Bhatti, Hammad A

Ho, Minh Q

English

University of Louisville

University of Louisville Journal of Respiratory InfectionsCORRESPONDENCECOVID-19 Case Complicated with Organizing Pneumonia and Pneumothorax:CorrespondenceTO THE EDITOR—Organizing pneumonia on imagingmay be seen as unilateral or bilateral peripheral peri-bronchovascular ground glass or air space consolida-tion, large nodules commonly with consolidation, or insome patients, peripheral consolidation. The bilateralconsolidation typically has subpleural extension with-out subpleural sparing. Subpleural sparing is typicallyseen in chronic lung disease such as nonspecific inter-stitial pneumonitis (NSIP). Other descriptions are of anodule with a reverse halo (atoll sign), where a groundglass nodule is surrounded by a rim of consolidation.This single axial computed tomography (CT) image ofthe lungs (Figure 1) shows findings more suggestive ofatypical pneumonia, such as COVID-19, which was thepatient’s clinical diagnosis.[1] Although many imagingfindings have been reported with COVID-19 pneumo-nia, the most predominate are ground glass opacitiesor ground glass opacities with consolidation, which aresubpleural. Figure 1 shows subpleural extension ofthe opacities, with just a few areas of subpleural spar-ing. The majority of the opacities extend to the pleu-ral surface. This CT appearance in a patient day 9 af-ter COVID-19 infection is most diagnostic of COVID-19 pneumonia, as the peak in CT chest findings is mosttypical around day 10. A radiologic diagnosis of or-ganizing pneumonia in the absence of the atoll signwould require a longer-term history of symptoms (sev-eral months) or a comparison exam showing long-termunresolved pulmonary opacities. Organizing pneumo-nia diagnosis, while it may be in a differential on CT,requires histologic sampling for diagnosis.Anonymous Reviewer1. Phillips TE, Bhatti HA, Ho MQ. COVID-19 case compli-cated with organizing pneumonia and pneumothorax: A casereport. Univ Louisville J Respir Infect 2022; 6(1):Article 12.doi: 10.55504/2473-2869.1237.THE AUTHORS’ REPLY—We thank the reviewers fortheir valuable and thought-provoking inputs. We agreewith most of their comments and have added addi-tional commentary to contribute to our diagnosis of or-ganizing pneumonia.(1) We agree that organizing pneumonia typically hasa sub-acute manifestation over months; however, it canpresent over several weeks as noted by King et al.[1] Itis possible that the patient had symptoms for longer pe-riod of time before he started seeking care as there wasother documentation that he has had cough for at least10 days prior. However, we chose to document 3 daysbecause that was what he reported to us.(2) We agree that the “atoll sign” is relatively spe-cific for organizing pneumonia; however, several othercomputed tomography (CT) imaging findings havebeen recognized as consistent with the diagnosis of or-ganizing pneumonia in the right clinical context.[2, 3]Organizing pneumonia can present as bilateral thickbands of consolidation (>8 mm) which are subpleuralin location and radial or curvilinear in configuration asindicated in Figure 2.Similarly, an “arcade-like” sign is also described in theliterature as a manifestation of organizing pneumonia.This is a feature of perilobular fibrosis, whereby orga-nizing pneumonia projects on imaging as curved orarched consolidation bands reaching the pleural sur-face as shown in Figure 3. Ujitaet et al. noted this per-ilobular pattern in 57% of patients presenting as orga-nizing pneumonia on CT scans.[4]We believe that both forms of these curvilinear CTimaging signs are present in our patient.(3) Diagnosis of organizing pneumonia is best madethrough lung biopsy. In many cases, this is not fea-sible, and a diagnosis of organizing pneumonia canalternatively be established by long-term radiologicalfollow-up showing persistent residual opacities post-therapy.[1] We believe that the CT comparison in Fig-ure 4 (approximately 3 months apart), speaks to thisstatement.Hammad Bhatti1; Minh Q. Ho1∗1Orlando VA Medical Center, Orlando, FL, USA; ∗minh.ho@va.gov1. King TE, Jr., Lee JS. Cryptogenic Organizing Pneumo-nia. N Engl J Med 2022; 386(11):1058-69. doi: 10.1056/NE-JMra2116777. PMID: 35294814.2. Baque-Juston M, Pellegrin A, Leroy S, Marquette CH,Padovani B. Organizing pneumonia: what is it? A concep-tual approach and pictorial review. Diagn Interv Imaging2014; 95(9):771-7. doi: 10.1016/j.diii.2014.01.004. PMID:24559802.3. Chiarenza A, Esposto Ultimo L, Falsaperla D, et al. Chestimaging using signs, symbols, and naturalistic images: aULJRI | https://ir.library.louisville.edu/jri/vol6/iss1/15 1ULJRI COVID-19 with Organizing Pneumonia and Pneumothorax: Correspondencepractical guide for radiologists and non-radiologists. InsightsImaging 2019; 10(1):114. doi: 10.1186/s13244-019-0789-4.PMID: 31802270.4. Ujita M, Renzoni EA, Veeraraghavan S, Wells AU, HansellDM. Organizing pneumonia: perilobular pattern at thin-section CT. Radiology 2004; 232(3):757-61. doi: 10.1148/ra-diol.2323031059. PMID: 15229349.Published: May 23, 2022Copyright: © 2022 The author(s). This original article isbrought to you for free and open access by ThinkIR: The Uni-versity of Louisville’s Institutional Repository. For more infor-mation, please contact thinkir@louisville.edu. This article isdistributed under the terms of the Creative Commons Attribu-tion 4.0 International License (CC BY 4.0), which permits un-restricted use, distribution, and reproduction in any medium,provided the original author and source are credited.Funding Source: The author(s) received no specific fundingfor this work.Conflict of Interest: All authors declared no conflict of inter-est in relation to the main objective of this work.Recommended Citation: Bhatti H, Ho MQ. COVID-19 casecomplicated with organizing pneumonia and pneumotho-rax: Correspondence. Univ Louisville J Respir Infect 2022;6(1):Article 15. doi: 10.55504/2473-2869.1247.Figure 1. Patient’s chest computed tomography from hospital day 0 of the first admission, which showed bilateral patchy curvilinear consolidationpattern with subpleural sparing consistent with organizing pneumonia post-COVID-19 infection (Figure 3 in original article).ULJRI | https://ir.library.louisville.edu/jri/vol6/iss1/15 2ULJRI COVID-19 with Organizing Pneumonia and Pneumothorax: CorrespondenceFigure 2. Bilateral thick bands of consolidation, subpleural in location and radial or cuvilinear in configuration.Figure 3. Perilobular pattern of curved or archied consolidation bands reaching the pleural surface.ULJRI | https://ir.library.louisville.edu/jri/vol6/iss1/15 3ULJRI COVID-19 with Organizing Pneumonia and Pneumothorax: Correspondencea)b)Figure 4. Computed tomography of the lungs, showing persistent residual opacities post-therapy. Images a) and b) were taken three monthsapart.ULJRI | https://ir.library.louisville.edu/jri/vol6/iss1/15 4

COVID-19 Case Complicated with Organizing Pneumonia and Pneumothorax: Correspondence

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COVID-19 Case Complicated with Organizing Pneumonia and Pneumothorax: Correspondence

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