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Pulmonary Hyalinizing Granuloma: a Rare Cause of a Benign Lung Mass

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Pulmonary Hyalinizing Granuloma: a Rare Cause of a Benign Lung Mass Case Report Pulmonary Hyalinizing Granuloma: A Rare Cause of a Benign Lung Mass Mandeep Singh Rahi * , Kulothungan Gunasekaran , Kwesi Amoah, Farheen Chowdhury and Jeff Kwon Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06258, USA; [email protected] (K.G.); [email protected] (K.A.); [email protected] (F.C.); Jeff[email protected] (J.K.) * Correspondence: [email protected]; Tel.: +571-314-1212; Fax: 203-330-7498 Received: 7 December 2020; Accepted: 27 January 2021; Published: 29 January 2021 Abstract: Pulmonary hyalinizing granuloma (PHG) is a rare, benign lung disease of unknown etiology. It usually manifests as solitary and sometimes as multiple pulmonary nodules. It may have irregular margins, cavitation, or calcifications mimicking metastasis or primary lung neoplasm. It should be considered in the differential diagnosis of pulmonary nodules or masses. In this report, we present an unusual case of incidental slow-growing lung mass in a patient with 30 pack-year smoking history, construction-based occupation. The pleural-based calcified nodule in the left upper lobe gradually increased in size over ten years without any hilar or mediastinal lymphadenopathy. For an accurate diagnosis, PET-scan and histopathological analysis through wedge resection by video-assisted thoracoscopic surgery (VATS) were done. The biopsy findings were consistent with pulmonary hyalinizing granuloma, a rare benign cause of lung mass with an excellent long-term prognosis. Keywords: lung mass; lung nodule; pulmonary hyalinizing granuloma; smoking 1. Introduction Pulmonary hyalinizing granuloma (PHG) is a benign and rare lung disease. It was first described by Benfield et al. in a 51-year-old female with retroperitoneal fibrosis and bilateral pulmonary granulomas [1]. It can present as single or multiple lung nodules. Most of the lesions are discovered incidentally as they are relatively asymptomatic. An accurate gauge of prevalence is hard to obtain. Peng et al. found one case of PHG in a cohort of 481 patients with lung disease [2]. Although the exact etiology is still unknown, it is hypothesized to be because of an exaggerated immune response to antigenic stimuli caused by infection or an autoimmune process [3,4]. The disease can mimic metastatic disease or primary lung malignancy, warranting appropriate diagnostic testing and management. Definitive diagnosis relies on histopathology showing central lamellar collagen sometimes arranged in whorls surrounded by giant cells and lymphocytes between the collagen bands [5]. Solitary nodule is usually managed effectively by complete resection. Surgery can be challenging and extensive in case of large lesions located close to critical structures. Whereas multiple lesions are difficult to manage surgically and may progress rapidly [6] We present a case of PHG describing characteristic calcification, histopathology, and growth over a period of ten years. 2. Case Presentation A 49-year-old male with a history of smoking presented to the emergency room with a one-week history of left shoulder pain, which started after mechanical trauma at his workplace. He endorsed burning micturition but denied fever, cough, shortness of breath, or chest pain. He was smoking one pack per day for the last 30 years. He was originally from Puerto Rico and moved to the mainland Clin. Pract. 2021, 11, 37–42; doi:10.3390/clinpract11010007 www.mdpi.com/journal/clinpract Clin.Clin. Pract. Pract.2021 2021, 11 , 11, FOR PEER REVIEW 382 of 5 pack per day for the last 30 years. He was originally from Puerto Rico and moved to the mainland UnitedUnited States States 20 years20 years ago. ago. He He worked worked as aas laborer a laborer in thein the construction construction business business throughout throughout his his life. life. HeHe had had no no known known exposure exposure to tuberculosis.to tuberculosis. On On examination, examination, he he was was afebrile afebrile with with a blood a blood pressure pressure of 131of 131/79/79 mm mm of of Hg, Hg, heart heart rate rate of of 89 89 beats beats perper minute,minute, respiratory rate rate of of 18 18 breaths breaths per per minute, minute, and andoxygen oxygen saturation saturation of of96% 96% while while breathing breathing ambient ambient air. air.Initial Initial laboratory laboratory examination examination showed showed a white a white blood cell count of 17,800/µL, hemoglobin of 15.3 g/dL, and platelet count of 229 103/µL. blood cell count of 17,800/μL, hemoglobin of 15.3 g/dL, and platelet count of 229 × 103/×μL. A plain A plainradiograph radiograph of the of theleftleft shoulder shoulder showed showed an an incidental incidental left upperupper lobelobe calcified calcified nodule. nodule. Serum Serum electrolyteselectrolytes and and renal renal function function tests tests were were within within normal normal limits. limits. Urinalysis Urinalysis showed showed significant significant pyuria pyuria withwith moderate moderate bacteria. bacteria. Urine Urine culture culture grew grew Escherichia Escherichia coli sensitivecoli sensitive to beta-lactam to beta-lactam antibiotics, antibiotics, and he and washe treated was treated with antibiotics. with antibiotics. For evaluation For evaluation of the of lung the nodule, lung nodule, a Computed a Computed Tomography Tomography (CT) of (CT) the of chest was obtained, which showed a 3.2 2.2 cm pleural-based mass with central calcification in the left the chest was obtained, which showed× a 3.2 × 2.2 cm pleural-based mass with central calcification in upperthe lobeleft upper with no lobe mediastinal with no mediastinal or hilar lymphadenopathy or hilar lymphadenopathy (Figure1A,D). (Figure A careful 1A,D). review A careful of the review chart of showedthe chart that showed he had the that same he had nodule the tensame years nodule back, ten but ye itars was back, only but 1.7 it cm was (Figure only 11.7C). cm The (Figure patient 1C). was The dischargedpatient was and discharged was followed and in was the followed out-patient in the clinic. out-patient A Positron clinic. Emission A Positron Tomography Emission (PET)Tomography scan was(PET) performed, scan was and performed, the pulmonary and the nodule pulmonary showed nodu mildle avidity showed with mild a standardized avidity withuptake a standardized value (SUV)uptake max value of 3.1 (SUV) (Figure max1B). of The 3.1 (Figure patient was1B). The discussed patient in was a multispecialty discussed in a tumormultispecialty board conference, tumor board andconference, the consensus and wasthe consensus to favor resection was to favor due toresection the size du ofe theto the mass, size growth of the mass, over thegrowth last tenover years, the last relativelyten years, young relatively age, and young possibility age, and of possibility the increased of the complexity increased of complexity resection with of resection further growthwith further in thegrowth tumor. in His the pulmonary tumor. His function pulmonary tests function showed test moderates showed obstruction moderate obstruction with a normal with gas a normal transfer. gas Thetransfer. patient underwentThe patient wedgeunderwent resection wedge by resection Video-Assisted by Video-Assisted Thoracoscopic Thoracoscopic Surgery (VATS). Surgery Pathology (VATS). showedPathology a focally showed calcified a focally nodule calcified with dense nodule lamellar with dense collagen lamellar consistent collagen with consistent hyalinized with granuloma hyalinized (Figuregranuloma2). No amyloid(Figure 2). fibers No amyloid were seen, fibers and were stains seen, were and negative stains forwere acid-fast negative and for fungal acid-fast organisms. and fungal Theorganisms. patient had The an patient unremarkable had an postoperativeunremarkable coursepostoperative and was course discharged and was after discharged 48 h. There after were 48 h. noThere complications were no reportedcomplications on the reported follow-up on visit the andfollow-up no recurrence visit and on no surveillance recurrence imagingon surveillance one yearimaging post-operatively. one year post-operatively. FigureFigure 1. ( A1.) ( isA) a is computed a computed tomography tomography of chestof chest in anin axialan axial plane plane showing showing a pleural a pleural based based left left upper upper lobelobe mass mass (denoted (denoted by aby star), a star), (B) ( isB) a is positron a positron emission emission tomography tomography of chest of chest in an in axialan axial plane plane showing showing mildmild avidity avidity in the in the left left upper upper lobe lobe mass, mass, (C) ( isC) computed is computed tomography tomography of chest of chest in axial in axial plane plane showing showing leftleft upper upper lobe lobe nodule, nodule, which which is smaller is smaller in size in ten size years ten back, years and back, (D) showsand (D the) shows left upper the left lobe upper nodule lobe withnodule central with calcification. central calcification. Clin. Pract. 2021, 11 39 Clin. Pract. 2021, 11, FOR PEER REVIEW 3 of 5 FigureFigure 2. 2.Is Is the the histopathology histopathology of the of resectedthe resected mass mass from thefrom left the upper left lobeupper showing lobe showing dense network dense network ofof hyalinizedhyalinized collagen collagen and and lymphocytic lymphocytic infiltrate infiltrate (A, B(A)., CollagenB). Collagen in lamellar in lamellar pattern pattern with with whorls whorls and andsurrounded surrounded by by lymphocytic lymphocytic
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