PMC6930180_01
Radiation-induced pneumonitis. (A) After receiving three-dimensional thoracic radiotherapy, a CT scan showed new patchy opacity developed in the irradiated area of hilum of the right lung, which did not occur outside the irradiated area. (B) This patient initiated steroid treatment, pneumonitis was partially resolved within 1 month, with a significantly clinical improvement. (C) Pulmonary inflammation disappeared 2 months later. White arrow indicates inflammatory lesions.
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F2
At that time, a computed tomography (CT) scan of the chest was performed and revealed new patchy ground-grass opacities in bilateral lobes of the lung, and small right pleural effusions, without new pulmonary tumor lesions (Figure 2A). Based on her clinical presentations and radiotherapy history, radiation-induced pneumonitis was diagnosed, and she initiated systematic steroid treatment and reported symptomatic improvement gradually (Figures 2B,C).
Immune-related pneumonitis. (A) A CT scan showed no any inflammatory lesions in the lungs following the treatment with first PD-L1 inhibitor atezolizumab. (B) Nivolumab was started when this patient progressed on atezolizumab treatment. A CT scan indicated new patchy ground-grass opacities in the bilateral lungs, with a small left pleural effusion. Immune-related pneumonitis was identified when blood and sputum culture did not reveal a causative microbial organism. (C) After treatment with corticosteroid for 1 week, this patient's symptom improved significantly, with a radiologic complete resolution of the ground-glass opacities and the pleural effusion. (D) Ten days later, a CT scan showed reoccurred pneumonitis, of grade 3 severity. (E) High-dose intravenous corticosteroid therapy did not alleviate her symptoms within 5 days, with worsening radiographic findings. (F) After she received immunosuppressive agents including infliximab, mycophenolate mofetil and human immunoglobulin, fever, dry cough, and dyspnea were relieved significantly, with a significant improvement of pulmonary inflammation. White arrow indicates inflammatory lesions.
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F3
A CT scan showed new patchy ground-grass opacities in the lung bilaterally, with a small right pleural effusion that was not present 1 month ago (Figures 3A,B). She received intravenous methylprednisolone (2 mg/kg every day for 5 days) and sequent treatment and inflammation was improved on day 15 (Figure 3C). An additional CT scan showed obvious reoccurred pneumonitis of the bilateral lungs, of grade 3 severity (Figure 3D). At that time, she was firstly diagnosed with concomitant bacterial pneumonia with Klebsiella pneumoniae, but the use of specific antibiotics did not improve her symptoms (Figure 3E). After treatment with combination immunosuppression, fever, dry cough and dyspnea on exertion were relieved significantly and oxygen saturation returned to a normal level, with a significant radiographic improvement of pulmonary inflammation (Figure 3F).