Radiologic findings: A chest radiograph (A) in early June shows patchy densities in the RUL and medial RLL, more extensive compared to May. The CT (B) shows a subpleural nodule and geographic, right apical ground-glass and mild reticular opacity.

A B

CT images C and D demonstrate scattered small nodules in the right upper lobe (C) and bilateral lung bases (D). The arrow marks one nodule in D.

C

D

Differential diagnosis: Understanding where the patient is in the course of bone marrow transplantation is key to interpretation of the chest radiographs. In the first month post-transplant (pre-engraftment), the most common causes of pulmonary abnormalities are non-infectious, such as pulmonary edema, diffuse alveolar hemorrhage, and drug reactions, although some infectious processes including bacterial, fungal, and viral pneumonias may occur.

After the second month post-transplant, there is a marked rise in pulmonary infections, some of which may have started earlier but are now manifest with recovery of the patient's neutrophils. Aspergillus, candida, herpes simplex virus, and respiratory syncytial virus are common infectious agents. Pneumocystis carinii and cytomegalovirus are now infrequent because of prophylactic therapies. Interstitial pneumonia (idiopathic pneumonia syndrome) with no organism identified is also common and has a poor prognosis.

Chronic graft-versus-host disease (GVHD) generally develops within 3 to 4 months post-tranplant. GVHD or its therapy predisposes patients to late infection (Streptococcus pneumoniae, Hemophilus influenzae, Staphylococcus aureus, aspergillus, CMV, and Pneumocystis carinii) , idiopathic pneumonia syndrome, and posttransplant lymphoproliferative disorder.

At 8 months post-transplant, this patient's radiographic findings could be consistent with fungal or CMV (or even bacterial) pneumonia or idiopathic pneumonia syndrome. Recurrent lymphoma may also appear as multiple patchy and nodular densities.

Reference:

Winer-Muram H, Gurney J, Bozeman P, Krance R: Pulmonary complications after bone marrow transplantation. Radiol Clin North Am 34:97-118, 1996.

Clinical summary

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