Case 1

JAMES KELLY
Royal Jubilee Hospital
Victoria, BC, Canada

Clinical Summary:

A 35 year old woman, 20 pack-year smoker, resident of Vancouver Island, presented with pleuritic chest pain. The pain came and went in multiple areas on both sides of the chest. There was no cough, hemoptysis or constitutional symptom and she felt well. Chest X-ray and CT showed multiple large nodules in both lung fields resembling "metastases, infection or, less likely, infarcts" but no hilar or mediastinal adenopathy. An attempt at needle biopsy failed and a bronchoscopy with washings and transbronchial biopsies was negative. A video-assisted thoracoscopic biopsy yielded a wedge of lung containing a 2.3 cm nodule which had a yellowish cut surface. The surgeon divided the tissue sending some to histopathology and some to microbiology.

Case 1 - Figure 1 - Wedge resection of lung (low power), showing a necrotizing granuloma.

Case 1 - Figure 2 - Wedge resection of lung (intermedicate power), with yeast cells visible in the areas of necrotizing granuloma

Case 1 - Figure 3 - Wedge resection of lung (high power), encapsulated yeast in area of necrosis. The fungi are round or elliptical with thin eosinophilic walls and a surrounding capsule or fuzzy zone and large clear halos.

Case 1 - Figure 4 - Mucicarmine stain - Wedge resection of lung, stain shows the mucinous capsules surrounding narrow-necked budding yeast consistent with Cryptococcus.

Case 2

MARGIE SCOTT
VA Medical Center
Little Rock, AR

Clinical Summary:

A 34-year old divorced mechanic presented to the emergency room with a 3 to 4 week history of malaise, fever, non-productive cough, left sided chest pain and night sweats. The patient recalls recent exposure to a friend's child who was diagnosed with "walking pneumonia." Past medical history was positive only for degenerative joint disease of the knee (ACL tear) and two bouts of "pink eye" in the past year. The patient lives in a rural area and enjoys outdoor activities such as hunting, rodeos and horseshows, but recalls no unusual exposures to wildlife, ticks or insects. The patient reports being HIV and PPD negative at time of military discharge. On physical examination there was mild fever of 99.9 F, BP 123/73, pulse 120, respiratory rate 20, and chest was clear to auscultation. Laboratory: WBC 7.3, Hgb 13.3, Hct 38.8, Plt 251, Basic metabolic panel and UA were normal. Chest X-ray was positive for a LUL infiltrate, 6.7cm maximum dimension with focal cavitation, very suspicious for TB. The patient was admitted with respiratory isolation precautions, started on broad-spectrum antibiotic therapy, a PPD and control were placed and the infection control team was notified. Blood and sputum samples were collected for bacterial, fungal and mycobacterial cultures. Serologic studies for Hepatitis C, Hepatitis B and HIV were obtained. The patient left the hospital AMA on hospital day 2, with the PPD and control noted as "no induration." The patient returned to the emergency room one week later with progressive respiratory symptoms and was admitted for pulmonary consultation, CT scan and bronchoscopy. The TB skin test was noted as "negative" by the patient. AFB smears were negative and previously obtained cultures were negative to date. CT scan confirmed the LUL density with three areas of early cavitation as well as a focal infiltrate in the RUL and mild hilar adenopathy. No additional abnormalities were identified. A transbronchial biopsy and BAL were obtained for work-up.

Slides for Review: Chest X-Ray, Transbronchial biopsy and BAL cell block, Hematoxylin & Eosin stain.

Case 2 - Figure 1 - Chest radiograph showing a left upper lobe infiltrate with focal cavitation. Read as suspicious for tuberculosis

Case 2 - Figure 2 - Transbroncial biopsy was non-contributory and does not reflect lesional sampling.

Case 2 - Figure 3 - BAL cell block, inflammatory process with a predominance of histiocytes and neutrophils.

Case 2 - Figure 4 - BAL cell block, some histiocytes show eosinophilic cytoplasm. (Gram stain, not shown, demonstrated rare gram-positive coccobacilli of Rhodococcus equi.

Case 3

S. DAVID HUDNALL
University of Texas Medical Branch
Galveston, TX

Clinical Summary:

Mar 02: 12 yr old Hispanic female s/p renal transplant (living related donor, 5/6 haplotype match) following septic shock-induced renal failure, four drug immunosuppression

Sept 02: Acute rejection episode confirmed by renal biopsy, treated with Solumedrol

Dec 02: Develops febrile illness with monocytosis, lymphadenopathy, serologic studies and cervical node biopsy obtained.

Case 3 - Figure 1 - Lymph node biopsy, shows effacement of the lymph node architecture by a polymorphic lymphoid proliferation

Case 3 - Figure 2 - Higher power of lymph node biopsy showing atypical lymphocytes admixed with plasma cells and immunoblasts.

Case 3 - Figure 3 - CD3 staining - Immunostains showing an admixture of CD3+ T-cells and CD20+ B-cells without kappa or lambda restriction characteristic of polymorphous post-transplant lymphoproliferative disorder.

Case 3 - Figure 4 - CD20 staining - Immunostains showing an admixture of CD3+ T-cells and CD20+ B-cells without kappa or lambda restriction characteristic of polymorphous post-transplant lymphoproliferative disorder.

Case 3 - Figure 5 - Kappa light chain staining - Immunostains showing an admixture of CD3+ T-cells and CD20+ B-cells without kappa or lambda restriction characteristic of polymorphous post-transplant lymphoproliferative disorder.

Case 3 - Figure 6 - Lambda light chain staining - Immunostains showing an admixture of CD3+ T-cells and CD20+ B-cells without kappa or lambda restriction characteristic of polymorphous post-transplant lymphoproliferative disorder.

Case 3 - Figure 7 - LN Biopsy #1

Case 3 - Figure 8 - CD3 LN Biopsy #1

Case 3 - Figure 9 - EBV LMP1 LN Biopsy #1

Case 3 - Figure 10 - LN Biopsy #2

Case 3 - Figure 11 - CD20 LN Biopsy #2

Case 3 - Figure 12 - EBER1 LN biopsy #2

Case 3 - Figure 13 - JH PCR: Oligoclonal PTLD; Polyclonal Control

Case 3 - Figure 14 - CT g PCR: Oligoclonal PTLD; Polyclonal Control

Case 4

ANN M. NELSON
Armed Forces Institute of Pathology
Washington, DC

Clinical Summary:

A 23-year old male with a one month history of non-healing ulcerated, erythematous plaques with rolled borders. The lesions are located on the right forearm and left lateral chest. He recently returned from Iraq. Biopsy of chest lesion was obtained.

Case 4 - Figure 1 - Punch biopsy of non-ulcerated skin with interface and deep dermal nodular infiltrates.

Case 4 - Figure 2 - Higher power of skin demonstrates the dense granulomatous inflammation.

Case 4 - Figure 3 - Oil immersion, reveals intracellular amistigotes of Leishmania species (center of the field) the nucleus and kinetoplast are visible.