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Virtual case of the month
Subtle lung lesion in a middle-aged woman with fever and cough
  1. Chung-Ting Chiang1,
  2. Chun-Hsin Wu2,
  3. Yi-Shan Tsai3,
  4. Min-Ching Lin1,
  5. Kung-Chao Chang1
  1. 1 Department of Pathology, National Cheng Kung University Hospital, College of Medicine, Tainan, Taiwan
  2. 2 Department of Internal Medicine, Division of Allergy, Immunology, and Rheumatology, National Cheng Kung University Hospital, College of Medicine, Tainan, Taiwan
  3. 3 Department of Radiology, National Cheng Kung University Hospital, College of Medicine, Tainan, Taiwan
  1. Correspondence to Professor Kung-Chao Chang, Pathology, National Cheng Kung University Hospital, Tainan 70428, Taiwan; changkc{at}mail.ncku.edu.tw

https://doi.org/10.1136/jclinpath-2019-205856

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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.

    Figure 1

    (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 …

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    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.