Diffuse Nodules Research Articles

BLAST VS MASS: USE OF FLEXIBLE BRONCHOSCOPY AND ENDOBRONCHIAL ULTRASOUND IN THE MEDICAL ICU

BLAST VS MASS: USE OF FLEXIBLE BRONCHOSCOPY AND ENDOBRONCHIAL ULTRASOUND IN THE MEDICAL ICU

ACUTE FIBRINOUS AND ORGANIZING PNEUMONIA (AFOP) PRESENTING AS DIFFUSE CAVITARY LESIONS IN THE SETTING OF EPSTEIN BARR VIRUS (EBV)-INDUCED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH)

ACUTE FIBRINOUS AND ORGANIZING PNEUMONIA (AFOP) PRESENTING AS DIFFUSE CAVITARY LESIONS IN THE SETTING OF EPSTEIN BARR VIRUS (EBV)-INDUCED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH)

LIVING WITH EHLERS-DANLOS SYNDROME: FOLLOWING A YOUNG BOY THROUGH HIS UPS AND DOWNS ON HIS JOURNEY INTO ADULTHOOD

LIVING WITH EHLERS-DANLOS SYNDROME: FOLLOWING A YOUNG BOY THROUGH HIS UPS AND DOWNS ON HIS JOURNEY INTO ADULTHOOD

WITHDRAWN

SESSION TITLE: Systemic Diseases Causing Pulmonary Havoc SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) is an immune-mediated disease characterized by necrotizing vasculitis of the small blood vessels. Pulmonary involvement is common in AAV. Nodules and pleural effusions are the most common pulmonary finding in AAV. Fibrosing interstitial lung disease (ILD) is rarely associated with AAV, and it has a significant prognostication impact. We present a case of usual interstitial pneumonia (UIP) found in a patient with anti-Myloperoxidase (MPO) ANCA and rapidly progressive disease. CASE PRESENTATION: A 71-year-old female presented to the hospital with progressive exertional dyspnea and weakness for several months. Her physical exam was remarkable for bilateral basilar crackles. Oxygen saturation was 91% on ambient air. Chest radiograph showed lower zones interstitial infiltrates. Computed tomography of the chest showed diffuse reticular opacities in both lungs with honeycombing and traction bronchiectasis consistent with definite usual interstitial pneumonia (UIP) pattern. Laboratory evaluation revealed elevated serum creatinine (5.73 mg/dL). Immunology tests showed elevated anti-MPO ANCA titers. A renal biopsy showed the presence of pauci-immune crescentic glomerulonephritis, confirming the diagnosis of ANCA-mediated vasculitis. The patient was treated with plasmapheresis and 500 mg of intravenous methylprednisolone for three days, followed by cyclophosphamide and a medium dose of prednisone. Her kidney function improved, and she was then discharged to follow-up with pulmonary clinic for initiation of anti-fibrotic. DISCUSSION: ANCA-associated vasculitis (AAV) is a small-vessel vasculitis that can involve multiple organs. Pulmonary involvement has been reported in 25%–80% of cases. Sometimes, it can be the initial manifestation of the disease. The most common form of pulmonary involvement in AAV is diffuse pulmonary nodules, with or without cavitation and pleural effusions. Occasionally, patients can present with fibrosing-ILD, particularly with anti-MPO. This presentation is more prevalent in males and the elderly. Among AAV patients with ILD, UIP is the most frequent radiographic pattern. Non-specific interstitial pneumonia (NSIP) pattern can also be seen. ILD has been linked to increased mortality in AAV patients, particularly those with a UIP pattern. Treatment of fibrosing-ILD in AAV patients is not well established, with a questionable role for immunosuppression. Anti-fibrotic agents might be helpful in patients with a UIP pattern. CONCLUSIONS: UIP is rarely associated with AAV, and it can be the leading diagnostic manifestation. A careful clinical history and laboratory evaluation should be performed in patients with UIP to identify and treat any underlying systemic disease. UIP is a poor prognostic sign in AAV. Clinical trials are needed to establish the role of anti-fibrotic in treating this condition. Reference #1: Maillet T, Goletto T, Beltramo G, Dupuy H, Jouneau S, Borie R, Crestani B, Cottin V, Blockmans D, Lazaro E, Naccache JM, Pugnet G, Nunes H, de Menthon M, Devilliers H, Bonniaud P, Puéchal X, Mouthon L, Bonnotte B, Guillevin L, Terrier B, Samson M; French Vasculitis Study Group (FVSG). Usual interstitial pneumonia in ANCA-associated vasculitis: A poor prognostic factor. J Autoimmun. 2020 Jan;106:102338. doi: 10.1016/j.jaut.2019.102338. Epub 2019 Sep 27. PMID: 31570253. Reference #2: Mohammad AJ, Mortensen KH, Babar J, Smith R, Jones RB, Nakagomi D, Sivasothy P, Jayne DRW. Pulmonary Involvement in Antineutrophil Cytoplasmic Antibodies (ANCA)-associated Vasculitis: The Influence of ANCA Subtype. J Rheumatol. 2017 Oct;44(10):1458-1467. doi: 10.3899/jrheum.161224. Epub 2017 Aug 1. PMID: 28765242. Reference #3: Zhou P, Ma J, Wang G. Impact of interstitial lung disease on mortality in ANCA-associated vasculitis: A systematic literature review and meta-analysis. Chron Respir Dis. 2021 Jan-Dec;18:1479973121994562. doi: 10.1177/1479973121994562. PMID: 33605150; PMCID: PMC7897823. DISCLOSURES: No relevant relationships by Mais Abdou No relevant relationships by Khaled Alshabani

S1679 A Case of Polyarthritis Panniculitis and Pancreatitis (PPP) due to Recurrent Alcoholic Pancreatitis

Introduction: Polyarthritis Panniculitis and Pancreatitis (PPP) is a rarely seen extra pancreatic morbidity hallmarked by the triad of joint pain (polyarthritis), tender skin lesions (panniculitis), and pancreatic inflammation (pancreatitis). The pathogenesis is mediated by pancreatic enzyme lipolysis of lipid rich skin and joint sites. Unfortunately, PPP is an elusive diagnosis given the minimal intrabdominal symptoms and a delayed diagnosis may worsen prognosis by as much as 24%. As such, we aim to present a case of this rare diagnosis to familiarize clinicians with the diagnosis of PPP. Case Description/Methods: 67 M with prior alcohol use disorder, recurrent pancreatitis, and complex pancreatic cyst (2.1 x 1.4 cm) status-post fine needle aspiration presented with fever, malaise, diffuse joint pain, and rash. Exam was notable for diffuse visible synovitis, tender joints, and subcutaneous nodules. Patient denied abdominal pain and was hemodynamically stable. Laboratory findings are shown in the Table. Work-up including tickborne panel, Hepatitis B & C serology, Blood cultures, Urinalysis, Chlamydia, Gonorrhea, ASO, CCP, ACE, ANA, ANCA, IgG4, SSA, and SSB were all within normal limits. Right knee aspiration revealed straw colored fluid with 8552 WBC, 86 Neutrophils, no crystals, no growth on culture, and < 3000 RBCs. CT of the Abdomen & Pelvis revealed complex cystic lesion of the pancreatic head measuring 2.2 cm, punctate foci of calcification, no pancreatic ductal dilatation, distal common bile duct within normal limits (Figure A). MRI of the left foot revealed multifocal intramedullary osteonecrosis with bone marrow edema, multifocal synovitis, and prominent intermetatarsal bursitis (Figure B and C). Skin biopsy of the right thumb revealed lobar panniculitis with necrosis of adipocytes and residual “ghost cells”. Patient was managed with IV solumedrol 80 mg, and prednisone taper. On follow-up one month later, patient’s symptoms completely resolved. Follow-up MRI of the abdomen showed stable 2 cm pancreatic cyst which was not consistent with underlying malignancy. Discussion: PPP is a potentially devastating pathology most commonly observed in males with prior alcohol use. The diagnosis often proves elusive given the lack of abdominal symptoms, but early intervention is crucial in reducing mortality and morbidities as seen in our case.Figure 1.: CT of abdomen (A) and MRI of left foot (B, C). Table 1. - Laboratory Findings Hematology Value Hemoglobin 12.2 g/dL Hematocrit 37 % White Blood Cells 12.4 K/uL Platelets 304 K/uL Chemistry Value Sodium 139 mmol/L Potassium 3.8 mmol/L Chloride 104 mmol/L Bicarbonate 26 mmol/L Blood Urea Nitrogen 18 mg/dL Creatinine 0.87 mg/dL Glucose 94 mg/dL Total Bilirubin 0.68 mg/dL Alkaline Phosphatase 69 IU/L AST 27 IU/L ALT 34 IU/L Lipase 20,521 IU/L C-Reactive Protein 14 mg/L Uric Acid 3.6 mg/dL

S2063 Mantle Cell Lymphoma Presenting as Multiple Lymphomatous Polyposis of the Colon

Introduction: Mantle Cell Lymphoma (MCL), a type of non-Hodgkin lymphoma (NHL) is an aggressive neoplasm affecting the lymphatic system. Its incidence is 1–2 cases/105 people/year and accounts for only 5-6% of all cases of NHL. Multiple lymphomatous polyposis (MLP) is a rare presentation seen in MCL consisting of diffuse nodules or polyps covering multiple sites of the gastrointestinal tract. Case Description/Methods: A 68-year-old female with a past medical history of hypertension presented to the clinic with a one-year history of mild diffuse abdominal pain, change in bowel habits including loose stools, and significant involuntary weight loss. A review of systems, physical examination, and routine blood work was non-remarkable. The upper endoscopy was normal but a colonoscopy revealed numerous 1-10 mm submucosal nodules in the entire colon. Biopsies obtained from the nodules of the colon revealed colonic mucosa infiltrated with monotonous, small to medium-sized lymphocytes with irregular nuclear contour, and scant cytoplasm. Immunohistochemistry and immunophenotypic analysis were positive for CD20, CD5, Cyclin D1, BCL6, BCL 2, SOX 11, and negative for CD 10, and P 53. FISH testing revealed 11,14 translocations, consistent with Mantle Cell Lymphoma. CT scan of the abdomen showed pre-carinal, right hilar, extensive para-aortic, and mesenteric lymphadenopathy consistent with stage 4 Mantle Cell Lymphoma. She was subsequently started on Bendamustine and Rituximab combination therapy followed by Rituximab for maintenance. There was a significant improvement in her clinical status with progressive weight recovery. Follow-up upper and lower endoscopic examinations after 6 cycles revealed complete remission with the absence of all polypoid lesions in the GI tract (Figure 1). Discussion: The initial presentation of MCL can widely vary from being asymptomatic to having systemic symptoms of fever and weight loss to marked lymphadenopathy on physical examination. Although 15-30% of individuals with Mantle cell lymphoma (MCL) are reported with involvement in the gastrointestinal (GI) tract, MLP is seen only in less than 10%. It is important for clinicians to not only incorporate MCL as a differential in their workup when they come across diffuse polyps in the GI tract but also to differentiate it from other similar disease processes that present with multiple polyps in the colon. A definitive diagnosis of MLP requires biopsy and histological examination of the tissue with immunophenotypic and immunohistochemistry analysis.Figure 1.: Multiple sessile polypoid lesions of different sizes throughout the colon.

Total spleen calcification - a rare clinical manifestation in systemic lupus erythematosus

Splenomegaly, infarction, spontaneous rupture and hyposplenism are among the frequently manifestations of splenic involvement in systemic lupus erythematosus (SLE) patients. Exceptionally, extensive splenic calcifications are found in SLE. This aspect is due to the periarterial thickening in an “onion-skin” model. Discrete, small, circular and diffuse nodules that are distributed at the level of the parenchyma, but that are missing at the capsular and subcapsular level, are the main characteristics of these calcifications. The aim of this report is to present the case of a SLE patient with this rare splenic calcifications association.

Investigation of newly diagnosed pneumoconiosis from artificial quartz stone manufacturers

Artificial quartz dust exposure may cause associated pneumoconiosis. From November 2019 to July 2020, a total of 27 cases of silicosis associated with artificial quartz stone manufacturers were diagnosed and treated in the Occupational disease Department of Suzhou Fifth People's Hospital. The average age of onset was (46.8±6.6) years, and the average working age of dust exposure was (5.7±1.7) years.The main feature of high KV chest radiography is P/S shadow with strip shadow. CT imaging findings showed diffuse small nodules and ground glass shadows with band shadows. The lesions were mainly distributed in the upper lung, accompanied by pleural thickening, lymphadenopathy and calcification. The pulmonary function impairment was mainly mild restrictive ventilation disorder, and the bronchial mucosa longitudinal plica was the main manifestation under tracheoscopy. The age of silicosis of workers in artificial quartz stone production enterprises is younger, the working age of dust exposure is short, the lung function and bronchial mucosa have a certain degree of damage, and effective preventive measures should be taken in time.

Centri-lobular pulmonary nodules on HRCT: incidence and approach for etiological diagnosis

BackgroundCentri-lobular nodules are the most common pattern of diffuse pulmonary nodules encountered on high-resolution computed tomography (HRCT). HRCT with post-processing techniques such as obtaining maximum intensity projection (MIP) is helpful in making centri-lobular nodules more conspicuous. The study aimed to highlight the role of HRCT with its reconstruction capabilities in the detection and characterization of centri-lobular pulmonary nodules, interpret the most frequent associated findings, and correlate with the clinical findings to reach the most appropriate diagnosis.ResultsThe study included 58 patients; 41.4% males and 58.6% females. Their age ranged from 2 to 67 years with mean age of 25.69. The centri-lobular nodules numbers, distribution, shape, and associated HRCT chest findings were identified. The top three etiological diagnoses were infection/inflammation in 50.0% of cases followed by acute viral bronchiolitis in 27.6% and inhalation bronchiolitis in 19.0% of cases. Correlation of HRCT findings with the clinical diagnosis was carried out with consequent formulation of an algorithm for the diagnostic approach of various etiologies of centri-lobular pulmonary nodules.ConclusionsHRCT is a useful tool in the detection and characterization of centri-lobular pulmonary nodules. It can be used to differentiate the different etiologies that share centri-lobular nodularity. Other associated features and multidisciplinary approach are essential for further characterization of the most relevant etiological diagnosis.

Teaching NeuroImage: A Starry Sky in the Brain.

A 30-year-old HIV-positive man with a history of frequent river bathing presented with headache and fever. Neurologic examinations revealed meningeal irritation. On brain MRI, contrast-enhanced T1WI showed diffuse intracranial nodules with high signal intensity, creating a starry sky appearance (Figure A). Serum IgG antibodies against Schistosoma species were detected using ELISA. High-throughput sequencing confirmed schistosomiasis in the CSF. These findings and the absence of granulomatous diseases indicated a diagnosis of disseminated cerebral schistosomiasis. The patient was treated with glucocorticoids and praziquantel (60 mg/kg, twice/day for 5 days). One year later, a follow-up MRI showed significant lesion absorption (Figure B).

A pulmonary lymphangioleiomyomatosis with multi-site angiomyolipoma: a case report

BackgroundLymphangioleiomyomatosis (LAM) is a rare low-grade malignant tumor featured with diffuse cystic changes due to the destructive proliferation of LAM cells, closely related to angiomyolipoma (AML). Here, we reported a rare case of pulmonary LAM coexisting with AMLs in multiple sites of the lung, liver, kidney, and retroperitoneum. We aimed to contribute to the body of knowledge regarding the diagnosis, identification and treatment of such cases.Case DescriptionA 48-year-old female with no symptoms underwent a chest computed tomography (CT) scan that showed diffuse thin-walled cysts and multiple solid nodules in the lungs. She received a right nephrectomy due to right kidney AML 30 years previously. The pathological manifestations of the right lower lung mass removed by thoracoscopic surgery was a multifocal AML with mutations in the tuberous sclerosis complex gene. Abdominal magnetic resonance imaging (MRI) reveals a vast area of fat signal shadow behind the peritoneum and multiple scattered fatty signal nodules in the liver parenchyma. No other treatment was given due to personal factors of the patient, and there was no significant change at the 1-year follow-up.ConclusionsLAM and AML are two different but substantively related rare neoplastic diseases. When typical LAM imaging features are found on chest CT or in pathological specimens collected from patients diagnosed with AML, multisystem screening should be performed for the early detection and diagnosis of LAM.

A Rare Case of Ulcerative Colitis with Diffuse Parenchymal Lung Disease, Spontaneous Pneumomediastinum and Subcutaneous Emphysema

A 50-year-old male, a tobacco smoker, who was known to have ulcerative colitis presented with dry cough, chest pain, dysponea and frequent passage of blood and mucous mixed stools. Physical examination revealed clubbing, subcutaneous emphysema of upper chest and auscultatory findings of crunching sound over pre-cordial area and basal crepitations. Spirometry was suggestive of restrictive pattern. High resolution computed tomography (HRCT) of thorax revealed pneumomediastinum, subcutaneous emphysema, bilateral diffuse centrilobular nodules and ground-glass haziness with mosaic pattern along with posterior basal fibrotic changes. The present case documents the uncommon pulmonary involvement of spontaneous pneumomediastinum and subcutaneous emphysema diffuse parenchymal lung disease, in a patient with ulcerative colitis.

Computed tomographic findings of peritoneal lymphomatosis in a cat: a case report

A 12-year-old castrated male Persian cat presented with abdominal distension, anorexia, and no defecation. The radiography revealed ascites, pleural effusion, and a cranioventral mediastinal mass. Ultrasonography showed a well-defined mass lesion within a thickened ileal segment with a transmural loss of layering and multiple hyperechoic nodules arising from the peritoneum. Computed tomography showed peritoneal thickening with contrast enhancement, a bulky heterogeneous ileal mass, and mesenteric involvement with diffuse nodules. An alimentary lymphoma was confirmed by fine needle aspiration of the small intestinal mass. Peritoneal lymphomatosis is rarely reported as a metastatic manifestation in veterinary medicine. This report describes the imaging features of lymphoma with peritoneal lymphomatosis in a cat.

THE 17TH CONFERENCE OF HO CHI MINH CITY SOCIETY OF DERMATO-VENEREOLOGY

Conidiobolomycosis is a rare fungal infection caused by Conidiobolus coronatus. We provide the first case of rhino-facial conidiobolomycosis in the North of Vietnam. A 32-year-old rural male patient presented with some diffuse subcutaneous nodules affecting centrofacial area. Histopathology showed granulomas with hyphae known as Splendore-Hoeppli phenomenon. The patient was successfully treated with combination therapy including saturated solution of potassium iodide and itraconazole.

RHINO-FACIAL CONIDIOBOLOMYCOSIS IN YOUNG VIETNAMESE MEN

Conidiobolomycosis is a rare fungal infection caused by Conidiobolus coronatus. We provide the first case of rhino-facial conidiobolomycosis in the North of Vietnam. A 32-year-old rural male patient presented with some diffuse subcutaneous nodules affecting centrofacial area. Histopathology showed granulomas with hyphae known as Splendore-Hoeppli phenomenon. The patient was successfully treated with combination therapy including saturated solution of potassium iodide and itraconazole.

ASYMPTOMATIC PULMONARY CRYPTOCOCCUS IN AN IMMUNOCOMPROMISED PATIENT

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: Cryptococcus is an opportunistic fungal infection known to cause symptomatic disease in both immunocompromised and immunocompetent patients. While asymptomatic cryptococcal infections have been observed in immunocompetent patients, they have never been identified in the immunocompromised population. We present a case of an asymptomatic pulmonary cryptococcus in an immunocompromised patient. CASE PRESENTATION: 51-year-old female with rheumatoid arthritis on Methotrexate and Tofacitinib was evaluated for an incidental 5 mm pulmonary nodule on commuted tomography (CT). 6-month interval imaging showed diffuse pulmonary nodules and ground glass opacities throughout the right lung. Her only symptoms included an episode of bronchitis that resolved completely with antibiotics 1 month prior to follow-up CT. The significant CT abnormalities prompted a bronchoscopy with transbronchial biopsy which demonstrated bronchiolitis obliterans and rare clusters of histiocytes not organized into distinct granulomas, suggestive of organizing pneumonia. Bronchoalveolar lavage grew less than 5 colonies of cryptococcus neoformans. Biopsy was sent for additional stains demonstrating cryptococcus neoformans. Given her immunocompromised state, fluconazole therapy was initiated. Follow-up imaging showed significant improvement of nodular and ground-glass opacities. DISCUSSION: Cryptococcus is well known to cause symptomatic disease in immunocompromised patients including meningoencephalitis, disseminated disease via hematogenous spread, or pneumonia. While our patient was at risk for a cryptococcal infection due to use of Methotrexate and Tofacitinib, she was asymptomatic. Further investigation was pursued only due to family history and significant CT abnormalities enabling proper diagnosis and treatment. CONCLUSIONS: Cryptococcus should remain on the differential of an immunocompromised patient regardless symptomatology. Bronchoscopy should be considered for appropriate diagnosis and treatment. DISCLOSURE: Nothing to declare. KEYWORD: fungus

Causes and implications of the seasonal dissolution and precipitation of pedogenic carbonates in soils of karst regions – A thermodynamic model approach

Red Mediterranean Soils developed over carbonate rocks can precipitate pedogenic carbonates at the base of their profiles, forming an evolutionary stage of calcretes. We studied a 0.6 m deep soil profile in Dalmatia (Croatia) where the lowest section of the soil is a calcic horizon formed by diffuse calcite particles and small nodules. These nodules record different events of dissolution and precipitation. Using a 3-month period of soil environmental monitoring, where soil temperature, soil water content, soil bulk electrical conductivity and soil air CO2 were measured, we implemented a thermodynamic model for dissolution and precipitation of calcite in the soil. The simulation shows a stage dominated by calcite dissolution during spring and early summer followed by a stage dominated by calcite precipitation. Soil air CO2 is the main control of the calcite reactions, with concentration of solutes also being of some importance during the stage of calcite precipitation. Soil water content and temperature, both affect soil air CO2. Precipitation events also have high-frequency impact on soil air CO2, but the response is complex. The model enables soil water solutions to be supersaturated in relation to calcite without precipitation of that mineral. Simulated soil water reached variable values of supersaturation in relation to calcite before its precipitation was triggered, suggesting that there is no fixed threshold value for the precipitation of calcite in a particular soil. During the 3-month simulated period, 83% of the calcite dissolved was reprecipitated as pedogenic carbonate. Most of the initially dissolved calcite, was expected to be diffuse pedogenic carbonate particles, although nodules and bedrock at the base of the soil should also have contributed to the solutes dissolved. Therefore, karst landscapes where soils have pedogenic carbonates are expected to record less denudation rates than those regions without calcretes.

Pre tibial myxedema associated with hypothyroid Hashimioto’s thyroiditis

Pretibial myxedema (PTM) is an infiltrative dermopathy due to accumulation of glycosaminoglycans in the dermis and sub cutis. It is commonly associated with Grave’s disease. However, it is infrequently associated with Hashimoto’s thyroiditis and primary hypothyroidism. It often presents as an asymptomatic diffuse non pitting edema, nodule or plaque involving both pretibial areas. Pretibial myxedema may undergo partial or complete remission and is primarily a cosmetic concern for the patient. Apart from treatment of the primary thyroid abnormality, topical or intralesional steroids remain the mainstay of treatment. We report a case of a 72-year-old lady who presented with non pitting edema on both legs. Her thyroid function tests were suggestive of hypothyroidism and thyroid auto antibody profile, ultrasonography and fine needle aspiration cytology favored Hashimoto’s thyroiditis. Histopathology of the pretibial skin was in consistent with pretibial myxedema. A paradox of pretibial myxedema in a patient with Hashimoto’s thyroiditis is a rare clinical entity.

A novel differential diagnosis for diffuse cavitating nodules: primary pulmonary plasmacytoma

BackgroundExtramedullary plasmacytoma is a rare monoclonal plasma cell neoplasm that originates from tissues other than the bone marrow and constitutes only 3%–5% of all plasma cell neoplasms. Most cases involve the upper respiratory tract. Extramedullary plasmacytoma involving the lung is extremely rare. Primary pulmonary plasmacytoma is a rare type of extramedullary plasmacytoma, usually presenting with a nodule or mass in hilar region. Literature search has shown very few cases of immunohistochemically confirmed cases of pulmonary plasmacytoma. Diffuse pulmonary infiltration is an unusual presentation.Case presentationWe report the case of a 56 year old lady with history of cough and breathlessness since one month. Computed Tomography revealed diffusely scattered multiple cavitating nodules and consolidation in both lungs. Computed Tomography guided biopsy of one of the lung nodules was done. Histopathologic examination and immunohistochemistry showed features of pulmonary plasmacytoma .This is an unique case of primary pulmonary plasmacytoma with the rare presentation as diffusely scattered multiple cavitating nodules and consolidation. According to our literature search, primary pulmonary plasmacytoma manifesting as cavitating nodules is being reported for the first time.ConclusionsPrimary pulmonary plasmacytoma should be also be considered in the differential diagnosis of multiple diffusely scattered cavitating lung nodules.

Drug-induced hypersensitivity syndrome caused by minodronic acid hydrate

BackgroundDrug-induced hypersensitivity syndrome (DIHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an important adverse reaction caused by a few drugs. Reactivation of human herpesvirus 6 (HHV-6) is known to be associated with its pathogenesis. DIHS occasionally manifests as pulmonary lesions with a variety of imaging findings.Case presentationAn 83-year-old woman started taking minodronic acid hydrate 5 years before admission. She noticed a generalized skin rash 44 days before admission and started oral betamethasone-d-chlorpheniramine maleate combination tablets for allergic dermatitis. She developed a fever and cough in addition to the rash, and was referred to our hospital. Laboratory data showed a high level of eosinophils and liver and biliary enzymes. Computed tomography (CT) studies revealed bilateral diffuse ground-glass opacities with ill-defined centrilobular nodules from the central to peripheral regions of the lungs. Transbronchial lung cryobiopsy specimens showed that lymphocyte infiltration was observed in the alveolar walls and fibrinous exudates and floating macrophages in the alveolar lumina. Immunohistochemistry of biopsy specimens showed more CD4+ lymphocytes than CD8+ lymphocytes, while few Foxp3+ lymphocytes were recognized. The serum anti-HHV-6 immunoglobulin G titer increased at 3 weeks after the first test. Based on these findings, we diagnosed her with DIHS. We continued care without using corticosteroids since there was no worsening of breathing or skin condition. Eventually, her clinical symptoms chest CT had improved. Minodronic acid hydrate was identified as the culprit drug based on the positive results of the patch test and drug-induced lymphocyte stimulation test.ConclusionsWe described the first case of DIHS caused by minodronic acid hydrate. Lung lesions in DIHS can present with bilateral diffuse ground-glass opacities and ill-defined centrilobular nodules on a CT scan during the recovery phase. Clinicians should be aware of DIHS, even if patients are not involved with typical DIHS/DRESS-causing drugs.