Organizing pneumonia in patients with hematologic malignancies: A steroid-responsive lesion

The relationship between organising pneumonia and invasive mould disease in patients with haematologic malignancy

BACKGROUND

Organising pneumonia (OP) is reported in patients with haematologic malignancy suspected of having invasive mould disease, yet little is known about this relationship.

OBJECTIVE

To investigate molecular evidence of invasive mould pneumonia in paraffin-embedded lung tissues from histologically diagnosed OP patients with suspected invasive mould pneumonia.

PATIENTS/METHODS

Patients with haematologic malignancy suspected to have invasive pulmonary mould disease who underwent lung biopsy at a tertiary hospital, Seoul, South Korea, between 2008 and 2020, were retrospectively reviewed. To find molecular evidence of fungal infection, PCR assay was used to detect Aspergillus- and Mucorales-specific DNA within OP lung tissue sections.

RESULTS

Forty-seven patients with suspected invasive mould pneumonia underwent lung biopsy and 15 (32%) were histologically diagnosed as OP without any evidence of fungal hyphae. Of these 15 patients, 3 (20%) received allogenic haematopoietic stem cell transplantation prior to developing OP. Before biopsy, 2 and 13 patients had probably and possible invasive mould disease, respectively. The median antifungal treatment length was 81 [8-114] days, and the median steroid treatment dosage was 0.35 mg/kg/day for 36 days (methylprednisolone equivalent doses), respectively. After biopsy, three patients with possible invasive mould infection revealed probable invasive pulmonary aspergillosis. From the 15 paraffin-embedded lung tissues, 6 (40%) exhibited positive PCR assay results for detecting Aspergillus- and Mucorales-specific DNA.

CONCLUSIONS

More than one third of OP cases in patients with suspected invasive mould pneumonia exhibited molecular evidence of invasive mould infection by fungus-specific PCR in lung tissues, likely associated with concurrent or prior fungal infection.

Systematic Review of Systemic Corticosteroids for Treatment of Organizing Pneumonia

Introduction

Regardless corticosteroids are recommended for the treatment of organizing pneumonia there is limited evidence supporting this practice. Thus, we performed a systematic review of the literature on systemic corticosteroid treatment for organizing pneumonia.

Methods

A search was implemented in the PubMed database (Medline) for articles published in the last 20 years. Those studies with incomplete or insufficient data and case reports were excluded. We collected data including: demographics, clinical data, diagnostic procedures, aetiology, treatment regimen (drug, posology, duration, response) and evolution.

Results

A total of 135 publications were selected and finally 13 studies with 849 patients were included in the review: 12 retrospective observational studies and a single prospective observational study. Most of the patients were started on treatment with systemic corticosteroids - a total of 627 (30-100% depending on the series), but there was a great heterogeneity regarding drug, doses and duration. On those that started treatment, 226 (36%) presented a relapse of the disease during follow-up. Only one study provided information regarding treatment side-effects.

Conclusion

The findings of this systematic review show the low quality data supporting the use of corticosteroids for the treatment of organizing pneumonia. This highlights a need to undertake appropriately designed studies to investigate which is the most appropriate treatment regimen that trades off benefits and risks of prolonged corticosteroid administration.

Characteristics and Follow-Up of Organizing Pneumonia Associated with Haematological Malignancies

Background

Organizing pneumonia (OP) is a secondary process in many diseases. Due to its low incidence and indistinct symptoms, there is limited information on OP associated with haematological malignancies. Therefore, the aim of this study was to discuss the characteristics and prognosis of OP associated with haematological malignancies.

Methods

We observed and analysed pathologically confirmed OP cases associated with haematological malignancies in a hospital record database and excluded cases of OP with known causes, including chemotherapy, radiotherapy, targeted therapy, transplantation and infection.

Results

There were five patients with OP underlying only haematological malignancies, including one case each of the following: myelodysplastic syndrome, acute myelogenous leukaemia, multiple myeloma, aplastic anaemia, and T cell lymphoma. Radiological findings did not show a distinct pattern, and two cases mimicked pulmonary aspergillosis with ground-glass opacity (GGO). The diagnosis of OP was confirmed by minimal invasive biopsy. Although all patients developed severe cases, steroids yielded favourable outcomes.

Conclusion

This study demonstrates that haematological malignancies may be a cause of OP and that minimal invasive biopsy may be an effective and safe method to confirm the diagnosis. Although OP associated with haematological malignancies may more frequently develop into severe cases, the OP lesions were steroid-responsive during follow-up.

Systemic Pulmonary Events Associated with Myelodysplastic Syndromes: A Retrospective Multicentre Study

Although pulmonary events are considered to be frequently associated with malignant haemopathies, they have been sparsely studied in the specific context of myelodysplastic syndromes (MDS). We aimed to describe their different types, their relative proportions and their relative effects on overall survival (OS). We conducted a multicentre retrospective cohort study. Patients with MDS (diagnosed according to the 2016 WHO classification) and pulmonary events were included. The inclusion period was 1 January 2007 to 31 December 2017 and patients were monitored until August 2019. Fifty-five hospitalized patients were included in the analysis. They had 113 separate pulmonary events. Thirteen patients (23.6%) had a systemic autoimmune disease associated with MDS. Median age at diagnosis of MDS was 77 years. Median time to onset of pulmonary events was 13 months. Pulmonary events comprised: 70 infectious diseases (62%); 27 interstitial lung diseases (23.9%), including 13 non-specific interstitial pneumonias and seven secondary organizing pneumonias or respiratory bronchiolitis-interstitial lung diseases; 10 pleural effusions (8.8%), including four cases of chronic organizing pleuritis with exudative effusion; and six pulmonary hypertensions (5.3%). The median OS of the cohort was 29 months after MDS diagnosis but OS was only 10 months after a pulmonary event. The OS was similar to that of the general myelodysplastic population. However, the occurrence of a pulmonary event appeared to be either an accelerating factor of death or an indicator for the worsening of the underlying MDS in our study. More than a third of pulmonary events were non-infectious and could be systemic manifestations of MDS.

[Cryptogenic organizing pneumonia versus secondary organizing pneumonia]

Die organisierende Pneumonie (OP) beschreibt ein histologisches Muster des akuten bzw. subakuten Lungenschadens. Klinisch fallen die Patienten mit Husten, Fieber und Dyspnoe auf. Es wird zwischen der idiopathischen bzw. kryptogen organisierenden (COP) und der sekundären organisierenden Pneumonie (OP) unterschieden. Bei der COP kann weder klinisch/radiologisch noch histologisch eine Ursache bestimmt werden. Sie wird zu den interstitiellen idiopathischen Pneumonien (IIP) gezählt nach Kriterien der American Thoracic Society (ATS) und der European Respiratory Society (ERS). Bei der sekundären organisierenden Pneumonie liegt ein bekannter auslösender Mechanismus vor, wie z. B. infektiöse Erreger, bestimmte Medikamente oder auch Begleiterscheinungen anderer primär pulmonaler Erkrankungen und Erkrankungen anderer Organsysteme. Beiden Formen gemeinsam ist das histologische Bild der intraalveolären Mesenchymknospen. Diese sind Myofibroblastenproliferate, welche sich zopfartig entlang der Alveolarräume verzweigen. Sie werden in der Regel von einem bis mäßigen interstitiellen und alveolären, chronischen und makrophagenreichen Entzündungszellinfiltrat begleitet. Wichtigste Differenzialdiagnose ist die gewöhnliche interstitielle Pneumonie (UIP). Diese zeigt ebenfalls Fibroblastenproliferate, welche allerdings interstitiell liegen. Die korrekte Zuordnung einer IIP als COP mittels klinischer, radiologischer und histologischer Befunderhebung ist essenziell, da die COP im Gegensatz zur UIP sehr gut auf Kortikosteroide anspricht und somit gegenüber der UIP eine exzellente Prognose hat. Der Verlauf sekundärer organisierender Pneumonien hängt von der jeweiligen Grunderkrankung ab. Hier ist es wichtig, dass der Pathologe histologische Begleitcharakteristika einer OP korrekt identifiziert, um Hinweise auf eine mögliche Ursache geben zu können.

Organizing pneumonia associated with T-cell lymphoma

A 61-year-old male with a history of coeliac disease was diagnosed with organizing pneumonia (OP) on transbronchial and transthoracic lung biopsies. He then developed refractory coeliac disease type II and haemophagocytic lymphohistiocytosis. Nine months after his initial diagnosis of OP and after multiple biopsies of the lung, duodenum, and bone marrow, he was diagnosed with enteropathy-associated T-cell lymphoma (EATL). Although OP in patients with lymphoma is most commonly attributed to chemotherapeutic agents or bone marrow transplant, it may be seen in the absence of prior anticancer treatment. The mechanism linking OP and lymphoma is unclear but OP could represent a syndrome of T-cell dysfunction or develop as a direct reaction to malignant infiltration of the lung. In patients with atypical presentations, exclusion of an alternate diagnosis must be pursued using surgical lung biopsy, wherever possible. This is the first reported case of OP associated with EATL.

Secondary pulmonary alveolar proteinosis during corticosteroid therapy for organising pneumonia associated with myelodysplastic syndrome

Myelodysplastic syndrome (MDS) is frequently complicated by pulmonary disease. Here, we describe secondary pulmonary alveolar proteinosis (sPAP) that developed during corticosteroid therapy for organising pneumonia (OP) associated with MDS. A 75-year-old woman with MDS complained of cough for 2 weeks. Chest CT showed bilateral patchy consolidations with reversed halo sign. Bronchoalveolar lavage (BAL) examination showed remarkably increased cell density with an increased lymphocyte proportion. Abnormal radiological findings improved rapidly on administration of systemic corticosteroid under the diagnosis of OP; however, they relapsed a few weeks later. Transbronchial lung biopsy showed periodic acid-Schiff stain-positive amorphous materials. Autoantibodies against granulocyte-macrophage colony-stimulating factor (GM-CSF) in serum and BAL fluid (BALF) were both negative, while GM-CSF level in BALF was elevated. The patient was diagnosed with sPAP. When chest radiological findings show exacerbation during corticosteroid therapy for OP in a patient with MDS, physicians should consider sPAP complication as a differential diagnosis.

Pulmonary alveolar proteinosis developing during steroid treatment in a patient with organizing pneumonia in association with atypical chronic myeloid leukemia

Organizing pneumonia (OP) and pulmonary alveolar proteinosis (PAP) are rare complications in patients with hematologic disorders. We herein report a case of PAP that developed during steroid treatment for OP in a patient with atypical chronic myeloid leukemia. Physicians should pay close attention to these complications in patients with hematologic malignancies.

Azacitidine-Induced Interstitial Pneumonitis

Azacitidine is a demethylating and cytotoxic drug for the treatment of adult patients with (1) myelodysplastic syndromes, (2) chronic myelomonocytic leukemia, and (3) acute myeloid leukemia who are not eligible for induction treatment or hematopoietic stem cell transplantation. Widely described in the literature, the main adverse events are hematotoxicity, digestive toxicity, asthenia, cutaneous toxicity, and infections such as neutropenic sepsis and pneumonia. The pivotal phase III comparative and supporting studies did not point out interstitial pneumonitis as a significant adverse event. Rare clinical data from literature report interstitial lung disease secondary to azacitidine administration, which should therefore be considered as a serious potential adverse event. We, herein, report a case of an 86-year-old white woman with acute myeloid leukemia and azacitidine-induced interstitial pneumonitis.

Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients (allogeneic SCT excluded): updated guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Up to 25% of patients with profound neutropenia lasting for >10 days develop lung infiltrates, which frequently do not respond to broad-spectrum antibacterial therapy. While a causative pathogen remains undetected in the majority of cases, Aspergillus spp., Pneumocystis jirovecii, multi-resistant Gram-negative pathogens, mycobacteria or respiratory viruses may be involved. In at-risk patients who have received trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis, filamentous fungal pathogens appear to be predominant, yet commonly not proven at the time of treatment initiation. Pathogens isolated from blood cultures, bronchoalveolar lavage (BAL) or respiratory secretions are not always relevant for the etiology of pulmonary infiltrates and should therefore be interpreted critically. Laboratory tests for detecting Aspergillus galactomannan, β-D-glucan or DNA from blood, BAL or tissue samples may facilitate the diagnosis; however, most polymerase chain reaction assays are not yet standardized and validated. Apart from infectious agents, pulmonary side-effects from cytotoxic drugs, radiotherapy or pulmonary involvement by the underlying malignancy should be included into differential diagnosis and eventually be clarified by invasive diagnostic procedures. Pre-emptive treatment with mold-active systemic antifungal agents improves clinical outcome, while other microorganisms are preferably treated only when microbiologically documented. High-dose TMP/SMX is first choice for treatment of Pneumocystis pneumonia, while cytomegalovirus pneumonia is treated primarily with ganciclovir or foscarnet in most patients. In a considerable number of patients, clinical outcome may be favorable despite respiratory failure, so that intensive care should be unrestrictedly provided in patients whose prognosis is not desperate due to other reasons.

Complete resolution of steroid-resistant organizing pneumonia associated with myelodysplastic syndrome following allogeneic hematopoietic cell transplantation

Pulmonary complications in patients with hematological malignancies are often caused by infection but are sometimes associated with an underlying disease such as organizing pneumonia (OP). Here, we report a case of life-threatening steroid-resistant OP associated with myelodysplastic syndrome (MDS) and successfully performed allogeneic hematopoietic cell transplantation (HSCT). A 33-year-old female with refractory anemia with excess blasts-1 that had progressed from refractory anemia with ringed sideroblasts and concomitant Sweet’s syndrome was admitted. Multiple pulmonary infiltrates were revealed on a chest computed tomography scan, which progressively worsened even after chemotherapy and corticosteroid therapy. No evidence of infection was observed in bronchoalveolar lavage fluid. A histological examination of a transbronchial lung biopsy specimen showed lymphocyte invasion with fibrosis, indicating that the pulmonary infiltrates were OP associated with MDS. Before transplantation, she suffered from respiratory failure and required oxygen supplementation. She developed idiopathic pneumonitis syndrome on day 61 that responded well to corticosteroid therapy, and the OP pulmonary infiltrates improved gradually after HSCT, She was discharged on day 104 and is well without recurrence of OP or MDS 2 years after HSCT.

Case of polycythemia vera with unusual organizing pneumonia mimicking the clinical features of military tuberculosis and possibly caused by the involvement of neoplastic megakaryocytes

Polycythemia vera (PV) is a clonal myeloproliferative neoplasm (MPN) of hematopoietic stem cells. Although the management of MPN patients generally focuses on the prevention of thromboembolic events caused by hypercoagulability, it is true that the patients with hematological malignancy often suffer from pulmonary diseases with atypical radiological patterns. We present here a 56-year-old woman with PV harboring a JAK2(V617F) mutation that had a diffuse reticulonodular pattern on chest radiography and was initially suspected of having military tuberculosis. Pathological assessment of a video-assisted thoracoscopic surgery lung biopsy revealed that the lesions were in fact organizing pneumonia (OP). Interestingly, pulmonary extramedullary hematopoiesis with a diffuse plugging of the alveolar blood capillaries by numerous atypical megakaryocytes was also observed around the granulation components. The histological findings of our case of unusual OP suggest that local activated neoplastic megakaryocytes and platelets played an important role in the development of spreading fibrotic lesions. JAK2 mutation or the preleukemic phase of MPN may accelerate the activation of megakaryocytes and result in the proliferative process of fibrosis.

Non-infectious pulmonary complications of myelodysplastic syndromes and chronic myeloproliferative disorders

INTRODUCTION

Non-infectious pulmonary complications of myelodysplastic syndromes and chronic myeloproliferative disorders are not rare but remain little known to respiratory physicians who may be confronted with various clinical pictures corresponding to different pathophysiological causes.

BACKGROUND

The few data in the literature only relate to isolated cases or small series. The non-infectious pulmonary complications of myelodysplastic syndromes and chronic myeloproliferative disorders can be classified into several clinical entities: tumour syndrome, pulmonary fibrosis or diffuse infiltrating pneumonia, autoimmune reactions including vasculitis, Sweet syndrome, organizing pneumonia, pulmonary alveolar proteinosis, pleural effusion and pulmonary arterial hypertension. The diagnosis is provided by the histology and management of these complications depends on the underlying pathology.

VIEWPOINTS AND CONCLUSION

Myelodysplastic syndromes and myeloproliferative disorders are entities which are becoming better characterized and understood. Better knowledge of the pathophysiological mechanisms involved in these complications should improve their diagnosis and their management, which still remains complex.

What Has Been Learned from Postmortem Studies?

Infectious and noninfectious pulmonary diseases are commonly found on postmortem autopsy studies in patients with hematological malignancy. Despite the technological advances in diagnostic testing and imaging modalities, obtaining an accurate clinical diagnosis remains difficult and often not possible until autopsy. Major diagnostic discrepancies between clinical premortem diagnoses and postmortem autopsy findings have been reported in these patients. The most common missed diagnoses are due to opportunistic infections and cardiopulmonary complications. These findings underscore the importance of enhanced surveillance, monitoring and treatment of infections and cardiopulmonary disorders in these patients. Autopsies remain important in determining an accurate cause of death and for improved understanding of diagnostic deficiencies, as well as for medical education and quality assurance.

Plasma cell leukemia presenting as organizing pneumonia refractory to high-dose steroid therapy

A case of steroid-refractory organizing pneumonia (OP) as the initial presentation of plasma cell leukemia (PCL) in a patient who had no prior exposure to chemotherapy or radiation is described. Since OP is traditionally a steroid-responsive disease, this case raises the possibility of a previously unknown patient subgroup with variable disease pattern and/or behavior in patients with plasma cell neoplasm.

Organising pneumonia mimicking invasive fungal disease in patients with leukaemia

Clinical charts from 63 consecutive highly immunocompromised haematologic patients presenting with pulmonary nodular lesions on CT scan, classified as either probable or possible invasive fungal disease (IFD) according to the revised EORTC/MSG classification, were retrospectively studied. Histopathological analysis of lung tissues, available for 23 patients, demonstrated proven IFD in 17 cases (14 invasive aspergillosis and 3 invasive zygomycosis), diffuse alveolar damage in one and organising pneumonia (OP) in five cases. In the OP cases, three of which have been defined as probable IFD according to EORTC/MSG classification, extensive immunohistochemical, molecular and immunological analyses for fungi were negative. Our case descriptions extend the notion that OP may be encountered as a distinct histopathological entity in pulmonary nodular lesions in patients with leukaemia with probable/possible IFD.