Pathology of the Pleura and Mediastinum

2018 Edition
| Editors: Timothy Craig Allen, Saul Suster

Granulomatous Pleuritis

  • Donald GuineeJr.Email author
Reference work entry


Pleural sarcoidosis; Pleural tuberculosis; Pleurisy


Granulomatous pleuritis is a descriptive term referring to granulomatous inflammation of the pleura. Causes of granulomatous pleuritis include infectious and noninfectious etiologies. Tuberculosis is the most common infectious cause. However, infection from nontuberculous mycobacteria, fungi, (e.g., Cryptococcus neoformans), parasites, and other bacteria (e.g., actinomyces) may also cause this pattern of injury. Causes of noninfectious granulomatous pleuritis include sarcoidosis, rheumatoid nodules in rheumatoid arthritis, and iatrogenic, causes among others.


Clinical Features

  • Incidence

    Worldwide, tuberculous pleuritis is the most common etiology of granulomatous pleuritis. Pleural tuberculosis is the second most common type of extrapulmonary tuberculosis (after tuberculous lymphadenitis). It accounts for 4% of tuberculosis cases in the United States and greater than 10% of cases in Spain (Baumann et...

This is a preview of subscription content, log in to check access.

References and Further Reading

  1. Abrams, W. B., & Small, M. J. (1960). Current concepts of tuberculous pleurisy with effusion as derived from pleural biopsy studies. Diseases of the Chest, 38, 60–65.CrossRefPubMedGoogle Scholar
  2. Akcay, S., Pinelli, V., Marchetti, G. P., & Tassi, G. F. (2008). The diagnosis of sarcoidosis pleurisy by medical thoracoscopy: Report of three cases. Tüberküloz ve Toraks, 56(4), 429–433.PubMedGoogle Scholar
  3. al-Qorain, A., Larbi, E. B., al-Muhanna, F., Satti, M. B., Baloush, A., & Falha, K. (1994). Pattern of pleural effusion in Eastern Province of Saudi Arabia: A prospective study. East African Medical Journal, 71(4), 246–249.PubMedGoogle Scholar
  4. Antoniskis, D., Amin, K., & Barnes, P. F. (1990). Pleuritis as a manifestation of reactivation tuberculosis. American Journal of Medicine, 89(4), 447–450.CrossRefPubMedGoogle Scholar
  5. Arakawa, A., Nabeshima, M., Takahashi, M., Yasunaga, T., Nakashima, K., Okuda, T., et al. (1994). CT findings of pulmonary sarcoidosis. Nippon Rinsho, 52(6), 1521–1524.PubMedGoogle Scholar
  6. Askin, F. B., McCann, B. G., & Kuhn, C. (1977). Reactive eosinophilic pleuritis. A lesion to be distinguished from pulmonary eosinophilic granuloma. Archives of Pathology and Laboratory Medicine, 101, 187–192.PubMedGoogle Scholar
  7. Baba, K., Dyrhol-Riise, A. M., Sviland, L., Langeland, N., Hoosen, A. A., Wiker, H. G., et al. (2008). Rapid and specific diagnosis of tuberculous pleuritis with immunohistochemistry by detecting Mycobacterium tuberculosis complex specific antigen MPT64 in patients from a HIV endemic area. Applied Immunohistochemistry & Molecular Morphology, 16(6), 554–561.CrossRefGoogle Scholar
  8. Barbolini, G., Bisetti, A., Colizzi, V., Damiani, G., Migaldi, M., & Vismara, D. (1989). Immunohistologic analysis of mycobacterial antigens by monoclonal antibodies in tuberculosis and mycobacteriosis. Human Pathology, 20(11), 1078–1083.CrossRefPubMedGoogle Scholar
  9. Baumann, M. H., Nolan, R., Petrini, M., Lee, Y. C., Light, R. W., & Schneider, E. (2007). Pleural tuberculosis in the United States: Incidence and drug resistance. Chest, 131(4), 1125–1132.CrossRefPubMedGoogle Scholar
  10. Blackmon, G. M., & Raghu, G. (1995). Pulmonary sarcoidosis: A mimic of respiratory infection. Seminars in Respiratory Infections, 10(3), 176–186.PubMedGoogle Scholar
  11. Bourkadi, J. E., Benjelloun, M. C., Amara, B., Bernoussi, Z., Lotfi, S., & Iraqi, G. H. (2000). Pleurisy and sarcoidosis. Apropos of 2 cases. Revue de Pneumologie Clinique, 56(5), 325–328.PubMedGoogle Scholar
  12. Chakrabarti, B., & Davies, P. D. (2006). Pleural tuberculosis. Monaldi Archives for Chest Disease, 65(1), 26–33.PubMedGoogle Scholar
  13. Chittock, D. R., Joseph, M. G., Paterson, N. A., & McFadden, R. G. (1994). Necrotizing sarcoid granulomatosis with pleural involvement. Clinical and radiographic features. Chest, 106(3), 672–676.CrossRefPubMedGoogle Scholar
  14. Closs, O., Harboe, M., Axelsen, N. H., Bunch-Christensen, K., & Magnusson, M. (1980). The antigens of Mycobacterium bovis, strain BCG, studied by crossed immunoelectrophoresis: A reference system. Scandinavian Journal of Immunology, 12(3), 249–263.CrossRefPubMedGoogle Scholar
  15. Cohen, M., & Sahn, S. A. (2001). Resolution of pleural effusions. Chest, 119(5), 1547–1562.CrossRefPubMedGoogle Scholar
  16. Diacon, A. H., Van de Wal, B. W., Wyser, C., Smedema, J. P., Bezuidenhout, J., Bolliger, C. T., et al. (2003). Diagnostic tools in tuberculous pleurisy: A direct comparative study. European Respiratory Journal, 22(4), 589–591.CrossRefPubMedGoogle Scholar
  17. Didilescu, C., Marica, M., & Jalba, M. (1992). The epidemiological aspects of tuberculous pleurisy in Romania. Pneumoftiziologia, 41(2–3), 83–87.PubMedGoogle Scholar
  18. English, J. C., & Leslie, K. O. (2006). Pathology of the pleura. Clinics in Chest Medicine, 27(2), 157–180.CrossRefPubMedGoogle Scholar
  19. Epstein, D. M., Kline, L. R., Albelda, S. M., & Miller, W. T. (1987). Tuberculous pleural effusions. Chest, 91(1), 106–109.CrossRefPubMedGoogle Scholar
  20. Fijolek, J., Wiatr, E., Gawryluk, D., Langfort, R., & Bestry, I. (2010). Pleural sarcoidosis – A report of three cases. Pneumonologia i Alergologia Polska, 78(1), 79–82.PubMedGoogle Scholar
  21. Gardiner, I. T., & Uff, J. S. (1978). Acute pleurisy in sarcoidosis. Thorax, 33(1), 124–127.CrossRefPubMedPubMedCentralGoogle Scholar
  22. George, R. B., Penn, R. L., & Kinasewitz, G. T. (1985). Mycobacterial, fungal, actinomycotic, and nocardial infections of the pleura. Clinics in Chest Medicine, 6(1), 63–75.PubMedGoogle Scholar
  23. Gopi, A., Madhavan, S. M., Sharma, S. K., & Sahn, S. A. (2007). Diagnosis and treatment of tuberculous pleural effusion in 2006. Chest, 131(3), 880–889.CrossRefPubMedGoogle Scholar
  24. Harisinghani, M. G., McLoud, T. C., Shepard, J. A., Ko, J. P., Shroff, M. M., & Mueller, P. R. (2000). Tuberculosis from head to toe. Radiographics, 20(2), 449–470; quiz 528–449, 532.CrossRefPubMedGoogle Scholar
  25. Haro, M., Ruiz-Manzano, J., Gallego, M., Abad, J., Manterola, J. M., & Morera, J. (1996). Pleural tuberculosis: Analysis of 105 cases. Enfermedades Infecciosas y Microbiología Clínica, 14(5), 285–289.PubMedGoogle Scholar
  26. Hasaneen, N. A., Zaki, M. E., Shalaby, H. M., & El-Morsi, A. S. (2003). Polymerase chain reaction of pleural biopsy is a rapid and sensitive method for the diagnosis of tuberculous pleural effusion. Chest, 124(6), 2105–2111.CrossRefPubMedGoogle Scholar
  27. Hashimoto, M., Watanabe, O., Sato, K., Endo, K., Heianna, J., Itoh, I., et al. (1996). The CT findings of pulmonary sarcoidosis. Tohoku Journal of Experimental Medicine, 179(4), 259–266.CrossRefPubMedGoogle Scholar
  28. Heidecker, J. T., & Judson, M. A. (2003). Pleural effusion caused by trapped lung. Southern Medical Journal, 96(5), 510–511.CrossRefPubMedGoogle Scholar
  29. Huggins, J. T., Doelken, P., Sahn, S. A., King, L., & Judson, M. A. (2006). Pleural effusions in a series of 181 outpatients with sarcoidosis. Chest, 129(6), 1599–1604.CrossRefPubMedGoogle Scholar
  30. Im, J. G., Whang, H. Y., Kim, W. S., Han, M. C., Shim, Y. S., & Cho, S. Y. (1992). Pleuropulmonary paragonimiasis: Radiologic findings in 71 patients. AJR. American Journal of Roentgenology, 159(1), 39–43.CrossRefPubMedGoogle Scholar
  31. Ishigami, A., Kubo, S., Tokunaga, I., Gotohda, T., & Nishimura, A. (2009). An autopsy case of severe pleuritis induced by misinsertion of a nasogastric nourishment tube: Diagnostic significance of multinucleated giant cells. Legal Medicine (Tokyo), 11(4), 191–194.CrossRefGoogle Scholar
  32. Ishikawa, S., Yano, S., Tokuda, Y., Kobayashi, K., Ikeda, T., & Takeyama, H. (2008). A case of Mycobacterium intracellulare pleurisy without active lung lesion. Kekkaku, 83(1), 27–31.PubMedGoogle Scholar
  33. Izumikawa, K., Zhao, Y., Motoshima, K., Takazono, T., Saijo, T., Kurihara, S., et al. (2008). A case of pulmonary cryptococcosis followed by pleuritis in an apparently immunocompetent patient during fluconazole treatment. Medical Mycology, 46(6), 595–599.CrossRefPubMedGoogle Scholar
  34. Johnson, N. M., Martin, N. D., & McNicol, M. W. (1980). Sarcoidosis presenting with pleurisy and bilateral pleural effusions. Postgraduate Medical Journal, 56(654), 266–267.CrossRefPubMedPubMedCentralGoogle Scholar
  35. Kakugawa, T., Mukae, H., Kajiki, S., Tanaka, A., Yamayoshi, T., Inoue, M., et al. (2008). Mycobacterium avium pleuritis in a non-immunocompromised patient. Internal Medicine, 47(19), 1727–1731.CrossRefPubMedGoogle Scholar
  36. Kim, H. J., Lee, H. J., Kwon, S. Y., Yoon, H. I., Chung, H. S., Lee, C. T., et al. (2006). The prevalence of pulmonary parenchymal tuberculosis in patients with tuberculous pleuritis. Chest, 129(5), 1253–1258.CrossRefPubMedGoogle Scholar
  37. Kirsch, C. M., Kroe, D. M., Azzi, R. L., Jensen, W. A., Kagawa, F. T., & Wehner, J. H. (1997). The optimal number of pleural biopsy specimens for a diagnosis of tuberculous pleurisy. Chest, 112(3), 702–706.CrossRefPubMedGoogle Scholar
  38. Kitamura, A., Matsuno, T., Narita, M., Shimokata, K., Yamashita, Y., & Mori, N. (2004). Rheumatoid arthritis with diffuse pulmonary rheumatoid nodules. Pathology International, 54(10), 798–802.CrossRefPubMedGoogle Scholar
  39. Kumar, S., Verma, S. K., Singh, R., & Prasad, R. (2009). Hemorrhagic pleural effusion secondary to sarcoidosis: A brief review. Annals of Thoracic Medicine, 4(1), 27–31.CrossRefPubMedPubMedCentralGoogle Scholar
  40. Lee, K. S., & Im, J. G. (1995). CT in adults with tuberculosis of the chest: characteristic findings and role in management. AJR. American Journal of Roentgenology, 164(6), 1361–1367.CrossRefPubMedGoogle Scholar
  41. Lynch, J. P., 3, Kazerooni, E. A., & Gay, S. E. (1997). Pulmonary sarcoidosis. Clinics in Chest Medicine, 18(4), 755–785.CrossRefPubMedGoogle Scholar
  42. Ma, Y., Gal, A., & Koss, M. N. (2007). The pathology of pulmonary sarcoidosis: Update. Seminars in Diagnostic Pathology, 24(3), 150–161.CrossRefPubMedGoogle Scholar
  43. Miyaji, A., Konno, H., Yamazaki, M., & Ohwada, A. (2005). A patient with pleural thickening of sarcoidosis. Nihon Kokyūki Gakkai Zasshi, 43(5), 308–312.PubMedGoogle Scholar
  44. Moore, D. A., Evans, C. A., Gilman, R. H., Caviedes, L., Coronel, J., Vivar, A., et al. (2006). Microscopic-observation drug-susceptibility assay for the diagnosis of TB. New England Journal of Medicine, 355(15), 1539–1550.CrossRefPubMedGoogle Scholar
  45. Moudgil, H., Sridhar, G., & Leitch, A. G. (1994). Reactivation disease: The commonest form of tuberculous pleural effusion in Edinburgh, 1980–1991. Respiratory Medicine, 88(4), 301–304.CrossRefPubMedGoogle Scholar
  46. Muller, N. L., Mawson, J. B., Mathieson, J. R., Abboud, R., Ostrow, D. N., & Champion, P. (1989). Sarcoidosis: Correlation of extent of disease at CT with clinical, functional, and radiographic findings. Radiology, 171(3), 613–618.CrossRefPubMedGoogle Scholar
  47. Nelson, O., & Light, R. W. (1977). Granulomatous pleuritis secondary to blastomycosis. Chest, 71(3), 433–434.CrossRefPubMedGoogle Scholar
  48. Nishimura, K., Itoh, H., Kitaichi, M., Nagai, S., & Izumi, T. (1993). Pulmonary sarcoidosis: Correlation of CT and histopathologic findings. Radiology, 189(1), 105–109.CrossRefPubMedGoogle Scholar
  49. Nishimura, K., Itoh, H., Kitaichi, M., Nagai, S., & Izumi, T. (1995). CT and pathological correlation of pulmonary sarcoidosis. Seminars in Ultrasound, CT and MR, 16(5), 361–370.CrossRefGoogle Scholar
  50. Patiala, J. (1954). Initial tuberculous pleuritis in the Finnish armed forces in 1939–1945 with special reference to eventual postpleuritic tuberculosis. Acta Tuberculosea Scandinavica. Supplementum, 36, 1–57.PubMedGoogle Scholar
  51. Porcel, J. M. (2009). Tuberculous pleural effusion. Lung, 187(5), 263–270.CrossRefPubMedGoogle Scholar
  52. Rakower, J., & Milwidsky, H. (1964). Hydatid pleural disease. American Review of Respiratory Disease, 90, 623–631.PubMedGoogle Scholar
  53. Roberts, P. P. (1988). Parasitic infections of the pleural space. Seminars in Respiratory Infections, 3(4), 362–382.PubMedGoogle Scholar
  54. Seibert, A. F., Haynes, J., Jr., Middleton, R., & Bass, J. B., Jr. (1991). Tuberculous pleural effusion. Twenty-year experience. Chest, 99(4), 883–886.CrossRefPubMedGoogle Scholar
  55. Shu, C. C., Lee, L. N., Wang, J. T., Chien, Y. J., Wang, J. Y., & Yu, C. J. (2010). Non-tuberculous mycobacterial pleurisy: An 8-year single-centre experience in Taiwan. The International Journal of Tuberculosis and Lung Disease, 14(5), 635–641, 634 p following 641.PubMedGoogle Scholar
  56. Solomon, A., Kreel, L., McNicol, M., & Johnson, N. (1979). Computed tomography in pulmonary sarcoidosis. Journal of Computer Assisted Tomography, 3(6), 754–758.CrossRefPubMedGoogle Scholar
  57. Soskel, N. T., & Sharma, O. P. (2000). Pleural involvement in sarcoidosis. Current Opinion in Pulmonary Medicine, 6(5), 455–468.CrossRefPubMedGoogle Scholar
  58. Sun, Y. C., Yao, W. Z., Shen, N., Shi, X. Y., & Zhao, M. W. (2006). Pleural sarcoidosis: Report of cases and review of the literature. Zhonghua Jie He He Hu Xi Za Zhi, 29(4), 243–246.PubMedGoogle Scholar
  59. Szwarcberg, J. B., Glajchen, N., & Teirstein, A. S. (2005). Pleural involvement in chronic sarcoidosis detected by thoracic CT scanning. Sarcoidosis, Vasculitis, and Diffuse Lung Diseases, 22(1), 58–62.PubMedGoogle Scholar
  60. Takagi, N., Hasegawa, Y., Ichiyama, S., Shibagaki, T., & Shimokata, K. (1998). Polymerase chain reaction of pleural biopsy specimens for rapid diagnosis of tuberculous pleuritis. The International Journal of Tuberculosis and Lung Disease, 2(4), 338–341.PubMedGoogle Scholar
  61. Tang, S. J., Xiao, H. P., Chen, G., Liu, Y. D., Fan, L., Zhang, Q., et al. (2009). Clinical, pathological and radiological characteristics of 83 cases of pleural tuberculoma. Zhonghua Jie He He Hu Xi Za Zhi, 32(4), 262–265.PubMedGoogle Scholar
  62. Tovar, M., Siedner, M. J., Gilman, R. H., Santillan, C., Caviedes, L., Valencia, T., et al. (2008). Improved diagnosis of pleural tuberculosis using the microscopic- observation drug-susceptibility technique. Clinical Infectious Diseases, 46(6), 909–912.CrossRefPubMedPubMedCentralGoogle Scholar
  63. Trajman, A., Pai, M., Dheda, K., van Zyl Smit, R., Zwerling, A. A., Joshi, R., et al. (2008). Novel tests for diagnosing tuberculous pleural effusion: What works and what does not? European Respiratory Journal, 31(5), 1098–1106.CrossRefPubMedGoogle Scholar
  64. Triebel, H. J., Kanzow, G., Heller, M., Magnussen, H., & Bucheler, E. (1990). The importance of thoracic CT in the diagnosis of pulmonary sarcoidosis. Rofo, 153(5), 557–564.CrossRefPubMedGoogle Scholar
  65. Tserkezoglou, A., Metakidis, S., Papastamatiou-Tsimara, H., & Zoitopoulos, M. (1978). Solitary rheumatoid nodule of the pleura and rheumatoid pleural effusion. Thorax, 33(6), 769–772.CrossRefPubMedPubMedCentralGoogle Scholar
  66. Ulrichs, T., Lefmann, M., Reich, M., Morawietz, L., Roth, A., Brinkmann, V., et al. (2005). Modified immunohistological staining allows detection of Ziehl-Neelsen-negative Mycobacterium tuberculosis organisms and their precise localization in human tissue. Journal of Pathology, 205(5), 633–640.CrossRefPubMedGoogle Scholar
  67. Valdes, L., Alvarez, D., Valle, J. M., Pose, A., & San Jose, E. (1996). The etiology of pleural effusions in an area with high incidence of tuberculosis. Chest, 109(1), 158–162.CrossRefPubMedGoogle Scholar
  68. Valdes, L., Alvarez, D., San Jose, E., Penela, P., Valle, J. M., Garcia-Pazos, J. M., et al. (1998). Tuberculous pleurisy: A study of 254 patients. Archives of Internal Medicine, 158(18), 2017–2021.CrossRefPubMedGoogle Scholar
  69. Villegas, M. V., Labrada, L. A., & Saravia, N. G. (2000). Evaluation of polymerase chain reaction, adenosine deaminase, and interferon-gamma in pleural fluid for the differential diagnosis of pleural tuberculosis. Chest, 118(5), 1355–1364.CrossRefPubMedGoogle Scholar
  70. Wada, R., Itabashi, C., Nakayama, Y., Ono, Y., Murakami, C., & Yagihashi, S. (2003). Chronic granulomatous pleuritis caused by nocardia: PCR based diagnosis by nocardial 16S rDNA in pathological specimens. Journal of Clinical Pathology, 56(12), 966–969.CrossRefPubMedPubMedCentralGoogle Scholar
  71. Watarai, M., Yazawa, M., Yamanda, K., Yamamoto, H., & Yamazaki, Y. (2002). Pulmonary sarcoidosis with associated bloody pleurisy. Internal Medicine, 41(11), 1021–1023.CrossRefPubMedGoogle Scholar
  72. Wilen, S. B., Rabinowitz, J. G., Ulreich, S., & Lyons, H. A. (1974). Pleural involvement in sarcoidosis. American Journal of Medicine, 57(2), 200–209.CrossRefPubMedGoogle Scholar
  73. Xanthakis, D. S., Katsaras, E., Efthimiadis, M., Papadakis, G., Varouchakis, G., & Aligizakis, C. (1981). Hydatid cyst of the liver with intrathoracic rupture. Thorax, 36(7), 497–501.CrossRefPubMedPubMedCentralGoogle Scholar
  74. Yilmaz, M. U., Kumcuoglu, Z., Utkaner, G., Yalniz, O., & Erkmen, G. (1998). Computed tomography findings of tuberculous pleurisy. The International Journal of Tuberculosis and Lung Disease, 2(2), 164–167.PubMedGoogle Scholar
  75. Young, E. J., Hirsh, D. D., Fainstein, V., & Williams, T. W. (1980). Pleural effusions due to Cryptococcus neoformans: A review of the literature and report of two cases with cryptococcal antigen determinations. American Review of Respiratory Disease, 121(4), 743–747.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Pathology, C6-PTHVirginia Mason Medical CenterSeattleUSA