67 Year Old Woman with an Abnormal Chest CT - PowerPoint PPT Presentation

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67 Year Old Woman with an Abnormal Chest CT

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A 67 year old woman with a history of breast cancer and ... Afebrile. 150/85. HR 125. RR 22. O2 sat 91% on RA. Coarse inspiratory crackles. No peripheral edema ... – PowerPoint PPT presentation

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Title: 67 Year Old Woman with an Abnormal Chest CT


1
67 Year Old Woman with an Abnormal Chest CT
  • Andrea Glassberg
  • March 11, 2003

2
(No Transcript)
3
Clinical Presentation
  • A 67 year old woman with a history of breast
    cancer and mediastinal mass presented to chest
    clinic with an abnormal CT scan of the chest.
  • She reported three months of progressive dyspnea
    on exertion and dry cough without chest pain or
    wheezing.

4
Past Medical History
  • Breast Cancer (1991), S/P lumpectomy, XRT
  • Mediastinal Mass (1999), initially believed to be
    metastatic disease
  • DM II
  • HTN

5
Medications
  • Losartan
  • Glucophage
  • Glyburide
  • Clonidine
  • HCTZ
  • Nifedipine
  • Celebrex
  • Prinomastat (metalloprotease inhibitor)

6
Exam
  • Obese, tired appearing AA woman
  • Afebrile
  • 150/85
  • HR 125
  • RR 22
  • O2 sat 91 on RA
  • Coarse inspiratory crackles
  • No peripheral edema

7
Additional Info?
8
PFT 9-8-02
  • VITAL CAPACITY 1.9 LITERS 71
  • EXPIRATORY RESERVE VOL 0.2 LITERS 33
  • TLC BY SINGLE BREATH 2.9 LITERS 56
  • TLC BY HE RE-BREATHING 3.6 LITERS 81
  • DIFFUSING CAP, HGB COR 15.1 59
  • DIF. CAP. HGB COR/TLC 5.2
    102
  • FORCED VITAL CAPACITY 2.0 LITERS 74
  • FORCED EXPIRED VOL 1 S 1.6 LITERS 77
  • EXPIRED 1 SECOND 81
    106
  • FEF 25-75 1.6 L/SEC 73
  • FEF 25 3.8 L/SEC 72
  • FEF 50 2.2 L/SEC 50
  • FEF 75 0.6 L/SEC 28

9
What is your differential diagnosis?
10
BAL
  • Hazy
  • 405 RBC
  • 395 WBC
  • 16 N
  • 34 L
  • 43 M/H/M
  • 6 Eos
  • Cx neg

11
Transbronchial Biopsy
  • The biopsy shows numerous polypoid plugs of
    granulation tissue within the airspaces, type II
    cell hyperplasia, and a sparse interstitial
    lymphocytic infiltrate.

12
What would you do now?
13
Interval History
  • The patient was started on Prednisone, 60 qd and
    had almost complete resolution of her symptoms
    within two weeks. However, she subsequently
    developed severe side effects from prednisone,
    including candida esophagitis, and difficult to
    control hyperglycemia.

14
PFT 11-12-02
  • TLC BY SINGLE BREATH 3.2 LITERS 62
  • DIF. CAP. HGB UNCOR. 15.4 61
  • DIF CAP HGB UNCOR/TLC 4.8 94
  • FORCED VITAL CAPACITY 1.8 LITERS 69
  • FORCED EXPIRED VOL 1 S 1.5 LITERS 75
  • EXPIRED 1 SECOND 84 110
  • FEF 25-75 1.8 L/SEC 83
  • FEF 25 4.3 L/SEC 80
  • FEF 50 2.5 L/SEC 56
  • FEF 75 0.7 L/SEC 34
  • PO2 ARTERIAL BLOOD GAS 124 MMHG
  • PCO2 ARTERIAL BL. GAS 32 MMHG
  • PH, ARTERIAL BLOOD GAS 7.48

15
Interval History
  • The dose of prednisone was tapered from 60mg qd
    to 20mg qd over 4 months. The patient then self
    d/cd the medication.

16
PFT 2-18-03
  • VITAL CAPACITY 2.3 LITERS
    86
  • TLC BY SINGLE BREATH 3.2 LITERS 60
  • TOTAL LUNG CAP. (BOX) 3.8 LITERS 86
  • TLC BY HE RE-BREATHING 3.9 LITERS 87
  • DIFFUSING CAP, HGB COR 17.0
    67
  • DIF. CAP. HGB UNCOR. 15.2
    60
  • DIF. CAP. HGB COR/TLC 5.4
    107
  • FORCED VITAL CAPACITY 2.3 LITERS 87
  • FORCED EXPIRED VOL 1 S 1.8 LITERS 89
  • EXPIRED 1 SECOND 79
    104
  • FEF 25-75 1.7 L/SEC
    80
  • FEF 25 4.9 L/SEC
    92
  • FEF 50 2.5 L/SEC
    55
  • FEF 75 0.5 L/SEC
    25
  • AIRWAY RESISTANCE 4.2 CMH2O/LPS

17
COP
  • Cryptogenic Organizing Pneumonitis

18
Classification of BOOP
  • Idiopathic (COP)
  • Rapidly Progressive
  • Focal Nodular
  • Postinfection
  • Drug Related
  • Rheumatologic/CTD
  • Immunologic
  • Organ Transplantation
  • Radiotherapy
  • Environmental Exposures
  • Miscellaneous
  • IBD
  • Lymphoma and cancer
  • HIV
  • MDS
  • Hunner Interstitial Cystitis
  • Chronic thyroiditis and ETOH cirrhosis
  • Seasonal syndrome with cholestasis
  • PBC
  • CABG

19
BOOP Syndrome
  • Radiation therapy to the breast within 12 months,
  • 2) General and/or respiratory symptoms lasting
    for at least 2 weeks,
  • Radiographic lung infiltrates outside the
    radiation port
  • 4) No evidence of a specific cause

20
Epidemiology of COP
  • Six to seven per 100,000 hospital admissions was
    found at a major teaching hospital.
  • Onset typically in the fifth or sixth decades.
  • Both genders affected equally.
  • Short duration of symptoms (lt3 mo).
  • Cigarette smoking is not a precipitating factor.

21
Duration of Symptoms
King, Cryptogenic Organizing Pneumonia. UpToDate
online 11.1
22
Clinical Findings
  • Often mimics CAP
  • Fever
  • Malaise
  • Fatigue
  • Cough
  • Persistent nonproductive cough
  • Dyspnea with exertion
  • Weight loss of greater than 10 pounds (57 )
  • Inspiratory rales (74)
  • Normal lung exam (25)

23
Imaging
  • Bilateral, diffuse alveolar opacities in the
    presence of normal lung volumes.
  • A peripheral distribution of the opacities,
    similar to that seen in chronic eosinophilic
    pneumonia.
  • Recurrent or migratory pulmonary opacities (up to
    50 ).
  • Irregular linear or nodular interstitial
    infiltrates rarely the only radiographic
    manifestation.
  • Honeycombing rare, occurs as a late manifestation
    in patients with progressive disease.
  • Rare features
  • pleural effusion
  • pleural thickening
  • Hyperinflation
  • cavities

24
(No Transcript)
25
Physiology
  • Moderate restrictive disorder
  • Diffusion abnormality
  • Resting hypoxemia common
  • Obstruction rare

26
King, Cryptogenic Organizing Pneumonia. UpToDate
online 11.1
27
King, Cryptogenic Organizing Pneumonia. UpToDate
online 11.1
28
King, Cryptogenic Organizing Pneumonia. UpToDate
online 11.1
29
Treatment
  • Prednisone 1-1.5mg/kg for 6-8 weeks.
  • Taper slowly over a period of 6 months to 1 year.
  • Cyclophosphamide as a steroid sparing agent.

30
Outcome
King, Cryptogenic Organizing Pneumonia. UpToDate
online 11.1
31
Relapses
Am J Respir Crit Care Med Vol 162. pp 571577,
2000
32
Relapses
Am J Respir Crit Care Med Vol 162. pp 571577,
2000
33
Relapses
Am J Respir Crit Care Med Vol 162. pp 571577,
2000
34
COP Pearls
  • Diagnosis of exclusion (BOOP w/o cause)
  • Histologic appearance is granulomatous
    infiltration of distal airspaces
  • Lung architecture is preserved
  • Responsive to steroids
  • Relapses common
  • No need to treat to prevent relapses

35
References
  • Crestani, et al., Bronchiolitis Obliterans
    Organizing Pneumonia Syndrome Primed by Radiation
    Therapy to the Breast. Am J Respir Crit Care Med
    (1998)15819291935.
  • Epler, Bronchiolitis Obliterans Organizing
    Pneumonia. Arch Intern Med. (2001) 161158-164.
  • King, Cryptogenic Organizing Pneumonia. UpToDate
    online 11.1.
  • Lazor, et al., Cryptogenic Organizing Pneumonia,
    Characteristics of Relapses in a Series of 48
    Patients, Am J Respir Crit Care Med (2000) 162
    571577.
  • Mokhtari, et al., Bronchiolitis obliterans
    organizing pneumonia in cancer a case series.
    Respiratory Medicine, (2002) 96 280-286.
  • Oikonomou and Hansell, Organizing pneumonia the
    many morphological faces. Eur Radiol (2002)
    1214861496.
  • Takigawa, et al., Bronchiolitis Obliterans
    Organizing Pneumonia Syndrome In
    Breast-conserving Therapy For Early Breast
    Cancer Radiation-induced Lung Toxicity. Int. J.
    Radiation Oncology Biol. Phys. (2000) 48
    751755.
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