A 41-year-old male with no toxic habits and a history of lactose intolerance, diagnosed in 2003 with Crohn's disease with an inflammatory pattern and ileal involvement, who had started two years earlier with an episode of uveitis.
Currently in clinical remission without any maintenance treatment.
She has had upper respiratory tract catarrh for two months, accompanied in the last days by cough, whitish sputum and fever of 38oC.
Initially diagnosed with right basal pneumonia, she was treated with antibiotics and mucolytics with little improvement.
She subsequently developed dyspnea, purulent sputum, asthenia and loss of 8-10 kg. After not improving the hospital, she was admitted to the pulmonology department.
Physical examination revealed diffuse scleroderma, Ta: 2 C, and right lung auscultation crackles.
-Additional investigations:
• stricture: SG: 66 mm 1 hour, leukocytes: 6900/ul with normal formula, walls: 457,000/ul; Hb: 11.9/dl; hematocrit: 3,000/ul.
Biochemistry: no significant findings.
Coagulation: normal.
Sat O2: 95%.
• Negative blood cultures for anaerobic and aerobic bacteria.
HIV serology: negative.
Negative sputum bacteriology.
Urine bacterial antigen: negative for pneumococcus and legionella.
• Chest X-ray at admission: alveolar infiltrates on the right base and minimal infiltrates on the left base, which in later controls become migrating to segment 6, also affecting the right middle lobe.
Days later, condensation in the right upper lobe decreased the basal infiltrates.
• Spirometry: FVC: 2.52 l (56%); FEV1: 2.23 l (60%); FEV1/VC: 78%; MMEF25-75: 1.96 l (46%): non-obstructive ventilatory failure.
• Chest CT: extensive parenchymal consolidation in the right upper lobe; consolidation in resolution and loss of volume in the right middle lobe; consolidation in partial resolution in the right lower lobe with image of alveolar infiltrate and image of left upper lobe in the posterior segment.
1.
• After the results, fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) were performed, with no evidence of endonasal lesions or mucosal changes.
LAB microbiology: normal flora of the upper airways with culture of Legionella, Gram, AFB and negative.
LAB: 80 cells/mm3, 65% macrophages, 25% lymphocytes (increased), 5% eosinophils and 5% PMN.
Lymphocyte populations: CD4/CD8 ratio: 0.87.
Transbronchial biopsy: interalveolar septa enlarged by chronic inflammation and fibrosis.
Alveolar cell hyperplasia with desquamation of pneumocytes to light and negative granular exudates SBP.
Myxoid granulation tissue emerging from the terminal bronchi into the lumen.
No granulomatous lesions or hyaline membranes.
All this is compatible with organizing pneumonia with bronchiolitis obliterans.
Treatment with prednisone at a dose of 1 mg/kg/day was started, yielding fever and improvement of other symptoms.
At one month and three months the patient is asymptomatic and controls are normal.
