A 44-year-old man presented to our department with a 1-month history of dyspnea and cough. There was no history of sputum, fever, loss of weight, and chest pain. He had smoked one pack cigarettes a day for 35 years. He had had mitral valve replacement 10-years ago and pericardiectomy 5-years ago. His current medications included diltiazem, warfarin, and digoxin.
On physical examination, he appeared cyanotic. Blood pressure was 100/70 mmHg, heart rate was 116 beats/min, body temperature was 36.7 C. His arterial oxygen saturation on room air was 84%. Auscultation of the chest revealed inspiratory crackles bilaterally. His abdominal examination was unremarkable. There was obvious (+2) pitting edema on pretibial region. Laboratory findings revealed were normal except Na: 121 mmol/L, K: 4.8 mmol/L, aspartate aminotransferase (AST): 204 U/L, alanine aminotransferase (ALT): 203 U/L, lactate dehydrogenase (LDH): 808 U/L.
The plain chest radiograph demonstrated diffuse opacities affecting both lungs. Thorax computed tomography (CT) scans revealed multiple mediastinal lymphadenopathies up to 22 mm [Figure 1]. In both upper lobes; there were diffuse, multifocal, patchy, ground-glass opacities resulting in a crazy-paving appearance [Figure 2].
There was no pathological finding of 18-fluorodeoxyglucose (18-FDG) uptake on positron emission tomography (PET) scan.
There were biatrial dilatation, prosthetic mitral valve, and second-degree tricuspid insufficiency on his echocardiography. Pulmonary artery pressure was 45-50 mmHg, ejection fraction of the left ventricle was 60%, and so confirmed diastolic dysfunction.
The patient underwent endobronchial ultrasound (EBUS) with bronchoalveolar lavage and lymph node transbronchial fine needle aspiration biopsies (TBNA) were performed to mediastinal lymph nodes bigger than 2 cm [Figure 3]. The lavage fluid was evaluated for routine cytology, gram stain and bacterial culture, acid fast stain and mycobacterial culture; all tests were negative. The cytology of bronchoalveolar lavage showed inflammatory features. Periodic acid Schiff (PAS) stain was performed for differential diagnosis of pulmonary alveolar proteinosis, but did not stain. The lymphadenopathy biopsies demonstrated no pathological changes. There were blood cells, bronchus epithelium cells, and lymphocytes.
The patient was treated with intravenous furosemide and he improved rapidly. The largest lymphadenopathy size decreased to 9 mm and the ground-glass opacities disappeared on CT scan obtained 1 month after the diagnosis [Figure 4].