Diagnostic Evaluation of Pulmonary Abnormalities in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation

Bianca Harris, Alexander I Geyer, Bianca Harris, Alexander I Geyer

Abstract

Pulmonary complications (PC) of hematologic malignancies and their treatments are common causes of morbidity and mortality. Early diagnosis is challenging due to host risk factors, clinical instability, and provider preference. Delayed diagnosis impairs targeted treatment and may contribute to poor outcomes. An integrated understanding of clinical risk and radiographic patterns informs a timely approach to diagnosis and treatment. There is little prospective evidence guiding optimal modality and timing of minimally invasive lung sampling; however, a low threshold for diagnostic bronchoscopy during the first 24 to 72 hours after presentation should be a guiding principle in high-risk patients.

Keywords: Bronchoscopy; Diagnosis; Hematologic malignancy; Hematopoietic cell transplant; Lung infiltrates; Pneumonia; Pulmonary complications.

Copyright © 2016 Elsevier Inc. All rights reserved.

Figures

Fig. 1
Fig. 1
Infectious and noninfectious pulmonary complications of hematopoietic cell transplantation. ARDS, acute respiratory distress syndrome; BOOP, bronchiolitis obliterans organizing pneumonia; BOS, bronchiolitis obliterans syndrome; CHF, congestive heart failure; CMV, cytomegalovirus; EBV, Epstein–Barr virus; GVHD, graft-versus-host disease; HHV-6, human herpes virus-6; HSV, herpes simplex virus; PE, pulmonary embolism; PERDS, periengraftment respiratory distress syndrome; PTLD, posttransplant lymphoproliferative disorder; VZV, varicella zoster virus. a Consider diagnostic bronchoscopy to (1) establish or rule out an infectious etiology, and/or (2) diagnose a noninfectious etiology for the pulmonary complication.
Fig. 2
Fig. 2
Spectrum of pulmonary complications in patients with hematologic malignancies and in hematopoietic cell transplant recipients. ALI, acute lung injury; APL, acute promyelocytic leukemia; ARDS, acute respiratory distress syndrome; ATRA, all-trans retinoic acid; BOS, bronchiolitis obliterans syndrome; CMV, cytomegalovirus; DAH, diffuse alveolar hemorrhage; DIP, desquamative interstitial pneumonia; EMH, extramedullary hematopoiesis; GNR, gram-negative rods; GPC, gram-positive cocci; HP, hypersensitivity pneumonitis; IPS, idiopathic pneumonia syndrome; NSIP, nonspecific interstitial pneumonia; PAP, pulmonary alveolar proteinosis; PERDS, periengraftment respiratory distress syndrome; PJP, Pneumocystis jiroveci pneumonia; PTLD, posttransplant lymphoproliferative disease.
Fig. 3
Fig. 3
Approach to the diagnostic evaluation of pulmonary infiltrates in patients with hematologic malignancies and in hematopoietic cell transplant recipients. a Transbronchial lung biopsy is generally reserved for suspicion of invasive viral, fungal or mycobacterial disease. b The unstable transplant patient who becomes clinically stable may benefit from early diagnostic bronchoscopy within 48 to 72 hours of initiating therapy (dashed line). c Diagnostic bronchoscopy should be considered before surgical lung biopsy in cases refractory to empiric therapy (dotted line). BNP, B-natriuretic peptide.

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