Title: 67 Year Old Woman with an Abnormal Chest CT
167 Year Old Woman with an Abnormal Chest CT
- Andrea Glassberg
- March 11, 2003
2(No Transcript)
3Clinical 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.
4Past Medical History
- Breast Cancer (1991), S/P lumpectomy, XRT
- Mediastinal Mass (1999), initially believed to be
metastatic disease - DM II
- HTN
5Medications
- Losartan
- Glucophage
- Glyburide
- Clonidine
- HCTZ
- Nifedipine
- Celebrex
- Prinomastat (metalloprotease inhibitor)
6Exam
- Obese, tired appearing AA woman
- Afebrile
- 150/85
- HR 125
- RR 22
- O2 sat 91 on RA
- Coarse inspiratory crackles
- No peripheral edema
7Additional Info?
8PFT 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
9What is your differential diagnosis?
10BAL
- Hazy
- 405 RBC
- 395 WBC
- 16 N
- 34 L
- 43 M/H/M
- 6 Eos
- Cx neg
11Transbronchial Biopsy
- The biopsy shows numerous polypoid plugs of
granulation tissue within the airspaces, type II
cell hyperplasia, and a sparse interstitial
lymphocytic infiltrate.
12What would you do now?
13Interval 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.
14PFT 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
15Interval History
- The dose of prednisone was tapered from 60mg qd
to 20mg qd over 4 months. The patient then self
d/cd the medication.
16PFT 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
17COP
- Cryptogenic Organizing Pneumonitis
18Classification 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
19BOOP 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
20Epidemiology 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.
21Duration of Symptoms
King, Cryptogenic Organizing Pneumonia. UpToDate
online 11.1
22Clinical 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)
23Imaging
- 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)
25Physiology
- Moderate restrictive disorder
- Diffusion abnormality
- Resting hypoxemia common
- Obstruction rare
26King, Cryptogenic Organizing Pneumonia. UpToDate
online 11.1
27King, Cryptogenic Organizing Pneumonia. UpToDate
online 11.1
28King, Cryptogenic Organizing Pneumonia. UpToDate
online 11.1
29Treatment
- 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.
30Outcome
King, Cryptogenic Organizing Pneumonia. UpToDate
online 11.1
31Relapses
Am J Respir Crit Care Med Vol 162. pp 571577,
2000
32Relapses
Am J Respir Crit Care Med Vol 162. pp 571577,
2000
33Relapses
Am J Respir Crit Care Med Vol 162. pp 571577,
2000
34COP 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
35References
- 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.