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Cryptogenic Organizing Pneumonia in a Lung Transplant Recipient With Thoracic Ultrasonographic Correlation FREE TO VIEW

Tathagat Narula, MD; Ajit Moghekar, MD; Valeria Arrossi, MD; Charles Lane, MD; Puneet Garcha, MD; Olufemi Akindipe, MD; Marie Budev, DO; Atul Mehta, MD
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Cleveland Clinic, Cleveland, OH

Chest. 2014;145(3_MeetingAbstracts):623A. doi:10.1378/chest.1826529
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SESSION TITLE: Transplantation Case Report Poster

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Cryptogenic organizing pneumonia (COP), a rare illness in lung transplant recipients, is typically seen early in the post transplant course. Here, we report the occurrence of COP 7 years after lung transplantation and the use of bedside ultrasound as an adjunct to traditional radiological modalities for its diagnosis.

CASE PRESENTATION: 64-year-old man with cystic fibrosis status post bilateral sequential lung transplantation 7 years ago was admitted with shortness of breath and intermittent fevers of 4 weeks duration. This was accompanied by a 10% decline in FEV1 and FVC. On examination, the patient had a low grade fever (100.6 F). He was hypoxemic requiring 3lpm of oxygen to maintain saturation above 90%. Rest of the physical examination as well as routine blood work was unremarkable. Portable chest radiograph revealed non-specific reticular shadows bilaterally. Bedside ultrasound revealed diffuse B lines with reduced lung sliding suggestive of an extensive alveolar-interstitial process. CT scan of the chest showed diffuse ground glass opacification (GGO) that had progressed from patchy GGO in a bronchocentric distribution noted 3 weeks earlier. Infectious, cardiac and immune work up was negative. With minimal clinical, biochemical or radiological clues to favor any particular pathological process, bronchoscopy with bronchoalveolar lavage and transbronchial lung biopsies (TBB) was performed. Although the lavage fluid results were unrevealing, the TBB specimens revealed changes typical of organizing pneumonia without any evidence of rejection, infection or complement fixation. With no obvious etiology forthcoming, a final diagnosis of cryptogenic organizing pneumonia (COP) was made. Patient was treated with augmented doses of oral corticosteroids with marked improvement in his clinical, radiological and spirometric parameters.

DISCUSSION: Organizing pneumonia (OP) is a pathologic entity characterized by the presence of buds of granulation tissue (Masson bodies) within the lumen of small airways and extending into the alveolar ducts and alveoli. When seen in the absence of any obvious etiology, the term COP (previously known as idiopathic BOOP) is used. Epidemiologic data suggest that COP is a rare illness with an incidence of approximately 1/100,000. In lung allograft recipients, only 2 cases of COP were discovered in a review of total of 278 patients across 2 large series. Changes of OP are usually seen early in the post-transplant course and are typically associated with infections or rejection. As clinical manifestations are protean, it is the typical radiologic pattern of bilateral patchy alveolar opacities that raises suspicion for OP. Characteristically, COP responds dramatically to steroid therapy. The prognosis of COP in lung transplant recipients is significantly less favorable. Minimal available literature suggests that COP in a lung allograft recipient increases the risk of progression to chronic rejection or bronchiolitis obliterans.

CONCLUSIONS: This case highlights that COP can occur even years after lung transplantation. This is also the first report on the use of bedside lung ultrasound to define pulmonary parenchymal abnormalities in a lung transplant recipient.

Reference #1: Chaparro C, Chamberlain D, Maurer J, et al. Bronchiolitis obliterans organizing pneumonia (BOOP) in lung transplant recipients. Chest. 1996;110(5):1150-4.

Reference #2: Siddiqui MT, Garrity ER, Husain AN. Bronchiolitis obliterans organizing pneumonia-like reactions: a nonspecific response or an atypical form of rejection or infection in lung allograft recipients? Hum Pathol. 1996;27(7):714-9.

Reference #3: Lichtenstein D. Lung ultrasound in acute respiratory failure an introduction to the BLUE-protocol. Minerva Anestesiol. 2009;75(5):313-7.

DISCLOSURE: The following authors have nothing to disclose: Tathagat Narula, Ajit Moghekar, Valeria Arrossi, Charles Lane, Puneet Garcha, Olufemi Akindipe, Marie Budev, Atul Mehta

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