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Weekly Chest CasesArchive of Old Cases

Case No : 1141 Date 2019-09-09

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  • Courtesy of Young-Hoon Cho, Hye Jeon Hwang / Asan Medical Center
  • Age/Sex 38 / M
  • Chief ComplaintAsymptomatic, incidental finding
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Follicular bronchiolitis
Radiologic Findings
Fig. 1. Ill-defined peribronchial infiltrations and nodular lesions in both lungs, mainly demonstrating upper lobe dominancy

Fig. 2-4. Diffuse ill-defined, fuzzy centrilobular nodules with with bronchial wall thickening in both lungs, predominant in both upper lobes, while relatively sparing of cardiophrenic areas.

Right upper and lower lobes, wedge resection
- Peribronchiolar lymphoplasmacytic infiltration with prominent follicle formation, consistent with follicular bronchiolitis.
Brief Review
Follicular bronchiolitis is a lymphoproliferative disease, usually of reactive and non-neoplastic etiology. It results mostly from hyperplasia of bronchial associated lymphoid tissue or BALT. It is more prominent in middle aged and elderly patients. Secondary causes include connective tissue disease, a state of immunodeficiency, autoimmune disease, and infections. Regarding histopathology, follicular bronchiolitis demonstrates hyperplastic lymphoid follicles with reactive germinal center along bronchovascular bundles, narrowing or obliterating bronchiolar lumen. Such findings may show extension along the interlobular septa with sparing of the alveolar septa. Immunohistochemistry of follicular bronchiolitis also shows CD20 and CD79a positivity with predominant B cell infiltrations within the peribronchial follicles.
With regards to the imaging of follicular bronchiolitis, chest X-rays are often negative in early cases. Lung hyperinflation due to air trapping, small nodules, reticular or reticulonodular infiltrations may be noted in moderate to severe cases. On HRCT, bilateral 1~3mm tiny centrilobular nodules with peribronchial distribution are commonly noted. Characteristically, nodules may demonstrate a fluffy tree-in-bud (or cotton-in-bud) appearance. Disease is limited to the airways and diffuse interstitial involvement is extremely rare. Treatment usually includes steroid and/or macrolide antibiotics for idiopathic cases, while removal of the causative antigen is the key to treatment of secondary cases.
References
1. Basheer Tashtoush, Ndubuisi C. Okafor, Jose F. Ramierz, et al. Follicular Bronchiolitis: A Literature Review. J Clin Diagn Res. 2015
2. Pipavath SJ, Lynch DA, Cool C, et al. Radiologic and Pathologic Features of Bronchiollitis. AJR 2005
3. Sarah J, Howling David. Follicular Bronchiolitis: Thin-section CT and Histologic Findings. Radiology 1999
Keywords
lung, bronchiolitis, lymphoproliferative disease,

No. of Applicants : 65

▶ Correct Answer : 4/65,  6.2%
  • - NIMS, HYDERABAD , India BHASKAR K
  • - DELTA CARE HOSPITAL, THANJAVUR, INDIA , India SIVARAJA SUBRAMANIAM
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Asan Medical Center , Korea (South) JIHOON KIM
▶ Correct Answer as Differential Diagnosis : 9/65,  13.8%
  • - Mayo Clinic , United States AKITOSHI INOUE
  • - Chonnam National University Hospital , Korea (South) MOON GYEONG IL
  • - Other , Korea (South) SEONGSU KANG
  • - Other , Korea (South) JUWON KIM
  • - Chonbuk National University Hospital , Korea (South) YOUNGKWANG LEE
  • - University of Tsukuba Hospital , Japan HIROAKI TAKAHASHI
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Private sector , Greece VASILIOS TZILAS
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
▶ Semi-Correct Answer : 4/65,  6.2%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - St. Lukes International Hospital , Japan DAISUKE YAMADA
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
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Current Editor : Sung Shine Shim, MD, PhD. Email : sinisim@ewha.ac.kr

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