Ground-glass Opacity Research Articles

Introduction: Heart failure (HF) affects interstitial lung structure and function. AI-assisted quantitative computed tomography (qCT) offers possibility of objective assesment of lung structure, allowing to detect the presence and the severity of HF. Hypothesis: Can automated qCT analysis discriminate HF from controls and identify tissue structures most linked to degree of congestion ? Methods: Subjects underwent right heart catheterization (RHC), native CT chest imaging (full inspiration/expiration) by Naeotom-α photon-counting CT scanner (Siemens), lab testing, echocardiography. Automated AI-based analysis (VIDA Diagnostics) was employed to evaluate lung volumes, densities and tissue texture. Image series were used in mediastinal and lung window reconstruction with slice thickness 0,8 mm and increments 0,5 mm. Results: 186 HF patients (85% HFrEF, NYHA 2.8±0.5, 58 y, 80% males, NTproBNP 4491 pg/ml, LVEF 26%) and 43 controls of similar sex and BMI were analyzed; both groups free of primary lung disease. In HF, 85 % had PH (mPAP>20mmHg). HF patients had comparable inspiratory lung volume, reduced air volume and increased lung tissue volume, compared to controls. Mean lung density (-782±50 vs -832±25 HU, p<0.0001), density variability and estimated lung fluid content (21.3 vs 16.7%, p<0.0001) were all higher in HF compared to controls. Across various density cut-offs, the most notable difference was at lung tissue density < -856 HU at inspiration. Lung tissue density corelated with mean PA pressure (r=0.49, p<0.0001), and less with pulmonary vascular resistance (r=0.21, p=0.006). Insp/exp scan analysis showed no difference in air trapping, but reduced lung tissue compliance (Jacobian strain: 1.8±0.4 vs 1.6±0.3, p=0.0005) in HF. Lung texture analysis showed increased ground-glass opacity (GGO) mass (48.8 g vs 9.1 g; p < 0.001), reticulation (42.2 g vs. 8.4 g; p < 0.001) and consolidation (0.5 g vs 0.2 g; p=0.0011) in HF compared to controls, with no difference in honeycombing. GGO mass correlated strongly with pulmonary capillary wedge pressure (PCWP) (r=0.48, p<0.001) and mitral regurgitation grade (r=0.28,<0.0001), but not with inflammation (hsCRP, IL6, WBC), smoking exposure or oncotic pressure. Conclusions: qCT distinguished HF patients from controls by increased lung tissue mass, reduced air volume, increased lung density and increased mass of GGO and reticulation. GGO mass in HF strongly reflects increased hydrostatic pressure, but not inflammation.

Cystic fibrosis (CF) is the most common autosomal recessive multisystemic disease in Europe, with pulmonary complications significantly influencing patients' morbidity and mortality. The objective of this review is to compare different imaging modalities and present characteristic pulmonary CF manifestations. X‑ray examinations of the chest are often considered the basic diagnostic tool increasingly replaced by magnetic resonance imaging (MRI). Cross-sectional imaging techniques (computed tomography [CT] and MRI) provide amore sensitive diagnostic of pulmonary manifestations of CF. Characteristic manifestations are-among others-bronchial dilatation, bronchial wall thickening, mucus retention, bronchiolitis pathologies with "tree-in-bud sign" and centrilobular nodules, consolidations, mosaic pattern with ground-glass opacities and air trapping. Typical pulmonary complications include acute exacerbations with inflammatory infiltrates and allergic bronchopulmonary aspergillosis (ABPA) with specific radiologic changes. Because of improved technologies, radiation exposure of CT examinations is continuously decreasing. MRI also shows continuous technical optimization. An important technical advance of MRI is the ability to obtain functional perfusion and ventilation images without radiation exposure and without intravenous contrast agent application. Due to improved treatment options-in particular modulator therapy-pulmonary manifestations typical of CF are today less pronounced than in the past. CT and MRI are suitable for therapy monitoring, with MRI being preferable because of its absence of radiation exposure and the possibility of functional information.

In the phase3 CONVERT trial, amikacin liposome inhalation suspension (ALIS) plus guideline-based therapy (GBT) achieved greater culture conversion than GBT alone in the treatment of refractory Mycobacterium avium complex pulmonary disease (MAC-PD). In the original analysis of safety data in CONVERT, the rate of hypersensitivity pneumonitis, a prespecified group of adverse events of special interest, was higher in patients receiving ALIS plus GBT (3.1%; n = 7) versus GBT alone (0.9%; n = 1), with half of the cases reported in Japanese patients. We present a summary of serious adverse events of hypersensitivity pneumonitis that investigators deemed related to ALIS treatment in Japanese patients enrolled in CONVERT (n = 3) and its extension study (INS-312; n = 1). Patients were women older than 65years diagnosed with pneumonitis (n = 3) or interstitial lung disease (n = 1) after initiation of ALIS (range 3-189days). Following ALIS discontinuation and medical intervention, all four patients recovered from pneumonitis. Additional investigator-collected imaging and serum Krebs von den Lungen6 (KL-6) data were available for two of these patients, permitting assessment of KL-6 and the potential diagnostic role of radiographic findings. At the time of diagnosis, one patient had ground-glass opacity, and the other patient had consolidation in the right lower lobe of the lung; both patients had serum KL-6 levels > 600U/mL. Changes in chest radiography and KL-6 levels at the onset of respiratory symptoms during ALIS treatment suggest that these assessments may help guide management strategies for potential hypersensitivity pneumonitis in patients taking ALIS.Clinical Trial Registration: NCT02344004 (CONVERT) and NCT02628600 (INS-312).

Background: Granulomatosis with polyangiitis (GPA) is a rare ANCA-associated vasculitis characterized by necrotizing granulomatous inflammation and small- to medium-vessel vasculitis. The COVID-19 pandemic has raised interest in its potential to trigger autoimmune diseases like GPA. This retrospective study investigates changes in GPA frequency, clinical features, and serological patterns before and after the COVID-19 pandemic. Methods: This retrospective study analyzed 72 patients with granulomatosis with polyangiitis (GPA) at one of the most referral hospitals (2016–2024), divided into pre-COVID (n = 27) and post-COVID (n = 45). Demographic, clinical, radiological, and laboratory data were collected. Pre and post-COVID groups were compared using t-tests and chi-square tests. Firth’s logistic regression identified predictors of post-COVID GPA, adjusting for age, sex, ANCA subtype, and clinical features. Results: A total of 72 patients with granulomatosis with polyangiitis (GPA) were analyzed, including 27 diagnosed pre-COVID-19 and 45 post-COVID-19. The post-COVID-19 cohort was significantly younger (mean age 37.75 ± 10.38 vs. 50.66 ± 12.76 years, P < 0.001) and showed increased prevalence of pulmonary ground-glass opacities (64.4% vs. 25.9%, P = 0.003), cutaneous manifestations (75.6% vs. 25.9%, P = 0.004), and ophthalmic involvement (44.4% vs. 11.1%, P = 0.007). Firth’s logistic regression identified younger age (OR = 0.89, 95% CI: 0.82–0.97, P = 0.008), male sex (OR = 1.94, 95% CI: 1.02–3.99, P = 0.044), pulmonary ground-glass opacities (OR = 5.71, 95% CI: 1.84–18.27, P = 0.002), and ophthalmic complications (OR = 3.27, 95% CI: 1.02–10.48, P = 0.047) as predictors of post-COVID-19 GPA. No association was found between COVID-19 vaccination and GPA onset or relapse (P = 0.429). Conclusion: This study reveals a higher frequency of granulomatosis with polyangiitis (GPA) and a younger age at onset post-COVID-19. Predictors of post-COVID-19 GPA included younger age, male sex, and pulmonary involvement. SARS-CoV-2 may trigger autoimmune activation, but no link with vaccination was found. GPA clinical features remained consistent, warranting ongoing monitoring and research into COVID-19’s autoimmune effects.

Introduction: Diffuse alveolar hemorrhage (DAH) is characterized by hemoptysis, anemia, and diffuse pulmonary infiltrates due to alveolar bleeding. Common causes include vasculitides, coagulopathy, infections, and valvular heart disease. DAH secondary to severe hypertension is extremely rare. We present a case of DAH in a patient with poorly controlled hypertension. Case Description: A 58-year-old man with diabetes and poorly controlled hypertension presented with three days of hemoptysis. He denied other episodes of overt bleeding, chest pain, arthralgias, weight loss, or fever. He had a prior history of treated latent tuberculosis. He traveled to Las Vegas and noted a blow of moldy dust which he recalled as the only significant recent exposure. On arrival, BP was elevated at 206/131 mm Hg, but he was otherwise hemodynamically stable. Troponin was mildly elevated but later normalized. CBC and BMP were unremarkable. Inflammatory markers were minimally elevated (CRP: 3 mg/L, ESR: 10 mm/hr). CT chest showed diffuse bilateral ground-glass opacities. Bronchoscopy with BAL revealed friable mucosa and progressively bloody aliquots, confirming DAH. There was no evidence of malignancy or infection from BAL analysis. Extensive workup for DAH, including ANA, ANCA, cryoglobulins, anti-GBM, QuantiFERON, AFB smears and cultures, Leptospira, Legionella, Strongyloides, fungal, and bacterial cultures, was negative. TTE demonstrated normal EF and moderate LV hypertrophy; there was no valvular abnormality. With no alternate etiology, severely uncontrolled hypertension was deemed the most likely cause of DAH, supported by a few published case reports. The patient was started on nifedipine 60 mg and losartan 50 mg daily. With improved blood pressure for the remainder of his hospital stay, hemoptysis gradually resolved. At the post-hospital visit, he remained asymptomatic with good blood pressure control and complete resolution of lung opacities on imaging. Conclusion: Severe hypertension can cause end-organ damage, affecting the heart, brain, and kidneys; however, DAH is a poorly recognized complication. Proposed mechanisms include alveolar capillary stress failure, microvascular endothelial injury, and pulmonary venous hypertension. While DAH is a rare presentation of severe hypertension with very few cases reported in the literature, our case highlights this unique complication and the importance of strict blood pressure control in its management.

BackgroundThis study aimed to investigate longitudinal change of idiopathic inflammatory myopathy-associated interstitial lung disease (IIM-ILD) on high-resolution computed tomography (HRCT).MethodsThis prospective cohort study was undertaken involving 514 IIM-ILD patients (367 females; median age 54 years) from 2016 to 2022. Deep learning algorithms were employed to quantify interstitial lesions on HRCT, while clinical parameters including pulmonary function tests, serum biomarkers, and arterial blood gas analysis were also considered.ResultsThe study identified anti-MDA5 antibody positivity (OR: 10.46, 95% CI: 3.40–32.22), reduced FVC (OR: 0.91, 95% CI: 0.84–0.98), and extensive ground-glass opacity (GGO) (OR: 1.07, 95% CI: 1.01–1.13)/ reticulation (OR: 1.23, 95% CI: 1.07–1.41) involvement as independent risk factors for rapidly progressive interstitial lung disease (RP-ILD) within IIM. During the rapid progressive period of RP-ILD, anti-MDA5-positive dermatomyositis (MDA5 + DM) showed greater progression in fibrotic, inflammatory, and emphysema lesions compared to anti-synthetase syndrome (ASS). In the slow progressive period, MDA5 + DM tended towards chronic fibrosis, while ASS exhibited overall improvement. The extent of lesion increase in non-RP-ILD patients is significantly smaller than in those who have experienced RP. Reticular and consolidation changes were strongly correlated with variations in VC%, FVC%, and FEV1%, and moderately associated with changes in TLC and DLCO. The prognostic impact of GGO proportion on adverse outcomes intensified with longer follow-up durations, with each 1-unit increase in whole-lung GGO proportion linked to a 0.56% higher risk of adverse outcomes (HR: 1.0056, 95% CI: 1.001–1.010).ConclusionsIIM-ILD cases with prior rapid progression will develop chronic fibrotic trajectories with persistent inflammation compared to non-progressive cases. ASS is characterized by sustained inflammatory activity in imaging manifestations, whereas MDA5 + DM shows post-acute fibrotic remodeling following initial injury. Longitudinal GGO emerges as a critical prognostic indicator, demonstrating time-dependent cumulative risk effects.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12890-025-03962-w.

Psoriasis-associated lung disease: A comprehensive review and case series.

Clinical characterization and diagnosis of 14 patients with Chlamydia psittaci pneumonia.

Ground-glass opacity component is a favourable prognostic factor in non-small cell lung cancer, whereas non-small cell lung cancer with interstitial lung abnormalities generally has poorer prognoses. We investigated the clinical significance of ground-glass opacity in patients with non-small cell lung cancer and interstitial lung abnormalities. Among 1319 patients who underwent pulmonary resection for clinical stage IA non-small cell lung cancer at two institutions between 2010 and 2020, we retrospectively assessed 216 patients with interstitial lung abnormalities based on preoperative computed tomography. Patients were divided into two groups: pure solid tumors without ground-glass opacity and subsolid tumors with ground-glass opacity. Among 216 patients with interstitial lung abnormalities, 146 (68%) had pure solid tumors, and 70 (32%) had subsolid tumors. Subsolid tumors had significantly better prognoses than pure solid tumors (5-year overall survival, 69.7% vs 48.6%, P = 0.0008; 5-year recurrence-free survival, 69.7% vs 42.3%, P <0.0001). Recurrence occurred in 4 patients (6%) with subsolid tumors and 41 (28%) with pure solid tumors. Although the 5-year cumulative incidence of lung cancer deaths was significantly lower in subsolid tumors than in those with pure solid tumors (2.6% vs 23.6%, P = 0.0011), an increase in other causes of mortality after 2 years post-surgery in subsolid tumors resulted in a comparable 5- year cumulative incidence of other causes of death (28.4% vs 36.1%, P = 0.260). In clinical stage IA non-small cell lung cancer with interstitial lung abnormalities, subsolid tumors have a lower lung cancer mortality than pure solid tumors; however, higher other-cause mortality after 2 years contributes to poorer overall survival. Optimizing comorbidity management may improve long-term prognosis.

Several patients exhibit a severity-dependent reduced pulmonary diffusing capacity (DLCOc) following coronavirus disease 2019 (COVID-19) infection. This has been attributed to fibrosis-like restrictive lung disease, as shown by chest high-resolution computed tomography (HRCT), and concurrent ventilatory disturbances observed by ventilation-perfusion single-photon emission computed tomography (V/Q SPECT) imaging. The aim of this study was to investigate whether reductions in DL,COc at short- and intermediate-term follow-up were associated with initial severity of COVID-19, and to which extend this was linked to the presence of fibrosis-like abnormalities on HRCT and ventilatory disturbances on V/Q SPECT. A total of 153 patients diagnosed with COVID-19 between March 2020 and March 2021 were included in the study. The patients underwent lung function testing, chest HRCT, and V/Q SPECT at short-term (5.6 months) follow-up. Individuals exhibiting any evidence of post-COVID-19 sequelae (n = 121) were also referred to intermediate follow-up (12.5 months). At short-term follow-up, a severity dependent reduction in DL,COc was observed, which was not evident at intermediate follow-up. At both short-term and intermediate follow-up, HRCT showed ground-glass opacity (GGO) and fibrosis-like abnormalities related to disease severity. Most patients had V/Q defects mainly with ventilatory abnormalities, including both matched and inversely matched defects at both follow-up times. The severity-dependent reduction in DL,COc at short-term follow-up, associated with restrictive lung function pattern, GGO and fibrosis on HRCT, and ventilatory disturbances on V/Q SPECT, showed spontaneous recovery by intermediate follow-up. However, the restrictive ventilatory disturbances and associated morphological changes persisted.

Interstitial Lung Abnormalities (ILAs) in the post-COVID-19era: A call for increased radiologist awareness

Human adenovirus type 55 (HAdV-55) is an emerging respiratory pathogen associated with severe pneumonia outbreaks, particularly in military populations and community settings. The lack of a suitable nonhuman primate model has limited the study of viral pathogenesis and the evaluation of vaccines and therapeutics. Cynomolgus macaques were first administered PBS intranasally and intratracheally as a negative control and allowed to recover for 20 days. The same animals were subsequently infected intranasally and intratracheally with HAdV-55. Clinical signs, hematologic parameters, cytokine responses, imaging, histopathology, and immunologic profiles were monitored over time. Infected macaques exhibited respiratory symptoms including nasal discharge, cough, weight loss, and increased respiratory and heart rates. Lung imaging revealed peri-bronchial consolidation and ground-glass opacities. Histopathology showed granulomatous inflammation and macrophage infiltration, resembling human disease. Hematological analysis demonstrated phase-specific immune responses: early neutrophilia and basophilia, followed by eosinophilia and increased large unstained cells. Cytokine profiling showed early induction of IFN-γ, IFN-β, and IL-6, with delayed IL-8 elevation and IL-4 suppression. Virus-specific antibodies were detectable by day 7, and neutralizing antibodies by day 3 post-infection. However, IFN-γ-producing T-cell responses remained undetectable up to day 14. This study establishes a cynomolgus macaque model that recapitulates key clinical and immunological features of HAdV-55-induced respiratory disease in humans. The model provides a robust platform for advancing our understanding of HAdV-55 pathogenesis and for the preclinical evaluation of candidate vaccines and therapeutics.

Human metapneumovirus (hMPV) is a globally prevalent respiratory pathogen, primarily affecting young children, the elderly, and immunocompromised individuals. Typical airway-centric radiological findings like other viral infections are commonly reported. However, atypical findings in computed tomography (CT) have yet to be reported in literature. We present a case of hMPV infection in an immunocompetent adult with rare findings of cystic lesions in CT thorax. A 67-year-old female with underlying valvular heart disease and chronic heart failure presented to our centre with respiratory symptoms and reduced effort tolerance. Initial chest radiographs were suggestive of an active pulmonary infection superimposed on acute pulmonary edema, leading to empirical antibiotic treatment with the differentials of community-acquired pneumonia. Despite antibiotics and diuretics treatment, her condition worsened requiring oxygenation supplementation. High-resolution computed tomography (HRCT) thorax was performed and demonstrated typical airway-centered findings including peribronchial wall thickening and ground-glass opacities. In addition, multiple cystic lung lesions of varying sizes in random distribution are seen scattered in both lung fields. Reverse transcription polymerase chain reaction (RT-PCR) confirmed an hMPV infection, with no evidence of bacterial or other viral co-infection. The patient improved with supportive care and was discharged after 5 days of admission. While there is no preceding literature on atypical lung changes during the course of hMPV infection, this case highlights the possibility of the broader imaging dynamics of this virus.

BackgroundSmoking-related interstitial fibrosis (SRIF) is an increasingly recognized entity characterized by localized areas with respiratory bronchiolitis (RB), emphysema and interstitial fibrosis that occurs in smokers or former smokers. First described in 2010, the pathogenesis of SRIF remains unclear, although it is believed to be linked to inflammatory processes derived from smoking. The diagnosis is often accidental through pulmonary parenchyma samples obtained for other purposes, as it is not usually associated with significant respiratory symptoms. Transbronchial lung cryobiopsy (TBLC) is an accurate and safe procedure for diagnosing smoking-related interstitial lung diseases (ILDs).Case presentationThis study presents a case series of 13 patients diagnosed with SRIF through TBLC. Patients were predominantly male (76.9%), with a median age of 55 years and a median smoking history of 44 pack-years. Common symptoms included cough (53.8%) and dyspnoea (30.8%), while 38.5% were asymptomatic. Lung Function Tests enclosed normal lung volumes but an impaired diffusion capacity (DLCO). High-resolution computed tomography (HRCT) revealed centrilobular and paraseptal emphysema in all patients, with bilateral ground‒glass opacities in 81.8% of them. Histologically, SRIF was characterized by hyalinized alveolar septal fibrosis and intra-alveolar pigmented macrophages. Over the follow-up period, clinical evolution was variable, however, despite this inconsistency, this series seems to corroborate that the majority of the patients have a stable clinical course. Nonetheless, it must be underline that a subset experienced radiological or functional progression, particularly a decline in DLCO, although any case of progressive fibrosis associated with respiratory insufficiency was noticed. Still, the small sample size and observed variability, limits definitive conclusions about the overall natural history of SRIF. Based on the available data, no therapeutic intervention is recommended at diagnosis besides smoking cessation.ConclusionsThis case series highlights the mostly indolent nature of SRIF, although progression can occur in a subset of patients. The variability in clinical evolution underscores the importance of accurate diagnosis and individualized follow-up. Further prospective studies with larger cohorts are needed to clarify the natural history of SRIF and guide management strategies. Smoking cessation remains the primary intervention recommended at diagnosis.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12890-025-03808-5.

Infective endocarditis is a serious condition that may cause atypical systemic complications beyond the cardiac structures. We report the case of a 65-year-old male admitted for fever and hemoptysis. Chest CT revealed bilateral alveolar and ground-glass opacities consistent with diffuse alveolar hemorrhage. Abdominopelvic CT demonstrated a regular thrombus located at the iliac bifurcation of the inferior vena cava, associated with a retroperitoneal fibrotic process encasing the great vessels and the development of collateral venous pathways. No edema of the lower limbs was noted. Blood cultures identified Staphylococcus aureus, and transthoracic echocardiography showed tricuspid vegetations, confirming the diagnosis of right-sided infective endocarditis. The patient received targeted intravenous antibiotic therapy and anticoagulation, leading to gradual clinical improvement. This case highlights a rare combination of complications venous thrombosis, pulmonary alveolar hemorrhage, and retroperitoneal fibrosis secondary to infective endocarditis. Radiologic imaging was essential in detecting these findings and guiding multidisciplinary management.

Seen but Overlooked: Ground Glass Opacities in Pulmonary Arterial Hypertension.

Disclosure: V. Moorthy: None. K. Jones: None. L.E. Kimball-Ravari: None.Background: Interstitial Lung Diseases (ILD) has a variable prognosis, and can lead to significant morbidity. Emerging evidence in literature links autoimmune thyroid disease (AITD) with ILDs. The scope of implications is not known. Case Report: We present the case of an 81-year-old female referred to Endocrinology for incidental goiter found on chest CT for evaluation of chronic dry cough. There were diffuse interstitial, slightly nodular, infiltrates throughout the lungs, more prominent in the lower lobes and a large goiter extending into the thoracic cavity. She did not have any symptoms of thyroid disease. Thyroid function labs were normal. TPO antibody titers were elevated pointing to Hashimoto’s. On ultrasound, the gland was enlarged, mildly heterogeneous with a benign appearing cystic nodule in the left lobe. The patient has no obvious risk factors for diffuse parenchymal lung disease (DPLD), including smoking, connective tissue disease (CTD), high-risk antigen exposure or potential drug-related cause. The patient was started on low-dose levothyroxine empirically for TSH suppression.Discussion: Idiopathic Nonspecific Interstitial Pneumonia is a subset of DPLD without known causes. On CT, ground glass and reticular opacities predominate the lower lung zones. Mononuclear cells infiltration and fibrosis lead to thickening of the alveolar septal walls. Depending on the signs and symptoms, current recommendations include testing for several autoimmune conditions. Autoimmune thyroid disease is overlooked. An increasing number of case reports and observational studies link AITD with DPLD. Interstitial Pneumonia with Autoimmune Features (IPAF) is a consensus category for interstitial lung diseases with features suggestive of autoimmunity that do not meet strict criteria for CTD-associated ILD. A 2022 study found that hypothyroidism is associated with increased mortality in IPAF patients, even accounting for relevant variables. The pathophysiology is likely an interplay between humoral & cytotoxic immune dysregulation, and mitochondrial dysfunction and oxidative stress. The presence of antibodies alone in a euthyroid milieu was sufficient to drive the disease process in our patient. Studying the association, its molecular basis, and therapeutic potential is an exciting direction for future research. Conclusion: AITD and hypothyroidism may be linked to ILD, warranting testing thyroid function and autoantibodies. The association is a promising venture with tremendous therapeutic potential for future thyroid research.Presentation: Saturday, July 12, 2025

Abstract Background and Aims Diabetes insipidus (DI) typically causes hypernatremia, but in rare cases like Paragonimiasis, which can lead to eosinophilic granulomatosis and result in syndrome of inappropriate antidiuretic hormone secretion, hyponatremia can occur even in the presence of DI. Method We present a case of a 37-year-old cachectic Filipino female with a history of possible resistant tuberculosis (TB). Despite extensive treatment, her condition did not improve, leading to admission due to severe pulmonary distress. During her hospital course, she experienced chronic polyuria, and her serum sodium levels remained low-normal, with episodes of hyponatremia. Due to inadequate clinical response to treatment, further investigation ultimately confirmed Paragonimiasis as the underlying etiology. Results Upon admission, a complete blood count revealed leukocytosis with a predominance of neutrophils and a significantly elevated eosinophil count. A high-resolution chest CT scan was subsequently performed, revealing multiple small non-calcified and calcified nodules scattered throughout both lungs. Additionally, ground-glass opacities were noted in the right lower lobe and left lung, suggesting pulmonary granulomas and fibrosis secondary to a prior inflammatory process, along with associated bilateral cicatricial atelectasis, bullous changes, air trapping, and a possible lung abscess. To address the underlying pneumonia, infected bullae, and possible lung abscess, the patient was started on a regimen of vancomycin and amikacin for 7 days, followed by ertapenem, which she completed over several months. Endobronchial aspiration was recommended for further evaluation at a specialized facility; however, due to unavailability of intensive care unit beds for potential resistant TB, transfer to another institution was not feasible. Despite aggressive antibiotic therapy, the patient continued to experience a productive cough, hemoptysis, and intermittent dyspnea. Given the CT scan findings, the possibility of pulmonary TB remained a differential diagnosis. The patient presented with significant polyuria, with urine output measured between 4.8 to 5.6 cc/kg/day. This polyuria contributed to her hypotension secondary to dehydration, necessitating continuous fluid resuscitation. Notably, despite episodes of polyuria, serum sodium levels remained low, ranging from 130 to 135 mmol/L. Urine biochemical analysis revealed a urine osmolality of only 171 mOsm/kg H2O and a urine specific gravity of 1.005, leading to a diagnosis of DI. Random serum osmolality was recorded at 287 mOsm/kg H2O. The presence of polyuria and elevated serum osmolality, despite relatively high basal level of vasopressin, suggests a diagnosis of nephrogenic DI. Given the persistence of symptoms and lack of response to treatment, further diagnostic workup was done, including testing for paragonimiasis, a parasitic infection caused by lung flukes. This parasitic infection can manifest with pulmonary symptoms that may be easily misdiagnosed as other respiratory illnesses, such as tuberculosis. Paragonimiasis is a globally prevalent but underrecognized disease, predominantly affecting regions in East Asia, particularly the Philippines, as well as endemic areas in Africa and South America. The diagnostic test confirmed the presence of the infection. Therefore, the patient was promptly treated with praziquantel at a dosage of 600 mg every 8 hours, specifically 2 tablets in the morning and 1 tablet at lunchtime and in the evening for 2 days. Following this treatment, the patient exhibited significant clinical improvement, including a marked reduction in polyuria, and was subsequently discharged. Conclusion This case highlights the importance of considering atypical infectious etiologies, such as Paragonimiasis, in patients with respiratory distress and eosinophilia, especially when standard tuberculosis treatments fail. The resolution of her symptoms following targeted therapy for Paragonimiasis emphasizes the importance of thorough diagnostic evaluations in challenging medical cases.

Anti-EJ-anti-synthetase syndrome (ASS) is a rare yet treatable subset within the ASS spectrum, characterised by a higher prevalence of interstitial lung disease (ILD), particularly with a relapsing or rapidly progressive (RP-ILD) course. Here we present a case with predominant ILD and arthritis, presenting with skin manifestations of Mechanic's hand and Gottron's papules. She had subtle myopathy of the proximal hip muscles. She was admitted three times, mostly due to worsening ILD. Her myositis profile showed positivity for anti-EJ and anti-Ro52 antibodies. Thigh muscle MRI revealed myofasciitis; however, the muscle biopsy was normal. Repeat computer tomography of the chest revealed progression of ground-glass opacities and reticulation, suggesting non-specific interstitial pneumonia (NSIP). She was treated with high-dose steroids, cyclophosphamide, and tacrolimus, with which she had a good response. Patients with anti-EJ myositis often present with ILD and arthritis without significant muscle involvement. When ILD occurs before other clinical features, anti-EJ positive ASS is especially prone to misdiagnosis or delayed recognition. Careful assessment of skin signs and musculoskeletal symptoms is vital, even if skin involvement appears minimal or subtle.

We report the first pathologically confirmed case of drug-induced interstitial lung disease (DI-ILD) with hypersensitivity pneumonitis (HP). A 63-year-old woman with triple-negative breast cancer developed a fever and cough 1 week after starting neoadjuvant pembrolizumab plus epirubicin and cyclophosphamide (EC). Chest computed tomography (CT) revealed diffuse centrilobular ground-glass opacities, and a cryobiopsy confirmed non-fibrotic HP. Although Krebs von den Lungen-6 levels were normal, surfactant protein-D levels were elevated. The patient's condition improved with drug discontinuation and brief corticosteroid therapy, enabling curative surgery. This presentation may represent a distinct phenotype of EC-induced ILD, underscoring the importance of an early diagnosis.