Abstract
Purpose
Chronic graft versus host disease (cGvHD) is a common complication of hematopoietic stem cell transplantation (HSCT). Eosinophilic lung disease is a rare poorly understood complication in HSCT patients with cGvHD. These patients present similarly to those with Acute Eosinophilic Pneumonia (AEP). The purpose of this study is to better elucidate the presentation and potential treatment of this phenomenon.
Methods
We reviewed over 170 bronchoscopies in post-HSCT patients with respiratory symptoms. Of these, four patients, whose course was complicated by cGvHD, presented with respiratory symptoms, diffuse ground-glass opacities (GGO) on chest computerized tomography (CT), bronchoalveolar lavage (BAL) eosinophilia, and no evidence of infection. The clinical course of these patients was reviewed.
Results
Despite clinical presentation similar to AEP, not all patients had > 25% eosinophils on BAL, one criterion for AEP, however all improved with steroids. Steroid initiation was often delayed in favor of empiric antibiotics despite negative infectious workup. Several patients had recurrent episodes. Regarding possible associations, we examined but found no link between particular demographics, reason for HSCT, chemotherapy, immunosuppressants, or peripheral eosinophil count and pulmonary eosinophilia in these patients. GGO present on initial CT imaging became chronic in several of these patients.
Conclusion
We propose that in post-HSCT patients with GvHD presenting with respiratory symptoms, GGO on CT, BAL eosinophilia of > 10%, and negative respiratory cultures, an autoimmune eosinophilic process may be occurring. Earlier recognition and initiation of corticosteroids in these patients may improve their outcomes as an autoimmune diagnosis was often delayed in favor of antibiotics.
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References
Copelan E (2006) Hematopoietic stem-cell transplantation. N Engl J Med 354(17):1813–1826
Pena E, Souza C, Escuissato D, Gomes M, Allan D, Tay J et al (2014) Noninfectious pulmonary complications after hematopoietic stem cell transplantation: practical approach to imaging diagnosis. Radiographic 34(3):663–683
Yoshimi M, Nannya Y, Watanabe T, Asai T, Ichikawa M, Yamamoto G et al (2009) Acute eosinophilic pneumonia is a non-infectious lung complication after allogeneic hematopoietic stem cell transplantation. Int J Hematol 89:244–248
Wagner T, Dhedin N, Philippe B, Rivaud E, Vernant J, Couderc L (2006) Acute eosinophilic pneumonia after allogeneic hematopoietic stem cell transplantation. Ann Hematol 85:202–203
Gross T, Hoge F, Jackson J, Sammut P, Warkentin P (1994) Fatal eosinophilic disease following autologous bone marrow transplantation. Bone Marrow Transplant 14(2):333–337
Richard C, Calavia J, Loyola I, Baró J, Cuadrado M, Gómez-Casares M et al (1994) Chronic eosinophilic pneumonia in a patient treated with allogeneic bone marrow transplantation. Med Clin 102:462–464
Akhtari M, Langston A, Waller E, Gal A (2009) Eosinophilic pulmonary syndrome as a manifestation of GvHD following hematopoietic stem cell transplantation in three patients. Bone Marrow Transplant 43:155–158
Allen J, David W (1994) Eosinophilic lung disease. Am J Respir Crit Care Med 150:1423–1438
Badesch D, King T Jr, Schwarz M (1989) Acute eosinophilic pneumonia: a hypersensitivity phenomenon. Am Rev Respir Dis 139(1):249–252
Yen K, Lee A, Krowka M, Burger C (2004) Pulmonary complications in bone marrow transplantation: a practical approach to diagnosis and treatment. Clin Chest Med 25:189–201
Bergeron A, Feuillet S, Meignin V, Socie G, Tazi A (2008) Late onset, non-infectious pulmonary complications after haematological stem cell transplantation. Rev Mal Respir 25(2):173–183
Hildebrandt G, Fazekas T, Lawitschka A, Bertz H, Greinix H, Halter J et al (2011) Diagnosis and treatment of pulmonary chronic GvHD: report from the consensus conference on clinical practice in chronic GvHD. Bone Marrow Transplant 46:1283–1295
Sakaida E, Nakaseko C, Harima A, Yokota A, Cho R, Saito Y et al (2003) Late-onset noninfectious pulmonary complications after allogeneic stem cell transplantation are significantly associated with chronic graft-versus-host disease and with the graft-versus-leukemia effect. Blood 102:4236–4242
Splitzer T (2001) Engraftment syndrome following hematopoietic stem cell transplantation. Bone Marrow Transplant 27:893–898
Filipovich A, Weisdorf D, Pavletic S, Socie G, Wingard J, Lee S et al (2015) National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: I. Diagnosis and staging working group report. Biol Blood Marrow Transplant 21(8):1343–1359
Kalaycioglu M, Bolwell B (1994) Eosinophilia after allogeneic bone marrow transplantation using the busulfan and cyclophosphamide preparative regimen. Bone Marrow Transplant 14:113–115
Ahmad I, Labbe A, Chagnon M, Busque L, Cohen S, Kiss T et al (2011) Incidence and prognostic value of eosinophilia in chronic graft-versus-host disease after nonmyeloablative hematopoietic cell transplantation. Biol Blood Marrow Transplant 17(11):1673–1678
Imahashi N, Miyamura K, Seto A, Watanabe K, Yanagisawa M, Nishiwaki S et al (2010) Eosinophilia predicts better overall survival after acute graft-versus-host disease. Bone Marrow Transplant 45:371–377
Fulkerson P, Rothenberg M (2013) Targeting Eosinophils in Allergy, Inflammation and Beyond. Nat Rev Drug Discov 12(2):117–129
Kaya J, Gümüş S, Uçar E, Aydoğan M, Muşabak U, Tozkoparan E et al (2012) Omalizumab as a steroid-sparing agent in chronic eosinophilic pneumonia. Chest 142(2):513–516
Acknowledgements
The authors would like to thank the University of Minnesota Medical Center and the Blood and Marrow Transplantation division for the collegiate atmosphere that enabled this research.
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Tawfik, P., Arndt, P. The Rare Complication and Diagnostic Challenges of Pulmonary Eosinophilia in Graft versus Host Disease Patients after Hematopoietic Stem Cell Transplantation. Lung 195, 805–811 (2017). https://doi.org/10.1007/s00408-017-0060-z
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DOI: https://doi.org/10.1007/s00408-017-0060-z