Correct!
5. Chronic aspiration pneumonitis
The pathology is consistent with bronchiolitis obliterans and all the diagnoses listed are associated with bronchiolitis obliterans (2). The diagnosis of rheumatoid arthritis is suspect. The drugs she is presently taking were not being taken at the time of the open lung biopsy. There is no evidence for tuberculosis although this remains a possibility with the patient chronically immunosuppressed. Granulomatosis with polyangitis was formerly known as Wegner’s granulomatosis and can be a very difficult diagnosis, especially when limited to the lungs. However, the clinical course is not compatible with this diagnosis.
Chronic aspiration was suggested by the pathologists because of the histological pattern. This seems to be increasingly recognized and can present with diffuse alveolar damage, bronchiolitis and/or organizing pneumonia (3). Chronic aspiration is not always associated with food particles on biopsy. Although usually thought of as a diagnosis where loss of consciousness or decreased gag reflex is present, 40% had gastroesophageal reflux as their only predisposing factor in a recent series (3).
The patient denied any symptoms associated with chronic aspiration. However, on barium swallow she had a hiatal hernia with free reflux to the upper esophagus in the recumbent position. Her steroids are being tapered, she is being treated for her gastroesophageal reflux and she feels well.
Subclinical aspiration should be considered as a possible cause of small airways disease that can appear similar to bronchiolitis obliterans. Pathology can be suggestive, even in the absence of food or other particulate matter. This case illustrates an Osler quote, “Listen to the patient, he is telling you the diagnosis.”. The patient was telling us that she did not have rheumatoid arthritis and so other diagnosis needed to be considered.
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