Pulse granulomas detected in gallbladder, fallopian tube, and skin

Abstract

Context: Foreign material typically elicits reactions dominated by multinucleated giant cells. Pulse granulomas are peculiar reactions to particles of food that are characterized by clusters of small to medium-sized hyaline rings. Pulse granulomas are rare and have occupied only the lungs, in association with aspiration, and the alimentary canal, in association with oral pathology, colonic diverticula, and a rectal mass.

Objective: To report pulse granulomas that occupied previously unrecognized sites and to alert pathologists to the diagnostic pitfall of mistaking pulse granulomas for other entities.

Design: We retrospectively reviewed 3 recently encountered cases that involved pulse granulomas in the gallbladder, fallopian tube, and skin.

Results: In all cases, pulse granulomas were associated with fistulae involving the gastrointestinal tract. One fistula was clinically occult. Microscopy showed barium-laden histiocytes admixed with hyaline rings, with or without vegetable matter, confirming fistulae involving the gastrointestinal tract. Absence of other features of chronicity, including sarcoid-type granulomas and Langhans-type giant cells, helped to essentially exclude Crohn disease. In 1 case, hyaline rings of pulse granulomas closely resembled hyaline vasculopathy of amyloidosis, diabetes, or hypertension. Surprisingly, polariscopy failed to detect any vegetable matter. In 1 case, negative polariscopy contributed to the difficulty in finding rare vegetable matter.

Conclusions: We demonstrated that pulse granulomas can occur outside the lungs and alimentary canal, and can be associated with fistulae involving the gastrointestinal tract. Awareness of this finding is necessary to avoid confusion with Crohn disease and hyaline vasculopathy. Polariscopy may fail to detect vegetable matter.