PMC4958431_01
Representative computed tomography (CT) sections of the chest. The CT scan from January 2011 reveals few and small nodules, of which one is wedge-resected from the posterior upper lobe (a, arrow). Three years later, nodules became larger and spread to both sides of the lung (b). CT scans half a year later show a massive increase in size and number but also change of morphology in bilateral lung lesions (c, d). Representative image of the surface from the lower lobe of the right lung, taken during thoracoscopy: white, star-shaped lesions appear retracted into the lung tissue, reminiscent of lung metastases (e).
CRJ2016-9254374.001.jpg
PMC4958431_01_CRJ2016-9254374.001.jpg
fig1
A 62-year-old male patient presented in January 2011 with cough and hemoptysis, microhematuria, polyarthritis of both ankles, knees, and left wrist, bilateral lymphadenopathy, and pulmonary nodules revealed by a CT-scan (Figure 1(a)). A thoracoscopically resected pulmonary lesion from the left upper lobe (Figure 1(a), arrow) revealed necrotic granuloma with centrally located silicoanthracosis consistent with silicosis. A follow-up thoracic CT scan (January 2014) revealed new bilateral multiple round lesions (Figure 1(b)). A CT scan (June 2014) showed a massive bilateral progression of nodules in size and number (Figures 1(c) and 1(d)), further aggravating the patient's symptoms. A bronchoscopic forceps biopsy with radial endobronchial ultrasound (R-EBUS) under fluoroscopic guidance from the largest lesion (Figure 1(c)), but also from other lesions, was performed; however, these biopsies were not diagnostic. Therefore, three representative nodules of the right lung were thoracoscopically resected and appeared as whitish, star-shaped lesions on the pleural surface, highly suggestive of metastases (Figure 1(e)).
Representative images of histology shows anthracosilicotic dust bands without necrobiotic granulomas and surrounding perivascular fibrotic dust deposition ((b)-(d), magnification 100x). In addition, giant cell vasculitis with fragmentation of the internal lamina elastic wall is seen ((a), arrow) (magnification 200x).
CRJ2016-9254374.002.jpg
PMC4958431_01_CRJ2016-9254374.002.jpg
fig2
However, there were no necrobiotic granulomas (Figures 2(a)-2(d)). As a new finding, vasculitis with fragmentation of the internal lamina elastic wall was found (Figure 2(a), arrow), and therapy with rituximab was started.