Major pulmonary complications following Hematopoietic stem cell transplantation: What the pulmonologist needs to know.

Hematopoietic stem cell transplantation (HSCT) is used for treatment of a myriad of both malignant and non-malignant disorders. However, despite many advances over the years which have resulted in improved patient mortality, this subset of patients remains at risk for a variety of post-transplant complications. Pulmonary complications of HSCT are categorized into infectious and non-infectious and occur in up to one-third of patients undergoing HSCT. Infectious etiologies include bacterial, viral and fungal infections, each of which can have significant mortality if not identified and treated early in the course of infection. Advances in the diagnosis and management of infectious complications highlight the importance of non-infectious pulmonary complications related to chemoradiation toxicities, immunosuppressive drugs toxicities, and graft-versus-host disease. This report aims to serve as a guide and clinical update of pulmonary complications following HSCT for the general pulmonologist who may be involved in the care of these patients.

Nosocomial Achromobacter xylosoxidans Infection Presenting as a Cavitary Lung Lesion in a Lung Cancer Patient.

Achromobacter xylosoxidans is a Gram-negative bacillus that is known to cause nosocomial infections, primarily in patients with hematological malignancies. The most common primary manifestation is bacteremia. We report a novel case of primary A. xylosoxidans infection presenting as a cavitary lung lesion with associated pneumonia in a lung cancer patient who showed no evidence of malignant disease progression after radiation therapy. Our patient was initially admitted for acute hypoxic respiratory failure requiring mechanical ventilation. Initial computed tomography (CT) revealed a cavitary lesion in the right upper lobe of the lung. Diagnostic bronchoscopy with bronchoalveolar lavage (BAL) was performed and was negative for infectious etiologies including tuberculosis (TB) and fungal infections. Cytology was also negative for malignancy. However, the bacterial culture grew A. xylosoxidans. Antimicrobial therapy was initiated based on culture susceptibilities and the patient showed significant improvement in oxygen requirements. Due to poor functional status, the palliative care route was pursued and mechanical ventilation weaning was not performed. Cavitary pulmonary infections secondary to A. xylosoxidans are rarely reported in the medical literature. After conducting a thorough PubMed database search of the medical literature, we believe this is the first case of A. xylosoxidans infection manifesting as a cavitary lung lesion with associated pneumonia in a lung cancer patient.

Intensity of Cancer Care Near the End of Life at a Tertiary Care Cancer Center in Jordan.

CONTEXT: Chemotherapy use in the last month of life is an indicator of poor quality of end-of-life care. OBJECTIVES: We assessed the frequency of chemotherapy use at the end of life at our comprehensive cancer center in Jordan and identified the factors associated with chemotherapy use. METHODS: We conducted a retrospective chart review to examine the use of chemotherapy in the last 30 days and 14 days of life in consecutive adult patients with cancer seen at King Hussein Cancer Center (KHCC) who died between January 1, 2010, and December 31, 2012. We collected data on patient and disease characteristics, palliative care referral, and end-of-life care outcome indicators. RESULTS: Among the 1714 decedents, 310 (18.1%) had chemotherapy use in the last 30 days and 142 (8.3%) in the last 14 days of life. Over half (910; 53.1%) had a palliative care referral. Chemotherapy use in the last 30 and 14 days of life were associated with younger age (odds ratio [OR] 0.99/yr, P = 0.01, and OR 0.99/yr, P = 0.01, respectively) and hematological malignances (OR 1.98, P < 0.001, and OR 2.85, P < 0.001, respectively). Palliative care referral was significantly associated with decreased use of chemotherapy in the last 30 (OR 0.30, P < 0.001) and 14 (OR 0.15, P < 0.001) days of life. CONCLUSIONS: A sizable minority of patients with cancer at KHCC received chemotherapy at the end of life. Younger patients and those with hematological malignancies were more likely to receive chemotherapy, whereas those referred to palliative care were significantly less likely to receive chemotherapy at the end of life.

Primary Liver Diffuse Large B-Cell Lymphoma following Complete Response for Hepatitis C Infection after Direct Antiviral Therapy.

INTRODUCTION: Hepatitis C infection is highly prevalent worldwide and has a well-known association with B-cell lymphoid malignancies. Antiviral therapy has successfully decreased the rate of liver cirrhosis and improved the outcome in patients with hepatitis C-associated lymphomas. However, although there are a few case reports of aggressive lymphomas after successful hepatitis C therapy, the mechanism behind this association remains unclear. CASE PRESENTATION: We present the case of a 55-year-old man with chronic hepatitis C infection and liver cirrhosis who received antiviral therapy with sofosbuvir and ribavirin and achieved a sustained complete virological response. One year after successful therapy, there was an unexplained decline of his liver function and atypical liver nodularity, which led to the diagnosis of a primary liver diffuse large B-cell lymphoma. DISCUSSION: We review the evidence supporting possible mechanisms of lymphomagenesis after successful hepatitis C therapy, particularly involving late "second-hit" mutations after viral-induced DNA damage and antiviral therapy facilitating the emergence of latent malignant B-cell clones by decreasing local inflammation and immune surveillance. More reports may help elucidate any association between hepatitis C antiviral therapy and late lymphoid malignancies.