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Weekly Chest CasesArchive of Old Cases

Case No : 1124 Date 2019-05-14

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  • Courtesy of Hyun-ju Lim, Kun Young Lim, Soo Hyun Lee, Hyae Young Kim / National Cancer Center
  • Age/Sex 52 / F
  • Chief Complaintpatient with biopsy proven benign renal mass, abnormal chest radiograph
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Multifocal micronodular pneumocyte hyperplasia (MMPH) in tuberous sclerosis
Radiologic Findings
Fig 1. Chest PA shows bilateral diffuse fine nodular opacities.
Fig 2-3. Chest CT images demonstrate multiple nodules, varying in diameter from 1 to 5mm, with a diffuse and random distribution in both lungs.
Fig 4-5. CT images with a bone window setting reveal multifocal osteosclerotic lesions involving thoracic spines.
Brief Review
MMPH is a manifestation of tuberous sclerosis complex (TSC) in both female and male patients. It is a hamartomatous process of the lung that exhibits multiple tiny pulmonary nodules. Pathologically, it is characterized by the proliferation of type II pneumocystis along the alveolar septa.
Radiologically, MMPH presents as multiple nodules on CT. Nodules are 1-8mm in diameter and are diffusely scattered throughout the lung in a random distribution with regard to the secondary pulmonary lobule.
The differential diagnosis should also include a miliary granulomatous infection, Langerhans cell histiocytosis, hematogenous metastasis and multiple atypical adenomatous hyperplasia/adenocarcinoma in situ. The presence of multiple tiny pulmonary nodules in a random distribution in a TSC patient should suggest the presence of MMPH.
The clinical manifestations resulting from isolated MMPH are dyspnea, cough, and mild to moderate hypoxemia. The clinical course of MMPH is usually not progressive and treatment is unnecessary.
Please refer to
Case 543, Case 979,
KSTR imaging conference 2018 Spring  Case 15,
References
1. Ristagno R-L, Biddinger P-W, Pina E-M, Meyer C-A. Multifocal micronodular pneumocyte hyperplasia in Tuberous Sclerosis. AJR 2005;184-37-39
2. Lee I-S, Shim H-S, Lee H-J, Kang Y-A. Multifocal micronodular pneumocyte hyperplasia mimicking military tuberculosis. Am J Respir Crit care Med 2014;189:225-226
3. Pannu B-S, Apala D-R, Kotecha A, Boland J-M, Iyer V-N. Multifocal micronodular pneumocyte hyperplasia (MMPH) in a patient with tuberous sclerosis-evidence for long term stability. Respiratory Medicine Case Reports 2017; 20:113-115
Keywords
MMPH, Tuberous sclerosis, lung, bone,

No. of Applicants : 76

▶ Correct Answer : 65/76,  85.5%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - The University of Kyoto Hospital , Japan TOMOAKI OTANI
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Showa university Northern Yokohama Hospital , Japan KOTA WATANABE
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - Niigata University , Japan ATSUSHI UEHARA
  • - TWMU Medical Center East , Japan MASAFUMI KAIUME
  • - radiologist, aditya imaging centre , India VIVEK PATEL
  • - Mayo Clinic , United States AKITOSHI INOUE
  • - Juntendo University Hospital , Japan AKIFUMI HAGIWARA
  • - King Abdulaziz University Hospital , Saudi Arabia Amr M. Ajlan
  • - , Korea (South) HYEYOUNG CHOI
  • - McGill University Health Center , Canada Alexandre Semionov
  • - Soonchunhyang University Hospital Bucheon , Korea (South) JAEGU OH
  • - NIMS, HYDERABAD , India BHASKAR K
  • - , Korea (South) CHOHEE KIM
  • - Other , Korea (South) CHUNGEUN LIM
  • - Chonnam National University Hospital , Korea (South) MOON GYEONG IL
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Ajou University Hospital , Korea (South) KYUNGMIN LEE
  • - Other , Korea (South) SEONGSU KANG
  • - Seoul National University Hospital , Korea (South) Ju Gang Nam
  • - Cabinet Capricorne, clinique sainte-clotilde , Reunion FABIEN HO
  • - istanbul , Turkey AYHAN YILMAZ
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Kurashiki Central Hospital , Japan HISATAKA ITO
  • - Fujieda Municipal General Hospital , Japan HAYATO NOZAWA
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Gifu University Hospital , Japan Yo Kaneko
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - Medicheck health care , Korea (South) Chae hun Lim
  • - Ajou University Hospital , Korea (South) DAYOUNG KIM
  • - radiology bellvitge , Spain patricio luburich
  • - CLINIQUE STE CLOTILDE , Reunion PATRICK MASCAREL
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - , Japan NAOMI YUASA
  • - Maimonides Medical Center , United States NAOMI TWERSKY
  • - Ajou University Hospital , Korea (South) HYERIN KIM
  • - Seoul National University Hospital , Korea (South) SE WOO KIM
  • - Azienda Ospedaliera di Cremona , Italy Pietro Sergio
  • - Chonbuk National University Hospital , Korea (South) KUM JU CHAE
  • - Asan Medical Center , Korea (South) JIHOON KIM
  • - , Korea (South) JANG SEONG WON
  • - Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
  • - Fortis hospital , Mohali , India SHALEEN RANA
  • - Kizawa Memorial Hospital , Japan Shoji Okuda
  • - University of Tsukuba Hospital , Japan SODAI HOSHIAI
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - Kyoto Prefectural University of Medicine , Japan TADASHI TANAKA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Private sector , Greece VASILIOS TZILAS
  • - , Japan YUMI MAEHARA
  • - College of Medicine, CHA University , Korea (South) PARK JONG WON
  • - Hamamatsu University Hospital , Japan YUKI HAYASHI
  • - Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY
  • - Chonnam National University Hwasun Hospital , Korea (South) JONG EUN LEE
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Ajou University Hospital , Korea (South) YONG HO JANG
  • - Seoul Veterans Hospital , Korea (South) HYUN JUNG YOON
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 2/76,  2.6%
  • - Ondokuz Mayis University , Turkey CETIN CELENK
  • - National Center for Global Health and Medicine , Japan HIROSHI TAKUMIDA
▶ Semi-Correct Answer : 1/76,  1.3%
  • - Myongji Hospital , Korea (South) KI EON KWON
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Current Editor : Sung Shine Shim, MD, PhD. Email : sinisim@ewha.ac.kr

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