Pulmonary complications of bone marrow transplantation

Abstract

Bone marrow transplantation, now often known as haematopoietic stem cell transplantation (HSCT), is a complex choreographed procedure used to treat both acquired and inherited disorders of the bone marrow. It has proven invaluable as therapy for haematological and immunological disorders, and more recently in the treatment of metabolic and enzyme disorders. As the number of performed transplants grows annually, and with patients enjoying improved survival, a knowledge of both early and late complications of HSCT is essential for respiratory trainees and physicians in practice. This article highlights the spectrum of respiratory complications, both infectious and non-infectious, the timeline of their likely occurrence, and the approaches used for diagnosis and treatment, keeping in mind that more than one entity may occur simultaneously. As respiratory issues are often a leading cause of short- and long-term morbidity, consideration of a combined haematology/respiratory clinic may prove useful in this patient population.

FIGURE 1

Timeline of pulmonary complications following haematopoietic stem cell transplantation. GvHD: graft-versus-host disease; PERDS: peri-engraftment respiratory distress syndrome; TRALI: transfusion-related acute lung injury; DAH: diffuse alveolar haemorrhage; PTLD: post-transplant lymphoproliferative disorder; EBV: Epstein–Barr virus; ALS: air leak syndrome; PVOD: pulmonary veno-occlusive disease; IIP: idiopathic interstitial pneumonia; PPFE: pleuroparenchymal fibroelastosis; RSV: respiratory syncytial virus. Adapted from [13].

FIGURE 2

Idiopathic pneumonia syndrome developing 80 days post-allogeneic haematopoietic stem cell transplantation, characterised by diffuse bilateral pulmonary infiltrates.

FIGURE 3

Cryptogenic organising pneumonia in a patient 112 days post-allogeneic haematopoietic stem cell transplantation, with patchy bilateral consolidation.

FIGURE 4

Bronchiolitis obliterans in a 31-year-old female with progressive dyspnoea over 8 weeks, 14 months after allogeneic haematopoietic stem cell transplantation. Small airway narrowing leads to mosaic perfusion on computed tomography of the thorax.

FIGURE 5

Pleuroparenchymal fibroelastosis (biopsy confirmed) in a 55-year-old male with chronic graft-versus-host disease. This is characterised by the development of apical pleural thickening, subpleural fibrosis, traction bronchiectasis, hilar retraction and, frequently, pneumothorax.

FIGURE 6

Invasive pulmonary aspergillosis. A cavitary pulmonary nodule, an area of consolidation with a “halo” sign and small peripheral peribronchial nodular infiltrates.