Scientific Letter
Subacute Pneumonia as a Manifestation of Acute Fibrinous and Organizing Pneumonia
Neumonía subaguda como manifestación de una neumonía organizada fibrosante aguda
a Servicio de Neumología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade de A Coruña (UDC), A Coruña, Spain
b Servicio de Anatomía Patológica, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña, Sergas, Universidade da Coruña, A Coruña, Spain
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Marcos" "autores" => array:3 [ 0 => array:3 [ "nombre" => "Irene" "apellidos" => "Nieto-Codesido" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Teresa" "apellidos" => "Hermida-Romero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:4 [ "nombre" => "Pedro J." "apellidos" => "Marcos" "email" => array:1 [ 0 => "pedro.jorge.marcos.rodriguez@sergas.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade de A Coruña (UDC), A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña, Sergas, Universidade da Coruña, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumonía subaguda como manifestación de una neumonía organizada fibrosante aguda" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1125 "Ancho" => 1500 "Tamanyo" => 246450 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Chest radiograph: infiltrate in right upper lobes. (B) Infiltrates in right upper lobe, right lower lobe and left upper lobe with loss of volume in the right hemithorax. (C) Favorable radiological progress. (D) Computed tomography-guided lung biopsy: inflammatory thickening of the septa with intra-alveolar fibrin balls.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The histological pattern of acute fibrinous and organizing pneumonia (AFOP) is a very rare form of idiopathic interstitial pneumonia, characterized by fibrin balls distributed in patches within the alveoli. We report the case of a 72-year-old woman who presented with progressive subacute pneumonia associated with AFOP, diagnosed by computed tomography-guided large core needle biopsy, which responded well to treatment with corticosteroids.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 72-year-old woman was admitted with a 1-month history of progressive dyspnea, dry cough, low-grade fever, asthenia, anorexia and weight loss. Following a previous chest radiograph, she had been diagnosed with right upper lobe (RUL) pneumonia (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A), for which she had received levofloxacin 500<span class="elsevierStyleHsp" style=""></span>mg/day for 7 days, with no improvement. She had no occupational exposure of interest, and no toxic habits. Clinical history included childhood bronchial asthma, mild kidney failure, and hypothyroidism. On admission, her general condition was reasonable, temperature 37.2<span class="elsevierStyleHsp" style=""></span>°C, blood pressure 130/75<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate 69<span class="elsevierStyleHsp" style=""></span>bpm, no shortness of breath, with 92% oxygen saturation while breathing room air. Physical examination revealed dry crackles throughout the right hemithorax and left lung base on auscultation. Chest radiograph showed progression of the RUL infiltrate and loss of volume (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Clinical laboratory tests showed mild normocytic, normochromic anemia, with leukocytes 11<span class="elsevierStyleHsp" style=""></span>460, ESR 120<span class="elsevierStyleHsp" style=""></span>mm/h, CRP 29.5<span class="elsevierStyleHsp" style=""></span>mg/dl, and a pattern of cholestasis (alkaline phosphatase 389<span class="elsevierStyleHsp" style=""></span>IU/l, GGT 83<span class="elsevierStyleHsp" style=""></span>IU/l) with negative ANA and ANCA.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Suspecting that the slow resolution of the pneumonia was due to unusual pathogens, we started treatment with piperacillin–tazobactam, and a chest CT was performed, revealing extensive consolidations in the posterior regions of the right lung with pulmonary collapse. A bronchoscopy with transbronchial biopsy was performed twice, and was inconclusive on both occasions (chronic inflammatory component and pneumocytic hyperplasia with mild atypia). The patient's clinical situation worsened and radiological signs progressed, so a CT-guided lung biopsy was performed. The endoscopic samples obtained were negative for pathogens, so treatment began with methylprednisolone at a starting dose of 40<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h. Clinical progress was exceptional, with frank clinical and radiological improvement after 48<span class="elsevierStyleHsp" style=""></span>h, and radiography returned to normal after one week of treatment (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Biopsy showed a typical AFOP pattern (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D), characterized by inflammatory thickening of the septa and fibrin balls in the alveoli. After 10 months of tapering corticosteroid treatment (now at a dose of prednisolone 10<span class="elsevierStyleHsp" style=""></span>mg/48<span class="elsevierStyleHsp" style=""></span>h), the patient is currently asymptomatic.</p><p id="par0020" class="elsevierStylePara elsevierViewall">AFOP was first described in 2002 by Beasley et al. It consists of a rare histological pattern of interstitial pneumonia characterized by the presence of fibrin balls in the alveolar space (distinct from the intra-alveolar buds of cryptogenic organizing pneumonia) in a patchy distribution, with infiltration by inflammatory cells and pneumocytic hyperplasia type 2, and absence of hyaline membranes (differential diagnosis with diffuse alveolar damage).<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> Etiology is often unknown, although it has been described in association with autoimmune diseases, infections, drugs, lung transplantation, and cancer.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> While it can present as a very severe and acute form of acute respiratory distress, in most cases, like ours, onset is gradual and progressive, and prognosis is more favorable.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The lack of specific clinical and radiological signs<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> means that clinical suspicion and a lung tissue sample are essential for a correct diagnosis. Definitive diagnosis is obtained from a lung biopsy and treatment is based on corticosteroids, although no standard regimen has yet been determined. Immunosuppressive treatment, such as mycophenolate mofetil, azathioprine or cyclophosphamide, is reserved for cases associated with autoimmune disease or in case of relapse.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Given our patient's clinical course, we believe that AFOP should be considered in the differential diagnosis in an individual with poorly progressing pneumonia. If the patient's clinical condition permits, the diagnostic process should eventually include a lung biopsy, given the therapeutic implications in these cases.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Nieto-Codesido I, Hermida-Romero T, Marcos PJ. Neumonía subaguda como manifestación de una neumonía organizada fibrosante aguda. Arch Bronconeumol. 2017;53:167–168.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1125 "Ancho" => 1500 "Tamanyo" => 246450 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Chest radiograph: infiltrate in right upper lobes. (B) Infiltrates in right upper lobe, right lower lobe and left upper lobe with loss of volume in the right hemithorax. (C) Favorable radiological progress. (D) Computed tomography-guided lung biopsy: inflammatory thickening of the septa with intra-alveolar fibrin balls.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Life after acute fibrinous and organizing pneumonia: a case report of a patient 30 months after diagnosis and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Kuza" 1 => "T. Matheos" 2 => "D. Kathman" 3 => "S.O. 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Huang" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Chin Med J (Engl)" "fecha" => "2015" "volumen" => "128" "paginaInicial" => "2701" "paginaFinal" => "2706" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005300000003/v1_201703240112/S1579212916303408/v1_201703240112/en/main.assets" "Apartado" => array:4 [ "identificador" => "49861" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005300000003/v1_201703240112/S1579212916303408/v1_201703240112/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212916303408?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 2 | 9 |
| 2024 October | 93 | 24 | 117 |
| 2024 September | 69 | 20 | 89 |
| 2024 August | 98 | 46 | 144 |
| 2024 July | 69 | 31 | 100 |
| 2024 June | 83 | 40 | 123 |
| 2024 May | 90 | 27 | 117 |
| 2024 April | 64 | 27 | 91 |
| 2024 March | 61 | 21 | 82 |
| 2024 February | 48 | 25 | 73 |
| 2023 March | 10 | 4 | 14 |
| 2023 February | 46 | 13 | 59 |
| 2023 January | 45 | 36 | 81 |
| 2022 December | 65 | 40 | 105 |
| 2022 November | 81 | 29 | 110 |
| 2022 October | 62 | 39 | 101 |
| 2022 September | 52 | 30 | 82 |
| 2022 August | 49 | 40 | 89 |
| 2022 July | 38 | 42 | 80 |
| 2022 June | 57 | 39 | 96 |
| 2022 May | 70 | 37 | 107 |
| 2022 April | 69 | 26 | 95 |
| 2022 March | 74 | 41 | 115 |
| 2022 February | 87 | 25 | 112 |
| 2022 January | 101 | 44 | 145 |
| 2021 December | 69 | 43 | 112 |
| 2021 November | 82 | 36 | 118 |
| 2021 October | 67 | 43 | 110 |
| 2021 September | 58 | 47 | 105 |
| 2021 August | 42 | 34 | 76 |
| 2021 July | 35 | 24 | 59 |
| 2021 June | 54 | 31 | 85 |
| 2021 May | 62 | 42 | 104 |
| 2021 April | 141 | 89 | 230 |
| 2021 March | 164 | 11 | 175 |
| 2021 February | 63 | 30 | 93 |
| 2021 January | 63 | 21 | 84 |
| 2020 December | 58 | 11 | 69 |
| 2020 November | 49 | 28 | 77 |
| 2020 October | 102 | 25 | 127 |
| 2020 September | 50 | 9 | 59 |
| 2020 August | 40 | 13 | 53 |
| 2020 July | 51 | 16 | 67 |
| 2020 June | 42 | 5 | 47 |
| 2020 May | 47 | 16 | 63 |
| 2020 April | 42 | 19 | 61 |
| 2020 March | 29 | 7 | 36 |
| 2020 February | 54 | 19 | 73 |
| 2020 January | 56 | 21 | 77 |
| 2019 December | 58 | 23 | 81 |
| 2019 November | 40 | 30 | 70 |
| 2019 October | 57 | 13 | 70 |
| 2019 September | 48 | 10 | 58 |
| 2019 August | 41 | 17 | 58 |
| 2019 July | 43 | 17 | 60 |
| 2019 June | 43 | 17 | 60 |
| 2019 May | 50 | 21 | 71 |
| 2019 April | 60 | 38 | 98 |
| 2019 March | 53 | 29 | 82 |
| 2019 February | 40 | 17 | 57 |
| 2019 January | 48 | 17 | 65 |
| 2018 December | 49 | 12 | 61 |
| 2018 November | 83 | 26 | 109 |
| 2018 October | 81 | 20 | 101 |
| 2018 September | 29 | 15 | 44 |
| 2018 May | 19 | 2 | 21 |
| 2018 April | 49 | 13 | 62 |
| 2018 March | 39 | 10 | 49 |
| 2018 February | 32 | 11 | 43 |
| 2018 January | 23 | 6 | 29 |
| 2017 December | 40 | 5 | 45 |
| 2017 November | 31 | 15 | 46 |
| 2017 October | 29 | 8 | 37 |
| 2017 September | 28 | 8 | 36 |
| 2017 August | 42 | 13 | 55 |
| 2017 July | 43 | 17 | 60 |
| 2017 June | 54 | 21 | 75 |
| 2017 May | 1 | 1 | 2 |
| 2017 April | 2 | 0 | 2 |
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