[On the use of corticosteroids for critically ill patients with SARS-CoV-2 interstitial pneumonia]. / La corticothérapie chez le patient critique atteint d'une pneumopathie interstitielle à SARS-CoV-2.

The health crisis caused by SARS-Cov2 continues to question the scientific community on an effective treatment to combat the disease. To do this, understanding the pathophysiology is a key element of the research. Although the use of corticosteroids is debated, recent publications on pathogenesis and histologic pattern allow us to consider their use on a different way. Through these two case reports, it seemed interesting to take stock of the most recent data in the literature and on the potential interest of the corticotherapy in specific critically ill patient's cases.

La crise sanitaire provoquée par le SARS-CoV-2 n'a de cesse de questionner la communauté scientifique sur un traitement efficace pour combattre la maladie. La compréhension de la physiopathologie constitue un élément clé de la recherche. Bien que l'utilisation des corticoïdes soit débattue, des publications récentes sur la pathogenèse et l'analyse anatomopathologique nous permettent d'envisager leur utilisation avec un autre angle d'approche. À travers ces deux cas cliniques, il nous semblait intéressant de faire le point sur les données les plus récentes de la littérature sur l'intérêt de la corticothérapie chez le patient critique atteint par la COVID-19.

A case of herbicide-induced acute fibrinous and organizing pneumonia?

BACKGROUND: To improve the understanding of acute fibrinous and organizing pneumonia (AFOP), we present one case of AFOP proven by percutaneous lung biopsy along with clinical features, chest imaging and pathology. CASE PRESENTATION: A 50-year-old man was admitted to our department after he was given empiric therapy for community-acquired pneumonia (CAP). The clinical symptoms of the patient were dry cough, chills, night sweats and high fevers. Chest computed tomography (CT) scan showed a high-density shadow in the right lung lobe, similar to lobular pneumonia. The patient was preliminarily diagnosed with community-acquired pneumonia; however, antibacterial treatment was ineffective. To confirm the diagnosis, we performed bronchoscopy and percutaneous lung biopsy; pathology was consistent with AFOP. After he was treated with glucocorticoids, the patient's symptoms were relieved, and the shadow seen on imaging dissipated during the follow-up period. CONCLUSIONS: AFOP is a rare histopathological diagnosis that can be easily misdiagnosed. Clinicians need to consider the possibility of AFOP in the case of invalid antibacterial therapy.

A challenging case of drug-related acute fibrinous and organizing pneumonia: A rare case report.

A 65-year-old man presented with intermittent fever and progressive shortness of breath. He responded poorly to antibiotics and corticosteroids (methylprednisolone 40 mg/d). Chest computed tomography scans showed diffuse consolidations and ground glass density patchy opacities in both lungs and these lesions progressed rapidly. The diagnosis of acute fibrinous and organizing pneumonia (AFOP) was confirmed through transbronchial cryobiopsy. This patient had prostate cancer with bone metastasis for 4 months and took the anti-prostate cancer medications including apalutamide and leuprorelin acetate. Considering his medication history, the patient was diagnosed with AFOP induced by anti-prostate cancer medications through panel discussion of multidisciplinary teams. Intravenous methylprednisolone of 500 mg/day was administered for 3 days and then slowly tapered. The patient's shortness of breath gradually subsided. In addition, the lesions in the lungs improved significantly on follow up imaging. AFOP induced by anti-prostate cancer medications is rare. To our knowledge, this is the first reported case and high-dose glucocorticoid treatment may be required in some of these cases.

A rare pulmonary manifestation of Crohn's disease: Acute fibrinous and organizing pneumonia presenting as multifocal nodules.

Acute Fibrinous and Organizing Pneumonia (AFOP) is a rare pulmonary disease, and it has not been recorded in literature as a pulmonary manifestation of Crohn's disease. A 22-year-old individual with an extensive history of Crohn's disease presented to the hospital initially for hematochezia and diarrhea. Computed tomography of her abdomen and pelvis showed multiple pulmonary nodules bilaterally. The patient did not report cough, sputum production, or dyspnea. Autoimmune and infectious workup were overall unremarkable. A CT-guided percutaneous biopsy of a peripheral lung nodule was performed showing features consistent with AFOP. The patient was ultimately treated with a long taper of prednisone and Ustekinumab for Crohn's disease. Follow-up CT-chest showed interval reduction and improvement in lung nodules, which correlated with better control of the patient's Crohn's disease. Pulmonary manifestations of IBD are varied, including pleural disease, bronchiectasis, and organizing pneumonia. Bronchiolitis obliterans organizing pneumonia has been described more frequently in patients with ulcerative colitis compared to Crohn's. Pulmonary nodules are a rare manifestation of IBD and often tend to be granulomatous or necrobiotic. AFOP is a rare entity with no previously reported association with IBD. Secondary AFOP can be caused by autoimmune diseases, drug reactions, infections, or radiation. Treatment of AFOP is usually immunosuppression by glucocorticoids.

Lesson of urgent bilateral lobar lung transplantation for acute fibrinous and organizing pneumonia: a case report.

Background: Acute fibrinous and organizing pneumonia (AFOP) is one of acute expiratory diseases, which occurs rarely with a difficult diagnosis. AFOP is related to an idiopathic cause or autoimmune disease, drug use, infection, cancer, or transplantation. Variation of treatment depends on different institutions. To date, no evidence shows that lobar lung transplantation is applied in an urgent situation such as AFOP. Case Description: A 33-year-old female patient experienced fever, cough, and dyspnea four days prior to admission. She had no underlying health conditions. Initially, she received oxygen therapy and empiric antimicrobial treatment, but later developed pulmonary consolidation. Pathological examination confirmed the diagnosis of AFOP. Despite receiving standardized treatment involving extracorporeal membrane oxygenation (ECMO) and mechanical ventilation, the patient's respiratory function remained compromised. Consequently, an urgent lobar lung transplantation was performed. However, the patient encountered several challenges including carbapenem-resistant Pseudomonas aeruginosa pneumonia, exophytic granulation tissue, anastomotic stenosis, bronchopleural fistulae, anastomotic infections, septic shock, bacteremia, reperfusion syndrome, primary graft dysfunction, severe renal failure, and critical illness myopathy. Although the patient ultimately recovered and had a favorable survival outcome over 1-year post-discharge through multidisciplinary care, there are several key points to consider. Based on the findings from a systematic review, urgent transplantation may be a potential alternative treatment for AFOP. However, peri-transplantation programs should be enhanced, particularly regarding criteria selection, ECMO management, and the role of enhanced recovery after transplantation. Conclusions: The case demonstrates the feasibility of bilateral lobar lung transplantation in patients with AFOP, especially in an urgent situation.

Acute respiratory failure due to Aspergillus niger infection with acute fibrinous and organazing pneumonia: A case report.

A 59-year-old woman complaining of wet cough, hemoptysis, slight fever, anorexia, and malaise was admitted to hospital with suspected lobar pneumonia. She received treatment for myocardial infarction and deep venous thrombosis caused by familial protein C deficiency. Rapid deterioration due to respiratory failure occurred despite intensive care with broad-spectrum antibiotics. At a later date, sputum examination revealed the presence of Aspergillus niger. Based on clinical and autopsy findings, she was diagnosed with acute respiratory failure due to pulmonary aspergillosis with acute fibrinous and organizing pneumonia. This is the first reported case of pulmonary aspergillosis with acute fibrinous and organizing pneumonia complicated by calcium oxalate resulting from Aspergillus niger infection, leading to severe inflammation and tissue injury in the lungs.

Acute fibrinous and organizing pneumonia with myelodysplastic syndrome and pneumocystis jiroveci pneumonia: a case report.

Acute fibrinous and organizing pneumonia (AFOP) is an unusual pathological pattern which is characterized by intra-alveolar deposition of fibrin (fibrin ball) and organizing pneumonia in a scattered distribution, and the pathological diagnosis plays an irreplaceable role in the diagnosis. Most Patients cannot confirm etiology, till now, known etiology included connective tissue disease, infection, environmental and occupational exposure, drugs, organ transplant, and tumor. It can be divided into acute and subacute subtype according to the extent of progress. The most common symptoms of AFOP were fever, cough, and dyspnea. Bilateral consolidations and ground-glass opacities (GGO) usually can be seen on chest CT images. At present, the treatment protocol for AFOP has not reached a consensus Glucocorticoid, immunosuppressants, stem cell transplantation or lung transplantation may contribute to improved clinical outcome. Here, we report a case of AFOP with myelodysplastic syndrome and pneumocystis jiroveci pneumonia (PJP). After treatments of glucocorticoid, immunosuppressant, chemotherapy, antibiotics and blood transfusion, the patient's clinical symptoms, peripheral blood test, and imaging findings were obviously improved. In this case, we consider the AFOP was caused by MDS and the immunodeficiency after chemotherapy lead to secondary PJP. This typical case highlights the importance of appropriate therapy for coexisted diseases of those patients with refractory AFOP.

Histopathological features in fatal COVID-19 acute respiratory distress syndrome.

Background: COVID-19 acute respiratory distress syndrome (ARDS) shares the common histological hallmarks with other forms of ARDS. However, the chronology of the histological lesions has not been well established. Objective: To describe the chronological histopathological alterations in the lungs of patients with COVID-19 related ARDS. Design: A prospective cohort study was carried out. Setting: Intensive Care Unit of a tertiary hospital. Patients: The first 22 consecutive COVID-19 deaths. Measurements: Lung biopsies and histopathological analyses were performed in deceased patients with COVID-19 related ARDS. Clinical data and patient course were evaluated. Results: The median patient age was 66 [63-74] years; 73% were males. The median duration of mechanical ventilation was 17 [8-24] days. COVID-19 induced pulmonary injury was characterized by an exudative phase in the first week of the disease, followed by a proliferative/organizing phase in the second and third weeks, and finally an end-stage fibrosis phase after the third week. Viral RNA and proteins were detected in pneumocytes and macrophages in a very early stage of the disease, and were no longer detected after the second week. Limitation: Limited sample size. Conclusions: The chronological evolution of COVID-19 lung histopathological lesions seems to be similar to that seen in other forms of ARDS. In particular, lung lesions consistent with potentially corticosteroid-sensitive lesions are seen.

Antecedentes: El síndrome de dificultad respiratoria aguda (SDRA) asociado a la COVID-19 comparte características histológicas con otros tipos de SDRA. Sin embargo, no se ha establecido adecuadamente la cronología de las lesiones histológicas. Objetivo: Describir las alteraciones histopatológicas cronológicas en los pulmones de los pacientes con síndrome de dificultad respiratoria aguda asociado a COVID-19. Diseño: Estudio prospectivo de cohortes. Ámbito: Unidad de cuidados intensivos de un hospital terciario. Pacientes: Las primeras 22 muertes consecutivas por COVID-19. Intervenciones: Se llevaron a cabo biopsias pulmonares y análisis histopatológicos en pacientes fallecidos por SDRA asociado a COVID-19. Se evaluaron los datos clínicos y la evolución médica. Resultados: La mediana de edad de los pacientes fue de 66 (63-74) años y el 73% eran varones. La mediana de la duración de la ventilación mecánica fue de 17 (8-24) días. La lesión pulmonar inducida por COVID-19 se caracterizó por una fase exudativa durante la primera semana de la enfermedad, seguida de una fase proliferativa/organizativa en la segunda y tercera semana y, por último, una fase de fibrosis en fase terminal tras la tercera semana de evolución. Se detectaron proteínas y ARN vírico en neumocitos y macrófagos en una fase muy temprana de la enfermedad, pero estos ya no se volvieron a detectar a partir de la segunda semana. Limitación: Tamaño limitado de la muestra. Conclusión: La evolución cronológica de las lesiones histopatológicas pulmonares asociadas a la COVID-19 parece ser similar a la de otras formas de SDRA. En particular, se observan daños pulmonares coherentes con las lesiones potencialmente sensibles a los corticosteroides.

COVID-2019 - A comprehensive pathology insight.

Corona virus disease-2019 (COVID-19) caused by severe acute respiratory syndrome corona virus-2 (SARS CoV-2), a highly contagious single stranded RNA virus genetically related to SARS CoV. The lungs are the main organs affected leading to pneumonia and respiratory failure in severe cases that may need mechanical ventilation. Occasionally patient may present with gastro-intestinal, cardiac and neurologic symptoms with or without lung involvement. Pathologically, the lungs show either mild congestion and alveolar exudation or acute respiratory distress syndrome (ARDS) with hyaline membrane or histopathology of acute fibrinous organizing pneumonia (AFOP) that parallels disease severity. Other organs like liver and kidneys may be involved secondarily. Currently the treatment is principally symptomatic and prevention by proper use of personal protective equipment and other measures is crucial to limit the spread. In the midst of pandemic there is paucity of literature on pathological features including pathogenesis, hence in this review we provide the current pathology centered understanding of COVID-19. Furthermore, the pathogenetic pathway is pivotal in the development of therapeutic targets.

A case report of acute fibrinous and organizing pneumonia with pneumothorax and avian exposure history.

Acute fibrinous and organizing pneumonia (AFOP) is an uncommon variant of acute lung injury. Here, we report a patient with AFOP and a previously unreported condition, pneumothorax. After our experience with this case, we suggest that exposure to birds may be associated with AFOP; pneumothorax can develop in patients with AFOP; and glucocorticoids are very effective for treating AFOP.

Pathology-radiology correlation of common and uncommon computed tomographic patterns of organizing pneumonia.

Organizing pneumonia (OP) is a common pattern of lung injury that can be associated with a wide range of etiologies. Typical and not-so-typical imaging features of OP occur, as both common and rare lung pathologies can mimic the same imaging pattern as that of OP. This article will attempt to describe the difference between confusing terminologies that have been used in the past for OP and existence of primary versus secondary OP. The role of a multidisciplinary approach as an essential component to correctly diagnose and effectively manage challenging cases of OP will be highlighted. Additionally, we will discuss the limitation of transbronchial and importance of open lung biopsy to make the correct diagnosis. One example of an emerging diagnosis in the spectrum of OP and diffuse alveolar damage is acute fibrinous and organizing pneumonia. Ultimately, the reader should feel comfortable recognizing the many variable presentations of OP and be able to participate knowledgeably in a multidisciplinary team after reading this article. OP is a disease entity with variable radiographic and distinct histological characteristics that requires a multidisciplinary approach to correctly diagnose cryptogenic OP. Classic radiologic findings of OP occur in as low as 60% of cases. Secondary causes include infections, neoplasms, inflammatory disorders, and iatrogenic. Acute fibrinous and organizing pneumonia can appear similarly, but miliary nodules are a clue to diagnosis.

Acute Fibrinous and Organizing Pneumonia Associated With Allogenic Hematopoietic Stem Cell Transplant Successfully Treated With Corticosteroids: A Two-Patient Case Series.

Acute fibrinous and organizing pneumonia (AFOP) is an extremely rare, relatively new, and distinct histological pattern of acute lung injury characterized predominately by the presence of intra-alveolar fibrin and associated organizing pneumonia. AFOP may be idiopathic or associated with a wide spectrum of clinical conditions. It has a variable clinical presentation from mild respiratory symptoms to that similar to the acute respiratory distress syndrome. Currently there is no consensus on treatment, and corticosteroids previously were of unclear benefit. To date, there are less than 40 cases of AFOP reported in the literature and only one has been linked to hematopoietic stem cell transplantation. Here we report the first case series of 2 patients who developed AFOP following allogenic stem cell transplant that were successfully treated with high-dose corticosteroids.

Imaging of Acute Lung Injury.

Acute lung injury (ALI) is the clinical syndrome associated with histopathologic diffuse alveolar damage. It is a common cause of acute respiratory symptoms and admission to the intensive care unit. Diagnosis of ALI is typically based on clinical and radiographic criteria; however, because these criteria can be nonspecific, diagnostic uncertainty is common. A multidisciplinary approach that synthesizes clinical, imaging, and pathologic data can ensure an accurate diagnosis. Radiologists must be aware of the radiographic and computed tomographic findings of ALI and its mimics. This article discusses the multidisciplinary diagnosis of ALI from the perspective of the imager.

Diagnostic problems related to acute fibrinous and organizing pneumonia: misdiagnosis in 2 cases of lung consolidation and occupying lesions.

Acute fibrinous and organizing pneumonia (AFOP) is a histological pattern characterized by intra-alveolus fibrinous deposition accompanied with a spectrum of clinical condition. It also presents in other types of lung lesions, thus renders risks to its diagnosis with small biopsies. Here we present 2 cases of lung consolidation and occupying lesions with typical histological presentation of AFOP. One case is tuberculosis presented as massive lung consolidation, initially treated as AFOP, and eventually progressed to bilateral military tuberculosis. The other case presented an occupying mass in the lung which was initially suspected to be an inflammatory mass with AFOP. Lobectomy revealed a poorly-differentiated adenocarcinoma, with AFOP pattern present in the peripheral tissues of the neoplastic mass. In conclusion, we suggest that it is not preferable to diagnose idiopathic AFOP in lung consolidation and occupying lesions before excluding other types of lesions. The diagnostic significance of AFOP should be deliberated.

[Acute fibrinous and organizing pneumonia]. / Pneumonia aguda fibrinosa e organizante.

The histologic pattern of Acute Fibrinous and Organizing Pneumonia (AFOP), described by Beasley in 2002, is characterized by the existence of intra alveolar fibrin in the form of fibrin "balls" and diffuse organizing pneumonia. Presenting symptoms of this interstitial pulmonary disease can be acute or subacute. However, it differs from the well-recognized histologic patterns of acute pulmonary lesion - Diffuse Alveolar Damage (DAD), Organizing Pneumonia (OP) and Eosinophilic Pneumonia (EP).The authors carry out a review of the literature concerning this topic and describe the clinical case of a 44-year-old patient with unusual imaging features and outcome.