—  SPECIALTY CONFERENCE  — Pulmonary Pathology Thursday, March 12, 2009, 7:30 PM Convention Center 304 Infection ? Moderator: DANI ZANDER Penn State Milton S. Hershey Medical Center, Hershey, PA 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: CAROL FARVER, Cleveland Clinic Foundation, Cleveland, OH SANJAY MUKHOPADHYAY, SUNY Upstate Medical University, Syracuse, NY HELMUT H. POPPER, University of Graz, Graz, Austria HENRY D. TAZELAAR, Mayo Clinic, Phoenix, AZ SHERIF R. ZAKI, Centers for Disease Control and Prevention, Atlanta, GA 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: Henry D. Tazelaar - Mayo Clinic, Phoenix, AZ Clinical Summary: A 29-year-old female tri-athlete who frequently travels to South America presented with a 2 week history of shortness of breath and chest pain. She was treated with antibiotics, but remained symptomatic. Imaging studies showed multiple nodules, some cavitated. Her past medical history included Crohn disease which was currently inactive. ANCA and connective tissue disease serologies were negative. She underwent lung biopsy. Case 1 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer 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 1 - Figure 7 Case 2 Submitted by: Carol Farver - Cleveland Clinic Foundation, Cleveland, OH Clinical Summary: The patient is a 41-year-old female who presented with a three week history of shortness of breath and cough, productive of white sputum. She reported no history of fever, chills, or hemoptysis. Clinical exam revealed minimal bilateral wheezing. Laboratory tests revealed a microcytic anemia and a chest CT scan showed diffuse infiltration and prominence of the mediastinal fat, numerous bilateral enlarged axillary lymph nodes (approx. 1 cm) with diffuse mild pleural thickening of the mid and lower right lung. Lung windows showed diffuse interstitial changes with ill-defined or ground-glass opacities. Case 2 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer 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 3 Submitted by: Helmut H. Popper - University of Graz, Graz, Austria Clinical History: The male patient, born in 1916, died because of sclerosis and stenosis of the coronary arteries with multiple infarcts resulting in congestive heart failure, leading to decompensation. Pneumonia was clinically suspected. The medical history also included chronic renal insufficiency. At autopsy, the following macroscopic and microscopic changes were observed: Heart and large blood vessels: general arteriosclerosis of all large- and medium-sized arteries; severe sclerosis and stenosis of the coronary arteries and their main branches; multiple scars in the posterior myocardium with formation of an aneurysm; a heart stimulating device (VVI) implanted in the right posterior ventricle wall Pleura and pleural cavities: 200 ml pleural effusions and focal pleural fibrosis on both sides Lungs: emphysematous changes in both lungs; two round grayish-white nodules measuring 1.5 and 2 cm in diameter in the left lower and right upper lobes, respectively; mild arteriosclerosis of the pulmonary arteries Other pathology: cholelithiasis, fracture of the left distal radius Sections from both nodules were submitted for consultation, and a section of one is provided. Both demonstrated identical histologic features. 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 Case 3 - Figure 7 CD163 (IHC) Case 3 - Figure 8 HLA-DR (IHC) Case 3 - Figure 9 IgG (IHC) Case 3 - Figure 10 PAS Case 4 Submitted by: Sanjay Mukhopadhyay - SUNY Upstate Medical University, Syracuse, NY Clinical Summary: A 45-year-old previously healthy man presented with a 7-day history of daily high fevers, severe headache, nausea, vomiting, myalgia, dyspnea and overwhelming fatigue. On examination, he was found to be febrile and hypoxic. A chest X-ray showed bilateral diffuse reticulonodular infiltrates. Video-assisted wedge biopsies of the right lung were performed. 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 Case 4 - Figure 9 Case 5 Submitted by: Sherif R. Zaki - Centers for Disease Control and Prevention, Atlanta, GA Clinical Summary: The patient was an ex-premie four-month-old female who had been hospitalized for 3 months and intubated for 1 month, who underwent ligation of a patent ductus arteriosis but eventually was discharged home in good health and put on an apnea monitor. She presented to a children's hospital ER on April 28, 1997, afebrile with a 3-day history of upper respiratory tract infection. BP was 110/86, heart rate 160, and respiratory rate in the 50s. Lung auscultation revealed good air exchange. WBC was 17,900 with 17% segs, 15% bands, 57% lymphocytes. Hemoglobin, hematocrit, and platelet count were within normal limits. RSV titer was negative. Chest X-ray revealed bilateral central infiltrates. She was admitted with a diagnosis of bronchiolitis and possible pneumonia. Oxygen and erythromycin therapy were started. Follow-up chest X-ray demonstrated worsening perihilar central densities and episodes of intermittent stridor were also noted. On the 3rd day of hospitalization, WBC was 40,000 and she developed bradycardia and projectile vomiting. Ultrasound findings suggested pyloric stenosis. On the fourth day of hospitalization, WBC rose to 90,000. Pertussis cultures and Chlamydia titers were negative. Appropriate empiric antibiotic therapy was initiated. Her respiratory status deteriorated and she was noted to have intercostal and subcostal retractions. She was transferred to the PICU, intubated, and follow-up chest X-ray showed increasing consolidation of the right upper lobe. Gentamicin, Timentin, and Vancomycin were added to the antibiotic regimen. An echocardiographic study on the 5th day of hospitalization revealed a dilated right ventricle and atrium, dilated superior vena cava, depressed ventricular function, underfilled left ventricle and left atrium, tricuspid regurgitation, moderate pulmonary insufficiency and a patent foramen ovale. BP dropped to 60/30 and intravenous fluid therapy was started. She had an episode of hypertension and tachycardia of 190 with subsequent drop to 140. Her pupils became fixed and dilated. Aggressive cardiopulmonary resuscitative efforts were unsuccessful and she was pronounced dead on 05/02/97. A complete post-mortem examination was performed. Case 5 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 5 - Figure 1 Case 5 - Figure 2 Case 5 - Figure 3 Case 5 - Figure 4 Case 5 - Figure 5 IHC for etologic agent (?) Case 5 - Figure 6 IHC for etologic agent (?) 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