boop synd
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An interesting case ofAn interesting case of
unresolved pneumoniaunresolved pneumoniaModerator: Dr.Moderator: Dr. GovindappaGovindappa
Presented by: Dr.Presented by: Dr. JeevanJeevan
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ComplaintsComplaints
A 40yr old male patient, referred fromA 40yr old male patient, referred from
chikkamanguluruchikkamanguluru general hospital, presentedgeneral hospital, presented
to us with following complaints:to us with following complaints:
C/o Fever of 2 weeks durationC/o Fever of 2 weeks duration
C/o Cough with scanty sputum for 15daysC/o Cough with scanty sputum for 15days
C/oC/o HemoptysisHemoptysis for 10 daysfor 10 days
C/o breathlessness for 10 daysC/o breathlessness for 10 days
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H/o Present illnessH/o Present illness
--fever, intermittent, moderate, no chills and rigorsfever, intermittent, moderate, no chills and rigors
--cough with scanty sputum withcough with scanty sputum with hemoptysishemoptysis
--breathlessness on minimal exertionbreathlessness on minimal exertion
--nono pleuriticpleuritic/ ischemic pain/ ischemic pain--no exposure to STDSno exposure to STDS
He has received antibiotics before coming to ourHe has received antibiotics before coming to our
hospitalhospital
He is not a smoker/ alcoholicHe is not a smoker/ alcoholic
No past H/O major medical illnessNo past H/O major medical illness
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Examination findingsExamination findings
GENERAL EXAMINATION:GENERAL EXAMINATION:
Male patient, moderately built/ nourishedMale patient, moderately built/ nourished
Conscious, orientedConscious, oriented
tachypneictachypneic Vitals:Vitals:
BP: 110/70 mm of hgBP: 110/70 mm of hg
PR: 82/min, regularPR: 82/min, regular
Temp: 100 FTemp: 100 FSPo2: 82% at RASPo2: 82% at RA
91% with 491% with 4 litslits O2O2
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Examination findingsExamination findings
Resp. system: Bilateral scatteredResp. system: Bilateral scattered crepitationscrepitations
andand rhonchirhonchi
CVS: heart sounds are normal, no murmursCVS: heart sounds are normal, no murmurs
PA: soft, no tenderness/PA: soft, no tenderness/ organomegalyorganomegaly
CNS: no deficitsCNS: no deficits
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Summary of historySummary of history
Here we have a 40 yr old male patient withHere we have a 40 yr old male patient with
features of acute febrile illness withfeatures of acute febrile illness with
scattered bilateralscattered bilateral creptscrepts andand ronchironchi, a, adiagnosis of acute bronchitis was madediagnosis of acute bronchitis was made
and investigated further.and investigated further.
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InvestigationsInvestigations
CBC:CBC: HbHb-- 15.9 gm%15.9 gm%
TLCTLC-- 1000010000
DCDC--NN-- 93.1, L93.1, L--5.9, E5.9, E--0, M0, M--0.9, B0.9, B--0.10.1
ESRESR-- 3232
RBS: 265 mg%RBS: 265 mg%
Se.Se. creatininecreatinine: 1.17: 1.17
Se. electrolytes: Na+Se. electrolytes: Na+--135, K+135, K+-- 4.4,Cl4.4,Cl-- 104104 meqmeq
LFT: TBLFT: TB--0.4, DB0.4, DB--0.05, TP0.05, TP-- 6.4, Alb6.4, Alb-- 2.9,2.9,
SGOT/SGPTSGOT/SGPT-- 150/94, Alp150/94, Alp-- 115, GGT115, GGT-- 6161
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InvestigationsInvestigations
Chest XChest X--ray PA view: bilateralray PA view: bilateral
inhomogeneous opacities, suggestive ofinhomogeneous opacities, suggestive of
ARDS/ARDS/ pneumonitispneumonitis and bilateral mildand bilateral mild
pleural effusion.pleural effusion.
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Chest X rayChest X ray
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InvestigationsInvestigations
Dengue, malaria,Dengue, malaria, widalwidal: negative: negative
Sputum for AFB smear: negativeSputum for AFB smear: negative
Arterial blood gases:Arterial blood gases:pHpH-- 7.4, pCO27.4, pCO2-- 30.5, pO230.5, pO2-- 53.5, HCO353.5, HCO3-- 20.6,20.6,
O2satO2sat--87.387.3
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Hospital course: worsenedHospital course: worsened
Patient shifted to ICU on the same day eveningPatient shifted to ICU on the same day eveningas his O2 saturations were fluctuating betweenas his O2 saturations were fluctuating between75 and 85%75 and 85%
In ICU he was put on continuous BIPAP, andIn ICU he was put on continuous BIPAP, andstarted on IV antibiotics {started on IV antibiotics { MagnexMagnex,, LevodayLevoday },},antiviralsantivirals {{ T.TamifluT.Tamiflu,, VirenzaVirenza rotacapsrotacaps }}
O2 saturations were maintaining around 85 toO2 saturations were maintaining around 85 to
90% with BIPAP.90% with BIPAP. Repeat chest XRepeat chest X--ray showed persisting bilateralray showed persisting bilateral
patchy opacities.patchy opacities.
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Chest X rayChest X ray-- repeatrepeat
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InvestigationsInvestigations
As the patient is not responding to BIPAPAs the patient is not responding to BIPAP
and IV antibiotics, Venous Doppler lowerand IV antibiotics, Venous Doppler lower
limbs was done to rule out pulmonarylimbs was done to rule out pulmonary
embolism.embolism.
Report showed no evidence of DVTReport showed no evidence of DVT
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Hospital course andHospital course and
InvestigationsInvestigations After 6 days of treatment with antibiotics,After 6 days of treatment with antibiotics,
antiviralsantivirals, bronchodilators and BIPAP, bronchodilators and BIPAP
saturations didnt improved, so we considered asaturations didnt improved, so we considered a
possibility of AR
DS ?cause/
? Atypicalpossibility of AR
DS ?cause/
? Atypicalpneumoniapneumonia
Sputum AFB, sputum cultureSputum AFB, sputum culture-- negativenegative
Nasal swab cultureNasal swab culture-- negativenegative
H1N1: negativeH1N1: negative
Repeat CBC: TLCRepeat CBC: TLC-- 12800, DC12800, DC-- NN--91%, L91%, L--5.9%5.9%
Serial repeat chest X rays done doesnt showSerial repeat chest X rays done doesnt show
any improvement in shadows.any improvement in shadows.
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Chest X rayChest X ray
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InvestigationsInvestigations
Later ,HRCT chest was doneLater ,HRCT chest was done
-- Extensive patchy and confluentExtensive patchy and confluent
consolidation in bilateral lung parenchyma,consolidation in bilateral lung parenchyma,suggestive ofsuggestive of bronchiolitisbronchiolitis obliteransobliterans
organizing pneumonia.organizing pneumonia.
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CT ChestCT Chest
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CT ChestCT Chest
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Pulmonologist opinion was taken,Pulmonologist opinion was taken,
possibility of BOOP syndrome waspossibility of BOOP syndrome was
considered and started on IVconsidered and started on IV
MethylprednisoloneMethylprednisolone
Patient started responding to treatment atPatient started responding to treatment at
this stage, chest x ray repeated showedthis stage, chest x ray repeated showed
improvement in shadows.improvement in shadows.
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Chest x rayChest x ray
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Patient shifted to wards with intermittentPatient shifted to wards with intermittent
BIPAP, as saturations were maintainingBIPAP, as saturations were maintaining
around 85%.around 85%.
IV steroids were shifted to low dose oralIV steroids were shifted to low dose oral
steroidssteroids
Patient started mobilizing, going to toilet,Patient started mobilizing, going to toilet,
walking around in wards.walking around in wards.
His O2 saturations were maintainingHis O2 saturations were maintaining
around 85 to 90% with 3around 85 to 90% with 3 litslits ofO2ofO2
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Patient was discharged after 15 days ofPatient was discharged after 15 days of
hospital stay with saturation maintainedhospital stay with saturation maintained
around 90% at room airaround 90% at room air
He was discharged with oral steroids andHe was discharged with oral steroids and
advicedadviced to review after 2 weeks.to review after 2 weeks.
Chest X ray done after 2 weeks showedChest X ray done after 2 weeks showed
resolving changesresolving changes
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Chest X ray 2 weeks after dischargeChest X ray 2 weeks after discharge
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Topic discussionTopic discussion
BOOP SyndromeBOOP Syndrome
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BronchiolitisBronchiolitis ObliteransObliterans
Organizing PneumoniaOrganizing Pneumonia
[BOOP][BOOP]
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BOOPBOOP
First described in 1901 by LangeFirst described in 1901 by Lange
19851985---- More cases reported byMore cases reported by EplerEpler et alet al
Age incidence: 4thAge incidence: 4th-- 7th decades7th decades No gender predominance seenNo gender predominance seen
Incidence: 6Incidence: 6--7 per 100,000 admissions7 per 100,000 admissions
Smoking isSmoking is notnot a risk factora risk factor
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DefinitionDefinition
Inflammatory lung disease that involvesInflammatory lung disease that involves
both the terminal bronchioles and theboth the terminal bronchioles and the
alveolialveoli
Characterized by its pathologic andCharacterized by its pathologic and
histologic featureshistologic features
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BOOP: confusion of termsBOOP: confusion of terms
BOOP is sometimes referred to asBOOP is sometimes referred to ascryptogenic organizing pneumonia, a termcryptogenic organizing pneumonia, a termthat is considered more general andthat is considered more general and
representative of what happens clinically,representative of what happens clinically,pathologically, and structurally within thepathologically, and structurally within thelung tissue. However, the term BOOP islung tissue. However, the term BOOP isspecific for a lesion that occurs in thespecific for a lesion that occurs in the
distal bronchioles and alveolidistal bronchioles and alveolisimultaneously and is a popular term usedsimultaneously and is a popular term usedthroughout the worldthroughout the world
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EtiologyEtiology
Idiopathic (Cryptogenic organizingIdiopathic (Cryptogenic organizing
pneumonia)pneumonia)
Secondary to infection, drugs/toxins,Secondary to infection, drugs/toxins,rheumatologic/connective tissuerheumatologic/connective tissue
processes, immunologic disorders, organprocesses, immunologic disorders, organ
transplantation, radiation therapytransplantation, radiation therapy
Pathogenesis??Pathogenesis??
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Types and Classification of BOOPTypes and Classification of BOOP
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PathophysiologyPathophysiology
Inflammation in theInflammation in the
walls of the alveoliwalls of the alveoli
and bronchioles andand bronchioles and
an increase inan increase infoamy, lipidfoamy, lipid--ladenladen
macrophages in themacrophages in the
alveoli arealveoli are
significant and leadsignificant and leadto accumulations ofto accumulations of
fibromyxoidfibromyxoid
connective tissueconnective tissue
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PathologyPathology
ProliferationProliferation of granulation tissue within smallof granulation tissue within small
airways and alveolar ductsairways and alveolar ducts
Chronic inflammation in alveoliChronic inflammation in alveoli
PatchyPatchy peribronchialperibronchial distributiondistribution
Absence ofAbsence of granulomasgranulomas, necrosis,, necrosis,
neutrophilsneutrophils/abscesses, hyaline membranes,/abscesses, hyaline membranes,
vasculitisvasculitis, interstitial fibrosis, or, interstitial fibrosis, or eosinophiliceosinophilicinfiltrationinfiltration
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DiagnosisDiagnosis
Presentation:Presentation:
Onset typically 4Onset typically 4thth or7or7thth decades of lifedecades of life
Women and men affected equallyWomen and men affected equally
Fever, malaise, cough, fatigue, DOE, weightFever, malaise, cough, fatigue, DOE, weight
lossloss
InspiratoryInspiratory ralesrales (74%)(74%)
Hypoxia (>80%)Hypoxia (>80%)
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DiagnosisDiagnosis
Labs:Labs:
NonspecificNonspecific
Leukocytosis (50%)Leukocytosis (50%)
Elevated ESR and CRP (70Elevated ESR and CRP (70--80%)80%)
PFTsPFTs
Mild to moderate restrictive diseaseMild to moderate restrictive disease
DLCO reducedDLCO reduced
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DiagnosisDiagnosis
ImagingImaging
CXR: diffuse alveolar opacities, frequentlyCXR: diffuse alveolar opacities, frequently
peripherally distributed, usually bilateralperipherally distributed, usually bilateral
CT: patchy airCT: patchy air--space consolidation, groundspace consolidation, ground
glass opacities, small nodular opacities,glass opacities, small nodular opacities,
bronchial wall thickening and dilation, usuallybronchial wall thickening and dilation, usually
peripherally distributed and in lower lungperipherally distributed and in lower lungzoneszones
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DiagnosisDiagnosis
Pathology: diagnosis of exclusionPathology: diagnosis of exclusion
Proliferation of granulation tissue within smallProliferation of granulation tissue within small
airways and alveolar ductsairways and alveolar ducts
Chronic inflammation in alveoliChronic inflammation in alveoli
Patchy peribronchial distributionPatchy peribronchial distribution
Absence of granulomas, necrosis,Absence of granulomas, necrosis,
neutrophils/abscesses, hyaline membranes,neutrophils/abscesses, hyaline membranes,vasculitis, interstitial fibrosis, or eosinophilicvasculitis, interstitial fibrosis, or eosinophilic
infiltrationinfiltration
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TreatmentTreatment
Prednisone 1Prednisone 1--1.5mg/kg/day (max1.5mg/kg/day (max
100mg/day) for 2100mg/day) for 2--3 months, if improved,3 months, if improved,
decrease to 0.5decrease to 0.5--1mg/kg/day for 11mg/kg/day for 1--2 more2 more
months, then slowly tapermonths, then slowly taper
IV methylprednisolone (125IV methylprednisolone (125--250mg q6hrs)250mg q6hrs)
for 3for 3--5 days can be used initially for rapidly5 days can be used initially for rapidly
progressive diseaseprogressive disease
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PrognosisPrognosis
TwoTwo--thirds of patients completely resolvethirds of patients completely resolve
with steroid treatmentwith steroid treatment
One
One--third have persistent diseasethird have persistent disease
Relapses are commonRelapses are common
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ReferencesReferences
King, T.E.King, T.E. Cryptogenic organizingpneumonitisCryptogenic organizingpneumonitis..
UptodateonlineUptodateonline.. 2006.2006.
Epler, G.R.Epler, G.R. Bronchiolitis Obliterans OrganizingBronchiolitis Obliterans Organizing
PneumoniaPneumonia. ARCH INTERN MED.. ARCH INTERN MED.2001;161:1582001;161:158--164.164.
Katikireddy, etal.Katikireddy, etal. A 24A 24--yearyear--old woman withold woman with
bilateralpulmonary infiltrates, pericardialbilateralpulmonary infiltrates, pericardial
effusion, and bilateralpleural effusions.effusion, and bilateralpleural effusions. CHEST.CHEST.
2005;128:40132005;128:4013--4017.4017.