January 2025 Medical Image of the Month: Psoriasis with Pulmonary Involvement

Figure 1. Axial lung-windowed CT reconstructions through the mid (A,B) and lower (C) lungs from a 58-year-old man with psoriasis presenting for evaluation of interstitial lung disease.  There is peripheral and lower lung predominant reticulation, ground glass, and traction bronchiolectasis with architectural distortion and atelectasis. To view Figure 1 in a separate enlarged window click here.  

Figure 2. Low-power (A) and high-power (B,C) hematoxylin & eosin-stained pathology slides from a surgical lung biopsy (left lower lobe) demonstrating scattered lymphoid aggregates with patchy granulomatous organizing pneumonia and scattered loosely formed nonnecrotizing granulomas, concern for underlying systemic connective tissue disease-related interstitial lung disease. To view Figure 2 in a separate enlarged window click here.

A 58-year-old man presented to our pulmonary service for a second opinion concerning his interstitial lung disease (ILD), which had been diagnosed as rheumatoid arthritis associated ILD. The patient had a positive rheumatoid factor (barely) at an outside institution, but no other test results or historical or physical exam findings to suggest rheumatoid arthritis. He was being treated with mycophenolate, but did not feel that he was improving. To the contrary, there had been a recent decline in his overall lung function. The only other relevant medical history is psoriasis. The patient is a lifelong nonsmoker. Resting pulse oximetry was 95% on room air with a brief desaturation to 88% during ambulation, which quickly recovered with rest. The patient’s vital signs were otherwise normal. Physical exam findings were normal aside from mild cutaneous findings of plaque psoriasis. Results from pulmonary function testing at an outside institution were available, revealing a forced vital capacity 40% of reference and DLCO 37% of reference. The overall picture was consistent with restrictive lung disease. Images from an outside CT (Figure 1) demonstrated patchy findings of ILD with peripheral and lower lobe predominant reticulation, ground glass, and architectural distortion without any significant honeycombing or air trapping. The pattern was felt to be pretty nonspecific, but most consistent with ILD in the setting of autoimmune disease, favoring an NSIP or OP pattern over UIP.

Slides from the patient’s outside surgical lung biopsy were reviewed by our pathology department, who have expertise regarding pulmonary manifestations of psoriasis (1). Pathology (Figure 2) showed randomly distributed lymphoid aggregates in association with mild patchy chronic inflammatory infiltrates and patchy areas of numerous macrophages filling airspaces. There were scattered foci of organizing pneumonia focally with nonnecrotizing granulomas. In addition, there were a few scattered very loosely formed nonnecrotizing granulomas. Rare eosinophils were also present. Rare foci of osseous metaplasia were also identified.  While the findings were felt to be nonspecific, they are most concerning for an underlying systemic connective tissue disease involving the lung. The case was discussed at our multidisciplinary ILD conference and a consensus diagnosis of ILD related to psoriasis was made. There is limited data suggesting possible improvement in psoriatic ILD with psoriasis treatment using secukinumab (2). However, there are also reports of secukinumab exacerbating ILD in the setting of psoriasis (3). Given the patient’s lack of improvement on mycophenolate, a trial of secukinumab is being considered.

Interstitial pneumonia is relatively rare in the setting of psoriasis, with a series of 392 psoriasis patients demonstrating an incidence of 2% (4). In this series, the most common imaging findings were lower lung predominate ground glass and reticulation, as was seen in this case. Interestingly, one case series (5) found that a UIP pattern of fibrosis was the most common pattern of ILD on CT in patients with plaque psoriasis; however, many of these patients were smokers. Concomitant smoking seems to predispose the patient towards a UIP pattern of ILD in the setting of psoriasis. In non-smokers, NSIP and OP patterns of ILD seemed more prevalent. Although rare, ILD in psoriasis is an important possibility to consider given that some patients treated with biologic agents for their psoriasis experienced improvements in their ILD (2,4).

Clint Jokerst, MD1, Yasmeen M. Butt, MD2

Departments of 1Radiology and 2Pathology

Mayo Clinic Arizona

Phoenix, AZ USA

References

1. Butt YM, Smith ML, Tazelaar HD, Roden AC, Mengoli MC, Larsen BT. Surgical Pathology of Diffuse Parenchymal Lung Disease in Patients With Psoriasis or Psoriatic Arthritis. Arch Pathol Lab Med. 2022 May 1;147(5):525-533. [CrossRef][PubMed]

2. Miyachi H, Nakamura Y, Nakamura Y, Matsue H. Improvement of the initial stage of interstitial lung disease during psoriasis treatment with secukinumab. J Dermatol. 2017 Dec;44(12):e328-e329. [CrossRef][PubMed]

3. Kajihara I, Yamada-Kanazawa S, Maeda-Otsuka S, Jinnin M, Akaike K, Ihn H. Secukinumab-induced interstitial pneumonia in a patient with psoriasis vulgaris. J Dermatol. 2017 Dec;44(12):e322-e323. [CrossRef][PubMed]

4. Kawamoto H, Hara H, Minagawa S, Numata T, Araya J, Kaneko Y, Umezawa Y, Asahina A, Nakagawa H, Kuwano K. Interstitial Pneumonia in Psoriasis. Mayo Clin Proc Innov Qual Outcomes. 2018 Sep 20;2(4):370-377. [CrossRef][PubMed]

5. Rizzetto G, Tagliati C, Fogante M, et al. CT Patterns of Interstitial Lung Disease in Patients with Plaque Psoriasis: A Retrospective Case Series Study. Medicina (Kaunas). 2023 Sep 12;59(9):1650. [CrossRef][PubMed]

Cite as: Jokerst C, Butt YM. January 2025 Medical Image of the Month: Psoriasis with Pulmonary Involvement. Southwest J Pulm Crit Care Sleep. 2025;30(1):5-7. doi:

https://doi.org/10.13175/swjpccs054-24

PDF

Medical Image of the Month: Hot Tub Lung

Figure 1. Chest radiograph showing diffuse micronodular disease.

Figure 2. Representative images from the thoracic CT scan confirming diffuse micronodular disease with a centrilobular distribution.

Figure 3. Lung biopsy from VATS showing granulomas. Panel A: Low power view. Panels B & C: High power views.

The patient is a 65-year-old man with progressively worsening shortness of breath for 2 months. He had a past medical history of type 2 diabetes mellitus, hypertension, hypothyroidism and a 40 pack-year history of smoking. He suffered from chronic neck pain and sought relief by spending up to 6 hours daily in a hot tub. Chest x-ray (Figure 1) showed numerous small nodules which were confirmed on thoracic CT (Figure 2). The nodules spared the pleural space consistent with a centrilobular distribution. Bronchoscopy with bronchoalveolar lavage grew Mycobacterium avium intracellulare (MAC) and a lung biopsy obtained by video-assisted thorascopic surgery (VATS) showed non-caseating granulomas (Figure 3). Culture of the hot tub water also grew MAC.  He was advised to stop using the hot tub and was treated with prednisone, clarithromycin, rifampin and ethambutol. He rapidly improved though he stopped his therapy after about 3 weeks due to intolerance.  He continued to do well and was asymptomatic when last seen.

Hot tub lung may represent either an infectious process or a hypersensitivity pneumonitis to MAC inhaled from the hot tub. Improvement is usually seen with prednisone, anti-MAC therapy or both (1). The thoracic CT findings are consistent with subacute hypersensitivity pneumonitis including areas of ground-glass attenuation, centrilobular nodules, and air trapping on expiratory images (2). Granulomas, a compact collection of macrophages, are a nonspecific finding seen in both infectious (mycobacteria and fungi) and noninfectious lung diseases (sarcoidosis, hypersensitivity pneumonitis, hot tub lung, and several others) (3). In our patient’s case the clinical history, radiologic findings, lung histology and rapid improvement with removal of MAC exposure are all consistent with hot tub lung.

Allen R. Thomas, MD

Phoenix VA

Phoenix, AZ USA

References

1. Khoor A, Leslie KO, Tazelaar HD, Helmers RA, Colby TV. Diffuse pulmonary disease caused by nontuberculous mycobacteria in immunocompetent people (hot tub lung). Am J Clin Pathol. 2001 May;115(5):755-62. [CrossRef] [PubMed]
2. Hartman TE, Jensen E, Tazelaar HD, Hanak V, Ryu JH.CT findings of granulomatous pneumonitis secondary to Mycobacterium avium-intracellulare inhalation: "hot tub lung". AJR Am J Roentgenol. 2007 Apr;188(4):1050-3. [CrossRef] [PubMed]
3. Hutton Klein JR, Tazelaar HD, Leslie KO, Colby TV. One hundred consecutive granulomas in a pulmonary pathology consultation practice. Am J Surg Pathol. 2010 Oct;34(10):1456-64. [CrossRef] [PubMed]

Cite as: Thomas AR. Medical image of the month: hot tub lung. Southwest J Pulm Crit Care. 2018;17(3):93-4. doi: https://doi.org/10.13175/swjpcc077-18 PDF 

Medical Image of the Week: Pott’s Disease

Figure 1. Axial CT scan showing a heterogeneous dense mass-like consolidation in the medial aspect of the right lung apex (arrow).

Figure 2. MRI C-spine (axial T2-weighted images). Panel A: soft tissue marrow edema surrounding the posterior process of the C7 vertebral body and it’s contiguous with a heterogeneous infiltrative process of the right medial lung apex (arrow).  Panel B: C7 vertebral body compression (arrow).

Figure 3. Right upper lung biopsy showing necrotizing granulomas (arrow) and histiocytes aggregates.

A 22 year-old man with a history of asthma presented with a two-month history of progressive right upper extremity weakness with back pain, weight loss, and night sweats. CT scan of the chest revealed mass-like infiltrative mass in the right lung apex with mediastinal and hilar lymphadenopathy (Figure 1). An MRI cervical spine showed a large infiltrating process at the right medial lung apex with vertebral body compression (Figure 2).

A CT-guided lung biopsy was performed and it showed necrotizing granulomatous inflammation (Figure 3). Pott’s disease was diagnosed and the patient started on anti-tuberculous treatment with a good recovery.

Pott’s disease is a common cause of spinal infection and its clinical presentations are nonspecific. Early findings on imaging may reveal loss of vertebral body height, bone sequestration, sclerosis, and paraspinal mass with calcification (1).  A diagnosis of this condition must be made early as prompt treatment may reduce significant morbidity such as spine deformities to neurologic deficits.

Choua Thao MD¹, David G. Kuykendall MD², Matthew P. Schreiber MD, MHS⁴, and Carmen Luraschi MD³

University of Nevada School of Medicine: Las Vegas

¹Department of Internal Medicine

²Department of Family Medicine

³Division of Pulmonary and Critical Care

Las Vegas, NV

⁴MedStar Georgetown University Hospital/Washington Hospital Center, Washington, DC

Reference

1. Rivas-Garcia A, Sarria-Estrada S, Torrents-Odin C, Casas-Gomila L, Franquet E. Imaging findings of Pott's disease. Eur Spine J. 2013;22:567-78. [CrossRef] [PubMed]

Reference as: Thao C, Kuykendall DG, Schreiber MP, Luraschi C. Medical image of the week: Pott's disease. Southwest J Pulm Crit Care. 2015;11(1):36-7. doi: http://dx.doi.org/10.13175/swjpcc066-15 PDF 

September 2011 Case of the Month

Michael B. Gotway, M.D.
Associate Editor, Imaging

Reference as: Gotway MB. September 2011 case of the month. Southwest J Pulm Crit Care 2011;3:58-63. Click here for PDF version

Clinical History

A 44-year-old man presents for chest radiography for pre-operative screening prior to surgical repair of a meniscal tear in his right knee. An abnormality was noted on this study. 

Figure 1A and B: Frontal (A) and lateral (B) chest radiography.

What abnormality is seen on the chest X-ray? (Depending on your computer settings, you may need to enlarge the chest x-ray with your browser to identify the abnormality.)

1. Right lower lobe consolidation
2. Left lower lobe consolidation
3. Right lower lobe nodule
4. Left upper lobe nodule
5. Left lower lobe nodule

August 2011 Case of the Month

Michael B. Gotway, M.D.

Associate Editor, Imaging

Reference as: Gotway MB. August 2011 case of the month. Southwest J Pulm Crit Care 2011;3:54-7. Click here for PDF version

Clinical History

A 60-year-old woman with no significant previous medical history complains of shortness of breath. Chest radiography was performed (Figure 1).

Point to the lesion on the chest X-ray on the chest x-ray to proceed.