Correct!
4. Video-assisted thoracoscopic surgery (VATS) lung biopsy
The description on the repeat CT scan suggests the possibility of a perilymphatic distribution of lung nodules. These often involve the lung lymphatics are seen commonly in sarcoidosis, lymphangitic carcinomatosis, silicosis, coal worker's pneumoconiosis, nodular pulmonary amyloidosis, and lymphocytic interstitial pneumonia (1). Hypersensitivity pneumonitis and endobronchial spread of tuberculosis result in centrilobular distribution (1). None of the possibilities would seem to be easy to sort out without another biopsy.
A VATS biopsy was done and the histology is shown in Figure 6.
Figure 6. A: Low power view. B. Higher power view. C. Immunostaining with CD20 (B cell marker).
The biopsy was interpreted as showing nonspecific interstitial pneumonia with fibrosis and non-necrotizing granulomatous inflammation. There focal collections of large B cells. Epstein Barr virus staining was negative.
Which of the following is/are the most likely diagnosis? (Click on the correct answer to be directed to the sixth and final page)