CPC

Shamila Karuthu
Case
 43 year old white male was referred to a
pulmonologist with history of cough for 10
months (since Aug 2009)
 As his symptoms was progressive getting
worse, he had imaging: Chest xray and CT
thorax.
 Patient feels well despite the cough.
 PMH: Nil/ No surgery
 DH: no allergies/ lexapro
 SH: non smoker/ no alcohol/
 Occupation:
 No travel history
 Physical examination:
 Patient appears well. Comfortable.
 BP 120/80
 Chest : Clear CVS: S1S2
 CT scan: patchy nodular infilrates in the
right lung with mild mediastinal nodes.
 Spirometry was requested
 Patient was referred for tissue diagnosis.
 LABS
13.4

6.6 275

139 104 17
92
24 0.97
4.2

Calcium: 9.8
ACE levels: 9
CT findings
 Nodular pattern is a feature of interstitial and
airspace disease
 Distribution and density of nodules can help
narrow the differential diagnosis.
 Perilymphatic nodules are seen in the interlobular
septa, subpleural and peribronchovascular
regions: a distribution seen commonly in
sarcoidosis but also lymphagitis carcinomatosis.
Perilymphatic nodules
 Sarcoid -- Mid to upper lung field
distribution, nodules have irregular
margins, may have adenopathy
 Silicosis/CWP -- Mid to upper lung field
distribution, posterior, nodules have sharp
margins, may have adenopathy
 Lymphangitis Carcinomatosis --
Usually a lot of septal thickening as well
Centrilobular nodules
Centrilobular nodules are those which are central
with respect to the secondary pulmonary lobule.
They are regularly- spaced and do not touch the
pleura or fissures
 Infection -- Endobronchial spread. May or may
not be tree-in-bud
 Hypersensitivity Pneumonitis/Extrinsic
Allergic Alveolitis
 Langerhans Histiocytosis
 Tree-in- bud
• Tree-in-bud describes the appearance of an
irregular and often nodular branching structure,
most easily identified in the lung periphery.
It represents dilated and impacted (mucus or
pus-filled) centrilobular bronchioles.
• Tree-in-bud almost always indicates the
presence of:
• Endobronchial spread of infection (TB, MAC,
any bacterial bronchopneumonia)
• Airway disease associated with infection
(cystic fibrosis, bronchiectasis) less often,
an airway disease associated primarily with
mucus retention (allergic bronchopulmonary
aspergillosis, asthma).
• In centrilobular nodules the recognition of
tree-in-bud' is of value for narrowing the
differential diagnosis.
Random nodules
 Random nodules are those which are neither
perilymphatic nor centrilobular. In general, this is
refers to a hematogenous process, and thus the
differential is that of a miliary pattern:
 Miliary TB
 Miliary Fungal Infection -- Any granulomatous-
type infection
 Metastases -- Thyroid, melanoma, others
 Transbronchial biopsy: revealed
necrotizing granuloma.
Granulomas
 A granuloma is compact aggregate of
histiocytes.
 Aggregation of histiocytes is the minimum
requirement of a granuloma regardless
whether the lesion also contain necrosis,
lymphocytes, plasma cells or
multinucleated giant cells.
Non-Necrotizing granuloma Necrotizing granuloma
Differential Diagnosis of Granulomatous Lung Disease
Approach to DD of Granulomatous
Lung Disease
 Step 1: Attempt to identify an organism
 Organisms most commonly found:
mycobacteria and fungi.
 The search for organisms in the center of
necrotic zones
 Organisms may not be identified in up to
one-third of solitary necrotizing
granulomas.
 Absence of organism dose not imply a
noninfectious condition
TB
 Granulomas of TB are typically necrotizing.
 The granulomas may involve the blood
vessel( similar to wegener’s).
 In immunocompromised patients, the
inflammatory reaction may not be well
developed.
 The organism are well demonstrated in
Ziehl-Nielsen stain.
 PCR technique can be used to distinguish
M.TB from other acid-fast bacilli
NonTuberculous Mycobacterial
infections
 The most common atypical mycobacterial
infection is MAC (M.avium intracellulare complex)
and M.kansasii.
 A unique syndrome due to MAC : Lady
Windermere syndrome (right middle lobe or
lingular segment bronchiectasis due to MAI)
 Necrotizing granuloma is the most common.
 Non specific inflammatory reactions may be seen
and these may be completely absent in AIDS.
 Cultures are necessary for specific identification.
 Histoplasma Coccidioides immitis
capsulatum

Blastomyces
Cryptococcus neoformans yeast
Histoplasmosis
 Endemic in South Central USA ( Ohio and
Mississippi River valley)
 Clinical symptoms: Acute pulmonary
histoplasmosis, disseminated
histoplasmosis and chronic histoplasmosis.
 Infarct-like necrosis granulomas and
vasculitis similar to wegeners.
 Numerous organism within the necrotic
zones ( GMS stain)
Coccidioidomycosis
 Endemic in the southwest USA.
 Pulmonary involvement: Primary
pulmonary coccidioidomycosis, persistent
primary coccidioidomycosis and
disseminated coccidioidomycosis.
 Necrotizing granuloma is characteristic.
 Organism are generally present in
moderate to large numbers.
 If spherules and endospores are both
present, the diagnosis is straightforward.
Cryptococcus
 One-third patients are asymptomatic, others may
present with cough, low grade fever or life-
threatening illness.
 Cavitation occurs in 10-15%.
 The granulomas are often non-necrotizing.
 Appears pale blue / gray on H and E stain.
 The organism’s stains bright red with
mucicarmine.
 Immunocompromised patients with pulmonary
crypto frequent do not have a granulomatous
reaction to the organism.
Back to our patient
 His cultures were negative
 Step 2: Identifying histologic features of
Noninfectious Granulomatous Lung
Disease.
 Patient was started on prednisolone.
HOT TUB LUNG
 Patients usually presents with dyspnea,
cough, low grade fevers and hypoxia.
 There has been debate whether hot tub
lung is predominantly a hypersensitivity
reaction versus an infection.
 Pathological findings are distinct:
combnation of well formed non-necrotizing
granulomas and organizing pneumonia.