Cryptogenic Organizing Pneumonia


Article Author:
Deepak Chandra


Article Editor:
Daniel Hershberger


Editors In Chief:
Yvonne Carter
Jason Wallen


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
2/22/2019 6:48:02 PM

Introduction

Cryptogenic organizing pneumonia (COP) known formerly as bronchiolitis obliterans organizing pneumonia (BOOP) is a form of idiopathic diffuse interstitial lung disease. Davison et al. coined the term COP in 1983. This was followed by detailed descriptions of the disease under the term BOOP by Epler et al. in 1985. Cryptogenic organizing pneumonia is believed to be a consequence of alveolar injury and is characterized by the formation of organized buds of granulation tissue obstructing the alveolar lumen and bronchioles resulting in respiratory failure. Organizing pneumonia is a pathologic diagnosis and can be secondary to an identifiable etiology. Cryptogenic organizing pneumonia should be diagnosed only after exclusion of any other possible etiology.[1][2][3]

Etiology

The exact etiology of cryptogenic organizing pneumonia is unknown. It is thought to be secondary to alveolar epithelial injury due to an unknown insult. Various etiologic agents have been suggested to cause organizing pneumonia including viral infections, toxic gases, medications, gastro-esophageal reflux, radiation therapy, and connective tissue disorders. Smoking is not considered a risk factor for the development of cryptogenic organizing pneumonia. In fact, most patients with cryptogenic organizing pneumonia are non-smokers.

Epidemiology

Cryptogenic organizing pneumonia lacks precise prevalence data. Incidence is thought to be around 1 to 3 per 100,000 hospital admissions. Both genders are equally affected. Cryptogenic organizing pneumonia typically develops in the fifth to sixth decade of life.

Pathophysiology

Pathogenic mechanisms have not been clearly described, but alveolar epithelial injury due to an unknown provocative insult is thought to cause leakage of plasma proteins into the alveolar space resulting in recruitment of inflammatory cells. The subsequent process of organization occurs in 3 stages. The intra-alveolar stage is comprised of formation of bands of fibrin along with infiltration of mononuclear inflammatory cells. The second stage is characterized by proliferation of fibroblasts that lay down a reticulin framework. Meanwhile, the alveolar cells proliferate and re-epithelialize the basal lamina, restoring the alveolar basement membrane. The third stage is an organization of fibroblasts and connective tissue matrix. Vascular endothelial growth factor (VEGF) and basic fibroblast growth factor play a central role in organizing pneumonia. Matrix metalloproteinases are also up-regulated. In experimental models, glucocorticoids have been shown to inhibit the formation of the granulation tissue plugs.[4][5][6][7]

Histopathology

The histopathological hallmark is an excessive proliferation of fibrous tissue within the alveolar sacs and alveolar ducts with extension into the bronchioles. Organized plugs of intraluminal granulation tissue are known as Masson bodies. The granulation tissue buds extend into the bronchiole and may obstruct the lumen, hence the previous term bronchiolitis obliterans. The granulation tissue has a uniform appearance within the alveolar spaces with preservation of lung parenchymal architecture. Mild mononuclear cell interstitial inflammation and foamy macrophages can be seen in the lung immediately surrounding the lesion. Significant inflammatory cell infiltration diffusely in the lung should raise concern for alternative diagnoses such as Non-specific interstitial pneumonia (NSIP). Disruption of the normal lung architecture should also lead to consideration of an alternative diagnosis like Usual Interstitial Pneumonia (UIP) as seen in Idiopathic Pulmonary Fibrosis (IPF).

History and Physical

Patients typically present in the fifth or sixth decade of life with fever, malaise, cough, and shortness of breath. Cryptogenic organizing pneumonia is unique among interstitial lung diseases in that symptoms are subacute (weeks in duration). Patients frequently fail empiric antibiotics for presumed bacterial pneumonia. Their cough may be dry or productive. Sputum may be of clear or discolored. Rarely patients develop a rapidly progressive disease with severe dyspnea and hypoxemia. Chest pain, night sweats, significant weight loss and mild arthralgias are uncommon symptoms. Hemoptysis and pneumothorax have rarely been reported.

A detailed history and physical examination should be performed to rule out connective tissue diseases, as they can be associated with organizing pneumonia. A thorough medication and exposure history should also be obtained. The respiratory exam typically discloses inspiratory crackles, but the exam can be normal.

Evaluation

White cell count is typically elevated with neutrophilia. Inflammatory markers, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), are commonly elevated. When COP is suspected then testing for autoimmune diseases should be undertaken.

Radiography

The chest radiograph findings in COP include patchy diffuse consolidations mostly involving bilateral lower zones. Other described findings include migratory, irregular, linear, or nodular opacities. Pleural effusions can also be seen.

High-Resolution Computed Tomography (HRCT)

HRCT of the lungs reveals bilateral patchy peripherally located consolidations or ground glass opacities. These are often asymmetric. The classic HRCT sign described in COP is the atoll sign, also known as the reverse halo sign. This sign is characterized by a dense outer rim of consolidation around a focal ground-glass opacity. This sign, seen in about 20% of patients with COP and is non-specific as it can be seen in various other infectious and inflammatory conditions.

Other less common findings include irregular nodular opacities, cavitary lesions, and pleural effusions. Multiple nodules and cavitary lesions should raise suspicion for malignancy.

Pulmonary Function Testing (PFT)

PFTs typically reveal a restrictive defect with diffusion impairment. Desaturation with 6-minute walk testing is also commonly noted.

Bronchoscopy

Flexible bronchoscopy with bronchoalveolar lavage (BAL) is often performed to rule out infections, pulmonary hemorrhage, and malignancy. BAL fluid characteristically has mixed cellularity with neutrophils, lymphocytes, and eosinophils. Significant lymphocyte elevation (approximately 40%) is typical, and CD4/CD8 ratio reveals CD8 predominance. Lack of lymphocytosis on BAL portends a poor prognosis. Marked elevation of eosinophils (greater than 25%) suggests eosinophilic pneumonia or rarely an overlap phenomenon.

Lung Biopsy

Transbronchial lung biopsies may be attempted but are often inadequate to make a definitive diagnosis due to the small amount of lung tissue obtained and loss of tissue architecture from crush artifact. It can help rule out alternative diagnoses. A surgical lung biopsy is often required to make a definitive diagnosis. Wedge biopsies are preferably obtained from at least 2 lobes with distinct radiographic involvement. In patients with a convincing clinical and radiographic presentation, in whom risks of an invasive procedure outweigh benefits, treatment can be started without a lung biopsy, after discussion with the patient.

Treatment / Management

There have been no controlled trials comparing medications or duration of treatment in COP. Treatment regimens are based on consensus guidelines. The initial clinical presentation, severity of disease, and degree of responsiveness should be considered when deciding on an appropriate regimen and duration of therapy.[8][9][10][11]

Spontaneous remissions have been described for patients with mild symptoms and minimal radiographic and PFT abnormalities. The anti-inflammatory effect of macrolides particularly clarithromycin has been exploited in some reports to treat patients with mild symptoms.

The vast majority of patients with progressive symptoms and diffuse radiographic involvement are treated with oral glucocorticoids resulting in marked improvement in symptoms. British Thoracic Society guidelines recommend initiating prednisone at a dose of 0.75 to 1 mg/kg per day and weaning over 6 to 12 months. Alternative regimens include starting prednisolone at a dose of 1 to 1.5 mg/kg for 3 months and then tapering or starting methylprednisolone 0.5 to 1 g intravenously (IV) for the first 3 days followed by prednisolone at 20 mg daily, then tapering based on clinical response. Some authors have tried shorter courses tapered over 3 to 6 months with similar relapse rates. Regardless of the regimen, the initial dose is typically maintained for 4 to 8 weeks. Patients should be followed closely with follow-up clinical examination, pulmonary function testing, and chest radiographs. Relapses are common when tapering steroids but do not seem to affect the outcome. Delayed onset of initial treatment and evidence of cholestasis on laboratory testing are shown to be associated with multiple relapses. The last effective dose of glucocorticoids should be reinstituted at the earliest sign of worsening disease. Other groups have attempted lower dose of glucocorticoids with a goal of reducing cumulative steroid exposure, with slightly higher relapse rates but overall no change in morbidity and mortality. Close monitoring for adverse effects of glucocorticoids is recommended. Surgical resection is not recommended as treatment.

Patients who are unable to taper off glucocorticoids or have significant side effects to glucocorticoids can be started on a steroid-sparing agent, although COP is an unapproved indication for all steroid-sparing medications. Azathioprine and mycophenolate mofetil, among others, have been reported in case series for successful management of COP.

In patients who fail to improve despite high-dose steroid therapy, alternative diagnoses or infections should be first ruled out. Second-line agents such as cyclophosphamide and cyclosporine A have been reported to produce good clinical responses in these steroid non-responsive cases.

Differential Diagnosis

Variants of COP

Secondary Organizing Pneumonia

Organizing pneumonia (OP) due to a secondary cause has similar clinical, radiological and histological features as COP; hence, these causes have to be rigorously excluded prior to diagnosing COP. Secondary OP is associated with autoimmune diseases such as rheumatoid arthritis, granulomatosis with polyangiitis and polymyositis/dermatomyositis or after radiation exposure to lung or associated with hematological malignancies or secondary to drug exposures. It is important to distinguish from COP because treatment varies and secondary OP has a worse prognosis.

Acute Fulminant COP

Fulminant COP is suspected when patients present with rapidly-worsening respiratory failure and hypoxemia, often requiring invasive mechanical ventilation. The clinical presentation is similar to adult respiratory distress syndrome (ARDS) but histologically resembles OP without overt fibrosis. Clinically and radiographically it cannot be distinguished from acute interstitial pneumonia (AIP). Patients progress to worsening respiratory failure and have high mortality. If the diagnosis is made, reports have shown rapid response to glucocorticoids.

Acute Fibrinous and Organizing Pneumonia (AFOP)

This rare entity presents as acute respiratory failure but radiographically and histopathologically appears similar to organizing pneumonia. It is typically idiopathic but may be associated with collagen vascular disease, hypersensitivity pneumonitis, or drug reaction.

Fibrosing COP

Fibrosing COP is a rare entity with similar clinical and histological appearance to COP but with variable amounts of fibrosis. The fibrosis may or may not be evident radiographically but is seen on pathologic examination. These patients have a poor response to glucocorticoids or other agents. Patients often succumb to progressive respiratory failure. These cases may represent overlap with other idiopathic interstitial pneumonia.

Unifocal COP

Unifocal COP is typically diagnosed during evaluation of a solitary pulmonary nodule concerning for lung malignancy. No relapses have been reported.

Other Causes

Infectious Causes

Bacterial, fungal, or viral pneumonia are appropriately the first considered diagnosis in a patient presenting with fever, cough, and shortness of breath along with radiographic findings.

Inflammatory Causes

Other interstitial lung diseases could give a similar radiographic appearance including idiopathic interstitial pneumonia such as NSIP and UIP. Hypersensitivity pneumonitis could have a very similar clinical presentation, but radiographic changes are usually upper lobe predominant, and there is an identifiable exposure history. Hypersensitivity pneumonitis and COP share a lymphocyte predominant BAL, but histopathology reveals chronic inflammation with poorly formed granulomas in hypersensitivity pneumonitis.

Chronic eosinophilic pneumonia has a similar clinical and radiologic presentation but is differentiated by BAL fluid or peripheral eosinophilia and histology.

Malignancy

Radiographically pulmonary malignancies such as primary pulmonary lymphoma or adenocarcinoma in situ could have an appearance similar to a focal area of COP. The diseases can be typically differentiated based on the clinical presentation and histopathologic examination. Low-grade primary pulmonary lymphoma may have some response to glucocorticoids thus mimicking COP. Adenocarcinoma-in-situ tends to have associated nodules and do not respond to glucocorticoids.

Prognosis

COP is associated with excellent, long-term outcomes when treated. Spontaneous remissions are seen in about 50% of mild cases. Patients demonstrate a rapid symptomatic response to treatment and up to 80% achieve complete cure. Relapses are common but do not seem to affect long-term outcomes in terms of morbidity and mortality.

Pearls and Other Issues

Persistent pulmonary opacities with symptoms of pneumonia not improving despite antibiotic therapy should prompt suspicion for COP. Rigorous search for secondary causes should be made before diagnosing COP. Glucocorticoid therapy produces a dramatic response, and up to 80% of individuals achieve complete cure.

Enhancing Healthcare Team Outcomes

The diagnosis and management of COP requires a multidisciplinary team that includes a pulmonologist, infectious disease expert, thoracic surgeon, internist, pathologist and a radiologist. Once the diagnosis is made, the treatment is complex as there are no controlled trials comparing medications or duration of treatment in COP. Treatment regimens are based on consensus guidelines. The initial clinical presentation, severity of disease, and degree of responsiveness should be considered when deciding on an appropriate regimen and duration of therapy.

Spontaneous remissions have been described for patients with mild symptoms and minimal radiographic and PFT abnormalities. The anti-inflammatory effect of macrolides particularly clarithromycin has been exploited in some reports to treat patients with mild symptoms.

The vast majority of patients with progressive symptoms and diffuse radiographic involvement are treated with oral glucocorticoids resulting in marked improvement in symptoms. Close monitoring for adverse effects of glucocorticoids is recommended.  Patients who are unable to taper off glucocorticoids or have significant side effects to glucocorticoids can be started on a steroid-sparing agent, although COP is an unapproved indication for all steroid-sparing medications. 

COP is associated with excellent, long-term outcomes when treated. Spontaneous remissions are seen in about 50% of mild cases. Patients demonstrate a rapid symptomatic response to treatment and up to 80% achieve complete cure. Relapses are common but do not seem to affect long-term outcomes in terms of morbidity and mortality.[12]


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Cryptogenic Organizing Pneumonia - Questions

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Cryptogenic organizing pneumonia is characterized by which of the following features?



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A 55-year-old woman presents with increasing exertional dyspnea and productive cough for past 3 weeks with intermittent fevers. Chest radiograph had consolidations over both lower lung zones. She has completed 2 courses of antibiotics without any improvement in her symptoms. She has never smoked and has no toxic or industrial exposures. She lives in the city and has had no pet or bird exposures. On examination, she is afebrile, has mild respiratory distress but otherwise normal exam. Pulmonary function tests reveal restriction and impaired diffusing capacity of the lungs for carbon monoxide (DLCO). High-resolution CT of the chest reveals ground-glass opacities over bilateral mid to lower lung zones along with areas of dense consolidations. Bronchoscopy with bronchoalveolar lavage revealed a white cell count of 500/mm3 with 55% lymphocytes, 12% eosinophils, 23% neutrophils and 10% monocytes. Bacterial and fungal cultures remained negative. Transbronchial lung biopsy specimens revealed inflammatory cell infiltrate and granulation tissue plugs in small airways. What is the most appropriate next step in the management of this patient?



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What is the classic high-resolution CT finding described in cryptogenic organizing pneumonia?



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What is the histopathologic hallmark of cryptogenic organizing pneumonia?



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A 50-year-old white female presented with a 1-week history of worsening dyspnea on exertion and cough productive of whitish sputum. She also reports intermittent fever and weight loss. The only significant past medical history is that she is a former smoker. There has been no exposure to pets, birds, or other animals. Physical examination reveals mild respiratory distress and some inspiratory crackles at lung bases. The chest radiograph reveals consolidations over bilateral basal zones. She is started on antibiotics and returns a week later without any improvement in symptoms, and imaging shows the same findings. Symptoms persist despite another course of antibiotics. CT chest is obtained that reveals areas of ground glass opacities and consolidations over both lung bases. What is the most likely diagnosis?



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A 58-year-old male is referred for dyspnea on exertion and cough of 3 weeks duration. His primary care provider had diagnosed him with pneumonia and was prescribed two courses of antibiotics without significant improvement in symptoms. Vitals are normal except low oxygen saturation. Lung auscultation reveals intermittent crackles. High-resolution CT of the chest shows bilateral infiltrates predominantly in the lower lobes along with small pleural effusions. Which is the most appropriate next test that will enable to make a diagnosis?



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A patient with cryptogenic organizing pneumonia (COP) returns for a follow-up visit. He was on high dose prednisone for 2 months and now has started a taper. He notes significant improvement in symptoms and currently has no respiratory complaints. He is worried about disease recurrence and worsening lung function. What is known about disease relapse and long-term outcomes in COP?



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Cryptogenic Organizing Pneumonia - References

References

Bala-Hampton JE,Bazzell AF,Dains JE, Clinical Management of Pneumonitis in Patients Receiving Anti-PD-1/PD-L1 Therapy. Journal of the advanced practitioner in oncology. 2018 May-Jun;     [PubMed]
Shen L,Liu J,Huang L,Zhang Y,Xiao X,Yu H, Cryptogenic Organizing Pneumonia Presenting as a Solitary Mass: Clinical, Imaging, and Pathologic Features. Medical science monitor : international medical journal of experimental and clinical research. 2019 Jan 16;     [PubMed]
Saito Z,Kaneko Y,Hasegawa T,Yoshida M,Odashima K,Horikiri T,Kinoshita A,Saitoh K,Kuwano K, Predictive factors for relapse of cryptogenic organizing pneumonia. BMC pulmonary medicine. 2019 Jan 9;     [PubMed]
Wieruszewski PM,Herasevich S,Gajic O,Yadav H, Respiratory failure in the hematopoietic stem cell transplant recipient. World journal of critical care medicine. 2018 Oct 16;     [PubMed]
Oliveira DS,Araújo Filho JA,Paiva AFL,Ikari ES,Chate RC,Nomura CH, Idiopathic interstitial pneumonias: review of the latest American Thoracic Society/European Respiratory Society classification. Radiologia brasileira. 2018 Sep-Oct;     [PubMed]
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Neelambra AN,Acharya V,Sundararajan S, Cryptogenic Organizing Pneumonia with Sarcoidosis Overlap: An Atypical Case Study. Case reports in medicine. 2018;     [PubMed]
Vallard A,Rancoule C,Le Floch H,Guy JB,Espenel S,Le Péchoux C,Deutsch É,Magné N,Chargari C, [Medical prevention and treatment of radiation-induced pulmonary complications]. Cancer radiotherapie : journal de la Societe francaise de radiotherapie oncologique. 2017 Aug;     [PubMed]
Epler GR,Kelly EM, Systematic review of postradiotherapy bronchiolitis obliterans organizing pneumonia in women with breast cancer. The oncologist. 2014 Dec;     [PubMed]
Godbert B,Clement-Duchêne C,Regent D,Martinet Y, [Do all cryptogenic organizing pneumonias require lung biopsy and steroid treatment?]. Revue des maladies respiratoires. 2010 May;     [PubMed]
Kroegel C,Reissig A,Bonnet R,Albes JM,Thole H,Ollenschläger G,Wahlers T,Schneider CP,Gillissen A,Costabel U, [Current trends in pneumology 2002 -- Part 1]. Medizinische Klinik (Munich, Germany : 1983). 2003 Jan 15;     [PubMed]
Lebargy F,Picard D,Hagenburg J,Toubas O,Perotin JM,Sandu S,Deslee G,Dury S, Micronodular pattern of organizing pneumonia: Case report and systematic literature review. Medicine. 2017 Jan;     [PubMed]

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