Paul C. Stillwell

Cytomegalovirus Infection Is a Risk Factor for Invasive Aspergillosis in Lung Transplant Recipients

Invasive aspergillosis (IA) remains a major cause of morbidity and mortality following solid organ transplantation. To assess the incidence of IA following lung transplantation and to identify risk factors for its occurrence, we performed a case-control study involving 101 patients undergoing lung transplantation at our institution from 1990 to 1995 and reviewed the findings. Fourteen patients (14%) developed IA. The mean time from transplantation to diagnosis was 15 months. Nine patients died; the mean time to death from diagnosis was 13 days. Risk factors associated with developing IA included concomitant cytomegalovirus (CMV) pneumonia or viremia and culture isolation of Aspergillus species from a respiratory tract specimen after lung transplantation. Optimal strategies to prevent IA in lung transplant recipients remain to be determined, but prevention of aspergillus airway colonization and CMV viremia and disease after transplantation may be important targets for prophylactic interventions.

Airway Responsiveness to Inhaled Albuterol in Patients wit Pulmonary Hypertension

We studied patients with pulmonary hypertension who had evidence of bronchial respon-siveness to inhaled albuterol. The records of all patients evaluated for lung transplantation were reviewed: the charts of patients with pulmonary hypertension, either primary (PPH, n=46) or Eisen-mengers syndrome (n=12), were abstracted. Measurements of lung function revealed equal numbers of patients with normal, restrictive, obstructive, and mixed abnormalities. None were more than moderate. Airway responsiveness was defined as an increase of forced expiratory volume in 1 second (FEV1) >15% or forced expiratory flow between 25% and 75% of the vital capacity (FEF25-75) >25%. Of the 24 PPH and nine Eisenmengers patients, 14 and four, respectively, had reversible airflow obstruction. These patients were more likely to have a history of atopic disease and to have responded to calcium channels blockers during hemodynamic monitoring. They did not have more severe pulmonary hypertension, as measured by hemodynamic monitoring. Four patients had a history of asthma, which required hospitalization in three. Reversible airflow obstruction occurred in half of the patients with pulmonary hypertension and was clinically important in at least three.

Actinomycosis and plasma cell granuloma, coincidence or coexistence: patient report and review of the literature.

A 14-year-old female was seen for evaluation of unresolving pneumonia. Her symptoms started 3 months previously with right lower back and shoulder pain. This was associated with cough productive of bloody dark-colored sputum and dyspnea on exertion. She denied fever, chills, or night sweats. She was treated with multiple courses of oral and intravenous antibiotics with no improvement in symptoms or radiographic findings. She lost 10 pounds over the course of the ill-

The use of light's criteria in hospitalized children with a pleural effusion of unknown etiology

Pleural effusions are common in pediatrics. When the etiology of a pleural effusion remains unknown, adult literature recommends the use of Lights criteria to differentiate a transudate from an exudate. Pediatricians may rely on adult literature for the diagnostic management of pleural effusions as Lights criteria has not been validated in children. The purpose of this study was to review the use of Lights criteria in hospitalized children with a pleural effusion of unknown etiology.

Diagnostic yield and therapeutic impact of flexible bronchoscopy in lung transplant recipients

BACKGROUND Bronchoalveolar lavage and transbronchial biopsy are often used for definitive diagnosis of lung rejection and infection in lung transplant recipients. Although protected specimen brushing is of value in nosocomial bacterial pneumonia, its role in lung transplant recipients had not been widely reported. The aim of the study is to review the diagnostic yield and therapeutic impact of flexible bronchoscopy with the use of a combination of bronchoalveolar lavage, protected specimen brushing, and transbronchial biopsy in lung transplant recipients. METHODS We reviewed flexible bronchoscopy data in 83 transplant recipients between February 1990 and March 1995. Only those with bronchoalveolar lavage, protected specimen brushing, and transbronchial biopsy were included in the analysis. There were 282 bronchoscopies performed for clinically suspected lung rejection or infection (clinical bronchoscopy) and 38 bronchoscopies for follow-up of a previously detected histologic abnormality (follow-up bronchoscopy). RESULTS The total yields for rejection and infection for clinical and follow-up bronchoscopies were 67.4% and 58.9%, respectively. Acute rejection was detected with transbronchial biopsy in 26.2% and 34.2% of clinical and follow-up bronchoscopies, respectively. Cytomegalovirus pneumonitis was detected with transbronchial biopsy in 4.0% and 11.4% of clinical and follow-up bronchoscopies, respectively. Overall, bacteria was the most common cause of lower respiratory tract infection. When used together, protected specimen brushing and bronchoalveolar lavage were complementary techniques for detection of bacterial lower respiratory tract infection with a significantly higher proportion detected with protected specimen brushing ( > or = 10(3) colony forming units/ml) compared with bronchoalveolar lavage ( > or = 10(5) colony forming units/ml) (p < 0.001). Complications were hemorrhage (1.9%), pneumothorax (2.5%) and transient hypoxemia (10.5%). The results had an impact on management of rejection and infection in 57.8% of clinical and 39.5% of follow-up bronchoscopies. CONCLUSIONS We conclude that bronchoscopy, with the use of a combination of bronchoalveolar lavage, protected specimen brushing, and transbronchial biopsy, is safe with a high diagnostic yield and therapeutic impact for treating lung transplant recipients.

Thoracic Organ Transplantation in Children The State of Heart, Heart-Lung, and Lung Transplantation

Heart, heart-lung, and lung transplantation have become accepted modalities for treatment in children with serious cardiopulmonary disease. Although early deaths secondary to infection and/or acute rejection have been reduced dramatically, there is still an early mortality related to cardiac complications and a late mortality related to rejection and infection. The management of hypoplastic left heart syndrome remains a special problem and is outlined in the review. There is much less experience in the newer modalities of heart-lung and lung transplantation in children and the results of these operative procedures are similar to what was seen in heart transplantation some 10 years ago. Ongoing and significant improvement continues, however, in all forms of transplantation dealing with the lung.