Noncaseating vs caseating granulomas

Quick question for everyone...typically when diagnosed with sarc one has noncaseating granulomas. Has anyone actually has caseating granulomas instead when diagnosed with Sarc?

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Can you tell me what the difference of the two are please?

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I'm not a doc so please feel free to chime in on this one. Here's the definition of caseation:

1. the precipitation of casein.
2. a form of necrosis in which tissue is changed into a dry, amorphous mass resembling cheese.

Typically sarc patients have non caseating granulomas, typically the cells aren't dead. Tuberculosis patients typically have caseating granulomas, dead cells that look like cheese.

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Pardon me for guessing, but I believe Two_Labs is correct, with the exception (and, this is a question more than a statement), aren't TB cells alive, as it is a bacterial infection and contagious, while noncaseating granulomas contain dead cells, as the diseases such as Sarcoidosis are not contagious??
They also are not bacterial in nature. NEXT... JanetG

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Good morning all, my name is Tabitha, my husband has sarcoidosis.
Def from two labs is correct.
Difference as follows....
Granulomas are a natural part of our immune system, when something such as TB enters our body (in the lung) our immune system kicks in, surrounds the TB cell with like a capsule (i.e. grauloma) it engulfs and starves the cell from nutrients that it needs to survive and spread, after a time period kills/jails it so to speak. Hence ceasating grauloma (necrotic when you cut it open, dead in the middle.....when doctors see this, it tells them that it was your immune system acting correctly. With sarcodosis it is an autoimmune dysfunction. Your immune system basically goes haywire for no reason, or after a viral illness based off what researchers have uncovered. So your are now making granulomas for no reason, which is a not a good thing, so thats why they are solid granuloma, cause there was nothing to engulf and kill (i.e non ceasating granulomas)

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I just learned in June that I have ceasating granulomas which is the cheesy things. I have been experiencing more and more symptoms since I found out but I am still praying. Once I get more from my doctor I will let you all know. The big difference is, is that ceasating granulomas is bad and now I have developed asthma along with high blood pressure, chronic migraines and sleep apnea. When the biopsied the mass in my lung I thought that they would take it out but they only removed part of it and said that it would on come back if they remove all of it. I don't know what to do and I am now trying to get disability because I can't work. Anybody experiencing this situation?

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I was diagnosed with the ceasating granulomas that grew out a brevibacterium. Don't know if it was a fluke or not, but even though my biopsy was different I was still diagnosed with Sarcoid. All of my symptoms follow sarcoid, and my response to treatment (prednisone/methotrexate) all coorespond with sarc. It is possible you might have TB or another active infection instead of sarc. Have they ruled out/tested you for all the infectious dieseases since you did have the ceasating granulomas?

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Non-caseating granulomas are the hallmark of Sarcoidosis and pretty much definative.

Caseating granulomas are, as described, undergoing a type of necrosis in the center that begins to resemble cottage cheese - this should be considered TB until proven otherwise.

It all has nothing to do with live cells or dead cells other than the fact that caseation is a type of necrosis (cell death). Further, it is not "autoimmune" in nature simply because it is non-caseating - but this is really a technicality. Truth is, auto-immune is defined by the body supplying a reaction to an antigen that is part of "self." Sarcoidosis has no known antigen and therefor does not fit this definition - unlike rheumatoid arthritis and lupus, for instance.

Bottom line - Caseating Granulomas should be treated like TB until proven otherwise. It is not only possible to have both diseases, but used to be a particular problem back at the end of the 19th century.

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Thanks Paradox!

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When the results of my mediastenoscopy came back, it showed that I had both caseating and non-caseating granulomas... Instant TB test, but it was negative. Anything else to worry about there, I wonder? As I've heard no reference to it since, I'm assuming it's ok.

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"Sarcoidosis has no known antigen..."

What about the cases of sarc that are attributed to environmental toxins such as is found in people who were at the World Trade Center disaster? Would that type of sarcoidosis be considered to be caused by an antigen? Is it still possible that even though no antigen has been found, there could still be one, or does the fact that the granulomas are non-caseating mean that no infection exists?

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>>>>>>>>>>>>What about the cases of sarc that are attributed to environmental toxins such as is found in people who were at the World Trade Center disaster?<<<<<<<<<<<<

Unfortunately, this is a great example of a spurious relationship. The fact that people were around the WTC at the time of the tragedy almost guaranteed a later chest x-ray - so, just like in the findings that Sharma is finding in his collaborative effort in Japan - increased Chest X-rays mean increased findings... but why? Is it just because we looked? Is it random coincidence? Are people susceptible to sarc somehow more likely to have been there for prolonged periods? There is no causation shown by the correlation, especially since the people with WTC exposure were so much more likely to have a work up then the general public (much like Japan has a high rate of "screening" chest x-rays and therefore a higher rate of diagnosis per person). We just can't say what the actual cause is or if it's just a finding.

There's no proof of any specific environmental exposure that causes sarc even though a lot of people do think there is environmental influence. Environmental exposure can be of several forms including toxin and antigen, they aren't the same thing.

>>>>>does the fact that the granulomas are non-caseating mean that no infection exists?<<<<<<

What it means is that after over 100 years of looking for an infectious cause, no one has found one. Let me put that in perspective. Since sarcoidosis was first described and named man has invented the automobile, the gas powered engine, the television, the radio and the rocket. We have flown to the moon and done incredible things with satellites. At the time this was first described, the only computer availible to crunch numbers on was a slide rule.
Could there be an infectious cause that we just haven't identified yet? I can't say no because no one knows the cause. I can say that there has been no firm evidence that the Jack-a-lope doesn't exist either though.

As for non-caseating, that would tend to suggest non-infectious as the caseation is due to activation of cells other than the granuloma causing macrophages. The lack of completion of the other prongs of the immune system attack strongly suggests it is because there is nothing for them to attack.

I know the concepts of non-causitive correlations and the conflicting evidence can get very confusing. It comes up in many other diseases, too, so I have a lot of background in sorting through this kind of data.

Hope the answer is some help though

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A quick question: Can granulomas of any type (non-caseating or caseating) show up as non-caclified lesions? Or are granulomas always "calcified"?

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Granulomas can appear as either - calcified ones are usually quite a bit older.

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Any theories re: why these granulomas show up in different organs for different people? Does sarcoid always begin in the lungs or can? I have neurosarc with no apparent lung involvement although I do have 2 very small hilar lymph nodes. Glad to have had them though since biopsy plus my MRI provided an unequivocal diagnosis.

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Absolutely, it is some help, and I appreciate the opportunity to wade through this confusing data, with a good data-wader helping me!

>>>>>Chest X-rays mean increased findings... but why? Is it just because we looked? Is it random coincidence?>>>>>

It might be-- but in the case of those diagnosed as a result of post World Trade Center, maybe there might be a genetic response to an respiratory insult that in most would not create sarcoid, but in those with the gene, create the overdone immune response. Just a thought.

>>>>>Environmental exposure can be of several forms including toxin and antigen, they aren't the same thing>>>>>>>

I assumed that a toxin was a type of antigen, please correct me if I am are right when you say things are confusing! ; - )

Thanks for the help, as always, Paradox--

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>>>>>Chest X-rays mean increased findings... but why? Is it just because we looked? Is it random coincidence?>>>>>

It might be-- but in the case of those diagnosed as a result of post World Trade Center, maybe there might be a genetic response to an respiratory insult that in most would not create sarcoid, but in those with the gene, create the overdone immune response. <<<<<<<<<<<

It might be to any such insult - just more people got the insult than would usually get one from say fighting the california wildfires. Even more so, the attention on 9/11 was such that more people actually underwent extra screening and that means more asymptomatic cases will be found.

toxin and antigen are two completely seperate ideas. Something can be both (but most things aren't). A toxin causes cellular damage. An antigen is a specific target of the immune system. Cyanide is a toxin but not an antigen. The flu vaccine contains protien coating that is an antigen, but not a toxin (yes I see the opening here for many jokes about the vaccine). There was a vaccine built for serin gas at one point, which would make it both a toxin and an antigen... the plans to use the vaccine in the military were scrubbed however because the immune response merely slowed the toxic effects by about 7 seconds and was therfore deemed not worth the risks of the vaccine.

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That clears things up! So to take this a bit further then, in terms of sarcoid, the best guess for cause might be an antigen due to the lack of cellular damage, and the non-caseating granulomas. Not that other things are not possible, but if one were to make a "best guess", then perhaps this might be where to look, no?

Thanks again Paradox

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To Paradox and Company:

Antigens and Toxins and Infectious Agents...OH MY!

I have been told that that I have advanced cavitary (lung) sarcoidosis with necrotizing granulomas. No infectious agents have been found through the batteries of conventional culturing and staining in any of my open lung biopsy, bronchoscopies (2) or several sputum cultures.

Medical science has been looking for over one hundred years for ANY common infectious agent without success? If so I am curious to know how hard they have continued to look. Is it cynical to think perhaps they have slowed down or given up the search or is this an ongoing process? Researchers like Drs. Drake and Moller are finding a correlation of antibody and DNA markers from "tuberculin-type" mycobacteria with SOME sarcoidosis patients. Is it possible that we have not yet discovered the means of finding and identifying these possible hidden infectious agents? Is there any credence to the concept of "cell wall-deficient" bacteria that elude common staining methods? The idea of a yet-to-be-confirmed infectious microbe is tantalizing and makes
such practical sense...but is it simply a track driven by wishful thinking?

I enjoy the banter. Hope you do as well!


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Hello everyone,

I was diagnosed with sarcoidosis and had two biopsies of my lungs, plus one "open lung" biopsy. The purpose of the open lung biopsy was because of the "necrotizing" granulomas on my lungs. I was tested for everything from Wegener's disease to TB to "We don't know what the heck this is" disease! My doctors at Vanderbilt University eventually said "we think it sarcoid, it is not a rare cancer". I've asked over and over again if this will really cause more problems and honestly, I have not received a clear answer.

I'm being treated with Prednisone and Methotrexate. The sarcoid "seems" to be controlled with this combo, but I am praying to get off of the steriods soon. Besides the lung problems, I have more pain right now in my lower back and have been denied disability twice for this. I'm back to work but my back is really, really hurting from sitting too long!

Praying for you all,


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Hi all,

Paradox is probably busy at work again. Looks like he did a lot of work here over the weekend.

My Mediastinoscopy states: benign apppering mediastinal lymph nodes revealed no granulma changes.

Does that not mean I do have granulomas?

States I also have several lymph nodes on the outside of my left lung. Is this normal? I thought so.

I can't find the paper, tears, about if my granulomas where caseating or not. I keep looking.

Now Paradox talks about granulomas can calcify when they become old. Does this mean the lymph node in my thyroid is a granuloma because it has calcified.

Too many drs in my pot and some admit I have issues but not 1 knows what to do. I am getting a new primary today so I can move on or get 2nd opinions.

Thanks if you have any answers for me.
Gone Natural

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