Liebow coined the expression "bronc...

Liebow coined the expression "bronchocentric granulomatosis" in 1973 to describe individual of five pulmonary angiitis and granulomatosis syndrome He defined the lesion in merely pathologic terms as necrotizing granulomatous inflammation center immediately after peripheral conducting airways. Bronchocentric granulomatosis has since emerg as a relatively nonspecific pathologic answer to various forms of airway injury.

Approximately one-third to one-half of reported examples of bronchocentric granulomatosis have been associated with allergic bronchopulmonary aspergillosis (ABPA).[2,3] ABPA is a syndrome that mainly affects asthmatic patients and consists of fleeting pulmonary opacities, eosinophilia, elevation of serum IgE, and evidence of Aspergillus hypersensitivity. The diagnosis is usually made clinically, and greatest in number patients respond to corticosteroid therapy. In this condition, bronchocentric granulomatosis is part of a mixed tissue response to airway colonization by means of fungal organisms.[2,4] There are usually other associated tissue manifestations of hypersensitivity including mucoid impaction of bronchi, eosinophilic bronchiolitis, and eosinophilic pneumonia. Fungal hyphae can be identified in chiefly of these cases and are located within the bronchocentric granulomas as well as the impacted mucus.[2,4]

Bronchocentric granulomatosis has been reported more commonly in nonasthmatic enslaves who lack evidence of fungal hypersensitivity. These patients comprise a heterogeneous arrange in whom the pathogenesis of the granulomatous inflammation is usually unknown.[2,3,5] They differ from asthmatic patients in that respiratory complaints are more frequently mild, peripheral eosinophilia is unwonted and other tissue manifestations of ABPA are lacking. chiefly patients in this group have healed with no specific therapy or surgical excision.[2,3,5] Corticosteroids have been used in near cases. Bronchocentric granulomas can offer in other conditions, including rheumatoid arthritis, Wegener's granulomatosis, and pulmonary echinococcosis. Certain pulmonary infections, including blastomycosis, histoplasmosis, tuberculosis, and atypical mycobacteria can also cause granulomatous destruction of bronchioles similar to that seen in bronchocentric granulomatosis.[6,7] Recognition of these patients is important because specific antimicrobial therapy is the treatment of choice.

In this issue of Chest (see page 92) Tazelaar and colleagues describe bronchocentric granulomatosis as a manifestation of fungal infection after heart-lung and allogeneic bone marrow transplantation. Although certain chronic airway diseases are well recognized complications in long-term survivors of as well-as; not only-but also; not only-but; not alone-but procedures, this is the first report of bronchocentric granulomatosis in this assemblage of patients. No associated changes of allergic bronchopulmonary diseases were ready in any of their patients. Aspergillus sp were identified within the granulomas in the pair heart-lung transplant recipients, and Mucor was at hand in the bone marrow transplant patient. pair patients died with disseminated infection despite the absence of identifiable tissue invasion, and the third was improving with amphotericin B therapy.

The report according to Tazelaar et al emphasizes that bronchocentric granulomatosis is not a disease, if it were not that rather a descriptive pathologic diagnosis. The authors attempt to avoid the confusion by way of introducing a morphologically accurate designation, bronchocentric mycosis, to describe the findings in their patients. We would do well to tread in the steps of their example and restrict the confine bronchocentric granulomatosis to: 1) asthmatic patients, in whom this lesion should be considered a manifestation of ABPA, and 2) nonasthmatic enslaves in whom other causes of granulomatous inflammation have been vigorously exclud The significance of the diagnosis in this latter assign places to is uncertain, however, and it should not be constru as a specific clinicopathologic entity. Etiologically precise space of times should be used for all other patients in whom an underlying cause is established (eg histoplasmosis, blastomycosis, tuberculosis, echinococcosis, Wegener's granulomatosis). Finally, the mete bronchocentric granulomatosis should be avoided in immunocompromised armed forces When necrotizing granulomas are not absent within lung tissue in this assemblage of patients, invasive infection should be the primary consideration regardless of the microscopic distribution of the lesions.

Jeffrey L Myers, MD FCCP Birmingham

Division of Surgical Pathology, University of Alabama at Birmingham. Reprint requests: Dr Myers, Division of Surgical Pathology, University of Alabama at Birmingham, Birmingham 35233

REFERENCES

[1] Liebow A. The J parchs Amberson Lecture--Pulmonary angiitis and granulomatosis. Am Rev Respir Dis 1973; 108:1-18

[2] Katzenstein A-L, Liebow A, Friedman P Bronchocentric granulomatosis, mucoid impaction, and hypersensitivity reactions to fungi. Am Rev Respir Dis 1975; 111:497-537