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Clinical question
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.
Review 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.
(A) Axial image of non-contrast chest CT (5 mm 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 …
Footnotes
Handling editor Iskander Chaudhry.
Correction notice This paper has been corrected since it was published Online First. New hyperlinks to the digital slides have been added.
Contributors C-TC wrote the original version of the article; C-HW and Y-ST provided the clinical information and drafted the manuscript; K-CC revised the manuscript and supervised the whole study.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Obtained.
Provenance and peer review Commissioned; internally peer reviewed.
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