Case 1 - Click here for Text and References
Submitted by: Henry Tazelaar
Clinical Summary:
The patient is a 61-year-old man in previous good health with a 6-month history of fatigue, progressive SOBS, lower extremity pain and edema. He was found to have an enlarged heart and a pericardial effusion. He subsequently developed acute respiratory failure for which he underwent intubation, and right exploratory thoracotomy at which time a right upper lung biopsy, pericardial window, and pericardial biopsy were performed.
Case 1 - Slide 1
Case 2 - Click here for Text and References
Submitted by: Mari Mino-Kenudson
Clinical Summary:
A 47 year old man with a history of 13 pack-year smoking was admitted to a hospital with worsening dyspnea on exertion for 3–4 weeks and associated cough productive of greenish sputum. He had been diagnosed with SLE at age 39, with manifestations including oral ulcers, arthritis, pleuropericarditis, leukopenia, high anti-nuclear antibody titers, and positive anti-double stranded DNA and Smith antibodies. His symptoms had been controlled with prednisone 20 mg daily. At age 44, he developed antiphospholipid syndrome with ischemia of the left 5th finger, with persistently elevated antiphospholipid antibodies. Other past medical history included large B cell lymphoma diagnosed at age 44, in remission after six cycles of CHOP + rituximab, and latent tuberculosis treated with isoniazid at age 39. His current respiratory symptoms did not respond to increased steroid dosing. The angiographic CT of the chest performed on admission revealed multiple segmental and subsegmental pulmonary emboli and bilateral air space consolidations with air bronchograms. He was given levofloxacin and began anticoagulation with unfractionated heparin and tapering of steroid. Transthoracic echocardiography showed pericardial thickening with constrictive physiology. He underwent bronchoscopy and broncho-alveolar lavage that revealed pulmonary macrophages with mixed inflammation and no evidence of malignant cells. The patient left the hospital against medical advice on hospital day 4 on Lovenox. After discharge, the patient continued to have dyspnea on exertion without other symptoms. A follow up CT performed 41 days after discharge showed stable consolidation in a peripheral and peribronchovascular distribution. He underwent open right lower lobe lung wedge and pleural biopsy 49 days following discharge.
Airspace-occupying lesion (bottom half) in the background of subpleural interstitial fibrosis with bronchiolar metaplasia.
Intra-alveolar fibrinous exudate associated with mild to moderate interstitial inflammation and intraluminal organization (bottom).
Another area with Intra-alveolar fibrinous exudate associated with moderate interstitial inflammation.
High-power view of prior image showing intra-alveolar fibrin in the form of fibrin “balls” without classic hyaline membranes in a patchy distribution and a lymphoplasmacytic infiltrate in the adjacent alveolar walls to a moderate degree without eosinophils.
Organizing pneumonia consisting of intraluminal loose connective tissue within an alveolar duct.
Alveolar hemorrhage seen in a patchy distribution.
Subpleural fibrosis with bronchiolar metaplasia.
High-power view of previous image demonstrating homogenous fixed fibrosis.
A trichrome stain (corresponding to figure d) demonstrating the lack of significant fibrosis in the area with intra-alveolar fibrin.
Several small clusters of hemosiderin- laden alveolar macrophages identified in the areas with alveolar hemorrhage.
Pulmonary artery with medial hypertrophy consistent with pulmonary hypertensive changes grade 2/6.
Another area with fibrosis demonstrating a sharp demarcation from intact alveolar walls with congestion. No fibroblastic foci seen.
A trichrome stain highlighting fixed collagen fibrosis in the subpleural region.
Case 3 - Click here for Text and References
Submitted by: Alain Borczuk
Clinical Summary:
A 39 year old man, non-smoker, with a history of five months of shortness of breath (worsening in the last 3 months). Pulmonary function tests showed a restrictive physiology, performed in month 3 of the symptoms. Treated for presumptive hypersensitivity pneumonitis with prednisone. In month 4, patient developed joint swelling and fever, and in month 5, extensive CT scan documented infiltrates and respiratory failure resulting in VATS biopsy. A V/Q scan was negative.
Pertinent Laboratory Data:
These were pending at the time of biopsy.
second area low power
second area high power
second area
Case 4 - Click here for Text and References
Submitted by: Teri J. Franks
Clinical Summary:
1. 57-year-old female with a history of lymphangioleiomyomatosis
2. Status post right unilateral lung tranplantation in 2007 Complicated by acute cellular rejection in 2011 Subsequent organizing pneumonia Most recently severe end-stage bronchiolitis obliterans syndrome
3. Presented with a one-month history of worsening shortness of breath, confusion, and severe malnutrition
Chest radiograph
Chest CT
Chest CT MinIP
H and E
Case 5 - Click here for Text and References
Submitted by: Kevin O. Leslie
Clinical Summary:
A 60-year-old man presented with fatigue and shortness of breath of several months evolution. His past medical history is remarkable for pancreatitis. Imaging showed widespread air space disease, raising a differential diagnosis to include atypical pneumonia. The patient was treated empirically with antibiotics without response. A CT scan showed multifocal patchy airspace disease dominant in the left lung with some sparing of the medial apex. Areas that were not consolidated on the left side showed areas of ground-glass attenuation. Patchy consolidation also was seen in the right lower lobe, but the right upper lobe, middle lobe, and the superior segment of the right lower lobe were clear. Moderately enlarged anterior mediastinal lymph nodes were seen. Imaging through the upper abdomen revealed evidence for chronic pancreatitis. Transbronchial biopsies were obtained but were unrevealing. A surgical lung biopsy was performed.
Case 5 - Slide 1