An Unusual Presentation of Acute Fibrinous and Organizing Pneumonia

Abstract

Patient: Female, 56Final Diagnosis: Acute fibrinous and organizing pneumoniaSymptoms: Cough • dyspnea • feverMedication: —Clinical Procedure: —Specialty: PulmonologyObjective:Rare diseaseBackground:Acute fibrinous and organizing pneumonia (AFOP) is a newly evolving rare non-infectious lung pathology, characterized by intra-alveolar fibrin balls on histology. It is often difficult to diagnose and is usually mistaken for other lung pathologies. We present an interesting case of AFOP with unusual radiologic findings and disease course.Case Report:A 56-year-old woman presented with a 1-day history of high-grade fever, chills, and profuse sweating. She was febrile to 101.2 degree Fahrenheit on presentation. On physical examination, she had decreased air entry in the left upper lobe of the lung. Laboratory testing showed a white cell count of 27,000 cells per microliter of blood with left shift. A chest radiograph showed a left upper lobe consolidation. Computed tomography (CT) of the chest without intravenous contrast showed advanced centrilobular emphysema and left upper lobe consolidation measuring 6.2×5.9 cm. The patient was started on antibiotics. She clinically improved and was discharged on oral antibiotics. After discharge, a trans-bronchial lung biopsy showed acute inflammatory cell infiltrate with intra-alveolar fibrin balls but no hyaline membrane formation or significant eosinophils. These findings were consistent with acute fibrinous and organizing pneumonia. However, she was subsequently lost to follow-up.Conclusions:Our case adds to the literature a new and unusual finding of upper lobe infiltrates, in contrast to most cases presenting as bilateral lower lobe infiltrates. In our case, symptomatic improvement after antibiotic treatment suggests a possible role of antibiotics in management of this entity.

Acute fibrinous organising pneumonia presenting as a cavitary lung lesion and treatment response to azithromycin

“…Cavitation is rare in organising pneumonia and to our knowledge it has never been reported in acute fibrinous organising pneumonia. Our patient had left upper lobe infiltrate with cavitation, in contrast to most cases presenting as bilateral basilar infiltrates 2 4 5 7. Such presentation brings up mycobacterial and fungal disease among the top differential diagnoses, which were ruled out in our patient.…”

“…Other CT findings include peribronchovascular opacities, band-like consolidation, pleural effusion, solitary nodule and reverse halo sign 4 5. Jabbour et al 7 reported a case of acute fibrinous organising pneumonia with an unusual finding of upper lobe infiltrate. Cavitation is rare in organising pneumonia and to our knowledge it has never been reported in acute fibrinous organising pneumonia.…”

Acute fibrinous and organizing pneumonia in a patient with Sjögren’s syndrome and Legionella pneumonia: a case report and literature review

“…[ 1 ] reported that the amount of chronic inflammatory cell infiltration surrounding the fibrin balls in AFOP lesions varies and noted that AFOP may be associated with lung infection. AFOP may improve following antibiotic treatment [ 14 ], suggesting that infection may trigger the onset of AFOP. Previous reports have shown that a variety of infections may be associated with AFOP, including bacterial infections ( Haemophilus influenzae , Acinetobacter baumannii ), viral infections (respiratory syncytial virus, influenza virus A/H1N1, human immunodeficiency virus), and fungal infections ( Pneumocystis jirovecii , Penicillium citrinum ) [ 1 , 5 – 9 ].…”

“…[ 15 ] suggested that alveolar epithelial cell injury caused by Legionella infection and subsequent tissue repair are involved in the pathology of OP and the development of its imaging manifestations. After alveolar injury, proteins and serous fluid in the capillaries enter the alveolar cavity, where they may be involved in fibrin ball formation [ 14 ]. This may explain the AFOP manifestations in the lungs of this patient.…”