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ICU Readmission of a Lung Transplant Recipient With Acute Respiratory Failure FREE TO VIEW

Mauricio Acuña, MD; Jordi Riera, MD; Jordi Rello, PhD; Antonio Roman, PhD
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Critical Care Department Vall d Hebron University Hospital, Barcelona, Spain


Chest. 2014;145(3_MeetingAbstracts):563A. doi:10.1378/chest.1823743
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Abstract

SESSION TITLE: Miscellaneous Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: ICU readmissions after lung transplantation (LTx) have increased over the years, as a consequence of expanded criteria for LTx-list inclusion, with higher severity scores of patients in the list, together with the use of marginal grafts.

CASE PRESENTATION: 33 year-old woman with tuberous sclerosis who received a single-lung transplant in 2008, due to an obstructive pulmonary disease. The immunosuppressive guidance consisted on Tacrolimus and Sirolimus. Graft function was good (2009 FVC81% FEV155% - 2012 FVC79% FEV158%). By the end of 2012 Sirolimus was substituted by Mycophelonate because of surgery. In 2013 the patient was admitted for acute respiratory failure (ARF); initially under treatment with Ceftazidime, changed to Meropenem due to clinical deterioration. The FBC and biopsy reported a grade A4 acute cellular rejection. The patient was treated with Methylprednisolone and Basiliximab, obtaining limited clinical and radiological response. After positive PCR in BAL for Parainfluenza Virus, treatment with Ribavirin was initiated. A second biopsy showed mixed inflammatory infiltrate as well as perivascular lymphocytic cuffing revealing vasculitis and intimal infiltrate. Due to the suspicion of humoral component, plasmapheresis was firstly proceeded to; cancelled after negative C4d immunochemistry and poor clinical response. Positive results of CMV in blood tests were revealed, prescribing Ganciclovir. The patient died by refractory respiratory failure. The autopsy revealed signs of Obliterative Bronchiolitis (OB).

DISCUSSION: The most frequent causes in ARF requiring ICU admission after LTx are respiratory infections, acute rejection, exacerbation of chronic lung allograft dysfunction (CLAD) and sepsis. Due to the fact that their clinical and radiological displays are so unspecific, differential diagnosis turns out to be complex. Although pathology is the most illustrative diagnostic test, due to a patched pattern and to the possibility of coexistence of more than one pathology, its sensitivity is very variable. CLAD does not currently have an agreed definition and recent studies suggest it is a heterogeneous entity with various histopathological components.

CONCLUSIONS: Differential diagnosis in LTx with ARF readmitted in the ICU is based upon the experience of the clinician, epidemiology and the additional complementary examinations which have low sensitivity and specificity. Other techniques with more profitability are strongly required. Further characterization of CLAD is needed.

Reference #1: Hadjiliadis et al. Outcome of LTx patients admitted to the medical ICU. Chest 2004;125:1040-5.

Reference #2: Kotsimbos et al. Update on LTx: programmes, patients and prospects. ERR 2012;21:271-305.

Reference #3: Paraskeva et al. Acute fibrinoid organizing pneumonia after LTx. AJRCCM 2013;187:1360-8.

DISCLOSURE: The following authors have nothing to disclose: Mauricio Acuña, Jordi Riera, Jordi Rello, Antonio Roman

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