PMC6537269_01
Case 1: right lateral and ventrodorsal views of the thorax at (a,b) initial presentation and (c,d) 15 days later. (a,b) Increased soft tissue opacity of the right middle and left cranial lung lobes is visible at initial presentation, with a lobar sign and air bronchograms indicating an alveolar pattern. (a) Note the ventral distribution of the lung pattern in the right lateral view, commonly seen in aspiration pneumonia. (c,d) The alveolar pattern in the right middle and left cranial lung lobes is still present in the follow-up radiographs, with only mild improvement of the radiographic findings
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Thoracic radiographs revealed an alveolar pattern in the right middle and left cranial lung lobes, with a ventral distribution (Figure 1a,b). There was only a mild improvement of the lung changes on the follow-up thoracic radiographs 2 weeks after the initial onset (Figure 1c,d).
Cytology of the bronchoalveolar lavage of case 1. Quick Panoptic Stain reveals activated macrophages with lipid droplets within the cytoplasm
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The majority of the macrophages contained multiple round, clear and different-sized vacuoles compatible with lipid droplets (Figure 2).
Case 1: (a) ventrodorsal and (b) right lateral views of the thorax 1 year after the initial presentation. A miliary mineralised 'sponge-like' pattern is visible, affecting the previously consolidated lung lobes
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Thoracic radiographs were obtained before surgery and a miliary 'sponge-like' mineralised pattern was visible in the previously affected lung lobes (Figure 3).
PMC6537269_02
Case 2: (a,b) ventrodorsal and right lateral views of the thorax at initial presentation and (c,d) 2 months later. (a,b) A diffuse increase in soft tissue opacity of the lungs is visible, causing border effacement of the cardiac silhouette and with the presence of air bronchograms, indicating an alveolar pattern. (b) Note the cranioventral and perihilar distribution of the lung pattern in the right lateral view, where air bronchograms are clearly visible and a lobar sign between both left and right cranial lung lobes is present. (c,d) A miliary mineralised 'sponge-like' pattern is visible in the previously affected lung lobes and the diffuse alveolar pattern persists 2 months later. (c,d) Note the compensatory hyperinflation of the aerated caudodorsal lung field
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There was also a focal alveolar pattern with a perihilar distribution in the caudal and accessory lung lobes (Figure 4a,b). Two months later, follow-up thoracic radiographs showed an alveolar pattern (similar to that previously described) with granular mineral opacities and 'sponge-like' appearance of the previously affected lung lobes (Figure 4c,d).
CT images of case 2 in (a) a transverse plane displayed in a lung window (window level -500 and window width 1400) and (b) in a soft tissue window (window level 40 and window width 350) at the same level, showing the caudal and accessory lung lobes. (a) There is a ventral distributed alveolar pattern with punctiform mineral-attenuating areas in both caudal and accessory lung lobes. Note the air bronchograms in both caudal lung lobes (black arrows) in the lung window. (b) Patchy ill-defined fat-attenuating areas (white arrows) are visible within the consolidated lung lobes in the soft tissue window
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Within the consolidated lobes, patchy ill-defined fat-attenuating areas and punctiform mineral-attenuating structures were present (Figure 5).
PMC6537269_03
Case 3: (a) ventrodorsal and (b) left lateral views of the thorax. There is increased soft tissue opacity and granular mineral opacity in the caudal aspect of the right middle lung lobe (black arrows). A lobar sign is visible between the right middle and right caudal lung lobes in the left lateral view (white arrow)
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Increased soft tissue and granular mineral opacity were present in the caudal aspect of the right middle lung lobe (Figure 6).