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Pulmonary Nodules in Lung Transplant Recipients^*

Etiology and Outcome

^* From the Department of Respiratory Medicine and Critical Care Medicine (Dr. Lee), Singapore General Hospital, Singapore; and the Departments of Pulmonary and Critical Care Medicine (Drs. Minai and Mehta) and Thoracic and Cardiovascular Surgery (Drs. DeCamp and Murthy), The Cleveland Clinic Foundation, Cleveland, OH.

Correspondence to: Omar A. Minai, MD, FCCP, Staff Physician, Department of Pulmonary and Critical Care Medicine, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195; e-mail: minaio{at}ccf.org

Background: The pulmonary nodule (PN) poses a diagnostic and therapeutic challenge in the immunocompromised host. Common causes of PNs in lung transplant (LT) recipients include bacterial or fungal infections and posttransplant lymphoproliferative disorder (PTLD). However, experience in diagnosis and management of PNs is limited.

Methods: Two hundred thirty-four LTs were performed between February 1990 and December 2000. Medical records of all patients with PNs were reviewed retrospectively. Data on presentation, radiographic features, diagnostic methods, therapy, and outcome were collected and analyzed.

Results: Twenty-three patients had PNs after a follow-up of 20.1 ± 20.1 months (mean ± SD). The mean age was 45.5 ± 14.4 years, with a male:female ratio of 17:6. Thirteen patients received single LT, 9 patients received bilateral LT, and 1 patient received heart-LT. Cough and dyspnea were the most common symptoms at presentation, and PNs were better detected by CT than chest radiography. Solitary PNs were due to bronchogenic carcinoma and PTLD, while multiple PNs were due to invasive pulmonary aspergillosis (IPA), cytomegalovirus pneumonitis, bronchiolitis obliterans, and metastatic carcinoma. Bronchoscopy with BAL and transbronchial lung biopsy was the usual method of diagnosis (n = 17, 74%), and our mortality rate was 70%.

Conclusion: PNs are not uncommon in patients following LT. The majority were due to IPA and PTLD. Prophylaxis with itraconazole against Aspergillus, and acyclovir for Epstein-Barr virus-negative LT recipients, serial CT and surveillance bronchoscopy for early detection of Aspergillus infections, and rituximab therapy for PTLD could improve the outcome of these patients.

Key Words: Aspergillus • carcinoma • cytomegalovirus • lung transplant • posttransplant lymphoproliferative disorder • pulmonary nodule

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