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Pulmonary Pathology
Thursday, March 3, 2005 - 7:30 PM
Rivercenter Salon Rooms B,F
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Moderator:
Andrew Churg
University of British Columbia Health Science Center
Vancouver, BC, Canada
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Clinical histories are printed below.
Click on the case numbers for text and references of each case.
Click on each slide thumbnail image for an enlarged view
Submitted by:
Philip T. Cagle
Baylor College of Medicine
Houston, TX
The patient was a 16 year old girl who developed a nonproductive cough and intermittent wheezing in
the absence of any viral illness. She failed to respond to antibiotics and bronchodilators and
progressively worsened over three months with severe exertional dyspnea. Pulmonary function tests showed
severe airflow obstruction with no response to bronchodilators:
| PFT | Initial visit | 1 month | 3 months | 1 year |
FVC
(% predicted) | 1.80 L
(58%) | 1.35 L
(41%) | 1.12 L
(36%) | 1.00 L
(32%) |
FEV1
(% predicted) | 0.56 L
(22%) | 0.50 L
(18%) | 0.40 L
(15%) | 0.39 L
(14%) |
| FEV1/FVC | 32% | 37% | 36% | 39% |
TLC
(% predicted) | 4.31 L
(108%) | 5.88 L
(140%) | 5.82 L
(146%) | Not available |
She failed to respond to B-agonist inhalation and oral and intravenous theophylline and prednisone.
No evidence of alpha-1-antitrypsin disease, cystic fibrosis or aspiration was found on clinical,
radiologic or serologic evaluations. She had a weakly positive rheumatoid factor, but other work-up for
collagen vascular disease was negative. A clinical diagnosis of bronchiolitis obliterans was made. She
underwent a left thoracotomy and a diagnosis of "consistent with bronchiolitis obliterans" was made. She
required intubation and mechanical ventilation on several occasions and was eventually transferred to The
Methodist Hospital for lung transplantation.
The patient underwent transplantation of her heart and both lungs. Figure 1 shows the gross
cut surface of one of her native lungs. The remaining figures show microscopic views of sections taken
from her native lungs. Figures 3, 4 and 5 are consecutively higher powers of one lesion.
Case 1 - Figure 1 - Gross cut surface of the explanted lung shows scattered small yellow nodules.
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Case 1 - Figure 2 - Low power view of a bronchiole with mural infiltrates of foam cells and chronic inflammatory cells with exfoliation of foamy macrophages into the bronchiolar lumen.
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Case 1 - Figure 3 - Low power of bronchiole with intramural foam cells.
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Case 1 - Figure 7 - Constrictive bronchiolitis with fibrous obliteration of the bronchiolar lumen.
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Case 1 - Figure 8 - A tremendous number of foam cells fill the wall of this bronchiole.
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Submitted by:
William D. Travis
Armed Forces Institute of Pathology
Washington, DC
A 60 year old woman was found to have a right middle lobe lung mass on chest x-ray while undergoing
follow-up for a non-invasive, papillary, transitional cell carcinoma of the bladder. She had mild
progressive dyspnea and a slight, productive cough. Pulmonary function showed mild obstruction and
decrease in the diffusing capacity. She had a 70 pack year history of smoking but had quit for one
year. At thoracotomy, multiple pulmonary nodules were found in the right middle lobe and removed
surgically. Three of the nodules measured 1.0, 0.7 and 0.6 cm in diameter. A right middle lobectomy was
performed.
Case 2 - Figure 1 - The airways in the lung parenchyma surrounding the carcinoid tumor (right lower corner) show mild fibrosis and bronchiolectasis. Increased cellularity is focally appreciable at this low magnification
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Case 2 - Figure 2 - Immunohistochemistry for bombesin (gastrin releasing polypeptide) shows strong staining of the tumor and also the bronchiolar mucosa in surrounding airways with linear and nodular patterns. This reflects neuroendocrine cell hyperplasia and tumorlets.
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Case 2 - Figure 3 - Medium magnification of the carcinoid tumor shows spindle cell morphology.
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Case 2 - Figure 4 - The spindle-shaped tumors cells have finely granular nuclear chromatin. An organoid nesting pattern is seen. No mitoses or necrosis are seen.
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Case 2 - Figure 5 - This bronchiole shows a nodular clusters of neuroendocrine cells with infiltration of the bronchiolar wall.
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Case 2 - Figure 6 - Tumorlets are seen on both sides of this blood vessel. Above the cells are proliferating along airspaces. Below they are forming a nodule.
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Case 2 - Figure 7 - Neuroendocrine cell hyperplasia consisting of nodulear clusters of neuroendocrine cells (also known as neuroendocrine bodies) at the base of the mucosa.
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Case 2 - Figure 8 - Immunohistochemistry for bombesin (gastrin releasing polypeptide) shows strong staining of a linear pattern of neuroendocrine cells in the bronchiolar mucosa.
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Submitted by:
Joanne L. Wright
University of British Columbia
Vancouver, BC, Canada
The patient was a 41 year old gay male who was HIV positive and fulfilled the criteria for AIDS. He
had been placed on HAART (Highly Active Anti-Retroviral Therapy) for 5 weeks.
The patient presented with cough, fever, malaise, and weight loss. He did not have hemoptysis. The
CD4 count was greater than 100.
The CT scan showed bilateral infiltrates associated with bronchial thickening and bronchial
obstruction. A bronchoscopy was performed and found bronchial nodules of soft yellow tan tissue. A
biopsy of the nodules was performed.
Note: This case has only printed color micrographs. There are no glass slides
Submitted by:
Samuel A. Yousem
University of Pittsburgh
Pittsburgh, PA
A 30-year-old Black woman presented with a progressive shortness of breath and productive cough over
the last six months associated with chest radiographs showing a bilateral reticulonodular pattern with
bronchiectasis, greatest in the left lower lobe. Repeated cultures of sputum were negative. Past
medical history is pertinent only for a history of ulcerative colitis for which she had a colectomy in
1994. Pulmonary function studies showed predominantly obstructive lung disease. A diagnostic
thoracoscopic biopsy was performed (Case contributed by Michael D. Kanzer, MD, Christiana Care Health
Services, Newark, Delaware).
Case 4 - Figure 1 - Low magnification demonstrated suppurative bronchiectasis with peribronchiolar lymphoid hyperplasia and air space consolidation.
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Case 4 - Figure 2 - The bronchi and bronchioles had a luminal fibrinopurulent exudate with submucosal chronic inflammation.
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Case 4 - Figure 3 - The airways were intensely inflamed with neutrophil migration into the epithelium.
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Case 4 - Figure 4 - The airways were intensely inflamed with neutrophil migration into the epithelium.
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Case 4 - Figure 5 - The distal lung parenchyma showed an organizing pneumonia with obstructive changes.
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Submitted by:
Dani S. Zander
University of Texas
Houston, TX
A 50-year-old white female, status post bilateral modified radical mastectomies and chemotherapy 3
years earlier for breast cancer, developed a left upper lobe mass that grew from 2.4 cm to 5.5 cm in
maximum dimension over 3 months. Other medical history included probable systemic lupus erythematosus
with ocular sicca symptoms, arthralgias, and intermittent mild rash, treated with hydroxychloroquine.
Bronchoscopy with bronchial biopsy was negative for malignancy. A PET scan showed increased activity in
the left lung and hilar and mediastinal lymph nodes. Left upper lobectomy and thoracic lymphadenectomy
were performed. Gross examination of the left upper lobe revealed an ill-defined 6.5 cm zone of tan
consolidation with foci of necrosis, and bronchiectasis with thick brown mucus plugs.
Case 5 - Figure 1 - The bronchial wall is inflamed and its lumen is filled with numerous inflammatory cells and mucus.
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Case 5 - Figure 2 - The lumen of this inflamed bronchus contains layered mucus and basophilic inflammatory debris.
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Case 5 - Figure 3 - A large airway is filled with basophilic mucoid and inflammatory exudate, and shows extensive granulomatous inflammation. An adjacent smaller airway is replaced by a granuloma with focal necrosis.
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Case 5 - Figure 4 - This bronchus demonstrates granulomatous bronchitis with superficial ulceration and luminal filling by basophilic material and inflammatory cells.
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Case 5 - Figure 5 - Multiple aggregates of eosinophils and Charcot-Leyden crystals are present, in a background of mucus.
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Case 5 - Figure 6 - The bronchial mucosa contains dense infiltrates of mixed inflammatory cells including numerous eosinophils. There is superficial loss of epithelial cells.
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Case 5 - Figure 7 - This bronchiole is replaced by a necrotizing granuloma with neutrophils.
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Case 5 - Figure 8 - Several small airways are filled with necrotic material. Airway walls are replaced by granulomatous inflammation.
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Case 5 - Figure 9 - Occasional Aspergillus hyphae lie in the inflammatory exudate (methenamine silver stain).
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