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Cryptogenic Organizing Pneumonia

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Cryptogenic Organizing Pneumonia Cryptogenic organizing pneumonia Authors: Professor Jean-François Cordier1,2, Professor Ulrich Costabel1, Professor Roland M. du Bois1 Creation Date: August 2002 Update: October 2004 1members of the European editorial committee of Orphanet encyclopedia 2Service de pneumologie - Centre des Maladies Orphelines Pulmonaires, Hôpital cardiovasculaire et pneumologique Louis Pradel, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France. [email protected] Abstract Keywords Name of disease Synonym Definition Differential diagnosis Clinical description Treatment and prognosis of organizing pneumonia Pathogenesis of organizing pneumonia Conclusion and research perspectives References Abstract Cryptogenic organizing pneumonia (COP) or bronchiolitis obliterans with organizing pneumonia (BOOP) is an inflammatory lung disease with distinctive clinical, radiological and pathological features. The onset of symptoms is usually subacute with fever, nonproductive cough, malaise, anorexia and weight loss. Dyspnea, usually mild, is occasionally severe in some acute and life-threatening cases. Men and women are affected equally and are usually aged between 50 and 60 years. No predisposing factors have been identified. In most cases, symptoms develop over a few weeks and the diagnosis of COP is made after 6 to 10 weeks. In COP the organizing pneumonia is the most conspicuous pathological feature, examination of lung biopsy specimens shows intra-alveolar buds of granulation tissue consisting of fibroblasts, myofibroblasts, and loose connective tissue. The radiographic and computed tomography scan findings suggest the diagnosis when multiple patchy alveolar opacities with a peripheral and bilateral distribution are present. Video-assisted thoracoscopic lung biopsy is the currently preferred technique for diagnosing organizing pneumonia, because large lung specimens are necessary to make the diagnosis with confidence. Transbronchial lung biopsy may show organizing pneumonia but does not allow the exclusion of associated disorders. Corticosteroids are the current standard treatment of COP. Response to this treatment is generally impressive. Keywords Bronchiolitis obliterans, inflammatory lung disease, corticosteroids treatment Name of disease Definition Cryptogenic organizing pneumonia (COP) Organizing pneumonia corresponds to the presence of buds of granulation tissue Synonym (progressing from fibrin exudates to loose Bronchiolitis obliterans organizing pneumonia collagen embedding fibroblasts) in the lumen of (BOOP) the distal pulmonary airspaces [1]. The lesions predominate within the alveoli, but often Cordier JF, Costabel U, du Bois RM. Cryptogenic organizing pneumonia, Orphanet encyclopedia, October 2004 http://www.orpha.net/data/patho/GB/uk-CryptOrgPneum.pdf 1 associated buds of granulation tissue are found in the bronchiolar lumen (bronchiolitis Cryptococcus neoformans Fungi Penicillium janthinellum obliterans). This pathological pattern has no Pneumocystis carinii (in AIDS) etiologic specificity, and may thus be encountered in a variety of inflammatory pulmonary disorders. Drugs are another cause of organizing However, organizing pneumonia is the hallmark pneumonia (table 2). Resolution of organizing of the characteristic clinico-radiological entity of pneumonia after stopping the drug is the best unknown cause called cryptogenic organizing clue to establish causality. pneumonia (COP). The latter terminology is A syndrome quite similar to cryptogenic currently preferred to the other name of this organizing pneumonia has been identified condition, i.e. idiopathic bronchiolitis obliterans recently in women with breast cancer receiving with organizing pneumonia (BOOP). radiation therapy after surgery for a malignant COP was recognized as a distinct disorder in the tumor [6-13]. It is distinct from usual radiation early 1980s after the reports of Davison et al [2] pneumonitis, especially because pulmonary and Epler et al [3]. Further studies in the 1980s infiltrates occur or migrate outside the radiation [4,5] described its characteristic features, and fields and the response to corticosteroids is COP is now accepted as a rare but quite excellent without sequelae. characteristic clinicopathologic entity in pulmonary medicine. Table 2: Drugs identified as cause of organizing pneumonia Differential diagnosis - 5-aminosalicylic acid 1 The diagnosis of COP is based on both the - Acebutolol - Acramin FWN typical pathological findings of organizing - Amiodarone pneumonia and the lack of any identified cause. - Amphotericine Therefore, the following causes of organizing - Bleomycin pneumonia must be carefully excluded before - Busulphan - Carbamazepine2 concluding that organizing pneumonia is - Cephalosporin (cefradin) cryptogenic. - Cocaine - Doxorubicin Organizing pneumonia of determined cause - Gold salts3 Infection is a common cause of organizing - Hexamethonium - Interferon alpha pneumonia (table 1). In bacterial infections, - Interferon alpha + cytosine arabinoside organizing pneumonia occurs mostly in - Interferon + ribavirin nonresolving pneumonia where, despite control - Interferon β1a of the infectious organism by antibiotics, the - L-tryptophan - Mesalazine inflammatory reaction remains active with further - Methotrexate organisation of the intra-alveolar fibrinous - Minocycline exudate. - Nitrofurantoin - Nilutamide Table 1: Infectious causes of organizing - Paraquat - Phenytoin pneumonia - Sotalol Chlamydia pneumoniae - Sulfasalazine1 Coxiella burnetii - Tacrolimus Legionella pneumophila - Ticlopidine Mycoplasma pneumoniae - Transtuzumab Nocardia asteroids - Vinbarbital-aprobarbital Bacteria Pseudomonas aeruginosa 1 Serratia marcescens In patients treated by this drug for ulcerative colitis or Staphylococcus aureus Crohn's disease which may themselves be associated with Streptococcus group B organizing pneumonia. 2In the course of lupus syndrome induced by the drug. Streptococcus pneumoniae 3 In patients with rheumatoid arthritis which may itself be Cytomegalovirus associated with organizing pneumonia. Herpes virus Human immunodeficiency virus Organizing pneumonia of unknown cause but Viruses Influenza virus occurring in a specific context [14] Parainfluenza virus The connective tissue disorders may be Human herpes virus-7 associated with organizing pneumonia. The Parasites Plasmodium vivax idiopathic inflammatory myopathies may cause a characteristic organizing pneumonia syndrome. Cordier JF, Costabel U, du Bois RM. Cryptogenic organizing pneumonia, Orphanet encyclopedia, October 2004 http://www.orpha.net/data/patho/GB/uk-CryptOrgPneum.pdf 2 Organizing pneumonia also occurs in Bronchoalveolar lavage and laboratory rheumatoid arthritis and Sjögren's syndrome. findings Pathological features of organizing pneumonia Broncholveolar lavage is used in COP especially which may be present in Wegener's to exclude other disorders, or identify causes of granulomatosis usually consist of small foci of COP and particularly infections. The differential organizing pneumonia at the periphery of white cell count may show a rather characteristic otherwise typical granulomatous lesions. "mixed pattern" with increased lymphocytes (20- It is well established that both lung 40%), neutrophils (about 10%), eosinophils and transplantation and bone-marrow grafting may sometimes the presence of some plasma cells or be complicated by constrictive mural bronchiolitis mast cells [5,16,26]. obliterans with airflow obstruction. Less There are no specific laboratory findings in COP. commonly, organizing pneumonia occurs in The erythrocyte sedimentation rate and C- transplanted lungs or after allogeneic bone reactive protein levels are increased and there is marrow grafts. a moderate leucocytosis, with an increased proportion of neutrophils. Clinical description Diagnosis of cryptogenic organizing Clinical characteristics [2,3,5,15-19] pneumonia Men and women are affected equally and are The diagnosis of COP relies on the association usually aged between 50 and 60 years. No of typical pathological and clinico-radiological predisposing factors have been identified. features, without any recognized cause or The onset of symptoms is usually subacute with significant associated disorder. Pathological fever, nonproductive cough, malaise, anorexia examination of lung biopsy specimens shows and weight loss. Haemoptysis, bronchorrhea, intra-alveolar buds of granulation tissue chest pain, arthralgia and night sweats are consisting of fibroblasts, myofibroblasts, and uncommon. Dyspnea, usually mild, is loose connective tissue. The buds may extend occasionally severe in some acute and life- from one alveolus to the next, giving a rather threatening cases. In most cases, symptoms characteristic "butterfly" pattern. Bronchiolar develop over a few weeks (sometimes after a lesions consist of similar buds of granulation viral-like illness), and the diagnosis of COP is tissue inside the airway lumen in continuity with usually made after 6 to 10 weeks. At physical lesions in the alveoli [1, 27,28]. examination sparse crackles may be heard over In COP the organizing pneumonia is the most affected areas. conspicuous pathological feature and not just an accessory finding as seen in vasculitis, Imaging [2-5,16,18,20-23] eosinophilic pneumonia, hypersensitivity The radiographic and computed tomography pneumonitis, or nonspecific interstital (CT) scan findings are characteristic in typical pneumonia. Furthermore, it is important to rule cases. They suggest the diagnosis when out
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