PMC7262008_01
Chest CT scan on January 2. Peribronchial, subpleural patchy consolidations with an air bronchogram and multiple small nodules in both lungs. Small bilateral pleural effusions and multiple lymphadenopathies in both hilar, right lobar, right and left interlobar areas were also noted.
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On January 2, a chest computed tomography (CT) scan showed patchy consolidations and small nodules in both lungs (Fig. 1).
Chest CT scan on January 23. Progressed necrotic and cavitary changes of the multifocal consolidation and multiple small nodules in both lungs. Abundant bilateral pleural effusions were observed. Multiple lymphadenopathies also showed necrotic changes (arrowhead).
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On hospital day (HD) 9, a chest CT scan showed progressive necrotic and cavitary changes in areas with multifocal consolidations and multiple small nodules in both lungs (Fig. 2).
Bronchoscopic findings. The FOB showed scattered whitish plaque-like lesions, especially on the distal right intermediate bronchus (arrowhead) and right lower lobe bronchus (arrow) (A) and left lower lobe bronchus (arrow) (B).
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The FOB showed an erythematous, friable mucosa with scattered whitish plaque-like lesions especially on both lower lobe bronchi (Fig. 3).
Pathologic findings of the bronchoscopic biopsies (A) The bronchial wall showed extensive necrosis with acute inflammation. The remaining bronchial epithelial cells showed squamous metaplasia (x200). (B) There were multinucleated epithelial cells containing dense, ground glass intranuclear inclusions surrounded by a basophilic rim (Cowdry type B) (arrows) (x600). (C) IHC staining with the HSV confirmed the presence of viral cytopathic cells (arrows) (x600).
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A biopsy showed ulceration, necrotic inflammatory exudates, extensive squamous metaplasia and several multinucleated epithelial cells containing intranuclear inclusions in the exudate on H&E staining, consistent with HSV or varicella-zoster virus: IHC staining showed a positive reaction to HSV (Fig. 4) and a negative reaction to Cytomegalovirus.
Chest X-rays for RLL necrotic nodule. An RLL necrotic nodule (circles) developed on HD 41 (A), and deteriorated on HD 53 (B). The nodule finally improved on HD 103 (C).
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Acyclovir therapy was continued for 12 weeks and the condition of the RLL nodule subsequently improved (Fig. 5).