AMERICAN SOCIETY OF CLINICAL PATHOLOGISTS Commission on Continuing Education

Council on Anatomic Pathology

372

The 46th Annual Fall Anatomic Pathology Slide Seminar

"PULMONARY PATHOLOGY"

Stouffer's Riverfront Towers Grand Ballroom

Merle A. Legg. M.D.

St. Louis, Missouri October 31, 1980 9:00 am - 5:00 pm

PRELECTORS

Lynne M. Reid. M.D. Chair·man. Council on Anatomic Pathology American Society of Clinical Pathologists

Chairman, Department of Pathology New England Deaconess Hospital

Boston. Massachusetts

Chairman, Deps rl ment of Pathology The Children's Hospita l Medical Center

Boston. Massachusetts

MODERATOR

Azorides R. Morale~. M.D.

Professor and Chairman, Depar tment of Pathology University of Miami School of Medicine

MiAmi, Florida

PLEASE BRING 'I'HJS PROTOCOL TO THE SEMINAR

CASE HISTORIES

Case 1

Contributed by Dr . Yangja Jung-Legg Vet:erans Administration ~ledical Center, Boston, ~lass.

A 49-year-o ld black man who was a chronic alcoholic and who had smoked one pack of cigaret tes a day for many years was admitted t o the hospital for an epi­sode of acute pancrea t itis in January , 1978 . His physicians found in the chest x-ray film a 1 . 5 em. density i n the upper lobe of t he righ t lung . In retrospect, the nodule was present i n September, 1977, and measured 1 em. i n diameter in chest x-ray f i lms taken elsewhere. ·several sputum examinations did not reveal tumor cells . The patient left the hospital against advice before bronchoscopy could be done .

He returned in August, 1978, because of intermittent hemoptysis. Rigid bron­choscopy, mediastinoscopy and liver, spleen and brain scans al l were negative . A thoracotomy was scheduled, but the pat ient once again left the hospital. In De­cember , 1978, the righ t upper lobe nodule measured 2 x 2 . 5 em . and in July , 1979 , a new mass appeared in the right peri- hi l ar region .

He e ntered the hospital i n December, 1979 , because of hemoptysis . The bron­choscopist described a l obulated mass occl uding the ant eri o r segmental bronchus of the right upper lobe. The surgeons removed the right upper l obe .

A 2 . 5 em. firm, white and tan, sharply-circumscribed mass was underneath the pleura of the posterior segment. The anterior segmental bronchus was obstructed by a soft, friable , grey- pink to red , lobulated mass that extended along the en­tire length of the segmental bronchus and branched out i nto the subscgmental bronchi , the total l ength of the sol id, cylindricl!ll mass being approximately 5 . 0 em. Tha sections represen t the a ntet:i or segmental mass .

case 2

Contributed by Or. Merle A. Legg New England Deaconess Hospital, Boston, Mass .

Two patients, both men, one 65 years old and one 74 years old had pulmonary emphysema . The first, a 100-150 pack- year cigarett e smoker was referred from another hospital because of "low salt" found during an annual check-up. Seria l serum sodium levels were 124, 118 and 116m Eq./1. with a serum osmolality of 239 m Osm/1. at the same time that the urine osmolality was 607 m Osm/1. The radiologists found a mass in the superior segment of the l ower lobe of the right lung. Liver, spleen and brain scans were negative and the bone marrow biopsy contained no tumor. The bronchoscopist could not see a tumor, but the bronchial washings contained tumor cells . The right lung was removed. A 4.0 em. gray- tan, firm mass s urrounded the intermediate bronchus and occluded segmental bronchi of the lo1•er l obe.

'rhc second patient had had a very eventful medical his tory with nearly ten years of auricular fibrillation, a successfully by-pass grafted abdominal aortic aneurysm, and transient episodes of cerebrovascular insufficiency. In ~larch, he had an episode of pleural effusion with a scant infiltration of the base of the lower lobe of the right lung, thought to be viral pneumonitis. The infiltrate decreased before his discharge . In September, he was admitted to the New England Baptist Hospital because of nocturnal fevers of 1010F . for five days , some sore throat , and weight loss of 20-30 pounds over a year' s time. There was a density in the upper l obe of t he right l ill>g, but bone metastases could not be demons tra ted. Because oE drooping of tho mouth on the l eft side , EEG was done, and it was mildly but diffusely abnormal. No tumor cells were found in two sputum specimens . Diabetes mell itus was diagnosed. The physicians thought ~lat he had metastatic carcinoma and give him only supportive therapy. He died in December. h f riable gray mass involved the carina, both main bro nchi and the mediastinal lymph nodes and extended into both lungs.

Case 3

Contributed by Dr. Archi e Y. Hamil ton St. J oseph' s Community Hospital, Vancouver , l~ashington

The parents o f a 24-year-old white woman found her col l aps ed on a couch , s t i l l warm, but not breat h ing . Cardi opulmonary resuscitat i on was i ns t ituted , but she was dead on a rrival a t t he hospita l emergency room. The diagnosis was bilat eral pneumothorax .

She had suffer ed bi l ateral pneumo thorax a year p r evi ously, had been treated promptl y and had recove red completel y . Her mother reported t ha t her da ugh ter had been generally well prior to t hese episodes . As an i nfant , the· pat i ent had been diagnosed as having adenoma sebaceum. She was of average intell igence a nd graduated from high school wi th avera ge grades , Qnd she wa s learning to drive an automobile at the time of her death.

The pos t - mortem exami nation did support the diagnosis of b ilateral pneumo­thor ax with collapse of bo th l ungs . Hul t ipl e bul l ae were prese·nt i n t he lungs .

Case 4

Contribut ed by Dr . Frank Vel l ios Oniversity of Oregon Heal t h Sciences Center, Portland, Oregon

The patient was a six -day-ol d male \<ith signs and symptoms of respirator y failure. A chest .x-ray f ilm revealed .mul tiple cystic spaces with thickened , some•1hat nodular areas between the cystic foci throughout the upper lobe of the r ight l ung and most of the right middle and lower lobes. It was felt c l ini cally that t he lesi on threatened to cause t racheal obs t ruction. The surgeons removed the right upper lobe,_ which appeared grossly much l ike the radiographic desc-rip­tion .

Case 5

Contributed by Dr . Lynne Reid Children's Hospital Hedical Cent er, Boston, !1ass.

A 6 lb. 5 oz. baby boy was del ive r ed from a 25-year-old gravida 2, para 1 white woman by elective Caesarian section after a ges t ation of approximately 37 weeks . The mother had previousl y undergone Caesarian section for a pregnancy complicated by f etal-pelvic disproportion. At the time of section., the mem­branes were intact and the mother was not in active labor. Almost immediatel y following birth, the in.fant e>q:>,erienced progressive respiratory distress with grunting, f l aring and intercostal retractions. Arterial blood gases on 3.5% oxygen showed a Pao2 of 59 ·rnrn. Hg., Paco2 37 rnm. Hg and pH 7.29. Ches t roent­genogram showed a finely granular appearance of bo.th lungs with air broncho­grams . Antibiotics were instituted for possi ble sepsis and mechanical venti­latory assistance was begun. A hem9rrhagic diat hesis developed which was treated with heparin. The infant 's resp iratory status progressively worsened and increased ventilatory pressures using 100% oxygen were necessary. The final blood gases sh.owed a .Pao2 of 18 rnrn. Hg. , Paco2 164 mrn . Hg and pH 6. 7. He expired 24 hours after birtli.

Case 6

Contri buted by Dr. Lynne Reid Children's. Hospital Medical Center, Boston , Mass.

This male infant was born after a .30-week gestation and required prolonged intubation and ventilatory assistance because of severe respiratory distress. A patent ductus arteriosus was ligated at two weeks of age for a significant left to r ight shunt . One month after birth he was extubated and gradually weaned f.rom supplemental oxygen. During the remaining five months of life, pulmonary function gradually deteriorated with progressive hypoxia and hypercapnia . He had inter­mittent congestive hea~t failure with electrocard iographic evidence of right ven­tricular hypertrophy . Retrolental fibropl asia was noted on ophthalmol ogic examina­tion and chest x-ray f ilm showed mild cardiomegaly ~ith increased .opacities and

case 6 (continued)

irregular lucencies i n the, l ung fiel ds . During his l ast hospi t alization on 60% F1o2 the fol lowi ng ar teria l bl ood gases were obtained: Pao 2 38 rom . Hg., PaCO~ 40 mm. Hg and pH 7 . 35. His demise was presaged by sei zures and episodes of bradycardia.

case 7

Contributed by Dr. Lynne Reid Children's Hospit a l Medical Center, Boston, Hass.

A male i nfan t was examined a t 11 weeks of age because of progressive wheezing and tachypnea. He was initially treated f or bronchiolitis but with incomple·te response. A chest roentgenograph showed hyper l ucency and increase in s·ize of the upper lobe of the left l u ng with lower lobe a telectasis . A ~entilation-perfusion scan demonstrated marked decrease i n both aeration and perfusion of the upper lobe . Medical management was unsuccessful and at 2~ lllOnths of. age a l eft upper l obectomy was performed .

Ca s e 8

Con tri b u ted by Dr . Lynne Rei d Chi l dren ' s Hospit a l ~ledical Center, Bos t on , !~ass .

The patient, a 25- year- o l d woman, first came to medical attention a t 3., years OT age because o f fa i l ure to t hrive, recurrent p neumonia, steatorrhea and r ectal prolapse . Af ter the age of 17, she had numerous hospital admissions for exa·cer bation of pulmonary symp t oms with increased dyspnea and sput um produc tio n. Pseudomonas aeruginosa was r epeatedl y isol ated · from sputum s amp l es . Chest r oentgenographs sh01•ed progressive bronchiec t asis and chronic pul monary disease . Despite adva ncing disease she conti nued to remain as activ e as p ossible in vo­cational a nd social functions~ She was i n sever e r espira tory di s tress on her fi nal hospitalization , had s i gns of severe congestive h eart f a i l ure and d i ed.

Case 9 Contributed by Dr . Nilliam D. Dolan

The Arlington Hospital, Ar l ing·ton, Virginia

'rhe patient was a 26-year -old white woman who complained of a chronic cough f or thr ee months . The cough was productive of yell ow- green , thick, mucoid sputum without blood streaking . In s ix months , she had l ost 10 lbs . and fel t tired . She had a strong fami ly history for cancer , smoked one pack of cigarettes a day for ten years, a nd said that she had had frequent a t tacks of pneumonia .

No acid- fast bacilli or fungi Vler e found in the sputum, and complement fixa­tion tests for histoplasmosis ana coccidioidomycosis were negati ve. He r sed . rate was 102 and loJBC was 16,000/cu . mrn . I n t he x - ray studies of the chest, 'nhich in­cluded tomograms, the radio logists described a large, thick- walled cavity >~i th irregular outer borders i n the a n teri o r segment o 'f the upper l obe of the left l un§ and wi·thou t a f l uid level . A left upper l o bectomy was performed.

Case 9 (continued)

The lobe weighed 400 gm., had fibri nous pleuritis , and contained a large wedge-shaped consolidated area 9 x 6 x 5 em. Tho cut surface i n the area of consolidation appeared like congealed purul ent exudate with foci of liquefaction and a 2 em. cavity . The edge was sharply demarcated. The hilar lymph nodes were soft and gray and black.

Case 10

Submitted by Dr. Howard J . Christian and Dr. Ellen 1·1. lolaher Carney Hospital, Dorchester, Hass.

The patient was a 40-year-old whit'e man who came to the hospita l because of hemoptysis. The chest x-ray studies demonstrated a large mass in the lower lobe of the right lung , but with several other nodules in both lungs. Init i al studies were not diagnostic . Since the hemorrhage appeared to be coming from the right lower lobe and was a threat, the surgeon removed the right middle and lower lobes and biopsied a nodule from the upper lobe.

The right lower l obe weighed 1700 gm . and was mostly -replaced by a solid, firm, sharply demarcated, yellow mass focally liquefied. Similar single nodules, but much smaller, were present in t he middle and upper lobe specimens. The l ymph nodes were gray- black .

Case 11

Contributed by Dr . Lynne Reid Children' s Hospi t al Medical Center, Boston, Mass .

• A 5-year-ol d boy was in good health until 9 months before admission when he

was treated for a right lower lobe pneumonia of undetermined etiology . He im­proved with antibiotic therapy, but 8 months later was found radiologically to have a density in the same lobe . The infiltrate did not clear with continued antibiotics . A sharply outlined 6 x 6 em. shadow of soft tissue density was noted in the r ight lung base posteriorly. The primary radiologic consider ation was i ntralobar pulmonary sequestration , but angiogr aphy f ail ed to show any evidence of systemic vascular s uppl y to the mass . A r ight lower lobectomy was performed .

Case 12

Contributed by Dr . Saul Kay Medical College of Virginia, Richmond, Virginia

The patient was an 82-year-old black man transferred from a gcr~a tric hos­pital because of the finding o f a l arge mass in t he lower lobe of the left lung as seen in the chest x-ray film. Because of menta l problems due to adva nced ar ­terioscl eros i s , he had no rel iabl e previous history . There is no record in the

Case 12 (continued)

geriatric hospital that he had had either previous neoplasms o r surgical opera­tions .

CBC , urinalysis, chemistry profile, EKG and pulmonary function studies al l were normal . Bronchoscopy, scalene lymph node biopsies and medi astinoscopy were negative . The surgeons r emoved the lower lobe of the left lung .

Case 13

Con·tributed by Dr . H. Pa ul !•lakefield, Holyoke Hospi t al, Holyoke , Mass . ; by Dr. Yangja Jung- Legg, Veterans Administration Medical Center, Boston , !-lass.;

and by Dr. ~lerle A . Legg , New England Deaconess Hospital , Boston, Nass .

The patients we re three men, ages 34, 40 and 30 respectivel y . The first re­ported fever, cough, vomiting, diarrhea and weight loss of t wen t y pounds while working in New Mexico two months before admission to Holyoke. He was given an antibiotic in New ~lexica , but with persis t ent daily vomiti ng , cough with insig ­nificant sputum production, daily chills and fever up to 1010r. He had had known exposure to tuberculosis, occasional exposure to asbestos , smoked tw~ packs of c igarettes a day , and smoked marij uana which may have been contami nated wi t h para­quat. In the hospital, he was afebrile and extensive diagnosti c studi es were negative except for the diEEuse patchy infil trates in both lung fields demonstrated in the x- ray studies. Hi s pulmonar y function studies were normal. 1'. lung biopsy was taken .

The second patient was admitted to the V.A. Hospita l following the d i scovery of diffuse bilateral interstitial infiltrates in the lungs found by ches t x- ray in January, 1978 , follo1•ing an accident. He denied any symptoms initially and a July, 1977, chest x-ray film ~>•as normal. Hi th specific questioning , he concluded that he had lost twenty pounds in six months and had had some ••night sweats,

Casa 13 (cont inued)

fatigue and morning stiffness" in the past two months . Pulmonary function studies revealed increased functional residual capacity and residual volume and decreased one second forced expiratory volume. Arterial blood gases: pH 7 . 41, pe2 75, peo2 39 - A lung biopsy was taken- The specimen contained a grey-green nodular area.

The third man was hospitalized elsewhere in March, 1969 , with symptoms of fever , weight loss and productive cough. He was diagnose d a s ha ving pulmonar y J tuberculosis wi th bilateral cavities and positive sputum_ cultures. In October, 1969 , he complained of severe low back pain, and x-ray studies demonst r ated destruc tion and compression of the second lumbar vertebral body. Later in 1969, he de­veloped headache and left fronto- parietal swelling . There were four lytic lesions in the skull which were treated with 900 rad of unspecified type of radiation. In June, 1970 , further pulmonary infiltration was apparent while the patient was re ­ceiving isoniazid , ethambutol , pyridoxine and para- aminosalicylic acid . At the same time, he complained of cough; sometimes with yellow sputum , occasi onal an­terior p l euritic pain , low back pain and headache. In Augus t he was transferred to New England Deaconess Hospita L The main f indings were t hose o f t he ches t x-ray films : a diffuse, honeycomb-like i nfi l trate i n both lung fields and a cavity in the poster ior sub- segment of the left upper lobe . The surgeons biopsied the lingula , which contained multiple f irm gray-white and brown nodules up to 0 . 7 em. in diameter _

case 14

Contributed by Dr. . Lynne Reid Children ' s Hospital Nedical Cent"r, Boston, Mass.

A 2- year-old girl was evaluated for a cardiac murmur and episodes of dyspnea and diaphoresis. She was mildly cyanotic on examination and hacl a grade I II/VI holosystolic murmur at the left upper sternal border . Chest roentgenogram showed

case 14 (continued)

marked cardiomegal y particul arly invol v ing t he right ventric l e. Cathe t erization studies demonstrated a large atrial septal defect (ASD) of the secundum type with significant pulmonary arterial hyper tension (pressure: 75/37 mm Hg) . Elective closure of the ASD was done under total cardiopulmonary bypass. The immediate post-operative course was complicated by florid pulmonary edema which responded to administration of lasi x and mor phine and the mechanical ef fect of positive end- expiratory pressure. Continued pulmonary congestion pr ompted a repea t catheterization study when a large subaortic ventricular septal defect (VSD) was found . Two days following the first operation the VSD was closed. The post­operative course was compl i cated by systemic hypoperfusion, cyanosis and marked pulmonar y congestion and edema. Despi t e vigorous attempts to correct severo metabolic and electrolyte abnormalities, the child expired the following day .

Case 15

Contri buted by Dr. Archie Y. Hamilton st . Joseph Community Hospital , Vancouver , Washington

The patient was a 14-year-old boy who came into the hospital because of rapidly increasing shortness of breath . lie had been in the hospital two weeks before with a fulmi nant episode of s hortness of br eath wi t h the finding of bi­l ateral pulmonary infiltrates, pleural effusions and hypoxia . The physician a l so made a tentative diagnosis of ~~rfan 's syndrome . The boy responded rapidly to corticosteroids and intravenous penicillin . The x- ray film after treatment showed resolution of 90\ of the infiltrates . He was given t wo weeks of erythro­mycin and one wee k of corticosteroids . The physician saw t he pati e nt i n his of~ice , at which time t he boy had a low-grade fever and moderate dyspnea, but the physician could not find chest signs . Within thirty hours, the patient became markedly dyspneic with a respiratory rate of 42 per min . and was cyanotic. The blood gases on admission wore: pH 7 . 4, pco2-22 , pe2- 3S while on nasal oxygen . The chest x- ray

Ca se 15 (continued)

fi~m showed bi later a l f l uffy pul monary infiltra t es and pleural eff usions like t hose of t he prev i ous episode .

The t r eatment \vas intravenous ami nciphyl lin and corticoster oids on his way to the hospit al and antibiotics , cort icosteroids and oxygen in the hospita~ . The oxygen was s i x l iters per mi nute through a nasal .tube . He seemed t o s t abi l ize and then had a seizure about seven hours a f t er admiss.ion and became comatose . Cardi opulmonary resuscitation was required, but he did not recover .

The autopsy was l imited to the chest. The .prosector found t he r i ght lung to ~<Jeigh 900 gm. and the l eft 850 gm. The pleural surfaces were lea t hery and r ed- tan . The pulmonary parenchyma had a blotchy; hemorr hagic appearance wi t h decr eased crepitation .

Ca s e 16

Contributed by Dr . Merle A. Legg New Engl and Deaconess Hospital , Boston, ~ss .

The pat ient, a 73- year- old .vhite woman , c ame t o the hospital a second t i me f r om a nursing home. She had been admitted a month before beca\lse of t he s uspi ci on of t\lbe.rculosis , but she had refused diagnostic procedures and even a therape\lti o t r ial . She was a nurse who had worked in a t ubercul osis .sanatorium , had a posi­t ive tuberculin skin test, and had kno.vn cal c i fications in the upper l obe of the right lung and in the pericardium. She r e t urned wit h increased cough , shortness of breath , fever, and increasing infi l trates in both lung fields .

The exami ner found a grade III/VI systol ic murmur a t the left s t ernal border a nd atrJ.al flutter a nd fibri l lat ion, .vhich were kno\VI\ previously . The chest x-ray

Case 16 (con tinueU)

f ilms demonstrated c o nsol i dation of the midd l e and l ower lobes o f t h e righ t lung. iler hemog l obi n >~as 5 ·. 2 g /dL whereas i t had been 12 .8 g /dL the month bef ore , I<BC 1 3,500 per cu . rnm. ·With 80% po l ymor phonucl ear l eukocy t es, BUN 62 mg/ dL, creatini ne 3 . 1 mg/dL , p o t assium 5.4 mEq/1 ., sodium 133 mEq/1. and CO 18 mi / l. She was afebril e and l etharg ic. The physi cians gave her blood transfusions , Keflin, i soniaz id, streptomyci n , and ethambutol. Her cough was we a k and p ro­duc t ive of blood- s tained fluid . She rapi d l y became d isoriented, then cy a notic and died on the f ifth hosp i t al day.

At autopsy, tl1e l u ngs weighed 1250 gm . rt . , 550 gm. left. The righ t l ung· was f i rm with scatte red white nodules and deep r ed areas ; firm, dark r ed, sub­pl eural foci, t he larges t of which was 5.0 x 3 .o· x 2 . 5 em. , and the mi ddl e l obe was coll apsed. Bronchiectasis was present in both lungs. The left lung d id not have the white nodu l es, but had t he ·o t her features t o a less de-gree . The lingula 1~as col lapsed . Tracheobronchial and pu lmonary hil ar l ymph nodes wer e mottl ed b l ack and whi t e . The pulmonary arteries contained mult ipl e a t he r oscleroti c plaques .

Case 17

Contributed by Dr. Washington c. Winn, Jr. Uni versi ty o f vermont College of Medicine, Burling t on , V.ermon t

The pa t ien t was a 67- year- old whi t e man with kno~<n chronic obstructive pul ­monary disease who came into the hospi t a l in 1 977 because o f acute fever , cough and shortness o f breath. I n 1 969 and agai n i n 1971 he had had pneumococcal pneumon i a . His current sympt oms dev e l oped over about a week and were accompanied by chil l s . The cough was prod uctive of scant b r own sput um.

Case 17 (continued·)

On admissi on, he was o bvious l y dyspneic , respirations were 35 pe~ min . , a nd he had a r ectal l;emper ature of 39. 5°C . In the chest x- ray film, there app.eared predominantly peri-hilar infiltrat es and a patchy infiltrat e in the upper lobe of the left l ung . Bis WBC was 99000/c~ . mm. with 95\ l ymphocytes. The physicians treated him with nasal oxygen , ampicillin, ami nophyllin and furosemide. Sputum and blood cultu.r es grew nothing s ignifi cant . The pulmonary infiltra t es increased rap·idl y , and he died o n the second hospit a l day .

The autopsy p r osector descr ibed a r igh t Lung of 1425 gm . and left of 650 gm. The c ut s u r face of the r ight ~ung appear ed consol idated, g r ay and f ibr i nous with some of t he same on the left . I n addition, the r e was a solid mass 2 x 1. 5 x 1 . 0 em. i n the left l ower lobe. The sec t ions came f r om the :ti ght lung·.

Case 18

Cont ributed by D~ . Mer le A. Legg New Eng l and Deaconess Hospi tal , Boston , Mass .

A 34-year-old white '"oman came into the hospital because of increasing shortness of breath wi th e xe rtion in the p r evi ous one t o two l<eeks . She de ­vel oped a fever o;f 102. 4°F . tv;o days before admission and a cough producti ve of yello1• sputum . In November, 1977, she bad been found to have Hodgkin ' s disease , nodular sclerosis type, with cervical and mediastinal involvement and the superior vena caval syndrome. She r eceived 4000 ra-d in the man tle distribution and 3500 rad to the pa r a-aor t ic l ymph nodes . Nith t racheal compress ion in June, 1978, she was given 1400 rad to the r i ght par atracheal regi o n. The chemotherapis t s insti­tuted MOPP (nitrogen mustard , oncovin, prednisone and procar baz i ne) at the same t i me . In January , 1979 , she had b r onchi al obstruction and col lapse of the upper l obe of her left lung . The rad iotherapists gave the left hi l ar region 1600 rad

Case 18 (continued)

and the chemotherapists started her on adriamycin, bleomycin, velban and OTIC . She developed neutropenia and pneumonia . In July, 1979, because of continuing fever and shortness of breath, the radiotherapists gave the left lung 2000 rad . The chemotherapy was switched to CCNU .

On the l as t admission in September, 1979 , she was febrile (103 .8°1'), short of breath and had anterior cervical ru1d s upracl avicular lymphadenopathy . The chest x-ray film demonstrated bilateral , diffuse "interst iti a l and alveolar in­filtrates ," was hypoxic and had a 92% granulocytosis with a wac of 5 , 800/cu.w.m . A skin lesion on her back looked like herpes simplex to the examiner. A wide range of cultures produced none of the suspected organisms . The internists treated her with trimetboprim and sulfamethoxazolc, gentamycin , cephalexin and =ethylprcdnisolone. Viral throat cultures were positive for herpex simplex . Even with 70\ oxygen, later increased to 85\ oxygen, she was mi l dly hypoxic . The pulmonary infiltrates grew "'orse, BUN and creatinine started to ris" and the gcntamycin was changed to erythromyci n . She died on the sixth hospital d<!y .

The autopsy prosector described lungs of 980 gm . right and 750 gm. left. The pulmonary parenchyma was repl aced by ill-defined, diffuse, yellow-white, firm material, more defined nodules, and focally a rod, wet, fibril lar pattern with thick alveolar walls .

Case 19

Contributed by Or. Herle A. Legg New England Deaconess Hospi t al, !los ton, ~lass .

A 39-year-old \<hi te man , 1•ho had been diagnosed as having widespread nodular mal ignal\t l ymphoma eight years before the final admission , c ame into the hospi tal in September, 1976, because of increasing size of left cervical lymph nodes with a draining sinus having developed during outpatient radiation therapy . In the week before admission, he developed fever and then a dry cough .

His malignant l ymphoma had been treated £irst by ni trogen mustard and later by several cycles of Cytoxan, Vincristi ne , Prednisone and Procarbazine. He also had had total body radia tion , and finally C-~~PP chemotherapy . In the last seven months , he was given only corticosteroids. He had had an episode of pneumonitis a nd dr<dning right cervical lymph nodes two mon·ths before the l ast admission and received multiple antibiotics .

When he entered the hospital, he was febrile with 101°F. and had a very large, ulcerated left Submandibular lymph node. The chest x- ray fi lms demonstrated a wide mediastinum and peri-hil<>r pulmonary iniilt.ration . The physicians gave him Keflin and gentamycin with no response, but he became afebrile on chloramphenicol . Be­cause of hema~ologic findings, che chloramph~licol was discontinued and he was put back on three antibiotics . He slowl y became disoriented and died one month after admissio n.

At autopsy, the prosector described a 680 gm. right lung and 520 gm _ lefc lung. The lungs felt firm and there were i l l-defined gray- yellow areas on the cut sur­face with a background of pink-red par enchyma in which tho <>ir cell pat tern seemed more normal. A small caseati ng nodule 0 . 8 em . in diameter was in the left lower lobe . The bronchial and vascular trees appeared normal. The mediastinal and tracheobronchial lymph nodes were large, rubbery and gray-tan .

Case 20

Contributed by Dr. Me r le A. Legg New Eng l and Deaconess Hospita l , Boston, J4ass.

A 54-year -o! cl whi t e woman was referred to the )'le w Eng l and Bapti s t Hospit a l from Cape Cod because of a cough a nd infiltrat e o f t he l ower l o be of t he l eft lung tha t persisted . In April , 1978, t he surgeons had removed a benign parotid t umor . She fe l t t hat she had had a cough, ra t t l ing noise in her chest a n d i n­creasing shortness of breath since that operation . I n April of 19 79 she de­vel oped a fever of 103- 104<1: . and the Cape Cod physicians found the left l ower lobe i n f iltr ate . They treated her with anti biotics to whi ch there was some response, but the left l ower l0be infil t r a te per s i sted . She had been a 20 pack­·year cigarette s moker, bu·t stopped ten yea rs before t his episode . She had wor ked i n an au.totrobi le garage for 17 years .

Hhen she 1•as t rans ferred in June , 1979, no other s t ud ies, incl udi ng bron­choscopy , were significant . The surgeon r .emoved thee left lung when he £ound in­fil trates in both lobes at the time of the thoracotomy . The lo>~er l obe weighed 2 10 gt~~. and t he upper, 150 gm . An i.ll-defined, nodular p i nk to whi te mass up to 6 . 0 em. in grea t est dimension occupied much of the basal segments o£ the lowe:r lobe and small nodules were present i n the lingul a scat tered over a 4.0 e m. diameter area . The b r o nchial and vascular trees loo~ed normal .

Case 21

Contribut ed by Dr . L . Ra lph Rohr Tucs on Medical Center, Tuc son, Arizona

The pati ent , a 72-year- o l d man, ha d had pneumonia of the mi ddl e l obe of the right l u ng and t he density of the lobe pers i sted f or t wo year s without demon­s tra b l e reaso n . A needle biopsy produc ed necrotic debris suggesti ve 'o f a granu­l oma . The s urgeons r emoved the r ight .midd l e l o be·.

Case 2 1 (conti nued)

The lobe weighed 80 gm. Subpleurally the re was a circumscribed, but not e ncapsula ted , indurated, gray-white and tan , partially necrotic , partia lly c ystic a r ea , measuring 6 x 4 x 2 . 6 em .

Case 22

Contributed by Dr. Richard B. ~larshall

Bowman-Cray School of Nedicine , Winston-Sal em, Nor th Carolina

The patient was a s ix-year-old boy who had had hemoptysis and recurrent pneumonia for about twelve months . A mediastinal mass was evident in the chest x-ray film . At bronchoscopy, the examiner found a prott~ding intra-bronchi al mass suggesting a bronchial adenoma i.n the Left upper lobar bronchus . A left upper lobec tomy was per formed.

The lobe measured 15 . 0 x 7 . 0 x 5 . 5 em . A protruding , lobulated , soft mass 0 . 9 x 0 . 6 em . was in the d ilated lobar bronchus . This mass tlnuous with a sharply demarcated , bright yellow-tan mass 3 . 5 x 2 . 5 x Bronchi distally were dilated, cystic and filled with mucoid m;lterial. lymph nodes did not contai n tumor.

fleshy , wa s con-2.2 em.

The

case 23

Contributed by Dr . Merle A. Legg New England Deaconess Hospital, Boston, Mass.

A 39- year-old white woman fell from a motorcycle and injured her head. After four days of dizziness and headaches accompanied by heavy alcohol consumption and the use of chlordiazepoxide (Librium R), she was found comatose and br ought to tho hospital. Her aortic valve had been replaced three years before at a nother hospita l, she had suffered a righ t cerebrovascular accident from which she had recovered completel y , but she was on l ong-term anticoagul ant therapy . Her general status progr essively deteriorated to decerebrate and s he died .

Her lungs each weighed 450 gm ., there was bubbly , mucoid material in her seg­mental bronchi , and the left lower lobe was collapsed . The cut surfaces of tho l ungs were red-brown and exuded a small amoun t of red-brown f luid . The lungS felt rubbery, but the architecture was not disrupted.

Case 24

Contributed by Dr. David B. Kaminsky Eisenhower Medical Center, Rancho 14irage, california

The pat~ent , a 72-year-old whi te woman , came to the hospital because of. short­ness of breath on e xer t ion, weakness and rectal discomfort. Fifteen months before ~is admission , tho surgeons had widely e xcised a basosquamous carcinoma of the ano­rectal region. rol lowing the diagnosis of an inguinal lymph node metastasis ten months after the initial procedure, the physicians gave her a course of bleomycin, With an accumulated total dose of 300 mg . Her dyspnea had started three days be­fore the last admission. She was a twenty-year , i nsulin-dependent diabetic , had a mul tinodular goiter with hypothyroidism and was a long- term, one-pack- a - day ciga­rette s moker.

Case 24 (con tinued)

Ther e we r e b ilateral, ill - de fi ned , diffuse and reticular infil tra tes demon­str ated by the chest x-ray film. Pulmonary function studies were said to show res trictive, obstructive and di f fusion defects . She was thought to have a metabolic encephalopathy and died on the seventh hopsital day .

At a utopsy, the prosector desc ribed lungs which together weighed 1130 gm. Af ter i ns ufflation and f ixation , the l ungs were pale brown, the a ir cell pattern was accent uated, and there was an increa s e in density of the l ung parenc hyma. Particul.ar J.y in the lowe r lobes , s trands pr oduced a "delicate microc r ibi form network. "

Case 25

Contribu ted by Dr . Allan 1>'. Handy and Dr. LOuis R. Ziegra Fri s bie Nemori al Hospital , Rochester , New Hampshire

The pa t ient. was a 57-year-old white ma n who sought help because of shortness of bl:C<~th. /\bout thr ee weeks before hi s admi ssion , he had had a "chest cold" and since 1.hen was s hor t of br eath o n e xe r tion and es peci al l y with wa l king in col d air (it was January ) . He had l i ttl e cough e xce pt s ome i n t he morning the last f ew days produc tive of s cant brown sput um , occasionall y with red stre~ks . He may have lost wei ght , but the examiner was s kep t i cal . He l<as a "hol!lvy smoker ," worked as a highway l abor er f or a nearby town wi th no kno"'l1 pa r tic l e exposure , but had ~~rked for sL~ years as a mol der at the ~avy Yard f oundry 15-20 years earlier. Sixteen years bef or e h is admisgion , he had pleurisy and e l even years bef ore he had had left upper lobe lobar pneumonia which had completely resolved .

The radiologist d escribed the ches t x-ray film , as follows : granular-like infiltration i nvolv ing the entire lung fiel d , but more marked at both bases ."

Case 25 {continued)

The on ly s ignifica n t l aborato r y findings. were hemog l obin o f 1 7 .8 gm./ dL., hemat o ­crit o f 55% and WBC of 16, 300/ cu . mm . with a normal differ enti a l. Scalene l ymph nodes were b iopsied , but were nega t i ve. I n the three '"eeks between the f.i-rs t admission and lung biopsy , the ches t x - ray findings were constant, but t he patient f elt less shor t of breath. At the t ime of the l ung b i opsy t hrough a smal l r i gh t thoracic incision, the surg.eon r eport ed that the l Ung fel t i ndura t ed and nodular, and he biopsi ed both the right mi ddle and lower lobes . The sp ecimen wa.s cultured, producing Staphy~ococcus aureus coagulase negative gr01~th at s i x days. No fung i or acid fast bacilli were found.

Case 1 ,

Case 2.

Case 3.

Case 4.

Case s.

Case 6.

Case 7.

Case 8.

C">.se 9.

Case 10 •.

Case 11 .

Case 12,

Case 13 .

Case 14 .

Case 15 ,

Case 16.

Case 17.

~6! h .-\ 1-.'NL'.'\l FAll AN-\ TO~.HC PA THOlCCY Sll DE SE.\11•'>:-'.f<

PUL~WN'\RY PA THOlCCY

PRELECTCRS

Merle A. legg,M.D. Lynne .\1. Reid , M. D.

Bronc hi~l carcinoid with concomi tant undifferentiated carcinoma, small cell type

Undifferentiated carcinoma, small cell type (' Inappropriate ADH Syndrome' in one case)

Lymphangioleiomyomatosis in patient with tub•!rous sclerosis

Cystadenomatoid malformation

Hyaline Membrane Disease [lnfa11t R~spira tory Distress Syndrome)

Bronc hop ul mo nary dysplasia

Childhood lobar emphysema

Cyst ic fibrosis

Lymphomatoid gran ulomatosis

Spindle cell pseudotumor

Carcinosarcoma

Eosinophilic granuloma

Lung changes with ventricul ar septal defect

Primary pulmonary hypertension (veno-occluslve)

Polyarteritis nodosa

Legionnaire's Disease and chronic lymphocytic leukemia

. .

Case 18.

Case 19.

Case 20.

Case 21 .

C~se 22.

Case 23.

Case 24.

Case 25 .

Pneumocystls pneumonia and secondary alveo litis wit h Hodgkin's Disease

Cytomegalovirus pneumonia and focal herpes pneumonia with malignant l"t1!Ph0tP~

Bronchiolar carcinoma

• Intravascular bronchio le- al veolar t umor•

Mucous cell tumo r (muco-epidermoid carcinoma)

Talc lung

fibrosing alveolitis (Bieom.,.:in)

Alveolar proteinosis