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INDIANA ASSOCIATION OF PATHOLOGISTS



October 2019

A 79 year old male with hemoptysis and pleural nodule

Contributors: 




Jared Cobb, MD

Fellow, Surgical Pathology

Department of Clinical Pathology & Laboratory Medicine

Indiana University School of Medicine







Chen Zhang, MD, PhD

Associate Professor of Clinical Pathology & Laboratory Medicine

Indiana University School of Medicine


Clinical history: A 78 year old non-smoking male without a significant past medical history presents with recurrent hemoptysis over several years’ time with approximately 3-5 episodes every month for the past 10 months. The patient denies any shortness of breath, chills, night sweats, fever, or weight loss. The patient has no known allergies, no pets, no recent travel, and no significant work related exposures. Chest CT reveals a 2.0 cm pleural based density in the LUL with bilateral ground glass opacities and scattered solid nodules. Significant laboratory findings include a positive ANA and p-ANCA.

Gross Examination: Gross examination of the 2.0cm pleural nodule reveals a firm pale-tan lesion with indistinct borders. The remainder of the parenchyma is red-brown and spongy.

Microscopic examination and immunohistochemistry: Histologic sections exhibit pulmonary parenchyma with effacement of architecture by dense collagen type fibrosis with a mixed inflammatory infiltrate containing scant eosinophils and abundant plasma cells. Scattered lymphoid aggregates with germinal centers and occasional granulomas are present within the involved and uninvolved parenchyma. Furthermore, several small to medium sized vessels demonstrate intramural involvement by inflammatory cells and fibrous obliteration. Immunohistochemistry reveals an appropriate mix of T- and B-lymphocytes by CD3 and CD20, respectively, while CD138 exhibits increased plasma cells. Kappa and lambda demonstrate a polyclonal phenotype while CD30 and CD15 are negative. Up to 85 IgG4 positive cells are identified in a high power field with IgG4 positive cells comprising approximately 40% of total IgG positive cells. 

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Figure1: Effacement of normal pulmonary parenchyma by dense fibrosis with associated inflammatory infiltrate and scattered lymphoid aggregates.

                                

Fig. 1

Figure 2: Inflammatory infiltrate composed of increased plasma cells and occasional eosinophils. Plasma cell containing Russell bodies at approximately 5:00 position


   Fig.2

Figure 3: Vessel with fibrous obliteration by inflammatory infiltrate.


 Fig.3

Figure4: IgG+ plasma cells.


Fig.4

Figure 5: Increased IgG4+ plasma cells.


Fig.5

October 2019 Final Diagnosis and Discussion



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