PMC10470279_01
The high-resolution chest CT shows heterogeneity of the attenuation coefficient in both lungs (blue arrow). Ground-glass opacities with a perihilar predominance and prebronchial distribution (green arrow) are also present, along with subpleural nodular thickening in both upper lungs (red arrow) and interlobular interstitial thickening. No areas of consolidation are noted, and the hilum appears unremarkable. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
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High-resolution computerized tomography (HRCT) showed a heterogeneous attenuation coefficient in both lungs, with ground-glass opacities, perihilar predilection, peribronchiolar-vascular distribution, and subpleural nodular thickening in both superior lobes. High paratracheal and subcarinal adenomegalies of 10 mm in their short edges were also noted, suggesting hypersensitivity pneumonitis (Fig. 1).
The thoracoscopic biopsy sample (A) was analyzed using H&E staining at 40x magnification. It showed a dense fibrotic pulmonary interstitium with a small lumen in the obstructed bronchus (blue arrow). (B, C) Another analysis was performed using the Movat stain at 4x magnification, revealing obvious bronchiole occlusion within the peribronchovascular interstitium (red arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
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In some areas, there was complete obliteration of the bronchiole's lumen with intraluminal fibrosis, indicative of constrictive bronchiolitis (Fig. 2).
PMC10470279_02
(A) The lung explant specimen reveals numerous bronchi and bronchioles that are dilated with thickened walls and mucoid material in the lumen. Subpleural fibrosis areas and congested vessels are present in all lobules, but no masses or cavitary lesions are identified. In the scarred areas, there are occluded bronchi and bronchioles along with vascular walls (blue arrow). (B) H&E staining of the lung parenchyma shows abnormal tissue due to the progression of the fibrotic process at 4x magnification (C) and complete fibrotic areas due to pulmonary parenchymal destruction at 40x magnification. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
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The patient was discharged 17 days after transplantation, and the pathologic assessment of the explanted lung confirmed severe constrictive bronchiolitis (Fig. 3, Fig. 4, Fig. 5).
(A, B, C, D) Immunohistochemistry was performed using CK7 marker at 10x magnification. The respiratory epithelium in the areas of bronchiole occlusion showed positive staining for the CK7 marker (blue arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
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The patient was discharged 17 days after transplantation, and the pathologic assessment of the explanted lung confirmed severe constrictive bronchiolitis (Fig. 3, Fig. 4, Fig. 5).
The video bronchoscopy revealed the following findings: (A) The distal trachea and carina showed a normal appearance. (B) The right anastomosis showed no stenosis, dehiscence, or granulomas. (C) In the area prior to the anastomosis, the left main bronchus showed moderate to severe stenosis of the bronchial lumen. (D) A bronchial dilation balloon was seen in the image. (E, F) After dilation, the area of the left anastomosis showed the lumen of the left main bronchus and segmental bronchi with a normal appearance in the background.
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A subsequent bronchoscopy identified a stenosis of the anastomosis on the left bronchus, which was treated with balloon dilatation without any complications (Fig. 6).