PMC7658484_01
High resolution chest CT showing multiple cavitary lesions in bilateral lung fields with scattered ground glass opacities in a background of underlying granulomatous lymphocytic interstitial lung disease.
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T cell count at 649 (199-846 cells/mcL), and deficient CD19+ B cell count at 1 (91-409 cells/mcL). Chest computed tomography (CT) without intravenous contrast showed interval development of large indeterminate cavitary mass-like consolidative processes in the central left upper lobe and lingula (Fig. 1), and multifocal cavitary masses and nodules with scattered ground glass opacities in both lungs. There was also interval enlargement of mediastinal, hilar and supraclavicular lymph nodes. The overall picture was concerning for development of lymphoma in the left upper lobe/lingula with concomitant multifocal infection/inflammation changes.
Bronchoscopic view inside the cavitary lesion in the lingula. This showed an irregular gray appearance inside the cavity and six biopsies were taken.
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The small bronchoscope (Olympus P190) was advanced inside the lingular lung cavity which did not show significant purulent materials and biopsies of the cavity wall were obtained due to a concern of lymphoma or invasive fungal infection (Fig. 2).
Exuberant necrotizing granulomatous inflammation associated eosinophilic materials (hematoxylin and eosin stain, 200x original magnification) containing many Pneumocystis jirovecii organisms shown by Grocotts Methenamine Silver (GMS) stain (inlet; 400x original magnification).
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The biopsy from the mass-like lesion in the lingula showed necrotizing granulomatous inflammation with pneumocystis organism on Grocott methenamine silver (GMS) stain (Fig. 3).