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Obstructive Lung Diseases |

An Unusual Presentation of Follicular Bronchiolitis

Dionne Morgan, MBBS; Nariman Halabi, MD; Muhammad Khan, MD; Samir Fahmy, MD
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SUNY Downstate Medical Center, Brooklyn, NY


Chest. 2013;144(4_MeetingAbstracts):662A. doi:10.1378/chest.1674885
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Abstract

SESSION TITLE: Interstitial Lung Disease Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: The cardinal CT features of follicular bronchiolitis incldue small centrilobular nodules, variably associated with peribronchial nodules and ground glass opacities. Most cases are associated with collagen vascular diseases, immunodeficiency syndromes.

CASE PRESENTATION: A 54 y woman, non-smoker, with an unspecified connective tissue disease (probable SLE) was referred to the pulmonary clinic for evaluation of lung nodules observed incidentally on abdominal CT. She had positive ANA, SSA antibody serology. At the time of evaluation she was asymptomatic, no cough or dyspnea. The physical examination was unremarkable. CXR showed bilateral reticulo-nodular densities. High-resolution CT chest showed random distribution of diffuse sub-centimeter nodules without mediastinal or hilar adenopathy. Differentials considered included military TB, sarcoidosis or hematogenous metastases. Her PPD status was negative and no AFB identified on sputum samples. Transbronchial biopsy was performed which revealed interstitial fibrosis with lymphoid follicles consistent with follicular bronchiolitis and bronchitis; and areas of capilliaritis supporting a diagnosis of SLE. Patient declined treatment as she was asymptomatic.

DISCUSSION: Primary follicular bronchiolitis is most commonly associated with collagen vascular diseases especially rheumatoid arthritis and Sjögren’s syndrome. It can be an incidental biopsy finding usually in relation to chronic bronchial inflammation such as bronchiectasis. In the setting of collagen vascular disease, it occurs primarily in adults, mean age of 44 years. Patients typically present with progressive dyspnea and cough; less often with weight loss and fever. Bilateral reticular or reticulonodular infiltrates are seen on CXR. Key HRCT findings are bilateral 1-3mm nodules in a centrilobular or peribronchial distribution. Tree-in- bud pattern may be present. Less common findings include bronchial dilatation and mild interlobular septal thickening as well as ground-glass opacities. Random nodular pattern is highly unusual. Follicular bronchiolitis represents polyclonal lymphoid hyperplasia of bronchus-associated lymphoid tissue (BALT) secondary to antigenic stimulation. Hyperplastic lymphoid follicles with reactive germinal centers distributed along bronchioles and, less commonly along the bronchi are the characteristic histology features. Treatment regimes are often steroid based and directed at the underlying disease. The overall prognosis is usually favorable.

CONCLUSIONS: Follicular bronchiolitis with a random nodular pattern on HRCT in an asymptomatic patient is a very uncommon presentation.

Reference #1: Pipavath SJ et al. Radiologic and Pathologic Features of Bronchiolitis AJR 2005;185:354-363

Reference #2: Travis W D. Non-neoplastic pulmonary lymphoid lesions Thorax 2001; 56:964-971

Reference #3: Hare S et al. The radiological spectrum of pulmonary lymphoproliferative disease Br J Radiol. 2012;85(1015):848-64

DISCLOSURE: The following authors have nothing to disclose: Dionne Morgan, Nariman Halabi, Muhammad Khan, Samir Fahmy

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