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Noninfectious Lung Infiltrates That May Be Confused with Pneumonia in the Cancer Patient

  • Rana Kaplan
  • Lara Bashoura
  • Vickie R. Shannon
  • Burton F. Dickey
  • Diane E. Stover
Chapter
Part of the Current Clinical Oncology book series (CCO)

Abstract

The clinical and radiographic presentation of noninfectious pulmonary disease can often mimic pneumonia in the cancer patient. This chapter provides an overview of some of the most commonly observed noninfectious entities which may be observed in the immunocompromised host with cancer. Hydrostatic and nonhydrostatic pulmonary edema, as well as transfusion-related acute lung injury, may cause bilateral airspace opacification that may be confused with an infectious process. Chemotherapy induced lung injury can occur with many classes of chemotherapeutic agents and requires a high index of clinical suspicion for diagnosis. It often results in distinct patterns of pathologic injury, which may present acutely, subacutely or chronically, and in some cases, up to years after initial administration of the chemotherapeutic agent. Radiation induced lung injury often causes a distinct pattern of radiographic abnormalities, which may occur many months after the initial radiation exposure. In hematopoietic stem cell transplant recipients, many pulmonary diagnoses, such as engraftment syndrome, idiopathic pneumonia syndrome and diffuse alveolar hemorrhage (occurring early) and cryptogenic organizing pneumonia (occurring late), can mimic infectious pneumonias. Small airway mucus impaction can present with tree-in-bud opacities on chest CT and mimics infectious bronchiolitis. It may resolve with only pulmonary hygiene maneuvers. A combined approach involving careful review of the patient’s history, pattern of infiltrates on chest CT, and the use of bronchoscopy with bronchoalveolar lavage with or without transbronchial lung biopsy can often help provide clues to the noninfectious diagnosis.

Keywords

Noninfectious Lung infiltrates Diffuse alveolar hemorrhage Congestive heart failure Drug toxicity BOOP Pulmonary alveolar proteinosis Engraftment syndrome 

References

  1. 1.
    Yeh ET, Bickford C. Cardiovascular complications of cancer therapy: incidence, pathogenesis, diagnosis, and management. J Am Coll Cardiol. 2009;53(24):2231–47.PubMedCrossRefGoogle Scholar
  2. 2.
    Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119(14):e391–479.PubMedCrossRefGoogle Scholar
  3. 3.
    Wilson JF. In the Clinic. Heart failure. Ann Intern Med. 2007;147(11):ITC12-11–16.Google Scholar
  4. 4.
    Ware LB, Matthay MA. Clinical practice. Acute pulmonary edema. N Engl J Med. 2005;353(26):2788–96.PubMedCrossRefGoogle Scholar
  5. 5.
    Maeder MT, Kaye DM. Heart failure with normal left ventricular ejection fraction. J Am Coll Cardiol. 2009;53(11):905–18.PubMedCrossRefGoogle Scholar
  6. 6.
    Kollef MH, Schuster DP. The acute respiratory distress syndrome. N Engl J Med. 1995;332(1):27–37.PubMedCrossRefGoogle Scholar
  7. 7.
    Piantadosi CA, Schwartz DA. The acute respiratory distress syndrome. Ann Intern Med. 2004;141(6):460–70.PubMedCrossRefGoogle Scholar
  8. 8.
    Lohani S, O’Driscoll BR, Woodcock AA. 25-year study of lung fibrosis following carmustine therapy for brain tumor in childhood. Chest. 2004;126(3):1007.PubMedCrossRefGoogle Scholar
  9. 9.
    Grande C, Villanueva MJ, Huidobro G, Casal J. Docetaxel-induced interstitial pneumonitis following non-small-cell lung cancer treatment. Clin Transl Oncol. 2007;9(9):578–81.PubMedCrossRefGoogle Scholar
  10. 10.
    Sleijfer S. Bleomycin-induced pneumonitis. Chest. 2001;120(2):617–24.PubMedCrossRefGoogle Scholar
  11. 11.
    Rivera MP, Kris MG, Gralla RJ, White DA. Syndrome of acute dyspnea related to combined mitomycin plus vinca alkaloid chemotherapy. Am J Clin Oncol. 1995;18(3):245–50.PubMedCrossRefGoogle Scholar
  12. 12.
    Camus P, Bonniaud P, Fanton A, Camus C, Baudaun N, Foucher P. Drug-induced and iatrogenic infiltrative lung disease. Clin Chest Med. 2004;25(3):479–519, vi.PubMedCrossRefGoogle Scholar
  13. 13.
    Copper Jr JA. Drug-induced lung disease. Adv Intern Med. 1997;42:231–68.PubMedGoogle Scholar
  14. 14.
    Erasmus JJ, McAdams HP, Rossi SE. High-resolution CT of drug-induced lung disease. Radiol Clin North Am. 2002;40(1):61–72.PubMedCrossRefGoogle Scholar
  15. 15.
    Morikawa M, Demura Y, Mizuno S, Ameshima S, Ishizaki T, Okazawa H. FDG positron emission tomography imaging of drug-induced pneumonitis. Ann Nucl Med. 2008;22(4):335–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Costabel U, Guzman J, Bonella F, Oshimo S. Bronchoalveolar lavage in other interstitial lung diseases. Semin Respir Crit Care Med. 2007;28(5):514–24.PubMedCrossRefGoogle Scholar
  17. 17.
    Yale SH, Limper AH. Pneumocystis carinii pneumonia in patients without acquired immunodeficiency syndrome: associated illness and prior corticosteroid therapy. Mayo Clin Proc. 1996;71(1):5–13.PubMedCrossRefGoogle Scholar
  18. 18.
    Bollee G, Sarfati C, Thiery G, et al. Clinical picture of Pneumo­cystis jiroveci pneumonia in cancer patients. Chest. 2007;132(4):1305–10.PubMedCrossRefGoogle Scholar
  19. 19.
    McDonald S, Rubin P, Phillips TL, Marks LB. Injury to the lung from cancer therapy: clinical syndromes, measurable endpoints, and potential scoring systems. Int J Radiat Oncol Biol Phys. 1995;31(5):1187–203.PubMedCrossRefGoogle Scholar
  20. 20.
    De Jaeger K, Seppenwoolde Y, Boersma LJ, et al. Pulmonary function following high-dose radiotherapy of non-small-cell lung cancer. Int J Radiat Oncol Biol Phys. 2003;55(5):1331–40.PubMedCrossRefGoogle Scholar
  21. 21.
    Abid SH, Malhotra V, Perry MC. Radiation-induced and chemotherapy-induced pulmonary injury. Curr Opin Oncol. 2001;13(4):242–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Arbetter KR, Prakash UB, Tazelaar HD, Douglas WW. Radiation-induced pneumonitis in the “nonirradiated” lung. Mayo Clin Proc. 1999;74(1):27–36.PubMedCrossRefGoogle Scholar
  23. 23.
    Catane R, Schwade JG, Turrisi 3rd AT, Webber BL, Muggia FM. Pulmonary toxicity after radiation and bleomycin: a review. Int J Radiat Oncol Biol Phys. 1979;5(9):1513–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Gross N. Pulmonary effects of radiation therapy. Ann Intern Med. 1977;86:81–92.PubMedCrossRefGoogle Scholar
  25. 25.
    Rubin P, Casarett GW. Clinical radiation pathology. Philadelphia: WB Saunders; 1968. p. 423–70.Google Scholar
  26. 26.
    Stover DE, Milite F, Zakowski M. A newly recognized syndrome: radiation-related bronchiolitis obliterans and organizing pneumonia. A case report and literature review. Respiration. 2001;68(5):540–4.PubMedCrossRefGoogle Scholar
  27. 27.
    Kotloff RM, Ahya VN, Crawford SW. Pulmonary complications of solid organ and hematopoietic stem cell transplantation. Am J Respir Crit Care Med. 2004;170(1):22–48.PubMedCrossRefGoogle Scholar
  28. 28.
    Limdo H, Lee J, Lee HG, et al. Pulmonary complications after hematopoietic stem cell transplantation. J Korean Med Sci. 2006;21(3):406–11.CrossRefGoogle Scholar
  29. 29.
    Spitzer TR. Engraftment syndrome following hematopoietic stem cell transplantation. Bone Marrow Transplant. 2001;27(9):893–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Capizzi SA, Kumar S, Huneke NE, et al. Peri-engraftment respiratory distress syndrome during autologous hematopoietic stem cell transplantation. Bone Marrow Transplant. 2001;27(12):1299–303.PubMedCrossRefGoogle Scholar
  31. 31.
    Clark JG, Hansen JA, Hertz MI, Parkman R, Jensen L, Peavy HH. NHLBI workshop summary. Idiopathic pneumonia syndrome after bone marrow transplantation. Am Rev Respir Dis. 1993;147(6 Pt 1):1601–6.PubMedCrossRefGoogle Scholar
  32. 32.
    Watkins TR, Chien JW, Crawford SW. Graft versus host-associated pulmonary disease and other idiopathic pulmonary complications after hematopoietic stem cell transplant. Semin Respir Crit Care Med. 2005;26(5):482–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Yanik G, Hellerstedt B, Custer J, et al. Etanercept (Enbrel) administration for idiopathic pneumonia syndrome after allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant. 2002;8(7):395–400.PubMedCrossRefGoogle Scholar
  34. 34.
    Yanik GA, Ho VT, Levine JE, et al. The impact of soluble tumor necrosis factor receptor etanercept on the treatment of idiopathic pneumonia syndrome after allogeneic hematopoietic stem cell transplantation. Blood. 2008;112(8):3073–81.PubMedCrossRefGoogle Scholar
  35. 35.
    Tun HW, Wallace KH, Grinton SF, Khoor A, Burger CD. Etanercept therapy for late-onset idiopathic pneumonia syndrome after nonmyeloablative allogeneic hematopoietic stem cell transplantation. Transplant Proc. 2005;37(10):4492–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Shukla M, Yang S, Milla C, Panoskaltsis-Mortari A, Blazar BR, Haddad IY. Absence of host tumor necrosis factor receptor 1 attenuates manifestations of idiopathic pneumonia syndrome. Am J Physiol Lung Cell Mol Physiol. 2005;288(5):L942–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Robbins RA, Linder J, Stahl MG, et al. Diffuse alveolar ­hemorrhage in autologous bone marrow transplant recipients. Am J Med. 1989;87(5):511–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Afessa B, Tefferi A, Litzow MR, Krowka MJ, Wylam ME, Peters SG. Diffuse alveolar hemorrhage in hematopoietic stem cell transplant recipients. Am J Respir Crit Care Med. 2002;166(5):641–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Jules-Elysee K, Stover DE, Yahalom J, White DA, Gulati SC. Pulmonary complications in lymphoma patients treated with high-dose therapy autologous bone marrow transplantation. Am Rev Respir Dis. 1992;146(2):485–91.PubMedCrossRefGoogle Scholar
  40. 40.
    Majhail NS, Parks K, Defor TE, Weisdorf DJ. Diffuse alveolar hemorrhage and infection-associated alveolar hemorrhage following hematopoietic stem cell transplantation: related and high-risk clinical syndromes. Biol Blood Marrow Transplant. 2006;12(10):1038–46.PubMedCrossRefGoogle Scholar
  41. 41.
    Lewis ID, DeFor T, Weisdorf DJ. Increasing incidence of diffuse alveolar hemorrhage following allogeneic bone marrow transplantation: cryptic etiology and uncertain therapy. Bone Marrow Transplant. 2000;26(5):539–43.PubMedCrossRefGoogle Scholar
  42. 42.
    Salzman D, Adkins DR, Craig F, Freytes C, LeMaistre CF. Malignancy-associated pulmonary veno-occlusive disease: report of a case following autologous bone marrow transplantation and review. Bone Marrow Transplant. 1996;18(4):755–60.PubMedGoogle Scholar
  43. 43.
    Trobaugh-Lotrario AD, Greffe B, Deterding R, Deutsch G, Quinones R. Pulmonary veno-occlusive disease after autologous bone marrow transplant in a child with stage IV neuroblastoma: case report and literature review. J Pediatr Hematol Oncol. 2003;25(5):405–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Mandel J, Mark EJ, Hales CA. Pulmonary veno-occlusive disease. Am J Respir Crit Care Med. 2000;162(5):1964–73.PubMedCrossRefGoogle Scholar
  45. 45.
    Kuroda T, Hirota H, Masaki M, et al. Sildenafil as adjunct therapy to high-dose epoprostenol in a patient with pulmonary veno-occlusive disease. Heart Lung Circ. 2006;15(2):139–42.PubMedCrossRefGoogle Scholar
  46. 46.
    Barreto AC, Franchi SM, Castro CR, Lopes AA. One-year follow-up of the effects of sildenafil on pulmonary arterial hypertension and veno-occlusive disease. Braz J Med Biol Res. 2005;38(2):185–95.PubMedCrossRefGoogle Scholar
  47. 47.
    Cordonnier C, Fleury-Feith J, Escudier E, Atassi K, Bernaudin JF. Secondary alveolar proteinosis is a reversible cause of respiratory failure in leukemic patients. Am J Respir Crit Care Med. 1994;149(3 Pt 1):788–94.PubMedCrossRefGoogle Scholar
  48. 48.
    Tomonari A, Shirafuji N, Iseki T, et al. Acquired pulmonary alveolar proteinosis after umbilical cord blood transplantation for acute myeloid leukemia. Am J Hematol. 2002;70(2):154–7.PubMedCrossRefGoogle Scholar
  49. 49.
    Beccaria M, Luisetti M, Rodi G, et al. Long-term durable benefit after whole lung lavage in pulmonary alveolar proteinosis. Eur Respir J. 2004;23(4):526–31.PubMedCrossRefGoogle Scholar
  50. 50.
    Tazawa R, Hamano E, Arai T, et al. Granulocyte-­macrophage colony-stimulating factor and lung immunity in pulmonary alveolar proteinosis. Am J Respir Crit Care Med. 2005;171(10):1142–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Afessa B, Litzow MR, Tefferi A. Bronchiolitis obliterans and other late onset non-infectious pulmonary complications in hematopoietic stem cell transplantation. Bone Marrow Transplant. 2001;28(5):425–34.PubMedCrossRefGoogle Scholar
  52. 52.
    Maldonado F, Daniels CE, Hoffman EA, Yi ES, Ryu JH. Focal organizing pneumonia on surgical lung biopsy: causes, clinicoradiologic features, and outcomes. Chest. 2007;132(5):1579–83.PubMedCrossRefGoogle Scholar
  53. 53.
    Mokhtari M, Bach PB, Tietjen PA, Stover DE. Bronchiolitis obliterans organizing pneumonia in cancer: a case series. Respir Med. 2002;96(4):280–6.PubMedCrossRefGoogle Scholar
  54. 54.
    Stover DE, Mangino D. Macrolides: a treatment alternative for bronchiolitis obliterans organizing pneumonia? Chest. 2005;128(5):3611–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Papadopoulos EB, Ladanyi M, Emanuel D, et al. Infusions of donor leukocytes to treat Epstein–Barr virus-associated lymphoproliferative disorders after allogeneic bone marrow transplantation. N Engl J Med. 1994;330(17):1185–91.PubMedCrossRefGoogle Scholar
  56. 56.
    Loren AW, Tsai DE. Post-transplant lymphoproliferative disorder. Clin Chest Med. 2005;26(4):631–45, vii.PubMedCrossRefGoogle Scholar
  57. 57.
    Milpied N, Vasseur B, Parquet N, et al. Humanized anti-CD20 monoclonal antibody (Rituximab) in post transplant B-lymphoproliferative disorder: a retrospective analysis on 32 patients. Ann Oncol. 2000;11 Suppl 1:113–6.PubMedCrossRefGoogle Scholar
  58. 58.
    Wilczynski SW, Erasmus JJ, Petros WP, Vredenburgh JJ, Folz RJ. Delayed pulmonary toxicity syndrome following high-dose chemotherapy and bone marrow transplantation for breast cancer. Am J Respir Crit Care Med. 1998;157(2):565–73.PubMedCrossRefGoogle Scholar
  59. 59.
    Holness L, Knippen MA, Simmons L, Lachenbruch PA. Fatalities caused by TRALI. Transfus Med Rev. 2004;18(3):184–8.PubMedCrossRefGoogle Scholar
  60. 60.
    Popovsky MA, Moore SB. Diagnostic and pathogenetic considerations in transfusion-related acute lung injury. Transfusion. 1985;25(6):573–7.PubMedCrossRefGoogle Scholar
  61. 61.
    Looney MR, Gropper MA, Matthay MA. Transfusion-related acute lung injury: a review. Chest. 2004;126(1):249–58.PubMedCrossRefGoogle Scholar
  62. 62.
    Donaldson SH, Bennett WD, Zeman KL, Knowles MR, Tarran R, Boucher RC. Mucus clearance and lung function in cystic fibrosis with hypertonic saline. N Engl J Med. 2006;354(3):241–50.PubMedCrossRefGoogle Scholar
  63. 63.
    Elkins MR, Robinson M, Rose BR, et al. A controlled trial of long-term inhaled hypertonic saline in patients with cystic fibrosis. N Engl J Med. 2006;354(3):229–40.PubMedCrossRefGoogle Scholar
  64. 64.
    Lee A. VTE in patients with cancer-diagnosis, prevention, and treatment. Thromb Res. 2008;123 Suppl 1:S50–4.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Rana Kaplan
    • 1
  • Lara Bashoura
  • Vickie R. Shannon
  • Burton F. Dickey
  • Diane E. Stover
  1. 1.Pulmonary Medicine ServiceMemorial Sloan–Kettering Cancer CenterNew YorkUSA

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