A 28-year-old male presented with cough, dyspnea, fever, malaise, and weight loss. Chest X-ray and CT scan showed bilateral heterogeneous airspace opacities. He did not improve with antibiotics but responded well to steroids, suggestive of idiopathic bronchiolitis obliterans organizing pneumonia (BOOP). BOOP is a non-specific inflammatory reaction of small airways that can be idiopathic or secondary to various causes. It is treated with steroids and immunosuppressants if unresponsive to steroids.

1. IMAGE OF THE WEEK PROF.DR.G.SUNDARAMURTY’S UNIT S.DHANRAJ MD I YR

2. 28yrs old male presented with following features +non-productive cough exertional dyspnea - two weeks fever, malaise, weight loss AUSCULTATION--- Bilateral coarse crackles and wheeze +

4. 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 opacity

5. Bilateral Heterogenous air space opacity occupying right midzone extending to lower zone and left mid& lower zone. 03/00

6. 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

7. INVESTIGATIONS ESR--- 10/22mm MANTOUX---Negative AFB---Negative HIV---Non reactive ANA---Negative

8. Patient was started on empirical antibiotics SPUTUM CULTURE– Negative FUNGAL CULTURE—Negative CT SCAN was taken 03/00

9. CT SCAN CHEST 03/00

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11. ATOLL SIGN 03/00

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13. 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 03/00

14. 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 03/00

15. 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

16. BOOP- EPIDEMIOLOGY Smoking is not a risk factor

17. BOOP- Classification SECONDARY BOOP IDIOPATHIC BOOP

18. 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

19. SECONDARY BOOP Infections: Mycoplasma, HIV, HSV, CMV, Rubeola, Klebsiella, Hemophilus, Legionella, Grp B- Strep, Cryptococcus, Nocardia, PCP Pediatric RSV, Parainfluenza, Adenovirus, Mycoplasma 03/00

20. SECONDARY BOOP Obstructive Pneumonitis Hypersensitivity Pneumonitis Aspiration Pneumonitis Chronic Eosinophilic Pneumonia Diffuse Alveolar Damage Myelodysplastic Syndrome Hematological malignancy 03/00

21. 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 03/00

22. 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

23. BOOP- Bronchoscopy Gold standard- Open lung or thoracoscopic lung biopsy for histopathology

24. 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

25. 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

26. 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 00

27. Ch ronic 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

28. THANK YOU 03/00