question and answer
Incidental granuloma finding
November 2005
JIWEI LI, MD, of Burnaby, BC, reports, "A 55-year-old patient had an incidental granuloma finding on ultrasound (US), later confirmed by computed tomography (CT). The US was done initially for vague abdominal pain. There's no history of tuberculosis (TB). Are there other diagnoses that would fit such an image?"
Although you don't state in which organ the granuloma was discovered, I assume it was either the liver or the spleen. These are by far the most common areas in the abdomen to be infected with granulomatous diseases. These disorders derive from a local immune response resulting in secondary inflammation that leads to the formation of a granuloma, characteristically calcifying over time. The appearance is nonspecific and often the offending organism can't be identified unless it's associated with other systemic or laboratory findings.

The finding of a small punctate dystrophic calcification (or more likely numerous small similar calcifications) within the hepatic or splenic parenchyma is not an uncommon finding. The condition is more often seen within the spleen and is typically the result of past incidental benign fungal infection. The most common pathogen to produce this appearance in North America is histoplasmosis, which is endemic in certain regions of the U.S. and Canada. Less likely infectious candidates, but still possible, are candidiasis, coccidioidomycosis, tuberculosis and brucellosis, as well as a few bacterial, viral or parasitic disorders. Sarcoidosis may also produce focal visceral calcifications in the liver and spleen.

Primary hepatic granulomatous disease tends to have little or no associated calcification. Such diseases include primary biliary cirrhosis and granulomatous hepatitis. < br>The finding of small punctate granulomatous calcifications within the liver and spleen is most often incidental and unrelated to the presenting symptoms. These lesions can be safely ignored unless there are extenuating clinical circumstances necessitating otherwise, e.g. an altered immune status with concern for systemic dissemination. No other imaging or follow-up is required in most cases. MM
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