"SAGE-IN-BUD": A RARE CAUSE OF TREE-IN-BUD PULMONARY INFILTRATES

Abstract

SESSION TITLE: Case Report Semifinalists 3 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Tree-in-bud infiltrates on lung imaging may be caused by a number of infectious, neoplastic, congenital, and inflammatory etiologies, however is very rarely secondary to foreign body aspiration. We present a case with an unusual cause of diffuse pulmonary tree-in-bud infiltrates. CASE PRESENTATION: A 55-year-old female with a past medical history of systemic lupus erythematosus, diffuse alveolar hemorrhage, and lupus anticoagulant syndrome presented to the emergency department with a three-day history of a dry cough. A computed tomography (CT) scan of her chest revealed diffuse, uniform tree-in-bud infiltrates, involving every lobe of her lungs. The patient had a chronic, intermittent mild, dry cough, but an otherwise unremarkable review of systems. She was a never smoker and denied any other inhalation or illicit drug use. Her previous episode of diffuse alveolar hemorrhage occurred 13 months prior to this admission and had not recurred. Laboratory evaluation including complete blood count, metabolic profile, and HIV testing was unremarkable. Her vitals were normal, as were pulmonary function tests. .Bronchoscopy revealed a macrophage-predominant bronchoalveolar lavage sample, negative cultures, no acid fast bacteria, and cytology that was negative for malignancy. Transbronchial biopsies revealed extensive small airway impaction by foreign material with associated foreign-body giant cell reaction and granulomatous inflammation. Further evaluation demonstrated a positive reaction on a Periodic Acid-Schiff modification (PAS) of the foreign material. Given the histological appearance of the foreign body and positive PAS staining, forensic pathology determined that the foreign material seen on biopsy was consistent with plant material. An extensive exposure history was obtained and it was revealed that, as a part of her Native American religion, she would semi-regularly burn a bundle of white sage (Salvia apiana) leaves. While burning the bundle of white sage she would walk around her home, spreading the smoke in a ritual termed “smudging,” admittedly inhaling the smoke and particulate matter from the burning sage. DISCUSSION: Given her inhalation exposure to particulate plant matter, a paucity of other exposures, and the findings on transbronchial biopsy we believe her tree-in-bud infiltrate was secondary to her practice of “smudging.” CONCLUSIONS: To our knowledge, this is the only reported case of inhaled plant material causing an inflammatory small airway disease and a tree-in-bud infiltrates on chest imaging. Reference #1: Causes and Imaging Patterns of Tree-in-Bud Opacities. Miller, Wallace T. et al. CHEST , Volume 144 , Issue 6 , 1883 - 1892 DISCLOSURES: No relevant relationships by Vikramjit Khangoora, source=Web Response Speaker/Speaker's Bureau relationship with Genentech Please note: $5001 - $20000 Added 03/15/2019 by Joshua Sill, source=Web Response, value=Honoraria