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Pulmonary Pathology
Wednesday, March 24, 7:30 PM
Thurgood West
Diagnostic Challenges
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Moderator:
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DANI ZANDER
Penn State Hershey Medical Center, Hershey, PA
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Disclosure:
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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.
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Panelists:
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JEFFREY L. MYERS, University of Michigan, Ann Arbor, MI
DANI S. ZANDER, Penn State Hershey Medical Center, Hershey, PA
ANDRAS KHOOR, Mayo Clinic, Jacksonville, FL
KELLY J. BUTNOR, Fletcher Allen Health Care, Burlington, VT
DAVID M. HWANG, University Health Network, Toronto, Ontario, Canada
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Clinical histories are displayed below.
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Submitted by: Jeffrey L. Myers - University of Michigan, Ann Arbor, MI
A 79-year-old man presented for evaluation of a lung nodule. He had a history of idiopathic pulmonary fibrosis, a diagnosis established 5 months prior to admission on the basis of clinical and radiological abnormalities. He had experienced the insidious onset of shortness of breath over the 4 months prior to his initial evaluation. At that time high resolution CT scan showed not only diffuse abnormalities but also a 1.5 cm mass in the superior segment of his right lower lobe that enlarged to 2 cm over a 5 month interval (see CT scan image). Other significant past medical history included coronary artery disease for which he underwent bypass grafting three and a half years prior to admission. He had smoked 1 pack of cigarettes per day for 13 years, but quit about 4 years prior to developing respiratory symptoms. Pulmonary function studies showed a mild restrictive defect (FVC 68% of the predicted value) with moderate impairment in gas exchange (DLCO 55% of the predicted value). He underwent video-assisted thoracoscopic surgery and wedge biopsy of his right lower lobe.
Case 1 - Slide 1
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Submitted by: Kelly J. Butnor - Fletcher Allen Health Care, Burlington, VT
A 50-year-old male with an insignificant remote smoking history (3 pack years) presented with persistent dyspnea, left-sided pleuritic pain, and recurrent hemoptysis for the past two months that was unresponsive to antibiotics. His past medical history was significant for atrial fibrillation, for which he had undergone radiofrequency catheter ablation five years earlier. He was employed as a nuclear plant technician and had a pet cockatoo for the past ten years. Serial CT scans of the chest disclosed migratory nodular ground glass opacities involving the left upper lobe. A VATS biopsy of the left upper lobe was performed.
Case 2 - Slide 1
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Submitted by: David M. Hwang - University Health Network, Toronto, Ontario, Canada
This 24-year-old patient with cystic fibrosis was admitted for a pulmonary exacerbation. Co-morbidities at the time of admission included pancreatic insufficiency, diabetes, and gastroesophageal reflux, and he had been experiencing generally declining health over the past 3-4 years. He suffered multiple complications while admitted, including pneumothorax related to central line insertion, and recurrent line sepsis and Candidemia while on total parenteral nutrition. He was referred for lung transplant assessment after several months in the hospital and underwent bilateral lung transplantation several weeks thereafter. The post-operative course was largely uneventful, apart from some issues with a persistent air leak and with pain control. The patient underwent protocol bronchoscopy with transbronchial biopsies at 2 weeks post-transplant, from which H&E and GMS-stained sections are appended.
Case 3 - Slide 1
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Case 3 - Slide 2
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Submitted by: Andras Khoor - Mayo Clinic, Jacksonville, FL
A 32-year-old woman presented with a 4-month history of progressively worsening nonproductive cough. Her history was notable for frequent use of her neighbors' outdoor hot tub.
A chest radiograph (CXR) was suspicious for a cavitary lesion in the left base. Due to worsening cough and dyspnea, she was hospitalized for further evaluation. A CT scan of the chest confirmed a cavitary lesion in the left lower lobe (LLL). Sputum cultures and bronchial washings revealed Mycobacterium avium intracellulare complex (MAC). She was initially treated with ethambutol and azithromycin. Over the course of a week, fevers with temperatures up to 102.4°F, night sweats, progressive dyspnea, and a worsening, now productive cough developed. A repeat chest CT scan revealed the development of bilateral lower lobe infiltrates and a persistent LLL cavity. Therapy with ciprofloxacin was added without noticeable benefit. After 23 days of hospitalization, she was transferred to our facility for further evaluation.
On presentation, she was febrile. The physical examination revealed a very toxic-appearing, tachypneic, thin white female. She became dyspneic after walking < 20 feet. Her CXR revealed ill-defined, multifocal airspace consolidation in both the mid and lower lung zones. On admission to our institution, therapy with ethambutol, azithromycin, and ciprofloxacin was discontinued. Further evaluation included a chest CT scan, which revealed dense areas of consolidation in the lingula and bilateral lower lobes. A 2.8 X 2.9 cm cavitary lesion was present in the LLL. There were scattered small centrilobular nodular opacities in the upper lobes that were consistent with bronchiolitis. A new sputum smear revealed 4+ acid-fast bacilli (AFB), and the culture grew 4+ MAC identified by DNA probe. A BAL from the LLL produced seven colonies of MAC; no other organisms were identified. Transbronchial biopsy specimens revealed a single vaguely formed granuloma. An open lung biopsy specimen was obtained to exclude other etiologies and to confirm the diagnosis of MAC infection.
Case 4 - Slide 1
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Submitted by: Dani S. Zander - Penn State Hershey Medical Center, Hershey, PA
The patient is a 36-year-old male with a history of asthma, who noted the onset of hemoptysis about 5 weeks prior to the biopsy. The hemoptysis waxed and waned daily, but could be more than one cup per day. He also experienced a 12 lb. weight loss over the preceding month, with poor appetite, low-grade fevers, and night sweats. Chest CT revealed a solid left hilar mass measuring 4.0 x 2.6 cm, extending into the apical posterior segment of the left upper lobe. Another mass measuring approximately 17 x 13 mm was noted in the right lower lobe, with adjacent smaller masses. Mediastinal lymphadenopathy was also observed. Hemoglobin was 9.4 g/dl, hematocrit was 27.9%. Reticulocyte count was 98.5 K/ul, or 3.06%. ESR was elevated at 125 mm/hr. Serum electrolytes, WBC, platelets, AST, ALT, total and direct bilirubin, alkaline phosphatase, troponin-I, C3, C4, and urinalysis results were within normal limits. Cultures of blood, urine, sputum, and fine needle aspirate of the lung mass yielded no pathogenic bacteria, no viruses, and no fungi. Legionella pneumophila antigen was not detected in the urine. DFA for influenza A and B performed on nasopharyngeal swabs was negative. RF, CCP antibody, ANCA, anti-GBM antibody, ANA, AFP, HCG, and CEA were negative.
Case 5 - Slide 1 -
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