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A6504 - Focal Organizing Pneumonia in a Severe Hemophiliac: A Diagnostic Dilemma
Author Block: J. Lau; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States.
A 70 year old male with a history of tobacco use, severe hemophilia A, hepatitis C, and hypertension presents for evaluation of a right upper lobe lung mass. As part of an evaluation of chronic hepatitis C, an MRI abdomen was performed which revealed incidental right upper lobe lung scarring. A chest x-ray showed an irregular nodular opacity in the right upper lobe. This new right upper lobe opacity was further evaluated with a CT chest which showed a 37 x 17 mm spiculated right upper lobe mass. Given his smoking history, this finding was highly suspicious for malignancy. The patient had an occasional cough but did not report fever, weight loss, shortness of breath, or hemoptysis. A positron emission tomography (PET) scan was performed for staging. The right upper lobe lesion was found to be hypermetabolic. Surgical lung biopsy was considered with plan to first perform an endobronchial ultrasound with transbronchial needle aspiration and biopsy. Pathology was consistent with organizing pneumonia with pigmented macrophages. Bronchial washings were negative for malignancy. This represents a case of focal organizing pneumonia diagnosed on transbronchial biopsy.
Organizing pneumonia is a clinical, radiographic, and histologic finding that represents an area of inflammation and repair in response to lung injury related to infection, drug toxicity, or another lung pathology. If no underlying cause is identified, the process is considered to be cryptogenic. Organizing pneumonia has been found to mimic lung cancer on PET scan, which makes the management of such lesions challenging.
In this patient with hemophilia and associated right frontoparietal, retroperitoneal, and left calf hemorrhage, the finding of organizing pneumonia is thought to have represented an area of resolving spontaneous pulmonary hemorrhage. CT chest showed emphysematous changes of the upper lobes so it is thought that hemorrhage occurred into abnormal parenchyma, causing the irregular appearance of the mass. Pulmonary hemorrhage in hemophiliacs is an uncommon complication however abnormal chest imaging such as scarring, fibrosis, or pleural thickening, seen in hemophiliacs, may represent previous hemorrhage.
Given the benign pathology and lack of symptoms, surgical resection was deferred and repeat imaging will be performed for continued observation of this right lung mass attributed to pulmonary hemorrhage.
It is important to recognize that while organizing pneumonia may be diagnosed on transbronchial biopsy, an adjacent pulmonary lesion may be missed. Therefore close monitoring is required with the consideration of surgical resection as an alternative diagnostic and therapeutic approach.