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Radiographic patterns in the diagnostic approach to organizing pneumonia
Patrones radiológicos en la aproximación diagnóstica a la neumonía organizativa
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A) Corte axial de TC de tórax donde se observan opacidades nodulares mal definidas, de diferentes tamaños, que no superan el centímetro, de distribución parcheada y que no presentan predominio regional. B) Corte axial de TC de tórax donde se evidencian consolidaciones parcheadas con vidrio deslustrado periférico, ilustrando un ejemplo de «signo del halo» (flechas blancas). C) Reconstrucción coronal de TC de tórax donde, en el lóbulo inferior derecho, se evidencia un área central de atenuación en vidrio deslustrado (estrella blanca) con un área periférica de consolidación, formando un anillo casi completo, en relación con signo del «halo invertido» o del «atolón» (flechas blancas). D) Corte axial de TC de tórax donde se evidencia patrón en empedrado, distribuido por ambos pulmones, de predominio en lóbulos inferiores.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Utrilla Contreras, M. Fernández-Velilla Peña, F. García Río, M.I. 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In the activation of the alternative complement pathway, C3 convertase cleaves C3 into C3a and C3b, the latter of which is a potent C3 convertase amplifier and generator. This process is regulated by factor H (which inhibits C3 convertase) and factor I (which converts C3b into inactive C3b, thereby slowing the cascade). In addition, C5 convertase is generated from the products derived from the action of C3 convertase. This enzyme cleaves C5 into C5a and C5b. The binding of C5b with C6–C9 forms the membrane attack complex (MAC) with chemotactic activity in the cell surfaces, resulting in cell lysis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. de Lorenzo, S. Tallón, B. Hernández-Sevillano, G. de Arriba" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "de Lorenzo" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Tallón" ] 2 => array:2 [ "nombre" => "B." "apellidos" => "Hernández-Sevillano" ] 3 => array:2 [ "nombre" => "G." 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"apellidos" => "Muñoz-Sanz" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256514000708" "doi" => "10.1016/j.rce.2014.02.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256514000708?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887414000629?idApp=WRCEE" "url" => "/22548874/0000021400000005/v1_201406010020/S2254887414000629/v1_201406010020/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical up-date</span>" "titulo" => "Radiographic patterns in the diagnostic approach to organizing pneumonia" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "258" "paginaFinal" => "265" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "C. Utrilla Contreras, M. Fernández-Velilla Peña, F. García Río, M.I. Torres Sánchez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Utrilla Contreras" "email" => array:1 [ 0 => "cristina.utrilla@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Fernández-Velilla Peña" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "García Río" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M.I." "apellidos" => "Torres Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sección de Imagen cardio-torácica, Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Correponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Patrones radiológicos en la aproximación diagnóstica a la neumonía organizativa" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1051 "Ancho" => 1344 "Tamanyo" => 174719 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Other radiological patterns. (A) Axial slice of chest computed tomography in which ill-defined nodular opacities of various sizes can be observed, which do not exceed 1 centimeter, with patchy distribution and no regional predominance. (B) Axial slice of chest computed tomography in which patchy consolidations with peripheral ground-glass attenuation can be observed, illustrating an example of the “halo sign” (white arrows). (C) Coronal reconstruction of chest CT in which a central area of ground-glass attenuation (star white) with a peripheral area of consolidation can be observed in the lower right lobe, forming an almost complete ring, suggesting an “inverted halo” or “atoll” sign (white arrows). (D) Axial slice of chest CT in which a cobblestone pattern can be seen, distributed through both lungs, predominantly in the lower lobes.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">The clinical problem</span><p id="par0045" class="elsevierStylePara elsevierViewall">Organizing pneumonia (OP) is defined from the histopathological point of view due to the presence of intraalveolar clusters of granulation tissue composed of a mixture of myofibroblasts and connective tissue. Although not specific, this histological pattern combined with specific clinical and imaging findings defines OP. This condition is known as cryptogenic when a specific cause has not been identified. Steroid treatment achieves rapid improvement in the symptoms and imaging test results, although OP tends to relapse after the treatment is withdrawn.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The Fleischner Society and the American College of Chest Physicians define OP, previously known as bronchiolitis obliterans with OP, according to 2 main elements: the pathological findings<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and the abnormalities observed in the imaging tests (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Consolidation of the air space is the main radiological finding and is detected in the plain radiographs and in the computed tomography (CT) scans. The distribution of this condition is characteristically subpleural and basal, although it sometimes presents peribronchial involvement. Other manifestations include ground-glass opacities, tree-in-bud patterns and nodular opacities. The considerable progress in recent years in imaging tests, particularly in CT, dramatically increases their role in the diagnostic evaluation of patients with suspected OP. It is therefore appropriate to update the various patterns of presentation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Suspected diagnosis</span><p id="par0055" class="elsevierStylePara elsevierViewall">In general terms, the suspicion of OP is established based on a collection of clinical manifestations, abnormal laboratory test results and lung function data. The most paradigmatic example usually corresponds to patients diagnosed with a respiratory infection that progresses very slowly, although there are other less common forms of presentation in which it is more difficult to establish a suspicion of OP.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical manifestations</span><p id="par0060" class="elsevierStylePara elsevierViewall">The incidence of OP is similar in men and women and is more frequent between the ages of 50 and 60 years. OP is a lung disorder that is not related to smoking.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> An increased seasonal incidence (at the start of spring) has been reported, with a recurrent course every year in the same time period.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The start of symptoms is usually insidious, with respiratory symptoms, cough, progressive dyspnea, fever, occasional hemoptysis, general malaise, anorexia and weight loss. In addition to these symptoms, there are those of the underlying disease, which sometimes appear a few days after a catarrhal process. Joint pain and myalgia are infrequent. Dyspnea is generally mild to moderate, although it can be more severe in acute cases. The physical examination typically detects focal crackles but can be almost normal. Given that the most common clinical manifestations are not specific, the diagnosis is usually delayed (6-13 weeks).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Laboratory tests</span><p id="par0065" class="elsevierStylePara elsevierViewall">Hemograms do not have much value in establishing the diagnosis of OP. Sometimes mild to moderate leukocytosis with neutrophilia is identified, and the erythrocyte sedimentation rate can be high. An increase in C-reactive protein levels can also be detected, although all these findings are completely nonspecific. Performing a bronchoalveolar lavage (BAL) is indicated in all patients with suspected OP. BAL is useful for ruling out other diseases and for determining the etiology of the OP in some cases. In 20–40% of OP cases, the fluid extracted during BAL shows lymphocytes with a reduced CD4/CD8 ratio, sometimes with neutrophilia or eosinophilia (less than 25% of patients).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pulmonary function</span><p id="par0070" class="elsevierStylePara elsevierViewall">The most common finding is a mild to moderate restrictive pattern, although patients who smoke or who have COPD can present a certain obstructive component. When the patient's clinical condition permits its measurement, the carbon monoxide diffusing capacity presents a mild to moderate reduction, with a preserved alveolar volume. Hypoxemia is typically mild both at rest and during exercise, although patients with extensive involvement or with rapidly progressing disease can present severe hypoxemia. In any of these circumstances, hypercapnia is rarely observed, while the alveolar–arterial oxygen gradient is usually high. It is not uncommon for the hypoxemia to be refractory to the administration of oxygen due to the presence of a certain degree of right-to-left shunting.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Imaging tests</span><p id="par0075" class="elsevierStylePara elsevierViewall">Although imaging findings in OP are heterogeneous and nonspecific, a number of presentation forms in plain radiography and in CT are often so characteristic that they can demonstrate the diagnosis. In a study of the diagnostic precision of CT in a series of patients with idiopathic interstitial pneumonia, the correct diagnosis of OP was reached in 79% of the cases,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> this being the highest correlation among all these conditions, which suggests that CT findings are fairly characteristic.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> From the radiological point of view, OP is characterized by the presence of unilateral or bilateral areas of consolidation.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Consolidations are present in 90% of CT scans of patients with OP. Its distribution is subpleural or peribronchial in 50% of cases.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Air bronchograms are another common finding, as well as the ground-glass pattern (in approximately 60% of cases).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">There are multiple presentation forms for OP, although the 3 main radiological patterns are multiple alveolar opacities, focal isolated opacity and interstitial involvement, known as an infiltrative pattern.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Multiple alveolar opacities</span><p id="par0085" class="elsevierStylePara elsevierViewall">Multiple alveolar opacities constitute the most frequent and characteristic presentation pattern (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). They are typically bilateral and peripheral and can be migratory. They can measure just a few centimeters or can affect the entire lobe. CT scans can show evidence of ground-glass opacities or actual consolidations, at times with air bronchograms. The sensitivity of this technique is greater than that of radiography for detecting opacification of the alveolar space.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This image pattern limits the differential diagnosis to chronic eosinophilic pneumonia (CEP), low-grade lung lymphoma or adenocarcinoma with lepidic growth (previously classified as bronchioloalveolar carcinoma). CEP associates eosinophilia and occasionally asthma. Its histopathological diagnosis sometimes overlaps with OP, because it tends to present clusters of granulation tissue.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Additionally, cases of OP associated with CEP have been described, and even BAL in patients with OP can show a high eosinophil count. Lastly, both conditions can have a relapse/recurrence course.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> Low-grade primary pulmonary lymphomas usually have good initial response to corticosteroids, although not as fast as OP. Adenocarcinoma with lepidic growth is usually associated with nodules in the lung parenchyma and does not respond to corticosteroids.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Focal isolated opacity</span><p id="par0090" class="elsevierStylePara elsevierViewall">This pattern is not characteristic of OP and typically requires histopathological diagnosis, because bronchogenic carcinoma should be ruled out in the presence of a solitary lung node or mass. An additional problem in the differential diagnosis is that OP can present fluorodeoxyglucose uptake on PET-CT; ruling out tumoral etiology is therefore not always possible. Another differential diagnosis proposed for this radiological presentation is with round pneumonia, which usually responds to antibiotherapy,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> or with lung abscesses, which usually predominate in the upper lobes and cavitate with greater frequency.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Infiltrative pattern</span><p id="par0095" class="elsevierStylePara elsevierViewall">This pattern consists of a slight thickening of the interlobular septa, which occasionally have polygonal morphology and are often associated with alveolar opacities, especially consolidations (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The presence of linear images directed toward the lung periphery has also been described. These are visible especially when performing a CT scan during the resolution of the process.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The presence of an interstitial pattern associated with small alveolar opacities is not exclusive to OP given that it can be identified in other idiopathic interstitial pneumonias, especially in idiopathic pulmonary fibrosis and in nonspecific interstitial pneumonia. In the histological analysis of this last condition, foci of OP are sometimes observed.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Other imaging findings</span><p id="par0105" class="elsevierStylePara elsevierViewall">Other findings have been reported (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), which, while much less common in OP, should be taken into account<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">–</span><p id="par0110" class="elsevierStylePara elsevierViewall">“Nodular” pattern: This is characterized by the presence of centrilobular nodules that vary between 3<span class="elsevierStyleHsp" style=""></span>mm and 5<span class="elsevierStyleHsp" style=""></span>mm and/or small nodular opacities (from 1<span class="elsevierStyleHsp" style=""></span>mm to 10<span class="elsevierStyleHsp" style=""></span>mm), typically ill-defined. Differential diagnosis with metastatic involvement is important, especially in patients with a history of cancer, because of the association between OP and this disease.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">–</span><p id="par0115" class="elsevierStylePara elsevierViewall">“Bronchocentric” pattern: This is characterized by areas of consolidation with peribronchovascular distribution.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">–</span><p id="par0120" class="elsevierStylePara elsevierViewall">“Halo” sign: This is an area of ground-glass opacity surrounding a node or mass,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> which has classically been described as associated with OP.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">–</span><p id="par0125" class="elsevierStylePara elsevierViewall">“Inverted halo” or “atoll” sign: This corresponds to an area of ground-glass opacity surrounded by a more or less complete consolidation ring.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is an uncommon sign that was first described as specific to this entity,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> but subsequent studies have identified it in other diseases, mainly in paracoccidioidomycosis.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">–</span><p id="par0130" class="elsevierStylePara elsevierViewall">“Cobblestone” or “crazy-paving” pattern: This is an uncommon manifestation, which affects both the interstitium and the air space. It presents as a thickening of the interlobular and intralobular septa, which overlap the ground-glass opacities, a pattern reminiscent of a cobblestone path.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">–</span><p id="par0135" class="elsevierStylePara elsevierViewall">On rare occasions, OP can be present with other parenchymal or accompanying findings (pleural effusion, mediastinal adenopathies, etc.).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></li></ul></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Diagnostic confirmation</span><p id="par0140" class="elsevierStylePara elsevierViewall">When suspecting OP, a lung tissue sample should be obtained to establish the histopathological diagnosis. The most characteristic finding is the presence of clusters of granulation tissue, composed of fibroblasts and myofibroblasts surrounded by connective tissue.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This clinical picture is one of nonspecific tissue repair with opacification of distal air spaces and the peripheral airway by Masson bodies, a name by which the clusters of loose connective tissue are known. This tissue extends from one alveolus to another through Pores of Kohn, resulting in a patchy distribution around the small airway. This proliferation of fibroblasts is the result of the organization of inflammatory intraalveolar exudates that are produced as an interstitial inflammatory cell response, although the interstitial inflammatory component is minimal.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The presence of an accumulation of granulation tissue is insufficient for making the diagnosis of OP,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> because this histological pattern is also observed in other lung disorders, such as various infectious pneumonia, hypersensitivity pneumonia and various collagen diseases. The presence of eosinophilic microabscesses and microgranulomas should be investigated so as to exclude eosinophilic and hypersensitivity pneumonia. The performance of microbiological studies on lung tissue samples, especially stainings to exclude opportunistic infections, can be of use in these cases. To perform all of these processes, a large histological specimen is required.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Video-assisted thoracoscopic surgery (VATS) enables lung biopsies to be performed in optimal conditions of safety and facilitates removing sufficient tissue for the various analyses. Samples for different lobes can also be obtained if the appearance of the lesions in the CT scan is different. VATS is currently the technique of choice for the majority of patients. However, before proposing the performance of VATS, it is recommended that transbronchial biopsies be performed, because the identification of intraalveolar accumulation of granulation tissue provides for the diagnosis of OP, albeit provisionally.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The biopsy can also be performed with a thick CT-guided needle.</p><p id="par0155" class="elsevierStylePara elsevierViewall">There have been reported cases of OP following various infectious processes (chlamydia, mycoplasmas, viral processes, etc.).<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> In bacterial infections, OP is produced in cases of pneumonia with poor outcomes, in which the infectious agent is neutralized by antibiotics but the inflammatory reaction persists with intraalveolar fibrin exudates. In clinical practice, it is sometimes difficult to satisfactorily complete the search for the etiological agent, either because serological or molecular tests are not available for all the infectious agents that are potentially involved or because an uncontrolled inflammatory process could be triggered resulting in persistent OP, even when the microorganism that caused it has disappeared.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Various drugs and radiation therapy can trigger OP.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> A specific type of OP is associated with breast radiation therapy (tangential field radiation).<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> This differs from pneumonitis by traditional radiation because it can affect nonirradiated areas and can be migratory. A number of series have reported an incidence of up to 2.5% of cases.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Collagen and rheumatic diseases can also be associated with OP. Similarly, lung and bone marrow transplants can have lung complications similar to OP. There was a reported case in a pregnant woman with HIV infection who was being treated with lamivudine and zidovudine.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">When it is not possible to associate the process to a cause or when it does not fit with a specific clinical context, the diagnosis of cryptogenic OP (COP) is established. Obviously, it is essential to conduct a thorough etiological diagnosis of exclusion before accepting the identification of a COP (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,35</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Treatment approach</span><p id="par0175" class="elsevierStylePara elsevierViewall">Treatment with systemic corticosteroids usually achieves rapid improvement in symptoms, with the resolution of alveolar opacities, without significant sequelae. However, when the corticosteroids are withdrawn or the dosage is decreased, the disease can reoccur. Prolonged treatments are therefore necessary at times.</p><p id="par0180" class="elsevierStylePara elsevierViewall">The treatment regimens with corticosteroids are not completely defined. The initial dosages vary between 0.75 and 1.5<span class="elsevierStyleHsp" style=""></span>mg/kg/day. The administration of methylprednisolone bolus for the first few days has also been proposed, with a progressive dosage reduction in the following weeks.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,36</span></a> The treatment duration has not been completely established but has been suggested at a year. Cordier<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> suggests the use of lower dosages of corticosteroids with shorter treatment duration to prevent adverse effects.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Relapses are common and their frequency depends on the presence of associated disease and the treatment duration. The relapses vary from 13% to 58%, depending on the series.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,37</span></a> Relapses have not been associated with increased mortality and long-term morbidity; therefore, the majority of patients assume the risk of relapse compared with the unquestionable iatrogenesis inherent in treatments with corticosteroids for a year.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Cases of spontaneous improvement have been reported for patients with OP<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> and even cases of improvement with antibiotic treatment, especially with macrolides.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0195" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">–</span><p id="par0200" class="elsevierStylePara elsevierViewall">Is it possible to perform the diagnosis of OP exclusively from the clinical manifestations?</p><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The clinical suspicion of OP is established based on a set of clinical manifestations, abnormal laboratory test results and data on lung function. Sometimes these findings, along with a poor clinical evolution and compatible imaging findings, firmly suggest the diagnosis of OP, although histological confirmation is necessary</span>.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">–</span><p id="par0210" class="elsevierStylePara elsevierViewall">Are the findings in imaging tests pathognomonic?</p><p id="par0215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">There are forms of OP presentation (in radiography and in chest CT scans) that are so characteristic that they often demonstrate the diagnosis, although in general imaging findings are heterogeneous and nonspecific. It is therefore essential to known the pathological findings of OP to understand the various radiological patterns of this disease, which will facilitate the radiological diagnosis</span>.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">–</span><p id="par0220" class="elsevierStylePara elsevierViewall">Is the performance of a lung biopsy required to confirm the diagnosis of OP?</p><p id="par0225" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Clinical manifestations, abnormal laboratory test results and data on lung function as a whole, combined with certain specific findings in the imaging tests, can demonstrate the diagnosis of OP. The clinician should be familiar with the various presentation patterns of OP in order to identify the disease and not confuse it with other conditions, although a lung biopsy is required for confirmation</span>.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">–</span><p id="par0230" class="elsevierStylePara elsevierViewall">Is it necessary to wait for histological confirmation before starting treatment when OP is suspected?</p><p id="par0235" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Despite the fact that OP does not present pathognomonic findings in chest radiography or CT scan, OP should be considered in the presence of any of the described radiological patterns along with a poor clinical response to treatment with antibiotics. It is therefore reasonable to start treatment with corticosteroids based on the clinical suspicion, while awaiting histological confirmation</span>.</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres343295" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec324875" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres343296" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec324876" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "The clinical problem" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Suspected diagnosis" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Clinical manifestations" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Laboratory tests" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Pulmonary function" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Imaging tests" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Multiple alveolar opacities" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Focal isolated opacity" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Infiltrative pattern" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Other imaging findings" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Diagnostic confirmation" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Treatment approach" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack84206" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-10-01" "fechaAceptado" => "2013-10-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec324875" "palabras" => array:5 [ 0 => "Organizing pneumonia" 1 => "Cryptogenic" 2 => "Computed tomography" 3 => "Radiographic patterns" 4 => "Alveolar opacities" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec324876" "palabras" => array:5 [ 0 => "Neumonía organizativa" 1 => "Criptogenética" 2 => "Tomografía computarizada" 3 => "Patrones radiológicos" 4 => "Opacidades alveolares" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 56-year-old woman, non-smoker, who complained of dry cough and dyspnea during the last month came to the emergency department due to increased dyspnea. The chest <span class="elsevierStyleSmallCaps">X</span>-ray showed areas of poorly defined, bilateral alveolar opacities, leading to the diagnosis of bronchopneumonia with partial respiratory failure. During admission, she experienced an exacerbation of the dyspnea. A high-resolution computed tomography scan was performed, showing areas of ground glass opacities with interlobular septal thickening (“crazy-paving” pattern), predominantly in lower lobes. She required mechanical ventilation and was admitted to the intensive care unit. Subsequently, an open lung biopsy was performed. The following questions should be proposed:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0005" class="elsevierStylePara elsevierViewall">Is it possible to make the diagnosis of organizing pneumonia (OP) only by clinical findings?</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">–</span><p id="par0010" class="elsevierStylePara elsevierViewall">Are the imaging test findings pathognomonic?</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">–</span><p id="par0015" class="elsevierStylePara elsevierViewall">Is a lung biopsy required to confirm the diagnosis of OP?</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">–</span><p id="par0020" class="elsevierStylePara elsevierViewall">Is it necessary to wait for histologic confirmation to start treatment when OP is suspected?</p></li></ul></p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Una mujer de 56 años, no fumadora, que presentaba tos irritativa y disnea de medianos esfuerzos desde hacía un mes acudió a urgencias por aumento de su disnea. En la radiografía de tórax se apreciaban zonas de incremento de densidad mal definidas, bilaterales, por lo que fue diagnosticada de bronconeumonía con insuficiencia respiratoria parcial. Durante el ingreso empeoró su disnea y se realizó una tomografía computarizada torácica donde se observaron áreas de atenuación en vidrio deslustrado con engrosamiento de septos interlobulillares (“patrón en empedrado”), de predominio en lóbulos inferiores. Requirió ventilación mecánica en la Unidad de Cuidados Intensivos. Posteriormente se realizó una biopsia pulmonar abierta. Se plantean las cuestiones siguientes:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">–</span><p id="par0025" class="elsevierStylePara elsevierViewall">¿Es posible realizar el diagnóstico de neumonía organizativa (NO) exclusivamente mediante las manifestaciones clínicas?</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">–</span><p id="par0030" class="elsevierStylePara elsevierViewall">¿Son patognomónicos los hallazgos en las pruebas de imagen?</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">–</span><p id="par0035" class="elsevierStylePara elsevierViewall">¿Se requiere la realización de una biopsia pulmonar para confirmar el diagnóstico de NO?</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">–</span><p id="par0040" class="elsevierStylePara elsevierViewall">¿Es necesario esperar a la confirmación histológica para iniciar el tratamiento ante la sospecha de NO?</p></li></ul></p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Utrilla Contreras C, Fernández-Velilla Peña M, García Río F, Torres Sánchez MI. Patrones radiológicos en la aproximación diagnóstica a la neumonía organizativa. Rev Clin Esp. 2013;214:258–265.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1152 "Ancho" => 1860 "Tamanyo" => 321913 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Radiological and pathological presentation suggestive of OP. (A) Posteroanterior chest radiography that shows areas of increased density accompanied by predominantly reticular septal thickening with basal predominance. (B) Chest computed tomography, viewed on lung window (axial and coronal), with areas of ground-glass attenuation with interlobular septal thickening (cobblestone pattern), predominantly in the lower lobes. (C) Lung tissue stained with hematoxylin–eosin (125×), with interstitial inflammation (black rings) and opacification of the terminal bronchioles and alveolar ducts by polypoid granulation tissue (black stars). (D) Lung tissue, collagen staining with Masson's trichrome (125×), with markedly thickened interalveolar septa, infiltration by lymphocytes and plasma cells and alveolar spaces occupied by lymphocytes and multinucleated histiocytes (black stars). (E) Posteroanterior chest radiography of the same patient, 6 months after starting the treatment with corticosteroids. There is evidence of marked improvement, with only laminar atelectasis persisting.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 549 "Ancho" => 1860 "Tamanyo" => 120222 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Alveolar opacities in the OP. (A) Coronal reconstruction of chest computed tomography, alveolar opacities with patchy consolidations in right hemithorax. Associated mild cylindrical bronchial dilatations can be observed (curved arrow). (B) Opacification of the air space, which presents areas of ground-glass attenuation and consolidation, with air bronchogram (black arrow). (C) Patchy bilateral consolidations, with air bronchogram (black arrow). Areas of increased homogeneity of lung parenchymal attenuation (consolidations), which preclude seeing the underlying vessels (black stars).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1051 "Ancho" => 1344 "Tamanyo" => 174719 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Other radiological patterns. (A) Axial slice of chest computed tomography in which ill-defined nodular opacities of various sizes can be observed, which do not exceed 1 centimeter, with patchy distribution and no regional predominance. (B) Axial slice of chest computed tomography in which patchy consolidations with peripheral ground-glass attenuation can be observed, illustrating an example of the “halo sign” (white arrows). (C) Coronal reconstruction of chest CT in which a central area of ground-glass attenuation (star white) with a peripheral area of consolidation can be observed in the lower right lobe, forming an almost complete ring, suggesting an “inverted halo” or “atoll” sign (white arrows). (D) Axial slice of chest CT in which a cobblestone pattern can be seen, distributed through both lungs, predominantly in the lower lobes.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">From determined causes</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">A) Infectious</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Bacteria \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Burkholderia cepacia, Chlamydia pneumoniae, Coxiella burnetii, Legionella pneumophila, Mycoplasma pneumoniae, Nocardia asteroides, Pseudomonas aeruginosa, Serratia marcescens, Staphylococcus aureus, Streptococcus pneumoniae</span>, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Viruses \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Adenovirus, Cytomegalovirus, Influenza, Parainfluenza, Human Herpes Virus 7, HIV, respiratory syncytial virus, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Parasites \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Plasmodium vivax, Dirofilaria immitis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Fungi \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Cryptococcus neoformans, Penicillium janthinellum, Pneumocystis jiroveci</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">B) Drugs</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5-Aminosalicylic acid, acebutolol, amiodarone, amphotericin B, bleomycin, busulfan, carbamazepine, cephalosporin, cyclophosphamide, chlorambucil, doxorubicin, phenytoin, fluvastatin, hexamethonium, interferon, L-tryptophan, mesalazine, methotrexate, minocycline, nilutamide, nitrofurantoin, salts gold, sirolimus, sotalol, sulfasalazine, tacrolimus, ticlopidine, trastuzumab, vinbarbital-aprobarbital \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">C) Radiation therapy</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Associated with specific disorders</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">A) Tissue connective diseases</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Idiopathic inflammatory myopathy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Rheumatoid arthritis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Sjögren's syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Systemic lupus erythematosus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Systemic sclerosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">B) Vasculitis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Wegener's granulomatosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Polyarteritis nodosa \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">C) Lung transplantation</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">D) Bone marrow transplantation</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">E) Other</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Sweet's Syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Ulcerative colitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Crohn's Disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Polymyalgia rheumatica \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Thyroiditis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Behçet's disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Mesangiocapillary glomerulonephritis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Myelodysplasia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Leukemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Myeloproliferative disorders \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Cancer \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Common variable immunodeficiency \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Hepatitis C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Idiopathic or cryptogenic</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab509736.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Main causes of organizing pneumonia.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:39 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fleischner Society: glossary of terms for thoracic imaging" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.M. 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