An interesting case of unresolved pneumonia

Moderator: Dr. Govindappa Presented by: Dr. Jeevan

Complaints
‡ A 40yr old male patient, referred from chikkamanguluru general hospital, presented to us with following complaints: ‡ C/o Fever of 2 weeks duration ‡ C/o Cough with scanty sputum for 15days ‡ C/o Hemoptysis for 10 days ‡ C/o breathlessness for 10 days

H/o Present illness
-fever, intermittent, moderate, no chills and rigors -cough with scanty sputum with hemoptysis -breathlessness on minimal exertion -no pleuritic/ ischemic pain pleuritic/ -no exposure to STD¶S ‡ He has received antibiotics before coming to our hospital ‡ He is not a smoker/ alcoholic ‡ No past H/O major medical illness

Examination findings
GENERAL EXAMINATION: ‡ Male patient, moderately built/ nourished ‡ Conscious, oriented ‡ tachypneic ‡ Vitals: BP: 110/70 mm of hg PR: 82/min, regular Temp: 100 F SPo2: 82% at RA 91% with 4 lits O2

Examination findings ‡ Resp. no murmurs ‡ PA: soft. no tenderness/ organomegaly ‡ CNS: no deficits . system: Bilateral scattered crepitations and rhonchi ‡ CVS: heart sounds are normal.

.Summary of history ‡ Here we have a 40 yr old male patient with features of acute febrile illness with scattered bilateral crepts and ronchi. diagnosis of acute bronchitis was made and investigated further. a ronchi.

10000 DC-N.4.4. Alp.9. TP.4.6.2. DB-0.115. K+.05.4.4. E-0. electrolytes: Na+-135.15.9. L-5. B-0.9.1 DCLE. creatinine: 1. TBDBTPAlbSGOT/SGPT. Alb.104 meq Na+K+. GGT.17 creatinine: ‡ Se.150/94.Cl‡ LFT: TB-0.32 ‡ RBS: 265 mg% ‡ Se. M-0.9 gm% HbTLCTLC.1.MBESRESR.61 SGOT/SGPTAlpGGT- .Investigations ‡ CBC: Hb.4.93.Cl.

Investigations ‡ Chest X-ray PA view: bilateral Xinhomogeneous opacities. suggestive of ARDS/ pneumonitis and bilateral mild pleural effusion. .

Chest X ray .

widal: negative widal: ‡ Sputum for AFB smear: negative ‡ Arterial blood gases: pHpH. pO2. pCO2.Investigations ‡ Dengue. malaria.5.30.4. HCO3. pCO2pO2HCO3O2satO2sat-87.5.6.20.3 .7.53.

Levoday }. .Hospital course: worsened ‡ Patient shifted to ICU on the same day evening as his O2 saturations were fluctuating between 75 and 85% ‡ In ICU he was put on continuous BIPAP.Tamiflu. antivirals { T. Magnex. Virenza rotacaps } T. and started on IV antibiotics { Magnex. ‡ O2 saturations were maintaining around 85 to 90% with BIPAP.Tamiflu. ‡ Repeat chest X-ray showed persisting bilateral Xpatchy opacities.

Chest X ray.repeat ray- .

Investigations ‡ As the patient is not responding to BIPAP and IV antibiotics. ‡ Report showed no evidence of DVT . Venous Doppler lower limbs was done to rule out pulmonary embolism.

so we considered a possibility of ARDS ?cause/ ? Atypical pneumonia ‡ Sputum AFB. antivirals.N-91%. sputum culture. DC. bronchodilators and BIPAP saturations didn¶t improved.negative culture‡ Nasal swab culture.Hospital course and Investigations ‡ After 6 days of treatment with antibiotics. .9% TLCDCL‡ Serial repeat chest X rays done doesn¶t show any improvement in shadows.negative culture‡ H1N1: negative ‡ Repeat CBC: TLC.12800. antivirals. L-5.

Chest X ray .

Extensive patchy and confluent consolidation in bilateral lung parenchyma. suggestive of bronchiolitis obliterans organizing pneumonia.HRCT chest was done .Investigations ‡ Later . .

CT Chest .

CT Chest .

‡ Pulmonologist opinion was taken. possibility of BOOP syndrome was considered and started on IV Methylprednisolone ‡ Patient started responding to treatment at this stage. chest x ray repeated showed improvement in shadows. .

Chest x ray .

‡ IV steroids were shifted to low dose oral steroids ‡ Patient started mobilizing. walking around in wards. as saturations were maintaining around 85%. going to toilet. ‡ His O2 saturations were maintaining around 85 to 90% with 3 lits of O2 .‡ Patient shifted to wards with intermittent BIPAP.

‡ Chest X ray done after 2 weeks showed resolving changes .‡ Patient was discharged after 15 days of hospital stay with saturation maintained around 90% at room air ‡ He was discharged with oral steroids and adviced to review after 2 weeks.

Chest X ray 2 weeks after discharge .

Topic discussion BOOP Syndrome .

Bronchiolitis Obliterans Organizing Pneumonia [BOOP] .

000 admissions 6Smoking is not a risk factor .7th decades 4thNo gender predominance seen Incidence: 6-7 per 100.BOOP ‡ ‡ ‡ ‡ ‡ ‡ First described in 1901 by Lange 1985-1985-.More cases reported by Epler et al Age incidence: 4th.

Definition Inflammatory lung disease that involves both the terminal bronchioles and the alveoli Characterized by its pathologic and histologic features .

and structurally within the lung tissue. a term that is considered more general and representative of what happens clinically. However.BOOP: confusion of terms BOOP is sometimes referred to as cryptogenic organizing pneumonia. the term BOOP is specific for a lesion that occurs in the distal bronchioles and alveoli simultaneously and is a popular term used throughout the world . pathologically.

rheumatologic/connective tissue processes. immunologic disorders. drugs/toxins.Etiology Idiopathic (Cryptogenic organizing pneumonia) Secondary to infection. organ transplantation. radiation therapy Pathogenesis?? .

Types and Classification of BOOP .

Pathophysiology Inflammation in the walls of the alveoli and bronchioles and an increase in foamy. lipid-laden lipidmacrophages in the alveoli are significant and lead to accumulations of fibromyxoid connective tissue .

neutrophils/abscesses. or eosinophilic infiltration . interstitial fibrosis. vasculitis.Pathology     Proliferation of granulation tissue within small airways and alveolar ducts Chronic inflammation in alveoli Patchy peribronchial distribution Absence of granulomas. hyaline membranes. neutrophils/abscesses. vasculitis. granulomas. necrosis.

DOE. malaise. weight loss Inspiratory rales (74%) Hypoxia (>80%) . cough.Diagnosis Presentation:      Onset typically 4th or 7th decades of life Women and men affected equally Fever. fatigue.

Diagnosis Labs:    Nonspecific Leukocytosis (50%) Elevated ESR and CRP (70-80%) (70- PFTs   Mild to moderate restrictive disease DLCO reduced .

usually bilateral CT: patchy air-space consolidation. frequently peripherally distributed. ground airglass opacities.Diagnosis Imaging   CXR: diffuse alveolar opacities. usually peripherally distributed and in lower lung zones . small nodular opacities. bronchial wall thickening and dilation.

hyaline membranes. or eosinophilic infiltration . interstitial fibrosis. necrosis.Diagnosis Pathology: diagnosis of exclusion     Proliferation of granulation tissue within small airways and alveolar ducts Chronic inflammation in alveoli Patchy peribronchial distribution Absence of granulomas. neutrophils/abscesses. vasculitis.

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Treatment Prednisone 1-1.5-1mg/kg/day for 1-2 more 0.5mg/kg/day (max 1100mg/day) for 2-3 months. if improved. then slowly taper IV methylprednisolone (125-250mg q6hrs) (125for 3-5 days can be used initially for rapidly 3progressive disease . 2decrease to 0.51months.

Prognosis TwoTwo-thirds of patients completely resolve with steroid treatment OneOne-third have persistent disease Relapses are common .

2006. pericardial effusion. Katikireddy.References King.128:40132005. 2005. etal. pneumonitis. . Epler.161:158-164. and bilateral pleural effusions. T.161:1582001. Uptodateonline. Bronchiolitis Obliterans Organizing Pneumonia. ARCH INTERN MED.E. A 24-year-old woman with 24-yearbilateral pulmonary infiltrates. G. 2001. Pneumonia. Cryptogenic organizing pneumonitis.R. CHEST.128:4013-4017. Uptodateonline.

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