Subtle lung lesion in a middle-aged woman with fever and cough

Abstract

A 45-year-old woman had a history of rheumatoid arthritis under medical control with independent daily activity. She presented with fever (38.5°C), dry cough and dyspnoea on exertion for 5 days, accompanied with intermittent headache. Chest X-ray and CT scan both showed clear lung fields, so she was treated as upper airway infection. However, the symptoms persisted on and off for 6 months. Laboratory data on follow-up showed thrombocytopenia (54 000/µL) and lymphopenia (2.7%). A repeated chest CT scan showed fibronodular lesions and linear atelectasis (figure 1A). Empirical antibiotics failed, so interstitial lung disease or atypical infection was suspected. A wedge biopsy of the lung was performed.\n\nReview the high quality, interactive digital Aperio slides at http://virtualacp.com/JCPCases/jclinpath-2019-205856001/ and http://virtualacp.com/JCPCases/jclinpath-2019-205856002/ and consider your diagnosis.\n\n\n\nFigure 1 \n(A) Axial image of non-contrast chest CT (5\u2009mm thickness) using lung window setting reveals ill-defined part-solid ground-glass opacity (GGO) and nodular interlobular septal thickening (ILST, white arrows) in the left lower lobe (LLL). A magnified coronal chest CT image shows another subpleural GGO and ILST in LLL (white arrowheads). (B) The lung biopsy shows open alveolar spaces with interstitial widening. In high-power field, the capillaries in thickened septa contain large atypical cells with moderate amount of cytoplasm and round or oval vesicular nuclei with large prominent nucleoli …