1. 8월 흉영 집담회 증례 발표 서울대병원 - F. 유노을 -
CPA?
+++ HP
HP upper…
PFT
CHP?
radiographics

2. Social Hx: 2년 전 알루미늄 공장에서 근무
M/35
C.C.: dyspnea (2 YA)
Social Hx: 2년 전 알루미늄 공장에서 근무
Had a occupational history of working at a Aluminum factory (2 years ago)

3. 2015-03-17 Chest PA Chest PA taken on march 17th, 2015 showed
Diffuse micronodular opacities in both lungs
In addition, there were suspicious bulging opacities at Rt. Paratracheal, AP window, and bilat. Hilar area

4. 2015-03-03 Chest CT Chest CT taken as a further w/u revealed
Diffuse confluent GGO in both lungs.
On the magnified view of the basal lung, ill-defined centrilobular nodules were also noted.
In addition, small cysts were also seen in BULs.

5. With regard to the anatomical distribution, bilat
With regard to the anatomical distribution, bilat. basal lungs were relatively spared.

6. On the mediastinal setting, Rt
On the mediastinal setting, Rt. upper, lower paratracheal, paraaortic, bilat. hilar and interlobar LNs were enlarged.

7. Radiologic Diagnosis
Diffuse confluent GGO and GGO nodules in both lungs: -slightly more prominent in BULs -small cysts at BULs  hypersensitivity pneumonitis (subacute to chronic stage), probably Enlarged 4R and 6 LNs  reactive LNs, probably No remarkable finding in the bony thorax No remarkable finding in the covered abdomen
Based on the findings, we reported ‘hypersensitivity pneumonitis’ as the most probable diagnosis

8. Bronchoscopy [ ]
Bronchoalveolar lavage fluid, cytology (liquid based cytology):
Negative for malignant cells,
Many alveolar macrophages,
Some multinucleated giant cells, lymphocytes
CD4(65%) / CD8 (21%)
BAL fluid analysis performed on march, 18th, 2015 showed multinucleated giant cells with an increased CD4/ CD 8 ratio around 3.

9. Pathology Lung, wedge resection:
Multiple non-caseating granulomas with mild interstitial lymphoplasmacytic
infiltration (FAVOR SARCOIDOSIS)
Noncaseating Granulomas
Granulomas without Necrosis

10. Atypical Presentation of Sarcoidosis
Although the typical manifestation of the sarcoidosis are bilat.symmetric hilar lymphadenopathy, micronodules of perilymphantic distribution, there are also a few atypical features including GGO as shown in our case.
RadioGraphics 2010; 30:1567–1586

11. Ground-glass Opacities
Patchy: 40% (Extensive: much less common)
Result from the confluence of micronodular granulomatous and fibrotic interstitial lesions
Cause airway compression, but not airspace filling (cf. alveolitis)
Ill-defined margins, and bronchoalveolar structures are frequently visible
Always accompanied by other abnormalities and often superimposed on a background of interstitial nodules
Patchy ground-glass opacities are seen in an estimated 40% of patients with parenchymal changes due to pulmonary sarcoidosis; extensive groundglass opacities are much less common. The patchy ground-glass opacities in sarcoidosis result from the confluence of multiple micronodular granulomatous and fibrotic interstitial lesions, which cause airway compression but not airspace filling like that seen in alveolitis (9,33). These ground-glass opacities have ill-defined margins, and bronchoalveolar structures are frequently visible within them at CT. Occasionally, intraalveolar granulomas, scattered desquamative cells, or hyaline membranes may lead to airspace opacity; however, the airways are more often patent, producing the appearance of air bronchograms at CT (Figs 10, 11). The patchy ground-glass opacities in sarcoidosis are always accompanied by other abnormalities and often are superimposed on a background of interstitial nodules.
좌)a diffuse ground-glass pattern produced by multiple confluent micronodules, with associated bronchiectasis.
우)Magnified axial high-resolution CT scan of the right lung clearly depicts separate nodules in a subpleural (black arrow) and fissural (white arrow) distribution and along the bronchovascular bundles (arrowheads).
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which cause airway compression but not airspace filling like that seen in alveolitis (9,33).
however, the airways are more often patent, producing the appearance of air bronchograms at CT (Figs 10, 11).
RadioGraphics 2010; 30:1567–1586

12. At the retrospective review of our case, micronodules were noted at peribronchovascular area, fissural, and subpleural area.

13. Sarcoid-like Reaction and Metals
Inhalation of metal dust or fume can cause granulomatous lung disease that mimics sarcoidosis.
Aluminum, barium, beryllium, cobalt, copper, gold, rare earths (lanthanides), titanium, and zirconium, silica, silicates, talc, iron, barium sulfate, and fibrous glass
Lastly, according to the literature review, inhalation of metal dust or fume can cause granulomatous lung disease that mimics sarcoidosis and aluminum is one of the many possible causes.
Presented case was that of atypical sarcoidosis which manifested as diffuse GGO.
Semin Respir Infect. 1998 Sep;13(3):212-20
Am Rev Respir Dis. 1987 Feb;135(2):493-7
Chest Nov;126(5):1431-8