Bronchocentric Granulomatosis: Computed Tomographic Findings ...

Clinical Radiology (2000) 55, 296–300
doi:10.1053/crad.1999.0380, available online at http://www.idealibrary.com on
Bronchocentric Granulomatosis: Computed Tomographic
Findings in Five Patients
S. WARD*, L. E. HEYNEMAN*, J. D. A. FLINT†, A. N. LEUNG‡, E. A. KAZEROONI,
N. L. MÜLLER*
Departments of *Radiology and †Pathology, Vancouver Hospital and Health Sciences Centre,
University of British Columbia, 855 W. 12 th Ave, Vancouver, BC, Canada V5Z 1M9; ‡Department of Radiology,
Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305; and Department of Radiology,
University of Michigan Hospitals, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, U.S.A.
Received: 17 June 1999 Revised: 31 August 1999 Accepted: 29 September 1999
AIM: The aim of this study was to assess the CT manifestations of bronchocentric granulomatosis.
SUBJECTS AND METHODS: The CT results of five patients with bronchocentric granulomatosis
were retrospectively analysed. The patients ranged from 20 to 72 years of age and included three men
and two women. The diagnosis of bronchocentric granulomatosis was made at lobectomy (n ¼ 2),
open lung biopsy (n ¼ 2), and transbronchial biopsy (n ¼ 1). Only one of the five patients had asthma.
RESULTS: The main findings consisted of a spiculated mass lesion (n ¼ 3) or lobar consolidation with
associated mild volume loss (n ¼ 2). One of the two patients with consolidation had extensive mucoid
impaction. The abnormalities involved predominantly an upper lobe in four patients and a lower lobe
in one patient. In the four resected specimens, the macroscopic pathological appearance was
consolidation (n ¼ 2) and mass lesion (n ¼ 2). Microscopically, the typical histology of airway-centred
necrotizing granulomata was present in all cases. Aspergillus hyphae were identified in two cases.
Nocardia sp. was cultured from the biopsy specimen in one case.
CONCLUSION: The CT manifestations of bronchocentric granulomatosis consist of a focal mass
or lobar consolidation with atelectasis. These reflect the presence of granuloma formation with
or without associated bronchial obstruction. Ward, S. et al. (2000). Clinical Radiology 55, 296–300.
2000 The Royal College of Radiologists
Key words: bronchocentric granulomatosis, computed tomography, asthma, aspergillosis.
Bronchocentric granulomatosis is a rare granulomatous disorder
characterized histologically by granuloma formation and
necrosis centred on bronchi and bronchioles [1,2]. Unlike the
other granulomatoses, angiitis is not a major component.
Vasculitis, when present, is incidental to inflammation in the
adjacent conducting airways.
In the original description by Liebow, the aetiology of
bronchocentric granulomatosis was not identified, although
two of the nine patients were noted to be asthmatic [1].
Therefore, a hypersensitivity reaction was postulated. Bronchocentric
granulomatosis has also been reported in association
with a variety of other conditions including Wegener’s granulomatosis,
rheumatoid arthritis, heart–lung transplantation,
bone marrow transplantation, red cell aplasia, obstructive
pneumonia secondary to a proximal bronchogenic carcinoma,
and infections such as histoplasmosis, blastomycosis, Mycobacterium
avium intracellulare and tuberculosis [3–8].
Author for correspondence: Dr Nestor L. Müller, Department of
Radiology, Vancouver Hospital and Health Sciences Centre, 855 W. 12 th
Ave, Vancouver, BC, Canada V5Z 1M9.
Guarantor of study: Suzanne Ward, MRCP, FRCR.
Bronchocentric granulomatosis is most commonly visualized
on the chest radiograph as extensive areas of consolidation or
as single or multiple nodules [1–3,5–7]. To our knowledge,
there has been no previous report describing the CT
appearances of bronchocentric granulomatosis in a series of
patients.
PATIENTS AND METHODS
A retrospective review identified five patients with histologically
proven bronchocentric granulomatosis who had undergone
investigation at one of four institutions between October
1989 and August 1997 (Table 1). The study group consisted of
three men and two women aged 20–72 years (mean 41 years).
One patient (patient 5) had a long history of asthma and a
known diagnosis of allergic bronchopulmonary aspergillosis.
The other four patients had no history of asthma. Pulmonary
function tests performed in three of these four patients showed
no evidence of reversible airflow obstruction. One patient had a
previous history of tuberculosis and was noted to have an
enlarging mass on the chest radiograph. One patient had
undergone allogeneic bone marrow transplantation for acute
0009-9260/00/040296+05 $35.00/0 2000 The Royal College of Radiologists

Table 1 – Summary of clinical data of five patients with bronchocentric granulomatosis
lymphoblastic leukaemia. The respiratory symptoms consisted
of cough (n ¼ 3), cough and shortness of breath (n ¼ 1), and
haemoptysis (n ¼ 1). Two patients had constitutional symptoms
of weakness and fatigue or weight loss.
A diagnosis of bronchocentric granulomatosis was made
histologically following lobectomy (n ¼ 2), open lung biopsy
(n ¼ 2), and transbronchial biopsy (n ¼ 1). Aspergillus hyphae
were identified in two of the specimens (cases 1 and 4, Table 1).
In the other three specimens, no organisms could be identified,
although Nocardia sp. was cultured from one of the biopsy
specimens (case 3). Abundant tissue eosinophilia was noted
within the specimen taken from the patient who had allergic
bronchopulmonary aspergillosis (case 5).
All patients underwent computed tomography. The median
time interval between CT and the surgical procedure or biopsy
was 18 days (range 7–41 days). Four patients had conventional
CT with slice thicknesses between 5 and 10 mm. In one patient
the conventional CT was supplemented by 1.5 mm sections
targeted to the right upper lobe. The images were photographed
at lung windows (W 800–2000; L ¹ 500 to ¹700 HU) and
mediastinal windows (W 300–450; L 0–40 HU). One patient
had high-resolution CT with 1 mm thick sections at 10 mm
increments. The images were reconstructed using a high
frequency spatial algorithm and photographed at lung windows
(W 1500; L ¹ 700 HU).
The CT results were analysed simultaneously by three
radiologists and a final decision was reached by consensus.
RESULTS
In three patients (cases 1–3, Table 1), the main CT finding
consisted of a spiculated mass or nodule ranging from 1 to 5 cm
BRONCHOCENTRIC GRANULOMATOSIS 297
Patient Age Sex History CT findings Mode of diagnosis Pathological features
(years)
1 72 F Enlarging LUL mass. 5 cm spiculated mass LUL Left upper lobectomy Consolidation. BCG.
Cough Aspergillus hyphae. Vasculitis
2 32 F Haemoptysis, Weakness, 2 cm cavitating nodule RLL. Open lung biopsy Consolidation surrounding
fatigue. Joint pains 2 cm nodule LLL. Centrilobular mucoid-filled cavity.
nodules RLL þ LLL. BCG. Foreign body-type
Lymphadenopathy giant cells. Vasculitis.
No organisms identified
3 20 M Post-bone marrow transplant. 3 cm spiculated mass LUL. Open lung biopsy Parenchymal mass. BCG.
Upper respiratory tract Ground-glass opacity LUL. Foreign body giant cells.
symptoms. Dry cough Thickened interlobular septa Focal organizing pneumonia.
Vasculitis.
Nocardia sp. isolated from culture
4 48 M Previous TB. Weight loss. Scarring and consolidation Right upper Inflammatory pseudotumour
Cough. Smoker. RUL. Bronchiectasis in RUL lobectomy containing area of cystic
Enlarging RUL mass and RLL. RLL nodules and bronchiectasis. BCG. Aspergillus
patchy consolidation hyphae and aspergilloma
identified
5 35 M Asthma. Allergic Consolidation and atelectasis Transbronchial BCG. Palisaded histiocytes.
bronchopulmonary LUL. Mucoid impaction LUL, biopsy Foreign body-type giant cells.
aspergillosis LING, RUL. Patchy Focal organizing pneumonia.
consolidation, RUL. No organisms identified
Lymphadenopathy
RUL, right upper lobe; RLL, right lower lobe; LUL, left upper lobe; LING, lingula; LLL, left lower lobe. BCG, Bronchocentric granulomatosis.
in diameter and situated in the upper lobe (n ¼ 2) or superior
segment of the lower lobe (Table 1) (Figs 1, 2, 3). One of these
three patients had bilateral 2 cm nodules; one of which had
cavitated and the other had a low attenuation, necrotic centre
(Fig. 2). Two cases had minor associated findings. In one case,
centrilobular nodules and a tree-in-bud pattern were seen
adjacent to both lower lobe mass lesions (Fig. 2). In another
case, air bronchograms were identified within the mass and
areas of ground-glass opacification and smoothly thickened
interlobular septa abutted the circumference of the lesion
(Fig. 3).
In the remaining two patients (cases 4 and 5, Table 1), the
predominant finding was lobar consolidation with mild associated
atelectasis (Figs 4, 5). One case exhibited dense consolidation
of the upper lobe. The affected lobar bronchi were
filled with dense, inspissated mucus (Fig. 4). Mucoid impaction
was present in two other lobes and segmental consolidation was
identified in the contralateral upper lobe. In the final case,
scarring and volume loss were detected within an upper lobe
(Fig. 5). This lobe showed evidence of traction bronchiectasis
and a focal area of consolidation. Minor bronchiectasis, patchy
airspace disease and multiple, less than 5 mm diameter nodules
were present within the ipsilateral lower lobe.
Mediastinal lymph node enlargement (short axis diameter
greater than 10 mm) was seen in two cases.
Pathological Findings
Macroscopically, two cases had the gross appearance of
bronchopneumonia with no definitive mass lesion (Table 1).
In one of these cases, a 1 cm cavity containing mucoid material
was seen. The gross appearance in the two other resected specimens
consisted of a parenchymal mass. In one an inflammatory

298 CLINICAL RADIOLOGY
(a)
(b)
(c)
Fig. 1 – 72-year-old woman with bronchocentric granulomatosis. (a)
Contrast-medium enhanced CT (7 mm collimation) demonstrates a 5 cm
irregular mass in the apical segment of the left upper lobe abutting the
mediastinum. (b) Low power microscopy shows the bronchial wall (straight
arrows) being replaced by granulomatous inflammation. Also noted are
intraluminal debris and minimal inflammation of the accompanying pulmonary
artery (curved arrow) (Haematoxilin and eosin stain, original
magnification × 10, reproduced here at 50%). (c) High power view (original
magnification × 40, reproduced here at 50%) of the bronchial mucosa shows
replacement by pallisading histiocytes (straight arrows) and occasional
giant cells (curved arrow). Also noted is luminal debris (open arrows).
Fig. 2 – 32-year-old woman with bronchocentric granulomatosis. CT
(5 mm collimation) reveals a 2 cm cavitating mass in the superior segment
of the right lower lobe (large arrow). Also noted are small nodules in the
superior segment of the left lower lobe (small arrows).
Fig. 3 – 20-year-old man with bronchocentric granulomatosis following
bone marrow transplant for acute lymphoblastic leukaemia. High-resolution
CT (1 mm collimation) demonstrates a 2.5 cm spiculated mass in the
apical segment of the left upper lobe. Areas of ground-glass opacification
(curved arrow) and smooth interlobular septal thickening (straight arrow)
are noted.
Fig. 4 – 35-year-old man with allergic bronchopulmonary aspergillosis and
bronchocentric granulomatosis. CT (8 mm collimation) demonstrates
mucoid impaction (arrows) and consolidation in the left upper lobe and
focal consolidation in the right upper lobe.

Fig. 5 – 48-year-old man with bronchocentric granulomatosis. Highresolution
CT (1.5 mm collimation) reveals scarring, traction bronchiectasis
and consolidation in the right upper lobe.
pseudotumour containing two 1 cm cavities, representing areas
of cystic bronchiectasis, was identified. One of these cavities
contained a mycetoma.
Necrotizing granulomatous bronchocentric inflammation
was noted in all specimens (Fig. 1). This consisted of a
mixed acute and chronic inflammatory infiltrate and was
associated with partial to complete erosion of the bronchial
mucosa. In one case (case 5), eosinophils were the predominant
inflammatory cell. Palisaded histiocytes (n ¼ 2) and foreign
body-type giant cells (n ¼ 3) were noted within the areas of
inflammation (Fig. 1). Vasculitis involving arterioles was
detected adjacent to areas of bronchocentric granulomatosis
(n ¼ 3). In none of the cases was vasculitis identified away from
regions involved by bronchocentric granulomatosis.
The affected bronchi and bronchioles were impacted with
necrotic material. In two cases, fungal hyphae consistent with
Aspergillosis sp. were found within the necrotic debris. Distal
to the more destructive bronchocentric lesions, patchy areas of
organizing pneumonia were seen in two cases.
DISCUSSION
Bronchocentric granulomatosis is a rare disorder. There have
been only a few reports describing the radiographic appearances
BRONCHOCENTRIC GRANULOMATOSIS 299
of bronchocentric granulomatosis. In his original description,
Liebow referred to nine cases of bronchocentric granulomatosis
[1]. Three cases had primarily lobar pulmonary infiltrates and
atelectasis, and six cases showed a nodular or alveolar pattern
on chest radiograph. The abnormalities were unilateral in
five patients and bilateral in four. In subsequent series, the
radiographic appearance of bronchocentric granulomatosis has
consistently been divided into two main patterns: lobar consolidation
or masses/nodules [2,3,5–7]. The mass lesions are
unilateral in the majority of cases [1,2] and have only occasionally
been reported to show cavitation [3,7]. The radiographic
appearance is similar regardless of the aetiology of
bronchocentric granulomatosis or the type of inflammatory cell
predominant in the pathological specimen [2–7]. These observations
are consistent with the findings in the current study.
It has been debated whether bronchocentric granulomatosis
is a separate disease entity or purely a pathological description
of one of the limited ways in which bronchi and bronchioles
respond to injury [9]. In the setting of asthma and allergic
bronchopulmonary aspergillosis, bronchocentric granulomatosis
is thought to develop as a result of a hypersensitivity
response to endobronchial aspergillosis. This is reflected by
the abundance of eosinophils at the site of inflammation in
pathological specimens. However, an almost identical histological
response can be seen secondary to other chronic pulmonary
infections or chronic systemic inflammatory disorders.
However, in these conditions, tissue eosinophilia is not a
predominant finding. In our series, only one of the five patients
had symptoms of asthma and a diagnosis of allergic bronchopulmonary
aspergillosis. This finding reflects the increased rate
of recognition of bronchocentric granulomatosis in nonasthmatic
individuals, a significant minority of whom are
immunocompromized [6,8,9]. This observation suggests a
move away from the traditional thinking of bronchocentric
granulomatosis as a specific disease entity and a step toward the
acceptance of bronchocentric granulomatosis as a pathological
description. This thereby emphasizes the importance of a
rigorous search for an infectious aetiology for bronchocentric
granulomatosis prior to the implementation of steroid therapy,
the recommended treatment for bronchocentric granulomatosis
in the setting of allergic bronchopulmonary aspergillosis.
We confirm that the CT appearance of bronchocentric
granulomatosis can be divided into two main patterns: mass
lesions and lobar consolidation with atelectasis. However, the
imaging features are non-specific and histological confirmation
is required. In the original descriptions, 30–50% of cases were
reported in asthmatic individuals. The present study emphasizes
the greater prevalence in non-asthmatic patients.
Acknowledgements. We would like to thank Dr Emily Folz from Wake
Radiology, Raleigh, NC for contributing one of the cases.
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