Case 176 -- Pulmonary Nodules

Contributed by Sonya Arnold, MD and Susan Hasegawa, MD, PhD
Published on line in December 1998

Disclosure Statement: In accordance with the policies on disclosure of the Accreditation Council for Continuing Medical Education and the Faculty Advisory Committee for Continuing Education in the Health Sciences, University of Pittsburgh, presenters for this program have identified no personal relationships with a health care product company which, in the context of their topics, could be perceived as a real or apparent conflict of interest.


After completing this exercise, the reader should be able to do the following:

  1. Define lymphocytic interstitial pneumonia
  2. Be familiar with the various disorders associated with lymphocytic interstitial pneumonia
  3. Recognize the most common clinical findings associated with lymphocytic interstitial pneumonia, including radiographic features
  4. Recognize the key histopathologic features of lymphocytic interstitial pneumonia and be able to develop a reasonable differential diagnosis


A twelve-year-old girl was referred to the pediatric pulmonary service for evaluation of recurrent lung nodules. She had a past medical history of multiple immunologic disorders, including idiopathic thrombocytopenic purpura (ITP), common variable immune deficiency (CVID), and autoimmune hemolytic anemia (AIHA). Her medication consisted of intravenous gamma globulin every other week. The lung nodules were initially seen on a chest x-ray and a computerized tomography (CT) scan 10 months earlier. At that time, the patient was hospitalized for an exacerbation of autoimmune hemolytic anemia. Her anemia was treated with steroids and the lung nodules resolved. The nodules reappeared with a more severe pattern after the steroids were tapered. She had some fatigue with exertion but was otherwise asymptomatic. Her physical examination was remarkable for bilateral crackles in the lung bases. Pulmonary function studies revealed combined obstructive and restrictive patterns. The patient underwent an open lung biopsy.


Anteroposterior (Image 01) and lateral (Image 02) chest x-rays (10 months earlier) demonstrated a reticulonodular pattern, most prominent in the lung bases.

Anteroposterior (Image 03) and lateral views (Image 04) of recent chest x-ray demonstrate a more pronounced reticulonodular pattern in the lower lobes. Most recent CT scan of the chest (Image 05) demonstrates recurrent nodular interstitial lung disease, with more extensive involvement than before.





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