Distinctive Ultrastructural Findings in a Case of Idiopathic Interstitial Pneumonia

86

SHURIN AND BLOCK DISCl'SSIO~

Hemoptysis may occur with nephritis in a variety of diseases, such as Wegener's granulomatosis, uremic pneumonitis, and periarteritis nodosa. In Goodpasture's syndrome, distinct pathologic findings in the lungs and kidneys differentiate this condition from others. Maddock and associates" reported immediate cessation of pulmonary hemorrhage in patients with Goodpasture's syndrome after total nephrectomy. Cleveland and co-workers" reported a patient with Goodpasture's svndrome who was surviving six months after kidney transplantation and Freeman et al 4 also reported a case of this disease in which pulmonary hemorrhage stopped after steroid therapy. They also reported prolonged survival with chronic hemodialysis. In the review by Proskey et al,> the mean time of survival in 28 of 36 patients receiving steroids was 12.7 months. These reports suggest that extirpation of the kidney as the cause of pulmonary hemorrhage might playa role in amelioration of the condition of the patients and cessation of pulmonary hemorrhage, although fulminating hemorrhage may occur even after successful nephrectomv or dialvsis. Baxter and Coodman," and Sheer and asso~'iates, 10 . speculated on the antigen similarity between alveolar and glomerular basement membrane and the ability to cause glomerulonephritis with antilung antisera in animals. Sturgill and associates!' have used fluorescent antibody technique and were ahle to localize immune reaction components, gamma G glohulin and beta-I C globulin in glomerular capillary and alveolar capillary basement membrane and confirmed the above hypothesis. Reports of others confirm the ineffectiveness of corticosteroids and immunosuppressive agents. Our observation in this patient confirms that steroids and immunosuppressive drugs may ameliorate the symptoms and even stop hemoptysis temporarily, but chronic hemodialysis and nephrectomy may be the only effective therapy in the case of Goodpasture's syndrome. REFERE~CES

Coodpasture E\V: Significance of certain pulmonary lesions in relation to the etiology of influenza. Arner J Med Sci 158:R63, HlW 2 Benoit 1"1., Rulon DB, Theil GB, et al: Coodpasture's syndrome: a clinicopathologic entity. Amer J \Ied .37 :424, 1H64 3 \llInro .IF, Ceddt,s A\I, Lamh \VL: Coodpasture's syndrom«: survival after acute renal failure. Brit \Ied J 4 :H.'5, HJ67 4 Fre-eman H\I, Vertt-l H\!, Easterling HE: Coodpasture's syndrome: prolonged survival with chronic hemodialysis. Arc-h Inte-rn \led 117:643,1966 .'5 Macldock HK, Stevens I.E, Heemstma K et aI: Coodpastun-s svndrouu-: Cessation of pulmonary he-morrhage after biiatl'fal nephrectomy. Ann Intern \led 67: 12.'58,

Wfi7

() Cleveland HJ, Lee H\I, Prout CR: Preservation of the cncluver kidney for renal homotransplantation in man. Snru, Cvnec amI Obstd 1HJ:HJHI, 1964 ilH: The basis of pulmonary disease resolution 7 Sie~el

15 9

10 1I

after nephrectomy in Goodpastllrt.'s syndrome. Amer J \led Sci 2.'59:201,1971 Proskey AJ, Weatherbee I., Easterling HE, et al: Goodpasture's syndrome: a report of fiv(' cases and review of the literutun-. Anu-r J \led 415: 162, 1970 Buxter JH, Coodman HC: Nephrotoxic serum nephritis in rats; Distribution and specificity of the antigen responsihie for the production of nephrotoxic antibodies. J Expt \led 104:467, 1962 Sheer RL, Grossmann \IA: Immune aspects for the glomerulonephritis associated with pulmonary hemorrhage. Aun Intern \led 60: 1009, 1964 Sturgill Be, Westervelt FB: Immuno-fluorescent studies in a case of Coodpasture's syndrome. JA\IA 194:914, 196.'5

Distinctive Ultrastructural Findings a Case of Idiopathic Interstitial . * Pneumoma

In

Paul A. Shurin, ltD. and A. Jay Block, M.D.

A patient with chronic interstitial pneumonia was treated with steroids with excellent results. Electron microscopic examination of a lung biopsy taken before treatment showed the functional defect to be associated with a gross increase in the width of the anatomic barrier to gaseous diffusion into the blood. A peculiar sudanophilic and osmiophilic inclusion was identified in the cytoplasm of his alveolar macrophages, and it is postulated that this material, which is of obscure origin, was the primary lung irritant. of diffuse lung diseases have been characterA number ized in recent years. Among these, alveolar prote-

inosis;' lymphocytic interstitial pneumonia," and desquamative interstitial pneumonia" are presently of unknown etiology. A larger numher of diffuse pulmonary conditions are caused bv inhaled irritants or allergens. Ultrastructural findings I;ave been reported in a number of these diseases,":" hut have not generally been of diagnostic significance. The purpose of this report is to describe a case of idiopathic interstitial pneumonia in which unique inclusions were present in the cytoplasm of alveolar macrophages, CASE REPORT

A .'50-Vl'ar-old lawver and part-time farmer was referred to Hopkins' Hospital on July 29, 1969 because of TIl(' Jol~ns progressive dyspnea and cough. He had been well until Octnlx-r, 19615, when 11(' hecame dyspneic while climhing a hill at a foothall gamp. Several months later, dyspnea recurred, along with a hrief period of diarrhea and fr-ver. A nonproductive cough persisted beyond the end of this illness. The cough was most severe at night and recurred intermit-

-

~.

°From the Departments of Pathology ami \ledicim', Johns Hopkins Hospital and the Johns Hopkins University School of \!Pdieine, Baltimore. Rcprillt requests: Dr. A. Jay Block, VA Hospital, Caillcscillc,

Florida

CHEST, VOL. 61, NO.1, JANUARY 1972

DISTINCTIVE ULTRASTRUCTURAL FINDINGS IN IDIOPATHIC INTERSTITIAL PNEUMONIA

87

Table I-Results o] Lung Function Tests DatI'

Prodir-ted

Prednisone, daily dose Vital capacity, FVC 1 second volume, FEV, CO diffusing capacity

-t.66 L 81% FVC 15.2 ml COl mm Hg/min

7 /:H i6H

8'18 '6H

!1/8!6H

IOn/6H

12/3/6H

2/-t170

-t/2/70

Xone

flO mil: for

60 mg

30 mil:

15 mg

10 rng

: \ OIl(' for prev, mo.

2A8 (53%)

3.!13 (8-t',:{J

4.22

(9W{)

(!)O("~)

4A4 (96%)

1.97 (79%) 7.2

3.20 (81%) 16.8

3,48 (83%) 18.9

3.22 (77%) lOA

prev, 7 d. 4.18

4.18

on c:; ) 3.15 (75';;1) 13.6

3,4-t

4.20 (!!I%)

15.6

3.2-t (77';;,) 20.0

(7gc;~)

CO extraction

40-55%

25%

39%

427c

36<;~

320;-

-toe;;

3-tc;{

Tidal volume

0.5-1.0 L

0.73

0.80

0.9-t

0.55

1.09

0.!!4

1.17

f>-10 L/min

13.8

15.1

15.1

9.9

19.5

is.:

2.'>.7

Minute ventilation

tently during the subsequent months. By July, 1969, he had developed exertional dyspnea which markedly limited his activity. Treatment with digitalis, diuretics and antibiotics had given no relief. The patient had lived on an Ohio farm for many years. His recent activities had included the planting of a large number of pine seedlings, burning of brush, use of 2-4-5T to kill tree stumps, and some haying. However, careful questioning disclosed no apparent connection between these activities and his disease. The herbicide had been dissolved in kerosene or diesel oil and brushed onto stumps. He had used no spray equipment for this or any other material. The hay was freshly mowed and stated to be dry and definitely not moldy. He had used motor oils to ignite wooden debris and thought that he might at times have inhaled some of the smoke. He had been taking no drugs before becoming ill; specifically, nose drops and aerosolized medications were not used. He was not a smoker. The past history was positive only for obesity and mild arthritis with minimal deformity of the hands. He was admitted for evaluation on August 12, 1969. His pulse rate was 68, respirations 36, blood pressure 112170 and he was afebrile. Mild cyanosis was present while at rest. There was no neck vein distention, hepatomegaly or peripheral edema. Crackling rales, which cleared with coughing, were heard at the lung bases. Aside from the arthritic deformity of the hands, the remainder of the physical examination was unrevealing. A chest x-ray film showed diffuse nodular and reticular infiltrates in both lung fields and possible hilar node enlargement. The heart shadow was of normal size and configuration. Results of lung function tests are shown in Tables 1 and 2. These showed moderate restrictive and slight obstructive defects with a 10 percent right-to-left shunt. There was no significant change after inhalation of nebulized isoproterenol. His hematocrit was ,52 percent, hemoglobin 16.8g per 100 ml and white count 6,800 per mm", The sedimentation rate, blood sugar and BUN, serum electrolytes, alkaline phosphatase, bilirubin, serum proteins and uric acid determinations were all within normal limits. Lactic dehydrogenase was 200 IU per ml and SGOT 4,5 IU per ml. Sputum cultures grew normal flora and we-re negative on culture for tubercle bacilli. Intermediate strength PPD and histoplasmin skin tests and latex fixation, Rose and LE cell tests all gave negative findings. Electrocardiogram was normal. Slit lamp examination revealed no ocular abnormalities. Needle biopsy of the liver showed slight and focal hepatocellular dt'gem'ration, but no evidence of granulomatous

CHEST, VOL. 61, NO.1, JANUARY 1972

disease. A biopsied scalene lymph node was hyperplastic. An open biopsy of the left lung was performed on August 7, 1969. The results will he described below. After the lung biopsy, the patient was begun on prednisone 60 mg per day orally. Within several days, the diminution in his dyspnea and cough was pronounced and exercise tolerance had increased dramatically. Repeat pulmonary function testing on August 18, 1969, after one week of prednisone treatment, (Tables 1 and 2) showed improvement in the forced vital capacity (FEV -I ), CO diffusing capacity and arterial oxygenation, with a persisting but mildly restrictive ventilatory defect. Reduction of prednisone dosage did not interrupt the continuing symptomatic improvement. By October 7, 1969, he was able to jog. Improvement in exercise tolerance continued despite a transient fall in the diffusing capacity. Continued clearing was noted in the chest x-ray film. When last seen on April 2, 1970, he was asymptomatic, the diffusing capacity was normal, and a mild obstructive defect was the only functional abnormality. METHODS

The lung biopsy specimen was fixed in formalin for light microscopy and for electron microscopy in 3 percent phosphate-buffered glutaraldehyde. Routinely processed paraffin sections were stained with hematoxylin-eosin, periodicacid Schiff, Ciemsa, Masson's trichrome, Verhoef! and Van Gieson, Mallory's phosphotungstic acid hematoxylin, methenamine silver, Kinyon's acid-fast, Feulgen, Gomori's iron and pyronine. The glutaraldehyde-fixed specimen was post-fixed in 1 percent osmium tetroxide, dehydrated in alcohol, and emTable 2-Arterial Blood Date

7 '31 Ifl!! Breathing Room Air

Peo, (rnrn Hg) pH

39 7.3!1

7 '31 'fl!! 100 e ; 0,

Closed System 30 7.-t-t

8 lI8/f)!!

Breathing Room Air 37

7AO

Standard bicarbonate (mEq/Ll

23

22

23

Po, (mm HI!:)

46

51-t

80

0, Saturation (%)

81

100

9f)

88

SHURIN AND BLOCK

b..dd"d in Aruklite. On« mic-ron thick s,'dions for light IIlitToscopy w .. r.. stain..d with nu-thyk-n« blue-Azure :\. and basic Iuchsiu.!" and with Sudan black for 4H hours. Crids for "I""troll Illi('1'oscopy wor« staiucd with Icad citrate. and ,'"ullilll'd in tl«- He:\. E\Il,' :3C or :311 microscope. HESVLTS

Ugl/t microscopy The alveolar walls were characterized by increased thickness, hypercellularitv and diminished vascularity (Fig I). The alveolar epithelium was hyperplastic. with a cuboidal uppearunce in many areas. Cells of various types. including fibroblasts. macrophagc-x. lymphocytes. mast cells and occasional polymorphonuclear lcukocytex, had infiltrated the inte-rstitium of the alveolar mcmhrunc-. A verv slight diHuse increase in conuect ive tissue was demonstrated with special stains. and there were focal nodules of loose, young-appearing fibrous tissue. The one micron sections showed clearly that most alveolar capillaries were buried within the swollen alveolar memhrune and the total volume occupied by vessels was verv small. A cellular exudate composed of sheets of normal appearing alveolar mucrophuges and some lvmphocvtes, mast

.

I

~ '

.

r, -t?: '.' •

..-'

I

2. Hepn-sentutive alveolar membrane as seen with "I,-dron microscop... Sev..ral inflammatory cells are present within a greatly enlarged and ..dematous interstitial space. A single "om pressed capillary is seen (arrow). The alveolar epithelium appears to be intact (I ..ad citrate stain X 3,730), FJ<:l'IJE

cells and polymorphs was present in the alveolar spaces. A few foreign body type giant cells were present in the alveolar spaces and within the tissue. Several of these contained typical asteroid bodies. \,'0 granulomata were present. A small amount of anthracotic pigment was identified. but there Wert' no crystals or birefringent material. :\'0 organisms could be seen with special stains, and there were no viral inclusions. In Araldite sections stained with Sudan black, spherical sudanophilic bodies could be seen in the cytoplasm of some alveolar rnacrophages (Fig I, inset). In paraffin sections, these appeared as dear vacuoles of uniform size. but could not be identified with certainty. Cells containing these inclusions were quite numerous, approximately 50 such cells being present in a one micron section measuring one square mm in surface area.

Electron microscopy I. Portion of the lung biopsy specimen seen with light microscope. Th« alveolar walls an' diffusely thickened and hyp.. rcx-llular and are infiltrat..d by a varie-ty of inflammatory cells, Cupilluric-s an- inconspicuous. Several macrophages are shown in th .. .rlvoolar lunu-ns. Inse-t shows osmiophilic inclusions within two alveolar mac-ropluun-s (uraldite emhedcled, om- micron Sl'dions: mr-thyk-n« blue-Azure A and basic fuchsin stain X ().')()), Inset: Sudan black stain X 1HOO. FICI'HE

The electron micrographs confirmed the nature of the structural abnormality and clearly demonstrated the anatomic basis of the diffusion defect. The alveolar epithelium formed a continuous layer lining the airspace. However, the large type II cells were more numerous than normal and the type I cells, instead of having

CHEST, VOL. 61, NO.1, JANUARY 1972

DISTINCTIVE ULTRASTRUCTURAL FINDINGS IN IDIOPATHIC INTERSTITIAL PNEUMONIA

89

extremely fine cytoplasmic extensions, were frequently ~reatly swollen. The alveolar and capillary basement membranes were quite uniform and normal in appearance. The interstitium, which is very scanty in normal lungs, II made up the major portion of the increased alveolar septal volume, In addition to the cellular infiltrate. there was considerable interstitial edema, The alveolar capillaries, instead of occupying approximately .'50 percent of the area of the septum as in normal lung sections, were difficult to find or absent in most fields. In addition, they were deeply buried within the interstitial exudate and had markedly swollen endothelial cytoplasm. A typical area is shown in Figure 2. Capillaries bulging into the alveolar lumen could be found in only a few sections. The minimum width of the air-blood barrier in the most normal-appearing capillaries found was, however, 1.09 (:!::0.15) microns, as compared to 0 ..35 (:!:: 0.0:3) microns in a similarly prepared normal lung, Most of the threefold increase, which should not be considered as necessarily representing the lung as a whole, was due to endothelial swelling. The patient's diffusion defect may be considered as the net ellect of these alterations. The unique feature of this case is the presence of the sudanophilic bodies described above. With the higher resolution of the electron microscopy, these inclusions could be seen to have a variable structure, showing in

FI(;UIIE 4. Inclusions with structure varying from a coarsely radial pattern to an amorphous one are seen within two macrophages, The inclusions within a single cell are of similar structure. Inset shows a pavement-like pattern in another inclusion, Portions of two granules of an adjacent mast cell are seen at the right (lead citrate stain X 20,700; inset,

X 31,200),

some cells a homogeneous internal fonn, and in others a coarse or fine radiating morphology (Fig .3,4). Their appearance in anyone cell was, however, quite uniform. As many as 100 of these bodies were visible in a single section of one cell, but many macrophages contained fewer. The bodies measured \..3 micron in maximum diameter, were membrane-bounded, and were densely osmiophilic. In this respect, they differed from the typical osmiophilic lamellated inclusions of the large alveolar cells, many of which were dissolved out during tissue processing, leaving clear vacuoles. There were no internal membranes or other structures to suggest that these bodies are of biologic origin, and photographs taken at high magnification did not show any crystalline material. They appeared to be present only within alveolar macrophages. None was found either free in the airspace or within the pulmonary tissue. DISCUSSIO:"

.'3, The cytoplasm of an alveolar macrophage is packed with spherical membrane-limited bodies having a radiating morphology, Inset shows one of these bodies at high power (lead citrate stain X .'5,330; Inset, X .'51,6(0). FI(;l'IIE

CHEST, VOL. 61, NO.1, JANUARY 1972

As has been pointed out by Liebow," little information has been published concerning the ultrastructure of the lung in cases of interstitial pneumonia or fihrosis. Those cases which have been studied have, with some

90

FALLAH-NEJAD, ABELSON AND BLAKEMORE

exceptions, yielded no specific diagnostic information. Such studies have, however, offered clarification of the nature of the alveolar proteinosis," desquamative interstitial pneumonia," Hamman-Rich lung,'·I" and of the pulmonary lesion of Coodpasture's syndrome." In addition, electron microscopy of respiratory secretions has aided in the diagnosis of viral and mycoplasmal infections.':' In four cases of diffuse pulmonary disease in which no diagnosis could be made by other means, electron microscopic examination in this laboratory has demonstrated herpes-like viral particles in one case.'> the apparently unique inclusions seen in the present case, and nonspecific fibrosis and inflammation in the remaining two. The nature and significance of these inclusions remains obscure. They appear to contain a significant amount of lipid, but do not resemble either the concentrically arranged myelin-like figures of normal pulmonary surfactant, the pathologically increased lipids seen in alveolar proteinosis,' mineral oil, which is amorphous and not osmiophilic, or the inclusions seen in previously described storage diseases. Spherical bodies of similar form have been demonstrated in the type I alveolar cells of rats injected with radioactive macroaggregated albumin. II A lung scan was not, however, performed in this patient. The size of the inclusions in this case (1.3 micron diameter) is consistent with the possibility of their having been deposited in the alveoli by inhalation, as is their location within alveolar macrophages. Their variable appearance suggests that the material involved is not metabolically inert, and that the typical radiating form may have been produced by metabolic alteration within macrophages. Finally, in view of the tremendous number of these inclusions which were present in this man's lungs, it seems probable that they acted as an irritant in the production of his disease. This investigation was supported from 7/1/69 to 6/30/70. We are grateful to Dr. Cottlieb C. Friesinger for permission to publish this report on his patient. Dr. John H. Yardley provided invaluable assistance with the electron microscopy.

ACKNO\VLEDG~fENTS:

by NIH Training Grant number G~I-41.'5

REFERENCES

2 :3

4

.'5

6

Rosen SH, Castleman B, Liehow AA: Pulmonary alveolar proteinosis. New Eng J ~fed 2.'58: 1123, 19.'58 Liebow AA: New concepts and entities in pulmonary disease. In TIll' Lung (ed by Liebow AA) Baltimore, Williams and Wilkins, lH68, p 349 Lu-bow AA, Steer A, Billingsley JG: Desquamative interstitial pneumonia. AmN J ~Ied 39:369, lH6.'5 Aherne \VA, Cross K\V, Hey EN, et al: Lung function and pathology in a premature infant with chronic pulmonary insufficiency (Wilson-Mikity syndrome). Pediatrics 40:962, lH67 Blotting AJ, Brown AL jr, Divertie ~IB: The pulmonary lesion in a patient with Cooclpasture's syndrome: as studied with the electron microscope. Amer J. Clin Path 42::3H7. lH64 Brewer DB, Heath 0, Asquith P: Electron microscopy of desquamative interstitial pneumonia. J Path 97 :317, 1969

7 Cracey DH, Divertie ~IB, Brown AL [r: Alveolar capillary membrane in idiopathic pulmonary fibrosis: electron microscopic study of fourteen cases. Amer Hev Resp Dis 98:16, 1968 8 Hensley CT, Carancis JC, Cherayil CD, et al: Lung biopsies of pigeon breeder's disease. Arch Path 87 :.'572, 1969 9 Kuhn C, Cyorkey F, Levine BE, et al: Pulmonary alveolar proteinosis: a study using enzyme histochemistry, electron microscopy and surface tension measurement. J Lah Invest 1.'5:492, 1966 10 Belanger LF: Staining processed radioautographs. Stain Techno! 36:313, 1961 11 Ryan SF: The structure of the interalveolar septum of the mammalian lung. Anat Rec 16.'5:476, 1969 12 O'Shea PA, Yardley JH: The Hamman-Rich syndrome in infancy: report of a case with virus-like particles hy electron microscopy. Johns Hopkins ~Ied Bull 126:320, 1970 13 Joncas JH, Williams H, Berthiaume L, et al: Diagnosis of viral respiratory infections by electron microscopy. Lancet 1:956, 1969 14 Hapke EJ, Pederson HJ: Ultrastructural changes in rat lungs induced hy radioactive macroaggregated albumin. Amer Rev Hesp Dis 100: HJ4, 1969

Left Ventricular Pseudoaneurysm * A Rare Complication of Open-Heart Surgery with Unusual Doppler Manifestations Manoucher Fallah-ueiad, .\I.D., Denis M. Abelson, M.D., and William S. Blakemore, .\1.0., F.C.C.P.

A patient with postoperative ventricular pseudoaneurysm is reported. The rarity of this complication is discussed. The unusual ftow signal in the velocity Doppler cardiogram and its unique significance are emphasized. The surgical management of the aneurysm and the postoperative disappearance of the Doppler finding are presented.

V

e n tric ula r aneurysm is a rare complication of cardiac surgery. In 19.57, Smith et al! reported two cases of postoperative pseudoaneurysm treated successfully by surgery. There are numerous reports in the literature regarding the surgical aspects of true posttraumatic aneurysms, "-I but very few dealing with aneurysms following cardiac surgery. We are reporting a rare case of left ventricular pseudoaneurysm from the site of the left ventricular vent drain, discovered 18 months after open heart surgery for aortic valve replacement and successfully repaired. CASE REPORT

A .'59-year-old whiskey salesman had a sudden attack of pulmonary edema in February, 1968, at which time an aortic °From the Departments of Surgery and Medicine, Graduate Hospital, University of Pennsylvania, Philadelphia. Supported in part by U.S. Public Health Service grant \101HR-00322. Reprint requests: Dr. \V. S. Blakemore, Graduate Hospital, 19th and Lombard, Philadelphia 19146

CHEST, VOL. 61, NO.1, JANUARY 1972