Imaging: BOOP

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Imaging: BOOP

  1. 1. IMAGE OF THE WEEK PROF.DR.G.SUNDARAMURTY’S UNIT S.DHANRAJ MD I YR
  2. 2. <ul><li>28yrs old male presented with following features </li></ul><ul><ul><li>+non-productive cough </li></ul></ul><ul><ul><li>exertional dyspnea - two weeks </li></ul></ul><ul><ul><li>fever, malaise, weight loss </li></ul></ul><ul><ul><li>AUSCULTATION--- Bilateral coarse crackles and wheeze + </li></ul></ul>
  3. 3.
  4. 4. FINDINGS <ul><li>Chest x ray pa view </li></ul><ul><li>Rotated to left </li></ul><ul><li>Penetration adequate,Taken in full inspiration </li></ul><ul><li>Skin , soft tissue normal,Bony cage normal,Trachea,mediastinal shadow normal </li></ul><ul><li>Both dome of diaphragm normal in contour&shape </li></ul><ul><li>Card.phrenic angle obliterated by opacity </li></ul>
  5. 5. <ul><li>Bilateral Heterogenous air space opacity occupying right midzone extending to lower zone and left mid& lower zone. </li></ul>03/00
  6. 6. DIFFERENTIAL DIAGNOSIS <ul><li>USUAL INTERSTITIAL PNEUMONIA </li></ul><ul><li>ACUTE INTERSTITIAL PNEUMONIA </li></ul><ul><li>CHRONIC EOSINOPHILIC PNEUMONITIS </li></ul><ul><li>ACUTE RESPIRATORY DISTRESS SYNDROME </li></ul><ul><ul><li>MYCOPLASMA, HIV, HSV, CMV, RUBEOLA, KLEBSIELLA, HAEMOPHILUS, LEGIONELLA, GRP. B- STREP, CRYPTOCOCCUS, NOCARDIA, PCP </li></ul></ul>
  7. 7. INVESTIGATIONS <ul><li>ESR--- 10/22mm </li></ul><ul><li>MANTOUX---Negative </li></ul><ul><li>AFB---Negative </li></ul><ul><li>HIV---Non reactive </li></ul><ul><li>ANA---Negative </li></ul>
  8. 8. <ul><li>Patient was started on empirical antibiotics </li></ul><ul><li>SPUTUM CULTURE– Negative </li></ul><ul><li>FUNGAL CULTURE—Negative </li></ul><ul><li>CT SCAN was taken </li></ul>03/00
  9. 9. CT SCAN CHEST 03/00
  10. 10. 03/00
  11. 11. <ul><li>ATOLL SIGN </li></ul>03/00
  12. 12. 03/00
  13. 13. FINDINGS <ul><li>Peribronchial & subpleural consolidation with irregular margins with air bronchogram </li></ul><ul><li>Subpleural ground glass opacities </li></ul><ul><li>ATOLL Sign—ring shaped opacity with central ground glass attenuation </li></ul><ul><li>Interstitial thickening with ground glass opacities noted in midlobe/irregular/suprabasal segment of right lower lobe </li></ul>03/00
  14. 14. <ul><li>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— </li></ul><ul><li>suggestive of idiopathic boop </li></ul>03/00
  15. 15. BOOP--INTRODUCTION <ul><li>Bronchiolitis Obliterans Organizing Pneumonia - refers to a generic term of non-specific inflammatory reaction of small airways in response to exogenous/endogenous stimuli </li></ul><ul><li>Comprises two types - based on histopathology </li></ul><ul><li>Clinical features mimic pneumonia without response to antibacterial therapy </li></ul>
  16. 16. BOOP- EPIDEMIOLOGY <ul><li>Smoking is not a risk factor </li></ul>
  17. 17. BOOP- Classification <ul><li>SECONDARY </li></ul><ul><li>BOOP </li></ul><ul><li>IDIOPATHIC </li></ul><ul><li>BOOP </li></ul>
  18. 18. SECONDARY BOOP <ul><li>Connective tissue disorders - SLE, RA, Polymyositis - Dermatomyositis, Sjogren’s syndrome, MCTD, Ulcerative Colitis, Vasculitis </li></ul><ul><li>Inhaled/Systemic Toxins - gases, nicotine, cocaine, CO, nitrogen, chlorine </li></ul><ul><li>Drugs - Penicillamine, Amiodarone, Gold, Bleomycin, Mitomycin-c, Methotrexate, Sulfasalazine </li></ul>
  19. 19. SECONDARY BOOP <ul><li>Infections: </li></ul><ul><ul><li>Mycoplasma, HIV, HSV, CMV, Rubeola, Klebsiella, Hemophilus, Legionella, Grp B- Strep, Cryptococcus, Nocardia, PCP </li></ul></ul><ul><li>Pediatric </li></ul><ul><ul><li>RSV, Parainfluenza, Adenovirus, Mycoplasma </li></ul></ul>03/00
  20. 20. SECONDARY BOOP <ul><li>Obstructive Pneumonitis </li></ul><ul><li>Hypersensitivity Pneumonitis </li></ul><ul><li>Aspiration Pneumonitis </li></ul><ul><li>Chronic Eosinophilic Pneumonia </li></ul><ul><li>Diffuse Alveolar Damage </li></ul><ul><li>Myelodysplastic Syndrome </li></ul><ul><li>Hematological malignancy </li></ul>03/00
  21. 21. BOOP- IMAGING <ul><li>Chest Xray: Patchy peripheral bilateral migratory alveolar infiltrates </li></ul><ul><li>20-30% - reticular or nodular infiltrate </li></ul><ul><li>Pleural effusions in 30% due to secondary BOOP </li></ul><ul><li>CXR- can be normal in 4-10% </li></ul><ul><li>Cavitation & lymphadenopathy are absent </li></ul><ul><li>Focal consolidation is a marker for a good response to steroid therapy </li></ul>03/00
  22. 22. BOOP- IMAGING <ul><li>High Resolution CT scan of Chest: patchy consolidation, ground glass opacity, nodularity with subpleural lower lobe predeliction. </li></ul><ul><li>Bronchial wall thickening and dilatation denote severe disease </li></ul><ul><li>Honey combing not seen in idiopathic BOOP </li></ul>
  23. 23. BOOP- Bronchoscopy <ul><li>Gold standard- Open lung or thoracoscopic lung biopsy for histopathology </li></ul>
  24. 24. BOOP--Treatment <ul><li>Spontaneous recovery occurs rarely </li></ul><ul><li>Antibiotic therapy for underlying infections </li></ul><ul><li>Withdrawal of offending toxin/ drug </li></ul><ul><li>Supportive therapy </li></ul><ul><li>Steroids for idiopathic BOOP and BOOP secondary to connective tissue disorders </li></ul>
  25. 25. BOOP-- STEROID Rx <ul><li>Idiopathic BOOP responds to steroids better than BOOP due to connective tissue disorders </li></ul><ul><li>Immunosuppressive agents - cyclophosphamide, azathioprine for those who fail to respond to steroid Rx </li></ul>
  26. 26. <ul><li>Usual interstitial pneumonia/idiopathic pulmonary fibrosis- -Massive fibrosis appearing as a honeycomb </li></ul><ul><li>pattern on HRCT scans and traction </li></ul><ul><li>bronchiectasis (lung architecture distortion) </li></ul><ul><li>Irregular linear infiltrates generally in lower </li></ul><ul><li>lung zones </li></ul><ul><li>Acute interstitial pneumonia or Hammond rich syndrome- -Accelerated interstitial pneumonitis with fibrosis and ground-glass attenuation ,Interlobular septal thickening </li></ul>00
  27. 27. <ul><li>Ch ronic eosinophilic pneumonia — </li></ul><ul><li>Diffuse migratory, patchy alveolar infiltrates </li></ul><ul><li>often along the pleural edges </li></ul><ul><li>Ground-glass opacities </li></ul><ul><li>Infective pneumonias (community-acquired, nosocomial, aspiration)-- Generally, either unilateral or bilateral infiltrates. Aspiration pneumonia infiltrates common in gravity-dependent regions </li></ul><ul><li>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 </li></ul>
  28. 28. <ul><li>THANK YOU </li></ul>03/00

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