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Diffuse Lung Disease |

Cryptogenic Organizing Pneumonia: Between the Gold Standard Diagnosis Method or the Patient's Choice

Gilmar Zonzin, MD; Christian Boechat, MD; Gabriela de Souza, MD; Silvio Guerra; Priscila das Virgens; Jamile Abdalla; Vinícius Agostinho
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Centro Universitário de Volta Redonda, Volta Redonda, Brazil


Chest. 2014;145(3_MeetingAbstracts):217A. doi:10.1378/chest.1835801
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Abstract

SESSION TITLE: ILD Case Report Posters II

SESSION TYPE: Case Report Poster

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

INTRODUCTION: The cryptogenic organizing pneumonia (COP) is a disease characterized by impairment of alveolar ducts and terminal bronchioles with inflammation. It was previously known as bronchiolitis obliterans organizing pneumonia (BOOP). It affects men and women with the same incidence and may be secondary to infections, drugs or be a primary manifestation. This case report presents a patient with COP whose approach dispensed, in accordance with the patient, lung biopsy for diagnosis. Only clinical data,laboratorial and image exams were used to define the conduct.

CASE PRESENTATION: MCF, 55 years old, female, resident in the state of Rio de Janeiro and oligosymptomatic respiratory, exhibits extensive changes in pre-operatory chest X-ray performed during surgical risk for wrist fracture repair. She has a diagnosis of hypothyroidism and mild depression, which worsened after her father's death three monthis prior to her first symptons. It was requested a CT that showed diffuse alveolar consolidations, predominantly in iferior lingular segment and lower lobe of the left lung without pleural effusion and diffuse images of frosted glass, with slightly enlarged lymph nodes in the left pulmonary hilum. She had occasional episodes of low fever and frequent cough with yellowish expectoration with foamy aspect. Had three discrete episodes of hemoptysis. No pain reported. Was first treated empirically with antibiotics (a third generation quinolone), with no improvement. First pulmonary function tests presents FVC: 2,2/2,08L 0,69/0,65% (chg -4%), FEV1: 1,84/1,71L 0,72/0,66% (chg - 6%) , FEV1/FVC: 0,84/0,85 (chg 1%). The diffusion capacity (DLCO) was 11.9 mL/mmHg/min, 48% of predict. She was a social alcoholic and smoker(low level of smoking) and practiced physical exercises regularly for fifteen minutes per day. There was a slightly decrease in appetite. She was searched for rheumatologic diseases, with all tests negative for autoimmune disorders, including ANA, anti-RO and Waller Rose test. There were no collagen-vascular diseases. No microorganisms founded in sputum. No new medications or lung irritants identified in her clinical story. Normal glycemia and lipidogram, no anemia, no white blood cells total and differential abnormalities, normal renal and hepatic function. No changes in urinalysis and negative urine culture. Diagnostic hypothesis: Cryptogenic organizing pneumonia. It was suggested lung biopsy, which the patient refused vehemently, even by bronchoscopy. As an alternative it was stipulated therapeutic trial with 1 mg/kg/day of prednisone. She was previously tested for infectious diseases before the introduction of corticotherapy, with all tests negative. She evolved with rapid regression of all symptons and substantial improvement in the radiological (includes CT scan) and pulmonary function. The last evaluation, after 3 months of treatment exhibits: FVC: 2,45/2,53L 0,82/0,84% (chg 2%), FEV1: 2,47/2,25L 0,79/0,91% (chg 12%) , FEV1/FVC: 0,96/1,09% (chg 13%) , DLCO 27,1 mL/mmHg/min (109%). Totally assymptomatic in follow up.

DISCUSSION: Most interstitial lung diseases are indolent and can produce subacute or chronic symptoms that progress at various rates and are usually present for months to years before a diagnosis is established.The gold standard for diagnosis of COP is lung biopsy. Even transbronchial biopsy may be sufficient to establish it. Although, in elderly patients, debilitated or reluctant to biopsy, therapeutic trial with corticosteroids is acceptable, with a rigid follow up afterwards.

CONCLUSIONS: The patient improved dramatically after introduction of corticosteroid therapy, which has been decreasing gradually in posology. This case expresses an opportunity for choice by the patient, along with the physician and scientific evidence, to a personal approach for this disease.

Reference #1: Vasu TS, Cavallazzi R, Hirani A, Sharma D, Weibel SB, Kane GC. Clinical and radiologic distinctions between secondary bronchiolitis obliterans organizing pneumonia and cryptogenic organizing pneumonia. Respir Care. 2009.

Reference #2: Oymak FS, Demirbas HM, Mavili E, et al. Bronchiolitis obliterans organizing pneumonia. Clinical and roentgenological features in 26 cases. Respiration. 2005;723:254-262

Reference #3: Sveinsson OA, Isaksson HJ, Sigvaldason A, Yngvason F, Aspelund T, Gudmundsson G. Clinical features in secondary and cryptogenic organising pneumonia. Int J Tuberc Lung Dis. 2009

DISCLOSURE: The following authors have nothing to disclose: Gilmar Zonzin, Christian Boechat, Gabriela de Souza, Silvio Guerra, Priscila das Virgens, Jamile Abdalla, Vinícius Agostinho

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