AN UNUSUAL PRESENTATION OF NONSPECIFIC INTERSTITIAL PNEUMONIA

ABSTRACT

SESSION TITLE Fellows Diffuse Lung Disease Posters SESSION TYPE Fellow Case Report Posters PRESENTED ON October 18-21, 2020 INTRODUCTION: Nonspecific interstitial pneumonia (NSIP) is the second most common cause of idiopathic interstitial pneumonias. Even though ground glass capacities (GGOs) are thought to be the predominant feature of NSIP with high sensitivity, this disease has a varied presentation. Hence, reliance on imaging solely for its diagnosis can be erroneous. Here we present a case of cellular NSIP with atypical radiological findings. CASE PRESENTATION A 61-year-old female with history of chronic kidney disease presented with cough with productive sputum and dyspnea. She had a similar admission two months ago with hypoxic respiratory failure requiring oxygen with high flow nasal cannula. CT chest showed multifocal airspace consolidations bilaterally. She was initially treated with antibiotics with no significant improvement following which steroids were added for severe pneumonia resulting in rapid improvement of her symptoms. Hence, she was thought to have a steroid responsive lung disease such as acute eosinophilic pneumonia or organizing pneumonia and was discharged on a tapering dose of steroids with a plan for outpatient follow-up. However, patient did not follow up and presented with recurring symptoms two weeks after discontinuing the steroids. CT of her chest again showed multifocal new confluent airspace consolidations in bilateral lung fields with improvement of old consolidation. She underwent bronchoscopy with transbronchial cryobiopsy showing cellular NSIP. She was started on high dose steroids with subsequent improvement and was discharged on prednisone 40 mg daily. No clear etiology for NSIP could be identified. She was then started on mycophenolate as an outpatient for steroid sparing effect. Unfortunately, she returned to the hospital with a diagnosis of COVID-19 pneumonia and subsequently passed away. DISCUSSION: Lower lobe predominant GGOs with reticular abnormality and traction bronchiectasis are most common CT findings of NSIP. Patchy airspace consolidations are characteristic for eosinophilic lung disease or organizing pneumonia but is an uncommon finding in NSIP. It is essential to make a definitive diagnosis as each of these have different prognoses and treatment durations. Our case demonstrates that NSIP should be considered in the differential for patchy consolidative lung disease especially when steroid responsive and recurrent. Cryobiopsy in this case was instrumental in making this diagnosis without subjecting the patient to an an open lung biopsy. CONCLUSIONS: NSIP has variable clinical, pathological and radiological manifestations and is usually hard to differentiate from other form of diffuse lung diseases such as organizing pneumonia or HP. Reference #1 Kligerman, Seth et al (2009). Nonspecific Interstitial Pneumonia Radiologic, Clinical, and Pathologic Considerations. Radiographics;Inc. 29. 73-87. 10.1148/rg.291085096. Reference #2 Saraya, T., Takata, S., Fujiwara, M., & Takei, H. (2013). Cellular non-specific interstitial pneumonia masquerading as congestive heart failure. BMJ case reports, 2013, bcr2013010502. https//doi.org/10.1136/bcr-2013-010502 DISCLOSURES No relevant relationships by Sadia Benzaquen, source=Web Response No relevant relationships by Ena Gupta, source=Web Response No relevant relationships by ATUL MATTA, source=Web Response No relevant relationships by Corrado Minimo, source=Web Response