Interstitial Opacities Research Articles

Index of Suspicion in the Nursery

A female infant born at 36 weeks to a 25-year-old G2P2 mother by normal spontaneous vaginal delivery after an uncomplicated pregnancy, presents with respiratory distress and shock at 1 month of age. She has had 2 days of increased work of breathing with tachypnea and tracheal tugging; 2 weeks of cough, rhinorrhea, and nasal congestion; and currently an episode of cyanosis lasting 2 minutes. Weight gain has been appropriate since birth. On physical examination, rectal temperature is 34°C, heart rate is 126 beats per minute, blood pressure is 58/31 mm Hg, and oxygen saturation is 40% in room air. The patient has prolonged capillary refill indicative of poor peripheral perfusion, coarse breath sounds with rhonchi bilaterally, and hepatosplenomegaly. A chest radiograph shows diffuse coarse bilateral interstitial opacities with lucency over the right middle lobe (Fig 1). Figure 1. Chest radiograph demonstrating bilateral diffuse coarse interstitial markings with subsegmental left lower lobe opacity, right mid-lobe lucency, and small right-sided pleural effusion. Initial laboratory studies include an arterial blood gas with pH of 7.03, a Pco2 of 70 mm Hg, calculated bicarbonate of 18 mEq/L, and a base excess of –13; the patient’s serum lactate level was 6.7 mmol/L. The white blood cell count is 25.6 × 103/μL (25.6 × 109/L) with 41% neutrophils and 38% band forms. The C-reactive protein level is 107 mg/L. The serum total bilirubin is 1.3 mg/dL, alanine aminotransferase is 22 U/L, and aspartate aminotransferase is 88 U/L. Her prothrombin time (PT) is 31.9 seconds (international normalized ratio: 3.1), and activated partial thromboplastin time (aPTT) is 51.9 seconds. The cerebrospinal fluid cell count (CSF) cell count, differential, protein, and glucose are normal. Samples of blood, urine, CSF, and endotracheal tube aspirate were sent for viral and bacterial culture and polymerase chain reaction assays. Quantitative …

Interstitial pneumonitis from treatment with gemcitabine.

The use of gemcitabine may lead to numerous adverse effects ranging from mild to very severe, such as interstitial pneumonitis. The diagnosis of this complication is based on multiple laboratory findings, radiographic evidence, and high clinical suspicion. Presented is a case report of a patient who met these criteria and had onset consistent with drug-induced interstitial pneumonitis. A 76-year-old White female was treated with gemcitabine for pancreatic cancer. Two months after the initiation of therapy, she was admitted to the hospital for worsening dyspnea and cough. High clinical suspicion, bilateral interstitial opacities on chest x-ray, worsening pulmonary status, and onset 2 months after initiation of therapy led to the diagnosis of gemcitabine-induced interstitial pneumonitis. Steroid therapy with prednisone was initiated, and the patient's clinical symptoms and radiographic findings improved. Gemcitabine-induced interstitial pneumonitis is well described in the literature. It is a rare but serious complication associated with gemcitabine therapy in which patients present with worsening dyspnea. Most patients only require supportive care and discontinuation of the drug for treatment, but in severe cases supplemental oxygen and steroid therapy must be used before resolution of symptoms. It is important to obtain an accurate medication history to evaluate for other potentially pulmonary toxic medications. Radiographic findings such as bilateral infiltrates should be completely resolved after therapy. Radiographic findings, clinical symptoms, and clinical suspicion can lead to early recognition of interstitial pneumonitis from gemcitabine. Physician awareness of this adverse effect and early recognition are keys to providing prompt treatment in resolving symptoms and decreasing mortality.

Respiratory bronchiolitis-interstitial lung disease.

Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD) is a rare, mild inflammatory pulmonary disorder that occurs almost exclusively in current or former heavy smokers, usually between the third and sixth decades, most likely with no gender predilection. The onset is usually insidious with exertional dyspnea and persistent cough, which may be non-productive, developing over a course of weeks or months. RB-ILD may also be diagnosed in asymptomatic patients with functional impairment and chest radiograph or high-resolution computed tomography (HRCT) abnormalities. Histologically, RB-ILD is characterized by the accumulation of yellow-brown pigmented macrophages within the lumens of respiratory bronchioles and alveolar ducts, associated with a patchy submucosal and peribronchiolar chronic inflammation. Common findings also include mild bronchiolar and peribronchiolar alveolar fibrosis that expands contiguous alveolar septa and leads to architectural distortion as well as centrilobular emphysema. Chest radiographs in patients with RB-ILD typically show fine reticulonodular interstitial opacities, while on HRCT central and peripheral bronchial wall thickening, centrilobular nodules, and ground-glass opacities associated with upper lobe centrilobular emphysema are most frequently reported. Pulmonary function testing may be normal but usually demonstrates mixed, predominantly obstructive abnormalities, often combined with hyperinflation and usually associated with a mild to moderate reduction in carbon monoxide diffusion capacity (DLco). The course of RB-ILD is heterogeneous. Some patients respond favorably to corticosteroids and/or smoking cessation, but often there is no functional improvement and the disease progresses despite smoking cessation and treatment.

Hypersensitivity pneumonitis by Fusarium vasinfectum in a home environment

Hypersensitivity pneumonitis by Fusarium vasinfectum in a home environment

Pulmonary renal syndrome: peripheral lung sparing.

A 57-year-old female with a history of well-controlled asthma presented with sub-acute onset of fevers, unintentional weight loss, cough and haemoptysis. On evaluation, she was noted to have new onset acute renal failure in the presence of serum perinuclear anti-neutrophil cytoplasmic antibody (P-ANCA) and peripheral eosinophilia. Anti-glomerular basement membrane antibodies were not detected. A chest radiograph revealed diffuse interstitial opacities with relative sparing of the periphery consistent with pulmonary haemorrhage (Fig. 1a). This sparing of the peripheries is typical for alveolar haemorrhage and is due to gravity-dependent density gradients. A bronchoscopy with trans-bronchial biopsy demonstrated fresh blood consistent with diffuse alveolar haemorrhage, without evidence of infection, granulomas, or capillaritis [1]. Figure 1: (a) Pulmonary haemorrhage with peripheral lung sparing due to density dependent gradients and (b) pauci-immune necrotising crescentic glomerulonephritis with red fibrinoid necrosis (kidney biopsy). A renal biopsy demonstrated pauci-immune necrotising crescentic glomerulonephritis with red fibrinoid necrosis and focal mitotic activity (Fig. 1b). Pulmonary renal syndrome occurs as the result of inflammation and necrosis of small blood vessels. This syndrome can be induced by agents such as propylthiouracil or by immune-mediated processes such as SLE, IgA nephropathy, Goodpasture syndrome or ANCA-associated vasculitis [2–4]. In this case, a diagnosis of eosinophilic granulomatosis with polyangiitis with MPO antibodies was made. The patient had a partial response to high-dose corticosteroids, plasmapharesis and oral cyclophosphamide, but she was ultimately switched to Rituximab and remains in remission 6 months later [5].

Diagnostic Accuracy of Digitized Chest X-Rays Using Consumer-Grade Color Displays for Low-Cost Teleradiology Services: A Multireader–Multicase Comparison

In teleradiology services and in hospitals, the extensive use of visualization displays requires affordable devices. The purpose of this study was to compare three differently priced displays (a medical-grade grayscale display and two consumer-grade color displays) for image visualization of digitized chest X-rays. The evaluated conditions were interstitial opacities, pneumothorax, and nodules using computed tomography as the gold standard. The comparison was accomplished in terms of receiver operating characteristic (ROC) curves, the diagnostic power measured as the area under ROC curves, accuracy in conditions classification, and main factors affecting accuracy, in a factorial study with 76 cases and six radiologists. The ROC curves for all of the displays and pathologies had similar shapes and no differences in diagnostic power. The proportion of cases correctly classified for each display was greater than 71.9%. The correctness proportions of the three displays were different (p<0.05) only for interstitial opacities. The evaluation of the main factors affecting these proportions revealed that the display factor was not significant for either nodule size or pneumothorax size (p>0.05). Although the image quality variables showed differences in the radiologists' perceptions of the image quality of the three displays, significant differences in the accuracy did not occur. The main effect on the variability of the proportions of correctly classified cases did not come from the display factor. This study confirms previous findings that medical-grade displays could be replaced by consumer-grade color displays with the same image quality.

Intravascular large B-cell lymphoma presenting as interstitial lung disease.

Intravascular large B-cell lymphoma (IVLBL) is a rare subtype of diffuse large B-cell lymphoma that resides in the lumen of blood vessels. Patients typically present with nonspecific findings, particularly bizarre neurologic symptoms, fever, and skin lesions. A woman presented with shortness of breath and a chest CT scan showed diffuse interstitial thickening and ground glass opacities suggestive of an interstitial lung disease. On physical exam she was noted to have splenomegaly. The patient died and at autopsy was found to have an IVLBL in her lungs as well as nearly all her organs that were sampled. Although rare, IVLBL should be included in the differential diagnosis of interstitial lung disease and this case underscores the importance of the continuation of autopsies.

Neutrophilic Reversible Allograft Dysfunction (NRAD) and Restrictive Allograft Syndrome (RAS)

Lung transplantation is currently considered as an ultimate live-saving treatment for selected patients suffering from end-stage pulmonary disease. Long-term survival, however, is hampered by chronic rejection, or chronic lung allograft dysfunction (CLAD). Recently, various phenotypes within CLAD have been identified, challenging the established clinical definition of bronchiolitis obliterans syndrome (BOS). Some patients with presumed BOS, for instance, demonstrate an important improvement in forced expiratory volume in the first second of expiration (FEV1) after treatment with azithromycin. These patients are characterized by the presence of excess (≥ 15%) bronchoalveolar lavage (BAL) neutrophils, in absence of concurrent infection. This phenotype of CLAD has been redefined as neutrophilic reversible allograft dysfunction (NRAD), and these patients generally have a very good prognosis after diagnosis. Another group of patients with CLAD develop a restrictive rather than an obstructive pulmonary function defect (defined as a decline in total lung capacity of at least 10%) and demonstrate persistent interstitial and ground-glass opacities on chest computed tomographic (CT) scan. This phenotype is called restrictive allograft syndrome (RAS), and patients with RAS have a much worse prognosis after diagnosis. This review further discusses both of these CLAD phenotypes that do not fit the classical definition of BOS. Potential pathophysiological mechanisms, etiology, diagnosis, prognosis, and treatments are discussed.

Chest Radiographic Findings in Pediatric Patients with Intraluminal Pulmonary Vein Stenosis

Early recognition of pulmonary vein stenosis (PVS) is crucial for optimizing clinical outcomes. Our goal was to characterize radiographic patterns specific to pediatric patients with PVS to facilitate early detection. Pediatric patients with multivessel (≥2) intraluminal PVS were identified from a single-center registry. Initial chest radiographs were reviewed. Radiographic findings were summarized using frequencies and percentages for categorical data, and medians and ranges for continuous data. Interrater agreement was assessed using kappa statistics. Chest radiographs of 41 PVS patients were evaluated; median age at presentation 5.2 (0.5-102.6) months. Underlying congenital heart disease was present in 31 (76%), lung disease in four (10%), and neither in six (15%). Common heart diseases were hypoplastic left heart syndrome (five, 12%), totally anomalous pulmonary venous connection (nine, 22%), and heterotaxy (five, 12%). PVS was bilateral in 22 (54%), right-sided in six (14%), and left-sided in 13 (32%). All chest radiographs were abnormal. Increased interstitial opacity was present in all patients, reticular opacity in 35 (85%), and ground-glass opacity in 29 (71%). Consolidation (one, 2%), pleural effusions (four, 10%), and nodular opacities (0) were unusual. Distributional heterogeneity was common (17, 42%). Interrater agreement was generally high (kappa >0.84) except for lobe location. Findings were similar among patients with isolated PVS, PVS with congenital heart disease, and PVS with lung disease. Diagnosis of PVS should be considered in infants with increased interstitial opacity, reticular opacity, and ground-glass opacity on chest radiography, especially if findings are heterogeneous.

An unusual cause of haemoptysis in a smoker

A 33-year-old Caucasian male smoker presented to our rapid access lung cancer clinic with a single episode of moderate haemoptysis and no other respiratory or systemic symptoms. There was no...

Clinical Characteristics and Outcomes in Hospitalized Patients with Respiratory Viral Co-Infection during the 2009 H1N1 Influenza Pandemic

BackgroundThe clinical consequences of co-infection with two or more respiratory viruses are poorly understood. We sought to determine if co-infection with pandemic 2009–2010 influenza A H1N1 (pH1N1) and another respiratory virus was associated with worse clinical outcomes.MethodsA retrospective cohort study was performed of all hospitalized patients with a positive respiratory viral panel (RVP) for two or more viruses within 72 hours of admission at our institution from October 2009 to December 2009. We compared patients infected with one respiratory virus to those with respiratory viral co-infection.ResultsWe identified 617 inpatients with a positive RVP sample with a single virus and 49 inpatients with a positive RVP sample for two viruses (i.e. co-infection). Co-infected patients were significantly younger, more often had fever/chills, tachypnea, and they more often demonstrated interstitial opacities suggestive of viral pneumonia on the presenting chest radiograph (OR 7.5, 95% CI 3.4–16.5). The likelihood of death, length of stay, and requirement for intensive care unit level of care were similar in both groups, but patients with any respiratory virus co-infection were more likely to experience complications, particularly treatment for a secondary bacterial pneumonia (OR 6.8, 95% CI 3.3–14.2). Patients co-infected with pH1N1 and another respiratory virus were more likely to present with chest radiograph changes suggestive of a viral pneumonia, compared to mono-infection with pH1N1 (OR 16.9, 95% CI 4.5–62.7). By logistic regression using mono-infection with non-PH1N1 viruses as the reference group, co-infection with pH1N1 was the strongest independent predictor of treatment for a secondary bacterial pneumonia (OR 17.8, 95% CI 6.7–47.1).ConclusionPatients with viral co-infection, particularly with pH1N1, were more likely to have chest radiograph features compatible with a viral pneumonia and complications during their hospital course, particularly treatment for secondary bacterial pneumonia. Despite this, co-infection was not associated with ICU admission.

Restrictive Allograft Syndrome CT Findings Are a Recent Feature of Chronic Lund Allograft Dysfunction

Purpose RAS has recently been described as a form of CLAD with a decreased TLC and CT scan upper lobe opacities. This pattern seems to have recently appeared. Methods and Materials From 15/07/88 to 31/12/11, 181 adults (>16 years; 108 M/73F; 75 double lung, 75 single lung and 31 heart lung ) patients were transplanted. Initial diagnosis included: cystic fibrosis and bronchiectasis in 30%; emphysema in 24%; primary pulmonary hypertension in 18%. interstitial lung diseases in 16%. Before 15/07/01, 80 were transplanted (pre 01) and 101 after that date. (post 01). Until 2009 we used to routinely repeat CT scan as often as twice yearly in transplanted patients allowing us to describe early features of BOS. We reanalysed the last chest CT scan of each of the 181 patients for the presence in the upper zones of interstitial reticular shadows, interstitial opacities, ground glass opacities and architectural distorsion: traction bronchiectasis, honeycombing. Results Only 10 of them presented with such abnormalities: 3/80 in the pre 2001 period and 7/101 in the post 01. In marked contrast 27 patients of the pre 01 period and 19 of the post 01 period developped BOS≥1. Of note findings of RAS were not observed on CT scan performed before 2004 except on one occurrence in 1993. Among patients with abnormal CT scan, 5 had a double lung and 5 a single lung transplant; only one had no abnormal PFTs. Initial diagnosis included: cystic fibrosis in 1; emphysema in 2; primary pulmonary hypertension in 2 and interstitial lung diseases in 4 suggesting an overrepresentation of interstitial lung disease as a primary diagnosis for transplantation. Conclusions CT scan findings consistent with RAS is rare (10/180 i.e.5.55%) and has seldom been observed before 2004; interstitial lung disease as a cause for transplantation might favor it.

Mycobacterium tuberculosis Infections in Solid Organ Transplantation

Mycobacterium tuberculosis Infections in Solid Organ Transplantation

Acute Respiratory Failure in Idiopathic Pulmonary Fibrosis: Co-Infection With H1n1 And Cytomegalovirus: An Unexpected Common Denominator

We described a case of persistent influenza AH1N1 and cytomegalovirus respiratory infection in a patient with chronic interstitial lung disease and multiple bilateral pulmonary opacities. An open lung biopsy revealed diffuse organizing alveolar damage, necrotizing bronchiolitis, necrotizing pneumonia and alveolar hemorrhage, compatible with H1N1 infection as well as usual interstitial pneumonia. Diagnoses of an idiopathic CD4+ T cell lymphocytopenia and immunoglobulin G deficiency were made as an unexpected co-denominator of H1N1 and CMV persistent infection changing our treatment approach.

Pulmonary cryptococcosis in an immunocompetent patient—A case report

Cryptococcosis is an infection caused by fungi that belong to the genus Cryptococcus. There are several species of Cryptococcus, but two species—Cryptococcus neoformans and Cryptococcus gattii—cause nearly all cryptococcal infections in humans. Cryptococcosis is one of the most common fungal infections in Brazil and becomes even more important after the onset of the AIDS epidemic. The lung is the main gateway, and also is the most common site, with diverse clinical manifestations ranging from an asymptomatic to severe pneumonia. When symptommatic, most patients present with fever and cough with expectoration or hemoptysis. The most common radiological findings in immunocompetent patients are located images of masses and nodules, while immunosuppression shows interstitial infiltrates and diffuses interstitial opacity. This is a case report of a patient in the third decade of life with breathing-dependent pain at the base of the left hemithorax, who has radiological examination of a mass in the left lung base in contact with the pleura mimicking malignant lung. Lobectomy was performed, as well as the pathological diagnosis of cryptococcosis.

Pleuroparenchymal fibroelastosis as a manifestation of chronic lung rejection?

To the Editor: Idiopathic pleuroparenchymal fibroelastosis is a peculiar pulmonary fibrosis proposed by Frankel et al . [1] in 2003 and is almost the same concept as idiopathic pulmonary upper lobe fibrosis proposed by Amitani et al. [2]. There are no known causes for fibrosis in idiopathic pleuroparenchymal fibroelastosis. Sometimes, pleuroparenchymal fibroelastosis (PPFE) has underlying diseases or conditions, such as collagen vascular diseases, anti-cancer chemotherapy, irradiation, asbestos exposure and bone-marrow transplantation [3]. Herein, we report the case of a female who received living-donor lung transplantation and died of pulmonary fibrosis, which was pathologically compatible with PPFE in addition to constrictive bronchiolitis, which is a manifestation of chronic lung allograft dysfunction (CLAD) [4]. A 30-yr-old female suffering from idiopathic pulmonary arterial hypertension underwent living-donor lung transplantation surgery and received a right lower lobe from her younger sister and a left lower lobe from her mother in December 2003. 20 months after the lung transplantation she had dyspnoea and a chest radiograph disclosed bilateral ground-glass shadows. 1 month later, right open lung biopsy was performed and a diagnosis of interstitial pneumonia was obtained. Pulse therapy with methylprednisolone slightly improved her condition and prednisolone was administered after the pulse therapy. However, bilateral interstitial opacities gradually deteriorated (fig. 1) with increased dyspnoea. 49 months after the lung transplantation, her daily life had worsened to almost whole-day bed rest. 18 days prior to her death she …

Mimics in chest disease: interstitial opacities

Septal, reticular, nodular, reticulonodular, ground-glass, crazy paving, cystic, ground-glass with reticular, cystic with ground-glass, decreased and mosaic attenuation pattern characterise interstitial lung diseases on high-resolution computed tomography (HRCT). Occasionally different entities mimic each other, either because they share identical HRCT findings or because of superimposition of patterns. Idiopathic pulmonary fibrosis (IPF), fibrosis associated with connective tissue disease, asbestosis, end-stage sarcoidosis or chronic hypersensitivity pneumonitis (HP) may present with lower zone, subpleural reticular pattern associated with honeycombing. Lymphangiomyomatosis may be indistinguishable from histiocytosis or extensive emphysema. Both pulmonary oedema and lymphangitic carcinomatosis may be characterised by septal pattern resulting from thickened interlobular septa. Ill-defined centrilobular nodular pattern may be identically present in HP and respiratory bronchiolitis–associated with interstitial lung disease (RBILD). Sarcoidosis may mimic miliary tuberculosis or haematogenous metastases presenting with miliary pattern, while endobronchial spread of tuberculosis may be indistinguishable from panbronchiolitis, both presenting with tree-in-bud pattern. Atypical infection presenting with ground-glass mimics haemorrhage. Ground-glass pattern with minimal reticulation is seen in desquamative interstitial pneumonia (DIP), RBILD and non-specific interstitial pneumonia (NSIP). Obliterative bronchiolitis and panlobular emphysema may present with decreased attenuation pattern, while obliterative bronchiolitis, chronic pulmonary embolism and HP may manifest with mosaic attenuation pattern. Various mimics in interstitial lung diseases exist. Differential diagnosis is narrowed based on integration of predominant HRCT pattern and clinical history. Teaching Points • To learn about the different HRCT patterns, which are related to interstitial lung diseases. • To be familiar with the more “classical” entities presenting with each HRCT pattern. • To discuss possible overlap of different HRCT patterns and the more common mimics in each case. • To learn about some clues that help differentiate the various diagnostic mimics on HRCT.

Cryptococcus Pneumonia Complicating Churg-Strauss Syndrome

Crytpococcus neoformans usually infects individuals who are HIV-infected or immunosuppressed for other reasons and clinically presents as meningoencephalitis, pneumonia or disseminated disease. We describe a 57-year-old man with history of asthma, allergic rhinosinusitis, nasal polyps and chronic receipt of low dose steroids who presented to the emergency department with fever, dry cough, respiratory distress and hematuria. His laboratory studies showed leukocytosis and eosinophilia with a negative HIV antibody test. CT scan of the chest showed right lower lobe patchy opacities. The patient deteriorated during hospitalization, developed hemoptysis and hypoxia, and was electively intubated. Repeat CT scan of the chest showed diffuse alveolar and interstitial opacities with mediastinal lymphadenopathy. The cytoplasmic anti-neutrophil cytoplasmic antibody (C-ANCA) was markedly elevated and the patient was diagnosed with Churg-Strauss Syndrome (CSS). Culture of bronchoalveolar lavage fluid yielded growth of Cryptococcus neoformans . The patient responded well to treatment with cyclophosphamide, corticosteroids, plasmapharesis and fluconazole. This case highlights the possibility that Cryptococcus neoformans can either infect or colonize patients who are immunosuppressed, including those with CSS. doi: http://dx.doi.org/10.4021/jmc755w

Accuracy of low-dose computed tomography (CT) for detecting and characterizing the most common CT-patterns of pulmonary disease

PurposeTo assess the ability of low-dose CT to detect and characterize the most common CT patterns of pulmonary disease. Methods and materialsSixty patients with nodules, consolidations or interstitial disease were scanned using a low-dose (128mm×0.6mm, 40 reference mAs, 120kVp) and standard-dose CT protocol (150 reference mAs, 120kVp). Two radiologists with 3 and 10 years of thoracic imaging experience searched both exams in consensus for the most commonly observed CT patterns according to the Fleischner Society criteria, which consisted of 46 different subgroups of ground-glass opacities, nodules, interstitial and airspace diseases. The standard of reference was established by consensus of a panel of two experienced chest radiologists (9 and 12 years of experience). ResultsThe lung segments (1080) showed 813 nodules, 596 ground-glass opacities, 74 airspace and 575 interstitial diseases and 64 normal segments. In particular, air-space disease and nodules were unaffected by the increase in noise. However, the sensitivity to detect ground-glass opacities, ground-glass nodules and interstitial opacities decreased significantly, from 89% to 77%, 86% to 68% and 91% to 71%, respectively (all p-values<0.00001). Using iterative reconstruction instead of the applied filtered back projection sensitivity for ground-glass nodules rose to the sensitivity of standard-dose CT in an additional phantom study. ConclusionA low-dose CT of 40mAs/120kVp is feasible for detecting solid nodules, airspace, airways and pleural disease. For diagnosing pathologies consisting of ground-glass opacities or interstitial opacities, higher tube current or iterative reconstruction is required.

Newly diagnosed human immunodeficiency virus infection in an octogenarian with acute respiratory failure

A previously healthy 83-year-old man presented to our emergency department with 3-day history of fever and dyspnea. Physical examination findings were as follows: oral temperature of 38.2°C, pulse rate of 119 beats/min, respiratory rate of 32 breaths/min, blood pressure of 108/67 mmHg and diffuse crackles over bilateral lungs. Clinical laboratory findings were as follows: white blood cell count of 10.8 × 103/μl with 95% neutrophils, 3.2% lymphocytes, 1.7% monocytes, hemoglobin of 9.0 g/dl and platelets of 216 × 103/μl. Chest radiography revealed increased interstitial marking and ground-glass opacities of both lungs (Figure 1A). The patient received oral endotracheal intubation on account of persistent dyspnea and hypoxiemia. Figure 1 ( A ) Chest radiograph revealed increased interstitial marking, ground-glass opacities and patchy infiltration of the both lungs (obtained at our emergency department). ( B ) Chest radiograph revealed resolutions of these increased interstitial marking and ground-glass opacities of the both lungs (obtained 3 months after admission). On admission, a high-resolution computed tomography scan of the chest revealed diffuse ground-glass opacities with thickening of interlobular septa of both lungs (Figure 2). Sputum bacterial cultures were negative. Other tests for pulmonary pathogens were performed, including a tuberculosis culture, acid-fast stain, polymerase chain reaction (PCR) for Pneumocystis jiroveci , cytomegalovirus (CMV) and HERPES simplex virus, and blood tests for CMV and Cryptococcus antigens. Figure 2 Computed tomography of the chest revealed diffuse ground-glass-opacities with thickening of interlobular septa of both lungs …