INTRODUCTION

Pulmonary ground-glass shadow is a common clinical imaging manifestation shared by many pulmonary diseases such as interstitial pneumonia, pulmonary fungal infection, parasitic infection, viral pneumonia, and heart failure. Some of the lung cancers, especially lung adenocarcinoma, can also present ground-glass-like nodules. The early diagnosis and differential diagnosis of the ground-glass shadow are very important for lung cancer. Even though there are a lot of studies in this field in recent years, diffuse and uniform ground-glass opacity is rarely reported in lung adenocarcinoma. In this study, a case of lung adenocarcinoma complicated with respiratory failure is reported to show diffuse uniform ground-glass shadow in the chest computed tomography (CT). In addition, we discuss this case in the context of related literation hoping clinical and imaging doctors could be aware of this in clinical practice.

CASE REPORT

A 56-year-old female patient was admitted to Hangzhou Normal University Affiliated Hospital on November 12, 2014. She had fever for 1 week with the highest temperature reaching 39°C, coughed white sputum with no blood or yellowish stuff, and complained chest tightness and dyspnea when severe coughing. She felt nausea and even vomit in the course but no coffee-like objects were vomited. She was treated with intravenous cefuroxime and levofloxacin in outpatient service for 3 days without expected improvement. She had been diagnosed as type 2 diabetes in the past and had been given metformin and acarbose treatment. Clozapine and trihexyphenidyl and other drugs were daily administrated orally to treat schizophrenia diagnosed previously. She has no smoking and drinking history, no omophagia fish, and shrimp history. No obvious abnormalities were found in the regular physical examination and chest X-ray scan [Figure 1a] performed a half year before. Physical examination showed body temperature of 38.2°C, pulse rate of 89/min, respiratory rate of 22 breaths/min, blood pressure of 125/70 mmHg (1 mmHg = 0.133 kPa), and pulse oxygen saturation of 85% (concentration of oxygen inhalation: 21%). Her consciousness was clear, with poor spirit and mild cyanosis. No enlarged superficial lymph nodes were found and widely moist rales could be heard in two lungs. Her heart rate was 89 beats/min with no pathological murmur. The abdomen is soft, no lower limbs dropsy. On auxiliary examination, chest CT scan [Figure 1b–1e, November 12, 2014] found diffused uniform ground-glass shadow in two lungs with no enlarged mediastinal lymph nodes. On admission, preliminary diagnosis revealed: (1) diffuse lung disease of unknown origin, respiratory failure, (2) type 2 diabetes, and (3) schizophrenia. After admission, the patient presented high fever and pulmonary diffuse exudate with respiratory failure. Considering previous history of type 2 diabetes, we suspected pulmonary infection with unknown pathogen. Oxygen therapy and hypoglycemic therapy were given. In addition, 4.5 g of piperacillin-tazobactam by intravenous drip bid and 0.4 g of moxifloxacin once a day (QD) combined with anti-infection and cough expectorant were given to relieve symptoms and simultaneously improve the relevant inspection.

Laboratory examination: Routine blood test + high-sensitive C-reactive protein (hs-CRP), leukocyte 19.67 × 109/L, percentage of neutrophils 91.0%, 6.1% of lymphocyte percentage and 0 of eosinophil cell percentage, red-cell count 4.65 × 1012/L and 130 g/L of hemoglobin, platelet count of 216 × 109/L, hs-CRP 30.99 mg/L. Arterial blood gas analysis: pH 7.31, partial pressure of carbon dioxide in artery 27.10 mmHg, arterial partial pressure of oxygen 57.90 mmHg, arterial oxygen saturation 87.10%. B-type natriuretic peptide: 65.30 pg/ml. Allergen determination: total immunoglobulin E 11.50 IU/ml, no specific allergen was detected. Procalcitonin <0.5 ng/ml. Antinuclear antibodies, double-stranded-DNA, anti-Sjogren syndrome A antibody, anti-Sjogren syndrome B antibody and other autoantibodies were all negative. Perinuclear antineutrophil cytoplasmic antibody, cytoplasmic antineutrophil cytoplasmic antibodies and myeloperoxidase antibody was negative. Tumor screening: α-fetoprotein - 3.61 ng/ml, carcinoembryonic antigen (CEA) - 2.5 ng/ml, carbohydrate antigen (CA) 199-25 kU/L, CA 125-14 U/ml, all were in the normal range. Interferon gamma release test for tuberculosis infection: negative. 1,3-beta-glucan test: 300.2 pg/ml (reference value <100.5 pg/ml); galactomannan test: negative. Nucleic acid detection of influenza A virus (throat swab): negative; human immunodeficiency virus antibody: negative, urine cytomegalovirus DNA detection: negative. Acid fast bacilli is negative in 3 smear tests. Sputum cytology found no tumor cells. Electrocardiograph: sinus rhythm.

Cough, shortness of breath gradually worsened after 3 days treatment with piperacillin-tazobactam combined with moxifloxacin. Body temperature had been fluctuating between 37°C and 38°C since the admission. The patient was administered with 0.2 g voriconazole by intravenous drip q12h and 40 mg methylprednisolone by intravenous QD to inhibit fungal infections and inflammation for 4 days. Intermittent noninvasive ventilation was given as needed. On the 5th day of admission, electronic bronchoscopy was performed and showed that the trachea and bronchial lumen was smooth and the mucosa was congested. A huge amount of white foam sputum was found in the tracheal cavity to be constantly emitted after suction; no stenosis and neoformation, no cheese-like necrosis tissue was observed. Oxygen saturation increased from 70% to 80% to above 93% after foamy sputum was suctioned. Transbronchial lung biopsy (TBLB) was performed in the right lower lung and TBLB pathology reported adenocarcinoma [Figure 1f]. Epidermal growth factor (EGFR) gene and anaplastic lymphoma kinase-echinoderm microtubule-associated protein-like (ALK-EML4) fusion gene were further analyzed, and no mutation was found. The patient was given antitumor Chinese traditional medicine, anti-infection treatment, and nutritional support together with noninvasive ventilation and other treatment to relieve symptom. The patient died of respiratory failure on the 20th day after admission.

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Conflicts of interest

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