Pulmonary nodules secondary to total parenteral alimentation

Reduced risk of pulmonary emboli in children treated with long-term parenteral nutrition

BACKGROUND & AIMS

Pulmonary embolism (PE) is a complication of parenteral nutrition (PN) with a prevalence of 35% in children. In 2003 new intravenous lipid emulsions (ILEs) with MCT, olive and/or fish oil in addition to soybean oil were introduced. The aim was to compare the incidence of PE before and after introduction.

METHODS

327 surveillance ventilation-perfusion (V/Q) scintigraphies from 68 children aged 0.3-15 years, treated with PN from 1993 to 2010, were retrospectively reviewed. Rate of PE/1000 central venous catheter (CVC) days, number of children with PE pre- and post-introduction of ILEs were compared. Multivariate analyses were performed for risk factors.

RESULTS

Twenty-two (32%) children (19/42 before 2003 and 3/26 after 2003, p = 0.007) had at least one episode of PE. Thirty seven (11%) episodes of PE were detected accounting for a mean of 0.2/1000 CVC days prior to 2003 and 0.05/1000 CVC days after 2003, p = 0.04. Regression analysis indicated that higher content of ILE/infusion (p = 0.045) and frequency of ILE of >3 nights/week were associated with more PE (p = 0.001). New ILEs were associated with lower risk (p = 0.003).

CONCLUSION

With a four-fold fall in incidence with new ILE, PE remains a complication. We recommend 12-18 monthly surveillance with lung perfusion scan and anticoagulants if PE is diagnosed.

Pulmonary cytolytic thrombi: a newly recognized complication of stem cell transplantation

Over the past 5 years we have recognized a new pulmonary complication of hematopoietic stem cell transplantation (HSCT) associated with fever and pulmonary nodules termed 'pulmonary cytolytic thrombi' (PCT). Retrospective analysis of medical and radiographic records and pathologic material from 13 HSCT recipients with PCT and a review of the Blood and Marrow Transplant Database for all patients with radiographic evidence of pulmonary nodules or who underwent open-lung biopsy from 1 January 1993 to 31 December 1998 (n = 1228) were performed. The median age of patients with PCT was 11.9 years (range, 1.3-29.7 years). All patients developed fever at a median of 72 days (range, 8-343 days) post transplant, followed by pulmonary nodules on chest CT. Eleven patients were receiving therapy for active GVHD (acute, grades I-IV (n = 10); extensive chronic (n = 1)). Biopsy of the pulmonary nodules revealed a unique pattern of necrotic, basophilic thromboemboli with amorphous material suggestive of cellular breakdown products. This was descriptively labeled 'pulmonary cytolytic thrombi'. Immunohistochemical staining revealed entrapped leukocytes and disrupted endothelium, but was negative for histiocytes. Cultures and immunohistochemical stains were negative for infectious agents. Empiric therapy included systemic corticosteroids (n = 9) and amphotericin (n = 7). Nine patients survive with resolution of PCT at a median follow-up of 1.5 years. Bone Marrow Transplantation (2000) 25, 293-300.