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A 52-year-old man presented with fever, non-productive cough and progressive dyspnea for 10 days. Chest X-ray showed
pneumonia and serological test for Mycoplasma pneumoniae was positive. His symptoms exacerbated in spite of antibiotics treatment. Follow-up chest X-ray and CT scan of the lungs showed bilateral air space opacifications. For further evaluation, video-assisted thoracoscopic biopsy was performed and bronchiolitis obliterans organizing pneumonia (BOOP) was
diagnosed. Steroid was administered; clinical and radiographic findings then revealed marked and rapid improvements.
Mycoplasma pneumoniae is a common cause of community-acquired pneumonia. If clinical symptoms deteriorated after
appropriate treatment, BOOP must be considered. The key therapy of BOOP is steroid and early diagnosis is very important to avoid irreversible damage to lungs.
Key words: mycoplasma pneumoniae, bronchiolitis obliterans organizing pneumonia
INTRODUCTION
Bronchiolitis obliterans organizing pneumonia
(BOOP) is a clinicopathological entity that occurs in a
wide variety of pulmonary injuries. It is a nonspecific response, which is histologically characterized by intraluminal fibrosis involving the small conducting airways,
alveolar ducts and peribronchial alveolar space.1-3 This
rare disorder is either idiopathic or associated with various illnesses, including infections.1
Here, we describe an interesting case of Mycoplasma
pneumoniae infection and BOOP. The pneumonia was
revealed by radiographic findings and Mycoplasma pneumoniae infection was proven serologically. The failure of
antibiotics therapy and progressive symptoms indicated
a need for further diagnostic evaluation. The patient accordingly underwent a video-assisted thoracoscopic lung
biopsy, and BOOP was then diagnosed. We suggest that
BOOP should be included in the differential diagnosis for
CASE REPORT
A 52-year-old man was admitted to our hospital with
a 10-day history of intermittent fever, nonproductive
cough, and progressive dyspnea. Except a history of
smoking (34 pack years), there was no other significant
medical history. At the time of admission, his vital signs
were as follows: temperature, 38 oC; blood pressure,
117/61 mmHg; pulse rate, 119/min; and respiratory rate,
36/min. On auscultation, crackles were heard over both
lungs, and a grade 3/6 early diastolic murmur was heard
over the left lower sternal border. The patients arterial
blood gas analysis revealed the following: pH, 7.45;
PaO2, 70 mmHg; PaCO2, 35 mmHg; and O2 saturation,
99.4%. The results of other laboratory tests revealed
white blood cell counts of 1.8109/L (neutrophils, 84%;
lymphocytes, 8%; monocytes, 2%; and eosinophils, 0%)
and C-reactive protein of 1.05 mg/dl. Chest radiography
showed bilateral patchy infiltrates in both lungs along
with cardiomegaly (Fig. 1A). Empirical intravenous antibiotics (ceftriaxone, 2.0 gm every 24 h; and ciprofloxacin, 400 mg every 12 h) were administered; however,
by day 2, the patients respiratory status deteriorated,
and he required intubation with mechanical ventilation.
A follow-up chest radiography showed mixed air space
and diffuse reticular opacification (Fig. 1B). Serologi117
Fig. 1 (A) Chest radiograph shows bilateral patchy infiltration in both lung fields and
cardiac enlargement. (B) Another chest radiograph 2 days later, shows diffuse
consolidation, which is worse than before. (C) Chest computed tomography
demonstrates diffuse bilateral air space opacifications, ground-glass appearance with air-bronchograms, interlobular septal thickening and peribronchial
thickening. (D) Chest radiograph shows marked improvement as compared with
previous study, but still reveals mild residual infiltration of both lower lobes and
cardiomegaly.
Histological analysis of a biopsy specimen showed scattered fibroblastic plugs (Massonss bodies) of spindle
mesenchymal cells filling air spaces and obstructing
terminal bronchioles (Fig. 2). We therefore diagnosed
the patient with BOOP on 10th day of admission and discontinued the intravenous ceftriaxone and ciprofloxacin.
Systemic corticosteroid (methylprednisolone, 40 mg
intravenously every 12 h) was administered, and marked
clinical and radiological improvements were noted in 2
weeks. The steroid dosage was gradually reduced during
out-patient follow-up and tapered off after 6 months. At 6
months, follow-up of chest radiography showed marked
improvement of the pulmonary lesion (Fig. 1D).
DISCUSSION
We report a patient who developed increasing dyspnea and acute respiratory failure related to Mycoplasma
pneumoniae, with no improvement of clinical symptoms
and radiographic findings despite antibiotic treatment.
BOOP was documented by video-assisted thoracoscopic
lung biopsy and the subsequent course under corticoster-
Age (yr)/Sex
Patient number
1
57/F
39/M
Cough,
Respiratory
Cough,
symptoms dyspnea fever, dyspnea
fever
tachypnea
71/F
52/M
fever, malaise
Cough,
dyspnea,
fever,
tachypnea
Patchy and
A fine
nodular non-segmental
with
interstitial
pattern mixed alveolar
and interstitial
pattern
Mixed air
space and
diffuse
reticular
opacification
CxR
Bilateral,
migratory
patchy
infiltrates
Chest CT
Bilateral
airspace
consolidation
Diffuse
bilateral air space
opacifications
and
ground-glass
appearance
with air
bronchograms
Time to
diagnosis
1 month
3 days
10 days
Treatment
Steroid
Steroid
Minocycline
Steroid
Outcome
Recovered
Recovered
Recovered
Recovered
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