Steroid-dependent Non-specific Interstitial Pneumonia in an Asphalt Pothole Repair Worker

Document Type

Conference Proceeding

Publication Date

2025

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Non-Specific Interstitial Pneumonia (NSIP) is a small subset of idiopathic interstitial pneumonia that is distinguished by a relatively uniform pattern of interstitial inflammation and fibrosis. NSIP can be idiopathic or secondary to various conditions, including connective tissue diseases, drug toxicity, environmental exposures, and infections. A 48-year-old male with a history of moderate asthma and 36 pack-years of tobacco use presented to the emergency department with shortness of breath and dizziness that began four hours earlier during his first shift of pothole repair using cold asphalt. He was hypoxic on arrival with an oxygen saturation of 88%. Chest computed tomography (CT) showed prominent bilateral patchy opacities. He was treated with antibiotics and admitted for acute hypoxic respiratory failure. The onset of his symptoms coincided with his first occupational exposure to hydrocarbons that evening, during which he was not wearing personal protective equipment. His prior job involved steam cleaning floors, with triggers including cleaning products which exacerbated his asthma, though symptoms resolved with home inhalers and nebulizers—unlike in this instance. Furthermore, he had no peripheral eosinophilia in the setting of asthma to suggest eosinophilic lung injury. The patient was treated with methylprednisolone 125 mg taper for six days. A repeat chest CT revealed improved bilateral alveolar densities and new moderate pneumomediastinum without pneumothorax, likely secondary to parenchymal injury and cough-induced peripheral alveolar rupture. Additional studies were negative for hypersensitivity pneumonitis (mold and avian panels), and autoimmune/myositis markers and infectious workup were also negative. With clinical improvement, he was discharged on prednisone 60 mg with a six-week taper and prophylactic Bactrim. However, once steroids were discontinued, the patient redeveloped recurrent symptoms, including a severe cough leading to near-syncopal episodes. High-resolution CT imaging revealed stable peripheral reticulations and traction bronchiectasis, consistent with fibrotic NSIP. His pulmonary function test showed a mild restrictive pattern and reduced diffusing capacity for carbon monoxide. He was started on mycophenolate mofetil 500 mg twice daily, and prednisone 10 mg, with plans for a steroid wean once tolerated. With this regimen and removal of exposure, the patient's symptoms improved, and serial CT imaging showed a reduced disease burden. Although NSIP is uncommon, it typically responds well to steroids and has a favorable prognosis. When treatment is warranted, corticosteroids are the primary approach. In cases where patients do not adequately respond to corticosteroids or need long-term treatment, as in our patient, immunomodulators can be utilized.

Volume

211

First Page

A2132

Last Page

A2132

Comments

American Thoracic Society International Conference, May 16-25, 2025, San Francisco, CA

DOI

10.1164/ajrccm.2025.211.Abstracts.A2132

ISSN

1535-4970

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