Correct!
4. All of the above
The differential diagnosis of hemoptysis and multiple pulmonary nodules is large and includes all of the above. Metastatic carcinoma from a multitude of sources is certainly possible. In the Southwest US coccidioidomycosis is common and can present in a many ways including multiple pulmonary nodules. Paragonimiasis from eating inadequately cooked shell fish is common in Southeast Asia but uncommon in the US. Pulmonary arteriovenous malformations are a cause of multiple nodules but there is no evidence to support that diagnosis in this patient.
Metastatic tumors that tend to hemorrhage (choriocarcinoma, renal cell carcinoma, melanoma, thyroid carcinoma, Kaposi's sarcoma) or invasive infections may present with fuzzy borders or an area of ground glass density surrounding the nodule (halo sign). This patient had a reversed halo or atoll sign which is a focal, rounded area of ground-glass surrounded by an approximately complete ring of consolidation. Although originally described as being specific for cryptogenic organizing pneumonia the reversed halo sign has since been described in many conditions including sarcoidosis, infections (paracoccidioidomycosis, tuberculosis, zygomycosis, aspergillosis), Wegener's granulomatosis, lymphomatoid granulomatosis, and bronchioloalveolar carcinoma.
At this juncture a tissue diagnosis is needed and either bronchoscopy or needle biopsy is indicated. Bronchoscopy was chosen because it directly visualizes the airways and hemoptysis often results from airway lesions. Bronchoscopy did reveal blood in the airways but no endobronchial lesions were identified. Bronchoalveolar lavage had returns of bloody fluid with hemosiderin-laden macrophages seen on cytology but no malignant cells were identified. Smears and cultures were all negative.
The patient was referred for video-assisted thorascopic surgical (VATS) biopsy. The pathology slides are shown in Figure 3.
Figure 3. Panels A-C: Low power H&E stains of the VATS biopsy. Panel D: High power.
Which of the following are not shown on the biopsy?