Lucas Pitts

Effect of extracorporeal photopheresis on lung function decline for severe bronchiolitis obliterans syndrome following allogeneic stem cell transplantation.

Extracorporeal photopheresis (ECP) is a commonly used treatment for severe graft‐versus‐host‐disease (GVHD). We sought to evaluate the effects of ECP over a prolonged period on forced expiratory volume in 1 s (FEV1) in patients with pulmonary GVHD. We identified eight patients who developed new airflow obstruction following allogeneic stem cell transplantation and a substantial decline in FEV1 despite receiving corticosteroids and standard therapy for pulmonary GVHD. Those eight patients were treated with ECP for a period of 1 year, with a primary endpoint of FEV1 change during this treatment period. Over the first 3 months of ECP, there was no further decline in FEV1 in seven of the eight patients. However, over the 1 year period, only two of the eight patients had stability in FEV1. The rate of FEV1 decline was substantially less once ECP was initiated, though the median FEV1 continued to decline over 1 year of therapy. All patients survived through the first year of ECP therapy. There was a significant decrease in the median dose of prednisone per patient throughout the 12 months of ECP treatment. ECP shows promise in slowing rate of decline of FEV1 in pulmonary GVHD, though the effects may not be long lived. J. Clin. Apheresis 31:347–352, 2016.

Utility of galactomannan antigen detection in bronchoalveolar lavage fluid in immunocompromised patients

Diagnosis of invasive pulmonary aspergillosis (IPA) is a challenging process in immunocompromised patients. Galactomannan (GM) antigen detection in bronchoalveolar lavage (BAL) fluid is a method to detect IPA with improved sensitivity over conventional studies. We sought to determine the diagnostic yield of BAL GM assay in a diverse population of immunocompromised patients. A retrospective review of 150 fiberoptic bronchoscopy (FOB) with BAL for newly diagnosed pulmonary infiltrate in immunocompromised patients was performed. Patient information, procedural details and laboratory studies were collected. BAL and serum samples were evaluated for GM using enzyme‐linked immunoassay. Of 150 separate FOB with BAL, BAL GM was obtained in 143 samples. There were 31 positive BAL GM assays. In those 31 positive tests, 13 were confirmed as IPA, giving a positive predictive value of 41.9%. There was one false negative BAL GM. Of the 18 false positive BAL GM, 4 were receiving piperacillin–tazobactam and 11 were receiving an alternative beta‐lactam antibiotic. BAL GM assay shows excellent sensitivity for diagnosing IPA. There was a significant number of false positive BAL GM assays and several of those patients were receiving beta‐lactam antibiotics at the time of bronchoscopy.

Comparison of Nasopharyngeal Specimens and Bronchoalveolar Lavage Specimens of Immunocompromised Adult Patients Using the Genmark DX Esensor Respiratory Viral Panel

Purpose: To determine if the multiplex real-time polymerase chain reaction respiratory viral panel (RVP) provides the same results when performed on nasal wash versus bronchoalveolar lavage from the same patient within 5 days of each other. Methods: A retrospective chart review was performed on all adult immunocompromised patients who underwent bronchoalveolar lavage (BAL) with a respiratory viral panel (RVP) obtained from the BAL fluid from February 2011 to July 2012. All patients who also had a nasal wash RVP performed within 5 days of the BAL assay were included in this study. Results: There was exact concordance between BAL and NPW specimens in 45 of 58 patients: 26 cases in which both specimens were negative and 19 cases in which the exact same viruses were present in each specimen. In 8 cases, a virus was detected in BAL fluid that was not detected in NPW fluid; in 5 cases, a virus was found in NPW fluid but not BAL. Conclusions: There was good correlation between the two assays when performed within 5 days of each other from the 2 separate specimen sources. For optimal diagnostic detection, it may be useful to repeat the assay in both locations when clinically indicated.

Safety of nintedanib for treatment of fibrotic lung disease after allogeneic hematopoietic stem cell transplantation

Graft-versus-host-disease (GVHD) of the lung is most commonly manifested as bronchiolitis obliterans syndrome (BOS) and may occur in up to half of patients with GHVD [1]. Typical treatments include systemic corticosteroids coupled with inhaled steroids, inhaled beta agonists, macrolides, and various other therapies [1–5]. Pro-fibrotic mediators, including platelet-derived growth factor (PDGF) and vascular endothelial growth factor (VEGF), may play a role in the development of BOS [6, 7]. Nintedanib is a tyrosine kinase inhibitor that mediates multiple pro-fibrotic growth factors, including PDGF, VEGF, and fibroblast growth factor [8]. This drug can slow the rate of disease progression and reduce the risk of exacerbations in idiopathic pulmonary fibrosis (IPF) [9]. Potential side effects of nintedanib include diarrhea, nausea, increased liver enzymes, hemorrhage, and arterial thrombosis. Because of its mechanism of action, nintedanib may be a potential treatment option for patients with BOS due to pulmonary GVHD. Pirfenidone, an anti-fibrotic agent also approved for treatment of IPF [10], has had preliminary studies showing efficacy in a murine model of chronic GVHD [11]. Based on its favorable side effect profile, we sought to examine the efficacy of nintedanib when utilized in patients with fibrotic lung disease after allogeneic hematopoietic stem cell transplantation (HSCT) and determine whether this drug can be safely used in this patient population. We present two cases of patients treated with nintedanib following allogeneic HSCT.

Diagnostic Yield of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration for Sarcoidosis

INTRODUCTION Sarcoidosis is a multisystem granulomatous disease characterized by diffuse non-caseating granulomas predominantly consisting of epithelioid cells and macrophages (1, 2). There have been numerous environmental associations proposed, but the exact etiology remains unknown. Sarcoidosis can affect many organ systems, but it most commonly affects the eyes, lungs, and skin. It frequently presents with hilar lymphadenopathy and pulmonary infiltrates (3). The clinical course is variable and can range from lifeand organthreatening manifestations to self-limiting diseases in some variants, including Löfgren’s syndrome, characterized by arthritis, hilar adenopathy, and erythema nodosum (1, 4).