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Weekly Chest CasesArchive of Old Cases

Case No : 954 Date 2016-02-08

  • Courtesy of Soon Ho Yoon, Hyun Ju Lee, Jin Mo Goo / Seoul National University Hospital
  • Age/Sex 29 / M
  • Chief ComplaintCough, sputum, dyspnea which started a month ago. He underwent peritoneal dialysis for end-stage renal disease
  • Figure 1
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  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Acute fibrinous and organizing pneumonia
Radiologic Findings
Initial chest radiograph showed multiple patchy opacities in both middle and right lower lung zones. Subsequent chest CT scan showed multifocal patchy ground-glass attenuation and consolidation associated with thickening of interlobular septal lines. Some portions resembled “crazy-paving” appearance. The density and extent of these lesions increased on follow-up CT scan two weeks later. Video-assisted thoracoscopic lung biopsy was performed, and the pathologic diagnosis of the biopsy specimen turned out to be acute fibrinous organizing pneumonia. The above-mentioned lesions had markedly resolved three weeks after high-dose steroid therapy.
Brief Review
Acute fibrinous and organizing pneumonia (AFOP) is a rare idiopathic interstitial pneumonia (IIP) which is characterized by fibrin deposition, so called fibrin balls, and associated organizing pneumonia within alveolar spaces. Although AFOP does not meet the criteria for either diffuse alveolar damage or organizing pneumonia on histopathologic examination, it has been not clear whether AFOP is a new rare IIP or a variant of existing IIPs including diffuse alveolar damage and organizing pneumonia. Clinico-radiological manifestation of AFOP can be categorized into two patterns: diffuse alveolar damge and organizing pneumonia. In a series of 17 patients diagnosed as having AFOP, nine patients had fulminant respiratory failure and rapid progression to death similar to that of diffuse alveolar damage, whereas ten patients had a subacute respiratory distress with subsequent recovery. In AFOP mimicking diffuse alveolar damage, CT scan shows diffuse ground-glass opacities and consolidation with basilar predilection, while a focal or diffuse parenchymal consolidation can be identified resembling pneumonia or organizing pneumonia on CT scan in AFOP mimicking organizing pneumonia. AFOP may be idiopathic or associated with collagen vascular disease, hypersensitivity pneumonitis, or drug exposure.
References
1. Beasley MB1 Franks TJ, Galvin JR, Gochuico B, Travis WD. Acute fibrinous and organizing pneumonia: a histological pattern of lung injury and possible variant of diffuse alveolar damage. Arch Pathol Lab Med. 2002 Sep;126(9):1064-70.
2. Travis WD, Costabel U, Hansell DM, King TE Jr, Lynch DA, Nicholson AG, et al. An official American Thoracic Society/European Respiratory Society statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med. 2013 Sep 15;188(6):733-48.
3. Kligerman SJ, Franks TJ, Galvin JR. From the radiologic pathology archives: organization and fibrosis as a response to lung injury in diffuse alveolar damage, organizing pneumonia, and acute fibrinous and organizing pneumonia. Radiographics. 2013 Nov-Dec;33(7):1951-75.
4. Feinstein MB, DeSouza SA, Moreira AL, Stover DE, Heelan RT, Iyriboz TA, et al. A comparison of the pathological, clinical and radiographical, features of cryptogenic organising pneumonia, acute fibrinous and organising pneumonia and granulomatous organising pneumonia. J Clin Pathol. 2015 Jun;68(6):441-7.
5. Dai JH, Li H, Shen W, Miao LY, Xiao YL, Huang M, Cao MS, et al. Clinical and Radiological Profile of Acute Fibrinous and Organizing Pneumonia: A Retrospective Study. Chin Med J (Engl). 2015 Oct 20;128(20):2701-6.
Keywords
Lung, Idiopathic interstitial pneumonia, IIP,

No. of Applicants : 98

▶ Correct Answer : 6/98,  6.1%
  • - Seoul National University Hospital , Korea (South) Hyoung-In Choi
  • - SNUH , Korea (South) TAE HYUNG KIM
  • - Seoul National University Hospital , Korea (South) Jong Hyuk Lee
  • - Asan Medical Center , Korea (South) , Korea (South) Han Na Lee
  • - Seoul National University Hospital , Korea (South) Sunkyung Jeon
  • - SNUH , Korea (South) Juil Park
▶ Semi-Correct Answer : 31/98,  31.6%
  • - Osaka Rosai Hospital , Japan Hiromitsu Sumikawa
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Shiga University of Medical Science , Japan Akitoshi Inoue
  • - Juntendo University Hospital , Japan Akifumi Hagiwara
  • - SNUBH , Korea (South) Chee Guen
  • - King Abdulaziz University Hospital , Saudi Arabia Amr Ajlan
  • - Eren Hastanesi Istanbul , Turkey Armagan Sarac
  • - McGill University Health Center , Canada Alexandre Semionov
  • - All India Institute of Medical Sciences , India Ashish Gupta
  • - Ajou university hospital , Korea (South) Pae Sun Suh
  • - CH LA ROCHELLE , France TEOLI Camille
  • - Kashan University of Medical Sciences, kashan , Iran Ebrahim Razi
  • - Neurociti Diagnostics , India Justin Moses
  • - UWO , Canada S Lee
  • - Medicheck health care , Korea (South) Chae Lim
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Les cedres St malo , France nicolas gautier
  • - CHU Poitiers , France CHAN paul
  • - GHICL , France manuel toledano
  • - Shinmatsudo Central General Hospital , Japan Taku Tajima
  • - DAYA General Hospital,Thrissur,Kerala , India Raveendran TK
  • - Centre Imagerie de Fribourg , Switzerland Benoit RIZK
  • - Asan , Korea (South) Sania ALBlushi
  • - Fortis hospital , Mohali , India Shaleen Rana
  • - Kizawa Memorial Hospital , Japan Shoji Okuda
  • - National Center hospital of Neurology and Psychiatry , Japan Kaoru Sumida
  • - Niigata City General Hospital , Japan Takao Kiguchi
  • - The University of Tokyo Hospital , Japan Takana Yamakawa
  • - Private sector , Greece Vasilios Tzilas
  • - Asan medical center , Korea (South) Cherry Kim
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Current Editor : Sung Shine Shim, MD, PhD. Email : sinisim@ewha.ac.kr

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