IMAGE OF THE WEEK

PROF.DR.G.SUNDARAMURTY’S UNIT

S.DHANRAJ MD I YR

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• 28yrs old male presented with following features– +non-productive cough– exertional dyspnea - two weeks– fever, malaise, weight loss

AUSCULTATION--- Bilateral coarse crackles and wheeze +

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FINDINGS

• Chest x ray pa view

• Rotated to left

• Penetration adequate,Taken in full inspiration

• Skin , soft tissue normal,Bony cage normal,Trachea,mediastinal shadow normal

• Both dome of diaphragm normal in contour&shape

• Card.phrenic angle obliterated by opacity4

• Bilateral Heterogenous air space opacity occupying right midzone extending to lower zone and left mid& lower zone.

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DIFFERENTIAL DIAGNOSIS USUAL INTERSTITIAL PNEUMONIA

• ACUTE INTERSTITIAL PNEUMONIA

• CHRONIC EOSINOPHILIC PNEUMONITIS

• ACUTE RESPIRATORY DISTRESS SYNDROME

• MYCOPLASMA, HIV, HSV, CMV, RUBEOLA, KLEBSIELLA, HAEMOPHILUS, LEGIONELLA, GRP. B- STREP, CRYPTOCOCCUS, NOCARDIA, PCP

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INVESTIGATIONS

• ESR--- 10/22mm

• MANTOUX---Negative

• AFB---Negative

• HIV---Non reactive

• ANA---Negative

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• Patient was started on empirical antibiotics

• SPUTUM CULTURE– Negative

• FUNGAL CULTURE—Negative

• CT SCAN was taken

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CT SCAN CHEST

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ATOLL SIGN

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FINDINGS• Peribronchial & subpleural consolidation with

irregular margins with air bronchogram• Subpleural ground glass opacities• ATOLL Sign—ring shaped opacity with

central ground glass attenuation• Interstitial thickening with ground glass

opacities noted in midlobe/irregular/suprabasal segment of right lower lobe

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• Patient did not show any improvement with antibiotics and based on ct scan findings he was started on a course of steroids for which patient responded well and lesions cleared—

• suggestive of idiopathic boop

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BOOP--INTRODUCTION

• Bronchiolitis Obliterans Organizing Pneumonia - refers to a generic term of non-specific inflammatory reaction of small airways in response to exogenous/endogenous stimuli

• Comprises two types - based on histopathology• Clinical features mimic pneumonia without

response to antibacterial therapy

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BOOP- EPIDEMIOLOGY

• Smoking is not a risk factor

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BOOP- Classification

• SECONDARY

BOOP

• IDIOPATHIC

BOOP

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SECONDARY BOOP

• Connective tissue disorders - SLE, RA, Polymyositis - Dermatomyositis, Sjogren’s syndrome, MCTD, Ulcerative Colitis, Vasculitis

• Inhaled/Systemic Toxins - gases, nicotine, cocaine, CO, nitrogen, chlorine

• Drugs - Penicillamine, Amiodarone, Gold, Bleomycin, Mitomycin-c, Methotrexate, Sulfasalazine

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SECONDARY BOOP

• Infections: – Mycoplasma, HIV, HSV, CMV, Rubeola,

Klebsiella, Hemophilus, Legionella, Grp B- Strep, Cryptococcus, Nocardia, PCP

• Pediatric – RSV, Parainfluenza, Adenovirus, Mycoplasma

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SECONDARY BOOP

• Obstructive Pneumonitis

• Hypersensitivity Pneumonitis

• Aspiration Pneumonitis

• Chronic Eosinophilic Pneumonia

• Diffuse Alveolar Damage

• Myelodysplastic Syndrome

• Hematological malignancy

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BOOP- IMAGING

Chest Xray: Patchy peripheral bilateral migratory alveolar infiltrates• 20-30% - reticular or nodular infiltrate• Pleural effusions in 30% due to secondary BOOP• CXR- can be normal in 4-10%• Cavitation & lymphadenopathy are absent• Focal consolidation is a marker for a good response to steroid

therapy•

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BOOP- IMAGING

• High Resolution CT scan of Chest: patchy consolidation, ground glass opacity, nodularity with subpleural lower lobe predeliction.

• Bronchial wall thickening and dilatation denote severe disease

• Honey combing not seen in idiopathic BOOP

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BOOP- Bronchoscopy

• Gold standard- Open lung or thoracoscopic lung biopsy for histopathology

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BOOP--Treatment

• Spontaneous recovery occurs rarely

• Antibiotic therapy for underlying infections

• Withdrawal of offending toxin/ drug

• Supportive therapy

• Steroids for idiopathic BOOP and BOOP secondary to connective tissue disorders

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BOOP-- STEROID Rx

• Idiopathic BOOP responds to steroids better than BOOP due to connective tissue disorders

• Immunosuppressive agents - cyclophosphamide, azathioprine for those who fail to respond to steroid Rx

Usual interstitial pneumonia/idiopathic pulmonary fibrosis--Massive fibrosis appearing as a honeycomb

pattern on HRCT scans and traction

bronchiectasis (lung architecture distortion)

Irregular linear infiltrates generally in lower

lung zones• Acute interstitial pneumonia or Hammond

rich syndrome--Accelerated interstitial pneumonitis with fibrosis and ground-glass attenuation ,Interlobular septal thickening

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• Chronic eosinophilic pneumonia—

Diffuse migratory, patchy alveolar infiltrates

often along the pleural edges

Ground-glass opacities• Infective pneumonias (community-acquired,

nosocomial, aspiration)--Generally, either unilateral or bilateral infiltrates. Aspiration pneumonia infiltrates common in gravity-dependent regions

• Acute respiratory distress syndrome and diffuse alveolar damage-- Focal infiltrates initially, with rapid progression to diffuse bilateral interstitial infiltrates.Alveolar concolidation often in dependent lung zones

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THANK YOU

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