67 Year Old Lady with an Unusual Mid-section CT.


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She reported three months of dynamic dyspnea on effort and dry hack ... sort II cell hyperplasia, and a meager interstitial lymphocytic invade. ...
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67 Year Old Woman with an Abnormal Chest CT Andrea Glassberg March 11, 2003

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Clinical Presentation A 67 year old lady with a background marked by bosom tumor and mediastinal mass exhibited to mid-section facility with a strange CT sweep of the mid-section. She reported three months of dynamic dyspnea on effort and dry hack without mid-section torment or wheezing.

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Past Medical History Breast Cancer (1991), S/P lumpectomy, XRT Mediastinal Mass (1999), at first accepted to be metastatic illness DM II HTN

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

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Exam Obese, tired showing up AA lady Afebrile 150/85 HR 125 RR 22 O2 sat 91% on RA Coarse inspiratory crackles No fringe edema

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Additional Info?

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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. Top. 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 half 2.2 L/SEC 50 % FEF 75% 0.6 L/SEC 28 %

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What is your differential determination?

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BAL Hazy 405 RBC 395 WBC 16% N 34% L 43% M/H/M 6% Eos Cx neg

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Transbronchial Biopsy The biopsy demonstrates various polypoid fittings of granulation tissue inside the airspaces, sort II cell hyperplasia, and a scanty interstitial lymphocytic invade.

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What might you do now?

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Interval History The patient was begun on Prednisone, 60 qd and had verging on complete determination of her side effects inside two weeks. Be that as it may, she along these lines created serious reactions from prednisone, including candida esophagitis, and hard to control hyperglycemia.

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PFT 11-12-02 TLC BY SINGLE BREATH 3.2 LITERS 62 % DIF. Top. 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 half 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

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Interval History The measurements of prednisone was decreased from 60mg qd to 20mg qd more than 4 months. The patient then self d/c\'d the pharmaceutical.

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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. Top. HGB UNCOR. 15.2 60 % DIF. Top. 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 half 2.5 L/SEC 55 % FEF 75% 0.5 L/SEC 25 % AIRWAY RESISTANCE 4.2 CMH2O/LPS

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COP Cryptogenic Organizing Pneumonitis

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

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BOOP Syndrome Radiation treatment to the bosom inside 12 months, 2) General and/or respiratory side effects going on for no less than 2 weeks, Radiographic lung penetrates outside the radiation port 4) No confirmation of a particular cause

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Epidemiology of COP Six to seven for each 100,000 healing facility affirmations was found at a noteworthy instructing doctor\'s facility. Onset regularly in the fifth or 6th decades. Both sexual orientations influenced similarly. Brief length of indications (<3 mo). Cigarette smoking is not a hastening component.

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Duration of Symptoms King, Cryptogenic Organizing Pneumonia. UpToDate online 11.1

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Clinical Findings Often impersonates CAP Fever Malaise Fatigue Cough Persistent ineffective hack Dyspnea with effort Weight loss of more prominent than 10 pounds (57 %) Inspiratory rales (74%) Normal lung exam (25%)

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Imaging Bilateral, diffuse alveolar opacities within the sight of ordinary lung volumes. A fringe dissemination of the opacities, like that seen in interminable eosinophilic pneumonia. Repetitive or transitory aspiratory opacities (up to 50 %). Sporadic straight or nodular interstitial penetrates infrequently the main radiographic sign. Honeycombing uncommon, happens as a late indication in patients with dynamic illness. Uncommon elements: pleural emanation pleural thickening Hyperinflation cavities

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Physiology Moderate prohibitive issue Diffusion variation from the norm Resting hypoxemia basic Obstruction uncommon

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King, Cryptogenic Organizing Pneumonia. UpToDate online 11.1

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King, Cryptogenic Organizing Pneumonia. UpToDate online 11.1

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King, Cryptogenic Organizing Pneumonia. UpToDate online 11.1

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Treatment Prednisone 1-1.5mg/kg for 6-8 weeks. Decrease gradually over a time of 6 months to 1 year. Cyclophosphamide as a steroid saving specialist.

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Outcome King, Cryptogenic Organizing Pneumonia. UpToDate online 11.1

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Relapses Am J Respir Crit Care Med Vol 162. pp 571–577, 2000

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Relapses Am J Respir Crit Care Med Vol 162. pp 571–577, 2000

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Relapses Am J Respir Crit Care Med Vol 162. pp 571–577, 2000

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COP Pearls Diagnosis of prohibition (BOOP w/o cause) Histologic appearance is granulomatous penetration of distal airspaces Lung engineering is safeguarded Responsive to steroids Relapses basic No compelling reason to treat to counteract backslides

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References Crestani, et al., Bronchiolitis Obliterans Organizing Pneumonia Syndrome Primed by Radiation Therapy to the Breast. Am J Respir Crit Care Med (1998)158:1929–1935. Epler, Bronchiolitis Obliterans Organizing Pneumonia. Curve Intern Med. (2001) 161:158-164. Lord, 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: 571–577. Mokhtari, et al., Bronchiolitis obliterans sorting out pneumonia in tumor: a case arrangement. Respiratory Medicine, (2002) 96: 280-286. Oikonomou and Hansell, Organizing pneumonia: the numerous morphological countenances. Eur Radiol (2002) 12:1486–1496. Takigawa, et al., Bronchiolitis Obliterans Organizing Pneumonia Syndrome In Breast-rationing Therapy For Early Breast Cancer: Radiation-instigated Lung Toxicity. Int. J. Radiation Oncology Biol. Phys. (2000) 48: 751–755.

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