Wandering consolidation 685 Postgrad Med J: first published as 10.1136/pgmj.71.841.685 on 1 November 1995. Downloaded from Wandering consolidation

Michael AR Keane, David M Hansell, Charles RK Hind

A 63-year-old man who had previously been fit and well, developed an acute illness with headaches and fever. His chest X-ray is shown in figure 1. Other investigations revealed an elevated lactate dehydrogenase and gamma glutamyl transferase and transient microscopic haematuria for which no cause was found. Following antibiotic treatment, his symptoms settled. Over the next six weeks he complained of increasing breathlessness but had no other symptoms. His family doctor found signs ofleft lower lobe consolidation and treated him with antibiotics, but there was no symptomatic improvement and he was referred to hospital. It was noted that he had travelled to Canada, Fiji, Australia, and Singapore a year previously. On examination he appeared unwell and he had signs of left-sided consolidation. He was in atrial fibrillation and was normotensive. Routine blood tests were normal other than an erythrocyte sedimentation rate of 75 mm/h. His repeat chest X-ray is shown in figure 2.

Figure 1 Initial chest X-ray

Figure 2 Chest X-ray six weeks later

Royal Brompton http://pmj.bmj.com/ Hospital, London SW3 6NP, UK MAR Keane DM Hansell Royal Liverpool University Hospital,

Liverpool L7 8XP, UK on September 29, 2021 by guest. Protected copyright. CRK Hind Questions Correspondence to Dr DM 1 What is the most likely diagnosis? Hansell Accepted 3 May 1995 2 Suggest three alternative diagnoses. 686 Keane, Hansell, Hind

Answers obliterans organising pneumonia) which have come to be used interchangeably. An organis- QUESTION 1 ing pneumonia occurs when inflammation in Postgrad Med J: first published as 10.1136/pgmj.71.841.685 on 1 November 1995. Downloaded from Cryptogenic organising pneumonia (COP). the distal lung structures incompletely resolves The initial chest X-ray (figure 1) shows left and in the past was most commonly seen as a apical and basal consolidation and a small area sequel to bacterial pneumonia. However, of consolidation at the right base. The left- although a number of causes are now recog- sided consolidation improved over the suc- nised (box 2), in practice, the majority of cases ceeding six weeks, but at the same time the are truly cryptogenic. Organising pneumonia is right basal shadowing worsened (figure 2). perhaps best considered a response of the lung to injury by a variety of different agents. By QUESTION 2 definition, no identifiable agent, infective or Although there is a long list of causes of otherwise, is present in cases of COP. multifocal consolidation on a chest X-ray, The term BOOP was coined by the original causes of migratory consolidations, ie, new American authors because the respiratory areas of abnormality appearing whilst other bronchioles may become blocked by buds of areas resolve, are relatively few (box 1).' immature granulation tissue which originate in the alveoli. This terminology is unfortunate as Discussion it can cause confusion with obliterative bron- chiolitis, an entirely different disease affecting In this case the absence of peripheral the small airways. eosinophilia, aspiration, or other relevant his- tory make cryptogenic organising pneumonia CLINICAL AND RADIOLOGICAL FEATURES OF the most likely diagnosis. A trucut biopsy was COP subsequently obtained using computed tomog- The usual clinical presentation of COP is raphic (CT) guidance and histology confirmed rather non-specific with cough, fever, malaise, this. He responded well to treatment with and dyspnoea. The radiology is exemplified by prednisolone. this case with peripheral consolidations, often COP is a relatively recently described condi- in the mid and lower zones, appearing and tion but, confusingly, it has been given two disappearing over a period ofweeks or months.4 names: COp2 and BOOP3 (bronchiolitis Uncommonly, cavitation and pleural effusions occur. There has been a report of COP presen- ting seasonally, associated with disturbance of liver function.5 CT adds little, other than to confirm the presence of multifocal consolida- Causes of migrating consolidation tions but can be useful to identify a suitable site for biopsy. However, given a suitable history, * cryptogenic organising pneumonia including a lack of response to antibiotics, and * chronic eosinophilic pneumonia * aspiration pneumonia the typical radiographic findings, biopsy may * alveolar proteinosis not always be necessary and a trial of steroids * pulmonary infarcts can be instituted.6 * bronchioloalveolar cell carcinoma http://pmj.bmj.com/ TREATMENT Box 1 The importance ofmaking the diagnosis is that the condition is usually very sensitive to steroids with complete clinical and radiological remission being the rule, although relatively COP: associations high doses ofsteroids may have to be continued

for several months. on September 29, 2021 by guest. Protected copyright. * rheumatoid arthritis * ulcerative colitis * immunosuppression (eg, heart-lung Final diagnosis transplantation) * drugs: amiodarone, acebutolol Cryptogenic organising pneumonia * radiation pneumonitis Keywords: crytogenic organising pneumonia, chest Box 2 X-ray

1 Hansell DM. What are BOOP and COP? Clin Radiol 1992; 4 Haddock JAA, Hansell DM. The terminology and radiology 45: 369-70. of cryptogenic organizing pneumonia. Br J Radiol 1992; 65: 2 Davison AG, Heard BE, McAllister WAC, Turner- 674-80. Warwick MEH. Cryptogenic organizing pneumonitis. QJ 5 Spiteri MA, Klenerman P, Sheppard M, Padley S, Clark Med 1983; 207: 382-94. TJK, Newman-Taylor A. A seasonal cryptogenic organiz- 3 Epler GR, Colby TV, McLoud TC, Carrington CB, Gaens- ing pneumonia with biochemical cholestasis: a new clinical ler EA. Bronchiolitis obliterans organizing pneumonia. N entity. Lancet 1992; 340: 281-4. Engl J Med 1985; 312: 152-8. 6 Geddes DM. BOOP and COP. Thorax 1991; 46: 545-7.