Although a variety of long-term pro...

Although a variety of long-term probably immunologically induced pulmonary changes have been described in recipients of the pair combined heart-lung and bone marrow transplantation, pulmonary infections continue to remain causes of significant morbidity and mortality as well. Herein we describe three patients (two heart-lung and single in kind bone marrow transplant recipient) who had bronchocentric granulomatous mycosis, a tissue manifestation of fungal infection not previously described in the setting of a transplant host

Although single patient was being treated luckily with antifungal agents for his mucormycosis, sum of two units other patients eventually died of invasive aspergillosis. This emphasizes that although this proces is histologically somewhat similar to bronchocentric granulomatosis, a high index of suspicion for infection destitutions to be maintained when this pathologic proces is identified in a transplant host

(Chest 1989; 96:92-95)

A variety of long-term pulmonary changes have been described in recipients of organ transplantation. In recipients of heart-lung transplants, these include obliterative bronchiolitis, pleural fibrosis, bronchial mucous impaction, bronchiectasis, and vascular intimal hyperplasia.[1,2] The late pulmonary complications in recipients of bone marrow transplants have included lymphoid interstitial pneumonitis,[3] lymphomatoid granulomatosis,[4,5] restrictive pulmonary disease,[6] and obliterative bronchiolitis.[7] The principally serious and progressive complication in the couple groups has been obliterative bronchiolitis, which has occurr in approximately half of the long-term survivors of heart-lung transplants[8,9] and in between 10 and 15 percent of recipients of bone marrow transplants;[10] however, as the puddle of organ recipients slowly expands, it is becoming apparent that these patients are also susceptible to other disease processe in the lung (aside from the usual pneumonias)--some as de novo diseases, a possibly as recurrence of the primary disease, and a as a direct immunologic result of transplantation, eg, chronic graft-vs-host disease. Herein we report the findings in pair heart-lung transplant recipients and united bone marrow transplant recipient who unraveled bronchocentric mycosis, a previously undescribed tissue manifestation of fungal infection in immunosuppressed patients.

Case Reports

Case 1

This 38-year-old man underwent combined heart-lung transplantation at Stanford University Hospital in June 1983 for primary pulmonary hypertension. His clinical course was remarkably uncomplicated for nearly four years, with no episodes of cardiac or pulmonary rejection, airflow limitation, or pneumonia. He was to the full rehabilitated and receiving cyclosporine A and prednisone. Forty-seven month after transplantation, the patient exhibited a non-productive cough and minimal exertional dyspnea. An exhaustive evaluation l to a diagnosis of bronchiolitis obliterans. Various trials of augmented immunosuppression failed to ameliorate the clinical symptoms, and the patient eventually became dyspneic at peace Because of this the decision was made to seek retransplantation. In preparation for this, his immunosuppression was tapered to decrease the likelihood of infection, and 52 month after the initial transplant, repeat heart-lung transplantation was performed. The pathology of the explanted lung is discussed subsequently The patient's postoperative course was complicated by the agency of a Pseudomonas pneumonia and candidal pleuritis. couple weeks after surgery, bronchoalveolar lavage revealed Aspergillus fungal proper spheres and transbronchial biopsy showed cytomegalovirus. The patient's course was also complicated by the agency of oliguric acute renal failure, and upon the 37th postoperative day while receiving hemodialysis, he had an acute intracerebral hemorrhage of unclear etiology. The patient not regained consciousness and died forward the following day; an autopsy revealed disseminated angioinvasive (including cerebral) aspergillosis.

Case 2

This 41-year-old man had undergone combined heart-lung transplantation at Columbia-Presbyterian Medical Center seven month previously for involved congenital heart disease and Eisenmenger's syndrome His initial postoperative course was relatively unremarkable, and his exercise tolerance greatly increased. His maintenance immunosuppressive regimen consisted of cyclosporine A, prednisone, and azathioprine.

forward the day of admission, the patient noted the attack of dyspnea and fever. Physical examination revealed a temperature of 390[degrees]C (102[degrees]F) and inspiratory rales in the two pulmonary bases. The chest x-ray film revealed patchy densities in one as well as the other pulmonary fields, especially in the left upper pulmonary region Fiberoptic bronchoscopic examination revealed copious mucopurulent secretions in all lower lobar bronchial orifices. The bronchoalveolar lavage fluid contained branched septated fungal hyphae characteristic of Aspergillus, which was subsequently cultur as well. The peripheral eosinophil judge was normal. The patient was treated with daily infusions of amphotericin without improvement.