PMC6149979_01
Computed tomography of the chest before treatment of pembrolizumab. Left pleural effusion, left hilar lymphadenopathy, and left lower tumor were observed (A and B).
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However, as left pleural effusion, left hilar lymphadenopathy, and left lower tumor progressed (Figure 1), pembrolizumab treatment (200 mg/day) was initiated.
High-resolution computed tomography of the chest confirmed the presence of ground-glass opacities with subpleural sparing, interlobular septal thickening, a crazy-paving appearance, and traction bronchiectasis (A-C). Emphysema was also present in both upper lobes.
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Chest CT showed GGOs and consolidation in both the lungs around the bronchial vascular bundles, along with a crazy-paving pattern (Figure 2A-C).
The bronchoalveolar lavage fluid gradually became bloody from the left tube to the right tube.
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Bronchoalveolar lavage (BAL) fluid from the right lower lobe gradually became bloody (Figure 3) with 45% lymphocytes (24.0% CD4, 71.4% CD8), 40% macrophages, 15% neutrophils, and 0% eosinophil.
Pathological findings in biopsy specimens. Thickness of the alveolar walls with myxofibrous and lymphocytic infiltration changes. Agglutination of red blood cells with focal coagulate change was observed in the air spaces of the alveoli (H&E staining) (A). Thickening of the alveolar walls with focal myxomatous early fibrous change was seen (Alcian Blue-Periodic Acid Schiff staining) (B). Scale bars, 100 mum.
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A transbronchial lung biopsy (TBLB) specimen obtained from the right lower lobe showed thickening of the alveolar walls with myxofibrous and lymphocytic infiltration changes (Figure 4).
High-resolution computed tomography of the chest indicated resolution of ground-glass opacities, 2 weeks after corticosteroid therapy (A-C).
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The patient's radiographic abnormal findings resolved rapidly (Figure 5), and oral prednisolone was tapered and then discontinued 3 months later without a recurrence of pneumonitis.