Diffuse Lung Disease: Student/Resident Case Report Poster - Diffuse Lung Disease |

“Muddy-Brown Bronchoalveolar Lavage” A Pathognomonic Finding in Respiratory Bronchiolitis-Associated Interstitial Lung Disease? FREE TO VIEW

David Wenger, MD; Rosemary Adamson, MD
Author and Funding Information

University of Washington, Seattle, WA

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

Chest. 2016;150(4_S):522A. doi:10.1016/j.chest.2016.08.536
Text Size: A A A
Published online

SESSION TITLE: Student/Resident Case Report Poster - Diffuse Lung Disease

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: This case highlights an important observation in Respiratory Bronchiolitis-Interstitial Lung Disease (RB-ILD). Bronchoalveolar lavage (BAL) had a distinct “muddy brown” appearance and along with cellular analysis of lavage fluid may corroborate important criteria in the diagnosis of RB-ILD.

CASE PRESENTATION: A 26 year old woman presented with decreased exercise tolerance. Respiratory decline started 7 years prior to consultation, characterized by chronic cough and a gradual decline in her 2-mile-run time despite attempts to maintain physical fitness. The patient smoked “socially” as a teenager but since age 21 had smoked 12 cigarillos daily. No other pertinent exposures were noted on review. Pulmonary function testing showed a restrictive deficit (FEV1 2.1L (66.5% predicted), FVC 2.4L (65% predicted), FEV1/FVC 0.9, TLC 3.7L (75.4% predicted)) and profound reduction in DLCO (42% predicted). Rheumatologic studies including ANA, ANCAs, and rheumatoid factor were normal. Chest radiograph was without cardio-pulmonary abnormality but high resolution computed tomography (HRCT) of the chest (image 1) revealed diffuse ground-glass nodularity in a centrilobular distribution. BAL had increased cellularity with 1500 WBCs (95% macrophages) and was notable for brownish-black lavage fluid with densely pigment laden macrophages (image 2). The patient was diagnosed with RB-ILD and intensive smoking cessation strategies were initiated.

DISCUSSION: This case highlights a distinct finding in RB-ILD, a disease limited to smokers with classic clinical hallmarks of dyspnea, cough and decreased exertional tolerance, as well as restrictive pattern on spirometry, limitations in diffusion capacity, and ground glass opacities/centrilobular nodules on HRCT. Grossly brown, “muddy” appearing BAL correlated with densely pigment laden macrophages at exceedingly high cell count. This expands on a previously published case report of RB-ILD with similar “muddy” brown BAL with comparable cell count and differential (1). Ryu et al, in the largest case series of RB-ILD to date, identified the presence of pigment laden macrophages as critical to the diagnosis of RB-ILD but further characterization of cell count and pigment density may allow for more precise diagnostic criteria (2).

CONCLUSIONS: The BAL fluid in this case of RB-ILD had a distinctive muddy brown appearance. This adds to a single case of “muddy” brown appearing BAL previously reported. Additional cases may result in better characterization of diagnostic criteria important to RB-ILD.

Reference #1: Goedicke H, et al. “Muddy” Bronchoalveolar lavage- The Woes of smoking- A case of Respiratory Bronchiolitis- Associated Intersitial Lung Disease. Am J Respir Crit Care Med 191:2015:A1497.

Reference #2: Ryu JH et al. Desquamative interstitial pneumonia and respiratory bronchiolitis-associated interstitial lung disease. Chest. 2005;127(1):178-184.

DISCLOSURE: The following authors have nothing to disclose: David Wenger, Rosemary Adamson

No Product/Research Disclosure Information




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
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543