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Correspondence |

CNS Complications in Pulmonary Arteriovenous MalformationsPulmonary Arteriovenous Malformations FREE TO VIEW

Daniel A. Salerno
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From the Department of Medicine, Section of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center.

Correspondence to: Daniel A. Salerno, MD, Department of Medicine, Section of Pulmonary Diseases, Pulmonary and Critical Care and Environmental Medicine, Tulane University Health Sciences Center, 1430 Tulane Ave, JBJ Bldg, Office 204, New Orleans, LA 70112; e-mail: dsalerno@tulane.edu


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(2):426. doi:10.1378/chest.13-2145
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To the Editor:

I read with great interest the review article by Cartin-Ceba et al1 in CHEST (September 2013). The authors give a concise, yet complete, overall view of pulmonary arteriovenous malformations (PAVMs), covering different aspects about the cause, clinical manifestations, diagnosis, and treatment.

One quite perplexing issue about PAVMs is how it seems like cerebral complications (ie, strokes, abscesses) are much more common in PAVMs related to hereditary hemorrhagic telangiectasia (HHT) than in those related to hepatopulmonary syndrome (HPS). A review of the literature provides just a handful of case reports of cerebral complications in HPS.2,3 On the other hand, there is an abundance of literature regarding cerebral complications of HHT. A recent case series from Denmark estimated a 7.8% prevalence of brain abscesses in patients with HHT and PAVMs.4 Knowing that the prevalence of HPS in patients with cirrhosis is estimated to be between 5% and 30%,5,6 it is clear that there is a vast difference between these two entities and their CNS complications.

It could be argued that, mechanistically, PAVMs related to HPS are much smaller than those associated with HHT. But it is also true that patients with HPS usually have a much larger number of microscopic PAVMs (which explains why patients with HPS can have severe right-to-left shunt). In addition, patients with advanced cirrhosis often have altered mental status as a consequence of their own disease (hepatic encephalopathy), perhaps masking neurologic signs; therefore, some of the CNS complications of their HPS could be missed. But as a counterargument, many times patients with hepatic encephalopathy do have brain images taken, and one would expect that if brain abscesses were common in them, more case reports or series should be available. Local mechanisms for the clearance of microemboli and bacteria in the lung vasculature will require further study to elucidate the cause of this striking difference. At the current time, it is not clear if this is an issue related only to the size of the PAVMs or whether some other mechanisms are involved.

I truly enjoyed reading the comments of Cartin-Ceba et al1 about the difference in CNS complications between these two entities. There may be potential for research into the management of lung endotoxemia, phagocytosis, and clearance of microemboli that compare PAVMs related to HPS with those related to HHT.

References

Cartin-Ceba R, Swanson KL, Krowka MJ. Pulmonary arteriovenous malformations. Chest. 2013;144(3):1033-1044. [CrossRef] [PubMed]
 
Molleston JP, Kaufman BA, Cohen A, et al. Brain abscess in hepatopulmonary syndrome. J Pediatr Gastroenterol Nutr. 1999;29(2):225-226. [CrossRef] [PubMed]
 
Yanagihara T, Moriwaki A, Seki N, Akata K, Imanaga T. A brain abscess as a complication of hepatopulmonary syndrome coexisting with interstitial pneumonia [in Japanese]. Nihon Kokyuki Gakkai Zasshi. 2011;49(7):534-537. [PubMed]
 
Kjeldsen AD, Tørring PM, Nissen H, Andersen PE. Cerebral abscesses among Danish patients with hereditary haemorrhagic telangiectasia [published online ahead of print August 20, 2013]. Acta Neurol Scand. doi:10.1111/ane.12167.
 
Gupta D, Vijaya DR, Gupta R, et al. Prevalence of hepatopulmonary syndrome in cirrhosis and extrahepatic portal venous obstruction. Am J Gastroenterol. 2001;96(12):3395-3399. [CrossRef] [PubMed]
 
Schenk P, Fuhrmann V, Madl C, et al. Hepatopulmonary syndrome: Prevalence and predictive value of various cut offs for arterial oxygenation and their clinical consequences. Gut. 2002;51(6):853-859. [CrossRef] [PubMed]
 

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Tables

References

Cartin-Ceba R, Swanson KL, Krowka MJ. Pulmonary arteriovenous malformations. Chest. 2013;144(3):1033-1044. [CrossRef] [PubMed]
 
Molleston JP, Kaufman BA, Cohen A, et al. Brain abscess in hepatopulmonary syndrome. J Pediatr Gastroenterol Nutr. 1999;29(2):225-226. [CrossRef] [PubMed]
 
Yanagihara T, Moriwaki A, Seki N, Akata K, Imanaga T. A brain abscess as a complication of hepatopulmonary syndrome coexisting with interstitial pneumonia [in Japanese]. Nihon Kokyuki Gakkai Zasshi. 2011;49(7):534-537. [PubMed]
 
Kjeldsen AD, Tørring PM, Nissen H, Andersen PE. Cerebral abscesses among Danish patients with hereditary haemorrhagic telangiectasia [published online ahead of print August 20, 2013]. Acta Neurol Scand. doi:10.1111/ane.12167.
 
Gupta D, Vijaya DR, Gupta R, et al. Prevalence of hepatopulmonary syndrome in cirrhosis and extrahepatic portal venous obstruction. Am J Gastroenterol. 2001;96(12):3395-3399. [CrossRef] [PubMed]
 
Schenk P, Fuhrmann V, Madl C, et al. Hepatopulmonary syndrome: Prevalence and predictive value of various cut offs for arterial oxygenation and their clinical consequences. Gut. 2002;51(6):853-859. [CrossRef] [PubMed]
 
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