Case 2

I am presented with an HRCT study, which demonstrates generalised ground glass opacification in both lungs, predominantly in the lower lobes; there are also some centrilobular ground glass nodules.

There are thin walled cysts of varying size scattered throughout both lungs. I also note mild dilatation of the peripheral bronchi and bronchioles, indicating traction bronchiectasis. There is septal thickening and reticular opacities, mostly in the lower lobes.

There are a few moderately enlarged mediastinal lymph nodes. I cannot appreciate any pleural effusions.

These findings indicate an interstitial lung disease, the features of which are most characteristic of lymphocytic interstitial pneumonia.

I am now presented with a CT study of the neck, showing innumerable punctate calcifications in both parotid glands. The calcifications appear to be in the parenchyma rather than intra-ductal. The left parotid gland appears larger than the left, with a rounded, well defined lesion within that is hypo-enhancing on the post contrast phase, and shows benign characteristics.

I note that there is no dilatation of the main duct of the parotid gland on either side.

There is bilateral cervical lymphadenopathy, showing reactive rather than neoplastic appearance.

The findings in the parotid glands are likely due to chronic inflammation.

This constellation of findings is highly characteristic of Sjogren’s syndrome. I would contact the referring physician to ask if the patient has any known diagnosis, or if they presented with typical symptoms such as dry mouth and eyes. I would recommend serology to test for associated antibodies, namely anti-Ro and anti-La antibodies. I would flag this case for discussion at the relevant MDT.

Incidentally, there is a large thyroid nodule in the right lobe; this should be further investigated by ultrasound examination. Also, there are bilateral subcutaneous soft tissue densities overlying the maxilla, likely representing old filler material.