Pulmonary Pathology Society

Mystery Case Winners

First Prize: Dr. Alex Solterman

Second Prize: Dr. Alessandra Dubini

Third Prize (tie): Dr. Henry Tazelaar and Dr. Anja Roden

#1 20 year old male initially presented with a low grade fever, night sweats, and hemoptysis which was treated with oral antibiotics for presumed bronchitis.    As a hip hop musician, he had traveled to Mendocino, CA and also had a one day exposure to goats, horses, and chickens. Two weeks later, he presented to an outside ER with worsening dyspnea and hypoxemia and was intubated. Bronchoscopy, serological testing, and infectious work-up were unrevealing and he was treated with broad spectrum antibiotics and RIPE. He was transferred to Emory University Hospital on a ventilator for further evaluation. A VATS lung biopsy was performed. A Gal
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Diagnosis: Organizing pneumonia secondary to marijuana smoking (proposed new name POT-COP)

#2 A previously healthy 24-year-old male patient was admitted to the emergency room reporting pleuritic chest pain, dyspnea and cough with hemoptysis. He was a smoker (8 pack-years). He stated that he had not used injection drugs. He traveled to “Devil Cavern” with exposure to bats two weeks before. Physical examination was normal except for fingertips which were burned, raising suspicion of drug use. Laboratory studies including blood cultures, serologic studies for ANCA, HIV I and HIV II, sputum samples for acid fast bacilli and fungi, testing for illicit substances in urine were negative. Chest X-ray showed homogeneous area of consolidation in the middle lung fields. HRCT scan showed a peribronchial nodule with a great halo of ground-glass opacity, with evident involvement of the middle lung field and cavitation. V Capelozzi
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Diagnosis: Venous infarct secondary to cocaine use and additional finding of NE cell hyperplasia

#3 68 year old woman with increasing shortness of breath and cough over months. Non-smoker. E Duhig
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Diagnosis: Pneumoconiosis secondary to emu egg carving.

#4 A 39-year-old, non-smoker, woman was incidentally found to have small pulmonary nodules at chest X-rays (Figure 1). Computed tomography of the lungs confirmed the presence of several small, rounded nodules ranging from 0.5 to 1 cm of maximum diameter, randomly distributed (Figure 2 & 3). Imaging study originally suggested a metastatic tumor to the lungs. Routine laboratory tests, mammography and tumor serum markers (CA15.3, CA19.9, CEA and CA125) were unremarkable. Brochoscopic examination and a broncho-alveolar lavage were negative. Mantoux and Quantiferon tests gave a negative result.
The patient then underwent double segmentectomy of the right lung by video-assisted thoracoscopic surgery. Histology showed multiple nodules (Figures 4, 5, 6) G Rossi and A Cavazza
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Diagnosis: Chickenpox granulomas of the lung

#5 42-year-old female presented with a week of worsening cough, hypoxia, lightheadedness and high fever with no response to multiple antibiotics and methylprednisolone tablets. CT of the chest revealed diffuse peripheral ground-glass opacities throughout the lungs, more predominantly in the upper lobes. Bronchoscopy with BAL and biopsy was done. The BAL revealed Influenza A viral RNA and fungal elements. The transbronchial biopsy showed acute lung injury pattern. Due to her worsening course, she underwent video-assisted thoracoscopic surgery with wedge biopsies of the right upper and middle lobes. A Khoor
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Diagnosis: Acute lung injury with marked type II pneumocyte hyperplasia mimicking adenocarcinoma in situ

#6 An asymptomatic 70 years old man that in the context of a pre-op (inguinal herniation) study preformed a chest radiograph that revealed a solitary nodule in left lower lobe. In the CT scan it was an endobronchial 1 cm nodule.
Extra information: CK7, CK 5.6, CD56, chromogranin and TTF1 negative; FGFR1 – FISH negative. L Carvalho
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Diagnosis: Basal cell carcinoma of the bronchus

#7 81 year-old woman presented nodular lesion in left lower lobe. She has surgical history of right upper lung cancer (pT1aN0M0). The mass was removed due to slight increase of the size. J Fukuoka
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Diagnosis: Ciliary micronodular papillary tumor of the lung

#8 37 year old gentleman with sudden onset dyspnoea with pleuritic chest pain. CTPA showed an abnormal soft tissue mass encircling and obstructing the main right pulmonary artery.   Right pneumonectomy for ?angiosarcoma right main pulmonary artery. S Jogai
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Diagnosis: Takayasu's arteritis

#9 A 62 yo man presented with a cough productive of white sputum and slowly worsening SOBOE although he was still working. He had a significant history of interstitial lung disease, ischaemic heart disease (previous CABG) and multiple skin cancers including multiple BCCs, one of which was an infiltrative BCC of the left canthus with involved margins requiring re-excision in 2004. High-resolution CT scan showed bilateral widespread increased interstitial opacity with honeycomb changes in a predominantly peripheral distribution, with subtle progression over 6 months. The radiological DDx included UIP and chronic EAA. There was also an incidental 15 x 13mm RUL nodule which showed minor interval increase in size.
He underwent lung wedge for excision of the lung mass and diagnosis of ILD. B Clarke
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Diagnosis: Basaloid carcinoma of the lung in a background of pneumoconiosis secondary to spray painting

#10 A 78 year old male with a past medical history of head and neck squamous carcinoma treated with radiation therapy in the 1980's presented with new onset weight loss and hoarseness. CT scan of the chest revealed myriad 3-5mm bilateral pulmonary nodules. A wedge biopsy was performed. Provided images are H&E and synaptophysin stain.  MB Beasley
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Diagnosis: Metastatic medullary carcinoma of the thyroid mimicking multiple carcinoid tumorlets