PMC5943866_01
Chest CT findings. (A) Cluster of tiny lung nodules in the lower lobe of the left lung associated with mild peribronchial consolidation (1 month prior to presentation). (B) Mild mediastinal lymphadenopathy. (C) Circumferential pericardial effusion (day 20). (D-F) Progression of disease characterized by increase in size and number of lung nodules (D: 1 month prior to presentation, E: day 8, F: day 20). In part F, many nodules are subpleural and/or distributed along peribronchovascular interstitium, with new/worse patchy peribronchial consolidation, mainly in the lower lobes. Small pleural effusions are also present. CT = computed tomogram.
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F1
At the current time, chest CT showed a cluster of tiny lung nodules in the left lower lobe associated with mild peribronchial consolidation (Fig. 1A) and mild mediastinal lymphadenopathy (Fig. 1B). Chest CT showed new-onset pericardial effusion (Fig. 1C), progressively confluent airspace opacities in the lower lobes, progression of the nodular component in the mid to upper lung fields, and mediastinal lymphadenopathy. The progression of radiologic findings between the initial CT 1 month prior to presentation and the CT on day 20 is shown in Fig. 1 D to F.
Transbronchial lung biopsy (day 9). Nonnecrotizing granuloma (long arrow) is present in a background of organizing pneumonia (short arrows). The latter finding is a clue that the etiology is not sarcoidosis, but was originally overlooked (hematoxylin and eosin, X200).
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F2
The biopsy revealed nonnecrotizing granulomas (Fig. 2).
Surgical lung biopsy. (A) Scanning magnification showing a nodular, bronchopneumonia-like histologic picture (hematoxylin and eosin, X0.5). Short arrow: small pulmonary artery branch, long arrow: bronchiole, arrowhead: inflammatory infiltrate causing consolidation in peribronchiolar lung. The area indicated by the white arrow is shown at higher magnification in B. (B) High magnification shows occasional nonnecrotizing granulomas (black arrows) similar to those seen in the prior transbronchial biopsy adjacent to larger suppurative granuloma (white arrow). (C) Suppurative granuloma at high magnification. Black arrows: granulomatous rim, white arrow: suppurative necrosis (hematoxylin and eosin, X200). (D) Fungal pseudohyphae and a few yeasts were seen in the suppurative areas on Grocott methenamine silver stain (original magnification X1200).
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F3
The surgical lung biopsies showed extensive suppurative granulomatous inflammation involving >50% of the lung parenchyma (Fig. 3A-C). The process was prominent adjacent to bronchioles, mimicking acute bronchopneumonia (Fig. 3A). The suppurative granulomas contained a neutrophil-rich (abscess-like) necrotic center and a granulomatous periphery composed of epithelioid histiocytes and occasional multinucleated giant cells (Fig. 3C). Within the necrotic centers, fungal organisms (mainly pseudohyphae, and a few yeasts) were identified on GMS stains (Fig. 3D).
Chest CT. (A) One month after surgical biopsy (day 46). (B) Day 330. CT = computed tomogram.
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F4
A follow-up chest CT performed 1 year later showed resolution of nodules and infiltrates (Fig. 4).