Pulmonary haemorrhage following renal transplantation.

Abstract

The case history is presented of a 32 year old black man who developed haemoptysis leading to pulmonary haemorrhage and bilateral pulmonary infiltrates. He was found to have Kaposi's sarcoma ofthe lung with no evidence of skin or endobronchial lesions. (Thorax 1995;50:98- Laboratory data on admission were white blood cell count of 9000 with normal differential count, haemoglobin 13-2 g/l, platelet count 31 000/mm', prothrombin time 11 seconds (control 12 seconds), partial thromboplastin time 40 seconds (control 36 seconds), D-dimer >2, fibrinogen 4-8 g/l, electrolytes normal, blood urea nitrogen 22-84 mmol/l, creatinine 353-6 gimollI and glucose 6.6 mmol/l.Arterial blood tensions breathing 50% oxygen via a ventimask were pH 7 34, Pco2 3 19 kPa, Po2 11 30 kPa. The electrocardiogram showed left ventricular hypertrophy with non-specific ST segment depression in the anterolateral chest leads. Chest radiography showed extensive bilateral alveolar infiltrates on the left more than the right. He was given a rapid infusion of two litres of saline and his blood pressure improved to 100/60. Broad spectrum antibiotics (vancomycin, erythromycin, and ticarcillin) were started. Over the next few days his clinical state, platelet count, and renal function improved, but he continued to have episodes of haemoptysis and worsening hypoxaemia. Other investigations including sputum culture, blood culture, and sputum Legionella direct fluorescent antibody (DFA) were all negative. In view of his fluctuating pulmonary infiltrates bronchoscopy was performed and revealed normal vocal cords, trachea, carina, and bronchi. There was haemorrhagic fluid in several airways which was easily aspirated and no endobronchial lesions were noted. A transbronchial biopsy sample and bronchoalveolar lavage (BAL) fluid from the left lower lobe revealed negative DFA for Legionella, smears for acid fast bacilli, and fungi.The BAL fluid tested positive for cytomegalovirus by monoclonal antibody studies, but no viral inclusions were noted. Gancyclovir nevertheless was added to the treatment. Histological examination of the transbronchial biopsy specimen revealed an exuberant collection of spindle-shaped cells which were probably of endothelial origin and were von Willebrand antigen positive, compatible with Kaposi's sarcoma. Stains for cytokeratin and muscle specific antigen were negative in these tumour cells. Gallium scanning did not reveal any ab-

Hemoptysis in Renal Transplant Recipients

“…Ηemoptysis in renal transplant recipients, as immunocompromised patients, can occur in the context of infections (tuberculosis, mycetoma, invasive pulmonary aspergillosis, necrotizing parenchymal pneumonia, parasitic infection) [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]32]. Hemoptysis can also occur in the context of post-transplant malignancy due to immunosuppression (bronchial cancer, pulmonary metastases from other primary site) [28][29][30]33], in the context of potential drug toxicity [21][22][23][24][25][26]34], use of anticoagulants or antiplatelet agents [34], pulmonary embolism [35] or bronchiectasis due to recurrent pulmonary infections [36]. According to the existing literature, it cannot be concluded whether one or another reasons could lead to better or worse outcomes.…”

“…Kaposi sarcoma is a well established human herpesvirus-8 (HHV-8) driven complication of renal transplantation and immunosuppression with lung involvement. It is an uncommon malignancy thought to arise from precursor endothelial cells in a multicentric pattern resulting in tumor of mixed vascular and fibroblastic origin [ 28 ]. Kaposi sarcoma of the lung has been described to cause pulmonary hemorrhage, bilateral pulmonary infiltrates and hemoptysis [ 28 ] and acute hypoxic respiratory failure and hemoptysis [ 29 ] in renal transplant recipients.…”

“…Microbiological evaluation of different specimens and body fluids, with microscopic examination, culture and evaluation with polymerase chain reaction (PCR), has an important role in the investigation of hemoptysis in renal transplant recipients, confirming or excluding specific infections [ 6 - 9 , 12 , 14 - 16 , 18 - 20 , 22 , 24 - 26 , 28 - 29 ]. Serological testing for antibodies (IgG and IgM) to specific microorganisms has also been used for the diagnosis of underlining lung infections in renal transplant recipients with hemoptysis [ 15 , 21 ].…”

Pulmonary Malignancies in the Immunocompromised Patient

“…Alveolar hemorrhage was also reported in patients with non-AIDS pulmonary KS, and was particularly severe after renal transplantation [65]. It has been recently suggested that HHV8 DNA can be detected before the onset of a patent endobronchial lesion in BAL fluid from patients with AIDS-related or posttransplantation pulmonary KS [25, 26, 66].…”