PMC6031097_01
Chest radiograph on the admission shows diffused bilateral ground-glass opacity, particularly in the lower lung field.
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Chest radiograph showed reticulonodular opacities in the bilateral lower field (Fig. 1).
Chest computed tomography on the admission shows diffused ground-glass opacity, patchy areas of consolidation with slightly light granular shadow in the upper lobes but absence of honeycombing.
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Chest computed tomography (CT) showed diffuse ground-glass attenuation, preferentially located in the lower lobes (Fig. 2) with lymphadenopathy in the mediastinum.
18F-FDG PET shows the inflammatory FDG activity in the lungs, hilar and mediastinum lymph nodes.
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Positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro - d-glucose (18F-FDG PET) showed the inflammatory FDG activity in the lungs (SUVmax = 3.4), hilar and mediastinum lymph nodes (Fig. 3).
Papanicolaou staining shows 2% of hemosiderin-laden macrophages in the bronchoalveolar lavage fluid.
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Examination of BALF showed an increased total cell count of 7.8 x 105/mL, almost normal cell fraction (84.5% macrophages, 11.5% neutrophils, 3.1% lymphocytes, and 0.9% eosinophils), with 2% hemosiderin-laden macrophages (Fig. 4), and positive for iron staining, suggesting alveolar hemorrhage.
Histopathological findings of the lung from video-assisted thoracoscopic surgery shows a temporally uniform interstitial fibrosing process (nonspecific interstitial pneumonia pattern) and the mineral deposits throughout vascular elastic fibers, so-called endogenous pneumoconiosis visualized by the Prussian blue stain (F).
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The lung biopsy specimens of the right segments S2 and S8 obtained by video-assisted thoracic surgery (VATS) showed uniform interstitial fibrosis and mild chronic inflammation with lymphoid follicles, suggesting nonspecific interstitial pneumonia (NSIP) pattern (Fig. 5A-D). There are some areas of pigmented macrophages and multinucleated giant cells filling into alveolar spaces (Fig. 5E). The Prussian blue stain identified the mineral deposits throughout vascular elastic fibers, so-called endogenous pneumoconiosis (Fig. 5F).