Lung Pathology: Student/Resident Case Report Poster - Lung Pathology II |

A Case of Acute Fibrinous and Organizing Pneumonia FREE TO VIEW

Carlos Osorio, MD; Jose Caceres, MD; Christian Curcio, MD; Michael Silverberg, MD
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Rutgers NJMS, Bloomfield, NJ

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

Chest. 2016;150(4_S):808A. doi:10.1016/j.chest.2016.08.904
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SESSION TITLE: Student/Resident Case Report Poster - Lung Pathology II

SESSION TYPE: Student/Resident Case Report Poster

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

INTRODUCTION: Acute Fibrinous and Organizing Pneumonia (AFOP) is a rare interstitial pneumonia.

CASE PRESENTATION: A 53 year old woman with a history of hypertension and diabetes mellitus presented with 6 weeks of cough intermittently productive of clear sputum and occasional blood streaks. She reported dyspnea on exertion, subjective fevers, night sweats, weight loss, decreased appetite, and myalgias. A month prior, she was treated as an outpatient with a 2-week course of an unknown antibiotic. Initial vitals showed a pulse-ox saturation of 92% on ambient air and temperature of 103F. Physical exam revealed mild diffuse expiratory wheeze, bibasilar crackles, and a dry cough. Chest x-ray was followed by a CT scan which showed bilateral upper lobe infiltrates. She was treated with ceftriaxone and azithromycin. Cultures, labs, ANA, cANCA, pANCA were obtained and unremarkable with exception of elevated ESR and CRP. Bronchoscopy with BAL and tranbronchial biopsy were inconclusive. Wedge biopsy was obtained via VATS and showed organizing pneumonia with foci of intra-alveolar fibrin balls without evidence of granuloma, fungi, CMV, eosinophils, hyaline membranes or viral inclusions. The patient was electively intubated for the procedure, and due to continued hypoxia, and was transferred to the ICU where she remained intubated. She was unsuccessfully treated with 6 weeks of steroids alonside 2 weeks of cyclophosphamide and 3 weeks of mycophenolate. Her respiratory status continued to deteriorate and eventually led to her death after a prolonged ICU stay.

DISCUSSION: Patients commonly present with fatigue, cough, dyspnea and/or hemoptysis. On imaging, the lungs often display patchy opacities and ground glass appearance. Diagnosis requires histopathologic findings of intra-alveolar fibrin balls and organizing pneumonia. Proposed etiologies include connective tissue disease, infection, exposures, drug reactions, and autoimmune disease. Presentation varies between acute rapidly progressing disease course, and a subacute form. Acute disease and mechanical ventilation are associated with a poorer prognosis. Definite treatment has not been established, and results are variable. Corticosteroids are the most common treatment modality followed by immunosuppressive agents such as cyclophosphamide, azathioprine, and, mycophenolate mofetil.

CONCLUSIONS: AFOP is a rare pneumonia with an uncertain etiology. Though there are some case reports of favorable outcomes with corticosteroid therapy for patients with an indolent disease course, AFOP carries higher mortality when it presents acutely or when mechanical ventilation is required.

Reference #1: Kuza C, Matheos T, Kathman D, Heard SO. “Life after acute fibrinous and organizing pneumonia: a case report of a patient 30 months after diagnosis and review of the literature.” J Crit Care. 2016 Feb;31(1):255-61. doi: 10.1016/j.jcrc.2015.10.002. Epub 2015 Oct 9.

DISCLOSURE: The following authors have nothing to disclose: Carlos Osorio, Jose Caceres, Christian Curcio, Michael Silverberg

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