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Clinical cases

Nodular pulmonary amyloidosis rare cause of calcified pulmonary nodules

The article presents the case of a 60‑year‑old asymptomatic woman whose chest X-ray screening showed bilateral pulmonary nodules of uncertain etiology. Initially, the main suspicion concerned multiple pulmonary metastases, but the anatomical pathology examination of two of the surgically removed lung nodules revealed a benign pattern - foreign body granulomatous reaction to cholesterol crystals. Patient follow-up with a repeat computed tomography one year later showed that some pulmonary nodules had slightly increased in number and size, so the diagnosis required re-evaluation. Congo red staining revealed a positive reaction in the amorphous material, pointing to a nodular form of pulmonary amyloidosis. This case attests to the wide range of investigations needed to examine multiple pulmonary nodules and to the great variety of possible diagnoses. Surgical biopsy, alongside histopathological examination and immunohistochemical tests of the lung are critical in establishing a positive diagnosis. Pulmonary amyloidosis requires additional investigations and long-term follow-up of the patient, as this condition is frequently associated with MALT (mucosa-associated lymphoid tissue) lymphoma or multiple myeloma.
Keywords: calcified pulmonary nodules, nodular pulmonary amyloidosis, foreign body granuloma, MALT lymphoma, multiple myeloma

A curious case of Yellow Nail Syndrome

The Yellow Nail Syndrome is a rare clinical entity, first described in 1967 by P.D. Samman and W.F. White. The triad slow-growing dystrophic yellow nails, lymphedema and chronic respiratory disorders is the typical manifestation of the disease but some variations have been described as well as associations with chylothorax, chylous ascites, intestinal lymphangiectasia, thyroid abnormalities, malignancies and immunoglobulin A (IgA) deficiency. We present a case of a 55‑years‑old woman that had an insidious onset of respiratory disorders and chronic sinusitis, suspected to be infectious throughout the hospitalizations, associated with therapeutically neglected autoimmune thyroiditis.
Keywords: yellow nails, pleural effusion, rare syndromes, lymphedema, bronchiectasis, chronical sinusitis

Mediastinal Fibrosis and Hodgkin Lymphoma mimicking Bronchiolitis Obliterans Organizing Pneumonia

Bronchiolitis obliterans organizing pneumonia (BOOP) represents a kaleidoscope of concepts and morphologies, often being confused with a series of conditions, among which the most feared are Hodgkin's lymphoma and bronchioloalveolar carcinoma.
We shall present the case of a 56-year-old patient, diagnosed in August 2013 with a pulmonary tumour of the right upper lobe, which was CT staged - T4N0M0 (IIIA), who underwent a video-assisted thoracotomy for histopathological confirmation. A mediastino-pulmonary formation had been detected intraoperatively and multiple biopsies had been collected. The information brought by the histopathological examination suggested the presence of 2 synchronous pathologies, namely: the mediastinal biopsy showed an advanced degree of dense, compact fibrosis and the pulmonary biopsy highlighted the presence of granulation tissue and Masson bodies in the distal air space with destruction of vascular and alveolar structures, an aspect which was compatible with organizing pneumonia (BOOP). Once a diagnosis was established, an oral corticosteroid therapy was initiated (Prednisone 30 mg/day) over a period of one month, but the symptomatology of the patient worsened. A new thoracic CT carried out in November 2013 highlighted the progression and extension of the paramediastinal tumoral formation, exhibiting central necrosis and invading the mediastinal vessels, causing their compression (superior vena cava syndrome) associated with multiple mediastinal and hilar adenopathies. The non-favorable evolution and the extensive array of conditions that may mimic the BOOP histopathological pattern have been the key elements, which were the basis of our persistence in getting a real diagnosis. Therefore, in this respect, the biopsy parts performed by thoracotomy were sent for immunohistochemical testing. The CD30 and CD15 positive markers distinctive for Reed-Sternberg cells allowed the diagnosis of Hodgkin's lymphoma.
Keywords: Bronchiolitis obliterans organizing pneumonia (BOOP), Mediastinal fibrosis, Hodgkin's lymphoma.

Interstitial pneumonitis after treatment for hepatitis C virus infection

Pulmonary toxicity is a rare side effect of interferon treatment with a wide spectrum of lung tissue conditions, including interstitial pneumonitis, pulmonary sarcoidosis, bronchiolitis obliterans organizing pneumonia, pleural effusion, exacerbation of bronchial asthma, reversible pulmonary hypertension and acute respiratory distress syndrome. We report a case of interstitial pneumonitis in a patient treated with pegylated interferon α2-a and ribavirin for chronic hepatitis C virus infection, genotype 1. The case was marked by progression of the respiratory symptoms even after the withdrawn of the pegylated interferon. One‑year treatment with systemic corticosteroid ensured a considerable resorption of CT lesions but only a moderate improvement of symptoms and diffusion capacity without a complete recovery.
Keywords: interstitial pneumonitis, interferon treatment, side-effect, hepatitis C