Pleural Changes

The pleura had fibrinous exudate posteriorly and inferiorly and serosanguineous effusions (R 200 ml, L 100 ml).

Pleural surface of upper lobe

Irregularly-shaped, yellowish nodules, 2-3 mm in diameter, protrude slightly above the surrounding collapsed lung. Nodules were more profuse in the upper, than lower, lobes. They are larger and more profuse than in most cases of sarcoidosis. The intervening pleura is smooth here, but over the right lower lobe, there were fibrous adhesions between the lung and the chest wall and diaphragm.

Visceral pleura

This section of visceral pleura shows a collection of granulomas that have invaded the pleura from the lung (opposing arrows). The elastic van Gieson stain shows destruction of the inner and outer elastic layers of the pleura by the granulomas (follow the layers indicated by the single arrow to the granulomas). Note also the hyperemic vessels in the loose connective tissue that bound the lung to the chest wall and diaphragm.

Diaphragmatic pleura

This section of the tendinous portion of the diaphragm shows fatty tissue and dense collagenous tissue at the lower left. The pleural surface has a collection of fibrosing granulomas at the lower right (asterisk) and a large amount of active, vascular, granulation tissue next to it. Vessels similar to those shown here and above were probably responsible for the hemothorax that followed the diagnostic transbronchial biopsy. The adhesions prevented a pneumothorax. These vessels are supplied by systemic arteries.

Clinical summary Discussion

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