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A Case of Tacrolimus-Associated Organizing Pneumonia (OP)
Diffuse Lung Disease SESSION TITLE: Student/Resident Case Report Poster - Diffuse Lung Disease SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
A Case of Tacrolimus-Associated Organizing Pneumonia (OP) Nishal Brahmbhatt MD* Reid Ikeda MD; and Gehan Devendra MD University of Hawaii, Honolulu, HI INTRODUCTION: Tacrolimus has been used as an effective immune-modulating agent for treatment of a variety of ailments including eczema, rheumatoid arthritis, and post-transplant rejection for over 30 years. As with any therapeutic regimen, there are more commonly known side effects, but occasionally, rare side effects of treatment are encountered.
DIFFUSE LUNG DISEASE
CASE PRESENTATION: A 60 year old man with a history of end-stage renal disease secondary to polycystic kidney disease status-post living donor renal transplant in 2006 on tacrolimus, azathioprine and prednisone began experiencing dyspnea in September of 2015 which was initially attributed to pulmonary edema. He improved slightly with diuresis, but was hospitalized again in October 2015 for recurrent dyspnea. A CT scan of the chest then revealed bilateral patchy infiltrates and peripheral linear opacities consistent with the “atoll sign,” which can be associated with Cryptogenic Organizing Pneumonia (COP). Bronchoalveolar lavage was performed and microbiology studies were negative. Pulmonary function tests were consistent with mixed obstructive and restrictive physiology and diffusion impairment. His symptoms improved partially with diuresis, but after hospital discharge, a new mass-like consolidation was noted on CT and his prednisone dose was increased given concerns for COP as he had no signs of infection. He gained 14 lbs and was readmitted with dyspnea and worsening renal function. His prednisone dosage was reduced and diuresis slightly improved his dyspnea. A lung biopsy was performed and pathologic changes consistent with tacrolimus-associated organizing pneumonia were noted. 1 month after being tapered off tacrolimus, he was able to ambulate half a mile without dyspnea. A repeat CT scan of the chest revealed resolution of his lung opacities. DISCUSSION: Tacrolimus-induced lung injury has been rarely described in patients with rheumatoid arthritis but cases of tacrolimus-associated organizing pneumonia have been reported twice in the setting of opportunistic infections (1, 2). CONCLUSIONS: Tacrolimus-induced organizing pneumonia is extremely rare, and should be considered in patients who have persistent dyspnea and radiographic abnormalities. Treatment with prednisone may not be effective for this type of organizing pneumonia and obtaining a lung biopsy with discontinuation of tacrolimus if suggestive pathologic features are noted, may lead to improvement. Reference #1: Kleindienst R, et al. Bronchiolitis obliterans organizing pneumonia associated with Pneumocystis carinii infection in a liver transplant patient receiving tacrolimus. Clin Transplantation 1999: 13:65-67. Reference #2: Cunha BA, et al. Renal transplant with bronchiolitis obliterans organizing pneumonia (BOOP) attributable to tacrolimus and herpes simplex virus (HSV) pneumonia. Heart Lung. 2012 May; 41(3):310-5. DISCLOSURE: The following authors have nothing to disclose: Nishal Brahmbhatt, Reid Ikeda, Gehan Devendra No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.548
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
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150#4S CHEST OCTOBER 2016
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A Case of Tacrolimus-Associated Organizing Pneumonia (OP) Nishal Brahmbhatt MD* Reid Ikeda MD; and Gehan Devendra MD University of Hawaii, Honolulu, HI INTRODUCTION: Tacrolimus has been used as an effective immune-modulating agent for treatment of a variety of ailments including eczema, rheumatoid arthritis, and post-transplant rejection for over 30 years. As with any therapeutic regimen, there are more commonly known side effects, but occasionally, rare side effects of treatment are encountered.
DIFFUSE LUNG DISEASE
CASE PRESENTATION: A 60 year old man with a history of end-stage renal disease secondary to polycystic kidney disease status-post living donor renal transplant in 2006 on tacrolimus, azathioprine and prednisone began experiencing dyspnea in September of 2015 which was initially attributed to pulmonary edema. He improved slightly with diuresis, but was hospitalized again in October 2015 for recurrent dyspnea. A CT scan of the chest then revealed bilateral patchy infiltrates and peripheral linear opacities consistent with the “atoll sign,” which can be associated with Cryptogenic Organizing Pneumonia (COP). Bronchoalveolar lavage was performed and microbiology studies were negative. Pulmonary function tests were consistent with mixed obstructive and restrictive physiology and diffusion impairment. His symptoms improved partially with diuresis, but after hospital discharge, a new mass-like consolidation was noted on CT and his prednisone dose was increased given concerns for COP as he had no signs of infection. He gained 14 lbs and was readmitted with dyspnea and worsening renal function. His prednisone dosage was reduced and diuresis slightly improved his dyspnea. A lung biopsy was performed and pathologic changes consistent with tacrolimus-associated organizing pneumonia were noted. 1 month after being tapered off tacrolimus, he was able to ambulate half a mile without dyspnea. A repeat CT scan of the chest revealed resolution of his lung opacities. DISCUSSION: Tacrolimus-induced lung injury has been rarely described in patients with rheumatoid arthritis but cases of tacrolimus-associated organizing pneumonia have been reported twice in the setting of opportunistic infections (1, 2). CONCLUSIONS: Tacrolimus-induced organizing pneumonia is extremely rare, and should be considered in patients who have persistent dyspnea and radiographic abnormalities. Treatment with prednisone may not be effective for this type of organizing pneumonia and obtaining a lung biopsy with discontinuation of tacrolimus if suggestive pathologic features are noted, may lead to improvement. Reference #1: Kleindienst R, et al. Bronchiolitis obliterans organizing pneumonia associated with Pneumocystis carinii infection in a liver transplant patient receiving tacrolimus. Clin Transplantation 1999: 13:65-67. Reference #2: Cunha BA, et al. Renal transplant with bronchiolitis obliterans organizing pneumonia (BOOP) attributable to tacrolimus and herpes simplex virus (HSV) pneumonia. Heart Lung. 2012 May; 41(3):310-5. DISCLOSURE: The following authors have nothing to disclose: Nishal Brahmbhatt, Reid Ikeda, Gehan Devendra No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.548
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
534A
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150#4S CHEST OCTOBER 2016
]