Multiple pulmonary nodules.

A 35 year old Caucasian female housekeeper was admitted to our hospital on October 2, 1985 for investigation of pulmonary nodules discovered three weeks previously on a routine chest radiogram. Careful examination of the X-ray revealed four nodules of about 8 mm in diameter scattered in the middle and lower part of the left lung and in the middle and upper lobes of the right lung (fig. 1). The patient' s only complaint was a transient and mild basal left chest pain. She did not give any history of pulmonary tuberculosis, exposure to dusts, contact with sick persons, recent travel or allergy. She had been smoking 15 cigarettes daily for 13 yrs and was not taking any drugs. In April 1983, in another clinic, she underwent a hysterectomy for fibromyoma and, two weeks later, she presented a clinically well-documented chickenpox with respiratory symptoms. No chest radiogram was taken at that time but the X-ray before hysterectomy was reported normal. On admission, physical examination, routine laboratory tests, urinanalysis and electrocardiogram (ECG) were within normal limits. No calcification or cavitation was seen on the tomograrns and on the chest computerized tomography (CT)-scans. Examinations of sputum and gastric contents for cytological abnormalities, acid-fast bacilli and fungi were negative. Intradermal injection of tuberculin purified protein derivative (5 U PPD) or of sensitins (Pasteur Institute, Paris) were negative. An exhaustive study of the patient's immune function, determination of tumour markers and serology for Legionella, Mycoplasma, Chlamydia, Rick-ettsia and viruses were negative except for high varicella antibody titres (1/12,840 immurnoglobulin G (lgG) by enzyme-linked irnmuno-adsorbent assay (ELIS:A) method which were consistent with a persistent infection. Fibre-optic bronchoscopy displayed no abnormality. Cytology and cultures of the bronchoalveolar lavage fluid for pathogens were negative. Owing to the patient's age and the possibility of malig-nancy, an open lung biopsy was performed. During surgery , multiple small nodules were seen on the visceral surface of the pleura and palpated in the pulmonary tissue. Two nodules of 4 and 8 mm in diameter were removed. Histological examination showed two well-circumscribed, necrotic granulomas surrounded by normal pulmonary parenchyma (fig. 2). Central necrosis contained a few calcified deposits and was surrounded by a dense fibrohy-aline stroma. The outer portion of the nodules contained some lymphocytes, plasma cells and a few giant cells (fig. 3). Specific stainings and bacteriological cultures for Mycobacteria and fungi were negative. Such granulomatous lesions can be found in many …