Pulmonary Manifestations of Primary Autoimmune Hepatobiliary Disease

Interstitial Lung Disease in Primary Biliary Cholangitis: A Cohort Prospective Study

Interstitial lung disease (ILD) has been recognized as an extrahepatic manifestation ofprimary biliary cholangitis (PBC), althoughlimited data are available on its prevalence and clinical significance. Therefore, we evaluated the occurrence and clinical features of ILD in a cohort of PBC patients. Ninety-three individuals without concomitant rheumatic diseases were enrolled in our prospective cohort study. All patients underwent chest high-resolution computed tomography (HRCT). Liver-related and lung-related survival wereassessed. A lung-related outcome was defined as death from ILD complications; a liver-related outcome was defined as liver transplantation or death from liver cirrhosis complications. HRCT findings suggestive ofILD were detected in 38 patients (40.9%). A sarcoid-like pattern of PBC-associated ILD was the most frequent, followed by subclinical ILD and organizing pneumonia. Patients with ILD were less likely to have liver cirrhosis and liver-related symptoms and presented with higher serum immunoglobulin M(IgM) and M2 subtype antimitochondrial antibodies (AMA-M2) positivity rates. In a multivariate analysis, the absence of liver disease symptoms at the disease presentation (OR 11.509; 95% CI 1.210-109.421; p = 0.033), the presence of hepatic non-necrotizing epithelioid cell granulomas (OR 17.754; 95% CI 1.805-174.631; p = 0.014), higher serum IgM (OR 1.535; 95% CI 1.067-2.208; p = 0.020) and higher blood leukocyte count (OR 2.356; 95% CI 1.170-4.747; p = 0.016) were independent risk factors associated with ILD in PBC. More than a third of patients with ILD showed no respiratory symptoms, and only one ILD-related death occurred during a follow-up of 29.0 months (IQR 11.5; 38.0). Patients with ILD had better liver transplant-free survival.ILD in PBC had a benign course and was associated with a lower liver disease severity. PBC-associated ILD should be included in a list of differential diagnoses of ILD.

Interstitial lung disease preceding primary biliary cirrhosis in a male patient

A 47-year-old male was admitted with subacute onset of dry cough and fever. Chest tomography demonstrated multifocal areas of consolidation and ground glass attenuation. Cytological analysis of bronchoalveolar lavage revealed lymphocytosis and eosinophilia and anatomopathological exam of transbronchial cryobiopsy showed poorly formed non-caseous granulomas associated to interstitial lympho-plasmocitary infiltrate. The diagnosis of idiopathic granulomatous lung disease (GLD) was assumed and the patient started oral prednisolone, presenting clinical, functional and radiological improvement. Two years later, the patient was diagnosed with primary biliary cirrhosis (PBC). At this time, it was possible to associate GLD with the autoimmune hepatobiliary disease. Clinical, epidemiological and pathological aspects of this uncommon case of interstitial lung disease as first presentation of PBC in a male patient are discussed.

[Organizing pneumonia associated with primary biliary cirrhosis]

INTRODUCTION

Primary biliary cirrhosis is a hepatic auto-immune disease which is rarely associated with respiratory complications.

CASE REPORT

A 40-year-old woman had a 5-year history of primary biliary cirrhosis. Two years previously, she had begun to experience a chronic cough and dyspnea. On clinical examination, the patient had fever, jaundice and basal pulmonary crackles. Chest X-ray showed bilateral slowly migrating and spreading airspace consolidation refractory to antibiotics. Microbiological investigations evidenced no abnormalities. Routine biological studies revealed an inflammatory syndrome, a mild neutrophilic hyperleukocytosis without hypereosinophilia and a mild hepatitis picture with cholestasis. Antineutrophil cytoplasmic antibody testing and anti-nuclear factor testing were negative. Fibreoptic bronchoscopy showed diffuse bronchial inflammation with no specific pathological pattern at bronchial biopsy. The bronchoalveolar lavage revealed a mixed cellular pattern. The chest computed tomography revealed peribronchial pulmonary consolidation with septal and pleural thickening, suggestive of an organizing pneumonia. The patient was treated with oral corticosteroids which resulted in a prompt clinical improvement and complete resolution of radiographic pulmonary abnormalities within two months. Treatment continued for six months and no relapse was noticed during the six months following the end of treatment.

CONCLUSIONS

This case of organizing pneumonia highlights the importance of physicians considering this condition in women with primary biliary cirrhosis complaining of respiratory symptoms in the context of unresolved pneumonia.