0
Selected Reports |

Bilateral Symmetrical Upper-Lobe Opacities*: An Unusual Presentation of Bronchiolitis Obliterans Organizing Pneumonia FREE TO VIEW

Claus Kroegel, MD, PhD, FCCP; Angelika Reiβig, MD; Ulf Hengst, MD; Bettina Mock, MD; Daniela Häfner, MD; Paul Reinhard Grahmann, MD, FCCP
Author and Funding Information

*From the Department of Pneumology, Medical Clinic IV, Friedrich-Schiller-University, Jena, Germany.

Correspondence to: Claus Kroegel, MD, PhD, FCCP, Department of Pneumology, Medical Clinic IV, Friedrich-Schiller-University, Erlanger Allee 101, 07740 Jena, Germany; e-mail: kroegel@polkim.med.uni-jena.de



Chest. 2000;118(3):863-865. doi:10.1378/chest.118.3.863
Text Size: A A A
Published online

A 45-year-old man was admitted with nonresolving fever, cough, and dyspnea 2 months after a common cold. His chest radiograph demonstrated bilateral symmetrical upper-lobe opacities reminiscent of tuberculosis. Transbronchial biopsy revealed inflammatory nonspecific alveolar lesions suggestive of bronchiolitis obliterans organizing pneumonia, which responded well clinically and radiologically to oral corticosteroids. Here, the case of a previously unreported radiographic manifestation of bronchiolitis obliterans organizing pneumonia is presented.

Figures in this Article

Bronchiolitis obliterans organizing pneumonia (BOOP), or cryptogenic organizing pneumonia, is a specific clinicopathologic syndrome characterized by a“ pneumonia-like” illness and a chronic peribronchiolar inflammation accompanied by an excessive proliferation of granulation tissue within small airways and alveolar ducts.12 The most common radiographic abnormalities are patchy airspace opacities that are often multiple and bilateral. A peripheral distribution has been noted, very similar to that considered to be “virtually pathognomic” for chronic eosinophilic pneumonia.3Solitary opacities may also occur, and bilateral interstitial infiltrates and honeycombing mimicking interstitial pneumonias may be seen.4 Herein, an unusual case of BOOP is presented in which symmetrical upper-lobe opacities were primarily suggestive of tuberculosis.

A 45-year-old, previously healthy man with a 4-week history of recurrent fever, chills, cough, and shortness of breath was admitted to our hospital in September, 1998. He had no recollection of contact with an ill person. Two months before admission, the patient had suffered from a common cold that subsided after 5 days, but the symptoms recurred a few days later. He repeatedly underwent antibiotic treatment without any apparent effect. Sputum specimens for mycobacteria and other pathogens were smear and culture negative.

On examination, the patient had a temperature of 38.7°C, a heart rate of 105 beats/min, a BP of 136/72 mm Hg, and a partial respiratory insufficiency with a Pao2 of 61 mm Hg breathing room air. There were increased breath sounds and fine crackles in both lung apexes. Examinations of the heart and the abdomen were normal. His WBC count was 10.8 × 109/L, with 72% neutrophils, 12% monocytes, and 16% lymphocytes. The sedimentation rate was 77 mm/h, and the C-reactive protein was 50 mg/L. Lung function and diffusion capacity were normal. Serology for Chlamydia pneumoniae showed an indirect immunofluorescent technique-IgG titer of 1:512, with a borderline IgA titer of 1:80 but no IgM antibodies. No HIV antibodies were detected. Repeated sputum cultures for mycobacteria and other pathogens were negative. A skin reaction to tuberculin (Mantoux test 1:100 and 1:10 tuberculin units) could not be induced.

An upright chest radiograph revealed symmetrical opacities in the two upper lobes (Fig 1 ). Chest CT showed diffuse alveolar infiltrates in both dorsal and apical segments. A trend toward honeycomb changes in the right upper lobe was also noted. Transthoracic sonography of the lung apexes revealed an irregular-shaped hypoechogenic structure with air bronchograms suggestive of an infiltrate.

Transbronchial biopsies were performed in the left upper lobe posterior subsegment, along with BAL. No pathogen was cultured in the BAL fluid. In addition, DNA analysis for mycobacteria was negative. The BAL count revealed 78.4 × 103 cells/μL with 17.9% macrophages, 39.8% lymphocytes, 38.8% neutrophils, and 3.4% eosinophils. Immunocytometry of BAL cells showed a normal CD4+/CD8+ ratio of 1.9, an increased number of total γ/δ-T lymphocytes with a dominance of Vδ2 cells, and a moderately elevated number of both CD25+ and VLA-1+ lymphocytes, while other CD4+ subtypes (CD69+, CD103+, CD45RA+, CD45R0+) were within the normal range. Transbronchial lung biopsies revealed inflammatory alveolar lesions suggestive of BOOP.

Corticosteroid treatment was commenced (1 mg/kg body weight/d), leading to a rapid clinical improvement. Three weeks after initiation of corticosteroid treatment, arterial blood gas analysis showed a Pao2 of 85 mm Hg, a Paco2 of 42 mm Hg, and a pH of 7.43. In addition, the bilateral opacities normalized over the following 8 weeks (Fig 2 ).

A flu-like prodrome that is followed within 2 months by progressive cough, mild dyspnea, and patchy alveolar infiltrate is typical of BOOP (cryptogenic organizing pneumonia).12 The disorder is characterized by small airways damage preceding the development of intraluminal plugs and fibrous tissue that extend into and fill the alveolar spaces. This process results in unilateral or bilateral patchy airspace consolidations that are commonly localized in the lung periphery. However, interstitial infiltrates, honeycombing, cavities, and pleural effusions have also been described.4 Thus, on the basis of the clinical and radiologic presentation, a number of acute or subacute inflammatory disorders may be considered in the differential diagnosis (Table 1 ).

The present patient developed bilateral opacities in the apical lung segments showing an almost symmetrical distribution during the course of a flu-like prodrome. Both the clinical symptoms and chest radiographic abnormalities were highly suggestive of tuberculosis. However, there were several findings incompatible with the diagnosis of tuberculosis. First, sputum and BAL samples were both smear and culture negative for mycobacteria. Second, the Mantoux test was negative. Third, the presence of alveolar infiltrates in the absence of endobronchial or cavernous disease on CTs argues against tuberculosis. Finally, bronchoscopic transbronchial biopsy did not show granulomatous tissue but revealed pathologic features compatible with BOOP. On the basis of these findings, the diagnosis of tuberculosis appeared to be unlikely, and oral corticosteroid therapy was begun, leading to a rapid normalization of the symptoms and to a resolution of the radiographic abnormalities. Corticosteroids were discontinued after a 12-month treatment period, and regular clinical, radiologic, and sonographic controls failed to detect a recurrence of the disease for > 1 year.

Multiple primary disorders have been associated with pulmonary reactions and pathologic features of BOOP, including respiratory infections with various bacterial and viral agents, toxic inhalants, adverse drug reactions, or collagen vascular disease. In a large proportion of cases, however, no etiology may be apparent (idiopathic BOOP). On the basis of the available serologic data, the patient may have had a respiratory infection, presumably caused by C pneumoniae, as has previously been observed.5

The present case represents an unusual radiographic manifestation of BOOP, with an almost symmetrical involvement of the two apical lung segments. Comparable abnormalities affecting both upper lobes associated with BOOP have not been reported previously. Differential diagnosis of bilateral apical consolidations is primarily suggestive of tuberculosis, which could be excluded in the patient. The case presented herein demonstrates that BOOP can both clinically and radiographically mimic tuberculosis.

Abbreviation: BOOP = bronchiolitis obliterans organizing pneumonia

This work was supported by the County of Thuringia, Germany (01KC8906/1), the BMBF (VKF, Project 2,8 - 01ZZ9602) and the DFG (Kr 956/2–1 and Br 1949/1–1).

Figure Jump LinkFigure 1. Anterioposterior (top, A) and lateral (bottom, B) radiographs of the chest on admission, revealing symmetrical opacities in the two upper lobes.Grahic Jump Location
Figure Jump LinkFigure 2. Anterioposterior radiograph of the chest after a 2-month oral treatment with corticosteroids, showing that the bilateral abnormalities have almost completely resolved.Grahic Jump Location
Table Graphic Jump Location
Table 1. Differential Diagnosis of BOOP on the Basis of Chest Radiograph Findings
Epler, GR, Colby, TV, McLoud, TC, et al (1985) Bronchiolitis obliterans organizing pneumonia.N Engl J Med312,152-158. [CrossRef] [PubMed]
 
Davidson, AG, Heard, BE, McAllister, WAC, et al Cryptogenic organizing pneumonia.Q J Med1983;52,382-393. [PubMed]
 
Bartter, T, Irwin, RS, Nash, G, et al Idiopathic bronchiolitis obliterans organizing pneumonia with peripheral infiltrates on chest roentgenogram.Arch Intern Med1989;149,273-279. [CrossRef] [PubMed]
 
Izumi, T, Kitaichi, M, Nishimura, K, et al Bronchiolitis obliterans organizing pneumonia: clinical features and differential diagnosis.Chest1992;102,715-719. [CrossRef] [PubMed]
 
Diehl, JL, Gisselbrecht, M, Meyer, G, et al Bronchiolitis obliterans organizing pneumonia associated with chlamydial infection.Eur Respir J1996;9,1320-1322. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Anterioposterior (top, A) and lateral (bottom, B) radiographs of the chest on admission, revealing symmetrical opacities in the two upper lobes.Grahic Jump Location
Figure Jump LinkFigure 2. Anterioposterior radiograph of the chest after a 2-month oral treatment with corticosteroids, showing that the bilateral abnormalities have almost completely resolved.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Differential Diagnosis of BOOP on the Basis of Chest Radiograph Findings

References

Epler, GR, Colby, TV, McLoud, TC, et al (1985) Bronchiolitis obliterans organizing pneumonia.N Engl J Med312,152-158. [CrossRef] [PubMed]
 
Davidson, AG, Heard, BE, McAllister, WAC, et al Cryptogenic organizing pneumonia.Q J Med1983;52,382-393. [PubMed]
 
Bartter, T, Irwin, RS, Nash, G, et al Idiopathic bronchiolitis obliterans organizing pneumonia with peripheral infiltrates on chest roentgenogram.Arch Intern Med1989;149,273-279. [CrossRef] [PubMed]
 
Izumi, T, Kitaichi, M, Nishimura, K, et al Bronchiolitis obliterans organizing pneumonia: clinical features and differential diagnosis.Chest1992;102,715-719. [CrossRef] [PubMed]
 
Diehl, JL, Gisselbrecht, M, Meyer, G, et al Bronchiolitis obliterans organizing pneumonia associated with chlamydial infection.Eur Respir J1996;9,1320-1322. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
Pathogenesis of Middle East respiratory syndrome coronavirus. J Pathol Published online Oct 8, 2014.;
[Therapy-resistant pneumonia]. Praxis (Bern 1994) 2014;103(21):1271-4.
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543