Fibrosing alveolitis: its occurrence, roentgenographic, and pathologic features in von Recklinghausen's neurofibromatosis

Neurofibromatosis-Associated Diffuse Lung Disease: A Case Report and Review of the Literature

Neurofibromatosis-1 or von Recklinghausen’s disease is an autosomal dominant disorder. Cafe au lait macules are generally the initial presenting feature of the disease, and there can be varying degrees of involvement of the skeletal, neurological, and pulmonary organ systems as the disease progresses.

The existence of neurofibromatosis-associated diffuse lung disease (NF-DLD) as a separate entity has always been questioned and, is often attributed to cigarette smoking, rather than a manifestation of NF-1.

A 59-year-old male with a history of neurofibromatosis presented with shortness of breath and ataxia for 10 days. Exam findings were pertinent for tachycardia, tachypnea, and diffuse cutaneous neurofibromas. Workup showed white blood count (WBC) of 15.9 k/ul, electrocardiogram with biatrial enlargement and right axis deviation, and a chest X-ray showed left lower lobe infiltrate concerning for pneumonia. Computed tomography (CT) scan of the chest revealed left basilar consolidation with surrounding ground-glass opacities and innumerable bilateral thin-walled cysts. The latter finding raised suspicion for NF-DLD.

The patient was evaluated by pulmonology with recommendations to continue treatment for pneumonia and follow-up with high-resolution CT of the chest and complete pulmonary function testing in 12 weeks. He was discharged in a stable condition after five days of hospitalization.

NF-DLD is a pulmonary manifestation of NF-1 with non-specific respiratory symptoms and a characteristic pattern of upper lobe cystic and basilar interstitial lung disease. It usually presents in the 4th or 5th decade, earlier in tobacco users, but a few pediatric cases have also been reported.

The presentation of NF-DLD can be variable, ranging from dyspnea, chest pain, chronic cough, hemoptysis, or an incidental finding on CT. Multiple complications, including spontaneous pneumothorax due to the rupture of subpleural blebs, pulmonary hypertension, and chronic respiratory failure, are associated with NF-DLD.

NF-DLD can be prevented by smoking cessation but, there are no known modalities for treatment; however, complications can be managed symptomatically.

This case illustrates the diagnostic challenge that NF-DLD represents to clinicians. The patient's CT from two years ago showed emphysematous changes along with scattered fibrosis and scarring, and no cystic changes were mentioned, unlike his latest CT, which showed innumerable cysts. This patient had a history of smoking, which likely put him at a higher risk for the development of cysts. However, he quit smoking 10 years prior, which suggests that his lung changes are not secondary to cigarette smoke, further confirming our suspicion for NF-DLD. Although routine screening is not implemented due to the rarity of the disease, NF-DLD should not be ruled out in patients with NF-1 presenting with pulmonary symptoms until a high-resolution computed tomography (HRCT) is obtained.

Multiple bilateral trigger fingers in a child with neurofibromatosis type I following an acute viral infection: A case report

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We report on a case of multiple bilateral trigger fingers in a child with NF I.

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Triggering developed while the child was on chemotherapy following an acute viral infection.

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The pathogenesis is discussed.

Introduction

Triggering of the fingers in children is an uncommon entity. A review of the literature on the topic did not reveal any reports of multiple triggering in patients with neurofibromatosis.

Case report

Our patient is a known case of neurofibromatosis type I (NF 1). At the age of 4 years, the child required chemotherapy to treat symptomatic bilateral optic glioma. Chemotherapy was complicated by severe viral upper respiratory tract infection with concurrent multi-joint synovitis and mild triggering of the fingers. A second course of chemotherapy was required 2 years later. This was also complicated by a viral infection, joint synovitis, and worsening of the triggering. Surgical release of the A1 and part of the A2 pulleys was curative.

Discussion

Two factors contributed to the development of multiple triggering in our pediatric patient. The NF 1 itself predisposes to fibrosis. The second factor is the synovitis that accompanied the acute viral infection.

Conclusion

We report on a case of multiple bilateral trigger fingers in a child with NF 1 following an acute viral infection and discuss the pathogenesis.

Desquamative interstitial pneumonia in a non-smoker with neurofibromatosis type 1 (Von Recklinghausen syndrome)

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder with multiple systemic manifestations. Pulmonary involvement has been reported in the form of interstitial fibrosis, emphysema, pulmonary hypertension and thoracic neoplasm. We report a case of desquamative interstitial pneumonia in a non-smoker with NF1.

Genetic interstitial lung disease

The interstitial lung diseases (ILDs), or diffuse parenchymal lung diseases, are a heterogeneous collection of more than 100 different pulmonary disorders that affect the tissue and spaces surrounding the alveoli. Patients affected by ILD usually present with shortness of breath or cough; for many, there is evidence of pulmonary restriction, decreased diffusion capacity, and radiographic appearance of alveolar and/or reticulonodular infiltrates. This article reviews the inherited ILDs, with a focus on the diseases that may be seen by pulmonologists caring for adult patients. The authors conclude by briefly discussing the utility of genetic testing in this population.