PMC9640337_01
CT from July 2016.
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Computed tomography (CT) of the lung showed no sign of malignancy, but non-specific opacities in the upper lobe of the right lung were detected (Fig. 1).
Spirometry from referral to end of follow. Data for FEV1 and FVC are shown with a unit of liters. Arrows indicate when BAL was performed.
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FEV1/FVC ratio of 0.68 (Fig. 2). Follow-up due to mixed restrictive/obstructive lung disease was recommended, but no further investigations were initiated as the CT findings were interpreted as postinfectious.
HRCT, December 2017.
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HRCT showed bilateral infiltrates, suspicious for multifocal invasive mucinous adenocarcinoma, bleeding, infection and alveolar proteinosis (Fig. 3).
A) Cryobiopsy x200 HE, January 2018. B) Cryobiopsy x400 HE, January 2018. C) Cryobiopsy x400 HE, October 2020. D) BAL x400 Giemsa, January 2018.. A, B & D: Microscopy showed macrophages with vacuolated cytoplasm filling alveolar spaces and focally expanding the interstitium. Vacuolated macrophages were also found in bronchoalveolar lavage, occasionally with large intracytoplasmic vacuoles.. C: Vacuolated alveolar macrophages and fibrotic alveolar septa with sporadic chronic inflammation.
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Cryobiopsy from bronchoscopy showed macrophages localized to the alveolar and interstitial space with fine vacuoles (Fig. 4). Vacuolated macrophages were found in bronchoalveolar lavage, occasionally with large intracytoplasmic vacuoles (Fig. 4).
HRCT, May 2018.
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Three months later, a new CT showed stable distribution of crazy paving patterns (Fig. 5).
HRCT, September 2020.
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Four years after referral, HRCT showed progression of ground-glass opacities and consolidation, which raised new suspicions of possible pulmonary alveolar proteinosis in contrast to earlier bronchoscopy (Fig. 6).
Timeline of diagnostic imaging, endoscopies and biopsies.
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The patient's brother had previously been diagnosed with PD (Fig. 7).