Voriconazole and squamous cell carcinoma after lung transplantation: A multicenter study

This study evaluated the independent contribution of voriconazole to the development of squamous cell carcinoma (SCC) in lung transplant recipients, by attempting to account for important confounding factors, particularly immunosuppression. This international, multicenter, retrospective, cohort study included adult patients who underwent lung transplantation during 2005-2008. Cox regression analysis was used to assess the effects of voriconazole and other azoles, analyzed as time-dependent variables, on the risk of developing biopsy-confirmed SCC. Nine hundred lung transplant recipients were included. Median follow-up time from transplantation to end of follow-up was 3.51 years. In a Cox regression model, exposure to voriconazole alone (adjusted hazard ratio 2.39, 95% confidence interval 1.31-4.37) and exposure to voriconazole and other azole(s) (adjusted hazard ratio 3.45, 95% confidence interval 1.07-11.06) were associated with SCC compared with those unexposed after controlling for important confounders including immunosuppressants. Exposure to voriconazole was associated with increased risk of SCC of the skin in lung transplant recipients. Residual confounding could not be ruled out because of the use of proxy variables to control for some confounders. Benefits of voriconazole use when prescribed to lung transplant recipients should be carefully weighed versus the potential risk of SCC. EU PAS registration number: EUPAS5269.

Lung transplantation for cystic fibrosis: an update and practical considerations for referring candidates

In this article, the authors provide an update to Maurer and Chaparro's 1995 review in this journal of lung transplantation for cystic fibrosis. Bilateral (sequential) cadaver donor transplantation is the usual procedure of choice. The four-year survival rate for adult, all-disease, double-bilateral lung transplantation has improved to 53%. Because of lower [corrected] survival rate among adults, living-donor lobar transplantation should be performed only when cadaver lungs are unlikely to become available. The International Society for Heart and Lung Transplantation and the Cystic Fibrosis Foundation have promulgated uniform guidelines for transplantation candidate selection. Issues of diabetes mellitus, mechanical ventilation, osteoporosis, malnutrition, fungi and drug-resistant bacteria, pleural fibrosis, and sinusitis in relation to transplantation candidacy are discussed. Some practical points regarding transplantation center referral are presented, and a list of cystic fibrosis transplantation centers in the United States is supplied.

Management of the severe asthmatic

Asthma morbidity and mortality continue to increase. The clinical characteristics of the high risk asthmatic patient continue to be elucidated. These include historical features, current disease characteristics and psychosocial factors. Beta-Adrenergic agonists continue to be the mainstay of acute therapy. The following review details these topics.

Cystic fibrosis: bilateral living lobar versus cadaveric lung transplantation

Living donor transplantation is now an acceptable option that should be considered for selected cystic fibrosis patients with end-stage lung disease. Two lungs obtained from live donors can adequately support an adult cystic fibrosis patient. The morbidity from lobectomy to the healthy donor is minimal.

The detection of recurrent sarcoidosis by FDG-PET in a lung transplant recipient

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Critical care management of the asthmatic patient

The incidence and severity of asthma continue to increase despite advances in therapy. Two types of severe asthma exacerbations have been described: "sudden onset" and "slow onset." Beta-adrenergic agonists and corticosteroids are still the mainstay of therapy in the intensive care unit. Hypercapnic hypoventilation is advocated as a mode of mechanical ventilation to maintain oxygenation while minimizing barotrauma. Sedating and paralytic agents must be used with caution to prevent complications such as myopathy, which may occur with prolonged use of these agents. Future avenues of study could include the use of leukotriene and platelet-activating factor inhibitors. Asthma management guidelines should be practiced to prevent worsening of bronchospasm to the point of severe exacerbation.

Role of transplantation (lung, liver, and heart) in sarcoidosis

Organ transplantation is an option for sarcoidosis patients with end-stage lung, liver or heart disease. Survival statistics vary for the organ transplanted but are not too different from survival rates for other systemic disorders. Although infection and rejection are troublesome for all organ recipients including those with sarcoidosis, there is the added problem of recurrence of sarcoidosis in the allograft. Sarcoidosis is not an absolute contraindication for organ transplantation for the majority of transplantation centers.

Newer therapeutic interventions for pulmonary transplant rejection

Rejection of the lung allograft remains a significant problem and the primary cause of morbidity and mortality for the transplant recipient. Various strategies have been developed to prevent and minimize episodes of rejection. These methods involve either specific inhibitors or using a combination of barriers at precise sites in the immune response to induce graft tolerance. Another technique would be to create a tranquil environment between opposing populations of immunocompetent cells from both the donor and recipient by enhancing chimerism. Finding potent immunosuppressive agents is not the only impediment to prolonged graft survival. The challenge is also to develop techniques and agents that do not have global immunosuppressive properties that would cause the host to become more susceptible to infectious agents, as well as to prevent toxicity to other vital organs. A review of available new pharmaceutical therapies and an overview of potential future methods are presented here.

Bilateral lobar transplantation utilizing living related donors

As the recipient list for patients requiring lung transplantation continues to increase, cadaveric donor lung availability has remained static. Our experience with utilizing lobes from living related donors for bilateral pulmonary transplantation in 20 patients has yielded a 75% survival at 1 year follow-up. Morbidity and mortality have been predominately due to infection. Rejection episodes have been mild and unilateral and have responded to augmented corticosteroids. Pulmonary function tests in the recipients tend to improve steadily during the first year postoperatively, and the patients have excellent functional capacity. There have been no significant complications in the donors. On the basis of our clinical experience, we have found that bilateral lobar transplantation utilizing living related donors has resulted in organ availability that can be lifesaving in critically ill patients and can provide a good alternative in certain noncritical, deteriorating patients.

Lung transplantation in interstitial lung disease

A discussion of transplantation as an optional therapeutic modality for patients with end-stage interstitial lung disease follows. Single lung transplantation for pulmonary fibrosis has been shown to be a successful modality with good survival rates. A limited cadaveric donor pool has affected the number of patients who can undergo transplantation. Selection criteria have been established to identify the most appropriate candidates. Transplantation of lung lobes obtained from living-related donors has recently been performed successfully in a patient suffering from pulmonary fibrosis. Living-related donors can potentially increase the donor pool. Successful transplantation of sarcoidosis patients is clearly possible. Recurrence of sarcoidosis in the lung allograft has been recognized but the clinical significance is not yet clear.

The technique of percutaneous transthoracic needle aspiration biopsy

Consider percutaneous transthoracic needle aspiration biopsy when specimens of pulmonary malignancies or infections are needed and bronchoscopy is contraindicated or the lesion is in a peripheral location. Percutaneous needle aspiration biopsy can be performed rapidly, and its diagnostic yield is good to excellent. The chief limitation of this procedure is the high incidence of pneumothorax, which makes the technique unsuitable for ventilated patients. A needle is inserted through the chest wall under fluoroscopic or CT guidance; a small sample is then aspirated through the needle. Operator skill and the use of thin needles help reduce the incidence of complications.

Lymphocytic subpopulation profiles in bronchoalveolar lavage fluid and peripheral blood from tobacco and marijuana smokers

The effect of heavy, habitual marijuana use compared with tobacco smoking on the composition of bronchoalveolar and peripheral blood lymphocytic phenotypes was examined. Bronchoalveolar lavage (BAL) and peripheral blood (PB) samples were taken from 14 nonsmokers (NS), 14 tobacco smokers (TS), 19 heavy, habitual marijuana smokers (MS), and 9 marijuana and tobacco smokers (MTS). In BAL fluid, marijuana use was associated with significantly higher alveolar macrophage concentrations, whereas tobacco smoking was associated with significantly higher alveolar macrophage, as well as higher bronchoalveolar lymphocyte and neutrophil concentrations. The bronchoalveolar T-lymphocytic phenotypic profiles of marijuana users differed from those of tobacco smokers. Tobacco, not marijuana, was found to have a significant effect toward lower percentages of bronchoalveolar CD4 cells, toward higher concentrations of bronchoalveolar CD8 cells, and toward lower bronchoalveolar CD4:CD8 ratios. Marijuana use had a significant effect toward lower percentages of bronchoalveolar CD8 cells. In peripheral blood, marijuana, but not tobacco, use was associated with significantly higher percentages of CD4 cells, lower percentages of CD8 cells, and higher CD4:CD8 ratios. These findings suggest that tobacco and marijuana have effects on bronchoalveolar and peripheral blood immunoregulatory T-lymphocytic subpopulations that differ in type or magnitude.

Enhanced alveolar monocytic phagocyte (macrophage) proliferation in tobacco and marijuana smokers

We tested the hypothesis that enhanced cell division accounted for the augmented numbers of monocytic phagocytes with characteristics attributed to alveolar macrophages (AM) found in the lungs of habitual tobacco (T) and marijuana (M) smokers. The monocytic phagocytes, that is, alveolar macrophages, were obtained by bronchoalveolar lavage (BAL) from 12 nonsmoking subjects; 10 subjects who smoked T only (TS); 13 subjects who smoked M only (MS); and 6 smokers of both T and M (MTS). The replication of these cells was determined by measuring the incorporation of [3H]thymidine into the DNA of dividing cells and visually counting 2,000 cells on autoradiographically prepared cytocentrifuge cell preparations. This study demonstrated that the number of [3H]thymidine-labeled monocytic phagocytes with characteristics of alveolar macrophages from either TS or MS have a higher proliferative index compared to cells (macrophages) from nonsmokers, p less than 0.05 by one-way ANOVA. The total number of BAL macrophages that are in mitosis in TS (17.90 +/- 4.50 labeled AM x 10(3)/ml) or MTS (10.50 +/- 4.20 labeled AM x 10(3)/ml) are 18- and 10-fold greater, respectively, than the number obtained from nonsmokers (1.01 +/- 0.18 labeled AM x 10(3)/ml). Interestingly, the number of [3H]thymidine-labeled macrophages from MS (2.90 +/- 0.66 labeled AM x 10(3)/ml) are also greater than the number obtained from nonsmokers, although this is not statistically significant. The stimulus augmenting alveolar macrophage replication is as yet unknown but may likely be found in the T or M smoke.(ABSTRACT TRUNCATED AT 250 WORDS)

Asbestosis occurring after brief inhalational exposure: usefulness of bronchoalveolar lavage in diagnosis

A case of clinically and radiologically typical asbestosis manifesting in a 55 year old man occurred 36 years after a brief exposure period of less than one year. A transbronchial lung biopsy was performed but the samples were considered non-diagnostic. The diagnosis was supported by the use of bronchoalveolar lavage to obtain alveolar samples and scanning electron microscopy-energy dispersive x ray analysis of fibres found in the bronchoalveolar lavage fluid which showed a predominance of amosite.

Bronchoalveolar lavage cell and lymphocyte phenotype profiles in healthy asbestos-exposed shipyard workers

The cellular and lymphocyte phenotypic composition of bronchoalveolar lavage (BAL) fluid and peripheral blood (PB) from 15 healthy, nonsmoking, asbestos-exposed shipyard workers (AEW) and 10 nonsmoking, age-matched unexposed workers (UEW) were compared. None of the AEW had clinical, radiographic, or physiologic evidence of asbestosis, but six had radiographic evidence of pleural plaques and/or thickening. The mean duration of asbestos exposure was 16.3 +/- 2.3 yr, and the mean period since exposure was 10.8 +/- 0.5 yr. All but three of the AEW and none of the UEW had asbestos bodies detected in the first 20 ml of BAL fluid recovered (0.1 to 35 asbestos bodies/ml). The AEW had a significantly higher mean percentage (19.1 +/- 2.8% versus 9.7 +/- 1.6%) and concentration (31.6 +/- 5.2 x 10(3) cells/ml versus 14.7 +/- 2.5 x 10(3) cells/ml) of BAL lymphocytes compared with that in the UEW, with an increased mean concentration of each phenotype measured. In PB, the mean lymphocyte concentration was also higher in the AEW than in the UEW (2.0 +/- 0.3 x 10(3) cells/ml versus 1.5 +/- 0.3 x 10(3) cells/ml), but the difference was not statistically significant, and there was no increase of any phenotype measured. BAL lymphocytosis did not correlate with exposure history or BAL asbestos body count, but was greater in AEW with pleural abnormality (30.1 +/- 2.9% versus 11.8 +/- 1.6%). BAL concentrations of CD-20, CD-3, and CD-4, but not of CD-8 cells were significantly increased compared with those in the AEW without pleural abnormality. Further longitudinal studies are needed to determine the prognostic significance of these findings.

Antibody-dependent cellular cytotoxicity mediated by lung macrophages: a comparison of two target cells

Mononuclear cell-mediated cytotoxicity may be an important cellular immune function in host lung defense. Prior investigators have shown that lung macrophages participate in cell cytotoxicity which is antibody-dependent (ADCC). We tested the hypothesis that alveolar macrophages share some cell surface receptors for the Fc portion of IgG, i.e., Fc receptors, similar to those found on circulating monocytes in order to function in ADCC. Hence, ADCC mediated by autologous human blood monocytes and lung macrophages was studied by measuring the release of chromium-51 from prelabeled target erythrocytes coated with IgG. Alveolar macrophages were obtained from healthy adult subjects by bronchoalveolar lavage and tested against two different erythrocyte target cells to measure ADCC activity. Our results show significant activity by alveolar macrophages demonstrated against chicken erythrocytes at a target to effector cell ratio of 2:1 or 10:1 and with an antibody concentration of 1:100 or 1:400 (volume per volume, p less than 0.05, Student's test). However, when a peripheral blood monocyte specific target cell (human type B erythrocyte) was utilized, alveolar macrophages were not as capable of significant ADCC activity against these monocyte-specific target cells. The inability of lung macrophages to function in ADCC against other target cells (i.e., human type B erythrocytes) unlike the peripheral blood monocytes suggests that some Fc receptors are not shared. In other words, these different cell types share IgG receptors but differences in activity may be due to some changes in the Fc portions of IgG due to cellular differentiation. The use of these target cells may potentially be useful in functionally discriminating between two types of adherent autologous mononuclear cells (lung macrophages vs. blood monocytes).

Tracheobronchial changes in habitual, heavy smokers of marijuana with and without tobacco

We performed flexible fiberoptic bronchoscopy in 29 habitual, heavy marijuana smokers 25 to 45 yr of age, with and without concomitant tobacco smoking, to inspect and biopsy their proximal tracheobronchial tree for the evaluation of histopathologic changes. Control tobacco smokers (TS) and nonsmokers (NS) residing in the same metropolitan area were similarly studied and compared with the marijuana smokers (MS) and marijuana-tobacco smokers (MTS). Respiratory and drug histories, physical examination, and pulmonary function tests were obtained prior to bronchoscopy. The prevalence of respiratory symptoms and pulmonary function abnormalities was generally higher in the 3 smoking groups than in the NS group but was not statistically different across all groups. However, bronchoscopic inspection revealed airway hyperemia and other visible abnormalities in 32 (91%) subjects in the 3 smoking groups, unlike the unremarkable findings in the NS group. Light microscopy showed 2 or more histopathologic changes in the bronchial epithelium of all MS, MTS, and TS. Squamous metaplasia was observed in all MTS, a prevalence that was significantly different from that in MS, TS, and NS. Hyperplasia of basal and goblet cells was more prevalent in the MS than in the NS, whereas cellular disorganization was more prevalent in the MS than in the TS. A direct relationship between cumulative marijuana use (joint-years) and bronchoscopic and histopathologic changes was not apparent in this study sample. These results indicate that relatively young, habitual, heavy marijuana smokers have a high prevalence of abnormal airway appearance and histologic findings, irrespective of concomitant tobacco smoking.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential examination of bronchoalveolar lavage cells in tobacco cigarette and marijuana smokers

Cells derived from bronchoalveolar lavage (BAL) were obtained from 19 healthy non-smokers (NS) and from 43 healthy smokers of tobacco and/or marijuana. Thirteen subjects smoked tobacco cigarettes only (TS) (mean +/- SE: 17.4 +/- 5.5 pack-years). Thirty subjects smoked marijuana; of these, 14 smoked marijuana only (MS) (149.1 +/- 102.7 joint-years) and 16 smoked marijuana and tobacco (MTS) (43.3 +/- 7.2 joint-years and 18.4 +/- 3.2 pack-years). Cell counts were expressed as total number recovered and as number of cells per milliliter of BAL fluid returned. Cell differentials were performed on Giemsa-stained cytopreps. Total cell number was significantly increased in the MTS, TS, and MS compared with that in the NS (p less than 0.01). Heavy tobacco smoking (greater than 10 pack-years) was associated with higher total cell numbers in BAL than was light tobacco smoking (less than 10 pack-years). The MTS had a higher total BAL cell yield per milliliter than did the TS or the MS (p less than 0.004). Marijuana smoking had a significant effect on cell yield independent of the presence or absence of concomitant tobacco smoking (p less than 0.05). Macrophages were the predominant cells in the BAL of TS, MS, and MTS, as well as in the BAL of NS (greater than or equal to 90%). The number of neutrophils (as total recovered or per milliliter of BAL fluid) was significantly higher in the BAL fluid of all MTS and TS than in that of NS (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Bedside bronchoalveolar lavage for the diagnosis of Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome

We studied the utility of bronchoalveolar lavage (BAL) as the primary diagnostic procedure in 46 separate episodes of suspected Pneumocystis carinii pneumonia (PCP) in 42 patients with AIDS. 35 procedures were performed at the bedside. A separate group of 40 historical controls with AIDS and suspected PCP had transbronchial biopsy (TBB) as the primary procedure. At least 100 cc of saline in 50 cc aliquots was used for BAL. Specimens were processed using rapid silver methenamine, Papanicolau, and Ziehl Neelson stains with appropriate cultures. There were 29 positives and 17 true negatives for PCP with BAL, confirmed by biopsy in 11, and using clinical criteria in 6. Accuracy, sensitivity, and predictive value of a negative result were all 100%. There was no significant difference in yield between TBB and BAL (p greater than 0.10). BAL was useful to diagnose other opportunistic organisms including CMV, atypical mycobacteria, and fungi. The frequency of isolates in the TBB group were comparable. TBB was complicated by 4 episodes of major bleeding. The data indicate that bedside BAL is effective, and safer than TBB in patients with AIDS and suspected PCP. We advocate BAL as the primary diagnostic procedure which can be performed at the bedside in patients with suspected PCP and AIDS. The high accuracy and predictive value of a negative BAL for PCP suggests confirmatory procedures may not be necessary in many cases.

Cellular and T-lymphocyte subpopulation profiles in bronchoalveolar lavage fluid from patients with acquired immunodeficiency syndrome and pneumonitis

The cellular composition and T-lymphocyte subpopulations of bronchoalveolar lavage (BAL) fluid from 12 patients with acquired immunodeficiency syndrome (AIDS) and active pneumonitis were examined. Differential cell counts were performed on BAL specimens from each patient and from 25 normal subjects. The BAL and peripheral blood (PB) lymphocytes were isolated from 8 patients and 11 subjects. Leu 4 (mature T), Leu 2 (T suppressor), and Leu 3 (T helper) markers were identified by fluorescein-labeled monoclonal antibody agents and counted in an automated flow cytometer. Infectious pneumonitis caused by Pneumocystis carinii and/or cytomegalovirus and/or Mycobacterium avium-intracellulare was diagnosed in all but 1 patient. All but 2 patients demonstrated lymphocytosis in the BAL fluid; only 3 had greater than 1% neutrophils. The BAL cell differentials were not predictive of the type of pneumonitis. The Leu 3/Leu 2 ratios were (mean +/- SEM): 0.08 +/- 0.03, patients' BAL fluid; 1.55 +/- 0.21, subjects' BAL fluid; 0.18 +/- 0.06, patients' PB; 1.42 +/- 0.12, subjects' PB. The marked decrease in Leu 3/Leu 2 ratios primarily reflected severely diminished proportions of Leu 3 positive cells (3 +/- 1.3% compared with a control value of 35 +/- 4.0%), although the proportion of Leu 2 positive cells tended to be elevated as well (46 +/- 7.9% compared with a control value of 22 +/- 2.2%). Bronchoalveolar lavage specimens from patients with AIDS and these types of pneumonitis may contain increased proportions of lymphocytes. The accumulation of lymphocytes, however, does not reflect homing of helper T-lymphocytes to the site of pulmonary infection.

In vitro depression of human lymphocyte mitogen response (phytohaemagglutinin) by asbestos fibres

Asbestosis is a fibrotic lung disease associated with chronic inhalation of asbestos dust. The response of peripheral blood mononuclear cells (PBM) to phytohaemagglutinin (PHA) in asbestosis patients has been reported to be impaired, suggesting a disturbance in the cell-mediated response of chronically exposed individuals. We demonstrated that PHA responses of normal PBM are also depressed when exposed to various forms of asbestos fibres in vitro. Furthermore, we showed the primary effect of the fibres to be on lymphoid (non-adherent) populations rather than monocytes (adherent cells). Exposure as brief as 1 hr affected the subsequent PHA response of the cells. This effect did not appear to involve suppressor cell activation nor was it mediated by soluble factors. Our findings therefore offer an explanation for the alterations in the cellular immune response observed in humans as a result of lymphoid cells coming into transient contact with inhaled asbestos fibres residing in the lung.