters to several centimeters. Cavitation may be seen, but is rare.⁵ Sometimes finely speckled calcification is noted.⁵ Clinically, the patient usually presents with non-specific respiratory symptoms and weight loss.

Guccion et al.⁷ reported that although histochemical stains of the hyaline lamellae for amyloid may be focally positive, the ultrastructure of the hyaline lamellae consisted of electrondense, compact, amorphous material quite unlike fibrillar amyloid.

The major differential diagnosis includes sclerosing mediastinitis, sclerosing hemangioma, epitheloid hemangioendotheliomas, amyloidosis, hyalinized granuloma from histoplasmosis and tuberculosis, and nodular sarcoid or necrotizing sarcoid granulomatosis. 

References:

¹Gorini M, Forloni F, Pezzoli A, Pezzica E. Pulmonary hyalinizing granuloma. A limited form of Wegener's granulomatosis? Ann Ital Med Int 1998 Jul-Sep;13(3):176-9. 

³Eschelman DJ, Blickman JG, Lazar HL, et al. Pulmonary hyalinizing granuloma: a rare cause of a solitary pulmonary nodule. J Thorac Imaging 1991 Apr;6(2):54-6.  

⁴Pinckard JK, Rosenbluth DB, Patel K, et al. Pulmonary hyalinizing granuloma associated with Aspergillus infection. Int J Surg Pathol 2003 Jan;11(1):39-42.  

⁵Patel Y, Ishikawa S, MacDonnell KF. Pulmonary hyalinizing granuloma presenting as multiple cavitary calcified nodules. Chest 1991 Dec;100(6):1720-1.  

⁶Chalaoui J, Gregoire P, Sylvestre J, et al. Pulmonary hyalinizing granuloma: a cause of pulmonary nodules. Radiology 1984 Jul;152(1):23-6.

⁷Guccion JG, Rohatgi PK, Saini N. Pulmonary hyalinizing granuloma. Electron microscopic and immunologic studies. Chest. 1984 Apr;85(4):571-3.