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Pulmonary Pathology
Sunday, March 25, 2007, 7:30 PM
Manchester D - F
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Moderator:
ANDREW CHURG
University of British Columbia Health Science Center
Vancouver, BC, Canada
Disclosure: The speakers have indicated they have nothing to disclose.
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for Text and References
Submitted by: Kelly Butnor - University of Vermont, Burlington, VT
A 28 year old male presented with pleuritic chest pain, dyspnea, and low grade fever. He was a poor historian, but did state that he underwent "some lung procedure" performed by a radiologist at another institution one month prior to presentation. At presentation, a chest x-ray showed a left pleural effusion. A CT scan of the chest disclosed a large heterogeneous mass with irregular borders in the left lower lobe. The patient underwent exploratory thoracotomy with pleural fluid evacuation and wedge resection of the left lower lobe mass.
Case 1 - Slide 1
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Case 1 - Figure 1
Low power view of the lung wedge resection showing diffuse hemorrhage and infarction.
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Case 1 - Figure 2
Organizing thrombus adjacent to area of infarction.
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Case 1 - Figure 3
Higher power view of organizing thrombus demonstrating refractile foreign material.
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Case 1 - Figure 4
Foreign material within thrombus under polarized light.
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Case 1 - Figure 5
EVG stain highlights abnormally dilated, closely apposed blood vessels in area of infarction.
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for Text and References
Submitted by: Teri Franks - Armed Forces Institute of Pathology, Washington, DC
A 22-year-old HIV-positive, transsexual male presented to the emergency department with a four-day history of fever, chest tightness, cough, and increasing dyspnea. Admission physical examination was notable for somnolence, a temperature of 99.7°F, tachypnea, and tachycardia. Arterial blood gas measurements on room air were pH 7.40, PaCO2 38 mm Hg, PaO2 67 mm Hg, and oxygen saturation 92%. Patchy, bilateral, and strikingly peripheral areas of consolidation were present on the PA chest radiograph; similar findings were more clearly demonstrated on chest CT. At bronchoscopy, fresh blood was present in the mainstem bronchi. BAL fluid cell count included 50% PMN's, 44% macrophages, 4% lymphocytes, and 2% eosinophils. Special stains and cultures for bacteria, fungi, and mycobacteria were negative. Antiglomerular basement membrane antibody, antinuclear antibody, antineutrophilic cytoplasmic antibody, cryoglobulins, and drug screen for cocaine were negative. IV methylprednisolone was administered and resulted in rapid clinical and radiologic improvement. The patient was discharged home without further treatment on the sixth hospital day.
Case 2 - Figure 1
This section of lung demonstrates multiple vacuoles within the capillaries and interstitium of the alveolar walls. In the clinical setting of a transsexual male with dyspnea, the vacuoles represent silicone emboli.
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for Text and References
Submitted by: Francoise Galateau-Salle - Centre Hospitalier Universitaire, Caen, France
A 59-year-old white man, a storekeeper in a car factory, was transferred to our institution for evaluation of a bilateral pleural effusion, with increasing dyspnea, cough, and fatigue. He also complained of fever, drenching night sweats and progressive body weight loss (8 kg in 3 months). The patient had a previous history of systemic hypertension treated by Valsartan and Hydrochlorothiaside and additionally a neurologic disease. The CT scan confirmed a bilateral pleural effusion, and showed a diffuse bilateral pleural thickening and rounded atelectasis. Laboratory data showed a normal WBC count with 21 % lymphocytes, proteins: 73 g/L, C Reactive protein:138 mg/L, sedimentation rate: 107 mm and LDH: 652 (N:165 to 420). Thoracentesis disclosed bloody fluid with protein of 39 g/L and a normal adenosine desaminase activity. Cytology showed no evidence of malignancy.
Case 3 - Slide 1
Representative slide from the pleurectomy
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Case 3 - Figure 1
The CT Scan schowed bilateral pleural effusions, diffuse pleural thickening and rounded atelectasis.
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Case 3 - Figure 2
Severe diffuse thickened and fibrotic pleura with serofibrinous exudate at the surface.
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Case 3 - Figure 3
Some plump, atypical fibroblasts were deeply seated with few mitosis
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Case 3 - Figure 4
At higher magnification, immunohistochemistry showed AE1/3 positive cells under effusion, and positive spindle cells parallel to the surface.
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for Text and References
Submitted by: Allen Gibbs - Llandough Hospital, Cardiff and Vale NHS Trust, UK
A 56 yo male had recurrent left sided chest pain and pleural effusions over 12 months. He was an ex-smoker. His past medical history included radiotherapy and chemotherapy for a left-sided neck Hodgkin's lymphoma at age 34. He was a technical assistant in quality control at a factory producing rubber goods. Pleural biopsy was performed.
Case 4 - Slide 1
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for Text and References
Submitted by: Andrew Nicholson - Royal Brompton Hospital and Imperial College School of Medicine, London, UK
HRCT shows multiple odd shaped nodules of soft tissue density, many containing air bronchograms. The CT differential includes neoplastic disease, in particular multicentric adenocarcinoma and lymphoproliferative disease. There are no CT features to narrow the wide differential.
TBBx negative, BAL negative – proceeded to surgical lung biopsy. Two firm nodules were sampled from the periphery of the lung.
Case 5 - Slide 1
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Case 5 - Figure 1
Standard section from a CT (lower lobes) shows nodules of varying size and shape, the larger of these containing an air bronchogram.
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Case 5 - Figure 2
Standard section from a CT (upper lobes) shows multiple nodules of varying size and shape. The dominant lesion in the periphery has a ground-glass halo.
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Case 5 - Figure 3
Areas of consolidation comprise discrete and coalescent non-necrotising granulomas filling alveoli and the interstitium.
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Case 5 - Figure 4
Langhans-type giant cells are seen within areas of granulomatous inflammation.
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Case 5 - Figure 5
Granulomas are seen in close apposition to a pulmonary vessel.
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