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Acute Fibrinous and Organizing Pneumonia (AFOP) Associated with Chemotherapy Drug Reaction: A Case Report
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A6615 - Acute Fibrinous and Organizing Pneumonia (AFOP) Associated with Chemotherapy Drug Reaction: A Case Report
Author Block: M. Cerezoli1, M. R. Soares2, R. C. Tibana3, C. Y. Fukuda4, C. A. D. C. Pereira1; 1Federal University of São Paulo, Sao Paulo, Brazil, 2Respiratory Diseases, Federal University of São Paulo, São Paulo, Brazil, 3Pulmonary, Federal University of São Paulo, Sao Paulo, Brazil, 4PULMONARY, Federal University of São Paulo, SAO PAULO, Brazil.
Case description:A 38-year-old caucasian female with a history of breast cancer in neoadjuvant chemotherapy treatment (2 cycles of doxorubicin and cyclophosphamide) 2 months ago, was admitted due five weeks of progressive dyspnea associated with fatigue and some episodes of fever. She had no relevant exposure.On examination, she presented signs of respiratory discomfort, respiratory rate 26 breaths per minute, oxygen saturation 91% at room air, body temperature of 98°F, pulse 101 beats per minute and blood pressure 126/85 mmHg. Chest auscultation revealed crackles on right base.Laboratory data revealed a white blood count of 6,990/ml, C-reactive protein at 17. Sputum and blood cultures were negative.The patient was hospitalized for suspected pneumonia in immunocompromised patient. Chemotherapy was discontinued and treatment with piperacillin-tazobactam and sulphamethoxazol-thrimetropin was initiated.A HRCT scan of the chest revealed diffuse ground-glass opacity and ill-defined pulmonary opacities located predominantly in the lower lung periphery fields. Bronchoscopy performed did not show infectious agents at bronchoalveolar lavage. Transbronchial biopsy revealed an extensive area of epithelial hyperplasia and hypertrophy reaction pattern, besides fibrin alveolar deposits (fibromyxoid plugs) in the form of “fibrin balls”. No hyaline membranes were seen, and special stains for fungal and mycobacterial organisms were negative. Findings were consistent with the reported description of acute fibrinous and organizing pneumonia (AFOP). After establishing the diagnosis of AFOP, the patient was started on prednisone 1mg/Kg/day with a dramatic clinical response. Discussion:AFOP is a unique pathological entity defined as a rare idiopathic interstitial pneumonia according to the classification of ATS/ERS 2013. Tissue histopathology revealed intra-alveolar fibrin deposition in the form of “fibrin balls”, which involve their spaces with an average of 50%. There is no evidence of classic hyaline membranes, showing the difference between diffuse alveolar damage.
Numerous conditions have been described with AFOP, including infections, connective tissue disorders, hematological diseases and drugs reactions. In addition, several cases have no origin cause or association. Our case shows a distinct exposure to a chemotherapy drug (doxorubicin) that could explained the clinical presentation and the AFOP development, since other causes were excluded.There were reports that some drugs are associated with AFOP such as amiodarone, abacavir and decitabine. However, there is no report with doxorubicin.By this study, we suggest that AFOP should be considered for oncologic patients undergoing chemotherapy, like drug reaction, which presenting clinical and radiological data compatible with this disease.
Author Block: M. Cerezoli1, M. R. Soares2, R. C. Tibana3, C. Y. Fukuda4, C. A. D. C. Pereira1; 1Federal University of São Paulo, Sao Paulo, Brazil, 2Respiratory Diseases, Federal University of São Paulo, São Paulo, Brazil, 3Pulmonary, Federal University of São Paulo, Sao Paulo, Brazil, 4PULMONARY, Federal University of São Paulo, SAO PAULO, Brazil.
Case description:A 38-year-old caucasian female with a history of breast cancer in neoadjuvant chemotherapy treatment (2 cycles of doxorubicin and cyclophosphamide) 2 months ago, was admitted due five weeks of progressive dyspnea associated with fatigue and some episodes of fever. She had no relevant exposure.On examination, she presented signs of respiratory discomfort, respiratory rate 26 breaths per minute, oxygen saturation 91% at room air, body temperature of 98°F, pulse 101 beats per minute and blood pressure 126/85 mmHg. Chest auscultation revealed crackles on right base.Laboratory data revealed a white blood count of 6,990/ml, C-reactive protein at 17. Sputum and blood cultures were negative.The patient was hospitalized for suspected pneumonia in immunocompromised patient. Chemotherapy was discontinued and treatment with piperacillin-tazobactam and sulphamethoxazol-thrimetropin was initiated.A HRCT scan of the chest revealed diffuse ground-glass opacity and ill-defined pulmonary opacities located predominantly in the lower lung periphery fields. Bronchoscopy performed did not show infectious agents at bronchoalveolar lavage. Transbronchial biopsy revealed an extensive area of epithelial hyperplasia and hypertrophy reaction pattern, besides fibrin alveolar deposits (fibromyxoid plugs) in the form of “fibrin balls”. No hyaline membranes were seen, and special stains for fungal and mycobacterial organisms were negative. Findings were consistent with the reported description of acute fibrinous and organizing pneumonia (AFOP). After establishing the diagnosis of AFOP, the patient was started on prednisone 1mg/Kg/day with a dramatic clinical response. Discussion:AFOP is a unique pathological entity defined as a rare idiopathic interstitial pneumonia according to the classification of ATS/ERS 2013. Tissue histopathology revealed intra-alveolar fibrin deposition in the form of “fibrin balls”, which involve their spaces with an average of 50%. There is no evidence of classic hyaline membranes, showing the difference between diffuse alveolar damage.
Numerous conditions have been described with AFOP, including infections, connective tissue disorders, hematological diseases and drugs reactions. In addition, several cases have no origin cause or association. Our case shows a distinct exposure to a chemotherapy drug (doxorubicin) that could explained the clinical presentation and the AFOP development, since other causes were excluded.There were reports that some drugs are associated with AFOP such as amiodarone, abacavir and decitabine. However, there is no report with doxorubicin.By this study, we suggest that AFOP should be considered for oncologic patients undergoing chemotherapy, like drug reaction, which presenting clinical and radiological data compatible with this disease.
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