February 2025 Imaging Case of the Month: A Wolf in Sheep’s Clothing

Mathew T. Stib MD and Michael B. Gotway MD

Department of Radiology

Mayo Clinic Arizona

Phoenix, AZ USA

Clinical History: A 72-year-old man presents to his physician with chest pain. The patient awoke 2 weeks earlier with right-sided chest pain, thought to be the result of a pulled muscle. However, the pain did not remit over the next 2 weeks. The patient also complained of a mild cough productive of white sputum and some mild intermittent shortness of breath improving with albuterol. The patient denied fever.

The patient’s past medical history was remarkable for seasonal allergies, especially dust exposure, treated with fluticasone, and occasional wheezing, treated as needed with an albuterol inhaler. The patient was also diabetic and had hypertension and a history of hypothyroidism. The patient’s past surgical history included right knee total arthroplasty and lithotripsy for renal stones. The patient denied allergies, smoking, and illicit drug use. His medications included fluticasone, albuterol, amlodipine, atorvastatin, ramipril, sitagliptin-metformin, levothyroxine, and probiotics.    

The patient’s vital signs included a blood pressure of 121/75 mmHg, a pulse rate of 78/minute, a respiratory rate of 18/minute and a temperature of 36.4°C. Pulse oximetry on room air was 96%. The patient’s weight was 89.kg, his body mass index 28.15 kg/m². The physical examination was unremarkable. In particular, the breath sounds were normal.

A complete blood count showed a mildly elevated white blood cell count at 11.1 x 10⁹/L (normal, 3.4 – 9.6 x 10⁹/L), with a normal absolute neutrophil count of 3.36  x 10⁹/L (normal, 1.56 – 6.45 x 10⁹/L). His hemoglobin and hematocrit values were mildly decreased at 11.1 gm/dL (normal, 13.5 – 17.5 gm/dL) and 36.3% (normal, 38.8 – 50%). The platelet count was normal at 280 x 10⁹/L (normal, 149 – 375 x 10⁹/L). The patient’s serum chemistries and liver function studies were normal aside from an a mildly decreased serum calcium level of 8.6 mg/dL (normal, 8.8-10.2 mg/dL), an elevated glucose level of 186 mg/dL, (normal, 70-100 mg/dL), and a mildly elevated alkaline phosphatase level of 121 U/L (normal, 45-115 U/L). The urinary drug toxicity screen was negative, and coagulation parameters were normal. The thyroid stimulating hormone level was within the normal range. Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal and lateral chest radiography. To open figure 1 in a separate, enlarged window click here.

Which of the following statements regarding this chest radiograph is most accurate? (click on the correct answer to be directed to the second of eleven pages)

1. The frontal chest radiograph shows no abnormal findings
2. The frontal chest radiograph shows basal predominant fibrotic abnormalities
3. The frontal chest radiograph shows large lung volumes with a cystic appearance
4. The frontal chest radiograph shows a partially circumscribed opacity projected over the right thorax
5. The frontal chest radiograph shows abnormal mediastinal contours

Cite as: Stib MT, Gotway MB. February 2025 Imaging Case of the Month: A Wolf in Sheep’s Clothing. Southwest J Pulm Crit Care Sleep. 2025;30(2):14-25. doi: https://doi.org/10.13175/swjpccs003-25 PDF

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 and Lewis J. Wesselius MD³

Departments of ¹Radiology ²Pathology, and ³Pulmonary

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, Wesselius LJ. 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