MEETING No. 45 - SEPTEMBER 11th, 2002 - NIGUARDA HOSPITAL, MILAN

Case 1
Case 2
Case 3
Case 4
Case 5

Case 5


“LUNG NODULES”
E. BONACINA – Niguarda Hospital - Milano
(pict. by dr. Bonacina)

Clinical history (first): a 35y.o. woman is admitted in February 2001 in the Pneumology Dept. for cough and slight dyspnea.
A CT scan shows the “diffuse interstitial lung disease” like, so called changing, lung infiltrates (pict. 1).
A surgical biopsy is performed. After excluding an UIP (Usual interstitial pneumonia), an ILP (Interstitial Lymphoid Pneumonia) and a Bronchocentric Granulomatosis, the final histological diagnosis, in accordance with the clinical diagnosis, is BOOP (bronchiolitis obliterans organising pneumonia).
Microbiological investigations are negative. The patient is discharged with immunosuppressive therapy (Prednisone and Azatioprin), which is followed by an apparent improvement of the lung lesions.
Microscopical description of the first biopsy: the lung parenchyma is altered by the presence of confluent nodules, which consist of polymorph lymphoid cells with granulomatous lesions, which include multi-nucleated histiocytes (pict. 2 - pict. 3 - pict. 4 - pict. 5).
Clinical history (second): In March 2002 some ulcerated-infiltrative skin lesions appear on the left leg. The histological and microbiological examinations show the presence of Kansasii Mycobacterium (pict. 6).
The patient is treated with ABG. In April 2002 there is a new admission in the Pneumology Dept. for a new attack of BOOP with respiratory failure and the appearance of torpid skin ulcers. A CT scan of the thorax confirms the interstitial disease with parenchymal thickening and pleural involvement.
A further microbiological examination is negative. A BAL shows 89% lymphocytes, 2% macrophages, and 8% eosinophils. Molecular biology investigations performed on the BAL show a monoclonal rearrangement of the IGH gene (high weight chains).
A new lung biopsy is performed.
In April 2002 the genome of the Epstein-Barr virus is identified by PCR on the BAL.
Microscopical description of the second biopsy: the lung parenchyma shows nodular and interstitial aggregates of polymorphous lymphoid cells, which surround some of the medium sized blood vessels (pict. 7 - pict. 8.
Some of the nodules involve the adjacent alveoli (pict. 9).
The cells are of various aspect (pict. 10) mainly T-CD4 positive lymphocytes (pict. 11).
With immunohistochemical staining for CD20 the B cells are only scarcely represented (pict. 12).

Diagnosis

pict. 1	pict. 2
pict. 3	pict. 4
pict. 5	pict. 6
pict. 7	pict. 8
pict. 9	pict. 10
pict. 11	pict. 12

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