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A1579 - Frankincense for Organizing Pneumonia: A Steroid-Sparing Gift?
Author Block: A. Synn1, K. M. Berg2; 1Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital/Beth Israel Deaconess Medical Center, Boston, MA, United States, 2Department of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States.
Introduction: Cryptogenic organizing pneumonia (COP) remains a poorly understood and clinically challenging condition. Corticosteroids are associated with rapid improvement, and despite a lack of randomized trials, have become the mainstay of treatment. Unfortunately, relapses are common and many patients are unable to taper steroid therapy, leading to significant adverse effects. Frankincense is reported to have anti-inflammatory properties, and we report a case of COP responsive to frankincense.
Case Report: A 52-year-old man was referred to pulmonary clinic with worsening nonproductive cough, SOB, and pulmonary infiltrates. A surgical lung biopsy revealed organizing pneumonia. A thorough workup for associated conditions was unrevealing, and the patient was diagnosed with COP. Treatment with high-dose prednisone was initiated. Although his disease was steroid-responsive, multiple attempts to lower the dose below 20mg/day were unsuccessful due to recurrence of symptoms, worsening radiographic findings, and decline in pulmonary function. Azathioprine and mycophenolate mofetil were trialed but discontinued due to intolerable side effects. High-dose inhaled corticosteroids and daily azithromycin were initiated without effect on prednisone dose. Four years after his initial diagnosis, the patient began taking a commercial preparation of frankincense essential oil (inhalation via diffuser and oral ingestion). He noted an immediate improvement in symptoms, and over two years tapered off all other medications. Pulmonary function testing, which had previously demonstrated a low diffusing capacity and FVC, normalized. There have been no side effects related to frankincense.
Discussion: In the medical community, there is reasonable skepticism of most herbal and “natural” remedies, which are generally unsupported by rigorous scientific evaluation and vary widely in quality and purity due to a lack of regulation. However, here we report a case of pathologically confirmed, steroid-dependent COP with a dramatic clinical response to frankincense where standard therapies were intolerable or ineffective. Frankincense, the gum-resin of trees of genus Boswellia, has seen religious, cultural, and medicinal use since antiquity. More recently, frankincense has received attention for its potential anti-inflammatory, neuroactive, antibacterial, and antioxidant effects, and has been studied in conditions such as ulcerative colitis, multiple sclerosis, and asthma; one placebo-controlled randomized trial of Boswellia gum-resin resulted in improvement in bronchial asthma in 70% of patients compared to 27% of controls. The mechanism of action is not well understood but may be related to inhibition of leukotrienes and macrophage nitric oxide overproduction. Although the optimal dose, route, and formulation of frankincense are unknown, the dramatic response seen in this case merits further investigation.