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academies
Archives of General Internal Medicine | Volume 2
&
April 04-05, 2018 | Miami, USA
International Conference on
Internal Medicine & Practice and Primary Care
International Meeting on
Breast Pathology & Cancer Diagnosis
Non-specific interstitial pneumonitis cellular subtype: A challenging diagnosis
William Grist
and
Yasmine Elamir
RWJ Barnabas Health, USA
O
ur patient was a 52-year-old female who was admitted
for shortness of breath and productive cough with white
sputum. The patient reported that her symptoms began
gradually five months ago and had progressively worsened. The
patient associated symptoms with a five-pound weight loss.
She denied fever, chills, hemoptysis, and chest pain. She was
seen by her primary care physician one week prior to admission
and was placed on Doxycycline for presumed community
acquired pneumonia, as well as a trial of steroids, which slightly
improved her symptoms. Patient was advised to come to the
emergency department when symptoms persisted. Patient
denied smoking, drinking, environmental, or hazardous
exposures. Patient denied having any pets. Patient worked
as a secretary. The patient was originally from Arkansas and
admitted to taking a trip there four weeks prior to admission,
but reported her symptoms started prior to this. She hadmoved
to Illinois twenty years ago. On physical exam, patient was
tachypnea and had difficulty finishing sentences. Her breath
sounds were decreased in the lung bases with mild bibasilar
crackles. Labs were unrevealing. Chest X-ray revealed basilar
opacities with associated volume loss. CT showed bilateral
areas of airspace opacity with air bronchograms suspicious for
pneumonia with lymphadenopathy. The patient underwent an
echocardiogram that showed no signs of heart failure. Patient
was initially treated with a course Ceftriaxone and Azithromycin
with no improvement. The patient was then treated with
Levaquin without improvement of symptoms. A bronchoscopy
with bronchial washing and brushing was performed which
revealed reactive bronchial cells on cytology with no evidence
of malignancy. Cardiac thoracic surgery was consulted. The
patient underwent video assisted lung biopsy and lymph node
biopsy. Lung biopsy revealed interstitial fibrosis, intra-alveolar
macrophages, type II pneumocyte hyperplasia, and chronic
inflammation with lymphoid aggregates, diagnosed as non-
specific interstitial pneumonitis cellular subtype. This case
demonstrates firstly that idiopathic interstitial pneumonias (IIP)
should be considered in patients with diffuse lung disease and
unresolving pneumonia. Secondly, although some classic cases
of interstitial pneumonia can be diagnosed with high resolution
CT, some cases still require thoracic lung biopsy for definitive
diagnosis and classification to aid treatment and prognosis.
Non-specific interstitial pneumonitis (NSIP) is rare compared
to the other six causes of IIP. NSIP is further divided into two
groups based on pathology; a cellular type and a fibrotic type.
The former is rarer and has a better prognosis. The difference
in prognosis validates having a subdivision in NSIP, especially in
our patient. Thirdly diseases like collagen vascular disease and
pneumoconiosis can cause similar findings and should be ruled
out before reaching a final diagnosis.
e:
willgrist@gmail.com