—  SPECIALTY CONFERENCE  — Pulmonary Pathology Sunday, February 27, 2011, 7:30 PM CC 006 A/B An interesting case that taught me something I did not know before Moderator: THOMAS COLBY Mayo Clinic Arizona Scottsdale, AZ Disclosure: In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose. Panelists: Andrew Churg, University of British Columbia, British Columbia Patrizia Morbini, University of Pavia, Pavia, Lombardy, Italy Frank Schneider, University of Pittsburgh, Pittsburgh, PA Andrea Valeria Arrossi, Cleveland Clinic, Cleveland, OH Thomas V. Colby, Mayo Clinic Arizona, Scottsdale, AZ Clinical histories are displayed below. For the fastest viewing of virtual slides, click: under each thumbnail image below. You must have Aperio ImageScope installed on your PC. If you do not already have Aperio ImageScope, Windows users with administrator privileges may download and install a free version in order to view USCAP Virtual Slides. Click the icon on the right to get your free copy:   Or, click on slide thumbnail images to view each slide in a Web-based slide viewer, which is somewhat slower. If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137. Case 1 Submitted by: Andrew Churg - Clinical Summary: This is a 50 yo man with a history of traumatic perforation of the esophagus in 2003 in a motor vehicle accident. The esophagus was repaired with a colonic interposition. In early 2008 the patient presented with an upper lobe pneumonia and cultures grew an organism identified as Rhodococcus. The patient was HIV negative and had normal T cell counts. He improved on antibiotic therapy. In late 2008 the patient presented with a clinical picture of bilateral pneumonia and a lung biopsy was performed. Culture of the biopsy grew an organism identified as a Gordonia species. Case 1 - Figure 1 Case 1 - Figure 2 Case 1 - Figure 3 Case 1 - Figure 4 Case 1 - Figure 5 Case 1 - Figure 6 Case 2 Submitted by: Patrizia Morbini - Clinical Summary: A 52-years old male presented with persistent exertion dyspnea and chronic cough. His past clinical records were unremarkable; smoking history was negative. Lung function tests showed mild restrictive dysfunction and 14% DLCO reduction. CT scan showed diffuse ground glass opacities with centrilobular reticular infiltrates and bronchiectases. Minimal apical honeycombing was observed. Serology for ANA, ENA and ANCA was within normal limits. No bird exposure was reported. A videothoracoscopic lung biopsy was performed. A patient’s younger brother had long been suffering of fatigue, attributed to congestive heart failure. Their second degree female cousin had been diagnosed with interstitial lung fibrosis at the age of 13. The patient is alive 5 years after disease presentation, with minimal progression of the disease at functional and imaging studies. Case 2 - Figure 1 Case 2 - Figure 2 Case 2 - Figure 3 Case 2 - Figure 4 Case 2 - Figure 5 Case 2 - Figure 6 Case 2 - Figure 7 Case 2 - Figure 8 Case 3 Submitted by: Frank Schneider - Clinical Summary: A 26-year-old man presented to an emergency room in Pittsburgh, PA, with a 10-day history of worsening shortness of breath, productive cough and fatigue. He was admitted and treated with azithromycin and ampicillin for presumed community-acquired pneumonia. Despite antibiotic therapy he continued to remain febrile with persistent leukocytosis (eosinophilia) and increasing supplemental oxygen requirements eventually requiring intubation. A chest CT showed extensive, bulky mediastinal lymphadenopathy and a dense airspace consolidation within the right upper lobe with small cavitation. In addition, there were innumerable widespread centrilobular nodules. A bronchoalveolar lavage showed atypical lymphoid cells with 20 percent eosinophils. At the same time the present transbronchial biopsy was obtained. Case 3 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 3 - Figure 1 Case 3 - Figure 2 Case 3 - Figure 3 Case 3 - Figure 4 Case 3 - Figure 5 Case 3 - Figure 6 Grocott Case 3 - Figure 7 PAS Case 3 - Figure 8 Mucicarmine Case 4 Submitted by: Andrea V. Arrossi - Clinical History: A 50 year old woman, ex-smoker, presents with weakness and shortness of breath. The patient had a past medical history of medically controlled diabetes mellitus type 2, hypothyroidism and hypertension. She has a five-pack-year smoking history, quitting 8 years ago, and works in a factory making ceramic jet engine parts. Initial laboratory tests revealed severe anemia (hemoglobin of 5.6g/dL). An esophagogastric duodenal endoscopy showed features consistent with celiac sprue, confirmed with elevated titers of gliadin IgG and IgA and transglutaminase IgA antibodies. Colonoscopy and camera endoscopy were normal. Her symptoms slightly improved on a gluten-free diet. However, she continued to have weakness, and developed abdominal pain. A subsequent abdominal CT scan showed an infiltrative retroperitoneal soft tissue mass that encased and involved the pancreas and a chest CT scan showed several lung nodules ranging from 0.3 to 3.3 cm, in the right upper, middle and lower lobes. No pleural effusions or lymphadenopathies were seen. Two pancreatic percutaneous biopsies, a percutaneous biopsy of the right middle lobe nodule and a bone marrow biopsy were performed for suspected pancreatic malignancy or lymphoma with pulmonary involvement. The biopsies were non-diagnostic and the patient underwent a video assisted thoracoscopic biopsy (slides and pictures provided). Case 4 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 4 - Figure 1 Case 4 - Figure 2 Case 4 - Figure 3 Case 4 - Figure 4 Case 4 - Figure 5 Case 4 - Figure 6 Case 4 - Figure 7 Case 4 - Figure 8 Movat Case 5 Submitted by: Thomas V. Colby - Clinical Summary: A 28-year-old journalist who was a non-smoker and had never used illicit drugs presented with hemoptysis of 7 years duration. Since his initial presentation in 2003, he has had multiple recurrences of hemoptysis but it was never life threatening. This has been associated with transient infiltrates and alveolar opacities and at least two episodes of pneumothorax. At one point he had a cavitary lesion noted in the lung. Workup for alveolar hemorrhage syndromes was negative. His initial lung biopsy was taken in 2006 at the time of a left pneumothorax. Subsequently, in 2010, he presented with a second (right side) pneumothorax associated with hemoptysis and again lung biopsy was obtained and “apical bullae” were resected. Note: images 1-9 from 2006; images 10-17 from 2010 Case 5 - Figure 1 Case 5 - Figure 2 Case 5 - Figure 3 Case 5 - Figure 5 Case 5 - Figure 6 Case 5 - Figure 7 Case 5 - Figure 8 Case 5 - Figure 9 Case 5 - Figure 10 Case 5 - Figure 11 Case 5 - Figure 12 Case 5 - Figure 13 Case 5 - Figure 14 Case 5 - Figure 15 Case 5 - Figure 16 Case 5 - Figure 17 Handouts for all Specialty Conferences will be accessible via the "Educational Materials" section on the homepage the morning after each respective conference. Printed copies of the handout will not be available at the meeting.