Desquamative interstitial pneumonia associated with concurrent cytomegalovirus and Aspergillus pneumonia in a renal transplant recipient

Smoking-Related Interstitial Lung Diseases

Smoking-related interstitial lung diseases (ILDs) are a group of heterogeneous, diffuse pulmonary parenchymal disease processes associated with tobacco exposure. These disorders include pulmonary Langerhans cell histiocytosis, respiratory bronchiolitis-associated ILD, desquamative interstitial pneumonia, acute eosinophilic pneumonia, and combined pulmonary fibrosis and emphysema. This review summarizes the current evidence of pathogenesis, clinical manifestations, diagnostic approach, prognosis, and treatment modalities for these diseases. We also discuss the interstitial lung abnormalities incidentally detected in radiologic studies and smoking-related fibrosis identified on lung biopsies.

IgG4-related lung disease with a desquamative interstitial pneumonia pattern radiologically and pathologically

A man in his 60s exhibited persistent dry cough and dyspnoea, which persisted even after smoking cessation. Chest high-resolution CT showed diffuse ground-glass opacities in the subpleural areas of both lungs. He underwent bronchoscopy, but no definitive diagnosis could be made. Histopathological analysis of the specimen obtained by surgical lung biopsy showed a desquamative interstitial pneumonia (DIP) pattern, with lymphocyte and plasma cell infiltrates in the alveolar septa; the ratio of IgG and IgG4-positive cells was more than 90%. He quit smoking, but the radiological findings worsened. Based on the pathological findings, we diagnosed the patient with DIP due to IgG4-related lung disease. Prednisolone was initiated, and the symptoms and radiological findings improved.

Desquamative interstitial pneumonia: a systematic review of its features and outcomes

Background

Desquamative Interstitial Pneumonia (DIP) is a rare form of idiopathic interstitial pneumonia (IIP). Data on clinical features, aetiology, prognosis and effect of treatment strategies are limited. We aimed to collect all published cases to better characterise DIP.

Methods

A systematic literature search was performed for all original cases of adult patients with histopathologically-confirmed DIP. Individual patient data were extracted and summarised.

Results

We included 68 individual cases and 13 case series reporting on 294 cases. Most common presenting symptoms were dyspnoea and cough. Pulmonary function showed a restrictive pattern (71%) with decreased diffusion capacity. We found a high incidence (81%) of ever smoking in patients with DIP and 22% of patients had other (occupational) exposures. Characteristic features on high-resolution computed tomography (HRCT) scan were bilateral ground-glass opacities with lower lobe predominance (92%). Treatment and duration of treatment widely varied. Initial response to treatment was generally good, but definitely not uniformly so. A significant proportion of patients died (25% of individual cases) or experienced a relapse (18% of individual cases).

Conclusion

DIP remains an uncommon disease, frequently but not always related to smoking or other exposures. Furthermore, DIP behaves as a progressive disease more often than generally thought, possibly associated with different underlying aetiology.

This systematic review is the most comprehensive collection of published cases of DIP to date and yields novel information about aetiology, clinical characteristics, radiology and pathology features, treatment and outcomes.http://bit.ly/394YRPv

Desquamative interstitial pneumonia: Risk factors, laboratory and bronchoalveolar lavage findings, radiological and histopathological examination, clinical features, treatment and prognosis

Desquamative interstitial pneumonia is a type of smoking-associated major idiopathic interstitial pneumonia, which is characterized by accumulation of alveolar macrophages in alveolar lumens and septa and develops secondary to mainly active or passive exposure to cigarette smoke. Desquamative interstitial pneumonia mostly occurs in male smokers in association with non-specific symptoms responsive to steroid therapy and has a better prognosis than usual interstitial pneumonia. To date, no large-scale clinical studies have been performed on desquamative interstitial pneumonia patients. Factors responsible for the scarcity of data on the clinical course of this condition include the retrospective nature of the available information as well as its rare occurrence. Despite this, a general consensus exists as to the nature of its symptoms, association with smoking, age and gender distribution, findings of respiratory function tests, steroid responsivity and mortality. The objective of the present review article was to report on desquamative interstitial pneumonia and to describe its etiology, risk factors and clinical features, as well as the laboratory, bronchoalveolar lavage, radiological and histopathological findings, and the treatment and prognosis of affected patients.

Cytomegalovirus and Aspergillus spp. coinfection in organ transplantation: a case report and review of the literature

With the advent of potent immunosuppressive options, acute rejection episodes have decreased at the expense of increased incidence of opportunistic infections in solid organ recipients. In the absence of any preventive therapy, 30–75 % of transplant recipients develop cytomegalovirus (CMV) infection. Candida spp. and Aspergillus spp. account for more than 80 % of invasive fungal infections in solid organ recipients. This co-occurrence of two commonly seen opportunistic infections may end up in fatality. Here, we present a case of concomitant Aspergillus spp. and CMV infection and discuss the relevant literature. A 54-year-old male patient presented with fever, shortness of breath, and chest pain on the 9th posttransplant week after renal transplantation. CMV-DNA by polymerase chain reaction (PCR) was 1,680,000 copies/ml, thus, valganciclovir dose was increased. There were inspiratory crackles at both lung bases, and chest computed tomography (CT) revealed multiple fungal balls throughout the right lung. Galactomannan antigen was positive, and voriconazole and other antimicrobials were subsequently added to the treatment. At the end of the therapy, on control CT, pneumonic consolidation had disappeared, sputum cultures didn’t show Aspergillus spp., and CMV-DNA reduced to 700 copies/ml. The patient showed a favorable clinical response to combined treatment; fever, dyspnea, and pleuritic chest pain disappeared. Both CMV disease and aspergillosis may present as pulmonary disease; thus, the characterization of one may not preclude the search for the other and the timely initiation of treatment is of paramount importance for good outcomes.

What every radiologist should know about idiopathic interstitial pneumonias

The American Thoracic Society-European Respiratory Society classification of idiopathic interstitial pneumonias (IIPs), published in 2002, defines the morphologic patterns on which clinical-radiologic-pathologic diagnosis of IIPs is based. IIPs include seven entities: idiopathic pulmonary fibrosis, which is characterized by the morphologic pattern of usual interstitial pneumonia (UIP); nonspecific interstitial pneumonia (NSIP); cryptogenic organizing pneumonia (COP); respiratory bronchiolitis-associated interstitial lung disease (RB-ILD); desquamative interstitial pneumonia (DIP); lymphoid interstitial pneumonia (LIP); and acute interstitial pneumonia (AIP). The characteristic computed tomographic findings in UIP are predominantly basal and peripheral reticular opacities with honeycombing and traction bronchiectasis. In NSIP, basal ground-glass opacities tend to predominate over reticular opacities, with traction bronchiectasis only in advanced disease. COP is characterized by patchy peripheral or peribronchovascular consolidation. RB-ILD and DIP are smoking-related diseases characterized by centrilobular nodules and ground-glass opacities. LIP is characterized by ground-glass opacities, often in combination with cystic lesions. AIP manifests as diffuse lung consolidation with ground-glass opacities, which usually progress to fibrosis in patients who survive the acute phase of the disease. Correct diagnosis of IIPs can be achieved only by means of interdisciplinary consensus and stringent correlation of clinical, imaging, and pathologic findings. (c) RSNA, 2007.