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An interesting case ofAn interesting case of

unresolved pneumoniaunresolved pneumoniaModerator: Dr.Moderator: Dr. GovindappaGovindappa

Presented by: Dr.Presented by: Dr. JeevanJeevan

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ComplaintsComplaints

A 40yr old male patient, referred fromA 40yr old male patient, referred from

chikkamanguluruchikkamanguluru general hospital, presentedgeneral hospital, presented

to us with following complaints:to us with following complaints:

C/o Fever of 2 weeks durationC/o Fever of 2 weeks duration

C/o Cough with scanty sputum for 15daysC/o Cough with scanty sputum for 15days

C/oC/o HemoptysisHemoptysis for 10 daysfor 10 days

C/o breathlessness for 10 daysC/o breathlessness for 10 days

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H/o Present illnessH/o Present illness

--fever, intermittent, moderate, no chills and rigorsfever, intermittent, moderate, no chills and rigors

--cough with scanty sputum withcough with scanty sputum with hemoptysishemoptysis

--breathlessness on minimal exertionbreathlessness on minimal exertion

--nono pleuriticpleuritic/ ischemic pain/ ischemic pain--no exposure to STDSno exposure to STDS

He has received antibiotics before coming to ourHe has received antibiotics before coming to our

hospitalhospital

He is not a smoker/ alcoholicHe is not a smoker/ alcoholic

No past H/O major medical illnessNo past H/O major medical illness

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Examination findingsExamination findings

GENERAL EXAMINATION:GENERAL EXAMINATION:

Male patient, moderately built/ nourishedMale patient, moderately built/ nourished

Conscious, orientedConscious, oriented

tachypneictachypneic Vitals:Vitals:

BP: 110/70 mm of hgBP: 110/70 mm of hg

PR: 82/min, regularPR: 82/min, regular

Temp: 100 FTemp: 100 FSPo2: 82% at RASPo2: 82% at RA

91% with 491% with 4 litslits O2O2

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Examination findingsExamination findings

Resp. system: Bilateral scatteredResp. system: Bilateral scattered crepitationscrepitations

andand rhonchirhonchi

CVS: heart sounds are normal, no murmursCVS: heart sounds are normal, no murmurs

PA: soft, no tenderness/PA: soft, no tenderness/ organomegalyorganomegaly

CNS: no deficitsCNS: no deficits

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Summary of historySummary of history

Here we have a 40 yr old male patient withHere we have a 40 yr old male patient with

features of acute febrile illness withfeatures of acute febrile illness with

scattered bilateralscattered bilateral creptscrepts andand ronchironchi, a, adiagnosis of acute bronchitis was madediagnosis of acute bronchitis was made

and investigated further.and investigated further.

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InvestigationsInvestigations

CBC:CBC: HbHb-- 15.9 gm%15.9 gm%

TLCTLC-- 1000010000

DCDC--NN-- 93.1, L93.1, L--5.9, E5.9, E--0, M0, M--0.9, B0.9, B--0.10.1

ESRESR-- 3232

RBS: 265 mg%RBS: 265 mg%

Se.Se. creatininecreatinine: 1.17: 1.17

Se. electrolytes: Na+Se. electrolytes: Na+--135, K+135, K+-- 4.4,Cl4.4,Cl-- 104104 meqmeq

LFT: TBLFT: TB--0.4, DB0.4, DB--0.05, TP0.05, TP-- 6.4, Alb6.4, Alb-- 2.9,2.9,

SGOT/SGPTSGOT/SGPT-- 150/94, Alp150/94, Alp-- 115, GGT115, GGT-- 6161

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InvestigationsInvestigations

Chest XChest X--ray PA view: bilateralray PA view: bilateral

inhomogeneous opacities, suggestive ofinhomogeneous opacities, suggestive of

ARDS/ARDS/ pneumonitispneumonitis and bilateral mildand bilateral mild

pleural effusion.pleural effusion.

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Chest X rayChest X ray

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InvestigationsInvestigations

Dengue, malaria,Dengue, malaria, widalwidal: negative: negative

Sputum for AFB smear: negativeSputum for AFB smear: negative

Arterial blood gases:Arterial blood gases:pHpH-- 7.4, pCO27.4, pCO2-- 30.5, pO230.5, pO2-- 53.5, HCO353.5, HCO3-- 20.6,20.6,

O2satO2sat--87.387.3

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Hospital course: worsenedHospital course: worsened

Patient shifted to ICU on the same day eveningPatient shifted to ICU on the same day eveningas his O2 saturations were fluctuating betweenas his O2 saturations were fluctuating between75 and 85%75 and 85%

In ICU he was put on continuous BIPAP, andIn ICU he was put on continuous BIPAP, andstarted on IV antibiotics {started on IV antibiotics { MagnexMagnex,, LevodayLevoday },},antiviralsantivirals {{ T.TamifluT.Tamiflu,, VirenzaVirenza rotacapsrotacaps }}

O2 saturations were maintaining around 85 toO2 saturations were maintaining around 85 to

90% with BIPAP.90% with BIPAP. Repeat chest XRepeat chest X--ray showed persisting bilateralray showed persisting bilateral

patchy opacities.patchy opacities.

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Chest X rayChest X ray-- repeatrepeat

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InvestigationsInvestigations

As the patient is not responding to BIPAPAs the patient is not responding to BIPAP

and IV antibiotics, Venous Doppler lowerand IV antibiotics, Venous Doppler lower

limbs was done to rule out pulmonarylimbs was done to rule out pulmonary

embolism.embolism.

Report showed no evidence of DVTReport showed no evidence of DVT

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Hospital course andHospital course and

InvestigationsInvestigations After 6 days of treatment with antibiotics,After 6 days of treatment with antibiotics,

antiviralsantivirals, bronchodilators and BIPAP, bronchodilators and BIPAP

saturations didnt improved, so we considered asaturations didnt improved, so we considered a

possibility of AR

DS ?cause/

? Atypicalpossibility of AR

DS ?cause/

? Atypicalpneumoniapneumonia

Sputum AFB, sputum cultureSputum AFB, sputum culture-- negativenegative

Nasal swab cultureNasal swab culture-- negativenegative

H1N1: negativeH1N1: negative

Repeat CBC: TLCRepeat CBC: TLC-- 12800, DC12800, DC-- NN--91%, L91%, L--5.9%5.9%

Serial repeat chest X rays done doesnt showSerial repeat chest X rays done doesnt show

any improvement in shadows.any improvement in shadows.

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Chest X rayChest X ray

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InvestigationsInvestigations

Later ,HRCT chest was doneLater ,HRCT chest was done

-- Extensive patchy and confluentExtensive patchy and confluent

consolidation in bilateral lung parenchyma,consolidation in bilateral lung parenchyma,suggestive ofsuggestive of bronchiolitisbronchiolitis obliteransobliterans

organizing pneumonia.organizing pneumonia.

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CT ChestCT Chest

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CT ChestCT Chest

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Pulmonologist opinion was taken,Pulmonologist opinion was taken,

possibility of BOOP syndrome waspossibility of BOOP syndrome was

considered and started on IVconsidered and started on IV

MethylprednisoloneMethylprednisolone

Patient started responding to treatment atPatient started responding to treatment at

this stage, chest x ray repeated showedthis stage, chest x ray repeated showed

improvement in shadows.improvement in shadows.

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Chest x rayChest x ray

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Patient shifted to wards with intermittentPatient shifted to wards with intermittent

BIPAP, as saturations were maintainingBIPAP, as saturations were maintaining

around 85%.around 85%.

IV steroids were shifted to low dose oralIV steroids were shifted to low dose oral

steroidssteroids

Patient started mobilizing, going to toilet,Patient started mobilizing, going to toilet,

walking around in wards.walking around in wards.

His O2 saturations were maintainingHis O2 saturations were maintaining

around 85 to 90% with 3around 85 to 90% with 3 litslits ofO2ofO2

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Patient was discharged after 15 days ofPatient was discharged after 15 days of

hospital stay with saturation maintainedhospital stay with saturation maintained

around 90% at room airaround 90% at room air

He was discharged with oral steroids andHe was discharged with oral steroids and

advicedadviced to review after 2 weeks.to review after 2 weeks.

Chest X ray done after 2 weeks showedChest X ray done after 2 weeks showed

resolving changesresolving changes

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Chest X ray 2 weeks after dischargeChest X ray 2 weeks after discharge

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Topic discussionTopic discussion

BOOP SyndromeBOOP Syndrome

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BronchiolitisBronchiolitis ObliteransObliterans

Organizing PneumoniaOrganizing Pneumonia

[BOOP][BOOP]

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BOOPBOOP

First described in 1901 by LangeFirst described in 1901 by Lange

19851985---- More cases reported byMore cases reported by EplerEpler et alet al

Age incidence: 4thAge incidence: 4th-- 7th decades7th decades No gender predominance seenNo gender predominance seen

Incidence: 6Incidence: 6--7 per 100,000 admissions7 per 100,000 admissions

Smoking isSmoking is notnot a risk factora risk factor

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DefinitionDefinition

Inflammatory lung disease that involvesInflammatory lung disease that involves

both the terminal bronchioles and theboth the terminal bronchioles and the

alveolialveoli

Characterized by its pathologic andCharacterized by its pathologic and

histologic featureshistologic features

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BOOP: confusion of termsBOOP: confusion of terms

BOOP is sometimes referred to asBOOP is sometimes referred to ascryptogenic organizing pneumonia, a termcryptogenic organizing pneumonia, a termthat is considered more general andthat is considered more general and

representative of what happens clinically,representative of what happens clinically,pathologically, and structurally within thepathologically, and structurally within thelung tissue. However, the term BOOP islung tissue. However, the term BOOP isspecific for a lesion that occurs in thespecific for a lesion that occurs in the

distal bronchioles and alveolidistal bronchioles and alveolisimultaneously and is a popular term usedsimultaneously and is a popular term usedthroughout the worldthroughout the world

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EtiologyEtiology

Idiopathic (Cryptogenic organizingIdiopathic (Cryptogenic organizing

pneumonia)pneumonia)

Secondary to infection, drugs/toxins,Secondary to infection, drugs/toxins,rheumatologic/connective tissuerheumatologic/connective tissue

processes, immunologic disorders, organprocesses, immunologic disorders, organ

transplantation, radiation therapytransplantation, radiation therapy

Pathogenesis??Pathogenesis??

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Types and Classification of BOOPTypes and Classification of BOOP

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PathophysiologyPathophysiology

Inflammation in theInflammation in the

walls of the alveoliwalls of the alveoli

and bronchioles andand bronchioles and

an increase inan increase infoamy, lipidfoamy, lipid--ladenladen

macrophages in themacrophages in the

alveoli arealveoli are

significant and leadsignificant and leadto accumulations ofto accumulations of

fibromyxoidfibromyxoid

connective tissueconnective tissue

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PathologyPathology

ProliferationProliferation of granulation tissue within smallof granulation tissue within small

airways and alveolar ductsairways and alveolar ducts

Chronic inflammation in alveoliChronic inflammation in alveoli

PatchyPatchy peribronchialperibronchial distributiondistribution

Absence ofAbsence of granulomasgranulomas, necrosis,, necrosis,

neutrophilsneutrophils/abscesses, hyaline membranes,/abscesses, hyaline membranes,

vasculitisvasculitis, interstitial fibrosis, or, interstitial fibrosis, or eosinophiliceosinophilicinfiltrationinfiltration

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DiagnosisDiagnosis

Presentation:Presentation:

Onset typically 4Onset typically 4thth or7or7thth decades of lifedecades of life

Women and men affected equallyWomen and men affected equally

Fever, malaise, cough, fatigue, DOE, weightFever, malaise, cough, fatigue, DOE, weight

lossloss

InspiratoryInspiratory ralesrales (74%)(74%)

Hypoxia (>80%)Hypoxia (>80%)

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DiagnosisDiagnosis

Labs:Labs:

NonspecificNonspecific

Leukocytosis (50%)Leukocytosis (50%)

Elevated ESR and CRP (70Elevated ESR and CRP (70--80%)80%)

PFTsPFTs

Mild to moderate restrictive diseaseMild to moderate restrictive disease

DLCO reducedDLCO reduced

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DiagnosisDiagnosis

ImagingImaging

CXR: diffuse alveolar opacities, frequentlyCXR: diffuse alveolar opacities, frequently

peripherally distributed, usually bilateralperipherally distributed, usually bilateral

CT: patchy airCT: patchy air--space consolidation, groundspace consolidation, ground

glass opacities, small nodular opacities,glass opacities, small nodular opacities,

bronchial wall thickening and dilation, usuallybronchial wall thickening and dilation, usually

peripherally distributed and in lower lungperipherally distributed and in lower lungzoneszones

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DiagnosisDiagnosis

Pathology: diagnosis of exclusionPathology: diagnosis of exclusion

Proliferation of granulation tissue within smallProliferation of granulation tissue within small

airways and alveolar ductsairways and alveolar ducts

Chronic inflammation in alveoliChronic inflammation in alveoli

Patchy peribronchial distributionPatchy peribronchial distribution

Absence of granulomas, necrosis,Absence of granulomas, necrosis,

neutrophils/abscesses, hyaline membranes,neutrophils/abscesses, hyaline membranes,vasculitis, interstitial fibrosis, or eosinophilicvasculitis, interstitial fibrosis, or eosinophilic

infiltrationinfiltration

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TreatmentTreatment

Prednisone 1Prednisone 1--1.5mg/kg/day (max1.5mg/kg/day (max

100mg/day) for 2100mg/day) for 2--3 months, if improved,3 months, if improved,

decrease to 0.5decrease to 0.5--1mg/kg/day for 11mg/kg/day for 1--2 more2 more

months, then slowly tapermonths, then slowly taper

IV methylprednisolone (125IV methylprednisolone (125--250mg q6hrs)250mg q6hrs)

for 3for 3--5 days can be used initially for rapidly5 days can be used initially for rapidly

progressive diseaseprogressive disease

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PrognosisPrognosis

TwoTwo--thirds of patients completely resolvethirds of patients completely resolve

with steroid treatmentwith steroid treatment

One

One--third have persistent diseasethird have persistent disease

Relapses are commonRelapses are common

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ReferencesReferences

King, T.E.King, T.E. Cryptogenic organizingpneumonitisCryptogenic organizingpneumonitis..

UptodateonlineUptodateonline.. 2006.2006.

Epler, G.R.Epler, G.R. Bronchiolitis Obliterans OrganizingBronchiolitis Obliterans Organizing

PneumoniaPneumonia. ARCH INTERN MED.. ARCH INTERN MED.2001;161:1582001;161:158--164.164.

Katikireddy, etal.Katikireddy, etal. A 24A 24--yearyear--old woman withold woman with

bilateralpulmonary infiltrates, pericardialbilateralpulmonary infiltrates, pericardial

effusion, and bilateralpleural effusions.effusion, and bilateralpleural effusions. CHEST.CHEST.

2005;128:40132005;128:4013--4017.4017.