Bronchoscopic Findings

A view through the bronchoscope shows hyperemia, a nodular irregularity at the left, and distal concentric stenosis. This appearance was present in main, segmental, and proximal subsegmental bronchi. The trachea had a flat mucosa with some hyperemic patches, up to 3 mm.

The following two pictures were taken from the transbronchial biopsies.

What is the nature of the two lesions shown here, and what is the differential diagnosis?

What is the significance of this tissue? Answers 1 & 2

Clinical summary Image 1

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Answers

The biopsy shows two small, non-necrotizing granulomas.

The differential diagnosis includes mainly infectious granulomatous disease, hypersensitivity pneumonia, and sarcoidosis. Granulomas may also be seen with aspiration pneumonia, in chronic beryllium disease or exposure to titanium or aluminum dusts, as a response to certain drugs, and rarely with Wegener's granulomatosis, lymphocytic interstitial pneumonia or eosinophilic pneumonia.

Special stains for fungi and acid fast bacilli were negative in our case.

 

These are skeletal muscle fibers with peripheral nuclei. They indicate that the biopsy included the chest wall. The cause of the hemothorax, but not a pneumothorax, remained unexplained.

What is the diagnosis in this case? Answer

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Histologic diagnosis: Two small, non-necrotizing, non-fibrosing granulomas. Stains for acid fast and fungal organisms negative (transbronchial biopsies, right lower lobe)

Clinical diagnosis: Based on the radiographic appearance, histologic granulomas, and absence of identifiable organisms, the diagnosis is sarcoidosis.

Specimen evaluation: Cultures should be taken from excised tissues in the operating room to prevent contamination. For the non-immunocompromised patient, biopsies are routinely stained only with H&E. If granulomas are seen, stains for organisms are then ordered. If few granulomas are present, recuts for special stains may not show granulomas. Thus, if sarcoidosis is suspected, a note to that effect in the requisition will alert the pathologist to order stains for acid fast bacilli and fungi at the time the paraffin block is first cut. If fungal disease is present, the Gomori methenamine silver stain for fungi is usually positive; however, if mycobacterial disease is present and granulomas are non-necrotizing, acid fast stains are often negative.

Biopsy results: Diagnostic wording should indicate whether the granulomas are well-formed (consistent with sarcoidosis) or ill-defined (more likely hypersensitivity pneumonia), necrotizing or non-necrotizing, or fibrosing or non-fibrosing. The number seen should be given along with the results of stains for acid fast and fungal organisms. Finally the biopsy type (endobronchial, transbronchial, open) and site should be given.

Clinical Summary Continued

Four days later, the patient presented to the Emergency Department with acute onset of dyspnea. She reported continued hemoptysis of 1-2 tsp per day since discharge. She was hypoxic, hypertensive, and tachycardic. There were decreased breath sounds over the right lung. While getting decubitus films, she had hemoptysis of 150 cc, and became hypoxemic and bradycardic with an undetectable blood pressure. A right chest tube was placed with drainage of 150 cc of bloody fluid. Despite intubation and resuscitative efforts, she expired, seven days after the previous discharge. An autopsy limited to the chest was performed.

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