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Disorders of the Pleura |

FEV1 Decline Posttransplant: Think Beyond Bronchiolitis Obliterans!

Jasdip Matharu, MD; Lioudmila Karnatovskaia, MD; Cesar Keller, MD
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Mayo Clinic, Jacksonville, FL


Chest. 2013;144(4_MeetingAbstracts):492A. doi:10.1378/chest.1700941
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Abstract

SESSION TITLE: Pleural Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Bronchiolitis obliterans syndrome (BOS) is an uncommon complication within the first year of lung transplantation; however the incidence can increase up to 80% at the five year mark

CASE PRESENTATION: A 73-year old male who underwent a single left lung transplant for idiopathic pulmonary fibrosis demonstrated A2 rejection by transbronchial lung biopsy (TBLB) four months post transplantation. Spirometry at that time revealed an FEV1 of 2.99L and an FVC of 3.32L with FEV1/FVC of 90.06. Surveillance TBLB seven months post-transplantation again demonstrated A2 rejection. Spirometry at the eighth month demonstrated a decline in FEV1 to 2.23L, FVC to 2.35L with FEV1/FVC of 94.8; repeat diagnostic bronchoscopy and biopsy were unrevealing. One month later FEV1 and FVC dropped to 1.14L and 2.03L respectively with FEV1/FVC of 56.15; see Figure 1 for flow volume loops. A chest x-ray revealed a small left pleural effusion. Given a concomitant increase in dyspnea, patient was admitted for thymoglobulin infusion therapy and subsequently discharged. Several days later the patient was readmitted for worsening dyspnea and was found to have visceral pleural thickening with loculated pleural effusions around the allograft (Figure 2). Patient underwent left thoracotomy with decortication of the trapped lung. Pathology report described fibrosing pleuritis without evidence of rejection. Patient’s dyspnea gradually resolved.

DISCUSSION: BOS remains the most common terminal pathway limiting long-term survival among lung transplant recipients. Clinical course can vary from gradual decline over years to abrupt onset with catastrophic deterioration over a few weeks. Patients may present with cough, sputum production, hypoxia, and fever; dyspnea is the most common early symptom. Classification of BOS is based on changes in FEV1 with the maximum post-transplant FEV1 being the 100% predicted value, and subsequent decline in FEV1 thought to be the most reliable indicator of allograft dysfunction. Clinical diagnosis requires development of airway obstruction with a reduction in FEV1 that does not respond to bronchodilators, exclusion of acute rejection, anastomotic complications, infection or other disease affecting pulmonary function.

CONCLUSIONS: This case highlights importance of searching for alternative diagnostic possibilities in someone whose presentation may suggest a restrictive rather than obstructive pattern such as can be seen with a trapped lung which would not be typical of BOS despite declining spirometry values.

Reference #1: Todd JL, Palmer SM. Bronchiolitis obliterans syndrome: the final frontier for lung transplantation. Chest 2011;140(2):502-8.

DISCLOSURE: The following authors have nothing to disclose: Jasdip Matharu, Lioudmila Karnatovskaia, Cesar Keller

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