PMC6038330_01
a (400x): Histological findings of the transbronchial lung biopsy sample showed eosinophilic infiltration (arrows) (hematoxylin and eosin staining). b, c (200x): Immunohistochemically dense infiltration of IgG4+ plasma cells was evident in the #4R LN (b) and right S10 (c) sample. d (100x): Fibrosis of interstitium was not observed in the right S10 sample (Elastica van Gieson staining).
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Histological findings from transbronchial lung biopsy (TBLB) specimens showed eosinophilic infiltration (5 cells/high-powered field [HPF]) (Fig. 1a). In the right S10 specimen, patchy plasma cell-dominant inflammatory cell infiltration was apparent, but interstitial fibrosis or eosinophilic infiltration was not observed (Fig. 1d). IgG4+ plasma cells were observed in both the #4R LN and right S10 specimens (Fig. 1b and c), and the IgG4+/IgG+ plasma cell ratio was 36.4% (242/665 cells) in the #4R LN and 24.1% (123/510 cells) in the right S10, neither of which met the Comprehensive Diagnostic Criteria for IgG4-RD (IgG4+/IgG+ plasma cell ratio > 40%).
Chest computed tomography scan obtained at the first admission showed centrilobular granular nodules, ground glass opacity, thickening of the interlobular septa predominantly in the lower lung, consolidation in the right middle lobe and left lingula segment and swelling of the #4R lymph node.
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A chest CT scan showed swelling of the mediastinal lymph nodes, centrilobular granular nodules, ground glass opacity, thickening of the interlobular septa predominantly in the lower lung, and invasive opacity in the right middle lobe and the left lingula segment (Fig. 2).
Gallium scintigraphy obtained at the first admission showed accumulation in the lower lungs.
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Gallium scintigraphy showed accumulation in the lower lungs, but not in the submandibular or lacrimal glands (Fig. 3).
In chest computed tomography scans performed after 3 months of tocilizumab and prednisolone therapy, ground glass opacities in the lower lobe, on both sides, and consolidation in the left lingula segment and the right middle lobe were improved.
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In the chest CT scan, the ground glass opacities in the left lower lobe and the consolidation in the left lingula segment and the right middle lobe improved partially (Fig. 4).