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.