A 35-year-old woman comes to the office due to 3 months of progressive dyspnea on exertion, nonproductive cough, and fatigue. She has a history of seasonal allergies for which she takes over-the-counter antihistamines. The patient ascribes her symptoms to smoking cigarettes and has cut down from a pack to 3 or 4 cigarettes daily. Her mother has rheumatoid arthritis. CT-guided lung biopsy is performed; findings are shown in the image below. This patient most likely has which of the following conditions?

Question

A 35-year-old woman comes to the office due to 3 months of progressive dyspnea on exertion, nonproductive cough, and fatigue.  She has a history of seasonal allergies for which she takes over-the-counter antihistamines.  The patient ascribes her symptoms to smoking cigarettes and has cut down from a pack to 3 or 4 cigarettes daily.  Her mother has rheumatoid arthritis.  CT-guided lung biopsy is performed; findings are shown in the image below.  This patient most likely has which of the following conditions?

Quizplus · Accepted Answer

11ec160b_3a1b_bbbe_9249_d1646e32e758_MD0001_00 This patient likely has sarcoidosis, a chronic multisystem disorder characterized by the formation of noncaseating granulomas (eg, epithelioid macrophages, multinucleated giant cells). It typically affects young adults and is more prevalent in African American individuals and in women. Any organ can be affected, but the lungs are initially involved in most cases. Patients often have the insidious onset of respiratory symptoms (eg, cough, dyspnea, chest pain) accompanied by fatigue, fever, and weight loss. The disease may also be incidentally detected in asymptomatic patients with typical chest x-ray findings (eg, bilateral hilar lymphadenopathy, reticular opacities). (Choice A) Allergic bronchopulmonary aspergillosis commonly occurs in patients with asthma or cystic fibrosis and presents with recurrent disease exacerbations. Microscopic examination would likely show mucin within the bronchial lumens with numerous eosinophils and rare Aspergillus hyphae. (Choice B) Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis) usually presents with chronic rhinosinusitis, asthma, and eosinophilia. The granulomas seen with Churg-Strauss syndrome typically have eosinophilic infiltration and extensive necrosis. (Choices C, E, and G) Desquamative interstitial pneumonia (DIP), idiopathic pulmonary fibrosis (IPF), and pulmonary alveolar proteinosis (PAP) are associated with cigarette smoking and typically present with the insidious onset of progressive dyspnea and chronic cough. However, DIP is characterized by numerous intraalveolar macrophages, IPF is associated with patchy fibrosis and inflammation, and PAP demonstrates lipoproteinaceous material within the alveoli. (Choice D) Hodgkin lymphoma typically presents with lymphadenopathy and B symptoms (eg, fever, night sweats, weight loss), and histopathology demonstrates Reed-Sternberg cells surrounded by inflammatory cells. (Choice F) Systemic sclerosis results in progressive collagen deposition and fibrosis of the skin and visceral organs (eg, gastrointestinal tract, lungs, kidneys), which can lead to dyspnea and cough. However, biopsy would demonstrate excessive collagen deposition, not granulomas. (Choice I) Small cell carcinoma is a highly malignant lung cancer that is strongly associated with smoking. Histopathologic features include small cells with scant cytoplasm, granular nuclear chromatin (salt and pepper pattern), and indistinct nucleoli. Educational objective: Sarcoidosis often presents in young women with the insidious onset of respiratory symptoms (eg, cough, dyspnea, chest pain) accompanied by fatigue, fever, and weight loss. The characteristic histopathologic feature is noncaseating granulomas, which consist of aggregates of epithelioid macrophages, frequently with multinucleated giant cells.

A 35-Year-Old Woman Comes to the Office Due to 3