Question 1 Answer
B. Bronchoscopy and sampling from abnormal areas
Question 2 Answer
D. All of the above
Discussion
Haemoptysis requires prompt evaluation to determine its underlying
cause and initiation of appropriate therapy. Computed tomography
patterns in combination with history and physical examination can help
the clinician narrow the differential.(1) This patient imaging pattern
demonstrated mediastinal lymphadenopathy at lower paratracheal (4R),
subcarinal (7), bilateral hilar (10) stations along with diffuse
perilymphatic nodules.
The differential for perilymphatic nodules include silicosis,
sarcoidosis, amyloidosis and lymphangitic carcinomatosis.(2) Therefore,
establishing a tissue diagnosis is critical for management. Miliary
pulmonary tuberculosis presents with random micro-nodules on CT and
would require microbiological evidence which was lacking in our patient
(Question 1, answer A is incorrect). Due to concerns of diffuse
parenchymal lung disease with ongoing haemoptysis observation with
tranexamic acid would be inappropriate (Question 1, answer D is
incorrect). CT pulmonary angiography (CTPA) is a good modality for
patients with active haemoptysis but it would only convey to us the
source of bleeding but not the underlying aetiology (Question, 1 answer C
is incorrect).
Our patient underwent endobronchial ultrasound guided transbronchial
needle aspiration from mediastinal lymph nodes along with endobronchial
and transbronchial biopsies. Histopathology revealed amorphous material
filling the interstitium with apple green birefringence with Congo red
stain, consistent with amyloidosis.
Pulmonary amyloidosis is an uncommon disease that can present with a
broad range of radiographic findings, such as diffuse alveolar septal
involvement with perilymphatic lung nodules, interstitial involvement in
form of septal thickening and mediastinal and hilar lymph node
enlargement. Nodules and lymph nodes are often calcified. Diffuse
alveolar septal amyloidosis is often associated with amyloid light chain
(AL) amyloidosis. Other forms of pulmonary amyloidosis include
tracheobronchial involvement with submucosal plaques, localised nodular
amyloidosis and pleural effusion (Question 2 answer D). Ideally, tissue
biopsies should be obtained from the least invasive sites (abdominal
fat, minor salivary glands) due to an increased risk of bleeding in
these patients. Once diagnosed, further treatment of pulmonary
amyloidosis depends upon whether the disease is localised or systemic.
Treatment options also depend upon the fibril protein type and
underlying aetiology.(3)
Our patient underwent bone marrow aspiration and biopsy which
revealed hypercellular marrow with clonal plasma cells constituting
>1% of cell lines, abdominal fat pad biopsy stained positive for
amyloid and serum free light chain assay was positive. A final diagnosis
of AL amyloidosis secondary to plasma cell dyscrasia was made. Patient
is currently on chemotherapy combination of bortezomib, lenalidomide and
dexamethasone for this primary disease.
References
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Ketai LH, Mohammed T-LH, Kirsch J, Kanne JP, Chung JH, Donnelly EF,
et al. ACR appropriateness criteria® hemoptysis. Journal of thoracic
imaging. 2014;29(3):W19-W22.
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Criado E, Sánchez M, Ramírez J, Arguis P, de Caralt TM, Perea RJ, et
al. Pulmonary sarcoidosis: typical and atypical manifestations at
high-resolution CT with pathologic correlation. Radiographics.
2010;30(6):1567-86.
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Milani P, Basset M, Russo F, Foli A, Palladini G, Merlini G. The lung in amyloidosis. European Respiratory Review. 2017;26(145).