Lung Pathology: Chest Tumors |

Organizing Pneumonitis Masquerading as Malignancy FREE TO VIEW

Karishma Kitchloo, MD; Pavan Kumar Gorukanti, MD; Suchit Khanijao, MBBS; Animesh Gour, MBBS; Shyam Shankar, MBBS; Omar Taha, MD; Abhinav Saxena, MBBS; Kabu Chawla, MD
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Maimonides Medical Center, Brooklyn, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A342. doi:10.1016/j.chest.2016.02.356
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SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: The initial manifestation of organizing pneumonitis (OP) may present as a focal radiological infiltrate that can mimic the appearance of a malignancy. We present an case of a patient that presented with an incidentally detected right upper lobe mass on chest imaging.

CASE PRESENTATION: A 69-year-old female with a past medical history of type 2 diabetes, hypertension, and asthma on long-standing prednisone, presented after a mechanical fall with resulting left femoral fracture. On further questioning, she also admitted to intermittent hemoptysis for three weeks. Chest x-ray showed a right upper lobe wedge-shaped opacification that was suspcious for malignancy. On further work up, computed tomographic (CT) imaging showed a 4.1-cm soft tissue attenuation with extension to the surrounding right upper lobe compatible with tumor. Lab work was significant for an AM cortisol level of 3, likely due to secondary adrenal insufficiency from long-term steroid use. CT-guided lung biopsy was performed and results showed organizing pneumonitis with chronic and focally acute inflammation, with no tumor identified. Patient's prednisone dose was increased with recommended follow up after discharge.

DISCUSSION: Organizing pneumonitis is a nonspecific histopathologic diagnosis. It can be seen as a focal radiological finding in up to 13 percent of cases1. It is often confused for malignancy, where even positive emission tomography (PET) scan can show a hypermetabolic state. OP has many possible etiologies1,2, infection was only found in 12 percent of cases1. Most cases did not have an obvious etiology and were presumed to be consistent with crypotgenic organizing pneumonia1,2. Our patient was on long-term oral steroid supplementation secondary to recurrent asthma exacerbations with recent taper to prednisone 5mg daily. On admission, was found to have a very low AM cortisol level of 3, indicative of possible secondary adrenal insufficiency. We hypothesize that this is a possible provoking factor in her developing organizing pneumonitis. Although surgery is both diagnostic and curative, pulmonary resection should be avoided, as OP has a benign course3.

CONCLUSIONS: The first manifestation of organizing pneumonitis may present with focal radiological features that are indistiguishable from malignancy. Hence, organizing pneumonitis should be considered in the differential while working up focal radiological lesions with malignant features.

Reference #1: Maldonado, Fabien, Craig E. Daniels, Elizabeth A. Hoffman, Eunhee S. Yi, and Jay H. Ryu. “Focal Organizing Pneumonia On Surgical Lung Biopsy: Causes, Clinicoradiologic Features, And Prognosis.” CHEST Journal (2007): 1579-583.

Reference #2: Cordier, Jean-François. “Organising pneumonia.” Thorax 2000; 55:4 318-328.

Reference #3: Zheng Z, Pan Y, Song C, Wei H, Wu S, Wei X, Pan T, Li J. “Focal Organizing Pneumonia Mimicking Lung Cancer: A Surgeon's View.” The American Surgeon 78.1 (2012): 133-7.

DISCLOSURE: The following authors have nothing to disclose: Karishma Kitchloo, Pavan Kumar Gorukanti, Suchit Khanijao, Animesh Gour, Shyam Shankar, Omar Taha, Abhinav Saxena, Kabu Chawla

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