A Rare Case of Interstitial Pneumonia

Abstract

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 histologically characterized by intra-alveolar fibrin deposits. First described in 2002, it can be associated with conditions such as collagen vascular diseases and hypersensitivity pneumonitis.Patients present with acute to subacute non-specific symptoms of cough, dyspnea and fever;imaging findings show lobar consolidation and ground glass opacities, which are seen in other interstitial pneumonias.Given this, diagnosis of AFOP remains challenging.Timely diagnosis is crucial as acute presentation is associated with a rapidly progressive and potentially fatal course, with patients requiring ventilatory support.We report a unique case of idiopathic AFOP, diagnosed with transbronchial lung biopsy. CASE PRESENTATION: A 70 year-old incarcerated male presented with two week history of cough, dyspnea, hemoptysis, fever and night sweats.Initial assessment was significant for tachypnea (26bpm), and hypoxia (88%).Physical exam showed an ill-appearing male, with respiratory exam revealing diffuse crackles.Chest X-ray showed diffuse interstitial opacities; CT scan of the chest showed bilateral upper lung consolidations with ground glass opacities, diffuse reticulonodular opacities and mediastinal lymphadenopathy.Given his presentation, the suspicion for tuberculosis was high and the patient was placed on empiric rifampin, isoniazid, pyrazinamide, ethambutol, and broad-spectrum antibiotics.Tuberculosis treatment was discontinued on hospital day four when sputum cultures were noted to be negative for AFB.Due to respiratory deterioration, the patient underwent endobronchial ultrasound with transbronchial biopsy.Biopsy results showed acute fibrinous and organizing pneumonia.He failed post-procedure extubation and remained on ventilator support for several days. He was started on treatment for AFOP with IV methylprednisolone and transitioned to Prednisone 80mg twice daily post-extubation.No secondary cause for AFOP was identified on further evaluation. He was discharged with a two-month steroid taper and supplemental oxygen.One month post-discharge, the patient reported symptomatic improvement and chest X-ray showed resolution of bilateral interstitial opacities. Despite this, the patient has suffered several relapses of AFOP and continued to require supplemental oxygen. DISCUSSION: AFOP is a rare interstitial pneumonia with limited reports in the literature.In comparison to other interstitial pneumonias, it is associated with a higher relapse rate and longer duration of treatment.As evidenced in the present case, diagnosis requires keen suspicion given the risk for rapidly progressive respiratory compromise. CONCLUSIONS: This case highlights the importance of considering AFOP when evaluating interstitial pneumonias. Reference #1: Kuza C, Matheos T, Kathman D, et al. Journal of Critical Care. 2016;31(1):255-261. Reference #2: Beasley MB., Franks TJ, Galvin JR, et al. Arch Pathol Lab Med. 2002;126:1064-1070 DISCLOSURE: The following authors have nothing to disclose: Deepthi Sudhakar No Product/Research Disclosure Information