A 27-year-old male presented with fever and hemoptysis.
Personal history included two episodes of bilateral pneumonia in the last year, with clinical resolution and radiological improvement after conventional treatment, although with persistent left alveolar infiltrate on control chest X-rays.
There are no risk factors for HIV or immunosuppression.
Work as a mechanics in contact with environments where welds, fats, acids, and other irritants are used.
Physical examination, laboratory tests and respiratory function tests were normal.
A chest X-ray revealed a bilateral alveolar infiltrate similar to the previous radiographs.
It was then decided to perform thoracic computed tomography with high-resolution slices, consisting of thin sections of 1 mm collimation at 10 mm intervals from the lung parenchyma, in inspiration and with the patient in supine position.
The study shows areas of alveolar opacification in glass dispersed in the right side and superimposition of a linear septal thickening interlobular and intralobular septal, known as "crazy-paving" pattern of extensive patched lung.
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Considering the radiological pattern at HRCT and exposure to inhaled toxic agents, the differential diagnosis is reduced to PAP and lipoid pneumonia.
A fibrobronchoscopy with LAB was then performed, which is not conclusive, and was completed with transbronchial biopsy. The ultrastructural study identified within the alveoli a positive microscopic amorphous acid-fast granular material.
