Is acute fibrinous and organizing pneumonia the expression of immune dysregulation?

Acute fibrinous and organizing pfneumonia: two case reports and literature review

Background

Acute fibrinous and organizing pneumonia (AFOP) is a rare histologic interstitial pneumonia pattern characterized by the intra-alveolar fibrin deposition and organizing pneumonia. Its clinical characteristics are still not well known and there is no consensus on treatment yet.

Case presentation

We report two female cases in their fifties diagnosed with AFOP confirmed by a second lung biopsy. Case 1 was idiopathic AFOP with manifestation of 6-week fever, dyspnea, and cough, while case 2 was secondary to systemic lupus erythematosus and fever was the major symptom. Their chest CT scans revealed bilateral multiple consolidations, predominantly in the lower lobes. Both cases were initially diagnosed with pneumonia, but did not improve after treatment with broad-spectrum antibiotics. In both cases, transbronchial biopsy and bronchoalveolar lavage fluid examination were inconclusive and the pathological diagnosis was confirmed by percutaneous lung biopsy. Both patients had a good clinical response to prednisone.

Conclusions

We report two rare AFOP cases to highlight the importance of awareness of this disease. We further perform the most comprehensive review to date in AFOP, including 150 patients since 2002. Consolidation was the most common imaging pattern, followed by ground-glass opacity and nodules. A lung biopsy is required for a definitive diagnosis. Corticosteroids is recommended as the most effective therapy, but treatment options should depend on the etiology and disease severity.

Acute fibrinous and organizing pneumonia following hemophagocytic syndrome in two adult patients with hematological malignancies

Acute fibrinous and organizing pneumonia (AFOP) is a rare acute lung injury featuring pathological intra-alveolar fibrin balls and organizing pneumonia without hyaline membranes or eosinophils. AFOP forms acute and subacute patterns; the former often has a poor prognosis, whereas the latter has better survival. Secondary hemophagocytic syndrome (HPS) is a cytokine-related and potentially lethal disorder induced by various diseases, and pulmonary involvement in HPS is not rare. However, to our knowledge, no report has addressed the association between secondary HPS and AFOP development. We report two cases of subacute AFOP following HPS in hematological malignancies.

Acute fibrinous and organizing pneumonia as initial presentation of primary Sjögren's syndrome: a case report and literature review

Acute fibrinous and organizing pneumonia (AFOP) is a new histopathological pattern of acute lung injury first described by Beasley et al. in 2002. Hallmarks of pathological findings are characterized by the presence of intra-alveolar fibrin in the form of fibrin "balls" within the alveolar spaces and organizing pneumonia with a patchy distribution. Patients with AFOP may have an acute or subacute clinical presentation. Although the pathogenesis of AFOP is not fully elucidated, it may be associated with autoimmune diseases. Reported herein is a patient diagnosed of acute AFOP associated with primary Sjögren's syndrome. The patient's condition promptly improved after treatment with corticosteroid.

Acute fibrinous and organising pneumonia

Acute fibrinous and organising pneumonia (AFOP) is a rare histological pattern of interstitial lung disease. The authors describe a 60-year-old woman admitted to the hospital for sustained fever, presenting with an alveolar opacity on chest X-ray, with the presumed diagnosis of community-acquired pneumonia and the onset of antibiotics. Since serological results suggested that Legionella pneumophila was the infectious agent, she was discharged on levofloxacin. A week later, she was again admitted with fever. CT scan showed opacities with crescentic morphology and a central ground-glass area suggestive of cryptogenic organising pneumonia. Microbiological, serological and autoimmunity tests were negative. She underwent surgical lung biopsy that revealed inflammatory infiltrate, macrophage desquamation, fibroblasts proliferation and fibrin deposition in the alveolar spaces, consistent with AFOP. She started corticotherapy with good response. Disease relapsed after prednisolone discontinuation, 10 months later. Currently, the patient is on prednisolone 5 mg/day without clinical and radiological recurrence.

Clinical and Radiological Profile of Acute Fibrinous and Organizing Pneumonia: A Retrospective Study

Background:

Acute fibrinous and organizing pneumonia (AFOP) is a unique pathological entity with intra-alveolar fibrin in the form of “fibrin balls” and organizing pneumonia. It was divided into rare idiopathic interstitial pneumonia according to the classification notified by American Thoracic Society/European Respiratory Society in 2013. As a rare pathological entity, it is still not well known and recognized by clinicians. We reviewed the clinical features of 20 patients with AFOP diagnosed in a teaching hospital.

Methods:

The medical records of 20 patients with biopsy-proven diagnosis of AFOP were retrospectively reviewed. The patients’ symptoms, duration of the disease, comorbidities, clinical laboratory data, pulmonary function testing, radiographic studies, and the response to treatment were extracted and analyzed.

Results:

Fever was the most common symptom and was manifested in 90% of AFOP patients. For clinical laboratory findings, systematic inflammatory indicators, including C-reactive protein and erythrocyte sedimentation rate, were significantly higher than normal in AFOP patients. In accordance with this increased indicators, injured liver functions were common in AFOP patients. Inversely, AFOP patients had worse clinical conditions including anemia and hypoalbuminemia. For pulmonary function testing, AFOP patients showed the pattern of restrictive mixed with obstructive ventilation dysfunction. For high-resolution computerized tomography (HRCT) findings, the most common pattern for AFOP patients was lobar consolidation which was very similar to pneumonia. However, unlike pneumonia, AFOP patients responded well to glucocorticoids.

Conclusion:

Patients with AFOP manifest as acute inflammatory-like clinical laboratory parameters and lobar consolidation on HRCT, but respond well to steroid.

Acute fibrinous and organizing pneumonia: A case report and literature review

Acute fibrinous and organizing pneumonia (AFOP) is a rare lung disease with distinct histological characteristics that include the diffuse presence of intra-alveolar fibrin, and the absence of eosinophils and hyaline membrane. In the present study, a case of AFOP that was diagnosed by lung biopsy is described. The patient presented with high fever and a cough with expectoration. Computed tomography of the lung showed the presence of bilateral patchy infiltrates, predominantly in the lower lobes. Histopathological examination of lung biopsy from the lower pulmonary lobe confirmed the pathological diagnosis. The patient showed a poor response to treatment with prednisone. Based on a review of literature pertaining to documented AFOP cases, a summary of the clinical features, radiological characteristics, treatment outcomes and prognoses associated with AFOP are presented. The most common pulmonary symptoms included cough, dyspnea and fever. The primary imaging findings in AFOP were consolidation and ground-glass opacity in the bilateral lung.

Acute fibrinous and organizing pneumonia: A rare form of nonbacterial pneumonia

Acute fibrinous and organizing pneumonia (AFOP) is a rare disease characterized by bilateral basilar infiltrates and histological findings of organizing pneumonia and intra-alveolar fibrin in the form of “fibrin balls.” Here, we report a 43-year-old female with complaints of fever, dry cough, and shortness of breath with hypoxemia. High-resolution computed tomography thorax revealed diffuse confluent consolidation in bilateral lung zones. Bronchoscopy and transbronchial biopsy revealed features of AFOP. With prednisolone treatment, there was an improvement in her condition. AFOP is a rare disease and should be taken into consideration and differential diagnosis of severe acute pneumonias with no significant comorbidities.

Life after acute fibrinous and organizing pneumonia: a case report of a patient 30 months after diagnosis and review of the literature

Acute fibrinous and organizing pneumonia (AFOP) is a rare histologic interstitial pneumonia pattern recently described in the literature with fewer than 120 cases published. AFOP is often difficult to diagnose and may be mistaken for other pulmonary disorders such as interstitial pneumonias or pneumonitides. Patients often present with vague symptoms of cough, dyspnea, hemoptysis, fatigue, and occasionally respiratory failure. Radiological findings show diffuse patchy opacities and ground glass appearance of the lungs. On histologic examination, intra-alveolar fibrin balls are observed. We discuss a case of a man who presented with hemoptysis and dyspnea and whose open lung biopsy revealed AFOP. We will describe the presentation, diagnosis, and post-discharge course, and review the current literature. There are only 4 cases which have reported the patients' course of disease after 1 year, the longest being 2 years. To our knowledge, this is the only case of AFOP in the literature that describes the course of a patient more than 2 years after the diagnosis of AFOP, and is the most comprehensive review of the current literature.

Acute fibrinous and organizing pneumonia masquerading as a lower respiratory tract infection: a case report and review of the literature

Background

Acute Fibrinous and Organizing Pneumonia is a rare entity characterized by the histological pattern suggestive of diffuse alveolar damage, eosinophilic pneumonia and organizing pneumonia; the presence of intra alveolar “fibrin balls” distinguishes it from these conditions. Herein, we describe the association of acute fibrinous and organizing pneumonia with a respiratory tract infection. We believe that such an association has been extremely rarely described.

Case presentation

We report the case of a 68 year old female patient of Afghan descent who presented with shortness of breath, cough and high grade fever not responding satisfactorily to standard antibiotic therapy. Imaging revealed bilateral basilar infiltrates and ground glass opacification of the right lower lung zone. Though the inflammatory markers decreased with antibiotic therapy, there was minimal improvement in the patient’s symptoms and radiological appearance of the lungs. Bronchoscopy was refused by the patient’s family and a Computed Tomography guided biopsy of the lung revealed a histological diagnosis of acute fibrinous and organizing pneumonia. Patient was initiated on high dose intravenous corticosteroid therapy followed by a maintenance dose of prednisolone at 40 mg/day. She recovered dramatically. However, due to poor compliance with treatment, she relapsed and was re-treated with the same regimen. Currently she is completely symptom free and is on a tapering corticosteroid dose.

Conclusion

We conclude that AFOP may be a rare but under diagnosed entity and recommend that it should be considered in the differentials of a suspected pulmonary infection unresponsive to optimum antibiotic therapy.