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1. BY
DR. ANIMESH ARYA
CONSULTANT PULMONOLOGIST
MAX HOSPITAL AND BALAJI ACTION
MEDICAL INSTITUTE
NEW DELHI

2. 58 YRS FEMALE OBESE H/O
DOE FOR 2 YRS PROGRESSIVE
ADMITTED FOR INVESTIGATION
AND BEING TREATED FOR HYPOXIC
RESPIRATORY FAILURE

14.  Lung window shows bilateral reticularity in the right and the left mid
zones anterioly ( right>left ) with A haze suggestive of interestitial
thickening with interestitial pnuemonitis.
 Some alveolar opacities are also seen amidst the above suggestive of
the alveolar exudates. The apical basal segments of both lower lobes
also show reticularity with haze suggestive of interestitial thickening
and interestitial pnuemonitis
 The right lower zone shows an area of rounded cystic air spaces
suggestive of areas of bronchiectasis. Some area of bronchiectasis are
also seen in the above apical basal patches of pnuemonitis. A tiny
emphysematous bulla is seen in the right upper zone peripharally.basal
early honeycombing is seen.

15.  Fob and lavage and TBLB
 Treatment with steroids
 Pulse therapy VS. regular dose
 OLB and the treat /not treat
 Supportive

16.  THE LUMEN OF ALVEOLI SHOW DESQUAMMATED EPITHILIAL
CELLS
 THE WALL IS THICKENED EXPANDED AT CERTAIN FOCII BY
COLLAGENOUS TISSUE WHILE AT PLACES THERE ARE LYMPHOID
AGGREGATES.
 CERTAIN ALVEOLAR SPACES SHOW PLASMA CELL, LYMPHOCYTES
AND FEW HISTOCYTE COLLECTIONS.
 THE TERMINAL BRONCHIOLES ARE THICKENED, WITH
COLLAGENOUS WALL AROUND IT.
 SECTION B FROM THE MIDDLE LOBE SHOW CERTAIN NORMAL
LOOKING ALVEOLI WHILE AT PLACES THE INTERESTITIUM IS
EXPANDED LYMPHOMONONUCLEAR CELLS

17.  FEATURES OF DIP IN THE MIDDLE LOBE AND
 FEATURES OF DIP AND UIP IN THE LOWER
LOBE

18.  A CRP diagnosis of UIP made with acute
exacerbation
 Treated with steroids 30 mg /day and
azathioprine with oxygen and diuretics and
LTOT
 Uneventful course initially with worsening to
resting hypoxia without oxygen and gr. IV
dyspnoea

19.  INCRESED ABDOMINAL FULLNESS, ACIDITY, FREQUENCY OF STOOLS AND
SHORTNESS OF BREATH ON WALKING UPTO ABOUT A KM. GR I – II DYSPNOEA
in may2006
 NO H/O WHEEZING. CHEST PAIN H/OCOUGH,
EXPECTORATION,SLIGHTLY YELLOWISH TO HGIC
 NO PEDAL OEDEMA, NO CHEST PAIN , PND,ORTHOPNOEA
 NO SIGNIFICANT PAST HISTORY
 PATIENT IS EX SMOKER – 30 PACK-YEARS TILL ABOUT 6 MONTHS BACK
 ALCOHOLIC –LEFT SINCE 3 MONTHS

20.  AS PER RECORD AVAILABLE WITH US GPE/
NAD, S/E NAD
 PREVIOUS HISTORY- TMT IN MAY 2005- NAD
 REFERRED TO CHEST SPECIALST

21.  HB-16.2
 TLC-6800, P71,L22,M1,E6, ESR =10MM
 URINE –NAD
 BLOOD SUGAR 131
 CXR

24.  FVC=3.52/3.58 (98%)
 FEV1=2.83/2.88 (98%)
 FET==6.81 Seconds
 PEFR=8.08/7.02 lps (115%)
 FEF 25-75 =2.89/3.14 (92%)

30.  Non contrast HRCT scan was done
 Multiple patchy foci of consolidation showing a predominantly
peripheral distribution seen at the lung bases bilaterally. The largest
lesion is seen in the right lower lobe abutting the pleura with an
adjacent area of ground glass density. Other lesions are significantly
smaller and are seen in both the lower lobes as well as lingula and the
middle lobe
 B/L peripherally distributed patchy consolidation/infiltrates are also
seen
 No lymphadenopathy
 Radiological D/D – nonspecific shadows, ?infective, ?BOOP, ?EP,?OP

31.  WAIT AND WATCH AS PT. IS MILDLY
SYMPTOMATIC?
 INVESTIGATE?
 WHICH INVESTIGATIONS?

32.  CONSULTED ANOTHER CHEST PHYSICIAN AND
TREATED WITH AB. FOR A WEEK AND REVIEW AGAIN
AND INVESIGATE FOR AFB SMEAR AND CULTURE FOR
THREE DAYS, AND SPUTUM CULTURE
 SP CULTURE NEGATIVE, SP AFB NEG FOR 3 DAYS
 HIS COUGH WORSENED AND THE SPUTUM WAS MORE
BLOOD TINGED
 HE THEN REPORTED TO US FOR FOB AND
BIOPSY WITH INTENT TO RULE OUT
MALIGNANCY (SUGGESTED BY
SOMEBODY)

33.  MX TEST, ACE LEVEL ,HIV, TEMP RECORD AND
BRONCHOSCOPY
 FOB PERFORMED
 MILD PURULENT SECRETIONS COMING OUT OF
APICAL AND POSTERIOR BASAL SEGMENTS OF
RLL, APICAL SEGMENT WAS NAROWED
 SENT FOR CYTOLOGY, AFB CULTURES AND TBLB
TAKEN FROM THE RLL APICAL SEGMENT

34.  CYTOLOGY, INCONCLUSIVE AFB SMEAR -NEG
 BIOPSY- A PIECE OF BRONCHIAL MUCOSA, IT
HAS PSEUDOSTRATIFIED LINING
DISCONTINUOUS AT PLACES THERE IS
SUBMUCOUSAL LYMPHONUCLEAR INFILTRATE,
FEW FOAMY CELLS.AND A FEW ILL DEFINED
GRANULOMAS
 IMP: EPITHELOID GRANULOMATOUS
INFLAMMATION BRONCHIAL TISSUE - ?CAUSE

35.  TUBERCULOSIS
 ALVEOLAR SARCOID
 OP
 PUMONARY VASULITIS
 ???? IIP

36.  PATIENT WAS TOLD OF THE REPORT AND HE
DISCUSSED THIS WITH THREE DIFFERENT
PULMONOLOGISTS AND THE OPINION WAS VARIED
ABOUT
 1. ATT,
 2. ATT AND STEROIDS
 3. STEROIDS
 4 .WAIT AND WATCH FOR CULTURE
HOWEVER PATIENT WAS STARTED ON
ANTITUBERCULAR TREATMENT WITH 4 DRUGS
WITH THE CONSENT OF THE PT.

39.  His symptoms worsened and the patient became
dyspnoeic, with worsening hemoptysis and loss of
weight
 His CXR did not show much change , RATHER
WORSENED
 He was suggested to take steroids and discontinue ATT
but he again went to at least three more pulmonologists
and all agreed to same approach
 In the mean time to get sputa for AFB for 3 more days,
c-ANCA, p-ANCA, ACE levels, complement levels, repeat
urine exam and ENT exam
 All investigations came out to be normal. Meanwhile pt’s
dyspnoea worsened.
 He was suggested repeat CT scan thorax and PFT

41.  FVC: 2.04 vs 3.52
 FEV1: 1.61 vs
2.83

51.  CT Report (18-8-05): There is marked volume loss of
both lower lobes which show areas of collapse
consolidatoion in both the lung bases. Evidence of
thickened interstitium with ground glass density are also
seen. Similar changes are evident in few areas of
middle lobe and lingula. A few scattered infiltrates are
seen in the upper lobes but these portions of lung are
mostly spared. There is no lymph nodes and or pleural
effusion
 There is marked progression of lesions as compared to
the previous scan of 30-6-05.
 No definitive radiological opinion was volunteered.

55.  Patient was advised to undergo OLB at this
stage for a conclusive diagnosis
 Pt refused procedure and continued on steroids
 Went to AIIMS and subjected to FOB and TBLB
again ON 26/08/05
 Biopsy result-shows respiratory epithelium,
subepithelium showing mild thickening of the
interalveolar septae and sparse chronic
inflammatory infiltrate. The possibility of
inflammatory lung disease can not be ruled out
in the small biopsy.

56.  REPEAT FOB WITH BAL
 OPEN LUNG BIOPSY AND MICROBIOLOGICAL
SAMPLING
 CHANGE MX WITH ADDITION OF
IMMUNOSUPPRESSIVES

57.  D/D ??
 Continued on steroids and we reemphasised the
need for a firm diagnosis by larger biopsy by way
of OLB

58.  Patient undergoes open lung biosy on 14/09/05 at
another institute after consulting five
pulmonologists in Delhi and Bombay
 Reported as widening of the interstitial tissue
which is infiltrated by the inflammatory cells. Some
of the alveolar lumina contain macrophages and
chronic inflammatory cells consisting of
lymphocytes - Intersitial Pneumonitis of Lung
 Review of OLB in AIIMS - Compatible with
organising pneumonia. No granuloma seen
 Review at another institution - UIP

59.  INTERSTITIAL PNEUMONIA
 VARIETY?
 UIP
 NSIP-SUBTYPE=
 CELLULAR
 FIBROTIC
 MIXED
 -OP-FIBROTIC NSIP

60.  After OLB patient was also given
azathioprine besides steroids
 Meanwhile AFB culture on lung biopsy and
bronchial aspirate came out to be negative

61.  WAS THE CLINICAL DIAGNOSIS CORRECT?
 DID WE MISS AT ANY INVESTIGATION?
 WAS APPROACH CORRECT?
 FOB AND BIOPSY WERE INADEQUATE AND
CONFUSING
 OLB DID IT GIVE US THE FINAL ANSWER?
 VARIANCE OF VARIOUS PATHOLOGISTS
IMPRESSION

64.  NSIP
 OP-NSIP
 ?? USUAL INTERSTITIAL PNEUMONITIS
 ?? UIP WITH COP
 ?? COP
 ???? OTHER

66.  DIFFICULT TO ARRIVE AT A DIAGNOSIS
 BETTER CLINICAL , RADIOLOGIC AND SURICAL
CORELATION IS MANDATORY
 OPEN LUNG BIOPSY IS THE NEED OF THE HOUR ,
CAN BE EASILY PERFORMED BUT PERHAPS THE
APPROPRIATE INTERPRETATION OF THE FINDINGS
IS STILL ELUSIVE AND MAY NOT BE THE GOLD
STANDARD

67.  48 MALE, NON SMOKER
 DOE -2MONTHS
 REVIEWD BY PHYSICIANS
 NO DIAGNOSIS
 CXR – BASAL LINEAR SHADOWS
LOSS OF LUNG VOLUME
EXAM –BIBASILAR FINE CRACKLES
ADVISED CT SCAN CHEST AND PFT

77.  PATCHY GROUND GLASS
 LOSS OF LUNG VOLUMES
 NO THICKENING OF INTERSTITIUM
 NO HONEY COMB
INTERSTITIAL PNEUMONITIS-NSIP
PFT – RESTRICTIVE DISORDER

78.  FOB AND LAVAGE – INCONCLUSIVE
 TREATMENT AS CELLULAR NSIP
 PULSE 1 GM OF METHYLPREDNISOLONE X 3
DAYS AND THEN
 START ON 10 MG WYSOLONE AND
AZATHIOPRINE 50 MG/DAY

108.  DOE –HIGH INDEX OF SUSPICION
 MUST R/OOTHER DISEASES
 A HIGH QUALITY CT-WITH A CR CONF
 AGOOD PFT WITH DLCO MANDATORY
 TIME PLANE
 HIGH PROBABLITY OF IIP
 ALGORITMIC APPROACH
 IF DIA CERTAIN NO NEED FOR OLB , FOB COULD BE DONE TO
R/O INFECTIONS
 BAL ROLE IN INDIA
 IF OLB ATTEMPED SELECT THE SITE NO. SIZE AND GOOD
PATHOLOGIST

109.  TREATMENT
 AIM AT WHAT
 POTENTIAL CURE
 CELLULAR/GG-TREAT /PULSES
 FIBROTIC –NO GOOD ONLY SUPPORTIVE
 NEWER DRUGS-NAC /OTHERS