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Cortes-Santiago N, Patel KR, Wu H, Sartain SE, Bhar S, Silva-Carmona M, Pogoriler J. Pulmonary Histopathologic Findings in Pediatric Patients After Hematopoietic Stem Cell Transplantation: An Autopsy Study. Pediatr Dev Pathol 2023; 26:362-373. [PMID: 37165556 DOI: 10.1177/10935266231170101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND Pathologic characterization of pulmonary complications following hematopoietic stem cell transplantation (HSCT) is limited. We describe lung findings in pediatric patients who died following HSCT and attempt to identify potential clinical associations. METHODS Pathology databases at Texas Children's Hospital and the Children's Hospital of Philadelphia were queried (2013-2018 CHOP and 2017-2018 TCH). Electronic medical records and slides were reviewed. RESULTS Among 29 patients, 19 received HSCT for hematologic malignancy, 8 for non-malignant hematologic disorders, and 2 for metastatic solid tumors. Twenty-five patients (86%) showed 1 or more patterns of acute and organizing lung injury. Sixty-two percent had microvascular sclerosis, with venous involvement noted in most cases and not correlating with clinical history of pulmonary hypertension, clinical transplant-associated thrombotic microangiopathy, irradiation, or graft-versus-host disease. Features suggestive of graft-versus-host-disease were uncommon: 6 patients had lymphocytic bronchiolitis, and only 2 patients had evidence of bronchiolitis obliterans (both clinically unexpected), both with a mismatched unrelated donor transplant. CONCLUSIONS Acute and subacute alveolar injury (diffuse alveolar damage or organizing pneumonia) is common in pediatric patients who died following HSCT and is difficult to assign to a specific etiology. Microvascular sclerosis was frequent and did not correlate with a single distinct clinical feature.
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Affiliation(s)
- Nahir Cortes-Santiago
- Department of Pathology and Immunology, Texas Children's Hospital, Houston, TX, USA
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Kalyani R Patel
- Department of Pathology and Immunology, Texas Children's Hospital, Houston, TX, USA
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Hao Wu
- Department of Pathology, Yale School of Medicine and Yale New Haven Hospital, New Haven, CT, USA
| | - Sarah E Sartain
- Department of Pediatrics, Section of Hematology/Oncology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Saleh Bhar
- Department of Pediatrics, Section of Hematology/Oncology and Critical Care Medicine, Bone Marrow Transplantation, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Manuel Silva-Carmona
- Department of Pediatrics, Section of Pulmonology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Jennifer Pogoriler
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Zinter MS, Melton A, Sabnis AJ, Dvorak CC, Elicker BM, Nawaytou HM, Kameny RJ, Fineman JR. Pulmonary veno-occlusive disease in a pediatric hematopoietic stem cell transplant patient: a cautionary tale. Leuk Lymphoma 2017; 59:1494-1497. [PMID: 28958195 DOI: 10.1080/10428194.2017.1382697] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- M S Zinter
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,b Department of Pediatrics, Division of Critical Care Medicine , University of California , San Francisco , CA , USA
| | - A Melton
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,c Department of Pediatrics, Division of Allergy, Immunology, and Blood and Marrow Transplantation , University of California , San Francisco , CA , USA
| | - A J Sabnis
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,d Department of Pediatrics, Division of Hematology and Oncology , University of California , San Francisco , CA , USA
| | - C C Dvorak
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,c Department of Pediatrics, Division of Allergy, Immunology, and Blood and Marrow Transplantation , University of California , San Francisco , CA , USA
| | - B M Elicker
- e Department of Radiology , University of California , San Francisco , CA , USA
| | - H M Nawaytou
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,f Department of Pediatrics, Division of Cardiology , University of California , San Francisco , CA , USA
| | - R J Kameny
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,b Department of Pediatrics, Division of Critical Care Medicine , University of California , San Francisco , CA , USA
| | - J R Fineman
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,b Department of Pediatrics, Division of Critical Care Medicine , University of California , San Francisco , CA , USA
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Abstract
OPINION STATEMENT Pulmonary hypertension is caused by cancer and its therapeutic agents including chemotherapy, radiotherapy, and even the targeted therapies. Ironically, some of the cancer therapies that cause one type of pulmonary hypertension (PH) could potentially be employed in the treatment of another PH type. Greater awareness on the role of cancer therapeutic agents in causing PH is required. Conversely, since PH is mostly incurable, the potential role of some of these cancer therapeutic agents in the cure of PH should be recognized. In short, the relationship between cancer, cancer therapy, and PH is an interesting one requiring further attention, education, and research.
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4
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Koifman J, Granton J, Thenganatt J. A case of pulmonary arterial hypertension associated with adult hemophagocytic lymphohistiocytosis. Pulm Circ 2016; 6:614-615. [PMID: 28090306 PMCID: PMC5210061 DOI: 10.1086/688490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 06/30/2016] [Indexed: 01/28/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an aggressive, life-threatening syndrome of excessive immune activation. Presentation is most common among the pediatric population, and cases in adults are rare. The number of nonhematologic presentations described in relation to HLH has been growing. We present a case involving a woman who developed HLH after autologous stem cell transplantation for mantle cell lymphoma. Months later, she received a diagnosis of pulmonary arterial hypertension (PAH) while undergoing treatment for her HLH. To our knowledge, PAH associated with adult HLH has only been described in the literature once before. PAH may now be a potential differential diagnosis for patients with HLH who present with respiratory symptoms.
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Affiliation(s)
- Julius Koifman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Granton
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Thenganatt
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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5
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Ranchoux B, Günther S, Quarck R, Chaumais MC, Dorfmüller P, Antigny F, Dumas SJ, Raymond N, Lau E, Savale L, Jaïs X, Sitbon O, Simonneau G, Stenmark K, Cohen-Kaminsky S, Humbert M, Montani D, Perros F. Chemotherapy-induced pulmonary hypertension: role of alkylating agents. THE AMERICAN JOURNAL OF PATHOLOGY 2014; 185:356-71. [PMID: 25497573 DOI: 10.1016/j.ajpath.2014.10.021] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 10/06/2014] [Accepted: 10/14/2014] [Indexed: 01/16/2023]
Abstract
Pulmonary veno-occlusive disease (PVOD) is an uncommon form of pulmonary hypertension (PH) characterized by progressive obstruction of small pulmonary veins and a dismal prognosis. Limited case series have reported a possible association between different chemotherapeutic agents and PVOD. We evaluated the relationship between chemotherapeutic agents and PVOD. Cases of chemotherapy-induced PVOD from the French PH network and literature were reviewed. Consequences of chemotherapy exposure on the pulmonary vasculature and hemodynamics were investigated in three different animal models (mouse, rat, and rabbit). Thirty-seven cases of chemotherapy-associated PVOD were identified in the French PH network and systematic literature analysis. Exposure to alkylating agents was observed in 83.8% of cases, mostly represented by cyclophosphamide (43.2%). In three different animal models, cyclophosphamide was able to induce PH on the basis of hemodynamic, morphological, and biological parameters. In these models, histopathological assessment confirmed significant pulmonary venous involvement highly suggestive of PVOD. Together, clinical data and animal models demonstrated a plausible cause-effect relationship between alkylating agents and PVOD. Clinicians should be aware of this uncommon, but severe, pulmonary vascular complication of alkylating agents.
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Affiliation(s)
- Benoît Ranchoux
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Sven Günther
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France; Assistance Publique des Hôpitaux de Paris (AP-HP), the Reference Center for Severe Pulmonary Hypertension, Pneumology and Respiratory Intensive Care Service, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - Rozenn Quarck
- Respiratory Division, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Marie-Camille Chaumais
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France; AP-HP, Pharmacy Service, Département Hospitalo-Universitaire Thorax Innovation, Hôpital Antoine Béclère, Clamart, France
| | - Peter Dorfmüller
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France; Pathology Service, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Fabrice Antigny
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Sébastien J Dumas
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Nicolas Raymond
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France; Pathology Service, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Edmund Lau
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France; Assistance Publique des Hôpitaux de Paris (AP-HP), the Reference Center for Severe Pulmonary Hypertension, Pneumology and Respiratory Intensive Care Service, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - Laurent Savale
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France; Assistance Publique des Hôpitaux de Paris (AP-HP), the Reference Center for Severe Pulmonary Hypertension, Pneumology and Respiratory Intensive Care Service, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - Xavier Jaïs
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France; Assistance Publique des Hôpitaux de Paris (AP-HP), the Reference Center for Severe Pulmonary Hypertension, Pneumology and Respiratory Intensive Care Service, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - Olivier Sitbon
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France; Assistance Publique des Hôpitaux de Paris (AP-HP), the Reference Center for Severe Pulmonary Hypertension, Pneumology and Respiratory Intensive Care Service, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - Gérald Simonneau
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France; Assistance Publique des Hôpitaux de Paris (AP-HP), the Reference Center for Severe Pulmonary Hypertension, Pneumology and Respiratory Intensive Care Service, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - Kurt Stenmark
- Department of Pediatrics, University of Colorado at Denver, Aurora, Colorado
| | - Sylvia Cohen-Kaminsky
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France; Assistance Publique des Hôpitaux de Paris (AP-HP), the Reference Center for Severe Pulmonary Hypertension, Pneumology and Respiratory Intensive Care Service, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - David Montani
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France; Assistance Publique des Hôpitaux de Paris (AP-HP), the Reference Center for Severe Pulmonary Hypertension, Pneumology and Respiratory Intensive Care Service, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - Frédéric Perros
- Faculty of Medicine, Université Paris-Sud, Faculté de Médecine, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM U999, Pulmonary Arterial Hypertension: Pathophysiology and Therapeutic Innovation, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, Paris, France.
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6
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Huertas A, Girerd B, Dorfmuller P, O’Callaghan D, Humbert M, Montani D. Pulmonary veno-occlusive disease: advances in clinical management and treatments. Expert Rev Respir Med 2014; 5:217-29; quiz 230-1. [DOI: 10.1586/ers.11.15] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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7
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Pulmonary hypertension after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2013; 19:1546-56. [PMID: 23891748 DOI: 10.1016/j.bbmt.2013.07.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 07/16/2013] [Indexed: 12/17/2022]
Abstract
Pulmonary hypertension (PH) is a potentially fatal complication of hematopoietic stem cell transplantation (HSCT). Given its nonspecific clinical presentation, it is likely that this clinical entity is underdiagnosed after HSCT. Data describing the incidence, risk factors, and etiology of PH in HSCT recipients are minimal. Physicians caring for HSCT recipients should be aware of this severe post-transplant complication because timely diagnosis and treatment may allow improved clinical outcomes. We summarize the pathophysiology, clinical presentation, diagnosis, and management of PH in HSCT recipients.
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8
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Pulmonary arterial hypertension in pediatric patients with hematopoietic stem cell transplant-associated thrombotic microangiopathy. Biol Blood Marrow Transplant 2012; 19:202-7. [PMID: 22960385 DOI: 10.1016/j.bbmt.2012.08.022] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 08/30/2012] [Indexed: 12/19/2022]
Abstract
Pulmonary arterial hypertension (PAH) is rarely included in the differential diagnosis of cardiorespiratory failure after pediatric hematopoietic stem cell transplant (HSCT) as the clinical presentation is nonspecific and may mimic other etiologies. The pathogenesis of PAH in HSCT is poorly understood and the diagnosis requires a high degree of suspicion. We describe 5 children diagnosed with PAH after allogeneic HSCT. All 5 patients had prolonged clinical signs of transplantation-associated thrombotic microangiopathy (TA-TMA) when they presented with hypoxemic respiratory failure and evidence of PAH. Four of the 5 patients had echocardiographic evidence of PAH, and 1 patient was diagnosed with PAH only on autopsy. PAH was diagnosed a median of 76 days (range, 56-101 days) after a diagnosis of TA-TMA. Despite aggressive medical management, including inhaled nitric oxide, 4 of the 5 patients died. One patient recovered from PAH after 11 months of sildenafil therapy. Three of the 4 deceased patients had an autopsy performed, demonstrating severe pulmonary vascular disease consistent with TA-TMA and severe PAH. We conclude that TA-TMA can be associated with significant pulmonary vascular injury presenting as hypoxemic respiratory failure with PAH after HSCT. Pediatric patients with unexplained hypoxemia after HSCT should be evaluated for both transplantation complications, TA-TMA and PAH, accordingly.
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Azoulay E. What Has Been Learned from Postmortem Studies? PULMONARY INVOLVEMENT IN PATIENTS WITH HEMATOLOGICAL MALIGNANCIES 2011. [PMCID: PMC7123032 DOI: 10.1007/978-3-642-15742-4_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Infectious and noninfectious pulmonary diseases are commonly found on postmortem autopsy studies in patients with hematological malignancy. Despite the technological advances in diagnostic testing and imaging modalities, obtaining an accurate clinical diagnosis remains difficult and often not possible until autopsy. Major diagnostic discrepancies between clinical premortem diagnoses and postmortem autopsy findings have been reported in these patients. The most common missed diagnoses are due to opportunistic infections and cardiopulmonary complications. These findings underscore the importance of enhanced surveillance, monitoring and treatment of infections and cardiopulmonary disorders in these patients. Autopsies remain important in determining an accurate cause of death and for improved understanding of diagnostic deficiencies, as well as for medical education and quality assurance.
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Affiliation(s)
- Elie Azoulay
- Service de Réanimation Médicale, Hôpital Saint Louis, Avenue Claude Vellefaux 1, Paris, 75010 France
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10
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Nakaoka H, Sakata Y, Yamamoto M, Maeda T, Arita Y, Shioyama W, Nakaoka Y, Kanakura Y, Yamashita S, Komuro I, Yamauchi-Takihara K. Pulmonary hypertension associated with bone marrow transplantation. J Cardiol Cases 2010; 2:e23-e27. [PMID: 30546702 DOI: 10.1016/j.jccase.2010.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2009] [Revised: 01/04/2010] [Accepted: 01/14/2010] [Indexed: 11/27/2022] Open
Abstract
Bone marrow transplantation (BMT) is one of the promising methods of treatment of hematologic malignancy. However, it has a variety of complications since it involves fatal doses of anti-cancer drugs and radiation during the conditioning period. Among the various complications of BMT, pulmonary hypertension is rare and its pathogenesis is poorly understood. A 35-year-old female with acute myeloid leukemia (AML) presented with pulmonary hypertension after BMT. Although she exhibited severe dyspnea on admission, her general condition markedly improved after oxygen therapy and treatment with warfarin and beraprost sodium. Her pulmonary hypertension was diagnosed as pulmonary arterial hypertension (PAH) related to BMT. Although PAH has only rarely been reported as a complication of BMT, we present here for the first time an adult patient with PAH associated with BMT who exhibited marked improvement with medical treatment. This case indicates that attention needs to be paid to the clinical symptoms and physical findings of PAH as a complication of BMT.
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Affiliation(s)
- Hajime Nakaoka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masaki Yamamoto
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tetsuo Maeda
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoh Arita
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Wataru Shioyama
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshikazu Nakaoka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuzuru Kanakura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shizuya Yamashita
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiko Yamauchi-Takihara
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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11
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Yoshihara S, Yanik G, Cooke KR, Mineishi S. Bronchiolitis obliterans syndrome (BOS), bronchiolitis obliterans organizing pneumonia (BOOP), and other late-onset noninfectious pulmonary complications following allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2008; 13:749-59. [PMID: 17580252 DOI: 10.1016/j.bbmt.2007.05.001] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Accepted: 05/01/2007] [Indexed: 12/19/2022]
Abstract
Pulmonary dysfunction is a significant complication following allogeneic hematopoietic stem cell transplantation (HSCT), and is associated with significant morbidity and mortality. Effective antimicrobial prophylaxis and treatment strategies have increased the incidence of noninfectious lung injury, which can occur in the early posttransplant period or in the months and years that follow. Late-onset noninfectious pulmonary complications are frequently encountered, but diagnostic criteria and terminology for these disorders can be confusing and therapeutic approaches are suboptimal. As a consequence, inaccurate diagnosis of these conditions may hamper the appropriate data collection, enrollment into clinical trials, and appropriate patient care. The purpose of this review is to clarify the pathogenesis and diagnostic criteria of representative conditions, such as bronchiolitis obliterans syndrome and bronchiolitis obliterans organizing pneumonia, and to discuss the appropriate diagnostic strategies and treatment options.
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Affiliation(s)
- Satoshi Yoshihara
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
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12
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Pulmonary veno-occlusive disease following hematopoietic stem cell transplantation: a rare model of endothelial dysfunction. Bone Marrow Transplant 2008; 41:677-86. [PMID: 18223697 DOI: 10.1038/sj.bmt.1705990] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Veno-occlusive disease is among the most serious complications following hematopoietic stem cell transplantation. While hepatic veno-occlusive disease occurs more commonly, the pulmonary variant remains quite rare and often goes unrecognized antemortem. Endothelial damage may represent the pathophysiologic foundation of these clinical syndromes. Recent advances in the treatment of hepatic veno-occlusive disease may have application to its pulmonary counterpart.
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13
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Mandel J. Pulmonary Veno-occlusive Disease. Vasc Med 2006. [DOI: 10.1016/b978-0-7216-0284-4.50065-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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14
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Abstract
Tens of thousands of patients undergo hematopoietic stem cell transplantation (HSCT) each year, mainly for hematologic disorders. In addition to the underlying diseases, the chemotherapy and radiation therapy that HSCT recipients receive can result in damage to multiple organ systems. Pulmonary complications develop in 30% to 60% of HSCT recipients. With the widespread use of prophylaxis for certain infections, the spectrum of pulmonary complications after HSCT has shifted from more infectious to noninfectious complications. This article reviews some of the noninfectious, chronic pulmonary complications.
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Affiliation(s)
- Bekele Afessa
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Sharma S, Nadrous HF, Peters SG, Tefferi A, Litzow MR, Aubry MC, Afessa B. Pulmonary Complications in Adult Blood and Marrow Transplant Recipients. Chest 2005; 128:1385-92. [PMID: 16162733 DOI: 10.1378/chest.128.3.1385] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To describe the pulmonary findings at autopsy of blood and bone marrow transplant (BMT) recipients. DESIGN Retrospective. SETTING An academic medical center. PATIENTS Seventy-one deceased adult BMT recipients. INTERVENTIONS None. MEASUREMENTS Antemortem and postmortem pulmonary findings. RESULTS The transplants were allogeneic in 39 patients (55%), with a peripheral stem cell source in 43 patients (61%). Death occurred at a median of 1.30 months after transplant. Ninety-six pulmonary complications were noted in 63 patients (89%): 27 infectious (bacterial bronchopneumonia, n = 13; pulmonary aspergillosis, n = 11; cytomegalovirus pneumonia, n = 2; and Candida bronchopneumonia, n = 1) and 69 noninfectious (diffuse alveolar damage, n = 35; diffuse alveolar hemorrhage [DAH], n = 10; amyloidosis, n = 9; pulmonary embolism, n = 5; lymphoma/leukemia, n = 4; bronchiolitis obliterans, n = 2; bronchiolitis obliterans organizing pneumonia, n = 1; pulmonary alveolar proteinosis, n = 1; aspiration pneumonia, n = 1; and acute and organizing pneumonia, n = 1). Twenty-seven of the 96 complications (28%) were diagnosed antemortem. Infectious complications were more likely to be diagnosed antemortem compared to noninfectious complications (48% vs 20%, p = 0.006). Six of the 13 patients with bronchopneumonia (46%), 5 of the 11 patients with pulmonary aspergillosis (45%), and 7 of the 8 patients with DAH (88%) at autopsy were not receiving treatment for these conditions at the time of death. Ten patients being treated for suspected pulmonary aspergillosis, 7 patients treated for suspected pulmonary cytomegalovirus infection, 22 patients treated for suspected bacterial pneumonia, 2 patients treated for suspected Pneumocystis carinii pneumonia, and 12 patients treated for DAH at the time of death had no evidence of these conditions at autopsy. The most common immediate cause of death was respiratory failure (n = 37, 52%). CONCLUSIONS Pulmonary complications, the majority not diagnosed antemortem, are the most common cause of death in BMT recipients. As the result of underdiagnosis, BMT recipients may not receive appropriate therapy for potentially treatable pulmonary complications.
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Affiliation(s)
- Sunita Sharma
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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16
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George JN, Li X, McMinn JR, Terrell DR, Vesely SK, Selby GB. Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome following allogeneic HPC transplantation: a diagnostic dilemma. Transfusion 2004; 44:294-304. [PMID: 14962323 DOI: 10.1111/j.1537-2995.2004.00700.x] [Citation(s) in RCA: 170] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) has been described as a specific sequela of allogeneic HPC transplantation (HPCT). Nevertheless, because multiple transplant-related sequela can cause the characteristic clinical features of TTP-HUS, the diagnosis is difficult. STUDY DESIGN AND METHODS All English-language articles describing patients with TTP-HUS following HPCT were identified. Articles reporting five or more total patients, including at least one patient diagnosed with TTP-HUS following allogeneic HPCT, were reviewed. All articles describing autopsies of patients diagnosed with TTP-HUS following allogeneic HPCT were also reviewed. RESULTS Thirty-five articles reporting 5 or more total patients described 447 patients diagnosed with TTP-HUS following allogeneic HPCT. The frequency of diagnosis of TTP-HUS following allogeneic HPCT varied by 125-fold (0.5%-63.6%). Twenty-eight different sets of diagnostic criteria were described in the 35 articles; 25 articles included both RBC fragmentation and increased serum LDH. Many risk factors described as correlating with the diagnosis of TTP-HUS also predict greater risk for multiple transplant-related complications. Benefit of plasma exchange treatment could not be documented. Survival information was reported for 379 patients, 232 (61%) died, and reported mortality rates varied from 0 to 100 percent. Autopsies have been reported for 35 patients who were diagnosed with TTP-HUS following allogeneic HPCT; none had systemic thrombotic microangiopathy, the diagnostic abnormality of TTP-HUS; and infection (19 patients) was the most commonly reported cause of death. CONCLUSIONS The clinical features of TTP-HUS following allogeneic HPCT may be caused by common transplant-related complications; the benefit from plasma exchange treatment is uncertain.
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Affiliation(s)
- James N George
- Department of Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City 73190, USA.
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17
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Trobaugh-Lotrario AD, Greffe B, Deterding R, Deutsch G, Quinones R. Pulmonary veno-occlusive disease after autologous bone marrow transplant in a child with stage IV neuroblastoma: case report and literature review. J Pediatr Hematol Oncol 2003; 25:405-9. [PMID: 12759629 DOI: 10.1097/00043426-200305000-00011] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pulmonary veno-occlusive disease (PVOD) is a rare, almost universally fatal complication of chemotherapy and bone marrow transplantation with few treatment options. A 19-month-old boy with stage 4 neuroblastoma with fatal PVOD following high-dose chemotherapy with autologous peripheral blood stem cell rescue is described here. A comprehensive literature review revealed 40 case reports of PVOD in oncology patients. Various therapeutic modalities were attempted, with four survivors. PVOD should be considered in patients with dyspnea and cardiomegaly. Less invasive diagnostic methods and more effective therapies are needed.
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Affiliation(s)
- Angela D Trobaugh-Lotrario
- Section of Pediatric Hematology/Oncology/Bone Marrow Transplantation, Children's Hospital of Denver, Colorado, USA
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18
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Sarkodee-Adoo C, Sotirescu D, Sensenbrenner L, Rapoport AP, Cottler-Fox M, Tricot G, Ruehle K, Meisenberg B. Thrombotic microangiopathy in blood and marrow transplant patients receiving tacrolimus or cyclosporine A. Transfusion 2003; 43:78-84. [PMID: 12519434 DOI: 10.1046/j.1537-2995.2003.00282.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cyclosporine A (CSA) and tacrolimus (FK-506) are both associated with thrombotic microangiopathy (TMA) in allogeneic BMT recipients, although it is not known which drug is more likely to cause the syndrome. The optimal treatment of BMT-associated TMA is also not known. STUDY DESIGN AND METHODS To estimate the risks, predisposing factors, and outcomes of TMA, data were analyzed from two cohorts of BMT patients who had received CSA or FK-506 in our institution with the same clinical definition for TMA. TMA was diagnosed in 11 of 55 patients (CSA, 3 of 24; FK-506, 8 of 31). RESULTS The daily risk of developing TMA was 0.12 percent for patients receiving CSA and 0.26 percent for those receiving FK-506 (p = 0.16, chi-square). Among patients receiving FK-506, sibling donor BMT recipients were as likely to develop TMA as matched unrelated donor recipients. Serum CSA and FK-506 concentrations were not elevated above the therapeutic range in most patients with TMA. The blood urea nitrogen to serum creatinine ratio was elevated in patients with TMA. Despite daily plasmapheresis, 9 of 11 patients died without resolution of TMA; however, the causes of death were multifactorial, including GVHD. Histologic evidence for TMA was absent in 1 patient who died with persistent clinical signs attributed to microangiopathy. CONCLUSIONS In this study, a high incidence of TMA was found in patients receiving either CSA or FK-506 following BMT, with uniform diagnostic criteria and strict monitoring. Neither drug showed elevated levels in most patients with TMA. Plasmapheresis was unsuccessful in reversing most cases of TMA.
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Affiliation(s)
- Clarence Sarkodee-Adoo
- Division of Hematology and Oncology, University of Maryland School of Medicine, Baltimore, USA.
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Affiliation(s)
- J Mandel
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Seguchi M, Hirabayashi N, Fujii Y, Azuno Y, Fujita N, Takeda K, Sato Y, Nishimura M, Yamada K, Oka Y. Pulmonary hypertension associated with pulmonary occlusive vasculopathy after allogeneic bone marrow transplantation. Transplantation 2000; 69:177-9. [PMID: 10653399 DOI: 10.1097/00007890-200001150-00030] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pulmonary vasculature abnormalities, including pulmonary veno-occlusive disease, have been demonstrated in marrow allograft recipients. However, it is often difficult to make a correct diagnosis of pulmonary lesions. METHODS An open lung biopsy was performed on a patient who developed severe pulmonary hypertension after bone marrow transplantation for T-cell lymphoma. RESULTS An open lung biopsy specimen demonstrated pulmonary arterial occlusion due to intimal fibrosis and veno-occlusion. The most striking alteration was partial to complete occlusion of the small arteries by fibrous proliferation of the intima. CONCLUSION High-dose preparative chemotherapy and radiation before transplantation are thought to have contributed to the development of vasculopathy in this patient, because arterial occlusion by intimal fibrosis and atypical veno-occlusion are often associated with lung injury due to chemoradiation. An open lung biopsy is essential for diagnosing pulmonary vascular disease presenting signs compatible with posttransplantation pulmonary hypertension.
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Affiliation(s)
- M Seguchi
- Third Department of Internal Medicine, Yamaguchi University School of Medicine, Ube, Japan
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