PMC6126109_01
Nonpalpable purpura on lower limbs. Multiple dispersed petechiae are observed, which converge in their great majority in the left lower limb.
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fig1
Associated with this, she had 10 days of fever, malaise, myalgias, non-palpable purpura on the lower limbs (Figure 1), mild dyspnea, and intermittent cough without hemoptysis.
HRCT of the thorax, axial view, pulmonary window. There are multiple nodules with random distribution in both lung fields, some of which demonstrate discrete halo sign in ground-glass opacity and others demonstrate cavitation. The largest size is subpleural, in the posterior segment of the right upper lobe, measuring 23 x 32 x 30 mm.
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fig2
In this context, due to pulmonary nodular involvement evidenced in the non-contrast computed tomography (CT) scan of the chest, an HRCT was requested (Figures 2 and 3) which showed multiple generalized, noncalcified nodular lesions, some with cavitations, and the presence of focal areas of ground-glass opacity associated with suggestive basal predominance subpleural cysts that are suggestive of lymphocytic pneumonia.
HRCT of the thorax, axial view, pulmonary window. Right lung with cavitated nodules, noncalcified, with the halo sign evident in one of them (red arrow). Areas of ground-glass opacity in the middle lobe, lingula, and inferior lobes, with thickening of intralobular septa. There are some residual cysts.
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fig3
In this context, due to pulmonary nodular involvement evidenced in the non-contrast computed tomography (CT) scan of the chest, an HRCT was requested (Figures 2 and 3) which showed multiple generalized, noncalcified nodular lesions, some with cavitations, and the presence of focal areas of ground-glass opacity associated with suggestive basal predominance subpleural cysts that are suggestive of lymphocytic pneumonia.
Hematoxylin and eosin stain in lung biopsy. 4X. Pulmonary parenchyma with distortion of its architecture, anthracite pigment is observed, and alveolar septa thickened with inflammatory infiltrate of lymphocyte predominance. Presence of peribronchiolar lymphocytic inflammatory infiltrate in some lymphoid nodules.
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fig4
Presence of inflammatory infiltration of peribronchiolar lymphocyte predominance in some lymphoid nodules is shown in Figure 4.
Crystal violet staining in lung biopsy. 4X. Pulmonary parenchyma where nodules are made up of dense amorphous eosinophilic material that captures the coloration, which confirms the presence of amyloid. In the middle of it, there are inflammatory cells of the lymphoplasmacytic type.
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fig5
In addition, with positive CD3: immunohistochemical markers for reactive T lymphocytes, CD20: for reactive B lymphocytes, and CD38: for plasma cells and kappa and lambda positivity, similar areas of nodular formation were found with amyloid deposition using special staining for crystal violet (Figure 5) and Congo red (Figure 6).
Congo red staining in lung biopsy. 4X. Pulmonary parenchyma with distortion of its architecture, thickened alveolar septa, and nodules constituted by dense amorphous eosinophilic material that captures the coloration, accompanied by lymphoplasmacytic inflammatory cells.
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fig6
In addition, with positive CD3: immunohistochemical markers for reactive T lymphocytes, CD20: for reactive B lymphocytes, and CD38: for plasma cells and kappa and lambda positivity, similar areas of nodular formation were found with amyloid deposition using special staining for crystal violet (Figure 5) and Congo red (Figure 6).