case_images: PMC9972090_01
case_images: Chest radiographs before exposure and after 27 months of exposure. (A, B) No small nodules are observed on chest radiographs before exposure and after exposure for 15 months. (C) Diffuse small nodules are demonstrated on the radiograph after 27 months of exposure during work.
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case_images: PMC9972090_01_fmed-10-1085716-g0001.jpg
case_images: F1
case_images: On 8 October 2018, her chest radiograph of regular occupational medical check-ups at the local occupational disease hospital showed diffuse punctate and nodular shadows in the bilateral lungs (Figure 1B), while the initial chest radiograph taken on June 2016 (before work) was normal (Figure 1A).
case_images: Timeline of the clinical course. (A, B) Chest CT showing scattered GGOs on bilateral lobular areas of ground glass attenuation and centrilobular nodules throughout the lung parenchyma before treatment. (C, D) GGOs are significantly reduced after the cessation of occupational exposure and using oral prednisone for 3 months. (E, F) GGOs and centrilobular nodules recurred after the cessation of prednisone for 3 months. (G, H) GGOs and centrilobular nodules significantly reduced after the second course of using oral prednisone for approximately 28 weeks. (I-L) Follow-up after the cessation of occupational exposure for 3 years (I, J) and 4 years (K, L), the number of ground glass nodules in her lungs is slightly increased when compared, and fiber streak shadows are observed in the lower lobe of her right lung. CT, high-resolution computed tomography; GGOs, ground-glass opacities; PSL, prednisolone.
case_images: fmed-10-1085716-g0002.jpg
case_images: PMC9972090_02_fmed-10-1085716-g0002.jpg
case_images: F2
case_images: The dosage was gradually tapered to 5 mg/day for a total of 36 weeks (Figure 2). The discontinuation of occupational exposure and the first course of using corticosteroids resulted in an improvement of symptoms and a slight reduction of the multiple nodules in lung fields (Figures 2C, D). In November 2019, after the cessation of oral prednisone for 3 months, the symptoms worsened, her lung function value of DLco (Figure 2) was significantly reduced to 50%, and findings on the chest CT (Figures 2E, F) were more severe than before. The dosage was gradually tapered to 5 mg/day (Figure 2). Her lung function was almost improved to the initial level, with FVC of 3.15 L (110% predicted) and DLco of 62.3% predicted (Figure 2) after the second course of using prednisone in the local hospital. HRCT revealed multiple ill-defined centrilobular nodules and patchy GGOs gradually reduced with oral prednisone therapy (Figures 2G, H). During the 36-month follow-up observational period, her chest CT (Figures 2I, J) revealed that GGOs slightly increased, and fiber streak shadows were observed in the lower lobe of the right lung, as well as the value of DLco reduced to 54%; however, her respiratory symptoms were stable. A 48-month follow-up revealed that her symptoms of dyspnea on exertion gradually worsened, while GGOs (Figures 2K, L) gradually increased and DLco reduced to 46%.
case_images: PMC9972090_02
case_images: Timeline of the clinical course. (A, B) Chest CT showing scattered GGOs on bilateral lobular areas of ground glass attenuation and centrilobular nodules throughout the lung parenchyma before treatment. (C, D) GGOs are significantly reduced after the cessation of occupational exposure and using oral prednisone for 3 months. (E, F) GGOs and centrilobular nodules recurred after the cessation of prednisone for 3 months. (G, H) GGOs and centrilobular nodules significantly reduced after the second course of using oral prednisone for approximately 28 weeks. (I-L) Follow-up after the cessation of occupational exposure for 3 years (I, J) and 4 years (K, L), the number of ground glass nodules in her lungs is slightly increased when compared, and fiber streak shadows are observed in the lower lobe of her right lung. CT, high-resolution computed tomography; GGOs, ground-glass opacities; PSL, prednisolone.
case_images: fmed-10-1085716-g0002.jpg
case_images: PMC9972090_02_fmed-10-1085716-g0002.jpg
case_images: F2
case_images: The dosage was gradually tapered to 5 mg/day for a total of 36 weeks (Figure 2). The discontinuation of occupational exposure and the first course of using corticosteroids resulted in an improvement of symptoms and a slight reduction of the multiple nodules in lung fields (Figures 2C, D). In November 2019, after the cessation of oral prednisone for 3 months, the symptoms worsened, her lung function value of DLco (Figure 2) was significantly reduced to 50%, and findings on the chest CT (Figures 2E, F) were more severe than before. The dosage was gradually tapered to 5 mg/day (Figure 2). Her lung function was almost improved to the initial level, with FVC of 3.15 L (110% predicted) and DLco of 62.3% predicted (Figure 2) after the second course of using prednisone in the local hospital. HRCT revealed multiple ill-defined centrilobular nodules and patchy GGOs gradually reduced with oral prednisone therapy (Figures 2G, H). During the 36-month follow-up observational period, her chest CT (Figures 2I, J) revealed that GGOs slightly increased, and fiber streak shadows were observed in the lower lobe of the right lung, as well as the value of DLco reduced to 54%; however, her respiratory symptoms were stable. A 48-month follow-up revealed that her symptoms of dyspnea on exertion gradually worsened, while GGOs (Figures 2K, L) gradually increased and DLco reduced to 46%.
case_images: Transbronchial lung biopsy (TBLB) of the right lower lobe. (A) Lower power view showing the granulomas distributed in the interstitium, not in the airspace. Some of them have a centrilobular distribution, while some are distributed in the interlobular septum. A video-assisted thoracoscopic surgery (VATS) biopsy of the right lower lobe. (B) Many well-formed non-necrotizing granulomas are composed of epithelioid and multinucleated giant cells, with fibrous hyperplasia (hematoxylin and eosin [HE], x40). (C) Multiple sarcoid-like granulomas composed of clustered epithelioid and multinucleated giant cells, a Schaumann body is observed (arrows) (HE, x100).
case_images: fmed-10-1085716-g0003.jpg
case_images: PMC9972090_02_fmed-10-1085716-g0003.jpg
case_images: F3
case_images: The histological appearance under the microscope showed many well-formed non-necrotizing granulomas composed of epithelioid and multinucleated giant cells, mainly around the bronchi and vessels, with fibrous hyperplasia and lymphocytic inflammation (Figures 3A, B); a Schaumann body was also observed (arrows) (Figure 3C).