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Background Development of bronchiolitis obliterans syndrome (BOS) after lung transplantation confers increased patient morbidity and mortality. Fibrocytes are circulating bone marrow–derived mesenchymal cell progenitors that influence tissue repair and fibrosis. Fibrocytes have been implicated in chronic pulmonary inflammatory processes. We investigated the correlation of circulating fibrocyte number with BOS development in lung transplant patients. Methods We prospectively quantified circulating fibrocyte levels among lung transplant patients. Patients were stratified according to the development of BOS as indicated by predicted forced expiratory volume in 1 second. Fibrocyte activity was analyzed by flow cytometry (cluster of differentiation 45 + , collagen 1 + ) in a blinded manner related to clinical presentation. Results Thirty-nine patients (61.5% men) underwent double (33.3%), left (25.6%), or right (41.0%) lung transplantation. Average patient age was similar between BOS and non-BOS patients (58.3 ± 3.9 vs 60.3 ± 2.0 years, p = 0.67). Chronic obstructive lung disease was the most common indication for lung transplantation (41.0%). Median forced expiratory volume in 1 second was lower among BOS patients compared with non-BOS patients (1.08 vs. 2.18 L/s, p = 0.001). Importantly, circulating fibrocyte numbers were increased in BOS patients compared with non-BOS patients (8.91 vs 2.96 × 10 5 cells/mL, p = 0.03) by flow cytometry and were incrementally increased with advancing BOS stage ( p = 0.02). Conclusions Increased circulating fibrocyte levels correlate with the development of BOS after lung transplantation and positively correlate with advancing BOS stage. Quantification of circulating fibrocytes could serve as a novel biomarker and possible therapeutic target for BOS development in lung transplant patients.

Advanced recipient age is reported to negatively affect survival after lung transplantation (LTX). We hypothesized that LTX in patients agedor = 60 years could be performed with acceptable outcomes.We identified 182 consecutive LTX recipients from 1995 to 2005. Outcomes were analyzed and survival compared with results in recipients aged60, as well as with United Network for Organ Sharing (UNOS) registry outcomes for the same age and study period. Actuarial survivals were calculated by the Kaplan-Meier method.During the study period, 29% (52/182) of LTX recipients wereor = 60 years old (range, 60 to 69 years). Median follow-up was 2.9 years (range, 0 to 10 years). All patients but one received a single lung. Indications included chronic obstructive pulmonary disease in 63% (33/52), idiopathic pulmonary fibrosis in 27% (14/52), and other in 10% (5/52). In-hospital mortality was 12% (6/52) for those agedor = 60 compared with 7% (9/130) for those aged60 (p = NS). Complications included reoperation in 10% (5/52), requirement for extracorporeal membrane oxygenation in 6% (3/52), renal failure in 12% (6/52), and stroke in 4% (2/52). Actuarial survivals at 30 days, and 1, 3, and 5 years were 90% (82, 98), 86% (76, 96), 71% (56, 85), and 55% (37, 73), respectively. No significant difference in survival was observed between age cohorts for our institutional data by Kaplan-Meier analysis (p = 0.34) or by Cox proportional hazard model (p = 0.15). A significant survival advantage was noted for our institution compared with UNOS for this cohort (p = 0.018).In carefully selected recipientsor = 60 years of age, LTX offers acceptable outcomes and survival.

This is a report of fatality immediately after administration of epoprostenol. The patient was previously diagnosed with CREST syndrome and associated interstitial lung disease. She developed worsening pulmonary hypertension and was clinically diagnosed with pulmonary veno-occlusive disease. The patient developed flash pulmonary edema and arrested after administration of low-dose epoprostenol in the intensive care unit. An autopsy revealed the patient suffered from pulmonary capillary hemangiomatosis. We review our case and what is known about this rare disease.

Rhizomucor is a genus of zygomycetes that can cause pulmonary mucormycosis. In the immunocompromised host, mucormycosis was fatal until advances in anti-fungal therapy were combined with surgery. Although uncommon, fungal infection at the bronchial anastomosis is associated with a significant risk of morbidity and mortality after lung transplantation. Our patient is a middle-aged woman with end-stage chronic obstructive pulmonary disease who received a bilateral lung transplant. After discharge, she developed increasing dyspnea. Bronchoscopy revealed stenosis and Rhizomucor at the right anastomosis. Repeated endobronchial debridement, systemic lipid-soluble amphotericin, and inhaled amphotericin successfully resolved the infection. The residual stenosis was treated with a self-expandable metal stent. At 3 months, the patient continues on inhaled amphotericin suppression therapy without sequelae. Anastomosis mucormycosis is a grave complication after lung transplantation. Without combination therapy of surgery and anti-fungal drugs, mortality has been exceedingly high. We present a case wherein endobronchial debridement and anti-fungal therapy were successful without surgery.

Background . Bronchiolitis obliterans syndrome (BOS) is the most common cause of long-term morbidity and mortality after lung transplantation. Our hypothesis was that early ischemia-reperfusion injury after lung transplantation increases the risk of BOS. Methods . Data on 134 patients who had lung transplantation between January 1, 1990 and January 1, 2000, was used for univariate and multivariate logistic regression analysis. Results . After lung transplantation, 115 patients (115 of 134, 86%) survived more than 3 months. In that group, 41 patients developed BOS, of which 23 had progressive disease. Univariate analysis revealed that ischemia-reperfusion injury ( p = 0.017) and two or more acute rejection episodes ( p = 0.032) were predictors of BOS onset, whereas ischemia-reperfusion injury ( p = 0.011) and cytomegalovirus infection ( p = 0.009) predicted progressive BOS. Multivariate logistic regression analysis showed that ischemia-reperfusion injury was an independent predictor for both BOS development and BOS progression. Two or more acute rejection episodes were also an independent predictor of BOS development, whereas cytomegalovirus infection was an independent predictor of progressive BOS. Conclusions . Ischemia-reperfusion injury increases the risk of BOS after lung transplantation.

A 59-year-old woman who underwent laparoscopic cholecystectomy for symptomatic cholecystitis presented four months later with fever, malaise, anorexia, hemoptysis and lithoptysis. Chemical analysis of the expectorated lithes revealed them to be gallstones. Ultrasound studies of the right upper quadrant demonstrated both supradiaphragmatic and subdiaphragmatic fluid collections containing echogenic fragments. ERCP failed to demonstrate retained ductal stones or fistula formation. To our knowledge, this is the first reported case of cholelithoptysis and demonstrates an unusual complication of gallstone retention following laparoscopic cholecystectomy.