Successful Lung Retransplantation in a Patient With Acute Fibrinous and Organizing Pneumonia: A Case Report

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.

Diagnostic procedures and clinico-radiological findings of acute fibrinous and organizing pneumonia: a systematic review and pooled analysis

OBJECTIVES

To evaluate the clinico-radiological findings of acute fibrinous and organizing pneumonia (AFOP) in the literature according to whether a surgical or non-surgical biopsy was performed, as well as to identify prognostic predictors.

METHODS

We searched the Embase and OVID-MEDLINE databases to identify studies that presented CT findings of AFOP and had extractable individual patient data. We compared the clinical and CT findings of the patients depending on whether a surgical or non-surgical biopsy was performed and identified survival predictors using a multivariate logistic regression analysis.

RESULTS

Eighty-one patients (surgical biopsy, n = 52; non-surgical biopsy, n = 29) from 63 studies were included. The surgical biopsy group frequently experienced an acute fulminant presentation (p = .011) and dyspnea (p = .001) and less frequently had a fever (p = .006) than the non-surgical biopsy group. The surgical biopsy group had a worse prognosis than the non-surgical biopsy group in terms of mechanical ventilation and mortality (both, p = .023). For survival analysis, the patients with the predominant CT finding of patchy or mass-like air-space consolidation survived more frequently (p < .001) than those with other CT findings. For prognostic predictors, subacute indolent presentation (p = .001) and patchy or mass-like air-space consolidation on CT images (p = .002) were independently associated with good survival.

CONCLUSIONS

Approximately one-third of alleged AFOP cases in the literature were diagnosed via non-surgical biopsy, but those cases had different symptomatic presentations and prognosis from surgically proven AFOP. Subacute indolent presentation and patchy or mass-like air-space consolidation at the presentation on CT images indicated a good prognosis in patients with AFOP.

KEY POINTS

• Acute fibrinous and organizing pneumonia (AFOP) cases diagnosed via non-surgical biopsy had different symptomatic presentations and prognosis from surgically proven AFOP. • Subacute indolent presentation and patchy or mass-like air-space consolidation on CT images indicated a good prognosis in patients with acute fibrinous and organizing pneumonia.

Urgent lung transplantation in acute fibrinous and organizing pneumonia: a sliding door or a new perspective?

BACKGROUND

Lung transplantation is nowadays the standard therapy for certain well-defined chronic end-stage lung diseases, even in patients on mechanical ventilation or extracorporeal life support. While these latter techniques have been used worldwide as bridging options to lung transplantation for listed patients, they are not commonly used in previously healthy patients developing acute not-reversible lung failure.

METHODS

We will discuss two patients without any relevant medical history developing acute lung failure evolving to irreversible acute fibrinous and organising pneumonia (AFOP), thus listed for urgent lung transplantation.

RESULTS

The patients recovered well, and both are still alive.

CONCLUSIONS

In the absence of clear guidelines, our approach showed, in these patients, the possible benefits of lung transplantation regarding survival in AFOP.

Acute Fibrinous and Organizing Pneumonia: A Case Report and Review of the Literature

BACKGROUND Acute fibrinous organizing pneumonia (AFOP) is a rare condition of the lung that is associated with acute lung injury, and has a poor prognosis. AFOP is characterized histologically by intra-alveolar fibrin. AFOP has been described to be associated with lung infections, connective tissue disorders, drugs, toxic environmental exposure, and in lung transplantation. However, most cases of AFOP remain idiopathic, and because the condition can present with a wide variety of clinical manifestations, open lung biopsy or video-assisted thoracoscopic (VAT) lung biopsy is necessary for the diagnosis. Currently, treatments for AFOP remain under investigation. CASE REPORT A 35-year-old woman presented with a cough and dyspnea, and was initially diagnosed to have pneumonia.  Due to the progression of her symptoms and increasing respiratory failure she underwent video-assisted thoracoscopic (VAT) biopsy and was diagnosed with AFOP, 19 days following hospital admission. She was treated with mechanical ventilation, intravenous steroids, and cyclophosphamide. She required tracheostomy after 14 days of mechanical ventilation and died two weeks later. CONCLUSIONS AFOP is an uncommon clinical condition, with a poor prognosis, which often has a delay in diagnosis. Some patients benefit from steroids and immunosuppressive therapy. Currently, new treatments for AFOP are under investigation.

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.

"White-Out" After Lung Transplantation: A Multicenter Cohort Description of Late Acute Graft Failure

Graft failure represents a leading cause of mortality after organ transplantation. Acute late-onset graft failure has not been widely reported. The authors describe the demographics, CT imaging-pathology findings, and treatment of patients presenting with the latter. A retrospective review was performed of lung transplant recipients at two large-volume centers. Acute late-onset graft failure was defined as sudden onset of bilateral infiltrates with an oxygenation index <200 without identifiable cause or concurrent extrapulmonary organ failure. Laboratory, bronchoalveolar lavage (BAL), radiology, and histology results were assessed. Between 2005 and 2016, 21 patients were identified. Median survival was 19 (IQR 13-36) days post onset. Twelve patients (57%) required intensive care support at onset, 12 (57%) required mechanical ventilation, and 6 (29%) were placed on extracorporeal life support. Blood and BAL analysis revealed elevated neutrophilia, with CT demonstrating diffuse ground-glass opacities. Transbronchial biopsy samples revealed acute fibrinoid organizing pneumonia (AFOP), organizing pneumonia, and diffuse alveolar damage (DAD). Assessment of explanted lungs confirmed AFOP and DAD but also identified obliterative bronchiolitis. Patients surviving to discharge without redo transplantation (n = 2) subsequently developed restrictive allograft syndrome. This study describes acute late-onset graft failure in lung allograft recipients, without known cause, which is associated with a dismal prognosis.

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.

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.