Clinicopathological study of migratory lung infiltrates

Natural history of Mycobacterium fortuitum pulmonary infection presenting with migratory infiltrates: a case report with microbiological analysis

Background

Presence of Mycobacterium fortuitum in respiratory tracts usually indicates mere colonization or transient infection, whereas true pulmonary infection occurs in patients with gastroesophageal disease. However, little is known about the diagnostic indications for true M. fortuitum pulmonary infection and the natural history of the disease.

Case presentation

A 59-year-old man was referred to our hospital for treatment against M. fortuitum pulmonary infection. Fifteen years before the referral, he underwent total gastrectomy, after which he experienced esophageal reflux symptoms. After the referral, the patient was closely monitored without antimicrobial therapy because of mild symptoms and no pathological evidence of M. fortuitum pulmonary infection. During the observation, chest imaging showed migratory infiltrates. Two years after the referral, his lung biopsy specimen revealed foamy macrophages and multinucleated giant cells, indicating lipoid pneumonia. However, he was continually monitored without any treatment because there was no evidence of nontuberculous mycobacterial infection. Four years after the referral, he developed refractory pneumonia despite receiving adequate antibiotic therapy. After confirmation of granulomatous lesions, multiple antimicrobial therapy for M. fortuitum resulted in a remarkable improvement with no exacerbation for over 5 years. Random amplified polymorphic DNA polymerase chain reaction analysis revealed identical M. fortuitum strains in seven isolates from six sputum and one intestinal fluid specimens obtained during the course of the disease.

Conclusions

We have described a patient with M. fortuitum pulmonary infection who presented with migratory infiltrates. The pathological evidence and microbiological analysis suggested that M. fortuitum pulmonary infection was associated with lipoid pneumonia and chronic exposure to gastrointestinal fluid. Therefore, physicians should carefully monitor patients with M. fortuitum detected from lower respiratory tract specimens and consider antimicrobial therapy for M. fortuitum infection when the patient does not respond to adequate antibiotic therapy against common pneumonia pathogens.

Migrating persistent pulmonary consolidation in a child: A case of follicular bronchiolitis

Migrating pulmonary lesions in children are uncommon, and most are caused by eosinophilic lung disease and parasite, fungus, and tuberculosis infections. A 12-year-old boy was referred to our hospital because of an abnormal chest x-ray. Serial computed tomography scans performed over several months showed a migrating pulmonary consolidation in the left lung, although the patient remained asymptomatic. Finally, surgical biopsy was performed and follicular bronchiolitis was diagnosed. The consolidation disappeared 17 months later without treatment, and the patient has remained asymptomatic. Primary follicular bronchiolitis could be considered as one of the differential diagnosis in patients with pulmonary reticulo-nodular consolidation. It should also be noted that follicular bronchiolitis can migrate. Pediatr Pulmonol. 2017;52:E22-E25. © 2016 Wiley Periodicals, Inc.

Pulmonary migratory infiltrates due to mycoplasma infection: case report and review of the literature

Pulmonary migratory infiltrates (PMI) are observed in a few diseases. We report here a case of PMI attributed to Mycoplasma pneumonia (Mp) infection. The patient's past medical history was characterized by fleeting and/or relapses of patchy opacification or infiltrates of parenchyma throughout the whole lung field except for left lower lobe radiographically. Serological assays revealed an elevation of IgG antibody specific to Mp and its fourfold increase in convalescent serum. Histopathological findings showed polypoid plugs of fibroblastic tissue filling and obliterating small air ways and interstitial infiltrates of mononuclear inflammatory cells in the vicinal alveolar septa. The patient was treated with azithromycin which resulted in a dramatic improvement clinically and imageologically. In spite of the increasing incidence of Mp, the possible unusual imaging manifestation and underlying mechanism haven't attracted enough attention. To our knowledge, there are rare reports of such cases.

The spectrum of presentations of cryptogenic organizing pneumonia in high resolution computed tomography

BACKGROUND

Various radiologic patterns of cryptogenic organizing pneumonia (COP) in X-rays have been reported for more than 20 years, and later, in computed tomography scans. The aim of the present study was to describe the spectrum of radiologic findings on high resolution computed tomography (HRCT) scans in patients with COP.

MATERIAL/METHODS

HRCT scans of 31 sequential patients (mean age: 54.3±11 years; 55% male) with biopsy-proven COP in a tertiary lung center between 2009 and 2012 were reviewed by two experienced pulmonary radiologists with almost perfect interobserver agreement (kappa=0.83). Chest HRCTs from the lung apex to the base were performed using a 16-slice multi-detector CT scanner.

RESULTS

The most common HRCT presentation of COP was ground-glass opacity (GGO) in 83.9% of cases, followed by consolidation in 71%. Both findings were mostly asymmetric bilateral and multifocal. Other common findings were the reverse halo (48.4%), parenchymal bands (54.8%) and subpleural bands (32.3%). Pulmonary nodules were found in about one-third of patients and were frequently smaller than 5 mm in diameter. Both GGOs and consolidations were revealed more often in the lower lobes.

CONCLUSIONS

The main presentations of COP on HRCT include bilateral GGOs and consolidations in the lower lobes together with the reverse halo sign.

[Post-infectious bronchiolitis obliterans]

Post-infectious bronchiolitis obliterans (BO) is characterized by inflammatory and fibrotic lesions of small airways following a pulmonary infection and leading to some degree of airway obstruction. It represents a rare cause of chronic obstructive pulmonary disease, and is probably underestimated, especially when the lesions affect small areas of the lungs. The clinical features differ between children and adults. In children, adenovirus is the most frequently involved infectious agent, especially the more virulent serotypes 3, 7 and 21. The clinical and radiological signs vary widely and the functional outcome depends on the extent of the lung injury. The diagnosis is based on the medical history, the CT-scan and functional data. The treatment is symptomatic. The most severe forms may result in chronic respiratory insufficiency. In adults, the frequency of obstructive injuries of the small airways in the context of lung infection is unclear. Parenchymal lesions are often present, resulting in BO with organizing pneumonia. These lesions alter the clinical presentation and the radiographic features of the initial infectious disease and often prove difficult to diagnose and manage. Several authors have published clinical cases describing presumed efficacy of systemic corticosteroids but the data are scarce.

Bronchiolitis obliterans syndrome (BOS), bronchiolitis obliterans organizing pneumonia (BOOP), and other late-onset noninfectious pulmonary complications following allogeneic hematopoietic stem cell transplantation

Pulmonary dysfunction is a significant complication following allogeneic hematopoietic stem cell transplantation (HSCT), and is associated with significant morbidity and mortality. Effective antimicrobial prophylaxis and treatment strategies have increased the incidence of noninfectious lung injury, which can occur in the early posttransplant period or in the months and years that follow. Late-onset noninfectious pulmonary complications are frequently encountered, but diagnostic criteria and terminology for these disorders can be confusing and therapeutic approaches are suboptimal. As a consequence, inaccurate diagnosis of these conditions may hamper the appropriate data collection, enrollment into clinical trials, and appropriate patient care. The purpose of this review is to clarify the pathogenesis and diagnostic criteria of representative conditions, such as bronchiolitis obliterans syndrome and bronchiolitis obliterans organizing pneumonia, and to discuss the appropriate diagnostic strategies and treatment options.

Chlamydial infection showing migratory pulmonary infiltrates

A 70-year old man was admitted to our hospital because of nonproductive cough, fever and increasing dyspnea associated with alveolar opacities on chest roentgenogram, which later migrated to previously unaffected areas. The diagnosis of Chlamydial pneumonitis was made on serological grounds. Organizing pneumonia was documented by transbronchial lung biopsies and the subsequent course was satisfactory under minocycline therapy. Chlamydial infection should be considered in the differential diagnosis of migratory pulmonary infiltrates.

Pulmonary Lesions Associated With Visceral Larva Migrans Due toAscaris suumorToxocara canis: Imaging of Six Cases

OBJECTIVE

The objective of our study was to evaluate chest radiographic and CT findings of patients with pulmonary lesions associated with visceral larva migrans due to Ascaris suum or Toxocara canis. CT investigation was focused on the location, size, contour, and internal features of the lesions; migration of lesions; mediastinal lymphadenopathy; and pleural effusion.

CONCLUSION

Pulmonary visceral larva migrans appears on CT as multifocal subpleural nodules with halo or ground-glass opacities and ill-defined margins.

[Cryptogenic organising pneumonia]

Organising Pneumonia (formerly called Bronchiolitis Obliterans with Organising Pneumonia) is a particular form of inflammatory and fibroproliferative lung disease. Its idiopathic form called Cryptogenic Organising Pneumonia, was recently defined by an ATS/ERS consensus conference. The disease onset is subacute with cough, dyspnea, fever, asthenia, weight loss, crackles, and elevation of biological inflammatory markers. Bronchoalveolar lavage reveals a mixed alveolitis with elevated lymphocyte, neutrophil, and eosinophil counts. Chest imaging usually shows multifocal alveolar opacities predominating in the subpleural regions, often with a migratory pattern. Lung biopsy reveals budding connective tissue filling the distal airspaces. Diagnosis is established by combining clinical, radiological and histological criteria. Similarities with other disease processes can lead to delayed or erroneous diagnosis. Most patients respond well to corticosteroid therapy. Relapses are frequent but can generally be controlled with moderate doses of prednisone and do not worsen the prognosis. The therapeutic strategy aims at reducing the steroid doses while maintaining an optimal disease control.

Cryptogenic organizing pneumonia

Cryptogenic organizing pneumonia is a rare, distinct disorder that is sufficiently different from the other diseases in the group of idiopathic interstitial pneumonias to be designated as a separate entity. In its most typical presentation, it is characterized by dyspnea and cough, with multiple patchy alveolar opacities on pulmonary imaging. Definite diagnosis is obtained by the finding of buds of granulation tissue in the distal airspaces at lung biopsy. No cause (as infection, drug reaction, or associated disease as connective tissue disease) is found. Corticosteroid treatment is rapidly effective, but relapses are common on reducing or stopping treatment.

Association between acute and chronic graft-versus-host disease and bronchiolitis obliterans organizing pneumonia in recipients of hematopoietic stem cell transplants

Bronchiolitis obliterans organizing pneumonia (BOOP) has been reported following hematopoietic stem cell (HSC) transplantation, but the clinical features and risk factors for this disorder have not been well characterized. This case-control study of 49 patients with histologic BOOP and 161 control subjects matched by age and year of transplantation describes the clinical features and analyzes the risk factors for BOOP following HSC transplantation. Data on clinical features and outcome were collected by chart review. Odds ratios, estimating the relative risk of BOOP in allogeneic HSC recipients, were calculated by conditional logistic regression with adjustment for potential confounding factors. Clinical features of BOOP in this population were similar to idiopathic BOOP and BOOP occurring in other disease settings. There was an association between acute and chronic graft-versus-host disease (GVHD) and the subsequent development of BOOP (odds ratios, 3.8 [95% CI, 1.2 to 12.3] and 3.1 [95% CI, 1.1 to 9.2], respectively). Patients with BOOP were more likely to have acute GVHD involving the skin (odds ratio, 4.6; P =.005) and chronic GVHD involving the gut (odds ratio, 6.6; P =.018) and oral cavity (odds ratio, 5.9; P =.026). This study shows that histologic BOOP following HSC transplantation has clinical features that resemble idiopathic BOOP and is strongly associated with prior acute and chronic GVHD. These results have important implications for the care of patients who develop respiratory symptoms after HSC transplantation and may help elucidate the pathogenesis of idiopathic BOOP.

Levitating consolidation in eosinophilic lung disease

The authors describe a case of histologically proven eosinophilic lung disease in a patient with ulcerative colitis. The patient was not using sulfasalazine or other medications known to be associated with lung disease. Serial chest radiographs revealed an unusual pattern of levitating consolidation.

High-resolution CT of idiopathic interstitial pneumonias

Important recent changes have occurred in our understanding of the IIPs. IPF (characterized histologically as UIP) is recognized as a progressive disease with a relatively poor prognosis, and with a characteristic CT appearance. The radiologist must be able to distinguish between UIP and the other IIPs. Complications of IPF include accelerated progression, lung cancer, and secondary infection. NSIP has a better prognosis than IPF, and has ground-glass attenuation as its salient CT feature. COP (formerly known as BOOP) is included as an IIP because its clinical, physiologic, and imaging features overlap with those of the other IIPs. It is characterized on CT by consolidation and ground-glass attenuation. AIP is the idiopathic form of ARDS. LIP and DIP are less common IIPs, both characterized by ground-glass attenuation.

Recurrent flu-like illness with migrating pulmonary infiltrates of unknown aetiology

Migrating pulmonary infiltrates present a difficult diagnostic and therapeutic challenge. We report on eight patients (mean age 51 years, range 32-78 years, with a prolonged history of migrating pulmonary infiltrates of unknown aetiology despite a very elaborate search for infectious causes, hypersensitivity pneumonitis or inhalation fever due to occupational or domestic exposure to fungi, or to other environmental causes, and for humoral or cellular immunological incompetence. These patients (one male, seven females) presented with recurrent episodes (mean 6, range 2-13) of a flu-like illness, often with cough, wheezing and pleuritic chest pain, but without systemic involvement. Previous medical histories were unremarkable. There was no relation with smoking habits, occupation, drug use or other possible exposures. Biochemical data were non-specific. There was no peripheral nor pulmonary eosinophilia; total IgE was normal, with negative RASTs and precipitins to a variety of antigens. Cultures and serological tests for bacteria, viruses, fungi, etc were non-contributory. Chest X-ray and computed tomography (CT) scan showed bilateral migratory pulmonary infiltrates, with a predilection for the middle and lower lung zones, often with a minor-to-moderate pleural effusion. Lung function tests were usually normal; at the most a slight decrease in diffusing capacity was noted in some patients. There was no or only a slight response to antimicrobials; systemic corticosteroids were not given. Further evolution was benign with patients being asymptomatic between the episodes. Despite elaborate investigations, the cause of these 'pneumonias' remains frustratingly unknown.

Mycoplasma pneumoniae-associated bronchiolitis causing severe restrictive lung disease in adults: report of three cases and literature review

STUDY OBJECTIVES

To characterize adult Mycoplasma pneumoniae-induced bronchiolitis requiring hospitalization.

DESIGN

We encountered an adult patient with severe bronchiolitis in the absence of pneumonia due to M. pneumoniae. To determine the relative frequency of such a condition, we retrospectively reviewed the medical records of adults over a 4-year period with a hospital discharge diagnosis of "bronchiolitis" from a university hospital.

SETTING

University Hospital of the University of Colorado Health Sciences Center, Denver, CO.

STUDY SUBJECTS

From 1994 to 1998, 10 adult inpatients were identified with a diagnosis of bronchiolitis. There were two with respiratory bronchiolitis, one with panbronchiolitis, one patient with bronchiolitis obliterans organizing pneumonia (BOOP), and six with acute inflammatory bronchiolitis. Including the initial patient, three had a definitive clinical diagnosis of Mycoplasma-associated bronchiolitis.

RESULTS

The three adult patients with bronchiolitis due to M. pneumoniae are unusual because they occurred in the absence of radiographic features of a lobar or patchy alveolar pneumonia. Hospital admission was occasioned by the severity of symptoms and gas exchange abnormalities. One patient had bronchiolitis as well as organizing pneumonia (BOOP) that responded favorably to corticosteroid treatment. The other two had high-resolution CT findings diagnostic of an acute inflammatory bronchiolitis. One of the patients with inflammatory bronchiolitis had an unusual pattern of marked ventilation and perfusion defects localized predominantly to the left lung. All three had restrictive ventilatory impairment on physiologic testing.

CONCLUSIONS

In adults, Mycoplasma-associated bronchiolitis without pneumonia is rarely reported, but in hospitalized patients, it may be more common than expected and may be associated with severe physiologic disturbances.

Idiopathic chronic eosinophilic pneumonia. A clinical and follow-up study of 62 cases. The Groupe d'Etudes et de Recherche sur les Maladies "Orphelines" Pulmonaires (GERM"O"P)

Idiopathic chronic eosinophilic pneumonia (CEP) is a rare disorder of unknown cause with nonspecific respiratory and systemic symptoms but rather characteristic peripheral alveolar infiltrates on imaging, developing mainly in women and in atopic subjects. The disorder is highly responsive to oral corticosteroid therapy, but relapses are frequent on reducing or stopping treatment. The long-term course of the disease and data regarding outcome, particularly the need for prolonged oral corticosteroid therapy and the development of severe asthma, are somewhat contradictory. A multicentric retrospective study was conducted in an attempt to describe better the initial features and, above all, the later course of CEP in a large homogeneous series of 62 stringently selected patients of whom 46 were followed for more than 1 year. The prevalence of smokers was low (6.5%) and about half of our patients (51.6%) had a previous, and often prolonged, history of asthma. The clinical and roentgenographic features were in keeping with previous studies, but we found that computed tomography could disclose ground glass opacities not detected by X-ray, and that migratory infiltrates before treatment were more frequent (25.5%) than reported previously. The bronchoalveolar lavage cellular count always showed a striking eosinophilic pattern, thus allowing distinction between CEP and cryptogenic organizing pneumonia, both syndromes sharing many common clinical and imaging features. About two-thirds of the patients (68%) showed a ventilatory defect in pulmonary function tests, with about one-half of these presenting with an obstructive pattern, sometimes without previous asthma. Along with the submucosal eosinophilic infiltration noted in 2 patients without ventilatory defect, this is strong evidence to confirm that CEP is not only an alveolointerstitial but also an airway disease. The dramatic response to oral corticosteroid therapy was observed in all treated patients. Although only 1 patient initially treated for less than 6 months did not relapse, longer oral corticosteroid therapy in no way provided protection from further relapses. We thus propose to try to wean oral corticosteroid therapy after 6 months in patients without severe asthma, because recurrences remain responsive to oral steroids. However, prolonged oral corticosteroid therapy was necessary in the majority of patients, with 68.9% of those followed for more than 1 year still on oral corticosteroid therapy at the last follow-up, either because of relapse or because of severe asthma.

Cryptogenic organizing pneumonia. A report of 25 cases and a review of the literature

Cryptogenic organizing pneumonia (COP), also known as bronchiolitis obliterans organizing pneumonia (BOOP), is an uncommon lung disease characterized by the presence of granulation tissue within the alveolar ducts and alveoli. Because of the limited published literature on this topic and limited information on outcome we reviewed our own experience over an 8-year period and also critically evaluated the literature. We reviewed all cases of COP diagnosed from 1985 through 1992 at Vancouver General Hospital: 25 patients (14 male, 11 female) aged 20-77 years (mean, 49 yr, SD +/- 17 yr). Nine patients had myeloproliferative disorder, including 6 who had allogenic bone marrow transplants; 2 patients had connective tissue disease; and 14 patients had no underlying disease (idiopathic). Data retrieved retrospectively from clinical records included demographics, risk factors, symptoms, chest radiographs, computerized tomograms, lung function tests, therapy prescribed, and response to therapy. Symptoms included dyspnea and cough (n = 15) (60%), cough only (n = 10) (40%), and fever (n = 15) (60%). Twenty-two patients were diagnosed by open lung biopsy and 3 by transbronchial biopsy. Lung imaging showed bilateral patchy airspace consolidation or nodular opacities as the main finding in 22 patients. Pulmonary function tests showed a combined restrictive and obstructive pattern. All patients received prednisone therapy except 1 patient whose idiopathic findings resolved completely with minimal treatment. Eight patients died, including 4 of the 9 patients with myeloproliferative disorder--2 from a combination of respiratory failure due to COP and graft-versus-host disease. One of 2 patients with connective tissue disease died, and 3 of 14 patients with idiopathic COP died. COP is an uncommon condition but should be considered in patients with bilateral airspace disease, especially those who fail to respond to antibiotics for presumed pneumonia. Although pulmonary function tests and CT scan findings in conjunction with the clinical features usually suggest the diagnosis, definite confirmation usually requires either open lung biopsy or transbronchial biopsy. Histologic confirmation of the diagnosis is particularly warranted as therapy with corticosteroids is usually needed for a number of months. The prognosis is excellent with idiopathic cases but more guarded especially when COP is associated with lymphoproliferative or connective tissue disease.

The histological diagnosis of clinically documented cases of cryptogenic organizing pneumonia: diagnostic features in transbronchial biopsies

Eleven cases of clinically diagnosed cryptogenic organizing pneumonia were examined in order to establish the histological features found at transbronchial biopsy and to correlate this with open lung biopsy which followed in six cases. The essential pathological feature was the presence of buds of granulation tissue (Masson bodies) indicating organization of a persistent exudate by fibroblasts and capillaries within alveoli, with preservation of the alveolar architecture. In addition, both acute and chronic inflammatory cells were present in the interstitium. These features, combined with the clinical history, were sufficient for a diagnosis in seven of the 11 cases on transbronchial biopsies. Four biopsies lacked these features. Patients proceeded to open lung biopsy in addition to the two with histological features of cryptogenic organizing pneumonia on transbronchial biopsy, but where the clinician wanted to eliminate other pathology because of rapid clinical deterioration. Five of the six cases coming to open lung biopsy confirmed cryptogenic organizing pneumonia with Masson bodies within alveoli, but changes were focal in three with very few Masson bodies in one. One case which had the features on transbronchial biopsy lacked them in the open lung biopsy. Transbronchial biopsy, therefore, can yield diagnostic material in the majority of patients with cryptogenic organizing pneumonia while open lung biopsy, which is considered the gold standard for interstitial lung disease, may yield negative results because of sampling error and the rapid evolution and changing pattern of the disease.

Levitating lung lesions due to bronchiolitis obliterans organizing pneumonia

A 68-year-old man developed symmetrical bibasal infiltrates. Transbronchial lung biopsy specimen demonstrated abnormalities consistent with bronchiolitis obliterans organizing pneumonia (BOOP). The infiltrates appeared to migrate cephalad over a period of months, gradually disappearing after reaching the pulmonary apices.

The usefulness of step sectioning of transbronchial lung biopsy specimen in diagnosing sarcoidosis

To evaluate the usefulness of step sectioning of the transbronchial lung biopsy (TBLB) specimens obtained from patients with suspected sarcoidosis, we examined all TBLB specimens obtained from 132 patients who were diagnosed clinically as having sarcoidosis at our institute. When routine sections of TBLB specimens did not show sarcoid granuloma, we prepared additional serial sections from each block and stained every fifth section with hematoxylineosin (step sectioning). All step sections were examined histologically. With the aid of step sectioning, the diagnostic yield of sarcoidosis increased from 38 percent (18/47) to 47 percent (22/47) in stage 1 patients, and from 57 percent (37/65) to 82 percent (53/65) in stage 2 patients. All of the newly detected granulomas were identified between the first and seventh sections. We conclude that step sectioning is useful method in diagnosing sarcoidosis.

BOOP and COP

BOOP and COP are essentially the same condition and represent one of many ways in which the lung may respond to an inflammatory stimulus. Some underlying causes of BOOP have been identified but in many cases no cause can be found. The clinical and radiological features are of a pneumonic illness that responds to corticosteroids rather than antibiotics, but as milder cases are being identified the clinical spectrum is widening. Most cases can be confidently diagnosed only by open lung biopsy, but bacteriological lavage and transbronchial biopsy followed by a trial of steroids may sometimes be considered.