SC-49 Interstitial Lung Disease: What Your Clinician Wants to Know Kristen L. Veraldi, MD PhD, University of Pittsburgh, Pittsburgh, PA Frank Schneider, MD, The Permanente Medical Group, Oakland, CA For review by pre-registrants prior to the meeting This document provides clinical histories and radiographs for the virtual slides posted on the USCAP website. Histopathologic differential diagnosis of ILDs can often be enhanced by integrating radiographic and clinical information. This course will place into clinical context a variety of histopathologic features one might see in lung biopsies of patients with ILD. In this course we will discuss 1. which particular histologic features are of most interest to the clinicians in which clinical setting, 2. how to recognize the clinical setting based on the often limited information available at the time of slide review, 3. multidisciplinary practice guidelines addressing various ILDs, and 4. treatment decisions made based on the tissue diagnoses. The course, presented by a pulmonologist and a pathologist, will be organized as a series of case presentations illustrating challenging situations in the diagnosis and reporting of ILD. A comprehensive syllabus will be distributed at the course. After the meeting, all course registrants will also be able to access to the PowerPoint slides presented at the USCAP Annual Meeting.

Case 1 – Virtual Slide Labeled 3 A 35-year-old woman with obstructive lung disease, recurrent pneumonia and fibromyalgia presents with a chief complaint of episodic pleuritic chest pain and exertional dyspnea with minimal nonproductive cough for the last 6 years. Her chest CT (see image) was reported to show subpleural, basilar-predominant interstitial abnormalities with some anterior right upper lobe ground glass opacities and minimal traction bronchiolectasis of the right base. The whole slide image (labeled "3") shows a representative section of the patient's surgical lung biopsy. Differential diagnosis: Other history or tests I wish I had:

Case 2 – Virtual Slide Labeled 9 A 62-year-old male never-smoker with coronary artery disease presents with non-resolving dry cough and exertional dyspnea. His skin was notable for hypo-pigmented areas over dorsal services of bilateral hands, face and inguinal regions consistent with vitiligo. Pulmonary function tests demonstrated mixed obstructive-restrictive abnormality and moderately reduced diffusing capacity for carbon monoxide. Laboratory studies were remarkable for a mild peripheral eosinophilia. His chest CT (see image) was reported to show basilar-predominant diffuse bilateral interstitial abnormalities with basilar traction bronchiectasis and mild dilation of the mid-esophagus. The whole slide image (labeled "9") shows a representative section of the patient's surgical lung biopsy. Differential diagnosis: Other history or tests I wish I had:

Case 3 – Virtual Slide Labeled I A 35-year-old woman presents with a 2 year history of varying degrees of shortness of breath. She has no occupational exposures but lives with her boyfriend who has two dogs and a cockatiel. She feels better when she goes on business trips to Asia. Her chest CT (see image) shows micronodules, predominantly in the upper lobe, but no fibrosis. The whole slide image (labeled "I") shows a representative section of the patient's surgical lung biopsy. Differential diagnosis: Other history or tests I wish I had:

Case 4 – Virtual Slide Labeled 2 A 57-year-old woman with rheumatoid arthritis and hypothyroidism presents with high fever and abdominal pain. She has been treated with prednisone, 7.5 mg daily. She had also been on methotrexate for 10 years, off for three years due to skin infections, and had resumed 4 months prior to presentation. Her chest CT (see image) was reported to show diffuse bilateral ground glass opacities and areas of septal thickening. The whole slide image (labeled "2") shows a representative section of the patient's surgical lung biopsy. Differential diagnosis: Other history or tests I wish I had:

Case 5 – Virtual Slide Labeled H A 36 year old man presents with progressive non-productive cough for 15 years and progressive shortness of breath over the last 2-3 years. He is a rare social tobacco smoker and has no significant past medical history. His fingernails and toenails have been thickened and yellow for at least the past 6-7 years. He worked for 15 years in the cemented carbide industry. His chest CT (see image) shows diffuse micronodular and reticular abnormalities with relative sparing of the bases without honeycomb change and traction bronchiectasis. The whole slide image (labeled "H") shows a representative section of the patient's surgical lung biopsy. Differential diagnosis: Other history or tests I wish I had:

Case 6 – Virtual Slide Labeled 10 A 69-year-old female never-smoker with inflammatory polyarthritis in her late 20s (treated with prednisone for two years) presents with a chief complaint of low-grade fever, chills, mild dyspnea and cough. Progressive symptoms resulted in hospital admission. Her chest CT (see image) was reported to show extensive bilateral consolidation with a mid- and lower-lung predominance and small bilateral pleural effusions. The whole slide image (labeled "10") shows a representative section of the patient's surgical lung biopsy. Differential diagnosis: Other history or tests I wish I had:

Case 7 – Virtual Slide Labeled 8 A 61-year-old man with ulcerative colitis (treated with mesalamine, infliximab and prednisone), renal cell carcinoma and “lung injury as a child” presents with a chief complaint of one year of progressive dyspnea on exertion with nonproductive cough and several weeks of accelerated symptoms and subjective fevers not significantly improved with antibiotics. His pulmonary function testing revealed a moderately severe restrictive pattern and severely decreased diffusing capacity for carbon monoxide. His chest CT (see image) was reported to show extensive bilateral reticulation throughout all lung lobes with traction bronchiectasis. The whole slide image (labeled "8") shows a representative section of the patient's surgical lung biopsy. Differential diagnosis: Other history or tests I wish I had:

Case 8 – Virtual Slide Labeled 7 A 42-year-old male never-smoker with ulcerative colitis, status post colectomy, adult-onset asthma and nasal polyps presents with a chief complaint of one year of mild dyspnea on exertion. His laboratory studies were remarkable for peripheral eosinophilia (14%, absolute 1.89 x 10E+09/L), positive atypical ANCA (negative P-ANCA, C-ANCA), weak positive rheumatoid factor (29 IU/mL, reference range <20) and elevated IgE (518 IU/mL, reference range <160). His chest CT (see image) was reported to show patchy, predominantly juxtapleural and apical, ground glass opacities and mild thickening of the small airways. The whole slide image (labeled "7") shows a representative section of the patient's surgical lung biopsy. Differential diagnosis: Other history or tests I wish I had:

Case 9 – Virtual Slide Labeled 4 A 21-year-old obese woman, who underwent cholecystectomy 4 months prior, presents with scant hemoptysis that did not resolve with antibiotic therapy. Her laboratory studies were remarkable for a positive anti-nuclear antibody (ANA) that was negative on repeat testing, negative ANCA on two separate occasions, negative rheumatoid factor, but positive anti-CCP (6.8 U/mL, reference range <3.0) and elevated C- reactive protein. Her chest CT (see image) was reported to show a right lower lobe cavitary lesion and mediastinal adenopathy. The whole slide image (labeled "4") shows a representative section of the patient's surgical lung biopsy. Differential diagnosis: Other history or tests I wish I had: