Pathology cases– Multiple granulomata from plant material in abdomen

UPDATE:  This case was originally posted as an unknown.  The consensus of emails and a mailinglist I read is that this is most likely plant material.  See the final paragraph.

This is from a middle-aged woman who died of fentanyl intoxication.  At autopsy, he had a zillion little capsular nodules on the liver, all less than 2mm.  Similar nodules were noted on the serosa of the stomach and bowel, as well as the spleen. I didn’t think much about it at the time.  Subcapsular nodules are a dime a dozen around here, and they are almost all just acellular fibrotic nodules without any diagnostic features.  I usually take a section just to see if I can find a few Histoplasmosis with GMS stain.  I’ve never seen AFB in one since I’ve been doing this (in contrast to lung nodules), but I do an AFB too, just in case.   Since they are so common, I didn’t think to take a gross photo. For those of you in practice, imagine the standard subcapsular nodule, only smaller and bunches of them.

On histology, this is not subcapsular, but is in the capsule itself.  Plus, it’s clearly and old granuloma build around some foreign material.  I’m thinking it’s plant material and the decedent likely had a bowel perforation in the past.  There were *no* medical records, but there was a C-section scar.  But, I’m wondering if it might be some odd parasite.  Unfortunately (or, I guess, fortunately), I have run across very few parasites on histology, so my practical knowledge base is smaller than I’d like.  The cell wall material is not birefringent.

The consensus of my colleagues is that this is more likely to be plant material than parasites.  The reasons are that there are no eosinophils or other evidence of parasitic infection, and the structure is consistent with plant material.   Medical records were sparse, so I can’t confirm it, but I suspect that there was a bowel perforation at some point that washed the abdomen in gastric or small bowel contents, and it was not adequately lavaged.  But I don’t know.


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