PMC10205530_01
Chest X-ray at days 1 and 3.. Chest X-ray shows para-hilar bilateral alveolar opacities with air-bronchogram (A). Chest X-ray taken three days later shows some resolution of the previously seen para-hilar opacities but new upper fields opacities have emerged (B).
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COVID-19, was negative. Chest X-ray demonstrated para-hilar bilateral alveolar opacities with air-bronchogram, which were more dominant in the right lung fields (Fig. 1A). After 3 days without any clinical improvement, a second chest X-ray was done that showed partial resolution in the para-hilar opacities with new upper fields opacities (Fig. 1B). A CT imaging of the chest was performed that showed bilateral non-homogenous pleural based opacities, mostly ground glass and some alveolar, a reverse halo sign, and bronchus dilation (Fig. 2 A+C).
Chest CT taken four months apart (A+C on the left column on August 21 and B+D on the left column on January 22).. Chest CT shows the pattern of infiltrating opacities coincides with the diagnosis of organizing pneumonia. Images A+B at the height of the left atrium. Image B showing new patchy infiltrates in the RLL and lingual. Images C+D at the height of the aortic arch. Image C showing bilateral non-homogenous pleural based opacities, mostly ground-glass and some alveolar. Image D shows significant resolution of the opacities.
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After 3 days without any clinical improvement, a second chest X-ray was done that showed partial resolution in the para-hilar opacities with new upper fields opacities (Fig. 1B). A CT imaging of the chest was performed that showed bilateral non-homogenous pleural based opacities, mostly ground glass and some alveolar, a reverse halo sign, and bronchus dilation (Fig. 2 A+C). A second chest CT was performed which demonstrated patchy non-homogenous opacities in different lung regions, with some resolution of previous opacities (Fig. 2B+D). Reverse halo sign (or Atoll sign) was prominent in our patient' CT images (Fig. 2A). Other radiologic findings supporting OP were also seen, such as sub-pleural triangle shaped opacities, bronchial wall irregularities, and bronchial dilatation (Fig. 2); all, in addition to the reverse halo sign, strongly suggesting diagnosis of OP.
Image A showing a significant improvement after 1 month of prednisone treatment. Image B taken 3 months later while continuing prednisone shows radiologic worsening with new patchy bilateral opacities, more dominant in the right lung fields.
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Updated chest x-ray showed significant improvement (Fig. 3A) and saturation while breathing room-air was 95%; however, after a mild effort of 25 stairs it dropped to 86%. An updated chest X-ray revealed patchy infiltrates in the right lung regions and alveolar opacities in the left field (Fig. 3B).
X-ray showing marked resolution of previously seen pulmonary infiltrates after Pulse Solumedrol and Cyclophosphamid treatments.
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The patient was started on a steroid pulse (1g of methylprednisolone per day for 3 days) and 1 g of cyclophosphamide infusions monthly, which led to fast clinical and radiologic improvement (Fig. 4).
Histological analysis of the lung biopsy.. H&E stained section in lower magnification (A) and high power magnification (B-E) shows alveolar hemosiderin - laden macrophages, mild septal thickening, and foci of chronic inflammation. Few foci suspicious for organizing pneumonia are seen.
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The microscopic analysis of lung cryo-biopsy samples demonstrated mainly intra alveolar hemosiderin - laden macrophages with only mild septal thickening and foci of chronic inflammation (Fig. 5).