A 76-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is found to have a laceration of the spleen and is taken for emergent laparotomy. During surgery, the patient goes into cardiac arrest and dies, despite aggressive resuscitation efforts. Autopsy examination is performed and shows areas of thickening inside the chest wall as shown below. Lung examination shows fibrosis of the lower lobes. Pathologic examination of these fibrotic areas is most likely to reveal which of the following findings?

Question

A 76-year-old man is brought to the emergency department after being involved in a motor vehicle collision.  He is found to have a laceration of the spleen and is taken for emergent laparotomy.  During surgery, the patient goes into cardiac arrest and dies, despite aggressive resuscitation efforts.  Autopsy examination is performed and shows areas of thickening inside the chest wall as shown below.  Lung examination shows fibrosis of the lower lobes.  Pathologic examination of these fibrotic areas is most likely to reveal which of the following findings?

Quizplus · Accepted Answer

11ec160b_3b2c_8fc5_9249_4f18356ae5ac_MD0001_00 This elderly patient had pleural plaques (focal thickening and calcification of the parietal pleura) and lower lung fibrosis, consistent with pleuropulmonary asbestosis. Asbestosis is a pneumoconiosis that occurs with inhalation of asbestos fibers (hydrated magnesium silicates), typically in patients with occupational exposure (eg, insulation installation, shipbuilding, pipe work). Patients are typically asymptomatic for 20-30 years after initial exposure; dyspnea, cough, and fatigue are common presenting symptoms. CT radiography in asbestosis demonstrates bilateral parenchymal fibrosis, most predominant in the lower lungs; honeycombing and upper lung involvement occur in advanced disease. Pleural disease is common and includes pleural plaques, diffuse pleural thickening, or benign pleural effusions. Histopathology typically demonstrates diffuse interstitial fibrosis in association with ferruginous bodies (golden brown, rod- or fusiform-shaped fibers coated with iron-protein complexes). Asbestos fibers can be differentiated from other ferruginous bodies (eg, carbon, talc) by their translucent fiber core. (Choice A) Hyaline membranes within the alveoli are seen in acute respiratory distress syndrome (ARDS) and can occur after severe trauma or sepsis. ARDS can lead to fibrosis, but this typically occurs weeks to months after the initial pulmonary insult and is not associated with pleural plaques. (Choice B) Birefringent silicate particles are seen in silicosis, which typically presents with innumerable nodules that predominate in the upper lungs; egg-shell calcifications of the hilar lymph nodes may also be seen. Pleural plaques are unexpected. (Choice C) Carbon-laden macrophages are seen in coal workers pneumoconiosis. Gross pathology demonstrates black coal nodules distributed throughout the upper lungs. (Choice D) Carcinoid tumors are neuroendocrine malignancies that appear histologically as sheets of uniform cells with dense core granules noted on electron microscopy. They sometimes cause carcinoid syndrome (eg, flushing, diarrhea, wheezing), which is seen more commonly with gastrointestinal tumors. However, they tend to involve the large bronchi; fibrosis and pleural plaques are unexpected. (Choice E) Chronic granulomatous disease is an immunodeficiency due to the inability of phagocytes to produce reactive oxygen species. Patients develop excessive granuloma formation and recurrent bacterial and fungal infections. Patients are typically diagnosed in childhood. Educational objective: Asbestosis is a pneumoconiosis that occurs with inhalation of asbestos fibers, most commonly in patients with occupational exposure (eg, insulation installation, shipbuilding, pipe work). Histopathology demonstrates diffuse interstitial fibrosis and ferruginous asbestos bodies (translucent fibers coated with a golden iron-containing material). Pleural disease (eg, plaques, benign effusions) is common.

A 76-Year-Old Man Is Brought to the Emergency Department After