PMC10332418_01
The clinical course of the patient (schematic). (Red color: During hospitalization, green color: After discharge).
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Medical University (CQMU), Chongqing, China, on May 6, 2021, due to "limb joint pain for more than one month" (Figure 1). More than a month before admission, the patient developed bilateral symmetrical pains in her wrists, elbows, knees, and ankles without obvious causes, along with tenderness.
Enhanced chest CT scanning of the patient. Chest CT enhancement showed bilateral interstitial pneumonia especially the right lower lobe under pulmonary window (A) and multiple mediastinal lymphadenopathies under mediastinal window (B) on hospital Day 2. Chest CT enhancement showed pneumonia of right lower lung was getting smaller under pulmonary window (C) but mediastinal lymphadenopathies were the same under mediastinal window (D) on hospital Day 7. Chest CT enhancement showed the interstitial changes of both lungs were further improved under pulmonary window(E) and the enlarged lymph nodes began to shrink under mediastinal window (F) one month later. Chest CT enhancement showed pneumonia of right lower lung was getting much smaller under pulmonary window (G) and mediastinal lymphadenopathy were getting smaller under mediastinal window (H) two months later. (I) Chest CT enhancement showed pneumonia of right lower lung disappeared under pulmonary window and mediastinal lymphadenopathy were getting much smaller under mediastinal window (J) on the follow-up of 141th days. (Red arrow: interstitial pneumonia, blue arrow: mediastinal lymphadenopathy).
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Enhanced CT scanning of chest (Figure 2) unexpectedly showed bilateral pulmonary interstitial inflammation, with multiple lymphadenopathies, thus pneumonia was considered (Figure 2A and B). One week later, a re-examination of chest CT scanning showed that the inflammation of both lungs was smaller, but lymphadenopathies were basically the same as compared to before (Figure 2C and D). A month later, not only did the interstitial changes in both lungs were further improved by re-examination of chest CT scanning, but also the enlarged lymph nodes began to shrink (Figure 2E and F). The symptoms of joint pain did not recur, the interstitial changes of both lungs on chest CT were further improved, and the enlarged lymph nodes were further reduced (Figure 2G and H). The interstitial lesions in both lungs disappeared completely on chest CT, and the enlarged lymph nodes became much smaller (Figure 2I and J).
(A) Changes of blood routine test based on the episode of treatment: curves of white blood cells and neutrophils percentage (The blue line shows the white blood cells count. The Orange line shows the neutrophils percentage. Thick horizontal line shows the medications administered). Exfoliated cytology (B-E) and pathological results of the patient (F and G). (B) N4: a few lymphocytes. (C) N7: some lymphocytes and individual epithelioid cells. (D) R10: a few inflammatory cells. (E) L11: a few inflammatory cells. (F) N4/N7: squeezed lymphocytes were found in the punctured plasma protein tissue, and a few epithelial like cells were also found. (G) R10/L11: lymphocytes and a few epithelial like cells were found in the plasma protein tissue. (Immunohistochemistry: CK (-), Vim (+), Ki-67 (+) 1%, CEA focus (+), CK7 (-), anti-acid staining (-)).
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Although the patient had no typical symptoms like fever, cough, expectoration, or shortness of breath, levofloxacin was given empirically with elevated neutrophils (Figure 3A). The results of exfoliated cytology showed a few lymphocytes and neutrophils (Figure 3B-E). Pathologist reported squeezed lymphocytes and a few epithelial-like cells (Figure 3F and G).