Pulmonary acute graft‐versus‐host disease and infections after allogeneic hematopoietic stem cell transplantation in pediatric recipients: A comparative study on CT

Abstract

Objective To compare the chest CT patterns of acute graft‐versus‐host disease (aGVHD) and infections within 100 days after allogeneic hematopoietic stem cell transplantation (allo‐HSCT) in pediatric recipients to help hematologist make definitive diagnosis as early as possible. Methods A total of 143 pediatric recipients from January 2015 to June 2019 who were diagnosed pulmonary aGVHD or infections within 100 days after allo‐HSCT were enrolled in this study. Two observers evaluated the extent and distribution (unilateral, bilateral) of the CT patterns. The patterns were then classified as ground‐glass opacity (GGO) (localized, patchy, diffuse), consolidation (localized, patchy, diffuse), reticulation (localized, patchy, diffuse), nodules (localized, multiple), bronchiectasis, pleural effusion, air trapping, tree‐in‐bud sign, and pneumomediastinum. The onset time and radiological patterns of the two cohorts were statistically compared. Results The mean onset time of aGVHD (n = 85) and infections group (viral n = 29, bacterial n = 22, fungal n = 7, total n = 58) was 36.89 ± 24.34 (range, 10‐99 days) and 23.48 ± 20.65 days (range, 4‐94 days) with a significant difference (P = .001). The top three underlying diseases were acute lymphoblastic leukemia (ALL) (n = 49, 57.6%); acute myeloid leukemia (AML) (n = 24, 28.2%); and aplastic anemia (AA) (7.1%) in aGVHD group and hemophagocytic syndrome (HPS) (n = 33, 56.9%); AA (n = 9, 15.5%); and ALL (n = 6, 10.3) in infection group. GGO (41.2%) in aGVHD prevailed on CT, whereas GGO (53.4%) and consolidations (43.1%) were more prevalent in infections. The distribution of GGO showed more diffuse in aGVHD (P = .031) and symmetric while patchier GGO prefers infections (P < .001). No differences were found in the reticulation. Nodules were more common in infections (P = .004) while pleural effusion was more common in aGVHD group (P < .035). Conclusion Imaging patterns of aGVHD on CT differ substantially from that of infections. Physicians and radiologists should be aware of such radiological differences in order to give accurate treatment. Notably, definite diagnosis should be made in combination with clinical manifestations, signs, and laboratory tests.

Complications of Cancer Therapy in Children: A Comprehensive Review of Body Imaging Findings

“…21 Imaging findings in aGVHD are nonspecific, but chest CT may aid in the differentiation between aGVHD and infection. 21 Imaging patterns in aGVHD include ground-glass opacities that are more likely to be diffuse and symmetric than those seen in patients with infections. 21,22 Pleural effusions or interstitial opacities may also be seen.…”

“…21 Imaging patterns in aGVHD include ground-glass opacities that are more likely to be diffuse and symmetric than those seen in patients with infections. 21,22 Pleural effusions or interstitial opacities may also be seen. 21 Corticosteroids and calcineurin inhibitors are typically the initial treatment of choice.…”

“…21,22 Pleural effusions or interstitial opacities may also be seen. 21 Corticosteroids and calcineurin inhibitors are typically the initial treatment of choice. 23…”

Novel approaches to the prediction and diagnosis of pulmonary complications in the paediatric haematopoietic stem cell transplant patient

“…Refining the use of CT chest as a diagnostic tool, in particular differentiating between infective and noninfective causes of pulmonary disease has also been recently studied. A study of 143 children post HSCT found the CT of patients with acute graft-versus-host disease (aGVHD) were more likely to have diffuse symmetrical patterns of ground glass opacities ( P = 0.31) or pleural effusions ( P < 0.035) compared to pulmonary infections that were more likely to have patchy ground glass opacities ( P < 0.001) or pulmonary nodules ( P = 0.04) [6]. In a separate study ( n = 12), the use of inspiratory-expiratory CT chest to assess for ventilation defects found defects were higher in HSCT patients who subsequently developed bronchiolitis obliterans (BO), compared to healthy controls (median 13.5% vs. 2.3%, P < 0.001) [7].…”

Imaging of pediatric hematopoietic stem cell transplant recipients: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper

“… A chest radiograph is the recommended initial imaging for symptomatic patients with suspected pulmonary infection and pulmonary edema (Grade D; SOR 1.67, strong recommendation) 2,24,26 Chest CT is recommended to better delineate sites of infection (Grade B; SOR 1.44, very strong recommendation) 2,27–32 Chest MRI is recommended in the setting of suspected complex pneumonia (Grade C; SOR 2.78, moderate recommendation) 33,34 .…”