Presentation
Chronic cough. Increasing dyspnea. Long-term exposure to eggshell dust.
Patient Data
- heart is enlarged with a cardiothoracic ratio of 0.59
- ill-defined "shaggy" left heart border suggests interstitial thickening in the lingula
- increased interstitial markings in a bibasal distribution
- no consolidation, pulmonary nodules, or pleural effusion
- degenerative change of the shoulders and thoracic spine
- increased interstitial markings in a bibasal distribution
- honeycombing in the lung bases
- traction bronchiectasis
- interspersed ground glass opacities
- scattered calcified granulomata
- surgical suture line in the left lower lobe post wedge resection biopsy
- no focal pleural mass
- no thoracic lymph node enlargement
- incidental ascending thoracic aortic aneurysm
Pathology report
The biopsy shows lung in which there is interstitial fibrosis and prominent intra-alveolar aggregates of cells. Some areas of lung appear to have preserved architecture but there are also areas with early honeycomb change. Within the alveolar spaces there are closely packed, almost cohesive appearing groups of alveolar macrophages, multinucleate giant cells and scattered admixed eosinophils, lymphocytes and neutrophils. This is associated with patchy organizing pneumonia. There are also cellular areas of loose, myxoid-appearing stroma beneath air spaces in keeping with fibroblastic foci. Blood vessels appear thick walled. This thickening appears to be predominantly intimal. Within the interstitium there is a mild patchy chronic inflammatory cell infiltrate including lymphocytes with very occasional lymphoid follicles. Some of the bronchi and bronchioles appear to have a normal mural architecture but there are scattered bronchioles in which there is peribronchiolar metaplasia. No significant inflammation is identified within the pleura. Although giant cells are identified within alveolar spaces, no well-developed interstitial granulomata are seen.
There is no evidence of malignancy.
Case Discussion
- patient was being investigated for increasing dyspnea
- chronic cough
- long term exposure to eggshell dust (calcium carbonate)
- interstitial thickening and ground glass changes in an NSIP pattern
- the cause of NSIP pattern in this case was giant cell interstitial pneumonia
- confirmed on left lower lobe lung biopsy