PMC5991914_01
Serial chest radiographs of the patient. The baseline chest radiograph from 2008 was unremarkable (A); a subsequent chest radiograph in December 2015 shows pneumonic consolidation in the left lower field and bilaterally diffuse linear, reticular, and cystic infiltrates (B); another chest radiograph in January 2016 shows resolution of the consolidation but persistence of the interstitial and cystic infiltrates (C).
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A chest radiograph taken in 2008 was unremarkable (Fig. 1A). The chest radiograph taken at that time showed, in addition to her left-lower-lobe consolidation, bilaterally diffuse linear and reticular infiltrations interspersed with finely-cystic lesions (Fig. 1B). A follow-up chest radiography approximately one month later revealed significant resolution of the left-lower-lobe consolidation, but persistent cystic lesions and reticular infiltrates in the rest of her bilateral lung parenchyma (Fig. 1C). T cells at the periphery (Fig. 4C and D). The multiplex polymerase chain reaction (PCR) with heteroduplex analysis revealed the polyclonality of these lymphoid cells (Supplementary Fig. 1).
Comparative images of the computed tomography of chest of the patient in 12-2015 and 07-2016. The left column displays images of transverse sections at the levels of the aortic arch (A), the carina (B), and the lower lungs (C), and coronal reconstruction (D), which show multiple centrilobular nodules, discrete thin-walled cysts, and extensive reticular infiltrates and interlobular septal thickening in bilateral lungs that are particularly prominent in the lower lung fields. The right column displays images of the same levels (E, F, G, H) that were taken approximately seven months later.
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CT scan of the chest revealed thickened interlobular septa, multiple centrilobular nodules, and discrete thin-walled cysts that were particularly predominant in her bilateral middle-to-lower lung fields (Fig. 2A-D). A follow-up CT of the chest about seven months later showed no interval change in the reticular and cystic lesions (Fig. 2E-H).
Gross appearance of the patient's lung under thoracoscopy. Multiple nodular and cystic lesions over the right lung surface of the patient were observed under video-assisted thoracoscopy.
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During the operation, multiple cystic and nodular lesions were observed on the surface of her right lung under thoracoscopy (Fig. 3).
Pathologic features of the biopsied lung parenchyma of the patient. Under lower power (100x), the hematoxylin and eosin (H&E) stained section shows dense infiltration of small mononuclear cells forming follicles adjacent to the respiratory bronchioles (A). Under higher power (400x), the infiltrating cells are small to medium-sized lymphoid cells with scanty cytoplasm, angulated nuclei, and indistinct nucleoli and clumping chromatin. They are mixed with some plasma cells and histiocytes (B). Immunohistochemically, these lymphoid follicles are composed of CD20-positive B cells at the germinal centers (C) and CD3-positive T cells at the periphery (D). No features of non-specific interstitial pneumonia (NSIP) was identified (E), and a small localized focus of fibrinoid vasculitis (which stained negative by Congo red) was observed (F).
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The most prominent histologic findings of the biopsied lung specimen were multiple foci of dense infiltration of many small to medium-sized lymphoid cells admixed with plasma cells and histiocytes (Fig. 4A and B). T cells at the periphery (Fig. 4C and D). The multiplex polymerase chain reaction (PCR) with heteroduplex analysis revealed the polyclonality of these lymphoid cells (Supplementary Fig. 1). No coexisting feature of non-specific interstitial pneumonia (NSIP) was found (Fig. 4E). Localized fibrinoid vasculitis was discerned but only in one small focus (Fig. 4F).