Air leak syndrome as one of the manifestations of bronchiolitis obliterans organizing pneumonia

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.

Air-Leak Syndrome with Spontaneous Tension Pneumothorax and Pneumomediastinum Caused by Bleomycin-Induced Organizing Pneumonia

Teaching Point: The appearance of pneumatoceles in a patient with organizing pneumonia is an early sign of leak syndrome and is a significant finding as its rupture can lead to a life-threatening tension pneumothorax. Air leak syndrome (ALS), consisting of pneumothorax, subcutaneous emphysema and pneumomediastinum, is a rare complication of organizing pneumonia (OP). We report a case of a patient with bleomycin-induced OP who develops a tension pneumothorax due to a ruptured pneumatocele caused by ALS and correlate with histopathological analysis. This is the third case in the literature with these findings and the first with a tension pneumothorax.

Air leak: An unusual manifestation of organizing pneumonia secondary to bleomycin

Organizing pneumonia (OP) is a less common interstitial lung disease with varying clinical picture. The development of pulmonary air leak in a case of OP is an extremely rare complication. Here, we report the case of a 46-year-old female with carcinoma ovary, postchemotherapy who developed respiratory distress with pneumomediastinum, and subcutaneous emphysema. Lung biopsy showed evidence of OP. This turned out to be a rare case of OP, secondary to bleomycin chemotherapy, presenting with pulmonary air leak.

Giant bulla formation in the lung because of a check-valve mechanism

The pathogenesis of bulla formation has not yet been demonstrated in pathologic examinations or through direct visualization during thoracotomy or thoracoscopic surgery. We present two cases of giant bulla formation after pneumothorax because of cryptogenic organizing pneumonia and lung abscess. The case findings suggested that the pathogenesis was attributable to a check-valve mechanism, secondary to bronchiolitis obliterans, or the presence of an obstructing air leakage due to a lung fistula. The lung fistula had been covered by inflammatory membranes consisting of blood and/or fibrous precipitates with detached visceral pleura.

Subcutaneous emphysema: an unusual presentation of foreign body aspiration

Two cases of subcutaneous emphysema owing to foreign body aspiration are described. In case 1, a 2½-year-old boy presented with complaints of respiratory distress, cough, and swelling over neck. Computed tomography scan of neck and thorax revealed subcutaneous emphysema along with emphysematous changes of left lung. In Case 2, a 5-year-old boy presented with left pneumothorax along with massive subcutaneous emphysema, extending from the face to the chest. Computed tomography scan of the chest revealed subcutaneous emphysema, pneumomediastinum, and left pneumothorax. Both of the patients underwent bronchoscopic removal of the foreign body from the left main bronchus. At present both are asymptomatic and doing well. Subcutaneous emphysema is rare as a manifestation of foreign body aspiration and this cause should be kept in mind, even in the absence of forthcoming history of aspiration.

Adjunctive effects of cyclosporine and macrolide in rapidly progressive cryptogenic organizing pneumonia with no prompt response to steroid

Cryptogenic organizing pneumonia (COP) generally responds well to corticosteroids with a favorable outcome. However, it can rapidly worsen and lead to respiratory failure that is refractory to corticosteroids. Adjunctive drugs have been used in refractory cases with various outcomes, but treatment experience is still lacking. We present a case of rapidly progressive COP accompanying air leak syndrome, which showed no prompt response to corticosteroids alone but gradual improvement with the addition of cyclosporine and macrolide. This case report supports the existing literature suggesting that an early therapeutic trial of this drug combination might be considered in COP patients whose condition worsens despite corticosteroid administration.

Bronchiolitis obliterans organizing pneumonia: pathogenesis, clinical features, imaging and therapy review

Bronchiolitis obliterans organizing pneumonia (BOOP) was first described in the early 1980s as a clinicopathologic syndrome characterized symptomatically by subacute or chronic respiratory illness and histopathologically by the presence of granulation tissue in the bronchiolar lumen, alveolar ducts and some alveoli, associated with a variable degree of interstitial and airspace infiltration by mononuclear cells and foamy macrophages. Persons of all ages can be affected. Dry cough and shortness of breath of 2 weeks to 2 months in duration usually characterizes BOOP. Symptoms persist despite antibiotic therapy. On imaging, air space consolidation can be indistinguishable from chronic eosinophilic pneumonia (CEP), interstitial pneumonitis (acute, nonspecific and usual interstitial pneumonitis, neoplasm, inflammation and infection). The definitive diagnosis is achieved by tissue biopsy. Patients with BOOP respond favorably to treatment with steroids.

Rapidly progressive Bronchiolitis Obliterans Organising Pneumonia presenting with pneumothorax, persistent air leak, acute respiratory distress syndrome and multi-organ dysfunction: a case report

Introduction

Bronchiolitis Obliterans Organising Pneumonia (BOOP) may often present initially as a recurrent spontaneous pneumothorax and then develop multi-system complications.

Case presentation

A 17-year-old boy presented with a pneumothorax, which developed into rapidly progressive Bronchiolitis Obliterans Organising Pneumonia (BOOP). He developed multi-organ dysfunction (including adult respiratory distress syndrome, oliguric renal failure, acute coronary syndrome, cardiac failure and a right atrial thrombus) which necessitated prolonged intensive care. Diagnosis was confirmed on open lung biopsy and he responded well to treatment with corticosteroids.

Conclusion

BOOP is exquisitely sensitive to oral corticosteroids but if the diagnosis is not considered in such patients and appropriate treatment instituted early, BOOP may often lead to prolonged hospital admission with considerable morbidity.

The Organizing Pneumonias

In this comprehensive review, two very closely related interstitial pneumonias are discussed: the cryptogenic form of organizing pneumonia (COP); and secondary forms of organizing pneumonia (OP), which occur in association with identifiable medical conditions. Some newer and lesser known of these associated conditions are described, most importantly post-radiation OP.Rapidly progressive, corticosteroid-resistant and poor prognostic forms of OP have been described. These types purportedly occur more frequently in secondary OP. However, OPs frequently coexist with other interstitial pneumonias, especially when associated with connective tissue diseases. Therefore, tissue sampling error or an incorrect morphologic diagnosis can be the basis for the occurrence of clinically aggressive OPs. By using the 2002 American Thoracic Society/European Respiratory Society diagnostic criteria, some pre-2002 cases reported as OP would be re-classified today.Although COP is considered to have a good prognosis and to be corticosteroid responsive, approximately 70% of patients, treated with corticosteroids, relapse even during initial treatment. Multiple and late relapses occur in about one-third of the patients. We performed a meta-analysis of second-line treatment options for corticosteroid-refractory forms of OP. Three alternative nonsteroid agents - cyclophosphamide, azathioprine, and cyclosporin - have been used in combination with corticosteroids. On careful review, in a number of cases reported as secondary OP, other histologic interstitial patterns besides OP were described. The need for second-line therapy in these patients might have been dictated by the non-organizing pneumonic component. Most of the scant number of reports come from outside the US. World experience with these is limited, but good clinical outcomes have been noted, even in patients with interstitial patterns in addition to OP.The initiation of the OP tissue response in the bronchiolar and sub-bronchiolar location may be due to the presence of bronchiolar-associated lymphoid tissue found at the bifurcations of the bronchioles. Inhaled antigens stimulate granulocyte colony stimulating factor-mediated airway inflammation, followed later by CD44-mediated clearance. Repair requires intrabronchiolar formation of granulation tissue and a favorable ratio of matrix metalloproteinase to tissue inhibitors of metalloproteinase (MMP : TIMP) within the stroma. This reparative milieu allows extracellular matrix degradation and re-synthesis to occur. MMP-expressing fibroblasts then phagocytose the collagen fibrils and microfibrils produced earlier in repair, reversing the initial fibrosis.

The organizing pneumonias: an update and review

PURPOSE OF REVIEW

Basic information as well as more recent concepts regarding cryptogenic organizing pneumonia and secondary forms of the disease.

RECENT FINDINGS

More recently described and less well recognized illnesses associated with organizing pneumonia, such as organizing pneumonia associated with radiation, are enumerated. In vitro studies from separate laboratories are integrated to create a proposed model of the pathogenesis and repair mechanisms that occur in organizing pneumonias. Using current criteria, we note other interstitial lung processes, in addition to organizing pneumonia, are present in some earlier reports.

SUMMARY

Cryptogenic organizing pneumonia has been reported to respond to corticosteroids with clinico-radiographic resolution in 70-80% of cases. Treatment duration is lengthy, and despite this, recurrences and late recurrences are common. Rapidly progressive, steroid resistant and poor prognostic forms of organizing pneumonia have been described and have been reported more frequently with secondary organizing pneumonia. Since other histologic interstitial patterns often coexist with organizing pneumonia, tissue sampling error or an incorrect morphologic diagnosis can be the reason for aggressive clinical behavior. Steroid nonresponsive patients have been treated with secondary non-steroidal agents. Good clinical outcomes have been reported. Inhaled antigens stimulate GM-CSF-mediated airway inflammation in organizing pneumonia. Repair requires the following: granulation tissue, upon which re-epithelialization occurs; a favorable stromal ratio of matrix metalloproteinase to tissue inhibitors of metalloproteinase; concurrent resolution of inflammation; and stromal fibroblast ingestion of collagen produced earlier in repair, reversing the initial fibrosis.