Correlation Between the Roentgenologic and Pathologic Findings in Chronic Pneumonitis of the Cholesterol Type

Abstract

THERE HAS BEEN seen with increasing frequency during the past few years a form of chronic pneumonitis that hitherto we have not recognized in the absence of bronchial obstruction. The process characterized by its chronicity, with either acute or insidious onset, has been considered as a particular type of chronic pneumonitis because of the unusual tissue reactions. The lung is involved in a chronic interstitial inflammation in which the exudate is largely composed of mononuclear cells filled with cholesterol and choJ.esterol esters. Often cholesterol is concentrated to such a high degree in the parenchyma that grossly the tissue appears bright yellow. This type of pneumonitis is common in the presence of bronchial obstruction and is often found in small localized areas in such chronic affections as bronchiectasis, pulmonary abscess, and tuberculosis. In the cases to be reported, however, no major bronchial obstruction or significant coexistent lung disease could be demonstrated roentgenologically or anatomically in the area of pneumonitis. Why this condition is now appearing is difficult to explain. No description of it has been found in the literature other than Adams' (1) presentation of a group of patients with chronic, non-specific suppurative pneumonitis. The possibility that it might represent atypical healing of an infarct has been suggested, but nothing in the histologic studies has confirmed this supposition, even though cholesterol is frequently laid down in slow necrosis of tissue. That the process might be a variation of the ordinary lipoid pneumonitis has also been considered, but again certain factors, from the standpoint of history and of pathology, are not in accord with such a diagnosis. The lesion has been observed in cases in which neither sulfonamides nor penicillin has been administered. The recognition of this type of pneumonitis may be in part due to the recent advances in thoracic surgery and anesthesia. With improvement in technic and the decreasing mortality rate, more and more conditions forme-rly considered inoperable are now being subjected to prompt surgical measures, particularly when there is the least suspicion of tumor. This study is based on 11 cases seen at the Massachusetts General Hospital during the past four years. All but one of the patients were males; the only female was a child of twelve. The age range for the remainder of the group was from thirty-two to sixty-seven years. In more than half, the onset of illness was quite abrupt, characterized by pain, cough, fever, and sputum. In the others, the onset was insidious, with gradual development of cough, sputum, night sweats, weight loss, and in certain instances pain in the chest. The sputum usually varied from mucoid to brownish; in only 3 cases was there frank hemoptysis. As a rule only bacteria of the species generally present in the respiratory tract could be isolated.