ABSTRACT
The role of pathology in the diagnosis of sarcoidosis is identification of granulomas in tissue specimens and performance of studies to exclude known causes of granulomatous inflammation. The granulomas of sarcoidosis are nonspecific lesions that, by themselves and in the absence of an identifiable etiologic agent, are not diagnostic of sarcoidosis or any other specific disease.
Among the diseases to be excluded are mycobacterial, fungal, and parasitic infections, chronic beryllium disease and other pneumoconiosis, hypersensitivity pneumonitis, and Wegener's granulomatosis. Even after extensive workup a substantial number of granulomas will remain unclassified. Not every disease that features nonnecrotizing granulomas of undetermined etiology is sarcoidosis.
The granulomas of sarcoidosis may exhibit focal necrosis of minimal amount. In cases with granulomas that exhibit a greater degree of necrosis an infectious or other nonsarcoid etiology should be strongly suspected.
Strict clinical, radiological, and pathological criteria must be used for diagnosis. In cases that exhibit necrotizing granulomas with more than minimal, focal necrosis, extrathoracic involvement only, and/or incompatible clinical and radiological findings, the diagnosis of sarcoidosis should be approached with great caution. The diagnosis is most secure when compatible clinical and radiological findings are supported by the demonstration of microorganism-negative, nonnecrotizing granulomas in a biopsy specimen accompanied by biopsy evidence or strong clinical evidence of multisystem involvement, and negative cultures for bacteria, mycobacteria, and fungi. A positive Kveim-Siltzbach test provides strong support for the diagnosis of sarcoidosis.
KEYWORDS
Sarcoidosis - pathology - granuloma - biopsy - diagnosis
REFERENCES
-
1
Statement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999.
Am J Respir Crit Care Med.
1999;
160
736-755
-
2
Reich J M.
What is sarcoidosis?.
Chest.
2003;
124
367-371
-
3
Judson M A.
The etiologic agent of sarcoidosis.
Chest.
2003;
124
6-8
-
4 Adams D O. The biology of the granuloma. In: Ioachim HL Pathology of Granulomas. New York; Raven 1983: 1-20
-
5
Rosen Y, Athanassiades T J, Moon S, Lyons H A.
Non-granulomatous interstitial pneumonitis in sarcoidosis: relationship to the development of epithelioid granulomas.
Chest.
1978;
74
122-125
-
6
Poletti V, Patelli M, Spiga L, Ferracini R, Manetto V.
Transbronchial lung biopsy in pulmonary sarcoidosis: is it an evaluable method in detection of disease activity?.
Chest.
1986;
89
361-365
-
7
Ginns L C, Goldenheim P D, Burton R C et al..
T-lymphocyte subsets in peripheral blood and lung lavage in idiopathic pulmonary fibrosis and sarcoidosis: analysis by monoclonal antibodies and flow cytometry.
Clin Immunol Immunopathol.
1982;
25
11-20
-
8
Semenzato G, Pezzutto A, Chisoli M, Pizzola G.
Redistribution of lymphocytes in the lymph nodes of patients with sarcoidosis.
N Engl J Med.
1982;
306
48-49
-
9
Modlin R L, Hofman F M, Meyer P R, Sharma O P, Taylor C R, Rea T H.
In situ demonstration of T lymphocyte subsets in granulomatous inflammation: leprosy, rhinoscleroma and sarcoidosis.
Clin Exp Immunol.
1983;
51
430-438
-
10
Modlin R L, Hofman F M, Sharma O P, Gottlieb B, Taylor C R, Rea T H.
Demonstration in situ of subsets of T-lymphocytes in sarcoidosis.
Am J Dermatopathol.
1984;
6
423-427
-
11
Maarsseven A C, Mullink H, Alons C, Stam J.
Distribution of T-lymphocyte subsets in different portions of sarcoid granulomas: immunohistologic analysis with monoclonal antibodies.
Hum Pathol.
1986;
17
493-500
-
12
Ricker W, Clark M.
Sarcoidosis: a clinico-pathologic review of 300 cases, including 22 autopsies.
Am J Clin Pathol.
1949;
19
725-749
-
13
Rosen Y, Vuletin J C, Pertschuk L P, Silverstein E.
Sarcoidosis from the pathologist's vantage point.
Pathol Annu.
1979;
14(Part 1)
405-439
-
14
Cree I A, Nurbhai S, Milne G, Beck J S.
Cell death in granulomata: the role of apoptosis.
J Clin Pathol.
1987;
40
1314-1319
-
15
Kunitake R, Kuwano K, Miyazaki H, Hagimoto N, Nomoto Y, Hara N.
Apoptosis in the course of granulomatous inflammation in pulmonary sarcoidosis.
Eur Respir J.
1999;
13
1329-1337
-
16
Jones Williams W.
The nature and origin of Schaumann bodies.
J Pathol Bacteriol.
1960;
79
193-201
-
17
Reid J D, Andersen M E.
Calcium oxalate in sarcoid granulomas.
Am J Clin Pathol.
1988;
90
545-558
-
18
Hamazaki T.
Uber ein neues, sauerfeste Substanz fuhrendes Spindelkorperchen der Menschlichen Lymphdrüsen.
Virchows Arch A Pathol Pathol Anat.
1938;
301
490-522
-
19
Wesenberg W.
On acid-fast Hamazaki spindle bodies in sarcoidosis of lymph nodes and on double refractile cell inclusions in sarcoidosis of the lungs.
Arch Klin Exp Dermatol.
1966;
227
101-107
-
20
Senba M, Kawai K.
Nature of yellow-brown bodies: histochemical and ultrastructural studies on the brown pigment.
Zentralbl Allg Pathol.
1989;
135
351-355
-
21
Ro J Y, Luna M A, Mackay B, Ramos O.
Yellow-brown (Hamazaki-Wesenberg) bodies mimicking fungal yeasts.
Arch Pathol Lab Med.
1987;
111
555-559
-
22
Rosen Y, Amorosa J K, Moon S, Cohen J, Lyons H A.
Occurrence of lung granulomas in patients with stage 1 sarcoidosis.
AJR Am J Roentgenol.
1977;
129
1083-1085
-
23
Sharma O P.
Sarcoidosis.
Dis Mon.
1990;
36
469-535
-
24
Laohaburanakit P, Chan A.
Obstructive sarcoidosis.
Clin Rev Allergy Immunol.
2003;
25
115-129
-
25
Kieszko R, Krawczyk P, Michnar M, Milanowski J.
The yield of endobronchial biopsy in pulmonary sarcoidosis.
Respiration.
2004;
71
72-76
-
26
Shorr A F, Torrington K G, Hnatiuk O W.
Endobronchial biopsy for sarcoidosis: a prospective study.
Chest.
2001;
120
109-114
-
27
Torrington K G, Shorr A F, Parker J W.
Endobronchial disease and racial differences in pulmonary sarcoidosis.
Chest.
1997;
111
619-622
-
28 Littler L PW. Bronchoscopy in sarcoidosis. In: Levinsky L, Macholda F Proceedings of the fifth international conference on sarcoidosis and other granulomatous disorders. Prague; Universita Karlova 1971: 463-465
-
29
Siltzbach L E, Cahn L R.
Random biopsy of bronchial and palatal mucosa in the diagnosis of sarcoidosis.
Acta Med Scand Suppl.
1964;
425
230-233
-
30
Sharma O P, Izumi T.
The importance of airway obstruction in sarcoidosis.
Sarcoidosis.
1988;
5
119-120
-
31 Miller A, Teirstein A S, Jackler I, Siltzbach L E. Evidence of airway involvement in late pulmonary sarcoidosis using flow-volume curves and nitrogen washout. In: Iwai K, Hosoda Y Proceedings of the Sixth International Conference on Sarcoidosis. Baltimore; University Park Press 1974: 421-424
-
32
Olsson T, Björnstad-Petersen H, Stjernberg N L.
Bronchostenosis due to sarcoidosis.
Chest.
1979;
75
663-666
-
33
Kumbasar O O, Kaya A, Ulger F, Alper D.
Multiple endobronchial mass lesions due to sarcoidosis.
Tuberk Toraks.
2003;
51
190-192
-
34 Rosen Y. Sarcoidosis. In: Dail DH, Hammar SP Pulmonary Pathology. New York; Springer-Verlag 1994: 615-645
-
35
Wilen S B, Rabinowitz J G, Ulreich S, Lyons H A.
Pleural involvement in sarcoidosis.
Am J Med.
1974;
57
200-209
-
36
Beekman J F, Zimmet S M, Chun B K, Miranda A A, Katz S.
Spectrum of pleural involvement in sarcoidosis.
Arch Intern Med.
1976;
136
323-330
-
37
Haitsch R, Frank W, Evers H, Pauli R.
Chylothorax as a complication of sarcoidosis.
Pneumologie.
1996;
50
912-914
-
38
Loughney E, Higgins B G.
Pleural sarcoidosis: a rare presentation.
Thorax.
1997;
52
200-201
-
39 Carrington C B, Gaensler E A, Mikus J P, Schachter A W, Burke G W, Goff A M. Structure and function in sarcoidosis. In: Siltzbach LE Seventh International Conference on Sarcoidosis and Other Granulomatous Disorders. Ann NY Acad Sci 1976;278:265-283
-
40
Rosen Y, Moon S, Huang C T, Gourin A, Lyons H A.
Granulomatous pulmonary angiitis in sarcoidosis.
Arch Pathol Lab Med.
1977;
101
170-174
-
41
Takemura T, Matsui Y, Saiki S, Mikami R.
Pulmonary vascular involvement in sarcoidosis: a report of 40 autopsy cases.
Hum Pathol.
1992;
23
1216-1223
-
42
Hsu R M, Connors Jr A F, Tomashefski Jr J F.
Histologic, microbiologic, and clinical correlates of the diagnosis of sarcoidosis by transbronchial biopsy.
Arch Pathol Lab Med.
1996;
120
364-368
-
43
Takemura T, Matsui Y, Oritsu M et al..
Pulmonary vascular involvement in sarcoidosis: granulomatous angiitis and microangiopathy in transbronchial lung biopsies.
Virchows Arch A Pathol Anat Histopathol.
1991;
418
361-368
-
44
Nunes H, Humbert M, Capron F et al..
Pulmonary hypertension associated with sarcoidosis: mechanisms, hemodynamics and prognosis.
Thorax.
2006;
61
68-74
-
45
Levine B W, Saldana M, Hutter A M.
Pulmonary hypertension in sarcoidosis.
Am Rev Respir Dis.
1971;
103
413-417
-
46
Smith L J, Lawrence J B, Katzenstein A A.
Vascular sarcoidosis: a rare cause of pulmonary hypertension.
Am J Med Sci.
1983;
285
38-44
-
47
Crissman J D, Koss M, Carson R P.
Pulmonary veno-occlusive disease secondary to granulomatous venulitis.
Am J Surg Pathol.
1980;
4
93-99
-
48
Hoffstein V, Ranganathan N, Mullen J BM.
Sarcoidosis simulating pulmonary veno-occlusive disease.
Am Rev Respir Dis.
1986;
134
809-811
-
49
Mikami R, Sekiguchi M, Ryuzin Y et al..
Changes in the peripheral vasculature of various organs in patients with sarcoidosis: possible role of microangiopathy.
Heart Vessels.
1986;
2
129-139
-
50
Fernandes S RM, Singsen B H, Hoffman G S.
Sarcoidosis and systemic vasculitis.
Semin Arthritis Rheum.
2000;
30
33-46
-
51
Kirks D R, McCormick V D, Greenspan R H.
Pulmonary sarcoidosis. Roentgenologic analysis of 150 patients.
Am J Roentgenol Radium Ther Nucl Med.
1973;
117
777-786
-
52
Sharma O P, Hewlett R, Gordonson J.
Nodular sarcoidosis: an unusual radiographic appearance.
Chest.
1973;
64
189-192
-
53
Sharma O P.
Sarcoidosis: unusual pulmonary manifestations.
Postgrad Med.
1977;
61
67-73
-
54
Romer F K.
Sarcoidosis with large nodular lesions simulating pulmonary metastases: an analysis of 126 cases of intrathoracic sarcoidosis.
Scand J Respir Dis.
1977;
58
11-16
-
55
Rose R M, Lee R GL, Costello P.
Solitary nodular sarcoidosis.
Clin Radiol.
1985;
36
589-592
-
56
Liebow A A.
The J Burns Amberson Lecture: Pulmonary angiitis and granulomatosis.
Am Rev Respir Dis.
1973;
108
1-18
-
57
Saldana M J.
Necrotizing sarcoid granulomatosis: clinico-pathologic observations in 24 patients [abstract].
Lab Invest.
1978;
38
364
-
58
Churg A, Carrington C B, Gupta R.
Necrotizing sarcoid granulomatosis.
Chest.
1979;
76
406-413
-
59
Koss M N, Hochholzer L, Feigin D S, Garancis J C, Ward P A.
Necrotizing sarcoid-like granulomatosis: clinical, pathologic, and immunopathologic findings.
Hum Pathol.
1980;
(Suppl 5)
510-519
-
60
Popper H H, Klemen H, Colby T V, Churg A.
Necrotizing sarcoid granulomatosis: is it different from nodular sarcoidosis?.
Pneumologie.
2003;
57
268-271
-
61
Rolfes D B, Weiss M A, Sanders M A.
Necrotizing sarcoid granulomatosis with suppurative features.
Am J Clin Pathol.
1984;
82
602-607
-
62
Weiss M, Gokel J M.
Die nekrotisierende sarkoide Granulomatose der Lunge.
Pathologe.
1990;
11
178-182
-
63 Gibbs A R, Jones William W. Necrotising sarcoidal granulmatosis. In: International Committee on Sarcoidosis. Tenth International Conference on Sarcoidosis and Other Granulomatous Disorders. Abstracts Baltimore; 1984: 1-2
-
64
Vracko R.
Significance of basal lamina for regeneration of injured lung.
Virchows Arch A Pathol Pathol Anat.
1972;
355
264-274
-
65
Rennard S I, Hunninghake G W, Bitterman P B, Crystal R G.
Production of fibronectin by the human alveolar macrophage: mechanism for the recruitment of fibroblasts to the site of tissue injury in interstitial lung diseases.
Proc Natl Acad Sci USA.
1981;
78
7147-7151
-
66
Judson M A, Strange C.
Bullous sarcoidosis: a report of three cases.
Chest.
1998;
114
1474-1478
-
67
Tomlinson J R, Sahn S A.
Aspergilloma in sarcoid and tuberculosis.
Chest.
1987;
92
505-508
-
68
Treaba D O, Benson M D, Assad L W, Dainauskas J R.
Sarcoidosis and immunoglobulin lambda II light-chain amyloidosis diagnosed after orthoptic heart transplantation.
Mod Pathol.
2005;
18
451-455
-
69
Komatsuda A, Wakui H, Ohtani H et al..
Amyloid A-type renal amyloidosis in a patient with sarcoidosis.
Clin Nephrol.
2003;
60
284-288
-
70
Sharma O P, Koss M, Buck F.
Sarcoidosis and amyloidosis. Is the association causal or coincidental?.
Sarcoidosis.
1987;
4
139-141
-
71
Artinian V, Kvale P A.
Cancer and interstitial lung disease.
Curr Opin Pulm Med.
2004;
10
425-434
-
72
Reich J M.
Mortality of intrathoracic sarcoidosis in referral vs. population-based settings.
Chest.
2002;
121
32-39
-
73 Huang C T, Heurich A E, Sutton A L, Rosen Y, Lyons H A. Mortality in sarcoidosis. In: Williams JW, Davies BH Eighth International Conference on Sarcoidosis and Other Granulomatous Diseases. Cardiff; Alpha Omega 1980: 522-526
-
74
Iwai K, Taschibana T, Hosoda Y, Matsui Y.
Sarcoidosis autopsies in Japan.
Sarcoidosis.
1988;
5
60-65
-
75
Perry A, Vuitch F.
Causes of death in patients with sarcoidosis.
Arch Pathol Lab Med.
1995;
119
167-172
-
76
Winterbauer R H, Moore K D.
A clinical interpretation of bilateral hilar adenopathy.
Ann Intern Med.
1973;
78
65-71
-
77
Ulbright T M, Katzenstein A LA.
Solitary necrotizing granulomas of the lung.
Am J Surg Pathol.
1980;
4
13-28
-
78
Teirstein A S, Judson M A, Baughman R P et al..
The spectrum of biopsy sites for the diagnosis of sarcoidosis.
Sarcoidosis Vasc Diffuse Lung Dis.
2005;
22
139-146
-
79
Koerner S K, Sakowitz A J, Appelman R I, Becker N H, Schoenbaum S W.
Transbronchial lung biopsy for the diagnosis of sarcoidosis.
N Engl J Med.
1975;
293
268-270
-
80
Koontz C H, Joyner L R, Nelson R A.
Transbronchial lung biopsy via the fiberoptic bronchoscope in sarcoidosis.
Ann Intern Med.
1976;
85
64-66
-
81
Khan M A, Corona F, Masson R G.
Transbronchial lung biopsy for sarcoidosis.
N Engl J Med.
1976;
295
225
-
82
Poletti V, Patelli M, Spiga L, Ferracini R, Manetto V.
Transbronchial lung biopsy in pulmonary sarcoidosis: is it an evaluable method in detection of disease activity?.
Chest.
1986;
89
361-365
-
83
Gilman M J, Wang K P.
Transbronchial lung biopsy in sarcoidosis: an approach to determine the optimal number of biopsies.
Am Rev Respir Dis.
1980;
122
721-724
-
84
Chapman J T, Mehta A C.
Bronchoscopy in sarcoidosis: diagnostic and therapeutic interventions.
Curr Opin Pulm Med.
2003;
9
402-407
-
85
Roethe R A, Fuller P B, Byrd R B, Hafermann D R.
Transbroncial lung biopsy in sarcoidosis.
Chest.
1980;
77
400-402
-
86
Anders G T, Linville K C, Johnson J E, Blanton H M.
Evaluation of the float sign for determining adequacy of specimens obtained with transbronchial biopsy.
Am Rev Respir Dis.
1991;
144
1406-1407
-
87
Shorr A F, Torrington K G, Hnatiuk O W.
Endobronchial biopsy for sarcoidosis: a prospective study.
Chest.
2001;
120
109-114
-
88
Morales C F, Patefield A J, Strollo Jr P J, Schenk D A.
Flexible transbronchial needle aspiration in the diagnosis of sarcoidosis.
Chest.
1994;
106
709-711
-
89
Trisolini R, Lazzari A L, Cancellieri A et al..
Transbronchial needle aspiration improves the diagnostic yield of bronchoscopy in sarcoidosis.
Sarcoidosis Vasc Diffuse Lung Dis.
2004;
21
147-151
-
90
Wang K P, Fuenning C, Johns C J, Terry P B.
Flexible transbronchial needle aspiration for the diagnosis of sarcoidosis.
Ann Otol Rhinol Laryngol.
1989;
98
298-300
-
91
Cetinkaya E, Yildiz P, Altin S, Yilmaz V.
Diagnostic value of transbronchial needle aspiration by Wang 22-gauge cytology needle in intrathoracic lymphadenopathy.
Chest.
2004;
125
527-531
-
92
Wang K P, Britt E J, Haponik E F, Fishman E K, Siegelman S S, Erozan Y S.
Rigid transbronchial needle aspiration biopsy for histological specimens.
Ann Otol Rhinol Laryngol.
1985;
94
382-385
-
93
Bilaceroglu S, Perim K, Gunel O, Cagirici U, Buyuksirin M.
Combining transbronchial aspiration and endobronchial and transbronchial biopsy in sarcoidosis.
Monaldi Arch Chest Dis.
1999;
54
217-223
-
94
Cetinkaya E, Yildiz P, Kadakal F et al..
Transbronchial needle aspiration in the diagnosis of intrathoracic lymphadenopathy.
Respiration.
2002;
69
335-338
-
95
Annema J T, Veselic M, Rabe K F.
Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of sarcoidosis.
Eur Respir J.
2005;
25
405-409
-
96
Siltzbach L E.
The Kveim test in sarcoidosis. A study of 750 patients.
JAMA.
1961;
178
476-482
-
97
Chase M W.
The preparation and standardization of Kveim antigen.
Am Rev Respir Dis.
1961;
84(Part 2)
86-88
-
98 Siltzbach L E. Qualities and behavior of satisfactory Kveim suspensions. In: Siltzbach LE Seventh International Conference on Sarcoidosis and Other Granulomatous Disorders. Ann NY Acad Sci 1976;278:665-669
-
99
Teirstein A S.
Kveim antigen: what does it tell us about the causation of sarcoidosis?.
Semin Respir Infect.
1998;
13
206-211
-
100
Kommareddi S, Abramovsky C R, Swinehart G L, Hrabak L.
Nontuberculous mycobacterial infections: comparison of the fluorescent auramine-O and Ziehl-Neelsen techniques in tissue diagnosis.
Hum Pathol.
1984;
15
1085-1089
-
101
Ulukanligil M, Aslan G, Tasci S.
A comparative study on the different staining methods and number of specimens for the detection of acid fast bacilli.
Mem Inst Oswaldo Cruz.
2000;
95
855-858
-
102
Koch M L, Cote R.
Comparison of fluorescence microscopy with Ziehl-Neelsen stain for demonstration of acid-fast bacilli in smear preparations and tissue sections.
Am Rev Respir Dis.
1965;
91
283-284
-
103
Tang Y W, Procop G W, Zheng X, Myers J L, Roberts G D.
Histologic parameters predictive of mycobacterial infection.
Am J Clin Pathol.
1998;
109
331-334
-
104
Hillemann D, Galle J, Vollmer E, Richter E.
Real-time PCR assay for improved detection of Mycobacterium tuberculosis complex in paraffin-embedded tissues.
Int J Tuberc Lung Dis.
2006;
10
340-342
-
105
Hofman V, Selva E, Landraud L et al..
Value of PCR amplification from formalin-fixed paraffin-embedded tissues in the diagnosis of Mycobacterium tuberculosis infection.
Ann Pathol.
2003;
23
206-215
-
106
Kommareddi S, Abramovsky C R, Swinehart G L, Hrabak L.
Comparison of the fluorescent auramine-O and Ziehl-Neelsen techniques in tissue diagnosis.
Hum Pathol.
1984;
15
1085-1089
-
107
Woodard B H, Rosenberg S I, Farnham R, Adams D O.
Incidence and nature of primary granulomatous inflammation in surgically removed material.
Am J Surg Pathol.
1982;
6
119-129
-
108
Azov A G, Koch J, Hamilton-Dutoit S J.
Improved diagnosis of mycobacterial infections in formalin-fixed and paraffin-embedded sections with nested polymerase chain reaction.
APMIS.
2005;
113
586-593
-
109
Fidler H M, Rook G A, Johnson N M, McFadden J.
Mycobacterium tuberculosis DNA in tissue affected by sarcoidosis.
BMJ.
1993;
306
546-549
-
110
Popper H H, Winter E, Höfler G.
DNA of Mycobacterium tuberculosis in formalin-fixed, paraffin-embedded tissue in tuberculosis and sarcoidosis detected by polymerase chain reaction.
Am J Clin Pathol.
1994;
101
738-741
-
111
Grosser M, Luther T, Muller J et al..
Detection of M. tuberculosis DNA in sarcoidosis: correlation with T-cell response.
Lab Invest.
1999;
79
775-784
-
112
Drake W P, Pei Z, Pride D T, Collins R D, Cover T L, Blaser M J.
Molecular analysis of sarcoidosis tissues for mycobacterium species DNA.
Emerg Infect Dis.
2002;
8
1334-1341
-
113
Fite E, Fernandez-Figueras M T, Prats R, Vaquero M, Morera J.
High prevalence of Mycobacterium tuberculosis DNA in biopsies from sarcoidosis patients from Catalonia, Spain.
Respiration.
2006;
73
20-26
-
114
Ghossein R A, Ross D G, Salomon R N, Rabson A R.
A search for mycobacterial DNA in sarcoidosis using the polymerase chain reaction.
Am J Clin Pathol.
1994;
101
733-737
-
115
Wilsher M L, Menzies R E, Croxson M C.
Mycobacterium tuberculosis DNA in tissues affected by sarcoidosis.
Thorax.
1998;
53
871-874
-
116
Vokurka M, Lecossier D, du Bois R M et al..
Absence of DNA from mycobacteria of the M. tuberculosis complex in sarcoidosis.
Am J Respir Crit Care Med.
1997;
156
1000-1003
-
117
Mohr L C.
Hypersensitivity pneumonitis.
Curr Opin Pulm Med.
2004;
10
401-411
-
118 Brincker H. Granulomatous lesions of unknown significance: the GLUS syndrome. In: James DG Sarcoidosis and Other Granulomatous Disorders. New York; Marcel Dekker 1994: 69-86
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