PMC7569537_01
Composite image of Maximal Intensity Projection images of high-resolution computed tomography (HRCT) of the thorax from patient 1 showing upper-lobe and peripheral-predominant miliary micronodules
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F1
HRCT showed profuse random micronodules without lymphadenopathy and an upper-lobe and peripheral predominance that was visualized better with maximum intensity projection (MIP, Figure 1).
Composite image of photomicrographs of surgical lung biopsy specimen of Patient 1 with left [Gross Pathological specimen, transverse plane] showing subpleural sparing and (right, Hematoxylin and Eosin stain (H & E), x 4) showing peribronchial and perivascular granulomas (arrow)
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F2
Surgical lung biopsy was performed and showed extensive perivascular non-caseating granulomas (Figure 2).
PMC7569537_02
Composite images of chest radiography of patient 2 showing miliary nodules (left) and HRCT images (major fissure level) showing upper lobe-predominant random nodules. No involvement of the fissure or "beading" of the fissure is seen
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F3
CT-Chest showed random micronodules without zonal preponderance and bilateral hilar lymphadenopathy (Figure 3, left). He remained asymptomatic with near-complete radiologic clearing (Figure 3, right) after one year of stopping methotrexate but relapsed by 18 months and remains on methotrexate.
Composite image of Photomicrographs of lung biopsy sample of Patient 2 with left, [Hematoxylin and Eosin stain (H & E), x scanner power] showing multiple non-necrotizing perivascular granulomas, and right, [H & E stain, x 40) showing a Schaumann body within a giant cell (arrow)
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F4
TBLB; BAL was negative for acid-fast bacilli and Xpert MTB/RIF. TBLB showed perivascular non-caseating granulomas with Schaumann and asteroid bodies (Figure 4).
PMC7569537_03
Composite image of the Chest Radiographs of Patient 3 at initial evaluation (left) showing extensive miliary nodules. Subsequent Chest radiograph (right) after six weeks of anti-tuberculosis treatment alone show profusion of nodules with diffuse ground-glass opacification. Worsening hypoxemia was clinically noted
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F5
Chest radiographs showed miliary nodules (Figure 5, left). However, his symptoms continued to worsen with worsening nodules and development of hypoxemia needing oxygen at four weeks (Figure 5, right).
Composite image of the HRCT image of Patient 3 at the level of major fissure during worsening hypoxemia corresponding to right-side of Figure 5 (left), showing random nodules with fissural prominence, with beading in both oblique fissures; some interlobular septal thickening and diffuse ground glass opacity can be seen and right, (Hematoxylin and Eosin stain, x 40) showing a non-necrotizing granuloma with peripheral lymphocyte cuffing
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F6
CT-Chest showed random micronodules without lymphadenopathy (Figure 6, left). TBLB; BAL was negative for acid-fast bacilli and Xpert MTB/RIF. TBLB showed well-formed perivascular granulomas with Langhans' giant cells, occasional fibrinoid necrosis and lymphocytes rimming (Figure 6, right).
PMC7569537_04
Composite image of chest radiography images (left) of Patient 4 showing miliary nodules at diagnosis and photomicrographs of the lung biopsy specimen [right, Hematoxylin and Eosin stain (H & E) x 4] showing multiple perivascular granulomas (arrow)
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F7
Chest radiographs showed miliary nodules (Figure 7, left). TBLB; BAL was negative for mycobacterial cultures and Xpert MTB/RIF. TBLB showed prominent perivascular non-necrotizing epitheloid granulomas with asteroid bodies (Figure 7, right).
Composite image of the HRCT image of Patient 4 showing (left, upper lobes) random nodules with perilymphatic predominance, beading of the right oblique fissure and perivascular nodules and (right, lower lobes) marked interlobular septal thickening in the lower lobes associated with random nodules
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F8
CT-Chest showed upper lobe predominant random micronodules and lower-lobe interlobular septal thickening (Figure 8, left & right).