2024年 · 第104卷第42期

The patient, a 73-year-old male, went to the outpatient clinic of respiratory and critical care medicine department of Qingdao Municipal Hospital for "right chest and back pain for more than 1 month". He had a history of hypertension and diabetes for more than 10 years. On physical examination, the breathing sounds of both lungs were clear, no obvious dry and wet rales were heard, and the heart rhythm was uniform. On admission, neuron-specific enolase was found to be 24.87 μ g/L, carcinoembryonic antigen was found to be 2.09 μ g/L, and cytokeratin 21 fragment antigen was found to be 1.65 μ g/L. Chest plain scan + enhanced CT showed a mass-like soft tissue density shadow at the apex of the right lung, with a maximum cross section of about 57 mm ×43 mm, a CT value of 43 HU and a CT value of 48 HU after enhancement (shown by arrows in Figure 1, A is the plain scan pulmonary window, and B is the enhanced image); Multiple nodular thickening of the right pleura and bone destruction of the adjacent ribs were seen (Figure 2, black arrows show multiple nodular thickening of the pleura; white arrows show bone destruction of the ribs). CT-guided percutaneous biopsy of lung and pleural lesions was performed, and the pathology showed patches of mild-moderate atypical epithelioid cell proliferation in fibrous tissue (arrows in Figure 3, hematoxylin-eosin staining, ×400); Immunohistochemistry: CD31 (+), EMA fraction (+), CD56 (-), CK (-), TTF-1 (-), P40 (-), CD34 (-), F8 (-), VIM (+), D2-40 (-), S-100 (-), HMB45 (-), Mlan-A (-), CD68/PGM1 (-), Calretinin (-), CAM5.2 (+ / -), CK7 (-), CD10 (-), RCC (-), CK8 (-), Ki-67 was 10%, predisposing to epithelioid hemangioendothelioma (EH). According to the imaging and pathology, the patient's pleura and lung EH were diagnosed clearly. EH is a rare low-grade malignant mesenchymal cell-derived tumor. It is rarely reported at home and abroad that EH is found in both pleura and lung. The typical CT manifestations of pleural EH are pleural thickening and pleural effusion, among which the pleural thickening is mostly heterogeneous and diffuse, and pleural collapse and pleural nodules with or without calcification can also be seen. The typical CT manifestations of pulmonary EH are multiple nodules of different sizes in the lungs, mainly distributed in the middle and lower lung fields, especially in the subpleura and around blood vessels. Pleural traction or pleural depression may occur, and some nodules are coagulative necrosis in the center, which can cause calcium salt deposition and calcification. EH with single nodules in the lungs is rare. EH is mainly treated by surgery, and for cases that cannot be completely resected, radiotherapy, chemotherapy or targeted therapy can be used. The overall prognosis of EH is poor, and it is prone to recurrence and metastasis.

A 29-year-old male patient went to the emergency department of Peking Union Medical College Hospital for "fever for 3 days and shortness of breath for 1 day". 3 days ago, high fever, sore throat and dry cough occurred, and the nucleic acid of influenza A virus was tested positive in another hospital, and oseltamivir and moxifloxacin were given orally; 1 d Shortness of breath before; Past physical fitness. Tracheal intubation, mechanical ventilation and vasoactive drug support were performed due to respiratory failure and septic shock. procalcitonin>100 μ g/L; Chest CT (Figure 1) shows multiple patches and consolidation shadows in both lungs, and bronchiectasis and cavity formation can be seen in them; Sputum culture and blood culture were oxacillin-resistant Staphylococcus aureus. Diagnosis of influenza A virus combined with Staphylococcus aureus (Staphylococcus aureus for short) pneumonia. After anti-infective and supportive treatment with vancomycin, linezolid and oseltamivir, the condition improved. After 6 days, the tracheal intubation was removed, and the reexamination of chest CT (Figure 2) showed that the exudation shadow in both lungs was partially absorbed and the cavity lesions increased compared with the previous. The patient was instructed to actively rehabilitate and exercise, excrete sputum, continue anti-Staphylococcus aureus treatment, and change to oral linezolid after discharge. After one month, reexamination of chest CT (Figure 3) showed that the intrapulmonary lesions were significantly improved compared with before, leaving multiple cord shadows and focal bronchiectasis. Staphylococcus aureus is a common pathogen of influenza virus co-infection/secondary bacterial infection, and it is also an important cause of severe illness and death in influenza patients. It can rapidly progress to necrotizing pneumonia with shock. Early identification and timely targeted anti-infective treatment and active supportive treatment can help to improve the prognosis of patients.

The patient, a 40-year-old female, went to the Department of Respiratory and Critical Care Medicine of Peking Union Medical College Hospital in December 2021 due to "intermittent shortness of breath for 27 years". When the patient was 13 years old, bilateral chylopleural effusion was found due to shortness of breath, and "thoracic duct ligation and pleural release" was performed, and the postoperative symptoms were partially relieved. No previous history of tuberculosis infection, no history of asbestos exposure. One month ago (November 2021), I visited the outpatient clinic of our hospital due to aggravation of shortness of breath and light bloody thin phlegm. Chest CT showed right thoracic collapse, bilateral pleural thickening, mediastinal widening with uneven soft tissue density shadow filling in the fat space, and thickening of bronchial vascular bundles and interlobular septa in both lungs (Figures 1 and 2). In November 2021, a CT-guided pleural puncture was performed in a foreign hospital. Pathology showed more irregular proliferation of lymphoid tissue, except lymphatic malformation or lymphangioma. Bronchoscopy in this visit showed vessel filling and inspiratory phase contraction under the tracheal mucosa. The patient did not have obvious manifestations of involvement of extrathoracic organs, and it was highly likely to consider diffuse pulmonary lymphangiomatosis (DPL). Ask the nutrition department to guide the diet, and add sirolimus 1 mg once/d and propranolol 30 mg 3 times/d, orally. The symptoms of the patients were stable after follow-up, and the reexamination of chest CT after 1 year was roughly the same as before. DPL is a rare lymphatic abnormal disease confined to the chest. It is mainly seen in congenital developmental abnormalities, and may also be secondary to trauma, surgery and other factors. Its histopathological features are mainly diffuse dilatation of chest lymphatic vessels with complex lymphatic hyperplasia.