Imaging: BOOP

1. IMAGE OF THE WEEK
PROF.DR.G.SUNDARAMURTY’S
UNIT
S.DHANRAJ MD I YR

1

2. 2
•28yrs old male presented with following
features
–+non-productive cough
–exertional dyspnea - two weeks
–fever, malaise, weight loss
AUSCULTATION--- Bilateral coarse crackles
and wheeze +

3. 3

4. FINDINGS
•Chest x ray pa view
•Rotated to left
•Penetration adequate,Taken in full
inspiration
•Skin , soft tissue normal,Bony cage
normal,Trachea,mediastinal shadow normal
•Both dome of diaphragm normal in
contour&shape
•Card.phrenic angle obliterated by opacity4

5. •Bilateral Heterogenous air space opacity
occupying right midzone extending to lower
zone and left mid& lower zone.
03/00 5

6. DIFFERENTIAL DIAGNOSIS
USUAL INTERSTITIAL PNEUMONIA
• ACUTE INTERSTITIAL PNEUMONIA
• CHRONIC EOSINOPHILIC
PNEUMONITIS
• ACUTE RESPIRATORY DISTRESS
SYNDROME
• MYCOPLASMA, HIV, HSV, CMV, RUBEOLA,
KLEBSIELLA, HAEMOPHILUS,
LEGIONELLA, GRP. B- STREP,
CRYPTOCOCCUS, NOCARDIA, PCP
6

7. INVESTIGATIONS
• ESR--- 10/22mm
• MANTOUX---Negative
• AFB---Negative
• HIV---Non reactive
• ANA---Negative
7

8. •Patient was started on empirical antibiotics
• SPUTUM CULTURE– Negative
• FUNGAL CULTURE—Negative
•CT SCAN was taken
03/00 8

9. CT SCAN CHEST
03/00 9

10. 03/00 10

11. ATOLL SIGN
03/00 11

12. 03/00 12

13. FINDINGS
•Peribronchial & subpleural consolidation
with irregular margins with air
bronchogram
•Subpleural ground glass opacities
•ATOLL Sign—ring shaped opacity with
central ground glass attenuation
•Interstitial thickening with ground glass
opacities noted in
midlobe/irregular/suprabasal segment of
right lower lobe
03/00 13

14. •Patient did not show any improvement with
antibiotics and based on ct scan findings he
was started on a course of steroids for
which patient responded well and lesions
cleared—
• suggestive of idiopathic boop
03/00 14

15. 15
BOOP--INTRODUCTION
•Bronchiolitis Obliterans Organizing Pneumonia -
refers to a generic term of non-specific
inflammatory reaction of small airways in
response to exogenous/endogenous stimuli
•Comprises two types - based on histopathology
•Clinical features mimic pneumonia without
response to antibacterial therapy

16. 16
BOOP- EPIDEMIOLOGY
•Smoking is not a risk factor

17. 17
BOOP- Classification
•SECONDARY
BOOP
•IDIOPATHIC
BOOP

18. 18
SECONDARY BOOP
•Connective tissue disorders - SLE, RA,
Polymyositis - Dermatomyositis, Sjogren’s
syndrome, MCTD, Ulcerative Colitis, Vasculitis
•Inhaled/Systemic Toxins - gases, nicotine,
cocaine, CO, nitrogen, chlorine
•Drugs - Penicillamine, Amiodarone, Gold,
Bleomycin, Mitomycin-c, Methotrexate,
Sulfasalazine

19. 03/00 19
SECONDARY BOOP
•Infections:
–Mycoplasma, HIV, HSV, CMV, Rubeola,
Klebsiella, Hemophilus, Legionella, Grp B-
Strep, Cryptococcus, Nocardia, PCP
•Pediatric
–RSV, Parainfluenza, Adenovirus, Mycoplasma

20. 03/00 20
SECONDARY BOOP
•Obstructive Pneumonitis
•Hypersensitivity Pneumonitis
•Aspiration Pneumonitis
•Chronic Eosinophilic Pneumonia
•Diffuse Alveolar Damage
•Myelodysplastic Syndrome
•Hematological malignancy

21. 03/00 21
BOOP- IMAGING
Chest Xray: Patchy peripheral bilateral
migratory alveolar infiltrates
•20-30% - reticular or nodular infiltrate
•Pleural effusions in 30% due to secondary
BOOP
•CXR- can be normal in 4-10%
•Cavitation & lymphadenopathy are absent
•Focal consolidation is a marker for a good
response to steroid therapy
•

•

22. 22
BOOP- IMAGING
•High Resolution CT scan of Chest: patchy
consolidation, ground glass opacity,
nodularity with subpleural lower lobe
predeliction.
•Bronchial wall thickening and dilatation
denote severe disease
•Honey combing not seen in idiopathic
BOOP

23. 23
BOOP- Bronchoscopy
•Gold standard- Open lung or thoracoscopic
lung biopsy for histopathology

24. 24
BOOP--Treatment
•Spontaneous recovery occurs rarely
•Antibiotic therapy for underlying infections
•Withdrawal of offending toxin/ drug
•Supportive therapy
•Steroids for idiopathic BOOP and BOOP
secondary to connective tissue disorders

25. 25
BOOP-- STEROID Rx
•Idiopathic BOOP responds to steroids
better than BOOP due to connective tissue
disorders
• Immunosuppressive agents -
cyclophosphamide, azathioprine for those
who fail to respond to steroid Rx

26. Usual interstitial pneumonia/idiopathic
pulmonary fibrosis--Massive fibrosis
appearing as a honeycomb
pattern on HRCT scans and traction
bronchiectasis (lung architecture distortion)
Irregular linear infiltrates generally in lower
lung zones
•Acute interstitial pneumonia or
Hammond rich syndrome--Accelerated
interstitial pneumonitis with fibrosis and
ground-glass attenuation ,Interlobular septal
thickening
00 26

27. •Chronic eosinophilic pneumonia—
Diffuse migratory, patchy alveolar infiltrates
often along the pleural edges
Ground-glass opacities
•Infective pneumonias (community-acquired,
nosocomial, aspiration)--Generally, either
unilateral or bilateral infiltrates.
Aspiration pneumonia infiltrates common in
gravity-dependent regions
•Acute respiratory distress syndrome and
diffuse alveolar damage-- Focal infiltrates
initially, with rapid progression to diffuse bilateral
interstitial infiltrates.Alveolar concolidation often
in dependent lung zones
27

28. THANK YOU
03/00 28