Download Pulmonary complications of leukemia.

Pulmonary
Fredric
Edward
and
Complications
L. Hildebrand,
C. Rosenow
Henry
D.
lii,
Tazelaar,
of Leukemia
Jr., M.D.;*
M.D.,
F.C.C.P;*
Thomas
M. Habermann,
(Chest
98:1233-39)
1990;
the parenchyma.
Other
causes
bacterial
and other
opportunistic
rhage,
leukemic
and lymphomatous
ALL = acute
lymphocytic
leukemia;
A.ML
acute
myelocytic
leukemia;
AMML
acute
myelomonocytic
leukemia;
Ara-C
cytosine
arabinoside;
ARDS
acute
respiratory
distress
syndrome;
CLLchronic
lymphocytic
leukemia;
CMVcytomegalovirus;
HSVherpes
simplex
virus;
JPAinvasive
palmonary
aspergillosis;
PAPpulmonary
alveolar
phospholipoproteinosis
T
he leukemias
natural
are
history
chronic
a diverse
and
leukemias
different
with
ent
upon
leukemia,
are
and
the presence
or
thrombocytopenia.
that 98
autopsy
dence
ofdisorders.
of the
distinctly
are
leukemias.
These
or absence
of
Hooper’
in
found
leukemia
reported
is
are
selected
for patients
with specific
pulmonary
problems
or particular
leukemias.
Moreover,
the incidence
varies over
a wide
range,
depending
upon
whether
symptoms,
chest
radiographs,
tests,
or autopsy
findings
alone
of disease.
Pulmonary
the
conditions
differential
host,
such
as the
not
due
patient’s
to the
must
of the
patient
leukemia
itself,
are
are
status,
medical
in
listed
abnormalities
but
immunocompromised
a complicating
considered
leukemia,
pulmonary
illness.
All
caused
by
in
139
with
patients
Genter
leukemia
infiltrates,
infiltrates
for which
attributed
Hooper’s’
conclusively
review
at the
to determine
pulmonary
here.
causes
of pulmo-
for
in leukemic
patients.
the
infiltrates,
infiltrates
majority
organisms
ofpulmonary
Sixty
infiltrates
to 75 percent
82 percent
offocal
and
had infectious
causes.
pathogens
were
infiltrates,
whereas
Table
of reported
underlying
infiltrates,
human
immunodeficiency
and
neoplasm
the
Drug-induced
pulmonary
disease
of
the
focal
accounted
in
Disease
Host
process
involving
complications
lymphoid
virus
of
interstitial
the
leukemia,
lungs
lym-
pneumonia
in
infection)
reaction
process
community-acquired
Unusual
most
of diffuse
bacterial
organisms
disease
unusual
carcinoma,
Nonspecific
for
opportunistic
phoma,
“Unrelated”
35 percent
Common
1 -Categories
ofPilmonary
the immunocompromised
of the
(1eukemic
responsible
infection
conditions
opportunistic
deaths
in leukemia
are due to infection.t57
In Tenholder
and Hooper’s’
series
of 68 patients
with
pulmonary
Opportunistic
or
and
(cardiogenic
pulmonary
edema
and
pneumonia)
fibrosis
complications
proteinosis;
ofthe
pulmonary
Combinations
of two
disease
or therapy
veno-occlusive
or more
of the
(pulmonary
alveolar
disease)
above
procedures.
invasive
Medical
is responsible
Opportunistic
medications,
of the
will not be discussed
bacteria
are
listed
in Table
1 should
be considered
during
evalualion ofthese
patients
in order to narrow
the differential
diagnosis
as much as possible
and to avoid unnecessary
diagnostic
In Tenholder
and
with
function
as the index
immunocompromised
with
of the
be
patients
The
bone
INFECTION
Recurrence
that
diagnosis
1.2,3 Many
Table
pulmonary
are used
transplant
review
summarizes
the major
complications
in leukemia.
Infection
who came
to
The true mci-
series
marrow
This
nary
of
neutropenia
and
pulmonary
complications
to assess
because
most
in
failure
(Table
2). These
will be discussed.
spectrum
of pulmonary
problems
in
depend-
the
type
of treatment,
percent
of leukemic
patients
had pulmonary
complications.
difficult
common
ofsignificant
Tenholder
and
Several
are
factors,
including
and time
course
kocytic
reactions,
heart
unique
included
infection
by
organisms,
hemorinvolvement,
leu-
leukemic
cell lysis pneumonopathy,
hyperleureaction,
alveolar
proteinosis,
adverse
drug
and other
processes
including
congestive
kostasis,
The
acute
different.
complications
any ofthe
multiple
the nature
group
management
pulmonary
patients
M.D.;t
M.D4
in 84
a cause
the
of the
Walter
etiology
instances
was
to leukemic
records
Reed
of
cell
ofPulmonary
With Leuke,nia
ftitients
in
Hemorrhage
Leukemia
10 were
infiltration
Disease
Infection
of parenchymal
only
2-Causes
Army
of associated
found,
Table
of
From
the
of Thoracic
Diseases
and Internal
Medicine,
the tDivision
of Hematology
and
Internal
Medicine,
and the
tDivision
of Pathology,
Mayo
Clinic
and Mayo
Foundation,
Rochester,
Minnesota.
I3nt
requests:
Dt Rosenow,
Ma
Clinic,
Rochester,
MN 55905
and
lymphomatous
involvement
Leukostasis
Leukemic
cell
lysis
Hyperleukocytic
reaction
Alveolar
proteinosis
Adverse
drug
Opportunistic
reactions
neoplasms
CHEST
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I 98 I 5 I NOVEMBER,
1990
1233
for
most
ofthe
diffuse
diffuse
infections
the significant
nonopportunistic
infiltrate
reasonable
Several
and
associates5
permits
193
patients
of which
Sixty percent
Kiebsiella
cases
clinician
pneunioniae,
Staphylococcus
( Pneumocystis)
are
Granulocytopenia
the
common
absolute
of infection.
With
there
is a steady
increase
cells/pA
there
100
fatal
decreasing
respiratory
consequences
likelihood
In addition,
cells/pi
in
below
and
the
leukemic
biopsy-proven
locytopenia
patients.9”#{176}
In
a study
causes
trum
can
is
of
subse(IPA)
with
and others”
found
grantsmost important
factor
in
been
shown
development
episodes
granu-
to
of
of hemop-
in these
ated
They
u’9
and
hairy-cell
leukemia
had
found
combmant
but
and
the
and
most
common,
pulmonary
infil-
cell-medi-
These
infections
in one series.#{176}Prior
approaches,
patients
no infectious
complicathan
re-
longer
interferon-a
(2 ‘ -deoxycoformycmn)
the natural
toxicities.21
my-
kansasii
to impaired
to live significantly
However,
Pentostatin
my-
atypical
,
distinctly
changing
and its infectious
atypical
granulomatous
and coccidioido-
monocytopenia.
9 of 186 patients
chemotherapeutic
tions
patients
due
of
Gram-
Mycobacterium
in
been
with
and
being
with
causes
bacteria,
chills,
probably
immunity
were reported
to effective
sec-
Infectious
Disseminated
with
by fever,
are
spec-
complications
infections,
M aviurn-intracellulare
trates.
infections,
defects
in cell-mediated
are the primary
causes
Opportunistic
blastomycosis
also
major
A wide
Gram-negative
infections,
to be
are
infections.’”5
infectious
fungal
are characterized
tract
leukemia.
mortality.m6m7
including
may
thought
and
respiratory
leukemia,
and
are
pathogens
is involved
bacteria,
cobacterial
and
persisted
has
the
viruses
lymphatic
include
positive
and
to the
harmful
increase
incidence
from
frequent
from
in acute
of morbidity
bacteremias
of patients
and
as respiratory
ofviruses
mycosis,
A rapidly
an
recovery
chemotherapy
of IPA, with
of morbidity
especially
500
it
Also,
leukemia,
important
and
below
of granulocytopenia
IPA, Gerson
to be the single
In childhood
in incidence,
further.8
more.
cavitation
pneumonitis
mci-
with
12,13
cobacterial
infections,
determine
the probability
of infection,
and
particular
importance
in the development
and
quent
course
ofinvasive
pulmonary
aspergillosis
in
for
ce11s/i.l
granulocyte
count
and
damage
mucosa
and cilia are particularly
of chemotherapy
which
also
of infection.
the duration
after
course
disease,
if granulocytopenia
ondary
to granulocytopenia,
immunity,
and monocytopenia
factor
1,000
or
In hairy-cell
protozoans
incidence,
increase
increase
and
demonstrated
count
counts
Gram-negative
infections
and
has been
is a marked
tract.
coli,
pathogens.56
neutrophil
dence
tysis.
Mucorales,
predisposing
correlation
locytopenia
worsen
the
more
almost
aeruginosa,
HSV),
is a Inajor
A direct
between
less
acute
setting,
(Candida,
(CMV,
viruses
infections.
hospital
in
in the respiratory
due to Escherichia
Fungi
a
weeks
pulmonary
infection
of the
50 percent
three
for
type
to offer
development
approaching
microbial
causes
Balducci
and
Pseudomonas
aureus.
Aspergillus),
of
in a general
were
located
of these
were
half
the
the
the
Clearly,
but
and
associated
differential
diagnosis.
have
described
the
in patients
with leukemia.
reported
leukemic
other
their
studies
of infection
below
abnormalities.
begin
as focal
infiltrates,
between
opportunistic
organisms
of pulmonary
more
infectious
may
disparity
history
of the
are
disease
‘p
....,,
Fmcuiu:
1A. Chest
roentgenogram
of a patient
with
acute
myelomonocytic
pulmonary
hemorrhage.
B. Massive
pulmonary
hemorrhage
in a 67-year-old
leukemia
associated
with
a low I)latelet
count
secondary
to chemotherapy
magnification,
x 64).
1234
leukemia
(AMML)
and
man with acute
lymphocytic
(hematoxylin-eosin,
original
Pulmonary
Complications
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21620/ on 05/10/2017
of Leukemia
(Hildebrand
et a!)
HEMORRhAGE
Alveolar
hemorrhage
patients
with
is often
leukemia.
found
at autopsy
It is frequently
1.23-28
other
pulmonary
pathologic
conditions,
pneumonia
from invasive
aspergillosis,
ally involves
blood
vessels.’
Alveolar
usually
not
suspected
or
because
patients
hemoptysis
occurs
in this setting.
The
the
before
hemorrhage
seen
of acute
leukemia.
In
bleeding
function,
was severe
enough
but hemoptysis
patients
and
in
none
a pneumonic
pat1 A). Unless
it is
may
sometimes
cells4i.l
is presenP’27
20,000
cells/pA.
Associated
findings
may
occult
pulmonary
mimic
if the
platelet
rhage
was
pulmonary
percent
and
ofdiffuse
the
usually
but,
as stated
than
noted
common
cause
(11 percent
alveolar
cause
percent
of
of infiltrates,
in
possibly
monary
hemorrhage
determined
hemorrhage
LEUKEMIC
the
may
rapid
and
chemotherapy
is
be
diffuse),
pleural,
pen(Fig 3 A and B).31#{176}
CLL
histologic
picture
to an
non-Hodgkin’s
This
is charac-
deterioration,
fever,
progres-
and
involve-
sites,
including
the lung.
This
in patients
who
have
had
no
The disease
mediastinal,
prognosis
remissions
treated
of
disease
may
hepatosplenomegaly,
previous
chemotherapy.’
bronchial,37
pleural,7’
based
at
die
themselves
transfonmation.
extranodal
may
occur
long-term
who
were
found
involvement
or high-grade
clinical
adenopathy,
chial.39’#{176}The
as the
especially
.
who
infiltrates
Leukemic
Richter’s
of
lavage
pulmonary
a low-grade
from
are
of patients
cell
2).
intermediate
by
infiltrates
symptomatic
(both
focal
or endobronchial
convert
terized
cell
leukemic
(Fig
parenchymal
bronchial,
hemosiderin
INVOLVEMENT
percent
but
to
A
of pul-
macrophage
LYNIPII0NIATous
to 66
leukemia,’3’
of 3 to
patients.7
measurement
is the
leukemic
in 31
uncommon
an incidence
through
bronchoalveolar
is a disorder
of exclusion.
ANI)
Pulmonary
due
with
quantitative
content
Alveolar
autopsy
patients.
Other
series
hemorrhage
is a less
immunocompromised
effective
ment
process
above,
is poor
may be penand endobron-
in these
have been
aggressively
patients,
but
reported
in patients
with
anthracyclmne-
programs.37
hemor-
of noninfectious
of focal
and
Contributing
8
sive
20,000/pi.
that
common
lymphoma,
of
it is below
and roentgenographic
and mask a diagnosis
were excluded
in these
that de novo pulmonary
aggressive
to death . In almost
count
of less than
and
fever
is greater
infiltrates).
the
diagnosis
for invasive
aspergillosis
must be undertaken,
Hooper’
the most
infiltrates
of these,
was
hemorrhage,
count
Tenholder
12 percent
infection
an aggressive
search
cause
of hemorrhage
is an
or open
lung
some degree
of
of 50 autopsied
to compromise
pulmonary
was absent
in all of these
made prior
a platelet
50,000
of
may
microscopically
of them
pulmonary
hemorrhage
all documented
cases,
death
in less than one-fourth
chest roentgenogram
artifact
induced
by transbronchoscopic
biopsy.
Bodey
and co-workers
found
pulmonary
hemorrhage
in 54 percent
cases
to
particularly
which
generhemorrhage
is
diagnosed
show
a well-localized
infiltrate(s),
tern,
or a diffuse
infiltrate
(Fig
massive
(Fig
1 B), the pathologist
assume
in
related
problems
suggest
pulmonary
LEUKOSTASIS,
LEUKEMIC
HYPERLEUKOCYI’IC
78
There
are
three
unusual
CELL
LYSIS,
ANI)
REAc-nioN
pulmonary
complications
31”
74.
S
#{149}
.‘::#{149}
.,
‘.
.‘
S
0m
-
,
S.
-‘
__
-
.
p
Fu tIRE 2A. Chest
roentgenograin
of a patient
with chronic
lyinplocytic
involvement.
B. Open-lung
biopsy
specimen
shows
mature
lymplax.ytes
right),
characteristic
of’ pulmonary
involvement
h
chronic
IVmplak’tic
original
magnification,
X 4(X)).
leukemia
dena)nstrates
interstitial
tracking
along
t vessel
(upper
k’uke,nia
(hemnatoxvlin-eosin,
CHEST
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21620/ on 05/10/2017
I 98 I 5 1 NOVEMBER.
1990
1235
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.
-
Ut
:
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.
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0
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,
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.;e
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- ‘
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.
,-
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,
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t
t
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:?:,.
c,.. ‘M’’..i
#
unique
leukemia:
to
.
acute
respiratory
leukocyte
an
or l)last
autopsy
review
nonlymphocytic
leukemia
leukemia,
McKee
vascular
“leukostasis”
l)y
()CCILI5iOI1
with
cell
count
in a group
leukemia
failure.
developing
Each
diffuse
hours
after
dying
from
respiratory
phenomenon
This
support.
lysis
patients
kocyte
and
infarctions,
edema.
and
blast
oxygen
being
stances
therapy.
leukemic
postulated
associated
by
and
local
of vascular
these
small
tissue
damage
and
by blast
cells,
with
the
toxic and thromboplastic
injury
sub-
released
by these
cells as a result
of chemoThe
lack of deformability
of myeloblastic
cells
has been
substantiated;
it is further
that
biopsy
A third
but
chemotherapy
may
alter
the
aggregation.45
symptoms
leukemic
In
and
with myeloblastic
count
nadir.
In
infiltrates
Each
diffuse
leukemia
had an
alveolar
specific
condition,
cell
cell
co-workers.4
fever,
without
similar
five
specimens
characteristic
and
dam-
therapy.
by a different
mech-
of
these
nisms
respiratory
counts
adaptation.
the same
in the cerebral
lung,
accounting
sumal)ly
above,
distress;
and
a slow
did
not
presumably
associated
It must
of extreme
to the
and
leukostatic
it was
to a “hyperleukocytic”
leukemia
leukocyte
falsely
pathologic
microhemorrhages,
proposed
rise
acute
culatory
scribed
died,
who
associated
In addition
ofmnjury
chronic
patients
revealed
pulmonary
leukostasis
with
the
accumulation
of blast cells in arterioles
edema.
a rapid
with
count
greater
than 245,000/pA
and
blasts,
with a rapid
increase
in the
and number
of blasts
over
several
capillaries,
alveolar
analysis.
worsen
and
demonstrating
all recovered
and
symptoms,
interstitial
obstruction
membrane
and thus promote
The observation
that pulmonary
1236
with
causes
as a result
consumption
perpetuated
from
hemorrhage,
leukostasis
This
48
three
and distention
of
and venules
by leu-
aggregates,
penivascular
hypoxemia
with
specimens
congestion
cell
respi-
within
initiated,
capillaries,
arterioles,
of
hypoxemic,
infiltrates
Tissue
demonstrated
pulmonary
type
acute
cell
of the
high
blast
of leukemic
has been observed
by Vernant
and co-workers7
in 25 leukemic
patients
with acute respiratory
distress;
failure
despite
ventilatory
was termed
“leukemic
cell
pneumonopathy.”
days
days.
and
severely
Tryka
symptoms,
in five patients
four
open-lung
age,
by
pulmonary
blasts,
was
nuclei
pneumonopathy
study,
all had a leukocyte
35 to 80 percent
leukocyte
count
pulmonary
let,kenia
(hematoxvlin-
iii’elo,nonoc’tic
angulated
with acute
nonlymphocounts
of greater
than
l)ecafl’le
chemotherapy
acute
anism,
200,000/pJ.
a second
this
within
in all patients
than
patients
leukocyte
.4
‘
after
chemotherapy
in patients
with
counts
has led to a similar
description
developed
acute
myelogenous
pulmonary
infiltration
and
vessel
described
70 to 90 percent
in-
common.4149
aggregates
greater
to
with
chronic
of
and
200,000/p.l,
ratory
lysis
(Table
due
are
discovered
or small
associates’
cytic
or
leukemic
and
reaction
cell
patients
Gollins4’
a leukocyte
Myers
cell
and
counts
206
.itt
.
leukeiuic
infiltrate
in patient
with
shows leukernic
cells with irregular,
reaction
failure
cell
of
7’
.R.#{149}-’L5,
-.,
lysis
with
Patients
In
leukemic
hyperleukocytic
,t
X 1(X)).
leukostasis,
and
iiietimiiiathy,
2).
creased
niagnification.
.
_%
‘-‘.“.
original
,,a##{149}’
4.:lt#{149}
.,,
f!lb,
eoSin,
.‘
-
.
-
Ft( t’ RF: 3A . Chest
roentgeiiograin
shows
(ANI NI L). B. I ugh-power
inagiiification
:v
,_#{149}‘Jl
-4:’
.#{234}Q..
.,.
?
,
h
‘
.
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iv_
.
,,
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“.
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:;Fs.-11. Q’
#{149}I.
#{149}V’
also
state
however,
rate
show
patients
of increase
the
same
vasculature
for the
and
with
in their
respiratory
as a consequence
Guttner
hyperleukocytic
mechanoted
that
correlated
of microcir-
associates48
dereaction
occurring
as commonly
somnolence
and
as in the
confusion
with this acute
respiratory
distress.
be remembered,
however,
that conditions
leukocytosis
or thrombocytosis
may cause
low
Pa02
values
This phenomenon
a result
of increased
Pulmonary
Ofl
Complications
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21620/ on 05/10/2017
peripheral
blood
gas
of pseudohypoxia
is preoxygen
consumption
by
of Leukemia
(Hildebrand
et a!)
these
numerous
ce1ls.’
diagnosis
of hypoxemia,
between
sampling
This
may
lead
particularly
and
analysis
nonproductive
to an incorrect
if there
ofthe
gram
is a delay
peripheral
though
blood
the
specimen.
ALVEOLAR
must
PAP
diagnosis
An
also
association
included
been
an
coexistent
made
found
various
leukemia.
22
hematologic
All had
infections
by
group
opportunistic
of5
that
on
the
defective
(8.5
of34
the
evidence
pool
ofintracellular
additional
Noa
substances
macrophages
of PAP,
et al52 suggested
that
characteristic
of leuke-
monocytes
are
and
from
results
and
in
phospho-
macrophages
are
load of debris,
not
recruited
ADVERSE
Adverse
drug
opportunistic
patient
not only to recurrent
infections,
but also to PAP
DRUG
reactions
infection,
REACTIONS
affecting
the
pulmonary
lung
can
edema,
and
The
onset
be insidious,
with busulfan.
is associated
of drug-induced
pulmonary
disease
subacute,
or chronic-the
last
Most drug-induced
pulmonary
with
fever,
but not necessarily
fever.
It is rarely
sweats.
Fever
associated
may
precede
with
the
shaking
onset
chills
leuin
in
can
especially
disease
a daily
or night
of symptoms
with
be
the
chest
roentgeno-
of exclusion.
may
show
some
as
well
as
other
a drug
features
exclusion
Even
atypia
of
cells
finding
is not diagpulmonary
disease
taking
histologic
corticosteroids.
disease
known
to
consistent
of other
of
Several
states
with
causes.
acute
It is
(Ara-G)
oftreatment
dyspnea
produces
and
with
a unique
completion.7’
fever
ofthe
mimics
patients
minimal
changes
fluid.
there
onset
occurs
the drug.57
roentgenograms
specimens
show
with
proteinaceous
edema
with corticosteroids;
and
receiving
occur.
Chest
and histologic
parenchymal
The
ARDS
Hemoptysis
may also
show a diffuse
infiltrate
percent
confused
picture
of noncardiogenic
pulmousually
beginning
during
treatment
or
30 days
veolar
portive
drug-induced
are frequently
arabinoside
clinicopathologic
nary
edema,
diffuse
intra-al-
Treatment
is supis approximately
50
mortality.
was
Ofl
of the first drugs
recognized
an adverse
effect on the lungs.
A review
with an estimated
incidence
of 6 percent
to
of 56
was
Busulfan
produce
cases
recently
published.
mal infiltrates
seen
asymmetric
fibrosis
and
as well
In the
84
series
months.
There
The onset
is insidious.
on chest
roentgenogram
may
mimic
idiopathic
as other
entities
such
pneumonia,
percent
are
and
by Massin
and
mortality
with
hundreds
of case
Parenchymay be
pulmonary
as CMV
miliary
associates,59
an
disease,
tuberculosis.
average
reports
there
was
onset
at
an
41
of methotrexate
pneumonitis
occurring
mainly
in children
being
treated
for acute lymphatic
leukemia.
This reaction
is
predominantly
a hypersensitivity
reaction
in that over
half of the cases are associated
with eosinophilia
and
the onset
initiating
mimic
kemic
infiltration
and
must
always
be considered
the differential
diagnosis
of pulmonary
infiltrates
patients
with leukemia
who are undergoing
treatment
with chemotherapeutic
agents.M
patient
have
and
Pneumocystis
because
of errors
in chemotaxis,
causing
further
filling
of the
alveoli
with
proteinaceous
substances.
Chemotherapeutic
agents
may
inflict
further
damage
to these
functions.
Thus,
the altered
cell-mediated
immunity
in leukemia,
manifested
by impaired
macrophage
function,
predisposes
the
opportunistic
pulmonary
the
and
in up to one-fourth
and
proliferation
derived
effect
of acute
et aP
feature
drug
within
Golde
lipoproteins
in the alveoli.
Defective
unable
to phagocytize
the increased
and
species,
antimicrobial
is a major
this
tion
(15 percent),
from
macrophage
of leukemic
specimens
pneumonocyte
that
cause
pulmonary
ARDS.
Cytosine
nine
with
concurrent
(Candida
promote
PAP Excessive
of type
II pneumocytes
accumulation
with
biopsy.
in vitro
function
circulating
and
percent)
reviewed
Bedrossian
et ale’ and Prakash
the macrophage
dysfunction
mias
may
desquamation
a review
Bedrossian
malignancies,
asymmetric
bilatinfiltrates,
and
“secondary
Several
of these
had coexisting
alveolar
chemotactic
In
fungi
patients
and
is a disease
important
to consider
a diagnosis
of pulmonary
drug
effect
because
it is frequently
fatal,
even
after
the
responsible
drug has been stopped
and after interven-
and
or bacteria,
particularly
and associates52
described
at open-lung
Based
PAP,
disorders,
including
alveolar
infiltrates
and
in whom
hematologic
eral
alveolar-interstitial
PAP”
were
present.
infections
hematologic
of
to date,
patients
Aspergillus,
Mucorales)
cardia
species.
Prakash
similar
patients.
between
incidence
reported
I!
requires
differential
pneumonias.
of PAP
co-workers5’
the
in leukemic
increased
opportunistic
cases
in
infiltrates
has
malignancies,
of 260
be
histologic
type
dyspnea,
It
characteristic
of drug
effect,
this
nostic.
A diagnosis
ofdrug-mnduced
PROTEINOSIS
ofpulmonary
cough,
abnormality.
a few
adding
cases
is within
a few days
to several
weeks
the medication.
The reaction
disappears
days of either
corticosteroids.
in which
tissue
but tissue
eosinophilia
usually
fatal pulmonary
intrathecal
administration
just
discontinuing
In at least
is available,
the
one-third
granulomas
is uncommon.
edema
has been
of methotrexate.
of
in
drug
or
of the
are seen,
An acute
reported
and
with
CONCLUSION
Several
practical
considerations
this review
Infection
is the
infiltrates,
with local infections
CHEST
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21620/ on 05/10/2017
can be derived
from
most
common
cause
of
being
more
common
I 98 I 5 I NOVEMBER,
1990
1237
than
using
diffuse.
blood
These
cultures
can be diagnosed
and specimens
bronchoalveolar
lavage,
and open-lung
biopsy.
Pulmonary
infiltrates
may be attributable
to new pulmonary processes,
such as cardiogenic
pulmonary
edema,
pulmonary
which
are
emboli,
unrelated
patient’s
and chemotherapeutic
to the underlying
immunocompromised
above,
for
potentially
effect,
or the
These
standard
infiltrates
condi-
leukocyte
count
greater
dication
for
count,
treatment.
discussed
than
urgent
or an absolute
100,000
cells/pi,
intervention,
alkalinization
urine,
and
in-
rapid
hy-
and hydroxyurea
followed
these
instances
it is essential
by chemoto prepare
for possible
cell
respiratory
distress
with
lysis
pneumonopathy
available
and
ventilatory
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I 98 I 5 I NOVEMBER,
1990
1239