SESSION TYPE: Miscellaneous Cases III
PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Lung transplant is the final common treatment pathway for end stage lung disease. We report a patient who suffered a failed left lung graft due to bronchiolitis obliterans (BO) that has progressed to a single enlarged cavity in the absence of chronic infection.
CASE PRESENTATION: A 56 year old female underwent left lung transplantation in 2006 due to end stage chronic obstructive pulmonary disease. The graft failed due to BO, requiring a right lung transplant twelve months later. She has since thrived clinically, with no evidence of rejection or infection by surveillance bronchoscopy except for one episode of left sided acinetobacter pneumonia in early 2011. She was successfully treated, and four week follow-up bronchoscopy demonstrated microbiologic resolution accompanied by clinical improvement. Over the five years since her second transplant, her left lung graft has radiographically deteriorated. Initially showing BO, it has progressed through fibrosis, consolidation, and now a single cavitary lesion (figure 1). Quantitative perfusion scan demonstrated an appropriate redistribution of flow with only 2.2% supplying the left lung. Pulmonary function tests showed an expected decline in total lung capacity and forced expiratory volume. Recent bronchoscopy reveals a large cavitary lesion with culture negative scant purulence and a visible, pulsating left pulmonary artery (figure 2). Her increased risk for infection and massive hemoptysis prompted surgical evaluation. Due to clinical stability and a high surgical pneumonectomy risk, we opted for conservative management.The patient continues to do well, suffering only from occasional cough and sputum production without hemoptysis.
DISCUSSION: BO in a transplanted lung is a well described complication that effects approximately 50% of all lung transplant patients at five years.(1) Infection frequently accompanies BO and cavitary lesions can occur, particularly when mycobacterium and aspergillus species are involved.(2) Though fibrosis is the expected long term sequelae in BO, our patient formed a single large cavity in the absence of inciting infection without a clear underlying mechanism. The same adaptive process of vascular redistribution in response to severe ventilation perfusion mismatch that frequently follows infectious cavitary lung disease may be responsible. Her computed tomography scans did not reveal evidence of pulmonary artery stenosis.
CONCLUSIONS: Lung transplant carries significant long term morbidity. We describe a novel case of a patient whose failed lung graft due to BO has undergone auto-pneumonectomy from a non-infectious cause.
1) Boehler A, Estenne M. Post-transplant bronchiolitis obliterans. European Respiratory Journal 2003; 22: 1007-1018.
2) Malouf MA, Glanville AR. The spectrum of mycobacterial infection after lung transplantation.
DISCLOSURE: The following authors have nothing to disclose: John Kingrey, Amy Pope-Harman
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