Outcome and prognostic factors of hematopoietic stem cell transplantation recipients admitted to a medical ICU

OBJECTIVE

To assess the outcome of adult hematopoietic stem cell transplantation (HSCT) recipients who were admitted to a medical ICU (MICU), and to identify the measurable predictors of their MICU outcome.

DESIGN

Retrospective chart review study.

SETTING

MICU in a tertiary care, university-affiliated medical center with a comprehensive cancer program.

PATIENTS

Consecutive adult HSCT recipients admitted to the MICU between January 1998 and June 2001.

MEASUREMENTS AND MAIN RESULTS

Eighty-five patients were admitted to the MICU, representing 11.4% of patients who had undergone HSCT during the study period. The mean (+/- SD) age at MICU admission was 46.6 +/- 11.4 years (women, 67%; men, 33%). Forty-five patients (53%) underwent allogeneic HSCT, and 40 patients (47%) underwent autologous HSCT. Fifty-one patients (60%) required mechanical ventilation (MV). Fifty-two patients (61%) survived their MICU stay, and 35 patients (41%) were discharged alive from the hospital. The long-term survival rate (ie, > 6 months) in this cohort was 28%. Nineteen mechanically ventilated patients (37%) survived their MICU stay, and 33 patients (97%) survived who did not require MV (p < 0.01). The independent predictors of poor outcome during the MICU stay were elevated serum lactate level on admission to the MICU, the need for MV, and the presence of more than two organ systems that failed.

CONCLUSIONS

The study showed short-term and long-term survival rates among adult HSCT recipients who had been admitted to MICU that were higher than those previously reported. While there were no absolute predictors of mortality, patients with higher MICU admission serum lactate levels, those requiring MV, or those developing more than two organ system failures had poor MICU outcomes.

Invasive Tracheobronchial Aspergillosis in an Immunocompetent Person

Tracheobronchial involvement is an uncommon form of invasive pulmonary aspergillosis and is found mainly in immunocompromised individuals such as patients with leukemia and prolonged granulocytopenia due to cytotoxic therapy, organ transplant recipients receiving high-dose corticosteroids, or patients with chronic granulomatous diseases. Rarely, such a pattern can also be seen in immunocompetent persons or can involve atypical sites such as the paranasal sinuses, skin, and the tracheobronchial tree. Occasionally, these patients require a prolonged course of antifungal agents. We report a case of aspergillosis involving the tracheobronchial tree in an immunocompetent young male that presented a diagnostic dilemma.

Surgical lung biopsy in patients with hematological malignancy or hematopoietic stem cell transplantation and unexplained pulmonary infiltrates: improved outcome with specific diagnosis

Using a retrospective review of medical records, we sought the findings of surgical lung biopsy (SLB) in patients with hematological malignancy or hematopoietic stem cell transplantation (HSCT) and unexplained pulmonary infiltrates and to determine the impact of this procedure on management and outcome of these patients. Sixty-two patients who underwent SLB were evaluated; 31 patients had underlying hematological malignancy and 31 patients were HSCT recipients; 58% of whom underwent allogeneic HSCT. Thirty-three patients (53%) had focal infiltrates on chest CT scan while 29 (47%) had diffuse infiltrates. Thirteen patients were mechanically ventilated prior to SLB, and 27 (43%) were neutropenic. There were 66 diagnoses in the 62 patients, 44 (67%) were specific and 22 (33%) were nonspecific. The most common specific diagnoses were infection (29%), malignancy (27%), and inflammatory conditions (11%). Aspergillosis was the most common diagnosis of all biopsies (21%). SLB led to a change in therapy in 40% of patients and was associated with complications in 7 patients (11%). Specific diagnosis was more likely to lead to a change in therapy (48% vs. 27%, P = 0.06) and was associated with a lower mortality when compared to a nonspecific finding (30% vs. 59%, P = 0.02). Nonspecific diagnosis, on the other hand, was seen more in patients on mechanical ventilation prior to SLB compared to those off mechanical ventilation (69% vs. 27%, P = 0.02). SLB provides a specific diagnosis in the majority of patients with hematologic malignancy or HSCT recipients and unexplained pulmonary infiltrates. Specific diagnosis is more likely to lead to a change in therapy and is associated with a better outcome.

Surgical management of pulmonary cavity associated with fungus ball

Surgery for pulmonary cavity associated with fungus ball is challenged by chronic lung disease. The purpose of this report was to review patient data, operative procedures and results of surgery. This was a retrospective study. Twenty patients were operated on between January 1997 and December 2002. Fourteen (70%) patients were male and the mean age was 46.30 +/- 13.10 years (range, 24 to 76 years). The most common underlying pulmonary disorder was tuberculosis (70%). Ninety five percent of the patients had a history of hemoptysis, and 35% presented with massive hemoptysis. Lobectomy was performed in 11 (55%) patients and 6 (30%) patients were operated on by cavernostomy with transposition of muscle flap technique. There was no operative mortality and 8 complications (3 prolonged airleaks, 2 wound infections, 1 postoperative bleeding, 1 seroma and 1 empyema). It was also found that emergency surgery and cavernostomy with transposition of muscle flap compromised the postoperative course. Surgery is very effective in controlling and preventing hemoptysis in patients who have pulmonary cavity associated with fungus ball. Elective surgery and formal pulmonary resection may be the proper option for low risk patients. Cavernostomy with transposition of muscle flap may be suitable for patients who have poor pulmonary reserve.

Superiority of voriconazole over amphotericin B in the treatment of invasive aspergillosis after heart transplantation

Invasive aspergillosis in immuncompromised patients occurs frequently. Surgical therapy in combination with chemotherapy with amphotericin B and itraconazole is standard therapy. We describe a heart transplant recipient with invasive Aspergillus fumigatus infection in the lung, which was treated successfully with voriconazole after systemically high-dose intravenous therapy with amphotericin B failed.

Variability of germinative potential among pathogenic species of Aspergillus

The objective of our study was to evaluate parameters influencing the germination of Aspergillus conidia. Inoculum concentration and age significantly influenced germination. Different incubation temperatures revealed significant differences among Aspergillus species. The internal human milieu provides the ideal conditions for the development of invasive disease by Aspergillus fumigatus but restricts invasion by Aspergillus flavus and Aspergillus niger.

Pathogenesis of allergic bronchopulmonary aspergillosis and an evidence-based review of azoles in treatment

BACKGROUND

Allergic bronchopulmonary aspergillosis (ABPA) is a complex condition that affects people with asthma and cystic fibrosis (CF). It results from exposure to the fungus Aspergillus fumigatus, which leads to worsening airway inflammation and progressive damage to the lungs. The aim of this review is to outline the pathogenesis of the disorder, diagnostic criteria and to discuss the use of anti-fungal agents in its treatment.

METHODS

The Cochrane library of systematic reviews and the Cochrane database of controlled trials were searched for controlled trials on ABPA and its treatment in both asthma and CF. In addition, articles included within the reviews were examined separately, and a separate search carried out using Medline.

RESULTS

A systematic review for the use of azole anti-fungal agents in ABPA was identified for their use in both CF and non-CF-related disease. The review of ABPA alone identified two randomized-controlled trials of itraconazole in chronic disease. These trials demonstrated improvements in symptoms and immune activation, but were short-term trials and failed to show a significant change in lung function. No trials were identified in CF.

CONCLUSIONS

The use of anti-fungal agents in ABPA seems to be a rational one, with short-term efficacy demonstrated for the use of itraconazole. Further investigations are required to identify individuals who will benefit most from treatment and to establish the correct dose and means of delivering treatment in ABPA. Longer-term studies are required to demonstrate that treatment modifies the progressive decline in lung function seen with the disease.

Incidence, outcome, and risk factors of late-onset noninfectious pulmonary complications after unrelated donor stem cell transplantation

We evaluated the incidence, the risk factors, and the outcome of late-onset noninfectious pulmonary complications (LONIPCs) among 50 patients who underwent allogeneic stem cell transplantation from unrelated donors. Of the 39 patients surviving at least 3 months, 10 (26%) fulfilled the diagnostic criteria of LONIPCs and were further subclassified as having bronchiolitis obliterans (four patients), bronchiolitis obliterans with organizing pneumonia (four patients), and interstitial pneumonia (two patients). Two patients had a durable partial remission after treatment with prednisone and cyclosporine; the remaining eight patients did not respond to treatment and five of them died of respiratory failure. Advanced stage of disease at transplant and chronic extensive graft-versus-host disease (GVHD) were significantly associated with the development of LONIPCs. Pulmonary function test (PFT) results before transplantation were similar in all patients, but patients with LONIPCs had a significant decrease in PFT indexes at the third month after BMT compared with controls. Moreover, the rate of cyclosporine taper during the fourth and fifth months after BMT was significantly more rapid in patients with LONIPCs than in controls, suggesting that the risk of LONIPCs may be influenced by a faster reduction of GVHD prophylaxis.

Accuracy and performance of a modified continuous intravascular blood gas monitoring device during thoracoscopic surgery

OBJECTIVE

The only commercially available continuous intravascular blood gas monitoring system for adults, the Paratrend (Diametrics Medical Inc, High Wycombe, UK), was modified by the manufacturer to the Paratrend 7+ (PT7+) in 1999. The aim of this study was to evaluate the modified probe over a wide range of blood gas and pH values during thoracoscopic surgery in a similar setup as done with the previous model.

DESIGN

Prospective methods comparison study.

SETTING

University hospital.

PARTICIPANTS

Twenty-three patients.

INTERVENTIONS

Elective thoracoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

One hundred thirteen PT7+ readings and their corresponding arterial blood gas and pH measurements (ABGA) were evaluated. The ranges for ABGA values were 50 to 474 mmHg for PO(2), 29 to 58 mmHg for PCO(2), and 7.28 to 7.49 for pH. Bland and Altman analysis revealed a bias +/- 2 standard deviation of -20 +/- 86 mmHg for PO(2), 3 +/- 9 mmHg for PCO(2), and -0.01 +/- 0.06 for pH. No specific complications attributable to the probe were observed.

CONCLUSION

In patients undergoing thoracoscopic surgery with rapidly changing blood gas parameters, the PT7+ device is a valuable trend indicator and hence may be helpful for clinical decision making. However, the underestimation of PO(2) values by 20 mmHg on average and the wide limits of agreement documented in this study must be regarded as limiting factors.

Chest imaging in iatrogenic respiratory disease

Iatrogenic respiratory disease is an important cause of patient morbidity and mortality. Clinical and radiologic findings are nonspecific and diagnosis can be difficult. Therefore, it is important for physicians to be familiar with the iatrogenic diseases for which their patients are at risk, as well as their common radiologic appearances. Causes of iatrogenic respiratory disease include drugs, transplantation, radiation, transfusion, or other miscellaneous therapies.

Pulmonary complications in bone marrow transplantation: a practical approach to diagnosis and treatment

Pulmonary complications occur in 40% to 60% of recipients of bone marrow trans-plants, account for more than 90% of mortality, and develop during identifiable phases. Phase 1 (Days 1-30) includes pulmonary edema; diffuse alveolar hemorrhage; and various bacterial, fungal, and viral infections; Phase 2 (Days 31-100) usually requires a distinction between cytomegalovirus pneumonitis and idiopathic pneumonia syndrome; and Phase 3 (Day 100+) includes complications that are due to chronic graft-versus-host disease and associated bronchiolitis obliterans. The spectrum of pulmonary complications has been influenced by changes in transplantation technique, prophylactic treatment for infections, and the use of new chemotherapeutic agents that contribute to lung injury. Nonetheless, infections remain a leading cause of morbidity and mortality. The most serious complications result in respiratory failure, for which the prognosis has not improved significantly over the last 2 decades. In this article, we describe our algorithmic approach to the diagnosis and management of these complications.

Eight cases of severe acute respiratory syndrome presenting as round pneumonia

OBJECTIVE

The purpose of this study was to describe the radiographic findings and evolution of round pneumonia found in eight patients with confirmed severe acute respiratory syndrome (SARS).

CONCLUSION

SARS may present as round pneumonia on chest radiographs initially or during the treatment course. It may remain unchanged for up to 9 days before evolution to ill-defined air-space opacities. Radiologists and physicians should consider the possibility of "SARS pneumonia" when spherical air-space opacities are noted on chest radiographs of febrile patients.

Imaging of opportunistic fungal infections in immunocompromised patient

Opportunistic fungal infection is a common cause of serious morbidity and mortality in the immunocompromised host. Combination of pattern recognition with knowledge of the clinical setting is the best approach to pulmonary infectious processes. The aim of this article is to assess the chest radiographs and CT imaging features of different opportunistic fungal infections in immunocompromised patients.

Engraftment syndrome emerges as the main cause of transplant-related mortality in pediatric patients receiving autologous peripheral blood progenitor cell transplantation

The authors examined data from 166 children who received autologous peripheral blood progenitor cell (PBPC) transplantation to ascertain the incidence of early transplant-related mortality (TRM) and the contributing risk factors. Eleven patients (6.6%) (6 boys, 5 girls) died within 180 days following PBPC infusion. The median age was 4 years (range 2-17). The overall probability of TRM was 6.9 +/- 2% at day +180. On univariate analysis, the status of disease at transplantation (complete remission vs. not in complete remission) was identified as the only pretransplant significant predicting factor for TRM (14% of patients who were not in complete remission died within 180 days after PBPC infusion, whereas only 2% of patients in complete remission died) (relative risk [RR] 1.13, 95% confidence interval [CI] 1.01-1.26, P = 0.01). Age, gender, conditioning, and number of CD34+ cells infused were not significantly associated with TRM. In the postinfusion phase, patients who developed multiorgan dysfunction during the neutropenic period, especially when the lung was the first failing organ (RR 16.1, 95% CI 7.16-36.18, P = 0.0001), and those with engraftment syndrome (RR 2.81, 95% CI 1.49-5.24, P = 0.001) had an increased risk for TRM. On multivariate analysis, development of engraftment syndrome was the only significant variable that influenced TRM. In conclusion, the authors found for the first time that engraftment syndrome emerges as the main cause of TRM after autologous PBPC transplantation in children with malignancies.

[An unusual cause of acute respiratory distress: obstructive bronchial aspergillosis]

We report the case of a 77-Year-old immunocompetent woman who required intensive care for acute dyspnea revealing complete atelectasia of the left lung related to an aspergillus mycelium plug blocking the principal bronchus. The clinical course was favorable after deobstruction by thermocoagulation and oral itraconazole given for six Months. The patient was free of parenchymatous or endobronchial sequelae. Adjuvant oral corticoid therapy was given temporarily during the second Month of treatment when signs of transition towards allergic aspergillosis developed. Four Months after discontinuing the antifungal treatment, the patient developed a new episode of acute dyspnea caused by atelectasia limited to the right lower lobe. Treatment by itraconazole was resumed and continued as long-term therapy. No recurrence has been observed for eighteen Months. The diagnostic and therapeutic problems raised by Aspergillus fumigatus are well known in the immunocompromised subject, but can also be encountered in the immunocompetent subject.

Prospective study of respiratory viral infections in pediatric hemopoietic stem cell transplantation patients

BACKGROUND

Community-acquired respiratory viruses are an important cause of respiratory disease in pediatric patients undergoing hemopoietic stem cell transplantation. However, there are no studies examining the impact of more rapid and sensitive diagnosis by real time polymerase chain reaction (PCR) in this population. We performed a prospective study to assess the impact of real time PCR diagnosis as well as protective isolation for community-acquired respiratory virus infections in pediatric patients undergoing hemopoietic stem cell transplantation.

METHODS

During a 2-year period, 39 pediatric patients undergoing hemopoietic stem cell transplantation were analyzed for presence of respiratory viruses. Samples were taken at regular intervals and analyzed by culture and newly developed real time PCR methods. All patients were cared for in protective isolation.

RESULTS

Respiratory symptoms were observed in 10 of the 39 cases (26%) and a virus was identified in 8 and 6 of these cases by PCR and culture, respectively. The PCR detected the respiratory infection a median of 8 days before culture. However, the morbidity of the respiratory infections was generally mild, and no mortality was observed. Additionally all infections were observed pretransplant or after discharge; no nosocomial infections were observed.

CONCLUSIONS

The real time PCR assay is more rapid and sensitive than culture and could be used to screen patients before transplant or as respiratory symptoms present for timely diagnosis.

Levels of total fungus and Aspergillus on a pediatric hematopoietic stem cell transplant unit

The purpose of this descriptive study was to determine the levels of total fungus (TF) and Aspergillus in a pediatric hematopoietic stem cell transplant (HSCT) unit. One hundred twenty air samples and 120 floor samples were collected from the same locations in 10 patient rooms and bathrooms for 4 consecutive days. The count in colony-forming units of TF and Aspergillus from each of the samples was measured by the institution's mycology laboratory. Means, standard deviations, minimum values, and maximum values were determined for levels of TF and Aspergillus from different locations and on different days in the air and on the floor. Determination of a mean value of TF and Aspergillus for each room allowed for analysis of mean values of TF and Aspergillus for sample category, room side, room type, and room status. After visual examination of the mean values for the air samples collected, it was determined that the TF and Aspergillus in the air were less than the institution's acceptable air baseline standard. t tests and analysis of variance were used to verify the findings.

Pulmonary complications of solid organ and hematopoietic stem cell transplantation

The ability to successfully transplant solid organs and hematopoietic stem cells represents one of the landmark medical achievements of the twentieth century. Solid organ transplantation has emerged as the standard of care for select patients with severe vital organ dysfunction and hematopoietic stem cell transplantation has become an important treatment option for patients with a wide spectrum of nonmalignant and malignant hematologic disorders, genetic disorders, and solid tumors. Although advances in surgical techniques, immunosuppressive management, and prophylaxis and treatment of infectious diseases have made long-term survival an achievable goal, transplant recipients remain at high risk for developing a myriad of serious and often life-threatening complications. Paramount among these are pulmonary complications, which arise as a consequence of the immunosuppressed status of the recipient as well as from such factors as the initial surgical insult of organ transplantation, the chemotherapy and radiation conditioning regimens that precede hematopoietic stem cell transplantation, and alloimmune mechanisms mediating host-versus-graft and graft-versus-host responses. As the population of transplant recipients continues to grow and as their care progressively shifts from the university hospital to the community setting, knowledge of the pulmonary complications of transplantation is increasingly germane to the contemporary practice of pulmonary medicine.

Collectins

Collectins are a family of collagenous calcium-dependent defense lectins in animals. Their polypeptide chains consist of four regions: a cysteine-rich N-terminal domain, a collagen-like region, an alpha-helical coiled-coil neck domain and a C-terminal lectin or carbohydrate-recognition domain. These polypeptide chains form trimers that may assemble into larger oligomers. The best studied family members are the mannan-binding lectin, which is secreted into the blood by the liver, and the surfactant proteins A and D, which are secreted into the pulmonary alveolar and airway lining fluid. The collectins represent an important group of pattern recognition molecules, which bind to oligosaccharide structures and/or lipid moities on the surface of microorganisms. They bind preferentially to monosaccharide units of the mannose type, which present two vicinal hydroxyl groups in an equatorial position. High-affinity interactions between collectins and microorganisms depend, on the one hand, on the high density of the carbohydrate ligands on the microbial surface, and on the other, on the degree of oligomerization of the collectin. Apart from binding to microorganisms, the collectins can interact with receptors on host cells. Binding of collectins to microorganisms may facilitate microbial clearance through aggregation, complement activation, opsonization and activation of phagocytosis, and inhibition of microbial growth. In addition, the collectins can modulate inflammatory and allergic responses, affect apoptotic cell clearance and modulate the adaptive immune system.

Diagnostic Invasive Procedures in Diffuse Infiltrative Lung Diseases

The diagnosis of infiltrative diffuse lung disease may require invasive procedures after all noninvasive tools have failed. The clinical context in which these diseases develop and the radiological patterns are crucial for defining the timing and the methods to be used. Immunocompromised hosts are usually acutely ill with fever, cough, shortness of breath, and often with progressive hypoxemia. In this context a prompt diagnosis is necessary to decrease mortality. Bronchoalveolar lavage [especially in cases that show ground-glass attenuation or alveolar opacification in high-resolution CT scan (HRCT)] is the most important invasive procedure allowing the identification of infectious agents, neoplastic elements and characteristic cytological and phenotypical profiles (for drug injury) in the majority of cases. Less frequently transbronchial lung biopsy, transbronchial needle aspiration and biopsy or surgical lung biopsy are necessary. In immunocompetent patients the clinical spectrum of diffuse lung disease is quite broad. Furthermore, in the last two decades HRCT, used in conjunction with clinical and other noninvasive investigative modalities, has increased the accuracy of diagnosis for some diseases without the need of surgical biopsy. Also in these patients bronchoalveolar lavage, frequently in combination with transbronchial lung biopsy, is sufficient to achieve a definitive diagnosis in the majority of cases. Surgical lung biopsy is, however, still relevant in cases with idiopathic interstitial pneumonias. In this article invasive diagnostic procedures in patients with diffuse lung infiltrates are discussed from the perspective of their clinical context and their imaging characteristics.

The natural history of respiratory syncytial virus infection in cancer and transplant patients: implications for management

Respiratory syncytial virus (RSV) has been reported to cause severe morbidity and mortality among cancer patients receiving chemotherapy with or without autologous peripheral blood stem cell transplantation (APBSCT). However, little is known about the natural history of this infection in these patients, and current standard practice, aerosolized ribavirin plus intravenous immunoglobulin (IVIG), is extremely expensive, difficult to use, and not supported by controlled clinical trials. The purpose of this observational study was to determine the frequency, seasonality, morbidity, and mortality of RSV infection in a group of cancer patients receiving cytotoxic chemotherapy with neither ribavirin nor IVIG treatment. During the period of October 3, 1997, through October 14, 1998, 190 cancer patients (median age, 58 years; 71 women) underwent viral nasopharyngeal washing prior to chemotherapy. Multiple myeloma (MM) accounted for most patients (147, 77%). RSV was recovered from cultures taken from 71 patients (37%) throughout the year, although more frequently during fall and winter seasons (P &lt; .001) than spring and summer. Serious respiratory complications developed in 19 (27%) of 71 RSV-positive patients versus 24 (20%) of 119 patients whose RSV cultures were negative (P = .384). The presence of renal failure or increased lactate dehydrogenase (LDH) prior to chemotherapy and the development of mucositis were the only predictive factors for severe respiratory complications. Recovery of RSV from nasopharyngeal washings among cancer patients is common, occurs throughout the year, and does not appear to increase serious morbidity or mortality. RSV infection may not necessarily be a contraindication for APBSCT or an indication for therapy with aerosolized ribavirin and IVIG.

Failure to eradicate AIDS-associated primary effusion lymphoma with high-dose chemotherapy and autologous stem cell reinfusion: case report and literature review

Primary effusion lymphoma (PEL), also known as body cavity-based lymphoma, is a newly recognized AIDS-related malignancy that is etiopathologically linked to Kaposi's sarcoma (KS)-associated human herpes virus type 8 (HHV-8). PEL is characterized by presentation in serous body cavities without identifiable tumor masses. Tumor cells have high-grade morphologic features, an indeterminate immunophenotype, B-lineage genotype, and contain HHV-8 and often Epstein-Barr virus. PEL rarely responds to systemic chemotherapy. Herein, we describe what we believe is the first patient with AIDS-associated PEL to be treated with high-dose chemotherapy and autologous stem cell reinfusion. Treatment was well tolerated but the patient succumbed to progressive cancer. Our experience with this patient serves to underscore the high mortality rate associated with this unique neoplasm.

Biatrial aspergillosis in a patient with immunocompetency

A 24-year-old man presented with a 24-hour history of pain and numbness in his left arm. The patient's clinical presentation of peripheral embolism was corroborated by angiography. Echocardiographic study showed masses in both right and left atria. Pathologic specimen from the embolus confirmed the diagnosis of aspergillosis.

Transfusion-related acute lung injury (TRALI) following allogeneic stem cell transplant for acute myeloid leukemia

Transfusion-related acute lung injury (TRALI) is a serious complication of transfusion characterized by dyspnea, hypoxemia, hypotension, fever, and bilateral pulmonary infiltrates. Although the frequency is estimated at 1/1,120 to 1/5,000 transfusions, few cases have been reported after hematopoietic stem cell transplant. We report a case occurring in an allogeneic transplant recipient who developed acute respiratory distress and bilateral pulmonary infiltrates 2 hr after a platelet transfusion due to the presence of anti granulocyte antibody HNA-3a in the product. As there is a wide differential diagnosis for pulmonary infiltrates developing post transplant, TRALI may be under-recognized and should be considered in this setting.

Capnography in Non-Tracheally Intubated Emergency Patients as an Additional Tool in Pulse Oximetry for Prehospital Monitoring of Respiration

Victims of minor trauma transported by paramedic-based rescue systems are usually monitored with pulse oximetry. Under the difficult surroundings of prehospital trauma care, pulse oximeters show considerable periods of malfunction. We tested the hypothesis that capnography is a good, easy to use tool for monitoring in nonintubated trauma victims. Seventy nonintubated trauma victims were included in this study. Vital variables and number and time of malfunctions were sampled for oximeter and capnometer recordings. Total number of alerts (63 versus 10), number of alerts per patient (3.3 [1.9] versus 0.3 [0.9]) (mean [SD]), total time of malfunction (191.5 [216.7] s versus 11.8 [40.2] s), time of malfunction per alarm (58.3 [71.4] s versus 5.5 [14.6] s), and the percentage of malfunction time during transport (13.2% [15.3%] versus 0.8% [2.8%]) differed significantly (P < 0.01) between oximetry and capnography. Although pulse oximetry is a standard method of monitoring in emergency care, we found capnography to be helpful as a monitoring device. We consequently recommend the use of capnography on transport as an additional monitoring tool to reduce periods lacking supervision of the vital variables.

IMPLICATIONS

Capnography is a useful tool to improve respiratory monitoring in nonintubated trauma victims on emergency transport and an easy to use supplement to pulse oximetry.

Dimensions of Neutropenia in Adult Cancer Patients

Neutropenia is a common and dangerous toxicity of cancer therapy that profoundly affects patients' lives. Neutropenia is typically defined by the numerical value of the absolute neutrophil count. However, considering neutropenia exclusively as the numerical value of the absolute neutrophil count limits its conceptualizations to physiologically related aspects, minimizes its complexities, and neglects dimensions of human response and the patient experience. This article offers a dimensional analysis of neutropenia derived from 42 research and clinical articles. Schatzman's dimensional analysis methods were applied to the literature to identify aspects of this phenomenon lying beyond its numerical boundaries. Dimensions of neutropenia that emerged were sorted into categories of perspective, context, conditions, processes, and consequences. The presence of the same dimension in more than 1 category and the circuitous relationships among categories begin to explicate the complexity and gravity of neutropenia. Articulation of these dimensions is necessary to assemble the beginnings of a theoretical understanding of neutropenia, which is crucial for the development and application of knowledge to research and practice. Limitations evident in the literature illuminate the urgent need for research into the psychosocial as well as physiologic dimensions of neutropenia.

Increased Exhaled Nitric Oxide Following Autologous Peripheral Hematopoietic Stem-Cell Transplantation

BACKGROUND

Increased production of nitric oxide (NO) and oxidative stress following bone marrow transplantation may play a role in the pathogenesis of idiopathic pneumonia syndrome (IPS). We hypothesize that patients who received high-dose chemotherapy followed by autologous peripheral hematopoietic stem-cell transplantation (APHSCT) have increased exhaled NO.

METHOD

We measured exhaled lower respiratory tract NO concentration with a chemiluminescent NO analyzer during a slow vital capacity maneuver against a positive pressure of 16 cm H(2)O at an expiratory flow rate of 50 mL/s in 20 female patients who received high-dose chemotherapy (cyclophosphamide, carmustine, and cisplatin) followed by APHSCT for the treatment of stage III or IV breast carcinoma. Pulmonary function tests were performed, and exhaled NO measurements and clinical and laboratory data were obtained before transplantation and at every 6-week visit after transplantation for 24 weeks.

RESULTS

All study patients had evidence of IPS with dyspnea and reduction in diffusion capacity of the lung for carbon monoxide (DLCO). Lower respiratory tract exhaled NO was significantly higher after APHSCT and during the 6 months of follow-up. Mean (+/- SD) exhaled NO increased from (mean +/- SD) 12.54 +/- 1.32 parts per billion (ppb) before APHSCT to 21.26 +/- 1.94 ppb at 6 weeks (p = 0.099), 21.26 +/- 1.94 ppb (p = 0.006) at 12 weeks, 24.62 +/- 2.55 ppb (p = 0.012) at 18 weeks, and 25.28 +/- 3.31 ppb (p = 0.013) at 24 weeks (all p values were compared to baseline). There was a strong negative correlation between DLCO and exhaled NO (regression coefficient - 0.60, p = 0.01).

CONCLUSION

Lower respiratory tract concentration of exhaled NO is significantly increased following APHSCT and correlates with reduction in DLCO. Increase in lower respiratory tract concentration of NO is a potential marker of IPS.

Pulmonary function after autologous bone marrow transplantation in children: a long-term prospective study

We performed serial pulmonary function tests (PFTs) consisting of spirometry and diffusing capacity in 26 children after BMT. The median follow-up was 10 years. The influence of total body irradiation (TBI) on long-term pulmonary function was of particular interest. In the 20 children who had received TBI, after an initial decrease the PFTs showed recovery, but the mean lung volumes were still significantly decreased 5 years after BMT at 10% below baseline. The proportions of children with restrictive impairment 5 and 10 years after BMT were 20 and 21%, respectively. Only one child was diagnosed with obstructive impairment. The proportions of children with isolated diffusing impairment at 5 and 10 years were 7/20 (35%) and 7/13 (54%), respectively. Six children had received chemotherapy only and showed isolated diffusing impairment as the only long-term sequela in 4/5 and 1/3 at 5 and 10 years. Our main finding was that there was little change in PFTs 1-10 years after BMT. TBI was associated with persistently decreased lung volumes in a proportion of patients, whereas chemotherapy also might have been of importance for the development of impaired gas exchange.

Late-onset noninfectious pulmonary complications after allogeneic stem cell transplantation are significantly associated with chronic graft-versus-host disease and with the graft-versus-leukemia effect

Late-onset noninfectious pulmonary complications (LONIPCs) occurring beyond 3 months after allogeneic stem cell transplantation (allo-SCT) have become recognized as life-threatening complications, and they reduce the recipient's quality of life. However, the pathogenesis and optimal treatment for LONIPCs are still unclear. In this study, we retrospectively analyzed the incidence and outcome of LONIPCs among allo-SCT recipients. Between October 1993 and September 2001, 96 patients underwent allo-SCT and 76 patients who survived and were free of disease for more than 3 months after SCT were enrolled. Among the 76 patients, 18 patients (23.7%) developed LONIPCs at a median interval of 227 days after allo-SCT (range, 91-1105 days). The patients with LONIPCs were subclassified into those with bronchiolitis obliterans (BO) (6 patients), with interstitial pneumonia (IP) (11 patients), or with both BO and IP (1 patient). The presence of extensive chronic graft-versus-host disease (GVHD) was significantly associated with the development of LONIPCs (P =.0008). Liver or skin involvement in chronic GVHD was not associated, but sicca syndrome was significantly associated with the development of LONIPCs (P <.0001). Most of the IP patients (58.3%) responded well to immunosuppressive treatment, while BO patients did not respond to the therapy. Eight of the 18 patients with LONIPCs died. The major cause of death was respiratory failure (62.5%). The relapse rate of primary malignant disease in the LONIPC patients was significantly lower than that of non-LONIPC patients (1 of 17 [5.9%] versus 16 of 52 [30.8%]; P =.0387). These results indicate that the development of LONIPCs was strongly associated with chronic GVHD and especially with sicca syndrome and the graft-versus-leukemia (GVL) effect.

Coronavirus 229E-related pneumonia in immunocompromised patients

Coronaviruses strains 229E and OC43 have been associated with various respiratory illnesses ranging from the self-resolving common cold to severe pneumonia. Although chronic underlying conditions are major determinants of severe respiratory virus infections, few data about coronavirus-related pneumonia in immunocompromised patients are available. Here we report 2 well-documented cases of pneumonia related to coronavirus 229E, each with a different clinical presentation. Diagnosis was made on the basis of viral culture and electron microscopy findings that exhibited typical crown-like particles and through amplification of the viral genome by reverse transcriptase-polymerase chain reaction. On the basis of this report, coronaviruses should be considered as potential causative microorganisms of pneumonia in immunocompromised patients.

Small-volume frequency-domain oximetry: phantom experiments and first in vivo results

We describe a new method to determine the oxygen saturation and the total hemoglobin content of tissue in vivo absolutely at small source-detector separations (<10 mm). Phase and mean intensity of modulated laser light of various wavelengths was measured at several predetermined source-detector separations in the frequency domain. From these measured quantities, the absorption coefficient was derived using the modified time-integrated microscopic Beer-Lambert law (MBL). In addition, the interaction volume of the photons was determined using a multi-layer Monte-Carlo model of human skin. To evaluate the method, we employed homogenous solid phantoms (consisting of TiO2 particles embedded in resin) with mean scattering and absorbing properties comparable to those of human skin. Furthermore, in vivo measurements were performed in a healthy volunteer to demonstrate that the technique is applicable for the determination of the oxygen saturation and the total hemoglobin content in the skin in vivo. The proposed technique is especially suited for the on-line determination of the oxygen saturation and total hemoglobin content in applications where small applicators are required (e.g., fetal oxygen monitoring sub partu).

Diffuse alveolar hemorrhage following allogeneic bone marrow transplantation in children

BACKGROUND

Diffuse alveolar hemorrhage (DAH) is a frequent life-threatening complication of bone marrow transplantation (BMT) in adults. This noninfectious pulmonary disorder is rarely reported following BMT in neonates and children.

STUDY OBJECTIVES

To review the clinical features and course of children who underwent allogeneic BMT and developed DAH in the posttransplant period.

DESIGN

A retrospective 6-year chart review.

SETTING

Pediatric ICU in a university hospital.

PATIENTS AND INTERVENTIONS

At total of 138 children who had undergone allogeneic BMT for nonmalignant (n = 66) or malignant (n = 72) diseases.

MEASUREMENTS AND RESULTS

Six of 138 children (4.3%) aged 2 months to 10 years (male/female ratio, 1:1) developed DAH. Each had a fulminant course with rapidly developing severe respiratory failure, mandating mechanical ventilation within 24 h following symptom onset. They were all treated with methylprednisolone, 6 mg/kg/d for 3 days. Only one child survived, and there have been no sequelae at 2 years post-BMT. Four children died of respiratory causes, and one died of multiorgan failure.

CONCLUSIONS

DAH is a potentially fatal respiratory complication that should be included early in the differential diagnosis of acute respiratory failure in children following allogenic BMT for both malignant and nonmalignant diseases. Therapy with high doses of steroids apparently do not affect the course of the disease.

Life-threatening pulmonary hemorrhages post bone marrow transplantation in Hurler syndrome. Report of three cases and review of the literature

Hurler syndrome (MPS-IH) is an autosomal recessive mucopolysaccharide storage disorder caused by deficiency of lysosomal alpha-L-iduronidase (IDU) enzyme activity. This results in accumulation of heparan sulfate and dermatan sulfate substances. Untreated children develop progressive developmental deterioration and multisystem morbidity with a median survival of 5 years. Allogeneic bone marrow transplantation (BMT) is the only long-lasting treatment that ameliorates or halts the aggressive course of the disease. Pulmonary hemorrhage (PH) is an unusual complication of BMT and has not been previously reported in MPS-IH post-BMT. We report three children with MPS-IH with life-threatening PH around the time of engraftment. All needed intensive-care support and one child developed recurrent PH that required prolonged ventilation.

Infectious pulmonary nodules in immunocompromised patients: usefulness of computed tomography in predicting their etiology

PURPOSE

To review the high-resolution computed tomography (CT) findings in immunocompromised patients who had nodular opacities and a proven diagnosis to determine whether the various infectious pulmonary nodules have distinguishing features on CT.

MATERIALS AND METHODS

The high-resolution CT scans obtained in 78 immunocompromised patients with solitary or multiple nodular opacities of proven infectious etiology were reviewed retrospectively by 2 independent thoracic radiologists. Patients whose predominant abnormality consisted of branching linear or nodular opacities (tree-in-bud pattern) characteristic of infectious bronchiolitis and endobronchial spread of tuberculosis were excluded. The CT scans were assessed for the presence, appearance, size, and distribution of parenchymal nodules. Relations between findings at CT and the different infectious etiologies of nodules were assessed with regression analysis. Agreement between the 2 observers was assessed using the kappa statistic.

RESULTS

The infectious causes included mycobacteria (n = 24), fungi (n = 22), bacteria (n = 20), and viruses (n = 12). Multivariate analysis demonstrated that a diameter <10 mm was the only independent predictor of etiology (P < 0.0001) and that patients whose nodules all measured less than 10 mm in diameter were most likely to have a viral infection. Nodules limited in size to less than 10 mm in diameter were seen in 83% of viral infections compared with 5% of bacterial infections (odds ratio [OR] = 95.0; 95% confidence interval (CI): 6.08-4,321.5, P < 0.0001), 0% of mycobacterial infections (OR = 91.7; 95% CI: 7.21-4,090.22, P < 0.0001), and 14% of fungal infections (OR = 31.67; 95% CI: 3.56-375.09, P = 0.0003).

CONCLUSION

Although some overlap exists, nodule size is helpful in the differential diagnosis of infectious causes of nodules in immunocompromised patients. Patients whose nodules are all less than 10 mm in diameter are most likely to have a viral infection.

Pulmonary complications following bone marrow transplantation

Pulmonary complications account for significant morbidity and mortality in patients following bone marrow transplants (BMT). They are distinct from other immunosuppressed patients in that there is a predictable course of immunosuppresion and therefore of likely pulmonary complications. This is important when interpreting abnormal radiology as the predictable time course will enable narrowing the differential diagnoses to certain pulmonary complications that characteristically occur at a particular time following BMT. Early recognition and correct treatment of the pulmonary complications should minimize the significant mortality and morbidity. This review aims to discuss the role of radiology in the diagnosis and management of pulmonary complications following BMT.

Granulomatous Pneumocystis carinii pneumonia complicating hematopoietic cell transplantation

Pneumocystis carinii pneunonia (PCP) is associated with a wide spectrum of clinical and histopathological presentations. While granulomatous PCP uncommonly occurs in AIDS patients, it is extremely rare in other non-AIDS immunocompromised patients. We identified three patients who developed granulomatous PCP after bone marrow or blood stem cell transplantation. In all cases, fiberoptic bronchoscopy with bronchoalveolar lavage was non-diagnostic, and an open lung biopsy was required for diagnosis. All patients were successfully treated with trimethoprim-sulfamethoxazole. The histological appearance varied from an ill-defined granulomatous pneumonia to well-formed necrotizing granulomas. The typical intraalveolar eosinophilic frothy exudate was absent. Often sparsely distributed, the organisms were detected by GMS and immunohistochemical stains for P. carinii. No other pathogens were identified by additional histochemical stains or by microbiological cultures. Awareness of this unusual granulomatous tissue response to P. carinii and initiation of specific treatment can lead to successful resolution of this potentially lethal infection.

Fungal pneumonias in transplant recipients

Fungi are ubiquitous in the environment. Opportunistic fungal pneumonias in the immunocompromised host continue to increase most commonly due to Aspergillus sp. Affected patients are usually hematopoietic stem cell and lung transplant recipients. Clinical presentation is protean, and the diagnosis is challenging. Culture of respiratory specimens has limited utility. The detection of circulating fungal antigens and DNA seems promising, but more studies are needed. Value of prophylactic strategies or preemptive therapy remains contentious. New antifungal drugs for managing invasive pulmonary aspergillosis continue to emerge, with better safety, efficacy, and pharmacologic profiles.

Infection of mesothelial cells with human herpes virus 8 in human immunodeficiency virus-infected patients with Kaposi's sarcoma, Castleman's disease, and recurrent pleural effusions

Recurrent pleural effusions are common complications of hospitalized patients with human immunodeficiency virus (HIV) infection and may pose difficult diagnostic dilemmas. A common cause of recurrent pleural effusions in up to 30% of HIV-seropositive patients is pulmonary involvement by Kaposi's sarcoma, a human herpesvirus 8 (HHV 8)-related neoplasm. The pathogenesis of these effusions is unclear. These recurrent effusions, although benign, have shown significant mesothelial atypia/reactive changes of uncertain etiology. We attempted to evaluate these effusions morphologically and molecularly for the presence of HHV 8, with particular attention to mesothelial cells. All recurrent pleural effusions, as defined by any effusion tapped for cytological examination on more than two occasions, in HIV-positive patients at the National Institutes of Health were examined from 1998 to the present. Cases were stratified according to patients with and without histologically confirmed HHV 8 disease manifestations. Five patients with HHV 8 diseases (four with disseminated Kaposi's sarcoma and one with Castleman's disease) were identified. As a control group, five effusions from HIV-seropositive patients without known HHV 8-related diseases were identified. Cytological examination of effusions in patients with HHV 8-related diseases demonstrated atypical/markedly reactive mesothelial cells accompanied by a polymorphous background of lymphocytes. Molecular studies for B- and T-cell clonality in microdissected whole samples showed no definitive clones in these cases. Conversely, polymerase chain reaction (PCR) studies for the HHV 8 virus was positive in these samples. PCR studies on pure populations of microdissected mesothelial cells from the HHV 8-related effusions were positive for HHV 8 sequences, whereas those from HIV patients with non-HHV 8 related diseases were negative. Immunohistochemistry for HHV 8 (monoclonal antibody to latent nuclear antigen (LNA-1; ORF-73) on cellblock material demonstrated scattered positive mesothelial cells in three of the five cases of HHV 8-associated effusions. HHV 8 has been recently implicated in the pathogenesis of Kaposi's sarcoma and primary effusion lymphoma. Mesothelial cells in recurrent pleural effusions from patients with Kaposi's sarcoma and Castleman's disease appear to be infected with HHV 8. Additional studies need to be done to define the role of mesothelial cell infection in the pathogenesis of these HHV 8-associated effusions and define the prognostic significance.

Calibration of three capnographs for use with helium and oxygen gas mixtures

Capnography is considered essential in the management of mechanically-ventilated patients. Helium, as an adjunct to mechanical ventilation, is the subject of renewed interest and used increasingly. However, helium affects the performance of infrared capnometry. We constructed a simple device to generate variable mixtures of helium, oxygen and carbon dioxide within the normal physiological range, and tested the performance of two side-stream and one in-line capnographs. We found that addition of helium to the gas mixture caused all three capnographs to underestimate the concentration of carbon dioxide. The underestimation increased as the proportion of helium increased. The maximum underestimation (30%) occurred in a 79:21 helium/oxygen mixture.