We report the case of a 38-year-old man with progressive unilateral bullous lung disease who ultimately underwent surgical resection revealing an unusual pathologic finding.

A 40-year-old woman presented with a 3-week history of progressive exertional dyspnea. She had previously been active, but her symptoms progressed to the point where she was short of breath with walking. Her oxygen level was 90% at rest and decreased to 70% to 80% after exertion. The patient denied fever, cough, sputum production, edema, syncope, or other clinically remarkable symptoms. No significant weight loss was noted recently. Two and a half years ago, the patient was diagnosed with stage IV poorly differentiated lung adenocarcinoma (cT2N3M1c) with a 70% PD-L1 expression level, along with metastases to the pelvis, liver, brain, and bone. The patient received sequential ROS1-targeted therapy (crizotinib, entrectinib, repotrectinib) plus local therapies for metastatic lesions. A tumor assessment 2 months prior showed stable disease. She had no history of smoking, substance misuse, or alcohol consumption. No family history of genetic diseases was reported.

A 72-year-old man with coronary artery disease, heart failure with preserved ejection fraction, smoldering multiple myeloma, treated latent TB, and Agent Orange exposure sought treatment for dyspnea, 10-lb weight loss over several months, and recurrent exudative pleural effusion. Outpatient workup included negative pleural fluid cytology and culture results. CT imaging showed diffuse mesenteric and retroperitoneal lymphadenopathy with mild PET imaging activity, but no cervical or thoracic lymphadenopathy. Thoracentesis had been performed 4 months previously, and again 1 week before admission, suggesting accelerated reaccumulation.

A 53-year-old White man underwent chest radiography as part of a diagnostic evaluation prompted by the incidental detection of hyperferritinemia (838 ng/mL; normal values [nv]: 24-300 ng/mL) during routine blood tests. It was prescribed by the general practitioner as part of the initial diagnostic workup, in the suspicion of a possible underlying pulmonary infectious/inflammatory condition.

A 50-year-old woman was admitted to our hospital with a 2-year history of productive cough and intermittent low-grade fever, which had shown only temporary improvement with short courses of antibiotics. Her past medical history was notable for hysteromyoma, treated with hysterectomy 6 years earlier. She did not smoke, did not report any occupational chemical exposures, and reported a family history of cor pulmonale in her father. Approximately 2 years before admission, a thoracic CT scan at a local hospital revealed diffuse cystic lesions with scattered bilateral nodules and calcifications. Bronchoscopy with bronchoalveolar lavage and transbronchial lung biopsy at that time demonstrated scattered inflammatory cells in the interstitium, but did not yield a definitive diagnosis. Subsequently, she was managed symptomatically with close monitoring. One year before admission, her serum creatinine level began to rise from normal levels, eventually peaking at 5.21 mg/dL and accompanied by renal hypertension. A renal biopsy at the same institution suggested acute interstitial nephritis, for which she received a 3-month course of methylprednisolone (initial dose, 40 mg). Unfortunately, neither her chest imaging results nor renal function improved.