Viral infection as a cause for bronchostenosis?
Chaaban S, Stagner L, Ray C, and Allenspach L. Viral infection as a cause for bronchostenosis? Am J Respir Crit Care Med 2015; 191.
Am J Respir Crit Care Med
Lung transplant is considered a treatment option for those with end stage lung disease, with more than 32,000 procedures performed to date. Despite the improvements in recipient and donor selection, lung allograft preservation, surgical technique for bronchial anastomosis, perioperative management and immunosuppressive regimen, airway complications are considered an important limitation for the lung transplant patient. We hereby present 2 cases that developed a bronchial stricture secondary to Herpes simplex virus (HSV) infection. A 67 year old male with history of Idiopathic pulmonary fibrosis (IPF) status post bilateral lung transplant and history of HSV stomatitis on maintenance valacyclovir presented to the clinic with cough and shortness which had been worsening over 2 weeks. He also had a 50% decline in his FEV1. Imaging including a chest xray and CT scan of the chest were unchanged when compared to previous studies. His labs were benign without leukocytosis. Bronchoscopy showed an 80% narrowing of the lateral segment of the left lower lobe that improved to 100% post balloon dilation. Endobronchial biopsies stained positive for HSV. Patient's immunosuppression was reduced and he received a trial of cidofovir due to in-vitro resistance to acyclovir. He was discharged on maintenance valacyclovir. A 67 year old male with a history of bilateral lung transplant for IPF and HSV laryngotracheobronchitis maintained on valacyclovir presented to clinic with dyspnea and hypoxemia. His labs were benign with no leukocytosis. CT scan of the chest revealed an occlusion in the left upper lobe bronchus. Rigid bronchoscopy showed a stenotic left upper lobe bronchus, pinpoint in appearance. The right anastomosis and bronchus intermedius revealed almost complete collapse on exhalation, requiring placement of a bare metal stent. Biopsies revealed HSV bronchitis. Treatment included a reduction in immune suppression and IV acyclovir. His dyspnea improved post stent placement and his oxygen requirements returned to baseline. He was discharged on maintenance therapy with valacylcovir. Airway complications post lung transplant fall into several categories including anastomotic stenosis, bronchomalacia, exophytic endobronchial granulation tissue, dehiscence and anastomotic infections. The incidence of a bronchial stricture is between 5-30% and is associated with 40% decrease in survival at 5 years. Early rejection has been shown to be associated with an increase in incidence of this pathology. Our cases developed segmental anastomosis likely related to. Segmental anastomotic stenosis should be considered a different category than the anastomotic complications and viral infection should be included in the differential for the pathology described. (Figure Presented).