PMC5558510_01
Chest high-resolution computed tomography (HRCT) scans over the clinical course. HRCT scans before the administration of temsirolimus (A, E) showed bilateral reticular shadows in both lower lobes that were slightly progressed, but not significantly differed from those seen on the patient's first admission (B, F). On the patient's second admission (C, G), a non-segmental ground glass appearance in the right upper and middle lobes was noted, as well as extension of the reticular shadows in the basal lungs bilaterally. On the tenth day of the patient's second admission (D, H), progressive exacerbation of the ground glass opacities was noted to spread throughout most of the lung fields.
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A high-resolution computed tomography (HRCT) scan of the chest showed reticular abnormality with the subpleural and basal dominance that was consistent with possible usual interstitial pneumonia (UIP) pattern (Fig. 1A, E). An HRCT scan of the chest showed bilateral reticular shadows in both lower lung lobes, which slightly spread, but not significantly differed from that before administration of temsirolimus (Fig. 1A, B, E, F). A chest HRCT scan revealed a non-segmental GGO of the right upper and middle lobes, as well as the left lung (Fig. 1C, G), which had not been noted on his previous visit. However, 9 days later, the patient's dyspnea gradually worsened once more and an HRCT scan of the chest (Fig. 1D, H) showed new consolidations in the bottom of the lungs bilaterally, with an increase in the density of ground glass lesions in the entire lung.
Clinical course of the patient. Chest X-ray films on the patient's first admission (B) and after discharge (C) did not show significant deterioration of ground glass opacity (GGO) in both lower lung fields compared with that before initiation of temsirolimus (A). Ten days after the patient's second admission, extended GGOs in the whole lung fields were revealed (D).
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His modified medical research council dyspnea scale improved from grade 4 to grade 2 and chest X-ray film showed no significant deterioration of GGO in both lower lung fields after discharge (Fig. 2).
Macroscopic pathological findings of the lungs at autopsy. Consolidation was noted mainly in the right middle and both upper lobes (A). A honeycomb structure (black arrow) was present at the bottom of the lung (B).
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A honeycomb structure was noted at the bottom of both lungs (Fig. 3).
Microscopic pathological findings of the lungs at autopsy. A diffuse organizational pattern with regional fibrin exudation (black arrow) was revealed in the alveolar region on hematoxylin and eosin staining (A). Expansion of remaining air spaces with epithelial metaplasia (arrow head) (B) and fibrosis with alveolar collapse (C) was identified on elastica-van Gieson staining. Hyperplasia of smooth muscles was shown on hematoxylin and eosin staining (D).
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Microscopically, a diffuse organization with regional fibrin exudation was observed, which is consistent with the organizing phase of diffuse alveolar damage (DAD) (Fig. 4A). Chronic interstitial changes were focally identified in the subpleural area at the bottom, which showed fibrosis with alveolar collapse, expansion of remaining air spaces with epithelial metaplasia, and hyperplasia of the smooth muscles (Fig. 4B-D).