Translation Results Requested Through Conyac Made Public

Dr. Nancy Lee Harris (Pathology): May we have
the medical students’ diagnosis?
A Harvard Medical Student: The medical students
based their differential diagnosis on several features
of the case: the fact that the patient smoked,
the presence of painful lytic bone lesions, the
presence of lung lesions characterized by cystic
lucencies in the upper lobes, the multiple negative
cultures and normal laboratory-test results,
and the presence of granulomatous-appearing
features on examination of the biopsy specimen.
We thought that the diagnosis that best unified
these features was LCH and that a transbronchial
or open-lung biopsy should be performed. Dr. Harris: Dr. Sievers, would you tell us what
you were thinking and what you did to establish
a diagnosis?
Dr. Sievers: An infectious process had been
strongly suspected, but after the negative workup
for infectious causes and the finding of features
on chest CT that the radiologists thought were
characteristic of pulmonary LCH, we favored that
diagnosis as an explanation of both his lung and
bone lesions. Before proceeding with video-assisted
thoracoscopic surgery, we asked the pathology
service to re-review the bone-biopsy specimen
with this diagnosis specifically in mind. This case illustrates the difficulty of establishing
the diagnosis of a histiocytic or dendritic-cell
disorder. Histiocytes and dendritic cells are common
components of both infectious and noninfectious
inflammatory processes, and histiocytic
disorders and neoplasms may have a prominent
inflammatory background. Thus, clinical correlation
is essential, and the clinician should not
hesitate to convey clinical suspicion of any histiocytic
disorder to the pathologist.
This patient has LCH involving bone and presumably
also lung, on the basis of imaging studies
and his smoking history, suggesting multisystem
disease27 (Table 2).