Puneet Garcha

Humoral Human Lung Allograft Rejection by Tissue-Restricted Non-HLA Antibodies

A third of lung recipients have preexisting antibodies against nonhuman leukocyte self-antigens (nHAbs) present in the lung tissue. These nHAbs also form de novo in about 70% of patients within 3 years after transplantation. Both preexisting and de novo nHAbs can cause murine lung allograft dysfunction. However, their role in human transplantation remains unclear. We report hyperacute rejection after right lung transplant in a recipient with preexisting nHAbs. The recipient of the left lung from the same donor had an uneventful initial course, but de novo nHAbs developed at 3 weeks, leading to acute humoral rejection. Both patients were successfully treated with antibody-directed therapies.

Clinical course after successful double lung transplantation in a patient with severe scoliosis

o the Editor: We report on the long-term clinical follow-up of a ecent case report. In this case, a 46-year-old woman ith severe scoliosis underwent successful double lung ransplantation for end-stage bronchiectasis due to conenital primary ciliary dyskinesia. Routine surveillance ronchoscopy, done 3 weeks post-transplant, revealed 0% stenosis of the right main stem bronchus. The atient denied any symptoms of airway obstruction at hat time. She was readmitted to the hospital 14 months ost-transplant with a history notable for 2 weeks of ough, productive for yellow-colored sputum and fever. he also noted that her symptoms were worse when she as lying on her right side. Chest radiography at admision was notable for right lower infiltrate. She underwent flexible bronchoscopy, which revealed complete bronhial obstruction at the level of the right mainstem just bove the right main stem anastomosis. As a result, a ustom-made silicon stent was placed under general ansthesia in the right mainstem, which relieved the bronhial obstruction. Repeat bronchoscopy 2 weeks later evealed adequate positioning of the stent in the right ain stem bronchus and resolution of symptoms. At 20 months post-transplantation, surveillance bronhoscopy revealed granulation tissue in the bronchus interedius distal to the right main bronchus stent, causing ignificant narrowing. She required another rigid bronchosopy in the operating room for cryotherapy and balloon ronchoplasty and silicon stent placement in the bronchus ntermedius. Repeat bronchoscopy 1 month later revealed dequate positioning of the right main stem bronchus and ight bronchus intermedius stents (Figure 1). Since then, at ast follow-up 30 months after surgery, she has continued to o well and her FEV1 is 49% of predicted, without any equirement for supplemental oxygen and no recurrent neumonias. As reported earlier this patient developed right-sided irway narrowing secondary to dynamic airway compresion against her scoliotic vertebral body. Chest imaging oth preand post-transplant was consistent with stable d

Endobronchial hamartoma causing massive hemoptysis.

Endobronchial hamartoma is an unusual clinical entity and infrequently causes hemoptysis. This brief report extends the sparse available experience with endobronchial hamartoma causing hemoptysis by presenting, to our knowledge, only the third such patient reported to have massive hemoptysis complicating an endobronchial hamartoma.

Diffuse Large B-Cell Lymphoma Presenting as Diffuse Bilateral Ground-Glass Opacities and Diagnosed on Transbronchial Lung Biopsy

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New Nodule-Newer Etiology

AIM To evaluate frequency and temporal relationship between pulmonary nodules (PNs) and transbronchial biopsy (TBBx) among lung transplant recipients (LTR). METHODS We retrospectively reviewed 100 records of LTR who underwent flexible bronchoscopy (FB) with TBBx, looking for the appearance of peripheral pulmonary nodule (PPN). If these patients had chest radiographs within 50 d of FB, they were included in the study. Data was compared with 30 procedures performed among non-transplant patients. Information on patients demographics, antirejection medications, anticoagulation, indication and type of lung transplantation, timing of the FB and the appearance and disappearance of the nodules and its characteristics were gathered. RESULTS Nineteen new PN were found in 13 procedures performed on LTR and none among non-transplant patients. Nodules were detected between 4-47 d from the procedure and disappeared within 84 d after appearance without intervention. CONCLUSION FB in LTR is associated with development of new, transient PPN at the site of TBBx in 13% of procedures. We hypothesize that these nodules are related to local hematoma and impaired lymphatic drainage. Close observation is a reasonable management approach.