Pulmonary Hyalinizing Granuloma Associated with Idiopathic Thrombocytopenic Purpura
The present case report is about a 39-year-old woman who presented with pulmonary nodules incidentally detected on abdominal computed tomography (CT) performed for renal calculi []. Further work-up revealed a 2-year history of minimally progressive, non-specific symptoms, which included fatigue, generalized weakness, dyspnea on exertion, and occasional cough associated with recumbent positioning. The patient denied fever, weight loss, chest pain, hemoptysis, or tobacco use. The patient's past medical history was significant for idiopathic thrombocytopenic purpura (ITP) for at least 4 years prior to presentation, for which she had never received any treatment. Additional history indicated chronic sinusitis and medical marijuana use for intractable pain and presumed ilioinguinal neuralgia that followed robotic hysterectomy. The patient also had a left oophrectomy for dysmenorhea 3 years prior to presentation. A chronic organizing abdominal wall hematoma resulting from an intraoperative inferior epigastric vessel injury probably also contributed to her chronic abdominal pain. A family history of malignancy included leukemia, lymphoma, and renal and prostate cancers.\nAdditional immune, infectious, and malignancy test results were negative. Specifically, fungal serologies, transglutanin antibody, phospholipid antibody, rapid plasma reagin, antinuclear antibody, anti-mitochondrial antibody, double-stranded deoxyribonucleic acid antibody, anti-Ro (SS-A/B) antibodies, anti-smith antibody, ribonucleoprotein antibody, striated muscle antibody, anti-smooth muscle antibody, anti-collapsin response mediator antibody, voltage-gated potassium channel antibody, N-type calcium channel antibody, and angiotensin-converting enzyme testing were within normal limits. A chest radiograph demonstrated bilateral rounded pulmonary opacities of various sizes []. A contrast enhanced chest CT showed multiple rounded, discrete pulmonary nodules bilaterally with relative lower lobe and peripheral predominance, which is a common presentation for metastases []. The largest nodule was 2 cm in diameter. Neither enlarged mediastinal or hilar nodes, nor pleural effusions were demonstrated. Positron emission tomography (PET) CT scan was negative []. CT-guided left lower lobe nodule biopsy yielded non-specific lymphoplasmacytic infiltrate, areas of fresh alveolar hemorrhage and no evidence of well-formed granuloma or malignancy. Transbronchial left lower lobe nodule biopsy 6 months later demonstrated fragments of normal lung parenchyma without evidence of a well-formed granuloma or malignancy.\nFollow-up CT scans performed 8- and 16-months after the initial abdominal CT demonstrated stability of the existing nodules and no new nodules. However, continued diagnostic uncertainty led to a thoracoscopic wedge resection of nodules in the superior segment of the left lower lobe and anterior segment of the left upper lobe. Microscopic analysis of each of the two resected round, well-circumscribed, indurated, tan nodules demonstrated some defining features for hyalinizing granuloma, including layers of collagen concentrically arranged in a whorled fashion around small blood vessels []. Inflammatory infiltrate both within and around the nodules consisted primarily of lymphocytes and plasma cells with a few neutrophils and histiocytes. No treatment has been initiated at this point in view of the documented stability of the lung lesions and a lack of significant evidence to suggest that the nodules were responsible for the patient's reported clinical symptoms. Steroids have been reported to be successful for symptom relief and nodule regression in patients with PHG.