Noninfectious Pulmonary Complications

Pulmonary function test (PFT) abnormalities occur frequently following allogeneic BMT. A decreased carbon monoxide diffusion (DLco) develops in up to 83% and restrictive and obstructive ventilatory defects in up to 35% and 23%, respectively, of allogeneic BMT recipients (3). Significant mucosal injury occurs in about 75% of BMT recipients. Upper airway inflammation due to mucositis may lead to laryngeal edema, dysphagia, and aspiration pneumonia. Life-threatening upper airway complications are more common in children. 

About 45% of long-term survivors of allogeneic BMT develop chronic GVHD. Histologic pulmonary manifestations of GVHD include diffuse alveolar damage. 

The treatment of BO consists of corticosteroids and augmented immunosuppression, targeting chronic GVHD. However, a minority of patients shows clinical improvement (5). There is a report of eight BMT recipients with BO whose pulmonary function improved after treatment with azithromycin (6) and one BMT recipient treated with infliximab (7). In addition to immunosuppression and anti-inflammatory therapy, prophylaxis against Pneumocystis jirovecii pneumonia and Streptococcus pneumoniae should be provided to patients with BO. In selected patients with respiratory failure secondary to BO, lung transplantation may be an option (1). 

The rate of decline in the forced expiratory volume in one second (FEVj) of BMT recipients is widely variable. Despite treatment with bronchodilators, corticosteroids, and immunosuppression, improvement in lung function is noted in only 8% to 20%. The reported case fatality rates of BO in BMT recipients range from 10% to 100%, with overall mean case fatality rate of 61% (1,5,8). 

Acute pulmonary edema in BMT recipients may result from a combination of both hydrostatic and nonhydrostatic (capillary leak) factors. Hydrostatic pulmonary 

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Palmas A, Tefferi A, Meyers JL, et al. Late-onset noninfectious pulmonary complications after allogeneic bone marrow transplantation. Br J Haematol 1998 100 680-687. 

White DA, Matthay RA. Noninfectious pulmonary complications of infection with the human immunodeficiency virus. Am Rev Respir Dis. 1989 140 1763-1787. 

Alam S, Chan KM. Noninfectious pulmonary complications after organ transplantation. Curr Opinion Pulmon Med 1996 2 412-418. 

The posttransplant period is divided into three phases preengraftment (0 to 30 days), early postengraftment (30-100 days) and late posttransplant (>100 days). The pulmonary complications follow characteristic time patterns (2). Although infections may present as diffuse pulmonary or bronchiolar disorders, this chapter will focus on noninfectious complications. Among the noninfectious pulmonary complications, pulmonary edema, diffuse alveolar hemorrhage (DAH) and periengraftment respiratory distress syndrome (PERDS) usually occur during... 

Figure 1 Timing of the major noninfectious pulmonary complications following blood and marrow transplantation. Abbreviations. BO, bronchiolitis obUterans DAH, diffuse alveolar hemorrhage GVHD, graft versus host disease IPS, idiopathic pneumonia syndrome P edema, pulmonary edema PERDS, periengraftment respiratory distress syndrome phase I, preengraftment period phase II, early postengraftment period phase III, late postengraftment period.

Pulmonary cytolytic thrombi (PCT) is a noninfectious pulmonary complication of unknown etiology. It occurs exclusively after allogeneic procedures, typically... 

Franquet T, Muller NL, Lee KS, Gimenez A, Flint JD (2005a) High-resolution CT and pathologic findings of noninfectious pulmonary complications after hematopoietic stem cell transplantation. AJR Am J Roentgenol 184 629-637... 

Tens of thousands of patients undergo blood and marrow transplantation (BMT) annually, primarily for hematologic malignancies. Since both their innate and acquired immune systems are impaired, infectious and noninfectious complications occur frequently in BMT recipients. The recovery of the immune system following BMT depends on the underlying disorder, stem cell source, and complications such as graft versus host disease (GVHD). Pulmonary complications develop in 25% to 60% of BMT recipients and are the immediate cause of death in approximately 61% (1). The main pulmonary complications are listed in Table 1. 

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