PMC5283967_01
Chest radiograph (A) and high-resolution chest CT scan (lung windowing) of the right lobe of the lung (B-D) in case 1.
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Chest radiography revealed the presence of bilateral reticular opacities (Fig. 1A), and a chest computed tomography (CT) scan demonstrated the predominance of ground-glass opacities and interlobular septal thickening in the periphery of the upper lobes (Fig. 1B-D).
An open lung biopsy specimen obtained from the periphery of the anterior segment of the right upper lobe (right S3) and stained with Elastica-Masson in the low-power field (A) and high-power field (B) in case 1. The intraluminal accumulation of macrophages and the focal proliferation of nodular fibrous plugs (arrow) are observed around the respiratory bronchioles (asterisk).
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In the periphery of this focus, alveolar ducts were obstructed by nodular fibrous plugs, which are known as Masson bodies (Fig. 2).
PMC5283967_02
Chest radiograph (A) and high-resolution chest CT scan (lung windowing) of the right lobe of the lung (B-D) in case 2.
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Chest radiography revealed the presence of interstitial shadows in both lung fields and an elevation of the diaphragm (Fig. 3A). A chest CT scan demonstrated the presence of fine bilateral nodular shadows in the middle lobe, and peripheral honeycomb cysts with lung consolidation in the lower lobe (Fig. 3B-D).
An open lung biopsy specimen obtained from the posterior basal segment of the right lower lobe (right S10) and stained with Elastica-Masson (A) and Alcian blue periodic acid Schiff (B) in case 2. Interstitial thickening, honeycombing (asterisk), and fibroblastic foci (arrow) can be observed.
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Microscopically, a usual interstitial pneumonia (UIP) pattern was observed in the lower and upper lobes of the right lung, and this pattern was characterized by interstitial fibrosis, fibroblastic foci, and moderately advanced honeycombing (Fig. 4).
An open lung biopsy specimen obtained from the anterior segment of the right upper lobe (right S3) and stained with Elastica-Masson in the low-power field (A) and high-power field (B) in case 2. The intraluminal accumulation of macrophages and the focal proliferation of nodular fibrous plugs (arrow) are observed around the respiratory bronchioles (asterisk).
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In addition, non-remodeling areas presented changes in the OP pattern, with the accumulation of various inflammatory cells around the bronchioles, obstruction of the peripheral alveolar ducts with Masson body, and the presence of terminal or respiratory bronchioles, which were all findings similar to those observed in case 1 (Fig. 5).
Anelectron probe microanalysis of the periphery of the anterior segment of the right upper lobe in case 1. (A) Hematoxylin and Eosin staining. The deposition of aluminum (B), iron (C), and silicon (D) is shown in yellow.
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In case 1, Fe, Si, Al, and Ca were primarily detected in the peribronchioles and alveolar walls (Fig. 6) and these elements coexisted with a relatively large amount of oxygen.
An electron probe microanalysis of the anterior segment of the right upper lobe in case 2. (A) Hematoxylin and Eosin staining. The deposition of aluminum (B), iron (C), and silicon (D) is shown in yellow.
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Si, Al, and Ca were primarily detected in the peribronchioles and alveolar walls in the OP zone (Fig. 7) and the same elements were detected in the UIP zone. Similar to what was observed in case 1, a high amount of oxygen coexisted with these elements.
Chest radiograph (A) and high-resolution chest CT scan (lung windowing) of the right lobe (B-D) after treatment in case 1.
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In case 1, his symptoms gradually improved (Fig. 8).
Chest radiograph (A) and high-resolution chest CT scan (lung windowing) of the right lobe (B-D) after treatment in case 2.
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The symptoms of case 2 gradually improved and the fine nodular shadows identified on the CT scan resolved after two months of treatment (Fig. 9).