Figure2- Bronchoscopy; the upper division of right bronchus that is obstructed by a mass.
There was no pathologic issue in his chest and abdominal sonography. His first laboratory data showed a leukocytosis (WBC 22,300 with PMN dominant pattern (85%)). ESR and CRP was in nearly normal range. Anti Echinococus antibody was negative. Other laboratory data was in normal range. After surgical consult, he was candidate for surgery and underwent right upper lobectomy and wedge resection. After thoracotomy, mass-like lesion with granulomatous tissue was resected. There was a fistula that was closed by resection. Chest tube size 28 was inserted and the sample was sent for pathologic examination.
Pathologist assessed wedge biopsy of lung, with brown outer surface, measuring 2.5×2 ×1 cm, and a central creamy-yellow nodular lesion, measuring 1 cm in diameter. Sections of the lung tissue with pleural fibrous thickening, revealing prominent interstitial nodular lymphoid proliferations surrounding large epithelioid cells (resembling granulomas), few of them with large nucleolated cells without necrosis. A diffused intra-alveolar infiltration of foamy histiocytes were noted. In addition, a central focus of pulmonary necrosis with mixed acute inflammatory cell infiltration (abscess formation) was present. Foci of hemorrhage was also repoted. In Zhiel-Neelson staining acid-fast bacilli were not seen. PPD test was negative. Because of nodular lymphoid proliferation of pulmonary interstitium with one necrotic area and abscess formation, it was suggestive for interstitial lymphocytic pneumonia or granulomatous disease and we ruled out it by checking CD20, CD3, CD15 and CD30 that shown no definite evidence of Hodgkin lymphoma. Inflammatory myo-fibroblastic tumor (IMT) was diagnosed by its pattern (Figure3). Patient discharged after the surgery and is following up to now for probable relapse.