A Case of Atypical Adenomatous Hyperplasia of Larger Than 2 cm
A 71-year-old female visited the outpatient department with a 2-week history of coughing with sputum and dyspnea on exertion. She had no other medical history with the exception of pulmonary tuberculosis at the age of 30 years. After administration of anti-tuberculosis medication, she was completely cured.\nA chest X-ray performed during the patient's first visit to the outpatient department showed consolidation in the right lower lung field and focal consolidation in the left lower lobe. Sputum acid-fast bacteria (AFB) staining was negative. On bronchoscopy, the inlet of the right lower lobe was crushed out, especially the superior segment of the lower lobe. However, intraluminal lesions were not found. Based on these results, the patient was diagnosed with community-acquired pneumonia and was prescribed clarithromycin for 7 days. She was scheduled for a follow-up chest X-ray after finishing the medication, but she did not return to the hospital.\nThe patient returned to the hospital after 6 months because of dyspnea on exertion (American Thoracic Society grade 2). A chest X-ray was again performed (). The right middle lobe and lower lobe showed increased haziness and density together with linear consolidation in the left lung. A chest CT scan was then performed (). Consolidation was seen in all right lung zones with the exception of the superior segment of the right upper lobe. The right middle and lower lobes were mainly collapsed. Both the upper lobe and left lower lobe had many nodules. They also showed GGOs. Compared with the first chest X-ray, increases in the extent and haziness of the lesions were observed. Therefore, due to suspicion of pneumonia aggravation, we administered cefepime and clindamycin after performing a culture. However, we could not rule out the possibility of pulmonary tuberculosis reactivation or a cancerous mimic of pneumonia. Therefore, sputum AFB staining and cytology were performed, followed by bronchoscopy. Transbronchial lung biopsy was attempted, but failed. The AFB stain and cytology tests were all negative, and there was no endobronchial mucosal lesion. Upon admission, vital signs were as follows: blood pressure 100/60 mm Hg, heart rate 114 beats per minute, respiratory rate 20/min, and body temperature 39.1℃. The patient was alert and oriented, but showed an acutely ill-looking appearance, and there were rales in the right lower lobe zone with a rough respiratory sound.\nPeripheral blood test results were as follows: white blood cells 25,200/µL (neutrophils 86%, lymphocytes 7.3%, monocytes 6.1%, eosinophils 0.5%, and basophils 0.3%), hemoglobin 14.6 g/dL, and platelets 205,000/µL. In addition, the C-reactive protein level increased to 6.6 mg/dL. Chemistry test results were as follows: aspartate aminotransferase 20 IU/L, alanine aminotransferase 15 IU/L, total bilirubin 1.4 mg/dL, lactate dehydrogenase 440 IU/L, total protein 7.1 g/dL, albumin 3.8 g/dL, blood urea nitrogen 12 mg/dL, and creatinine 0.6 mg/dL. The results of arterial blood gas analysis at room temperature were as follows: pH 7.46, pCO2 31 mm Hg, pO2 67 mm Hg, HCO3 22 mmol/L, and saturation 94%. There was no improvement on chest X-ray after finishing the antibiotics or after changing them. The bronchoscopic washing cytology test results obtained before admission were suspicious for malignancy. Thus, a peripheral blood carcinoembryonic antigen level was obtained, and the result was 0.8 ng/mL.\nFor a definitive diagnosis, an open lung biopsy was performed in the basal segment of the right lower lobe. The lesion in the right lobe showed a homogenous nodular pattern during the surgery, and the biopsy was extracted from the right basal segment. A 2.5×1.7-cm section of tissue was extracted for frozen biopsy and was diagnosed as AAH (). Regular biopsy using the rest of the tissue after frozen biopsy revealed AAH with a negative epidermal growth factor receptor (EGFR) mutation test. The blood and sputum cultures upon admission were both negative, as was the AFB culture of sputum. The patient's fever and other symptoms showed improvement after 26 days of hospitalization with supportive care. The patient was then finally discharged.\nAfter 4 months, the patient was admitted again due to aggravated dyspnea on exertion. Both a chest X-ray () and CT scan () were performed. On the chest CT scans, the right lung consolidation was improved, but the extent of the GGO had increased. In the lateral segment and posterior basal segment of the left lower lobe, the GGO pattern as well as the extent and haziness of the consolidation had increased. Moreover, the size of the multiple nodules with GGO increased. Thus, the patient was diagnosed with AAH in progression. According to these findings, positron emission tomography-CT (PET-CT) was performed to rule out malignancy and in preparation for possible chemotherapy. PET-CT was performed on the first day. The images in show that there was some glucose uptake in the lesions in the collapsed part of the right lower lobe, but no uptake in the regional lymph nodes. These observations were believed to be secondary to an infection rather than a cancerous lesion. The biopsy results were consistent with AAH. Gefitinib was administered to the patient after 7 days of hospitalization. After 17 days of treatment with gefitinib, a follow-up chest X-ray was performed. shows that the right lung and hazy left lower lobe consolidation had improved compared with the findings before gefitinib treatment.