Which pattern of inflammation is characterized by necrosis of the center of granulomas, producing a cheese-like gross appearance, and is the hallmark of tuberculosis?

• A Liquefactive necrosis — caused by leukocyte enzymes dissolving granuloma center
• B Fibrinoid necrosis — due to immune complex deposition within granuloma walls
• C Fat necrosis — due to lipase release from epithelioid cells
• D Caseous necrosis — a form of coagulative necrosis modified by the waxy mycobacterial cell wall lipids ✓

Explanation

Caseous necrosis is the characteristic form in tuberculosis granulomas; it is a variant of coagulative necrosis where normal tissue architecture is lost and replaced by amorphous, eosinophilic, structureless 'cheese-like' material. The mycobacterial cell wall lipids (particularly cord factor/trehalose dimycolate and mycolic acids) modify the typical coagulative pattern, preventing complete liquefaction while inducing the distinct cheesy consistency. Liquefactive necrosis is typical of pyogenic brain abscesses.

Reference: Robbins & Cotran Pathologic Basis of Disease, 10th ed.

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