Fatal Pulmonary Complications Research Articles

The Need for Continuing Chemotherapy for Leukemic Cell Lysis Pneumopathy in Patients with Acute Myelomonocytic/Monocytic Leukemia

Although fatal pulmonary complications frequently occur during the course of acute leukemia, a minor proportion of the complications are due to leukemia itself. Infections, drug reactions and concomitant medical conditions are the major causes of respiratory distress in leukemic patients. We treated four patients with acute myeloid leukemia complicated by leukemic cell lysis pneumopathy (LCLP). All of the patients had leukemia of monocytoid origin and their respiratory function deteriorated soon after chemotherapy initiation. Although two of the patients required mechanical ventilation, all four improved after continued chemotherapy. Our experience indicates that, in cases of LCLP, chemotherapy should be continued with maximal respiratory support.

Pulmonary tumor thrombotic microangiopathy caused by gastric cancer

Pulmonary tumor thrombotic microangiopathy (PTTM) is a fatal cancer-related pulmonary complication with rapidly progressing dyspnea, and occasionally induces sudden death. Here, we describe a postmortem-diagnosed PTTM case caused by gastric cancer, with the complaint of progressing dyspnea for 5 days.He did not have any abdominal symptoms or cancer history. PTTM should be considered in patients with rapidly worsening respiratory conditions, even if there is no cancer history.

Clinical Impact of Pre-transplant Pulmonary Impairment on Survival After Allogeneic Hematopoietic Stem Cell Transplantation

We retrospectively analyzed the clinical outcomes of patients with pulmonary impairment before undergoing allogeneic hematopoietic stem cell transplantation (HSCT) for the first time. Among 297 evaluable patients who underwent their first HSCT, 23 had restrictive, obstructive or mixed ventilatory impairment (n = 9, 13 and 1, respectively). Males predominated among the patients with pulmonary impairment (p = 0.037) and received a reduced intensity conditioning (RIC) regimen more frequently, although the difference did not reach statistical significance (p = 0.05). Among 23 patients with pulmonary impairment, 9 underwent post-transplant pulmonary function tests and obstructive ventilatory impairment progressed only in 2 patients, both of whom developed bronchiolitis obliterans. Kaplan-Meier estimates of 3-year overall (OS) among patients with and without pulmonary impairment were 57% and 47%, respectively, and those of relapse-free survival (RFS) were 70%, and 68%, respectively, with no significant differences between the groups (OS, p = 0.235; RFS, p = 0.287). The rates of non-relapse mortality also did not significantly differ (p = 0.835). Our results suggest that allogeneic HSCT is safe for patients with pulmonary impairment. The lower frequency of fatal pulmonary complications after HSCT and the RIC regimen might contribute to favorable survival rates.

Effect of long-term administration of amiodarone on rat lung and the possible protective role of vitamin E

Introduction Amiodarone is gaining support as a first-line antiarrhythmic drug despite its potentially fatal pulmonary complications involving inflammation and fibrosis. Objective This study was undertaken to investigate the effect of long-term amiodarone administration and withdrawal on the histological structure of rat lung. In addition, the possible protective role of vitamin E supplementation was studied. Materials and methods This study was carried out on 36 adult male albino rats, which were divided into four groups: group I, which was considered as control; group II (amiodarone-treated group), which received amiodarone orally in a daily dose of 30 mg/kg body weight for 12 weeks; group III (withdrawal group), which received the same dose of amiodarone for 12 weeks and were sacrificed 6 weeks after withdrawal of the drug; and group IV (protected group), which received vitamin E orally in a daily dose of 100 mg/kg body weight simultaneously with amiodarone for 12 weeks. At the time of sacrifice, the lungs were dissected and tissue samples were processed for both light and electron microscopic studies. Immuohistochemical study using anti-CD68 for showing alveolar macrophages was also performed and the number of positively stained cells was morphometrically estimated and statistically analyzed. Results Administration of amiodarone alone showed an alteration in the lung architecture in the form of collapsed alveoli with evident proliferation and vacuolation of pneumocytes type II. Thickening of interalveolar septa, cellular infiltration, and collagen deposition associated with an increased number of macrophages as proved by the morphometric study were demonstrated. Intrabronchial cellular debris and vascular congestion were also observed. Coadministration of amiodarone with vitamin E showed a considerable degree of preservation of the pulmonary alveolar architecture; however, a mild improvement in the lung injury was observed in animals after amiodarone withdrawal. The alveoli were lined mainly by vacuolated pneumocytes type II with moderately thickened interalveolar septa. Conclusion From this study it could be concluded that prolonged administration of amiodarone in rats can induce severe lung damage. Withdrawal of the drug showed little improvement of this harmful effect but concomitant administration of vitamin E effectively protected the lung tissue. In addition, the increased number of alveolar macrophages associated with amiodarone administration has supported the concept that these cells may play a role in the pathogenesis of lung injury caused by amiodarone.

Preoperative Placement of Inferior Vena Cava Filters and Outcomes After Gastric Bypass Surgery

To assess relationships between inferior vena cava (IVC) filter placement and complications within 30 days of gastric bypass surgery. IVC filters are increasingly being used as prophylaxis against postoperative pulmonary embolism in patients undergoing bariatric surgery, despite a lack of evidence of effectiveness. On the basis of data from a prospective clinical registry involving 20 Michigan hospitals, we identified 6376 patients undergoing gastric bypass surgery between 2006 and 2008. We then assessed relationships between IVC filter placement and complications within 30 days of surgery. We used propensity scores and fixed effects logistic regression to control for potential selection bias. A total of 542 gastric bypass patients (8.5%) underwent preoperative IVC filter placement, most of whom (65%) had no history of venous thromboembolism. The use of IVC filters for gastric bypass patients varied widely across hospitals (range, 0%-34%). IVC filter patients did not have reduced rates of postoperative venous thromboembolism (adjusted odds ratio [OR], = 1.28; 95% confidence interval [CI], 0.51-3.21), serious complications (adjusted OR, = 1.40; 95% CI, 0.91-2.16), or death/permanent disability (adjusted OR, = 2.49; 95% CI, 0.99-6.26). More than half (57%) of the IVC filter patients in the latter group had a fatal pulmonary embolism or complications directly related to the IVC filter itself, including filter migration or thrombosis of the vena cava. In subgroup analyses, we were unable to identify any patient group for whom IVC filters were associated with improved outcomes. Prophylactic IVC filters for gastric bypass surgery do not reduce the risk of pulmonary embolism and may lead to additional complications.

Rapid Fatal Pulmonary Complications in a Chinese Patient After Bortezomib Treatment for ALK-Negative Anaplastic Large-Cell Lymphoma

Bortezomib, a reversible proteasome inhibitor, is used for the treatment of hematologic malignancies. Common adverse events with bortezomib include gastrointestinal symptoms, thrombocytopenia, and neuropathy, whereas severe pulmonary complications have been rarely described. Herein, we present a case of rapid fatal pulmonary complications in a patient with ALK-negative anaplastic large-cell lymphoma after receiving a treatment with bortezomib.

Treatment-Related Pneumonitis and Acute Esophagitis in Non–Small-Cell Lung Cancer Patients Treated With Chemotherapy and Helical Tomotherapy

To assess clinical outcomes and complications in patients with non-small-cell lung cancer (NSCLC) treated with helical tomotherapy (HT) with or without chemotherapy. Data from 37 NSCLC patients treated between January 2007 and August 2008 were analyzed retrospectively. Twenty-eight patients had Stage III disease. Concurrent and neoadjuvant chemotherapy was given to 24 and 14 patients, respectively. Radiotherapy was delivered to a total dose of 60-70.4 Gy at 2.0-2.4 Gy per fraction to the gross tumor volume and 50-64 Gy at 1.8-2.0 Gy per fraction to the planning target volume. With a median follow-up of 18 months (range, 6-27 months), 2-year local control and overall survival rates were 63% and 56% for all 37 patients, respectively, and were 78% and 75% for the patients with Stage III disease who received concurrent chemoradiotherapy alone. Acute esophagitis and treatment-related pneumonitis (TRP) ≥Grade 3 occurred in 5 and 7 patients, respectively. Four patients died of treatment-related death (TRD) after HT. In univariate analysis, poor performance status, total lung V(5), contralateral lung (CL) V(5), and V(10) were associated with TRD. Only CL V(5) remained significant in the multivariate analysis (p = 0.029). HT with chemotherapy has shown promising clinical outcomes, esophagitis, and TRPs. However, HT has produced a somewhat high rate of fatal pulmonary complications. Our data suggest that CL V(5) should be considered and kept as low as possible (<60%) in addition to the conventional dosimetric factors.

Therapie der postoperativen Thrombose

For the treatment of deep vein thrombosis (DVT), rapid diagnosis and prompt therapy are crucial to minimize the risk of fatal pulmonary embolism and long-term complications, including the postthrombotic syndrome and recurrent thromboembolism. The treatment of acute DVT remains controversial. In this review, treatment options in relation to exposing and predisposing risk factors are discussed. Evidence-based data and recommendations from official guidelines are presented.

Fatal pulmonary complications associated with activated charcoal: An autopsy case

ABSTRACTActivated charcoal is commonly used in the treatment of patients experiencing an oral overdose of drugs and is considered to be a safe, inert agent. However, various complications associated with the use of activated charcoal have been reported, with acute respiratory failure being a fatal one. In the presenting case, a 29‐year‐old female arrived at an emergency room having taken an overdose of drugs. When a nasogastric tube was inserted for gastric lavage and charcoal administration, she vomited and respiration ceased. The patient subsequently developed acute respiratory failure and died 19 days after admission. Charcoal deposition in the trachea, bronchi and lungs was observed on the postmortem examination.

Multimodal Thromboprophylaxis for Total Hip and Knee Arthroplasty Based on Risk Assessment

Orthopaedic surgeons are increasingly challenged to find a prophylaxis regimen that protects patients from thromboembolism while minimizing adverse clinical outcomes such as bleeding. We used a multimodal approach in which the treatment regimen is selected according to patient risk factors. We retrospectively reviewed the records on 1179 consecutive total joint arthroplasties in 970 patients who had undergone primary and revision total hip and total knee replacement. Preoperatively, patients were assigned to one of two deep venous thrombosis prophylactic regimens on the basis of an assessment of their risk factors. Eight hundred and fifty-six patients (1046 operations) were considered to be low risk and were managed with aspirin, dipyridamole, or clopidogrel bisulfate as well as intermittent pneumatic calf compression devices. One hundred and fourteen patients (133 operations) were considered to be high risk and were managed with low-molecular-weight heparin or warfarin and intermittent calf compression. All patients were mobilized from bed within twenty-four hours after surgery, and all underwent Doppler ultrasonography within the twenty-four hours before hospital discharge. All of the patients were followed for six months postoperatively. The prevalence of asymptomatic and symptomatic distal and proximal deep venous thrombosis, symptomatic and fatal pulmonary emboli, overall mortality, and bleeding complications was determined. Thrombotic events were expressed as a percentage of 1179 operations because some patients had two or more operations. Overall, there were no fatal pulmonary emboli, three symptomatic pulmonary emboli (prevalence, 0.25%), and five clinically symptomatic deep venous thrombi (0.4%). Sixty-one asymptomatic deep venous thrombi (5.2%) were found with use of routine postoperative Doppler ultrasound scans. There were three deaths (prevalence, 0.25%) that were unrelated to thromboembolism, and there were two nonfatal gastrointestinal bleeding events (prevalence, 0.17%). Wound hematomas occurred in association with five (0.4%) of the 1179 operations. Three nonfatal pulmonary emboli (prevalence, 0.3%) were detected in association with the 1046 procedures in the low-risk group, and none were detected in association with the 133 operations in the high-risk group (p = 0.767). Clinically symptomatic deep venous thrombosis was detected in association with four (0.38%) of the 1046 operations in the low-risk group and one (0.75%) of the 133 operations in the high-risk group (p = 0.93). Asymptomatic distal deep venous thrombosis was detected in association with thirty-seven (3.5%) of the 1046 procedures in the low-risk group and four (3.0%) of the 133 operations in the high-risk group. Asymptomatic proximal thrombosis was detected in association with fourteen (1.3%) of the 1046 procedures in the low-risk group and six (4.5%) of the 133 procedures in the high-risk group (p = 0.03). Wound hematomas occurred only in patients being managed with warfarin or low-modular-weight heparin (p = 0.0001). A multimodal thromboembolic prophylactic regimen is consistent with protecting patients while limiting adverse clinical outcomes secondary to thromboembolic, vascular, and bleeding complications.

Dyskeratosis Congenita: Low Regimen-Related Toxicity Following Hematopoietic Cell Transplantation (HCT) Using a Reduced Intensity Conditioning Regimen.

Dyskeratosis congenita (DC) is a congenital disorder characterized by very short telomeres. Clinical presentation includes a diagnostic triad (lacey reticular pigmentation, nail dystrophy, and leukoplakia), aplastic anemia (the main cause of premature death), myelodysplastic syndrome/leukemia and solid tumors. Allogeneic HCT is the only curative option for the hematologic complications of DC but has been associated with a high risk of peri-transplant morbidity and early death. Only about fifty HCT for DC have been performed to-date, and the five year survival after related donor HCT has been about 75%, but only approximately 35% when an unrelated donor was used. To improve survival in DC patients by decreasing transplant mortality, we introduced a reduced intensity regimen including cyclophosphamide (50 mg/kg), fludarabine (200 mg/kg), low dose total body irradiation (200 cGy), and (in patients 3 and 4) campath 1H (1 mg/kg). To decrease the risk of graft rejection, grafts were not T-cell depleted. We report outcomes in four consecutive patients, two adults and two children, all of whom engrafted with donor hematopoiesis:Age (years)SexGraft and HLA matchNC dose (×108/kg)CD34 dose (×108/kg)Follow-up (months)Donor chimerism24MURD dUCB 4/6, 4/60.55, 0.390.5, 0.431 (dead*)83%29FREL PBSC 6/613.934.4320 (alive)100%5FURD BM 7/81.381.5516 (alive)100%2MURD BM 8/85.922.313 (alive)100%Legend: M, male; F, female; NC, nucleated cell; URD, unrelated donor; REL, related donor; BM, bone marrow; dUCB, double umbilical cord blood; PBSC, peripheral blood stem cells; *Patient had autologous recovery after the first dUCB and died of sepsis 1 month after the second dUCB; HLA matching is reported for antigen level HLA-A, B and allele level DRB1 for cord blood, and allele level typing for HLA-A, B, C, DRB1 for PBSC or BM. The most recent donor chimerism is reported. To decrease the risk of graft rejection and prevent graft versus host disease (GvHD) patients received cyclosporine and mycophenolate mofetil. Patient 2 developed limited chronic GvHD and patient 4 developed grade III skin acute GvHD. Both were treated successfully with systemic and topical steroids. Our data suggest that this conditioning regimen results in a low rate of transplant related complications without compromising engraftment. Critically, early fatal pulmonary and vascular complications, common in post-transplant courses in DC patients, were not observed. This highlights the need to avoid drugs that are associated with pulmonary toxicity such as busulfan, and to limit radiation to the lung in patients with DC. This new less intensive conditioning regimen appears to result in a low rate of transplant related complications, and yet has adequate immunosuppressive activity to permit engraftment from alternative donors in DC patients.

WE‐C‐M100F‐03: Underestimation Of Low‐Dose Radiation in Conventional Treatment Planning of Intensity‐Modulated Radiation Therapy

Purpose: In radiation therapy of thoracic cancers (e.g. lung cancers), a high volume of low‐dose radiation may lead to severe and fatal pulmonary complications. The purpose of this work is to investigate dosimetric accuracy in low‐dose regions from commercial treatment planning systems (TPS) and consequent clinical implications for using IMRT in treating lung and thoracic cancers. Methods and Materials: We retrospectively reviewed thoracic‐cancer patients treated with IMRT at our institution and for whom high‐grade lung complications occurred. These IMRT plans were evaluated and were recomputed using a Monte‐Carlo‐based (MC) treatment planning system (TPS) that explicitly accounts for modeling of the machine head and MLCs. Dose calculations from 2 commercial TPSs (Pinnacle and Corvus systems) were compared with those obtained from the MC system and measurements. Various factors that could contribute to the difference in IMRT dose calculations were analyzed, including tissue heterogeneity effect, MLC modeling, and beam modeling. Results: Significant dosimetric errors (∼25%) were found in the low‐dose regions below 5 Gy in the commercial TPSs. Accuracy of dose calculations in the high‐dose tumor regions was acceptable (&lt; 5%). In regions &lt; 5 Gy of IMRT plans, MLC transmission, leakage, and scattering were found to be important contributors to the dose. These factors were also spatially variant and field‐size dependent. Without explicit modeling of the MLCs, severe underestimation of the low‐dose volume could occur in commercial TPS. The degree of low‐dose error was particularly greater in IMRT plans with larger target volumes and higher degrees of beam modulation. Conclusions: Treatment planners should be aware of potentially significant underestimation of low doses in IMRT treatment plans for thoracic and other cancer sites. More accurate modeling of MLCs and low‐dose calculation may be achieved by using a Monte‐Carlo‐based planning system.

Intensive Immunosuppression Therapy for Aplastic Anemia Associated with Dyskeratosis Congenita: Report of a Case

Dyskeratosis congenita (DC) is a very rare inherited disorder characterized by skin pigmentation, nail dystrophy, and mucosal leukoplakia. It is also associated with a variety of noncutaneous abnormalities, such as fatal pulmonary complications, malignancy, and bone marrow failure. We report the case of a 32-year-old man with DC associated with severe aplastic anemia (SAA). The traditional treatment of DC-associated SAA is allogeneic hematopoietic stem cell transplantation (HSCT). However, in this case, an HLA-matched donor was not available. Therefore our patient was given intensive immunosuppressive therapy with antilymphocyte globulin (ALG) and cyclosporine A (CsA). The hemogram findings improved after the treatment, but the patient died of pulmonary complications after being in stable condition for 6 months. The results support the possible use of intensive immunosuppression with ALG and CsA for DC-associated SAA as an alternative treatment for patients who are not eligible for HSCT.

Fatal Pulmonary Complications after Arterial Embolization with 40–120-μm Tris-acryl Gelatin Microspheres

Hepatic arterial embolization is a recognized method of treating primary malignancies and some secondary hepatic malignancies. Particle embolization alone has been shown to be safe and effective and is routinely performed for hypervascular tumors. Tris-acryl gelatin microspheres have been widely acclaimed for their ease of delivery and uniform size, allowing for accurate targeting of particular end arteries. There have been three deaths at the author's institution related to respiratory compromise since the 40-120- micro m particles became available 31 months ago. These complications were never observed with larger tris-acryl gelatin microspheres or polyvinyl alcohol particles. This is an unusual and serious complication of which interventionalists performing embolotherapy need to be aware.

Pulmonary complications of sickle cell anemia. A need for increased recognition, treatment, and research.

One of every 650 African Americans (0.15%) is born with sickle cell disease and about 8% are heterozygous for the sickle cell gene. According to the United States Census Bureau there were 35,509,000 African Americans counted in the year 2000, which would indicate that there are approximately 50,000 patients with sickle cell anemia in this country. Thirty five per cent of the African American population was between 30 and 54 yr of age in the year 2000. This demographic explains the increasing number of adult patients with sickle cell disease. However, the increased number of adults with sickle cell anemia is due only in part to population growth. Mortality rates for children with sickle cell anemia have declined because of penicillin prophylaxis, Haemophilus influenzae and Streptococcus pneumoniae vaccination, widespread implementation of newborn screening programs for early detection, and improvements in parental education (1–5). Despite significant improvements in the life expectancy of patients with sickle cell disease the median age at death is 42 yr for men and 48 yr for women (2). Pulmonary complications account for a large proportion of deaths among adults with sickle cell anemia (Table 1) (2, 6–8). According to the Cooperative Study of Sickle Cell Disease (CSSCD), a prospective multicenter study of 3,764 patients, more than 20% of adults likely had fatal pulmonary complications of sickle cell anemia (2). Acute and chronic pulmonary complications of sickle cell anemia are common but often underappreciated by healthcare providers. These conditions have clearly emerged as major threats to the well-being and longevity of patients with sickle cell disease.

Prótese de carbono de disco basculante com revestimento de material biológico em posição mitral com baixa dose de anticoagulante oral: 3 anos de experiência

Introducao: Analise clinica apos tres anos de observacao com a valvula de disco Magalhaes - HP. Casuistica e metodos: Receberam alta hospitalar, a partir de 1994, um total de 34 pacientes. Todos os sobreviventes foram contatados nos ultimos tres meses e o tempo medio de observacao foi de 24,5 meses (variacao de 2 a 35 meses), somando 834 meses-paciente (69,5 anos-paciente). Resultados: A curva atuarial de sobrevida foi de 85,3%. Houve uma complicacao fatal nao relacionada com a valvula (insuficiencia renal) (0,98 por 100 pacientes-ano) (PCPA) e tres complicacoes fatais relacionadas com a valvula (trombose - 2,9 PCPA) (1 caso em outro hospital, 1 caso reoperado e 1 caso tratado por estreptoquinase com bom resultado inicial evoluindo com complicacao pulmonar). Houve tres complicacoes hemorragicas (2,94 PCPA) de importância, sendo uma fatal (0,98 PCPA), uma complicacao de grau moderado (0,98 PCPA) e 8 casos de menor importância (7,8 PCPA). Houve nove complicacoes nao fatais relacionadas com a valvula (8,8 PCPA): sopros, 6 casos (5,8 PCPA); Tromboembolismo sem sequela, 2 casos (1,96 PCPA); trombose, 1 caso (0,98 PCPA), reoperado com boa evolucao. Conclusao: O revestimento da valvula de disco com material biologico heterologo com uso de menor dose de anticoagulante parece reduzir apos o 1o ano a incidencia de trombose, tromboembolia e acidentes hemorragicos. Nos tres primeiros meses houve maior incidencia de trombose e acidentes hemorragicos devido a desvios no protocolo de anticoagulacao, quando ha necessidade de anticoagulacao plena e efetiva para propiciar minima deposicao de fibrina e cicatrizacao lenta e fina. A dose media semanal segura de fenprocumona foi de 4,5 comprimidos (minimo de 2,5 e maximo de 7 comprimidos). O excelente resultado nos tres ultimos anos de observacao clinica justifica plenamente o uso da valvula, porem redobrada atencao deve ser tomada nos tres primeiros meses para protecao anticoagulante efetiva.

Busulfan/cyclophosphamide in volunteer unrelated donor (VUD) BMT: excellent feasibility and low incidence of treatment-related toxicity.

An increasing number of volunteer unrelated donor bone marrow transplantations (VUD-BMT) are performed every year for hematological malignancies due to the availability of a large donor pool. Here we show the results of 36 VUD transplants from our institution using a chemotherapy-only conditioning regimen comprising busulfan 4 x 4 mg/kg and cyclophosphamide 2 x 60 mg/kg. All patients received heparin 200 IU/kg bw continuous i.v. infusion starting the day before conditioning until day +30. Thirty-four of 36 patients (94%) engrafted and no secondary graft failure was observed. The two non-engraftments occurred in patients with CML in blast crisis with extensive myelofibrosis. All 34 engrafted patients (100%) were in complete remission on day +30 as shown by bone marrow biopsy and cytogenetic examinations. No life-threatening treatment-related morbidity or mortality (TRM) were observed, in particular, no severe veno-occlusive disease (VOD) of the liver and no fatal pulmonary complication. Use of G-CSF significantly shortened the time of neutropenia by 5 days. GVHD prophylaxis consisted of CsA/methylprednisolone with or without MTX. Acute GVHD grade II-IV was observed in 18/34 patients (53%) and cGVHD in 12/27 patients (45%), who survived to day +100. In seven patients (four with HLA class I or II mismatch) anti-T-lymphocyte globulin (ATG) was added for acute GVHD prophylaxis. One of seven had aGVHD grade II and none developed grade III to IV GVHD or graft failure. We conclude that Bu/CY is a feasible, save and sufficiently immunosuppressive regimen for VUD transplantation. Severe acute GVHD might be avoided by additional use of ATG in GVHD prophylaxis.

Noncardiogenic Pulmonary Edema Complicating Diabetic Ketoacidosis

Objective To alert physicians to the possibility of pulmonary edema as a complication of diabetic ketoacidosis. Methods We report a case of adult respiratory distress syndrome after resuscitative efforts to compensate the first episode of diabetic ketoacidosis in a previously healthy young woman. Results In a 26-year-old woman with a 3-day history of malaise, polyuria, nausea, and vomiting, severe hypoxia and rales developed, and intubation and mechanical ventilation became necessary. Hemodynamic evaluation and striking electron microscopic findings on open-lung biopsy confirmed the diagnosis of adult respiratory distress syndrome. Despite adequate ventilatory support and hemodynamic management, death ensued and was attributed to irresponsive and progressive acute respiratory failure due to increased pulmonary capillary permeability edema. Conclusion Clinicians should be aware of this possibly fatal pulmonary complication of diabetic ketoacidosis. (Endocr Pract. 1996; 2:379-381)

Premarrow Transplant Evaluation for Risk of Critical Illness

Critical illness requiring support in an intensive care unit (ICU) is common after blood and marrow transplantation, occurring in > 20% in some series. Attempts have been made to identify patients at highest risk of respiratory, cardiac, hepatic, and renal failure before trans plantation. Whereas demographic features, such as age and presence of active malignancy, are strongly associated with complications after transplant, only a few specific laboratory studies are useful in identifying high-risk individuals. Pulmonary function testing is associated with fatal pulmonary complications, and hepatic function tests are associated with fatal veno-occlusive disease of the liver. Knowledge of the predictive value of specific risk factors is important to the evaluation of patients considered for transplant.

Pulmonary complications of bone marrow transplantation: A comparison of total body irradiation and cyclophosphamide to busulfan and cyclophosphamide

Purpose : To retrospectively compare the acute and long-term pulmonary toxicities of total body irradiation and busulfan in bone marrow transplantation. Methods and Materials : From March through February 1991, 144 patients received high-dose therapy with cyclophosphamide plus either total body irradiation (TBI-CY) or busulfan (BU-CY) followed by bone marrow rescue. Treatment protocols were based on disease type. Cyclophosphamide dose was 120–200 mg/kg, given in 2–4 days. Total body irradiation was given as 12 Gy in four fractions over 4 days, or 14.4 Gy in eight fractions over 4 days. Busulfan dose was 16 mg/kg given over 4 days. Results : Seventy-nine patients were treated with TBI-CY and 65 patients with BU-CY. More patients in the TBI group had allogeneic transplants (40 vs. 18). Pulmonary events occurred in 48 patients, 19 in BU-CY and 9 in TBI-CY. Of the 58 patients with allogeneic transplants, 21 (36%) developed chronic graft-vs.-host disease (GVHD), and 10 of those patients developed pulmonary complications (including 2 with obliterative bronchitis and 1 with asthma). Interstitial pneumonitis (IP) occurred in 14 patients, 12 in the TBI-CY group and 2 in the BU-CY group. Cytomegalovirus and pneumocytis infections were associated with IP in 11 of those patients. Fatal idiopathic IP occurred in one patient in each of the TBI-CY and BU-CY groups. Multivariate analysis showed that only chronic GVHD and prior bleomycin use were significant predictors of intersitial pneumonitis: no difference was seen between TBI-CY and BU-CY. Conclusion : Pulmonary complications were most commonly associated with GVHD and prior bleomycin use. The incidence of cytomegalovirus or pneumocystis carinii pneumonitis was greater in the patients receiving the TBI regimen; fatal pulmonary complications were not significantly different between TBI and nonTBI regimens.