These symptoms represent an obstructive pattern that is non-reversible with bronchodilator therapy, and need to be related to various lung insults. These insults include inhalation damage, post transplant auto-immune injury, post-infectious disease, drug reactions, and several auto-immune diseases. Cause
Bronchiolitis obliterans has many possible causes, including collagen vascular disease, transplant rejection in organ transplant patients, viral infection (adenovirus, respiratory syncytial virus, influenza, HIV, cytomegalovirus), Stevens–Johnson syndrome, Pneumocystis pneumonia, drug reaction, aspiration and complications of prematurity (bronchopulmonary dysplasia), and exposure to toxic fumes. Toxins implicated in the condition include diacetyl, sulfur dioxide, nitrogen dioxide, ammonia, chlorine, thionyl chloride, methyl isocyanate, hydrogen fluoride, hydrogen bromide, hydrogen chloride, hydrogen sulfide, phosgene, polyamide-amine dyes, mustard gas and ozone. It can also be present in patients with IBD, systemic lupus erythematosus, juvenile idiopathic arthritis, rheumatoid arthritis, GERD, IgA nephropathy, and ataxia telangiectasia. Activated charcoal has been known to cause it when aspirated. The ingestion of large doses of papaverine in the vegetable Sauropus androgynus has caused it. Additionally, the disorder may be idiopathic (without known cause). Lung transplant
Bronchiolitis obliterans is a common complication in lung transplants because transplanted lungs are at greater risk of alloimmunization as compared to healthy lungs. The disease is often termed bronchiolitis obliterans syndrome (BOS) in the setting of post lung transplantation and hematopoietic stem cell transplant (HSCT). Patients who develop BOS post lung transplant vary in disease latency and severity. Patients often initially have normal lung function on pulmonary function testing and have normal chest radiographs.
A common finding on HRCT is patchy areas of decreased lung density, signifying reduced vascular caliber and air trapping. This pattern is often described as a "mosaic pattern", and may indicate bronchiolitis obliterans. Lung biopsy
Transthoracic lung biopsies are preferable for diagnosis of constrictive BO compared to transbronchial biopsies; regardless of the type of biopsy, a diagnosis may only be achieved by examination of multiple samples. Transthoracic biopsies are preferred over transbronchial due to the heterogeneity and distribution of the lesions. OB can be further classified into two categories: constrictive or proliferative. The constrictive pattern is demonstrated by peribronchiolar cellular infiltrates which eventually causes small airway damage and leads to subepithelial fibrosis. The bronchial muscle can eventually become fibrosed which can be identified with trichrome staining. In regards to proliferative disease, intraluminal buds called "Masson bodies" fill the lumen, which results in bronchiolar plugging. Often people with proliferative disease will show butterfly wing-like appearance under microscopy. One key determinate that can be seen on biopsy to differentiate constrictive from proliferative disease is the extent of lesions. Both lesions are localized from the small bronchi to the membranous bronchi, but in constrictive disease, the lesions are intermittent while proliferative disease has a continuous distribution. Differential diagnosis
Other conditions that can present similarly include chronic obstructive pulmonary disease, asthma, bronchiectasis, hypersensitivity pneumonitis, and pneumonia.