PMC8551649_01
Portable chest radiographs. (A) The patient's chest radiograph upon emerging from the operating room after his orthotopic heart transplantation showed subtle reticular infiltrates interpreted at the time as mild postoperative pulmonary edema. (B) The patient's chest radiograph obtained upon arrival to our institution had shown clear lung fields as had his last preoperative chest radiograph taken 12 days prior to transplantation (not provided). (C) The patient's chest radiograph from the fifth postoperative day demonstrated progression of diffuse bilateral opacities in comparison to the initial postoperative film in panel (A). (D) The patient's chest radiograph obtained following completion of corticosteroid therapy for organizing pneumonia revealed marked improvement in the appearance of lung fields compared to panel (C).
gr1.jpg
PMC8551649_01_gr1.jpg
fig1
CXR performed on postoperative day (POD) 0 showed subtle bilateral infiltrates interpreted as mild postoperative pulmonary edema (Fig. 1A). A pre-operative CXR had been obtained 12 days prior to transplant, and at that time the lung fields were clear, as they had been when he first arrived to our institution (Fig. 1B). Despite normalization of left ventricular function and a course of diuresis, by POD 5 the patient remained mechanically ventilated and exhibited progressively worsening chest radiography (Fig. 1C). CXR markedly improved (Fig. 1D), and he was free of supplemental oxygen. Chest CT did, however, continue to show residual subpleural fibrosis.
Chest computed tomography (CT). (A) Axial chest CT section set to lung window from the scan obtained on the fifth postoperative day showing confluent bilateral ground glass opacities heavily affecting the upper lobes. (B) Axial CT section set to lung window from the scan repeated on postoperative day 35 showing residual ground glass opacities along with a subpleural focus of consolidation in the right upper lobe (arrows). The same pattern was observed in other lung zones, and areas of subpleural reticulation were noted elsewhere, concerning for evolving fibrosis (not shown).
gr2.jpg
PMC8551649_01_gr2.jpg
fig2
Chest computed tomography (CT) performed on that day showed diffuse ground glass opacities (GGO) bilaterally, most prominently affecting the upper lobes (Fig. 2A). On POD 35, chest CT was repeated, now showing a mixture of GGO and consolidation as well as subpleural reticulation, the latter consistent with evolving fibrotic changes (Fig. 2B).
(A) Lung histology from transbronchial biopsy. (A) Low power magnification showing lung parenchyma with thickened alveolar septa and mild chronic inflammation. Vaguely nodular and relatively demarcated areas of loose fibrosis, as well as numerous desquamated pneumocytes, are seen (H&E 100X). (B) High power magnification showing fibrocollagenous polypoid plugs (asterisks) within the alveolar spaces that also partially obstruct the bronchiolar lumina. Alveolar spaces are filled by loose collections of histiocytes, many of which reveal cytoplasmic vacuolization, indicative of amiodarone exposure. Yellow-brown pigment (arrow) is evident, suggestive of prior alveolar hemorrhage or exudation (H&E 400X). (C) Intermediate power magnification showing alveolar wall thickening with diffuse type II pneumocyte hyperplasia and focal squamous metaplasia (H&E 200X). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
gr3.jpg
PMC8551649_01_gr3.jpg
fig3
Vaguely nodular and relatively demarcated areas of loose fibrosis were evident (Fig. 3A). Yellow-brown pigment within the alveolar lumina was also seen, suggesting antecedent mild focal alveolar hemorrhage (Fig. 3B). Additionally, diffuse type II pneumocyte hyperplasia and focal squamous metaplasia were identified (Fig. 3C).