CASE HISTORY – July 2006

A case of follicular bronchiolitis


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Follicular bronchiolitis belongs to the group of benign lymphoproliferative disorders. Follicular bronchiolitis is characterized by bronchiolar narrowing due to external compression by hyperplastic lymphoid follicules. As a result, there is purulent bronchitis with subsequent pneumonitis. Bronchiolitis can occur as a primary or secondary phenomenon. Primary follicular bronchiolitis usually presents as a manifestation of a collagen vascular disease (rheumatoid arthritis, Sjögren syndrome). Secondary follicular bronchiolitis is a common finding in patients with chronic inflammatory diseases of the large airways, such as cystic fibrosis, bronchiectasis or chronic aspiration.The possible etiological factors are viral infection (Epstein-Barr virus, human immunodeficiency virus 8, human herpes virus) and cellular induced autoimmunity. A 54-year old lady, an athletic coach, was admitted to hospital on May 2004; she complained of progressive dyspnoea and weakness during physical activity, nonproductive cough and repeating high body temperature (38–39oC) accompanied by muscle pain during the preceding eight months. The patient’s working ability had not changed. At admission the lungs were clear upon auscultation, WBC 6.73 x 109/L with a normal differential count, CRP 13 mg/L, urea 5.5 mmol/L, creatinine 103 micromole/L. Tuberculin skin test (Mantoux) was positive – papule 22 mm. Bronchoscopy revealed slight endobronchitis. High resolution CT scan of the chest showed bilateral reticulonodular opacities. Sputum and bronchioalveolar lavage was negative for acid-fast bacilli. Despite the fact that lung tuberculosis was suspected due to the presence of fever, the positive tuberculin skin test, pulmonary infiltrates and a relatively good general condition video-assisted thoracoscopy was performed for a definitive diagnosis and biopsy material was taken from the upper-right and middle lobes. The histopathological finding was consistent with follicular bronhiolitis. Patients with follicular bronchiolitis typically have a favourable prognosis. Treatment is generally directed towards the underlying disease but patients with no identifiable underlying cause have been treated with corticosteroids or azathioprine. Erythromycin therapy has been reported to be of benefit. The patient studied by us was treated with prednisolone for a couple of weeks. The initial dose was 25 mg per day. When all symptoms disappeared the patient interrupted treatment. Yet she is under regular follow-up and is doing well.