Role of Conventional Radiography and High-Resolution Computed Tomography for Post Infectious Bronchiolitis Obliterans (PIBO): A Case Report

Role of Conventional Radiography and High-Resolution Computed Tomography for Post Infectious Bronchiolitis Obliterans (PIBO): A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Role of Conventional Radiography and High-Resolution Computed Tomography for Post Infectious Bronchiolitis Obliterans (PIBO): A Case Report Harry Galuh Nugraha, Muhammad Ris Lubis, Andreas Klemens Wienanda This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8401241/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Post-infectious bronchiolitis obliterans (PIBO) is a rare and severe lung disease characterized by chronic inflammation and irreversible changes in the small airways following lower respiratory tract infections or other insults. Case Description: A two-year-old boy presented with a cough and shortness of breath that had worsened over the past month. The child had experienced recurrent respiratory symptoms for four months and had a history of bronchopneumonia the previous year. Despite treatment with corticosteroids, his symptoms persisted, leading to further investigation. Chest x-ray (CXR) showed peribronchial thickening, hyperinflation, and reduced vascular markings in both lung fields. High-resolution computed tomography (HRCT) revealed bilateral mosaic attenuation with areas of decreased lung attenuation and patchy ground-glass opacities involving multiple lung segments, accompanied by focal fibrotic changes. As in this case, chest x-ray findings in PIBO are often inconclusive, and HRCT is essential for diagnosis. The mosaic attenuation pattern on HRCT is a hallmark of PIBO, caused by ventilation-perfusion mismatch due to localized airway obstruction and vascular shunting. Conclusion: Chest x-ray may show non-specific findings in PIBO, whereas HRCT provides characteristic imaging features that are crucial for diagnosis. HRCT plays a pivotal role in confirming PIBO by demonstrating mosaic attenuation and associated airway abnormalities, thereby facilitating accurate diagnosis and appropriate clinical management. Conventional radiography high-resolution computed tomography post-infection bronchiolitis obliterans case report Figures Figure 1 Figure 2 INTRODUCTION Post Infectious Bronchiolitis Obliterans (PIBO) is an uncommon and severe lung disease. 1 The current diagnosis is based on a history of insults to the lower respiratory tract and persistent symptoms that do not improve after two weeks of systemic corticosteroid and bronchodilator therapy. 2 Several lung diseases, such as lower respiratory infections, organ transplants, connective tissue diseases, toxic fume inhalation, chronic hypersensitivity pneumonia, aspiration, medications, and Stevens-Johnson syndrome (SJS), are known to cause obliterative changes in the small airways, which are referred to as PIBO. 2 Although PIBO can develop at all ages in patients ranging from infants to adults, PIBO is much more common in children. 3 PIBO has a persistent, and irreversible inflammatory process and few available treatments, it's critical to diagnose the condition early and begin therapy as soon as feasible. A definitive diagnosis is typically established based on characteristic clinical symptoms, evidence of fixed airway obstruction in pulmonary function tests, and relevant radiological findings. 4 The most commonly used imaging methods to evaluate PIBO are conventional chest x-ray (CXR), and high-resolution computed tomography (HRCT). This case report will provide information about the role of conventional radiographs and high-resolution computed tomography in a child with post infectious bronchiolitis obliterans. CASE DESCRIPTION A 2-year-old boy was diagnosed post-infectious with initial clinical symptoms of cough and dyspnoea. The patient came with complaints of shortness of breath and coughing for 4 months before coming to the hospital. Complaints have felt worse since the last 1 month. Cough with no phlegm and no blood. The patient experienced a weight loss of 2 kilograms for 1 month ago. The patient has a history of bronchopneumonia in the last 1 year. The patient is treated with corticosteroid drugs regularly until the complaint feels better. The patient has no history of previous surgery or organ transplantation. The family does not have the same complaints or history as the patient. This patient underwent a chest x-ray examination in the hospital emergency room. On chest x-ray examination, there are no specific images found. CXR revealed peribronchial thickening and revealed hyperinflation and attenuation of vascular marking in both fields. ( Fig. 1 ) In Fig. 2 , Chest HRCT demonstrated bilateral mosaic attenuation characterized by patchy ground-glass opacities and well-defined areas of decreased lung attenuation involving multiple segments of both lungs, with a predominance in the upper and lower lobes. Focal fibrotic changes were observed in several affected regions bilaterally There is dilatation of the bronchus and bronchioles accompanied by thickening of their walls in the apical and anterior segments of the superior lobe, the medial segment of the middle lobe, the mediobasal and posterior basal segments of the inferior lobe of the right lung, the inferior segment of the lingula of the superior lobe, the superior, mediobasal and posterior basal segments of the inferior lobe of the left lung. There are no enlarged lymph nodes or cardiomegaly. On the HRCT image, it can be concluded that there is a picture of ground glass opacity like mosaic patterns, fibrosis, traction bronchiectasis, and bronchiectasis in the segment mentioned above which supports a picture of post-infectious bronchiolitis obliterans. DISCUSSION Post-infectious bronchiolitis obliterans (PIBO) is an uncommon disease. It is a severe lung condition characterised by chronic inflammation and permanent damage or irreversible changes to the small airways. This condition typically develops following lower respiratory tract infections and any other insults. This lung obstructive disease is more prevalent in children, but it can also occur in adults. PIBO often occurs after a severe lower tract infection. Adenovirus, influenza, respiratory syncytial virus, rubeola, and mycoplasma pneumonia have been identified as potential triggers for PIBO with Adenovirus as the most common infectious agent that causes it. PIBO commonly occurs in children younger than one year, and the causative agents vary. Its course is marked by persistent symptoms, such as shortness of breath, cough, and abnormal breath sounds, which do not improve with long-term corticosteroid and bronchodilator treatment. Several lung diseases, such as lower respiratory infections, connective tissue diseases, toxic fume inhalation, chronic hypersensitivity pneumonia, organ transplantation, aspiration, medications, and Stevens-Johnson syndrome (SJS), are known to cause obliterative changes in the small airways, also resulting in PIBO. 2 Given a case of a two-year-old boy diagnosed with PIBO, he experienced a worsening cough and shortness of breath over the preceding month. The child had experienced recurrent respiratory symptoms for four months and also had a history of bronchopneumonia in the previous year. The symptoms remained unchanged despite corticosteroid treatment, leading to further investigation. The chest x-ray showed signs of peribronchial thickening, hyperinflated lungs, and reduced vascular markings in both lung fields. From a HRCT, it shows a mosaic pattern of ground-glass opacity and areas of reduced lung attenuation. These findings were widespread in both lungs, affecting multiple lung segments. Additionally, fibrosis was also noted in some areas. Since PIBO has a persistent and irreversible inflammatory process and few available treatments, early diagnosis and prompt initiation of treatment are crucial. The current diagnosis of PIBO is also based on history of insults to the lower respiratory tract and persistent symptoms that do not improve after two weeks of systemic corticosteroid and bronchodilator therapy. 2 A definitive diagnosis is typically established based on characteristic clinical symptoms, evidence of fixed airway obstruction in pulmonary function tests, and relevant radiological findings. 4 As demonstrated in this case, CXR findings in PIBO are often non-specific and inconclusive, making HRCT scans essential for accurate diagnosis. The mosaic attenuation pattern observed on HRCT is a hallmark of PIBO, resulting from ventilation-perfusion mismatch due to localised airway blockage and vascular shunting. It is also noted that children with PIBO exhibit variability in both the causative organism and the age at which the lung injury occurred. Paediatric pulmonologists can determine the cause and timing of the injury only through a retrospective evaluation made at the time of diagnosis. A limited number of studies or reports have examined the clinical course of PIBO, combining retrospective data collection for the pre-diagnosis period with prospective data collection in post-diagnosis. 5 , 6 Again, the common features of PIBO are tachypnoea, wheezing, and hypoxemia persisting for at least 2 months after a causative event. 7 Dyspnoea, abnormal breath sounds on auscultation, and cough were common symptoms experienced by the patients. The patients experience persistent symptoms that do not improve after two weeks of systemic corticosteroid and bronchodilator therapy. 2 A patient could have had a history of using corticosteroids and bronchodilators for a long period and underwent a chest x-ray with no specific images. It is similar to other studies where PIBO can sometimes be normal or present with peribronchial thickening and emphysema, also with revealed hyperinflation and attenuation of vascular marking in both lung fields. 8 Given the non-specific nature of CXR findings, HRCT is the most commonly employed imaging modality for PIBO due to its high sensitivity and specificity. Chest HRCT can assess regional heterogeneity as well as the global severity of the lungs. The typical findings of PIBO on chest HRCT include bronchial wall thickening, centrilobular opacities, central bronchiectasis, atelectasis, mucous plugging, and mosaic lung attenuation due to air trapping. Similar to Chen et al, we also found the mosaic pattern or bronchiectasis in the HRCT of patients. The mosaic pattern may be caused by vascular shunt from hypo-ventilated areas to normal or hyper-ventilated areas with decreased perfusion due to vessel constriction caused by regional tissue hypoxia. 2 , 8 And lastly, the severity of PIBO can be confirmed by assessing lung tissue damage. The literature recommends ventilation/perfusion (V/Q) scans and dual-energy computed tomography (DECT) to show a distribution pattern of the lesion. V/Q scan and DECT can highlight more damaged broncho-pulmonary areas. 9 , 10 Additionally, the degree of ventilation and perfusion abnormalities evaluated by V/Q scans have been associated with disease severity and may be used to predict the outcomes of patients with PIBO. 11 , 12 CONCLUSION Post-infectious bronchiolitis obliterans is a rare but serious chronic lung disease that requires careful diagnostic evaluation. CXR images are often demonstrates non-specific finding and can occasionally be normal. In contrast, HRCT plays a pivotal role in the diagnosis of PIBO by demonstrating a mosaic attenuation, followed by atelectasis, peribronchial thickening, air-trapping, and bronchiectasis. Recognition of these HRCT features is essential for early and accurate diagnosis, enabling timely clinical decision-making and appropriate management in pediatric patients with persistent respiratory symptoms. Declarations DISCLOSURES Funding This case report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflict of Interest The authors declare that there is no conflict of interest regarding the publication of this case report. There are no financial or personal relationships with other people or organizations that could inappropriately influence the work reported in this manuscript. Author Contribution All authors involved in concepting, designing and supervising the manuscript. All authors contributed to manuscript writing, critically reviewed the content, and approved the final version of the manuscript for submission. Acknowledgments The authors would like to express their gratitude to the medical and radiology staff involved in the care and imaging evaluation of the patient for their valuable assistance. We also thank the patient’s family for their cooperation and consent to publish this case report. References Chen IC, Hsu JS, Chen YW, Liu YC, Wu YH, Hsu JH, Cheng YF, Dai ZK. Post-infectious Bronchiolitis Obliterans: HRCT, DECT, Pulmonary Scintigraphy Images, and Clinical Follow-up in Eight Children. Front Pediatr. 2020 Dec 18;8:622065. Mauad T, Dolhnikoff M; São Paulo Bronchiolitis Obliterans Study Group. Histology of childhood bronchiolitis obliterans. Pediatr Pulmonol. 2002 Jun;33(6):466-74. Colom AJ, Teper AM. Post-infectious bronchiolitis obliterans. Pediatr Pulmonol. 2019 Feb;54(2):212-219. Lino CA, Batista AK, Soares MA, de Freitas AE, Gomes LC, M Filho JH, Gomes VC. Bronchiolitis obliterans: clinical and radiological profile of children followed-up in a reference outpatient clinic. Rev Paul Pediatr. 2013 Jan-Mar;31(1):10-6. Zhang L, Irion K, Kozakewich H, Reid L, Camargo JJ, da Silva Porto N, Abreu e Silva FA. Clinical course of postinfectious bronchiolitis obliterans. Pediatr Pulmonol. 2000 May;29(5):341-50. Yalçin E, Doğru D, Haliloğlu M, Ozçelik U, Kiper N, Göçmen A. Postinfectious bronchiolitis obliterans in children: clinical and radiological profile and prognostic factors. Respiration. 2003 Jul-Aug;70(4):371-5. Jerkic SP, Brinkmann F, Calder A, Casey A, Dishop M, Griese M, Kurland G, Niemitz M, Nyilas S, Schramm D, Schubert R, Tamm M, Zielen S, Rosewich M. Postinfectious Bronchiolitis Obliterans in Children: Diagnostic Workup and Therapeutic Options: A Workshop Report. Can Respir J. 2020 Jan 30;2020:5852827. Barker AF, Bergeron A, Rom WN, Hertz MI. Obliterative bronchiolitis. N Engl J Med. 2014 May 8;370(19):1820-8. Hasegawa Y, Imaizumi K, Sekido Y, Iinuma Y, Kawabe T, Hashimoto N, Shimokata K. Perfusion and ventilation isotope lung scans in constrictive bronchiolitis obliterans. A series of three cases. Respiration. 2002;69(6):550-5. Nakashima M, Shinya T, Oto T, Okawa T, Takeda Y. Diagnostic value of ventilation/perfusion single-photon emission computed tomography/computed tomography for bronchiolitis obliterans syndrome in patients after lung transplantation. Nucl Med Commun. 2019 Jul;40(7):703-710. Xie BQ, Wang W, Zhang WQ, Guo XH, Yang MF, Wang L, He ZX, Tian YQ. Ventilation/perfusion scintigraphy in children with post-infectious bronchiolitis obliterans: a pilot study. PLoS One. 2014 May 22;9(5):e98381. Goo HW. Dual-energy lung perfusion and ventilation CT in children. Pediatr Radiol. 2013 Mar;43(3):298-307. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8401241","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":567265792,"identity":"8c4469d6-0048-4a5d-8654-f23d2b5851aa","order_by":0,"name":"Harry Galuh Nugraha","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Harry","middleName":"Galuh","lastName":"Nugraha","suffix":""},{"id":567265793,"identity":"6980e46e-7c8b-4c46-9a08-63a56be45843","order_by":1,"name":"Muhammad Ris Lubis","email":"","orcid":"","institution":"Padjadjaran 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06:38:06","extension":"html","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":41298,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8401241/v1/6d485ad9ff783ad4f9e0eeb5.html"},{"id":99319615,"identity":"e587524b-78ff-4527-b2cf-c6d853d5d877","added_by":"auto","created_at":"2025-12-31 16:37:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":252844,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eChest x-ray anteroposterior view (a) and lateral view (b) revealed peribronchial thickening, hyperinflation, and attenuation of vascular marking in both fields. (yellow arrow)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8401241/v1/3e9165401c4eec2aea779944.png"},{"id":99273414,"identity":"ba21009c-478d-44cf-acf3-b173cf5e628f","added_by":"auto","created_at":"2025-12-31 06:38:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":346534,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eAxial view (a) and coronal view (b) of HRCT revealed mosaic patterns that are characterized by well-defined border areas of decreased lung attenuation. (yellow arrow),\u003c/em\u003e \u003cem\u003ebronchiectasis was seen in the medial segment of the middle lobe. (red arrow).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8401241/v1/e2cd367a37c478af490c176b.png"},{"id":99326246,"identity":"ecd75e06-b2eb-438d-a623-1821747a8020","added_by":"auto","created_at":"2025-12-31 16:50:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":981899,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8401241/v1/fd31416c-fcbc-4771-96d8-77fa6b6571be.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Role of Conventional Radiography and High-Resolution Computed Tomography for Post Infectious Bronchiolitis Obliterans (PIBO): A Case Report","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePost Infectious Bronchiolitis Obliterans (PIBO) is an uncommon and severe lung disease.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The current diagnosis is based on a history of insults to the lower respiratory tract and persistent symptoms that do not improve after two weeks of systemic corticosteroid and bronchodilator therapy.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Several lung diseases, such as lower respiratory infections, organ transplants, connective tissue diseases, toxic fume inhalation, chronic hypersensitivity pneumonia, aspiration, medications, and Stevens-Johnson syndrome (SJS), are known to cause obliterative changes in the small airways, which are referred to as PIBO.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Although PIBO can develop at all ages in patients ranging from infants to adults, PIBO is much more common in children.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e PIBO has a persistent, and irreversible inflammatory process and few available treatments, it's critical to diagnose the condition early and begin therapy as soon as feasible. A definitive diagnosis is typically established based on characteristic clinical symptoms, evidence of fixed airway obstruction in pulmonary function tests, and relevant radiological findings.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e The most commonly used imaging methods to evaluate PIBO are conventional chest x-ray (CXR), and high-resolution computed tomography (HRCT). This case report will provide information about the role of conventional radiographs and high-resolution computed tomography in a child with post infectious bronchiolitis obliterans.\u003c/p\u003e"},{"header":"CASE DESCRIPTION","content":"\u003cp\u003eA 2-year-old boy was diagnosed post-infectious with initial clinical symptoms of cough and dyspnoea. The patient came with complaints of shortness of breath and coughing for 4 months before coming to the hospital. Complaints have felt worse since the last 1 month. Cough with no phlegm and no blood. The patient experienced a weight loss of 2 kilograms for 1 month ago. The patient has a history of bronchopneumonia in the last 1 year. The patient is treated with corticosteroid drugs regularly until the complaint feels better. The patient has no history of previous surgery or organ transplantation. The family does not have the same complaints or history as the patient.\u003c/p\u003e \u003cp\u003eThis patient underwent a chest x-ray examination in the hospital emergency room. On chest x-ray examination, there are no specific images found. CXR revealed peribronchial thickening and revealed hyperinflation and attenuation of vascular marking in both fields. \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Chest HRCT demonstrated bilateral mosaic attenuation characterized by patchy ground-glass opacities and well-defined areas of decreased lung attenuation involving multiple segments of both lungs, with a predominance in the upper and lower lobes. Focal fibrotic changes were observed in several affected regions bilaterally There is dilatation of the bronchus and bronchioles accompanied by thickening of their walls in the apical and anterior segments of the superior lobe, the medial segment of the middle lobe, the mediobasal and posterior basal segments of the inferior lobe of the right lung, the inferior segment of the lingula of the superior lobe, the superior, mediobasal and posterior basal segments of the inferior lobe of the left lung. There are no enlarged lymph nodes or cardiomegaly. On the HRCT image, it can be concluded that there is a picture of ground glass opacity like mosaic patterns, fibrosis, traction bronchiectasis, and bronchiectasis in the segment mentioned above which supports a picture of post-infectious bronchiolitis obliterans.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003ePost-infectious bronchiolitis obliterans (PIBO) is an uncommon disease. It is a severe lung condition characterised by chronic inflammation and permanent damage or irreversible changes to the small airways. This condition typically develops following lower respiratory tract infections and any other insults. This lung obstructive disease is more prevalent in children, but it can also occur in adults. PIBO often occurs after a severe lower tract infection. Adenovirus, influenza, respiratory syncytial virus, rubeola, and mycoplasma pneumonia have been identified as potential triggers for PIBO with Adenovirus as the most common infectious agent that causes it.\u003c/p\u003e \u003cp\u003ePIBO commonly occurs in children younger than one year, and the causative agents vary. Its course is marked by persistent symptoms, such as shortness of breath, cough, and abnormal breath sounds, which do not improve with long-term corticosteroid and bronchodilator treatment. Several lung diseases, such as lower respiratory infections, connective tissue diseases, toxic fume inhalation, chronic hypersensitivity pneumonia, organ transplantation, aspiration, medications, and Stevens-Johnson syndrome (SJS), are known to cause obliterative changes in the small airways, also resulting in PIBO.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGiven a case of a two-year-old boy diagnosed with PIBO, he experienced a worsening cough and shortness of breath over the preceding month. The child had experienced recurrent respiratory symptoms for four months and also had a history of bronchopneumonia in the previous year. The symptoms remained unchanged despite corticosteroid treatment, leading to further investigation. The chest x-ray showed signs of peribronchial thickening, hyperinflated lungs, and reduced vascular markings in both lung fields. From a HRCT, it shows a mosaic pattern of ground-glass opacity and areas of reduced lung attenuation. These findings were widespread in both lungs, affecting multiple lung segments. Additionally, fibrosis was also noted in some areas.\u003c/p\u003e \u003cp\u003eSince PIBO has a persistent and irreversible inflammatory process and few available treatments, early diagnosis and prompt initiation of treatment are crucial. The current diagnosis of PIBO is also based on history of insults to the lower respiratory tract and persistent symptoms that do not improve after two weeks of systemic corticosteroid and bronchodilator therapy.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e A definitive diagnosis is typically established based on characteristic clinical symptoms, evidence of fixed airway obstruction in pulmonary function tests, and relevant radiological findings.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAs demonstrated in this case, CXR findings in PIBO are often non-specific and inconclusive, making HRCT scans essential for accurate diagnosis. The mosaic attenuation pattern observed on HRCT is a hallmark of PIBO, resulting from ventilation-perfusion mismatch due to localised airway blockage and vascular shunting.\u003c/p\u003e \u003cp\u003eIt is also noted that children with PIBO exhibit variability in both the causative organism and the age at which the lung injury occurred. Paediatric pulmonologists can determine the cause and timing of the injury only through a retrospective evaluation made at the time of diagnosis. A limited number of studies or reports have examined the clinical course of PIBO, combining retrospective data collection for the pre-diagnosis period with prospective data collection in post-diagnosis.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAgain, the common features of PIBO are tachypnoea, wheezing, and hypoxemia persisting for at least 2 months after a causative event.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Dyspnoea, abnormal breath sounds on auscultation, and cough were common symptoms experienced by the patients. The patients experience persistent symptoms that do not improve after two weeks of systemic corticosteroid and bronchodilator therapy.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e A patient could have had a history of using corticosteroids and bronchodilators for a long period and underwent a chest x-ray with no specific images. It is similar to other studies where PIBO can sometimes be normal or present with peribronchial thickening and emphysema, also with revealed hyperinflation and attenuation of vascular marking in both lung fields.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGiven the non-specific nature of CXR findings, HRCT is the most commonly employed imaging modality for PIBO due to its high sensitivity and specificity. Chest HRCT can assess regional heterogeneity as well as the global severity of the lungs. The typical findings of PIBO on chest HRCT include bronchial wall thickening, centrilobular opacities, central bronchiectasis, atelectasis, mucous plugging, and mosaic lung attenuation due to air trapping. Similar to Chen et al, we also found the mosaic pattern or bronchiectasis in the HRCT of patients. The mosaic pattern may be caused by vascular shunt from hypo-ventilated areas to normal or hyper-ventilated areas with decreased perfusion due to vessel constriction caused by regional tissue hypoxia.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAnd lastly, the severity of PIBO can be confirmed by assessing lung tissue damage. The literature recommends ventilation/perfusion (V/Q) scans and dual-energy computed tomography (DECT) to show a distribution pattern of the lesion. V/Q scan and DECT can highlight more damaged broncho-pulmonary areas.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Additionally, the degree of ventilation and perfusion abnormalities evaluated by V/Q scans have been associated with disease severity and may be used to predict the outcomes of patients with PIBO.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003ePost-infectious bronchiolitis obliterans is a rare but serious chronic lung disease that requires careful diagnostic evaluation. CXR images are often demonstrates non-specific finding and can occasionally be normal. In contrast, HRCT plays a pivotal role in the diagnosis of PIBO by demonstrating a mosaic attenuation, followed by atelectasis, peribronchial thickening, air-trapping, and bronchiectasis. Recognition of these HRCT features is essential for early and accurate diagnosis, enabling timely clinical decision-making and appropriate management in pediatric patients with persistent respiratory symptoms.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDISCLOSURES\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest regarding the publication of this case report. There are no financial or personal relationships with other people or organizations that could inappropriately influence the work reported in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors involved in concepting, designing and supervising the manuscript.\u0026nbsp;All authors contributed to manuscript writing, critically reviewed the content, and approved the final version of the manuscript for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their gratitude to the medical and radiology staff involved in the care and imaging evaluation of the patient for their valuable assistance. We also thank the patient’s family for their cooperation and consent to publish this case report.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eChen IC, Hsu JS, Chen YW, Liu YC, Wu YH, Hsu JH, Cheng YF, Dai ZK. Post-infectious Bronchiolitis Obliterans: HRCT, DECT, Pulmonary Scintigraphy Images, and Clinical Follow-up in Eight Children. Front Pediatr. 2020 Dec 18;8:622065.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMauad T, Dolhnikoff M; S\u0026atilde;o Paulo Bronchiolitis Obliterans Study Group. Histology of childhood bronchiolitis obliterans. Pediatr Pulmonol. 2002 Jun;33(6):466-74. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eColom AJ, Teper AM. Post-infectious bronchiolitis obliterans. Pediatr Pulmonol. 2019 Feb;54(2):212-219.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLino CA, Batista AK, Soares MA, de Freitas AE, Gomes LC, M Filho JH, Gomes VC. Bronchiolitis obliterans: clinical and radiological profile of children followed-up in a reference outpatient clinic. Rev Paul Pediatr. 2013 Jan-Mar;31(1):10-6. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eZhang L, Irion K, Kozakewich H, Reid L, Camargo JJ, da Silva Porto N, Abreu e Silva FA. Clinical course of postinfectious bronchiolitis obliterans. Pediatr Pulmonol. 2000 May;29(5):341-50.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eYal\u0026ccedil;in E, Doğru D, Haliloğlu M, Oz\u0026ccedil;elik U, Kiper N, G\u0026ouml;\u0026ccedil;men A. Postinfectious bronchiolitis obliterans in children: clinical and radiological profile and prognostic factors. Respiration. 2003 Jul-Aug;70(4):371-5. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eJerkic SP, Brinkmann F, Calder A, Casey A, Dishop M, Griese M, Kurland G, Niemitz M, Nyilas S, Schramm D, Schubert R, Tamm M, Zielen S, Rosewich M. Postinfectious Bronchiolitis Obliterans in Children: Diagnostic Workup and Therapeutic Options: A Workshop Report. Can Respir J. 2020 Jan 30;2020:5852827.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBarker AF, Bergeron A, Rom WN, Hertz MI. Obliterative bronchiolitis. N Engl J Med. 2014 May 8;370(19):1820-8.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHasegawa Y, Imaizumi K, Sekido Y, Iinuma Y, Kawabe T, Hashimoto N, Shimokata K. Perfusion and ventilation isotope lung scans in constrictive bronchiolitis obliterans. A series of three cases. Respiration. 2002;69(6):550-5.\u003c/li\u003e\n \u003cli\u003eNakashima M, Shinya T, Oto T, Okawa T, Takeda Y. Diagnostic value of ventilation/perfusion single-photon emission computed tomography/computed tomography for bronchiolitis obliterans syndrome in patients after lung transplantation. Nucl Med Commun. 2019 Jul;40(7):703-710.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eXie BQ, Wang W, Zhang WQ, Guo XH, Yang MF, Wang L, He ZX, Tian YQ. Ventilation/perfusion scintigraphy in children with post-infectious bronchiolitis obliterans: a pilot study. PLoS One. 2014 May 22;9(5):e98381.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGoo HW. Dual-energy lung perfusion and ventilation CT in children. Pediatr Radiol. 2013 Mar;43(3):298-307. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Conventional radiography, high-resolution computed tomography, post-infection bronchiolitis obliterans, case report","lastPublishedDoi":"10.21203/rs.3.rs-8401241/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8401241/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Post-infectious bronchiolitis obliterans (PIBO) is a rare and severe lung disease characterized by chronic inflammation and irreversible changes in the small airways following lower respiratory tract infections or other insults.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Description:\u003c/strong\u003e A two-year-old boy presented with a cough and shortness of breath that had worsened over the past month. The child had experienced recurrent respiratory symptoms for four months and had a history of bronchopneumonia the previous year. Despite treatment with corticosteroids, his symptoms persisted, leading to further investigation. Chest x-ray (CXR) showed peribronchial thickening, hyperinflation, and reduced vascular markings in both lung fields. High-resolution computed tomography (HRCT) revealed bilateral mosaic attenuation with areas of decreased lung attenuation and patchy ground-glass opacities involving multiple lung segments, accompanied by focal fibrotic changes. As in this case, chest x-ray findings in PIBO are often inconclusive, and HRCT is essential for diagnosis. The mosaic attenuation pattern on HRCT is a hallmark of PIBO, caused by ventilation-perfusion mismatch due to localized airway obstruction and vascular shunting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eChest x-ray may show non-specific findings in PIBO, whereas HRCT provides characteristic imaging features that are crucial for diagnosis. HRCT plays a pivotal role in confirming PIBO by demonstrating mosaic attenuation and associated airway abnormalities, thereby facilitating accurate diagnosis and appropriate clinical management.\u003c/p\u003e","manuscriptTitle":"Role of Conventional Radiography and High-Resolution Computed Tomography for Post Infectious Bronchiolitis Obliterans (PIBO): A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-31 06:38:01","doi":"10.21203/rs.3.rs-8401241/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fb6730b4-0ee3-42ae-9ab9-6b263c68839c","owner":[],"postedDate":"December 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-03T15:55:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-31 06:38:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8401241","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8401241","identity":"rs-8401241","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}