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Bronchiolitis Obliterans-Organizing Pneumonia Caused by Ticlopidine
- Jose Luis Alonso-Martinez, MD;
- Jose Ignacio Elejalde-Guerra, PhD; and
- Degona Larrinaga-Linero, MD
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TO THE EDITOR:
Ticlopidine, an inhibitor of platelet aggregation, is widely used to treat and prevent stroke and other thrombotic events and has been considered more effective than aspirin [1]. Side effects of ticlopidine include hematologic complications [2] and gastrointestinal and liver diseases [3]. We describe a patient who developed dyspnea, peripheral interstitial lung infiltrates, hypoxemia, and transbronchial biopsy alterations consistent with bronchiolitis obliterans-organizing pneumonia that resolved after withdrawal of ticlopidine therapy.
A 76-year-old nonsmoking woman in whom giant-cell (temporal) arteritis was proven by biopsy and who had had a normal chest radiograph was receiving prednisone, 45 mg/d, and ticlopidine, 250 mg twice daily, for persistence of cloudy vision. After 1 month of ticlopidine therapy, increasing dyspnea and a pruritic skin rash developed. No new symptoms of temporal arteritis occurred. Physical examination showed a respiratory rate of 28 breaths/min at rest, normal body temperature, scanty rales over both pulmonary fields, and a diffuse erythematosus maculopapular eruption. Chest radiography showed diffuse interstitial infiltrates predominantly affecting the periphery of both lungs.
Blood cell count, erythrocyte sedimentation rate, titers of antinuclear antibody and antineutrophil cytoplasmic antibodies, levels of rheumatoid factor and serum angiotensin-converting enzyme, and results of routine laboratory tests were normal. A sample of arterial blood taken while the patient was breathing ambient air showed a pH of 7.53, a PaO2 of 8.11 kPa, and a PaCO2 of 3.29 kPa. A test of lung function indicated a mild restrictive pattern with diminished CO diffusion (53% of the predicted value). No macroscopic findings were seen on bronchoscopy. Cultures of bronchioalveolar lavage fluid were negative, as were results of cytology of bronchoaspirated mucus and a serologic test for Mycoplasma and Chlamydia species. Ten percent of cells in bronchioalveolar lavage fluid were polymorphonucleotides, 24% were lymphocytes (lymphocytic populations in bronchioalveolar lavage fluid showed a predominance of CD8 cells with a CD4:CD8 ratio of 0.125), and 66% were macrophages without eosinophils. Transbronchial biopsy (Figure 1) showed widening of the alveolar walls with a mixed inflammatory infiltrate (neutrophils and lymphocytes), air spaces deformed by organizing connective tissue plugs, and foamy macrophages.
Ticlopidine therapy was withdrawn; prednisone was given in the same schedule and dose. The patient subsequently felt better, and dyspnea and blanching cutaneous lesions improved. Dyspnea disappeared in 3 months, and the interstitial pattern completely resolved in 5 months.
Bronchiolitis obliterans-organizing pneumonia is a clinical pathologic syndrome with a wide spectrum of causes, including idiopathic and secondary causes [4]. The latter are associated with several connective tissue diseases, inhaled substances and fumes, radiation therapy, and hematologic diseases [4]. No ticlopidine-related pulmonary effects have been reported. Increased CD8 lymphocyte counts and the communicated augmented respiratory-burst metabolism in human neutrophils caused by ticlopidine [5] seem to have contributed to the pathogenesis of lung injury in our patient.
Jose Luis Alonso-Martinez, MD
Jose Ignacio Elejalde-Guerra, PhD
Degona Larrinaga-Linero, MD
Hospital de Navarra; Pamplona, Spain
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
