3.3  Case 2 – Fibrosis
A 73-year old female was transferred to our ICU due to shortage of ICU beds in a nearby hospital. Prior to ICU admission, she was healthy but complained of diarrhoea and shortness of breath. Non-contrast chest CT at initial hospital admission showed multiple bilateral areas of ground-glass opacity along the bronchovascular bundles and periphery. There were some small areas of consolidation in the upper lobes. Subtle bronchiectasis were present in affected areas (Fig. 1-2A). Her respiratory condition required mechanical ventilation in prone position due to ARDS. After seven days, prednisolone treatment was started because of lack of improvement. Repeat chest CT-angiography showed segmental pulmonary emboli in the right lung. Ground-glass opacities persisted while the consolidations had disappeared. A reticular pattern combined with GGO was more pronounced with increasing traction bronchiectasis (Fig. 1-2B). BAL was performed twice, but GM and culture showed no signs of additional fungal infection. After one week of high dose glucocorticoid therapy BAL was repeated with a GM index 4.4. Fungal cultures showed growth of Aspergillus fumigatus. Therefore, prednisolone treatment was discontinued and antifungal treatment initiated. CT head was performed because of the development of an epileptic insult and showed small foci of haemorrhage in both frontal lobes. Neurologic condition worsened and progressive cerebral haemorrhage on follow up CT head was seen with poor prognosis. Palliative treatment was started and the patient deceased 27 days after onset of symptoms. Microscopic examination of lung tissue of this case showed an almost complete loss of normal lung architecture. Alveolar structures were unrecognizable and replaced by extensive fibrosis (Fig. 2B). What remained were several foci of pneumocytes, bronchial epithelium, and blood vessels without thrombi. In the PAS-D stain no fungi were observed. The prominent pattern in this patient is pulmonary fibrosis.