{"id":47325,"date":"2026-07-21T16:47:45","date_gmt":"2026-07-21T08:47:45","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/pathweb\/?page_id=47325"},"modified":"2026-08-08T21:34:09","modified_gmt":"2026-08-08T13:34:09","slug":"lc-1","status":"publish","type":"page","link":"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/lc-1\/","title":{"rendered":"Short cases &#8211; Lung case 1"},"content":{"rendered":"\r\n<h2>\r\n\t\t\tLung case 1\t<\/h2>\r\n\t<p><em>Case writer: A\/Prof Nga Min En<\/em><\/p>\r\n\t<p><strong>Clinical history:<\/strong><\/p>\r\n<ul>\r\n<li>83M, history of multiple myeloma, diagnosed 5 years ago, with several relapses. Currently on chemotherapy for relapsed myeloma.<\/li>\r\n<li>Presents with a persistently worsening cough, not improving with antibiotics. No significant weight loss.<\/li>\r\n<li>CT scan of the lung shows peripheral consolidation and nodules in both lungs, with mass-like consolidation involving almost the entire right lower lobe. Some calcified pleural plaques are seen. No mediastinal or hilar lymphadenopathy is noted.<\/li>\r\n<li>Transbronchial biopsy of the right lower lobe is performed.<\/li>\r\n<li>What are the histologic findings?<\/li>\r\n<li>What are your differential diagnoses?<\/li>\r\n<li>What clinical information would be helpful in your diagnostic workup?<\/li>\r\n<li>What ancillary tests would you do?<\/li>\r\n<\/ul>\r\n\r\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\r\n\t\t\t\t<a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/07\/LC2-scaled.png\"  target=\"_self\" itemprop=\"url\">\r\n\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/07\/LC2-scaled.png\" alt=\"LC2\" height=\"1920\" width=\"2560\" title=\"LC2\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\r\n\t\t\t\t<\/a>\r\n\t<\/figure>\r\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\r\n\t\t\t\t<a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/07\/LC1-scaled.png\"  target=\"_self\" itemprop=\"url\">\r\n\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/07\/LC1-scaled.png\" alt=\"LC1\" height=\"1920\" width=\"2560\" title=\"LC1\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\r\n\t\t\t\t<\/a>\r\n\t<\/figure>\r\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\r\n\t\t\t\t<a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/07\/LC3-scaled.png\"  target=\"_self\" itemprop=\"url\">\r\n\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/07\/LC3-scaled.png\" alt=\"LC3\" height=\"1920\" width=\"2560\" title=\"LC3\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\r\n\t\t\t\t<\/a>\r\n\t<\/figure>\r\n\t<p>Click picture to enlarge<\/p>\r\n\t\t\t\t\t<a role=\"heading\" aria-level=\"2\" tabindex=\"-1\"  id=\"fl-accordion--label-0\">Histologic findings <\/a>\r\n\t\t\t\t\t\t\t\t\t\t\t<button type=\"button\" id=\"fl-accordion--icon-0\" aria-expanded=\"false\" aria-controls=\"fl-accordion--panel-0\"><i>Expand<\/i><\/button>\r\n\t\t\t\t\t<p>&nbsp;<\/p>\r\n\r\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/07\/LC4.png\" alt=\"\" width=\"2174\" height=\"1623\" \/><\/p>\r\n<ul>\r\n<li>Lung parenchyma with features of organising pneumonia<\/li>\r\n<li>Some poorly formed epithelioid granulomas are present (circled)<\/li>\r\n<li>Scattered Langhans type giant cells are seen (arrows)<\/li>\r\n<\/ul>\r\n\r\n\t\t\t\t\t<a role=\"heading\" aria-level=\"2\" tabindex=\"-1\"  id=\"fl-accordion--label-1\">Differential Diagnoses<\/a>\r\n\t\t\t\t\t\t\t\t\t\t\t<button type=\"button\" id=\"fl-accordion--icon-1\" aria-expanded=\"false\" aria-controls=\"fl-accordion--panel-1\"><i>Expand<\/i><\/button>\r\n\t\t\t\t\t<p>&nbsp;<\/p>\r\n\r\n<p>In a lung lesion with granulomatous inflammation, main differential diagnoses are:<\/p>\r\n<ul>\r\n<li>Infection e.g. mycobacterial or fungal infection, and some parasitic infections (e.g. toxoplasmosis), occasional bacterial infections (e.g. <i>Bartonella <\/i><i>henselae<\/i>)<\/li>\r\n<li>Sarcoidosis (diagnosis of exclusion)<\/li>\r\n<li>Foreign body granulomatous reaction<\/li>\r\n<li>Less commonly:\r\n<ul>\r\n<li>Hypersensitivity pneumonitis<\/li>\r\n<li>Occupational exposures e.g. pneumoconiosis (silicosis etc)<\/li>\r\n<li>Drug-related causes e.g. IFN-\u03b1 therapy, biologics<\/li>\r\n<li>Vasculitic or autoimmune diseases (e.g. rheumatoid nodules)<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n\t\t\t\t\t<a role=\"heading\" aria-level=\"2\" tabindex=\"-1\"  id=\"fl-accordion--label-2\">Ancillary Tests <\/a>\r\n\t\t\t\t\t\t\t\t\t\t\t<button type=\"button\" id=\"fl-accordion--icon-2\" aria-expanded=\"false\" aria-controls=\"fl-accordion--panel-2\"><i>Expand<\/i><\/button>\r\n\t\t\t\t\t<p>&nbsp;<\/p>\r\n\r\n<table>\r\n<tbody>\r\n<tr>\r\n<td><img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/07\/GMS.png\" alt=\"\" \/><\/td>\r\n<td><img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/07\/PAS.png\" alt=\"\" \/><\/td>\r\n<td><img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/07\/MC.png\" alt=\"\" \/><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p>&nbsp;<\/p>\r\n<ul>\r\n<li>GMS and PAS shows the presence of round yeast organisms with narrow-based budding (inset), approximately 4-8 \u03bcm in diameter). The organisms appear to be both intra- and extracellular.<\/li>\r\n<li>Mucicarmine highlights the capsule of each organism.<\/li>\r\n<li>ZN stain did not demonstrate any acid-fast bacilli.<\/li>\r\n<\/ul>\r\n\t\t\t\t\t<a role=\"heading\" aria-level=\"2\" tabindex=\"-1\"  id=\"fl-accordion--label-3\">Diagnosis and Learning Points <\/a>\r\n\t\t\t\t\t\t\t\t\t\t\t<button type=\"button\" id=\"fl-accordion--icon-3\" aria-expanded=\"false\" aria-controls=\"fl-accordion--panel-3\"><i>Expand<\/i><\/button>\r\n\t\t\t\t\t<p>&nbsp;<\/p>\r\n\r\n<p><u><b>Diagnosis<\/b><\/u><\/p>\r\n<ul>\r\n<li>Granulomatous inflammation with micro-organisms seen, in keeping with <i>Cryptococcus <\/i>species<\/li>\r\n<\/ul>\r\n<p>Note: Follow-up microbiology investigations showed high cryptococcal antigen levels<\/p>\r\n<p><u><b>Learning Points<\/b><\/u><\/p>\r\n<ul>\r\n<li>Infectious conditions can sometimes give rise to mass-like lesions, mimicking neoplasms on imaging. In this case, the imaging differentials included infection, organising pneumonia and malignancy.<\/li>\r\n<li>When there are histiocytic aggregates seen in the lung parenchyma, it is important to do stains for micro-organisms: Ziehl-Neelsen and GMS for fungal organisms.<\/li>\r\n<li>Cryptococcal infections can affect both immunocompetent (e.g. isolated cryptococcomas which may be asymptomatic) and immunocompromised hosts.<\/li>\r\n<\/ul>\r\n<br \/>\r\nReferences:\r\n<ol>\r\n<li>Howard-Jones AR, Sparks R, Pham D, Halliday C, Beardsley J, Chen SC. Pulmonary Cryptococcosis. J Fungi (Basel). 2022 Oct 31;8(11):1156. PMID: 36354923<\/li>\r\n<li>Rosen Y. Pathology of Granulomatous Pulmonary Diseases. Arch Pathol Lab Med. 2022 Jan 2;146(2):233-251. PMID: 33905479<\/li>\r\n<\/ol>\r\n\r\n","protected":false},"excerpt":{"rendered":"<p>Lung case 1 Case writer: A\/Prof Nga Min En Clinical history: 83M, history of multiple myeloma, diagnosed 5 years ago, with several relapses. Currently on chemotherapy for relapsed myeloma. Presents with a persistently worsening cough, not improving with antibiotics. No significant weight loss. CT scan of the lung shows peripheral consolidation and nodules in both [&hellip;]<\/p>\n","protected":false},"author":828,"featured_media":0,"parent":47288,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-47325","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>NUS Pathweb<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/lc-1\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:description\" content=\"Lung case 1 Case writer: A\/Prof Nga Min En Clinical history: 83M, history of multiple myeloma, diagnosed 5 years ago, with several relapses. 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