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Feng SL, Li JY, Dong CL. Primary biliary cholangitis presenting with granulomatous lung disease misdiagnosed as lung cancer: A case report. World J Clin Cases 2024; 12:354-360. [PMID: 38313637 PMCID: PMC10835678 DOI: 10.12998/wjcc.v12.i2.354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/06/2023] [Accepted: 12/25/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND There are few cases of pulmonary granulomatous changes secondary to primary biliary cirrhosis (PBC). No case of granulomatous lung disease secondary to PBC misdiagnosed as lung cancer had been reported. CASE SUMMARY A middle-aged woman presented with lung nodules and was misdiagnosed with lung cancer by positron emission tomography/computed tomography. She underwent left lobectomy, and the pathology of the nodules showed granulomatous inflammation, which was then treated with antibiotics. However, a new nodule appeared. Further investigation with lung biopsy and liver serology led to the diagnosis of PBC, and chest computed tomography indicated significant reduction in the pulmonary nodule by treatment with methylprednisolone and ursodeoxycholic acid. CONCLUSION Diagnosis of pulmonary nodules requires integrating various clinical data to avoid unnecessary pulmonary lobectomy.
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Affiliation(s)
- Shan-Li Feng
- Department of Respiratory and Critical Care Medicine, The Second Hospital of Jilin University, Changchun 130041, Jilin Province, China
| | - Jun-Yao Li
- Department of Respiratory and Critical Care Medicine, The Second Hospital of Jilin University, Changchun 130041, Jilin Province, China
| | - Chun-Ling Dong
- Department of Respiratory and Critical Care Medicine, The Second Hospital of Jilin University, Changchun 130041, Jilin Province, China
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2
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Kalashnikov M, Akulkina L, Brovko M, Sholomova V, Yanakaeva A, Abdurakhmanov D, Moiseev S. Interstitial Lung Disease in Primary Biliary Cholangitis: A Cohort Prospective Study. Life (Basel) 2023; 13:life13020416. [PMID: 36836775 PMCID: PMC9962158 DOI: 10.3390/life13020416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Interstitial lung disease (ILD) has been recognized as an extrahepatic manifestation ofprimary biliary cholangitis (PBC), althoughlimited data are available on its prevalence and clinical significance. Therefore, we evaluated the occurrence and clinical features of ILD in a cohort of PBC patients. Ninety-three individuals without concomitant rheumatic diseases were enrolled in our prospective cohort study. All patients underwent chest high-resolution computed tomography (HRCT). Liver-related and lung-related survival wereassessed. A lung-related outcome was defined as death from ILD complications; a liver-related outcome was defined as liver transplantation or death from liver cirrhosis complications. HRCT findings suggestive ofILD were detected in 38 patients (40.9%). A sarcoid-like pattern of PBC-associated ILD was the most frequent, followed by subclinical ILD and organizing pneumonia. Patients with ILD were less likely to have liver cirrhosis and liver-related symptoms and presented with higher serum immunoglobulin M(IgM) and M2 subtype antimitochondrial antibodies (AMA-M2) positivity rates. In a multivariate analysis, the absence of liver disease symptoms at the disease presentation (OR 11.509; 95% CI 1.210-109.421; p = 0.033), the presence of hepatic non-necrotizing epithelioid cell granulomas (OR 17.754; 95% CI 1.805-174.631; p = 0.014), higher serum IgM (OR 1.535; 95% CI 1.067-2.208; p = 0.020) and higher blood leukocyte count (OR 2.356; 95% CI 1.170-4.747; p = 0.016) were independent risk factors associated with ILD in PBC. More than a third of patients with ILD showed no respiratory symptoms, and only one ILD-related death occurred during a follow-up of 29.0 months (IQR 11.5; 38.0). Patients with ILD had better liver transplant-free survival.ILD in PBC had a benign course and was associated with a lower liver disease severity. PBC-associated ILD should be included in a list of differential diagnoses of ILD.
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Affiliation(s)
- Michail Kalashnikov
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, 11 Rossolimo Str., Build. 5, Moscow 119435, Russia
- Hepatology Department, Vladimirsky Moscow Regional Research and Clinical Institute, 61/2 Shchepkina Str., Moscow 129110, Russia
- Correspondence: ; Tel.: +7-499-450-88-89
| | - Larisa Akulkina
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, 11 Rossolimo Str., Build. 5, Moscow 119435, Russia
| | - Michail Brovko
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, 11 Rossolimo Str., Build. 5, Moscow 119435, Russia
| | - Viktoria Sholomova
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, 11 Rossolimo Str., Build. 5, Moscow 119435, Russia
| | - Alisa Yanakaeva
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, 11 Rossolimo Str., Build. 5, Moscow 119435, Russia
| | - Dzhamal Abdurakhmanov
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, 11 Rossolimo Str., Build. 5, Moscow 119435, Russia
| | - Sergey Moiseev
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, 11 Rossolimo Str., Build. 5, Moscow 119435, Russia
- Faculty of Fundamental Medicine, Lomonosov Moscow State University, 27 Lomonosovsky Avenue, Build. 1, Moscow 119991, Russia
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3
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Lee HE, Churg A, Ryu JH, Bilawich AM, Larsen BT, Tazelaar HD, Yi ES. Histopathologic findings in lung biopsies from patients with primary biliary cholangitis. Hum Pathol 2018; 82:177-186. [PMID: 30067952 DOI: 10.1016/j.humpath.2018.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/05/2018] [Accepted: 07/19/2018] [Indexed: 11/26/2022]
Abstract
Primary biliary cholangitis (PBC) is a progressive autoimmune disease of the liver causing destruction of intrahepatic bile ducts, associated with lymphocytic and granulomatous inflammation. PBC has been associated with many extrahepatic manifestations including interstitial lung disease. However, comprehensive pulmonary histopathology in PBC has not been well documented. Sixteen PBC patients who underwent lung biopsies were identified from surgical pathology files in three institutions. Histopathologic review was performed. Patient age ranged 41 to 79 years (median 55 years) and 15 patients (94%) were women. Specimens consisted of lobectomy (n = 1), surgical biopsies (n = 12), transthoracic needle biopsy (n = 1) and transbronchial biopsy (n = 2). Fifteen of 16 (94%) cases showed lymphocytic inflammation, mainly localized to peribronchiolar stroma and alveolar septa. Thirteen (81%) cases revealed non-necrotizing granulomas, most of which were poorly formed, reminiscent of those seen in liver biopsies from PBC patients. Six cases also showed eosinophilic infiltrates. Organizing pneumonia was seen in 7 cases. Four cases showed diffuse interstitial fibrosis with nonspecific interstitial pneumonia and usual interstitial pneumonia patterns. One patient underwent lobectomy for a mass lesion and was diagnosed with light chain deposition disease with underlying κ-restricted extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue. In summary, PBC-associated histopathologic changes in the lung include lymphocytic inflammation predominantly around small airways and non-necrotizing granulomas in multiple compartments of lung tissue, which parallel PBC-associated histopathology in liver biopsies, often associated with other common patterns of diffuse lung disease.
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Affiliation(s)
- Hee Eun Lee
- Division of Anatomic Pathology, Mayo Clinic, Rochester, 55905 MN
| | - Andrew Churg
- Department of Pathology, University of British Columbia, Canada, V6T 2B5
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, 55905 MN
| | | | - Brandon T Larsen
- Division of Anatomic Pathology, Mayo Clinic, Scottsdale, 85259 AZ
| | - Henry D Tazelaar
- Division of Anatomic Pathology, Mayo Clinic, Scottsdale, 85259 AZ
| | - Eunhee S Yi
- Division of Anatomic Pathology, Mayo Clinic, Rochester, 55905 MN.
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4
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Koksal D, Koksal AS, Gurakar A. Pulmonary Manifestations among Patients with Primary Biliary Cirrhosis. J Clin Transl Hepatol 2016; 4:258-262. [PMID: 27777894 PMCID: PMC5075009 DOI: 10.14218/jcth.2016.00024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 07/30/2016] [Accepted: 07/31/2016] [Indexed: 12/28/2022] Open
Abstract
Primary biliary cirrhosis (PBC) is a chronic progressive cholestatic liver disease caused by diffuse inflammation, destruction and fibrosis of the intrahepatic bile ducts, ultimately leading to cirrhosis, portal hypertension and liver failure. The pathogenesis of PBC is incompletely understood, but current data suggest roles for genetic susceptibility and environmental factors. PBC is often thought of as an organ-specific autoimmune disease, which mainly targets the liver; however, lung tissue is also a site for autoimmune involvement of PBC. The pulmonary manifestations of PBC include abnormalities in gas transfer and pulmonary function, subclinical alveolitis, interstitial lung disease, granulomatous lung disease, airway disease, pulmonary hypertension, pulmonary hemorrhage and pleural effusion.
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Affiliation(s)
- Deniz Koksal
- Department of Chest Diseases, Hacettepe University School of Medicine, Ankara, Turkey
- *Correspondence to: Deniz Koksal, Department of Chest Diseases, Hacettepe University School of Medicine, Sihhiye Altindag, Ankara 06100, Turkey. Tel: +90-532-4653980, Fax: +90-312-3100809, E-mail:
| | - Aydin Seref Koksal
- Department of Gastroenterology, Sakarya University School of Medicine, Sakarya, Turkey
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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5
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Chen CT, Tseng YC, Yang CW, Lin HH, Chen PJ, Huang TY, Shih YL, Chang WK, Hsieh TY, Chu HC. Increased Risks of Spontaneous Bacterial Peritonitis and Interstitial Lung Disease in Primary Biliary Cirrhosis Patients With Concomitant Sjögren Syndrome. Medicine (Baltimore) 2016; 95:e2537. [PMID: 26765478 PMCID: PMC4718304 DOI: 10.1097/md.0000000000002537] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 11/25/2015] [Accepted: 12/21/2015] [Indexed: 12/11/2022] Open
Abstract
The incidence of Sjögren syndrome (SS) in primary biliary cirrhosis (PBC) patients is high. The influence of SS on the clinical outcomes of PBC patients, however, remains unclear. Our study retrospectively collected data on PBC-only patients and PBC patients with concomitant SS (PBC-SS) to compare the clinical differences of long-term outcomes between them.A total of 183 patients were diagnosed with PBC from January 1999 to December 2014 at our hospital. Of these, the authors excluded patients with diabetes, hypertension, advanced liver cirrhosis at initial diagnosis of PBC (Child-Turcotte-Pugh classification score of ≥7) and other liver diseases (ie, alcoholic liver disease, alpha-antitrypsin deficiency, viral hepatitis, and primary sclerosing cholangitis), and autoimmune diseases such as systemic lupus erythematosus and rheumatoid arthritis. Of the remaining 125 patients, 77 (61.6%) were PBC-only and 48 (38.4%) were PBC-SS patients.The mean follow-up duration was 8.76 years. During the observation period, the incidence of interstitial lung disease was higher in the PBC-SS group than in the PBC-only group (P = 0.005). The occurrence of spontaneous bacterial peritonitis was significantly different in PBC-SS patients than in PBC-only patients (P = 0.002). The overall survival was lower in PBC-SS patients than in PBC-only patients (P = 0.033). Although the incidence of hepatocellular carcinoma, end-stage renal disease, variceal bleeding, and hypothyroidism were all higher in the PBC-SS group than in the PBC-only group, the differences were not significant.Our study suggests that PBC-SS patients have a higher risk of developing interstitial lung disease and spontaneous bacterial peritonitis and have a poor prognosis. Aggressive surveillance of thyroid and pulmonary functions should therefore be performed in these patients.
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Affiliation(s)
- Chun-Ting Chen
- From the Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China (C-TC, Y-CT, C-WY, H-HL, P-JC, T-YH, Y-LS, W-KC, T-YH); and Division of Gastroenterology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan, Republic of China (H-CC)
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6
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Spagnolo P, Zeuzem S, Richeldi L, du Bois RM. The complex interrelationships between chronic lung and liver disease: a review. J Viral Hepat 2010; 17:381-90. [PMID: 20384964 DOI: 10.1111/j.1365-2893.2010.01307.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Lung complications may occur as a result of hepatic disease from any cause and represent a highly heterogeneous group of conditions. Early recognition of such complications may be challenging but is crucial both in forming a meaningful differential diagnosis and in avoiding severe sequelae and irreversible damage. Although a number of different pathogenetic mechanisms are likely to be involved, chronic liver dysfunction may cause pulmonary manifestations because of alterations in the production or clearance of circulating cytokines and other mediators. This is likely to be the case in hepatopulmonary syndrome, portopulmonary hypertension and primary biliary cirrhosis, although their pathogenesis remains largely speculative. Moreover, the severity of lung manifestations may or may not correspond to that of liver impairment, making disease outcome often unpredictable. Congenital and inflammatory disorders, however, may primarily affect both the liver and lung. Apart from specific diseases, a number of medications can also result in pulmonary and hepatic toxic effects. This is particularly important with cytokine therapy - used to treat viral hepatitis, among other diseases - because treatment consists of drug discontinuation, which, in turn, may cause reactivation or progression of the underlying disease that the drug was used for. This review summarizes salient diagnostic and therapeutic aspects of these often misdiagnosed conditions and highlights, based on the most recent literature, the need for early referral of such patients to centres with specific expertise in the field. In fact, a multidisciplinary approach involving pulmonologists, hepatologists and, in particularly severe cases, transplant surgeons has been already proven successful.
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Affiliation(s)
- P Spagnolo
- Center for Rare Lung Diseases, Department of Oncology, Haematology, and Respiratory Diseases, University of Modena and Reggio Emilia, Modena, Italy.
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7
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Primary biliary cirrhosis complicated with interstitial lung disease: a prospective study in 178 patients. J Clin Gastroenterol 2009; 43:676-9. [PMID: 19247207 DOI: 10.1097/mcg.0b013e31818aa11e] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To analyze the clinical features and prognosis of patients with primary biliary cirrhosis (PBC) complicated with interstitial lung disease (ILD). METHODS One hundred and seventy-eight consecutive PBC patients, who were admitted to Peking Union Medical College Hospital from January 2001 to March 2007, were included in this prospective study. A structured interview, systemic rheumatologic examination, laboratory tests (including autoantibodies), and high resolution computed tomography were conducted for each patient and compared between patients with and without ILD. RESULTS Twenty-eight (15.7%) PBC patients had ILD, and 53.6% of them had respiratory symptoms including dyspnea and cough, 88.2% showed diffusing and restrictive ventilation impairment on pulmonary function test. PBC patients with ILD were older and had higher erythrocyte sedimentation rate levels than those without ILD, P<0.05. There was no significant difference in liver biochemical parameters, positive rates of antinuclear antibodies, antimitochondrial antibodies (AMA), AMA-M2, anticentromere antibodies, anticardiolipin antibodies, and Mayo risk score between the 2 groups, P>0.05. Logistic regression analysis found that Raynaud phenomenon and association with other connective tissue diseases (CTDs) were risk factors for PBC patients to develop ILD (P=0.04, odds ratio=3.12 and P=0.01, odds ratio=3.18, respectively), though 42.9% of ILD-PBC patients did not have other CTDs. CONCLUSIONS ILD is a common and clinically significant complication of PBC. PBC patients who have Raynaud phenomenon and other CTDs are more likely to develop ILD.
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8
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Shen M, Zhang F, Zhang X. Pulmonary hypertension in primary biliary cirrhosis: a prospective study in 178 patients. Scand J Gastroenterol 2009; 44:219-23. [PMID: 18821172 DOI: 10.1080/00365520802400883] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
UNLABELLED OBJECTIVE. To analyze the incidence, clinical features, and prognosis of patients with primary biliary cirrhosis (PBC) complicated by pulmonary hypertension (PH). MATERIAL AND METHODS A total of 178 consecutive PBC patients, who were admitted to Peking Union Medical College Hospital from January 2001 to March 2007, were included in this prospective study. A structured interview, systemic rheumatological examination, laboratory tests (including autoantibodies), and Doppler echocardiography were conducted for each patient and compared between patients with and without PH. RESULTS Twenty-one PBC patients (11.8%) had PH. Among them, four patients (19.0%) had moderate to severe PH, and one patient died of right heart failure instead of liver failure. The incidences of Raynaud's phenomenon, interstitial lung disease, Sjögren's syndrome, and portal hypertension, the proportion of patients with a positive anti-SSA, the level of serum IgA, as well as the Mayo risk score in the PH-PBC patients were significantly higher than in the non-PH-PBC group (p = 0.02, 0.001, 0.02, 0.03, 0.006, 0.04 and 0.02, respectively). CONCLUSIONS PH, including moderate to severe PH, is not a rare complication of PBC. This complication is closely associated with portal hypertension and immunological dysregulation and indicates a poor prognosis.
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Affiliation(s)
- Min Shen
- Department of Rheumatology and Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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9
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Kishor S, Turner ML, Borg BB, Kleiner DE, Cowen EW. Cutaneous sarcoidosis and primary biliary cirrhosis: A chance association or related diseases? J Am Acad Dermatol 2008; 58:326-35. [PMID: 18222332 DOI: 10.1016/j.jaad.2007.07.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Revised: 07/02/2007] [Accepted: 07/24/2007] [Indexed: 12/26/2022]
Abstract
Sarcoidosis and primary biliary cirrhosis (PBC) are thought to be two distinct disorders of unknown origin. However, both are characterized by hepatic granuloma formation and may also manifest cutaneous granulomatous inflammation. In this report, we describe two cases of cutaneous sarcoidosis occurring in the setting of PBC and review 7 additional cases from the literature of granulomatous skin disease associated with PBC. Although the pathogenesis of both sarcoidosis and PBC remains elusive, the simultaneous occurrence of these uncommon diseases suggests a common pathway may contribute to granuloma formation in both disorders.
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Affiliation(s)
- Sowmya Kishor
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, Virginia, USA
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10
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Tomashefski JF, Cagle PT, Farver CF, Fraire AE. Collagen Vascular Diseases and Disorders of Connective Tissue. DAIL AND HAMMAR’S PULMONARY PATHOLOGY 2008. [PMCID: PMC7120184 DOI: 10.1007/978-0-387-68792-6_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The collagen vascular diseases, also referred to as connective tissue diseases, are a diverse group of systemic inflammatory disorders thought to be immunologically mediated. The concept of collagen vascular disease began to take shape in the 1930s, when it was recognized that rheumatic fever and rheumatoid arthritis can affect connective tissues throughout the body.1,2 During the following decade, as conditions such as systemic lupus erythematosus (SLE) and scleroderma came to be viewed as systemic diseases of connective tissue, the terms diffuse connective disease and diffuse collagen disease were proposed.3,4 During the same period, the designation of diffuse vascular disease was proposed for diseases such as scleroderma, polymyositis, SLE, and polyarteritis nodosa, which featured widespread vascular involvement.5 With the realization that many of these entities can exhibit both systemic connective tissue manifestations and vascular abnormalities, the unifying designation of collagen vascular disease was introduced.6
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Affiliation(s)
- Joseph F. Tomashefski
- grid.67105.350000000121643847Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH USA ,grid.411931.f0000000100354528Department of Pathology, MetroHealth Medical Center, Cleveland, OH USA
| | - Philip T. Cagle
- grid.5386.8000000041936877XDepartment of Pathology, Weill Medical College of Cornell University, New York, NY ,grid.63368.380000000404450041Pulmonary Pathology, Department of Pathology, The Methodist Hospital, Houston, TX USA
| | - Carol F. Farver
- grid.239578.20000000106754725Pulmonary Pathology, Department of Anatomic Pathology, The Cleveland Clinic Foundation, Cleveland, OH USA
| | - Armando E. Fraire
- grid.168645.80000000107420364Department of Pathology, University of Massachusetts Medical School, Worcester, MA USA
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Gur C, Lalazar G, Doviner V, Fridlender ZG, Molcho V, Abu-Much S, Shalit M, Elinav E. Late-onset sarcoidosis after liver transplantation for primary biliary cirrhosis. J Clin Gastroenterol 2007; 41:329-32. [PMID: 17426476 DOI: 10.1097/01.mcg.0000212653.51397.f6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Primary biliary cirrhosis (PBC) and systemic sarcoidosis are granulomatous diseases of unknown etiology whose hepatic manifestations may infrequently be imitative of one another. Described herein is the first reported case in the medical literature of systemic sarcoidosis developing after liver transplantation for PBC. The presented patient, who suffered from typical clinical, laboratory, and pathologic manifestations of PBC, developed decompensated liver cirrhosis within a course of 8 years, necessitating orthotopic liver transplantation. A year and a half after transplantation, the patient developed diffuse, biopsy-proven, dermatologic and pulmonary manifestations of systemic sarcoidosis, which promptly responded to corticosteroid treatment. In retrospect, the patient's longstanding liver disease was probably caused by an unrecognizable, isolated hepatic form of sarcoidosis or an overlap between PBC and sarcoidosis. This patient illustrates the complexity that may be rarely encountered in differentiating between PBC and hepatic sarcoidosis. Discussed are the clinical, laboratory, and pathologic overlaps between hepatic sarcoidosis and PBC, and clues that may aid in the diagnosis and differentiation between the 2 disorders. Hepatologists and liver transplantation specialists should be aware of the rare possibility of hepatic sarcoidosis imitating PBC, and exacerbating systemically after liver transplantation.
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Affiliation(s)
- Chamutal Gur
- Departments of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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12
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13
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Abstract
Hepatopulmonary syndrome is the most widely recognized of the processes associated with end-stage liver disease. Chronic liver dysfunction is associated with pulmonary manifestations due to alterations in the production or clearance of circulating cytokines and other mediators. Hepatopulmonary syndrome results in hypoxemia due to pulmonary vasodilatation with significant arteriovenous shunting and ventilation-perfusion mismatch. Hepatic hydrothorax may develop in patients with cirrhosis and ascites. Rarely, pulmonary hypertension occurs in the setting of portal hypertension. A second group of disorders may primarily affect the lungs and liver (the hepatopulmonary axis). Among these are the congenital conditions alpha(1)-antitrypsin deficiency and cystic fibrosis. Autoimmune liver disease may be associated with lymphocytic interstitial pneumonitis, fibrosing alveolitis, intrapulmonary granulomas, and bronchiolitis obliterans with organizing pneumonia. Sarcoidosis affects the lung and liver in up to 70% of patients. Medications such as amiodarone can result in a characteristic radiologic appearance of pulmonary and hepatic toxic effects. Knowledge of these associations will assist the radiologist in forming a meaningful differential diagnosis and may influence treatment decisions.
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Affiliation(s)
- C A Meyer
- Departments of Radiology and Medicine , University of Cincinnati, 234 Goodman St, ML 0742, Cincinnati, OH 45219-2316, USA.
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14
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15
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Strobel ES, Bonnet RB, Werner P, Schaefer HE, Peter HH. Bronchiolitis obliterans organising pneumonia and primary biliary cirrhosis-like lung involvement in a patient with primary biliary cirrhosis. Clin Rheumatol 1998; 17:246-9. [PMID: 9694063 DOI: 10.1007/bf01451058] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A 55-year-old woman with a 6-year history of primary biliary cirrhosis presented with an acute onset of fever, dyspnoea, crackles over both lower lung fields, and diffuse interstitial and bibasilar patchy pulmonary opacities. After exclusion of an infectious aetiology, an open lung biopsy was performed which revealed two histopathological features: (1) bronchiolitis obliterans organising pneumonia and (2) lympho-histiocytic interstitial pneumonitis and destructive bronchiolitis. Treatment response to corticosteroids and azathioprine followed a bimodal pattern with immediate resolution of her initial presenting symptoms and late resolution of residual gas exchange defects.
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Affiliation(s)
- E S Strobel
- Department of Medicine, Klinikum der Albert-Ludwigs-Universität Freiburg, Germany
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16
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 14-1998. A 49-year-old woman with primary biliary cirrhosis, pulmonary opacities, and a pleural effusion. N Engl J Med 1998; 338:1293-301. [PMID: 9565488 DOI: 10.1056/nejm199804303381809] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Sarcoidosis is a chronic disorder of unknown aetiology which causes tissue injury and granuloma formation in many organs. Although over 80% of cases have intrathoracic disease at presentation, pleural sarcoidosis remains an unusual manifestation. A case of sarcoidosis presenting with a discrete pleural mass is reported.
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Affiliation(s)
- E Loughney
- Department of Respiratory Medicine, Freeman Hospital, Newcastle upon Tyne, UK
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18
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Abstract
In a small number of cases the co-existence of primary biliary cirrhosis and sarcoidosis is assumed from clinical serological and histological findings. A case of sarcoidosis is reported in which the M2 antibody, a highly specific marker for primary biliary cirrhosis, was detected. The patient also developed a severe myositis and a possible overlap syndrome is discussed.
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Affiliation(s)
- P Hughes
- Department of Respiratory Medicine, Freedom Fields Hospital, Plymouth, Devon, UK
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19
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Abstract
The preoperative pulmonary evaluation of organ transplant candidates involves the diagnosis of unexplained pulmonary infiltrates or symptoms, interpretation of pulmonary function abnormalities, and an assessment of surgical risk. Pretransplant pulmonary considerations in patients with end-stage hepatic diseases relate primarily to hypoxemia from poorly understood intrapulmonary vascular dilatations, mechanical dysfunction, and states of increased extravascular lung water. Except in severe cases, however, these generally do not prohibit liver transplantation, and even are likely to improve after transplant surgery. Early postoperative complications may be categorized as those expected from extensive intra-abdominal surgery that requires significant volume resuscitation, which typically are managed in the usual manner for those clinical situations. As immunosuppression begins to have an effect, the LTx recipient becomes susceptible to the same opportunistic infectious organisms (with their frequent pulmonary involvement) that cause significant morbidity and mortality in recipients of other solid organ transplants. Because many of the immunosuppressive agents also are the same, noninfectious side effects such as pulmonary edema and malignancy also are similar. As with all immunocompromised patients, prophylaxis, when possible, persistent infection surveillance, and an aggressive diagnostic and therapeutic approach help decrease the impact of pulmonary dysfunction in LTx recipients.
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Affiliation(s)
- J D O'Brien
- Department of Internal Medicine, Barnes Hospital, St. Louis, Missouri, USA
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Krowka MJ. Recent pulmonary observations in alpha 1-antitrypsin deficiency, primary biliary cirrhosis, chronic hepatitis C, and other hepatic problems. Clin Chest Med 1996; 17:67-82. [PMID: 8665791 DOI: 10.1016/s0272-5231(05)70299-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Patients with metabolic, immunologic, viral, and other types of hepatic disorders can have a spectrum of complicating pulmonary abnormalities. The natural history of these associations is poorly understood. Significant reversibility in hepatic and pulmonary dysfunction, however, has been well documented in the era of organ transplantation. The continued relationship among pulmonologists, hepatologists, and transplant surgeons hopefully will provide enlightening data on these interesting clinical associations, their natural histories, and their response to evolving therapeutic approaches.
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Affiliation(s)
- M J Krowka
- Mayo Medical School, Mayo Clinic Jacksonville, Florida, USA
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21
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Shiomi S, Kuroki T, Fujimoto S, Yamaoka M, Sakaguchi H, Takeda T, Nishiguchi S, Nakajima S, Kobayashi K, Ochi H. Primary biliary cirrhosis complicated by severe hypoxemia. J Gastroenterol 1995; 30:790-4. [PMID: 8963401 DOI: 10.1007/bf02349650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The case reported here is of a 61-year-old woman diagnosed with hepatopulmonary syndrome. She had had severe hypoxemia for 5 years. In room air, her arterial oxygen tension was low, and although we anticipated that treatment with oxygen would increase it, the treatment failed to do so. Pulmonary perfusion imaging with Tc-99m-labelled macroaggregated albumin showed an arterio-venous shunt in the lungs. Blood tests and liver scanning with Tc-99m-labelled galactosyl human serum albumin showed abnormalities of liver function, and per-rectal portal scintigraphy with Tc-99m pertechnetate showed severe portal hypertension. Inspection of a biopsy specimen taken under ultrasonographic guidance showed primary biliary cirrhosis of Scheuer stage I. The causes of hepatopulmonary syndrome are unknown, but seem to include a decrease in hepatic functional reserve, portal hypertension, or other factors. The development of hepatopulmonary syndrome due to portal hypertension in this patient is of interest.
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Affiliation(s)
- S Shiomi
- Third Department of Internal Medicine, Osaka City University Medical School, Japan
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22
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Yoshida EM, Erb SR, Ostrow DN, Ricci DR, Scudamore CH, Fradet G. Pulmonary hypertension associated with primary biliary cirrhosis in the absence of portal hypertension: a case report. Gut 1994; 35:280-2. [PMID: 8307485 PMCID: PMC1374510 DOI: 10.1136/gut.35.2.280] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Pulmonary hypertension is well described in association with portal hypertension of any cause including end stage primary biliary cirrhosis (PBC). The essential feature of this association is the presence of portosystemic shunting, including surgically created shunts. A patient with primary pulmonary hypertension and PBC without portal hypertension is reported. This suggests that primary pulmonary hypertension may be associated with PBC in the absence of portal hypertension. Decisions regarding appropriate organ transplantation may depend on whether pulmonary hypertension is primary or secondary to portal hypertension.
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Affiliation(s)
- E M Yoshida
- Department of Medicine, University of British Columbia, Vancouver, Canada
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23
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Bissuel F, Bizollon T, Dijoud F, Bouletreau P, Cordier JF, Chazot C, Gouillat C, Trepo C. Pulmonary hemorrhage and glomerulonephritis in primary biliary cirrhosis. Hepatology 1992; 16:1357-61. [PMID: 1446892 DOI: 10.1002/hep.1840160609] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We observed life-threatening intrapulmonary hemorrhages and focal proliferative glomerulonephritis in a 41-yr-old woman with primary biliary cirrhosis. The severity of the symptoms necessitated blood transfusions and mechanical ventilation; the patient improved with the help of corticosteroid therapy. No formal evidence of either Goodpasture's syndrome or any other well-defined systemic vasculitis could be found. Neutrophil cytoplasmic antibodies were initially positive and became undetectable after 3 mo of immunosuppressive treatment without relapse. This association has not been described previously and may be added to the list of extrahepatic immune-mediated conditions associated with primary biliary cirrhosis.
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Affiliation(s)
- F Bissuel
- Services d'Hépato-gastroentérologie, Hôpital de l'Hôtel-Dieu, Lyon, France
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24
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Ettinger NA, Trulock EP. Pulmonary considerations of organ transplantation. Part I. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1991; 143:1386-405. [PMID: 2048827 DOI: 10.1164/ajrccm/143.6.1386] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- N A Ettinger
- Respiratory and Critical Care Division, Washington University School of Medicine, St. Louis, Missouri
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25
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