DOI: 10.1148/rg.274065141
Postoperative Complications of Lung Transplantation: Radiologic Findings along a Time Continuum1
Mayil S. Krishnam, MD,
Robert D. Suh, MD,
Anderanik Tomasian, MD,
Jonathan G. Goldin, MD, PhD,
Chi Lai, MD,
Kathleen Brown, MD,
Poonam Batra, MD, and
Denise R. Aberle, MD
1 From the Departments of Radiological Sciences (M.S.K., R.D.S., A.T., J.G.G., K.B., P.B., D.R.A.) and Pathology (C.L.), David Geffen School of Medicine, University of California at Los Angeles, Peter V. Ueberroth Bldg, Suite 3371, 10945 LeConte Ave, Los Angeles, CA 90095-7206. Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received July 25, 2006; revision requested September 27 and received February 27, 2007; accepted March 1. All authors have no financial relationships to disclose.
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Figure 1a. Ischemia-reperfusion injury in a patient with bilateral lung transplants for idiopathic pulmonary hypertension. (a) Chest radiograph, obtained 24 hours after lung transplantation, demonstrates bilateral lower-lobe heterogeneous airspace opacities (arrow) with peribronchial and perivascular thickening. (b) Chest radiograph, obtained more than 48 hours after transplantation, demonstrates interval resolution. Although the findings are nonspecific, the temporal relationship with regard to lung transplantation and the rapid resolution of the abnormal radiographic features are suggestive of this diagnosis.
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Figure 1b. Ischemia-reperfusion injury in a patient with bilateral lung transplants for idiopathic pulmonary hypertension. (a) Chest radiograph, obtained 24 hours after lung transplantation, demonstrates bilateral lower-lobe heterogeneous airspace opacities (arrow) with peribronchial and perivascular thickening. (b) Chest radiograph, obtained more than 48 hours after transplantation, demonstrates interval resolution. Although the findings are nonspecific, the temporal relationship with regard to lung transplantation and the rapid resolution of the abnormal radiographic features are suggestive of this diagnosis.
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Figure 2. Hemothorax in a patient with bilateral lung transplants for idiopathic pulmonary hypertension. Axial chest CT image (soft-tissue window), obtained more than 5 days after lung transplantation, demonstrates a moderate-sized high-attenuating collection of blood (40 HU) that extends into the major fissure (black arrow). A thoracostomy tube also is visible (white arrow).
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Figure 3a. Acute rejection in a patient with bilateral lung transplants for end-stage pulmonary fibrosis secondary to sarcoidosis. (a) Radiograph, obtained over 3 weeks after transplantation, shows pleural effusions, airspace opacities (arrow), and interlobular septal thickening. (b) Axial CT image shows patchy and multifocal bilateral ground-glass opacities, peribronchial and septal thickening (arrow), and pleural effusion due to acute cellular rejection. (c) High-power photomicrograph (original magnification, x200; hematoxylin-eosin [H–E] stain) of a transbronchial biopsy specimen shows moderate (A3) acute rejection, with a marked perivascular inflammatory infiltrate of mononuclear cells (arrow) that extends into alveolar septa and without evident pneumocyte damage.
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Figure 3b. Acute rejection in a patient with bilateral lung transplants for end-stage pulmonary fibrosis secondary to sarcoidosis. (a) Radiograph, obtained over 3 weeks after transplantation, shows pleural effusions, airspace opacities (arrow), and interlobular septal thickening. (b) Axial CT image shows patchy and multifocal bilateral ground-glass opacities, peribronchial and septal thickening (arrow), and pleural effusion due to acute cellular rejection. (c) High-power photomicrograph (original magnification, x200; hematoxylin-eosin [H–E] stain) of a transbronchial biopsy specimen shows moderate (A3) acute rejection, with a marked perivascular inflammatory infiltrate of mononuclear cells (arrow) that extends into alveolar septa and without evident pneumocyte damage.
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Figure 3c. Acute rejection in a patient with bilateral lung transplants for end-stage pulmonary fibrosis secondary to sarcoidosis. (a) Radiograph, obtained over 3 weeks after transplantation, shows pleural effusions, airspace opacities (arrow), and interlobular septal thickening. (b) Axial CT image shows patchy and multifocal bilateral ground-glass opacities, peribronchial and septal thickening (arrow), and pleural effusion due to acute cellular rejection. (c) High-power photomicrograph (original magnification, x200; hematoxylin-eosin [H–E] stain) of a transbronchial biopsy specimen shows moderate (A3) acute rejection, with a marked perivascular inflammatory infiltrate of mononuclear cells (arrow) that extends into alveolar septa and without evident pneumocyte damage.
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Figure 4. Bronchial dehiscence in a patient with a right lung transplant for  1-antitrypsin deficiency. Axial chest CT image, obtained more than 4 weeks after lung transplantation, shows a crescent of air outside the airway (black arrow), medial to the right main bronchus. This finding was due to an anastomotic leak. A small pneumothorax (white arrow) represents a bronchopleural fistula.
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Figure 5a. Bacterial infection. (a) Chest radiograph obtained in a patient with bilateral lung transplants for pulmonary fibrosis shows patchy and confluent airspace consolidation with air bronchograms (arrows) within the lingula. Transbronchial biopsy cultures revealed the presence of P aeruginosa. (b) Chest CT image obtained in another patient, who received a right lung transplant for chronic obstructive pulmonary disease (COPD), demonstrates foci of consolidation (arrows) within the right middle and lower lobes of the allograft lung, findings indicative of bacterial pneumonia.
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Figure 5b. Bacterial infection. (a) Chest radiograph obtained in a patient with bilateral lung transplants for pulmonary fibrosis shows patchy and confluent airspace consolidation with air bronchograms (arrows) within the lingula. Transbronchial biopsy cultures revealed the presence of P aeruginosa. (b) Chest CT image obtained in another patient, who received a right lung transplant for chronic obstructive pulmonary disease (COPD), demonstrates foci of consolidation (arrows) within the right middle and lower lobes of the allograft lung, findings indicative of bacterial pneumonia.
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Figure 6. Pneumonia in a patient with a right lung transplant for end-stage emphysema. High-resolution axial CT image, obtained more than 8 weeks after transplantation, shows extensive multifocal ground-glass and airspace opacities within the middle and lower lobes of the right lung. Sputum cultures later revealed the presence of Candida.
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Figure 7a. Bronchial stenosis in a patient with bilateral lung transplants for pulmonary fibrosis due to systemic sclerosis. (a) Axial chest CT image, obtained more than 12 weeks after transplantation, shows stenosis of the bronchus intermedius (arrow). Esophageal food residue from dilatation caused by scleroderma also is visible. (b) Axial chest CT image, obtained after balloon dilation of the intermediate bronchus, shows mild residual stenosis (arrow).
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Figure 7b. Bronchial stenosis in a patient with bilateral lung transplants for pulmonary fibrosis due to systemic sclerosis. (a) Axial chest CT image, obtained more than 12 weeks after transplantation, shows stenosis of the bronchus intermedius (arrow). Esophageal food residue from dilatation caused by sclero-derma also is visible. (b) Axial chest CT image, obtained after balloon dilation of the intermediate bronchus, shows mild residual stenosis (arrow).
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Figure 8a. Pneumonia due to CMV infection in a patient with bilateral lung transplants for end-stage pulmonary fibrosis. (a) Axial chest CT image, obtained more than 8 weeks after lung transplantation, shows patchy and confluent ground-glass nodularity (arrows) within the middle and lower lobes of the allograft right lung. A transbronchial biopsy specimen from the right middle lobe later demonstrated inclusion bodies, a finding suggestive of viral infection. (b) High-power photomicrograph (original magnification, x400; H–E stain) reveals a markedly enlarged endothelial cell with an intranuclear eosinophilic inclusion surrounded by a clear halo (arrow). Perivascular mononuclear cell inflammatory infiltration also is evident.
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Figure 8b. Pneumonia due to CMV infection in a patient with bilateral lung transplants for end-stage pulmonary fibrosis. (a) Axial chest CT image, obtained more than 8 weeks after lung transplantation, shows patchy and confluent ground-glass nodularity (arrows) within the middle and lower lobes of the allograft right lung. A transbronchial biopsy specimen from the right middle lobe later demonstrated inclusion bodies, a finding suggestive of viral infection. (b) High-power photomicrograph (original magnification, x400; H–E stain) reveals a markedly enlarged endothelial cell with an intranuclear eosinophilic inclusion surrounded by a clear halo (arrow). Perivascular mononuclear cell inflammatory infiltration also is evident.
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Figure 9a. Respiratory viral infection in a patient with a right lung transplant for lymphangioleiomyomatosis and a 2-week history of increasing cough and shortness of breath. (a) Chest radiograph, obtained 12 weeks after lung transplantation, shows diffuse ground-glass opacification with bronchial wall thickening in the allograft lung. (b) Axial chest CT image helps confirm diffuse ground-glass opacification and bronchial wall thickening (arrow) in the allograft lung. The native left lung shows diffuse disease with multiple thin-walled cysts, findings characteristic of lymphangioleiomyomatosis. Respiratory cultures were positive for RSV antigen.
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Figure 9b. Respiratory viral infection in a patient with a right lung transplant for lymphangioleiomyomatosis and a 2-week history of increasing cough and shortness of breath. (a) Chest radiograph, obtained 12 weeks after lung transplantation, shows diffuse ground-glass opacification with bronchial wall thickening in the allograft lung. (b) Axial chest CT image helps confirm diffuse ground-glass opacification and bronchial wall thickening (arrow) in the allograft lung. The native left lung shows diffuse disease with multiple thin-walled cysts, findings characteristic of lymphangioleiomyomatosis. Respiratory cultures were positive for RSV antigen.
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Figure 10a. Aspergillus infection in a patient with bilateral lung transplants for cystic fibrosis. Axial high-resolution CT images, obtained more than 8 weeks after lung transplantation, demonstrate dense airspace consolidation of the left lower lobe (a) and bilateral ground-glass nodules (arrows in b) with surrounding halos of decreased attenuation (halo sign). A bronchoalveolar lavage culture was positive for Aspergillus.
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Figure 10b. Aspergillus infection in a patient with bilateral lung transplants for cystic fibrosis. Axial high-resolution CT images, obtained more than 8 weeks after lung transplantation, demonstrate dense airspace consolidation of the left lower lobe (a) and bilateral ground-glass nodules (arrows in b) with surrounding halos of decreased attenuation (halo sign). A bronchoalveolar lavage culture was positive for Aspergillus.
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Figure 11a. Acute pulmonary embolism in a patient with a right lung transplant for usual interstitial pneumonitis. (a) Axial chest CT image, obtained more than 12 weeks after lung transplantation, shows fibrosis in the native left lung (black arrow) and acute pulmonary emboli in arteries within the allograft (white arrow). (b) Magnified view of an axial chest CT image demonstrates a central filling defect (arrow) and local distention of a middle-lobe segment of the right pulmonary artery.
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Figure 11b. Acute pulmonary embolism in a patient with a right lung transplant for usual interstitial pneumonitis. (a) Axial chest CT image, obtained more than 12 weeks after lung transplantation, shows fibrosis in the native left lung (black arrow) and acute pulmonary emboli in arteries within the allograft (white arrow). (b) Magnified view of an axial chest CT image demonstrates a central filling defect (arrow) and local distention of a middle-lobe segment of the right pulmonary artery.
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Figure 12. Pneumonia of the native lung in a patient with a left lung transplant for COPD. Axial chest CT image, obtained more than 12 weeks after transplantation, depicts masslike consolidation (arrow) in the posterior basal segment of the lower lobe of the native right lung. Fluid from bronchoalveolar lavage was positive for Scedosporium apiospermum.
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Figure 13a. Mycobacterium infection in a patient with bilateral lung transplants for end-stage pulmonary fibrosis. (a, b) Axial chest CT images, obtained more than 12 weeks after lung transplantation, demonstrate tree-in-bud nodularity and multiple ground-glass opacities (arrows in a) in the middle and lower lobes of the right lung and consolidation (arrow in b) in the lower lobe. Subsequent bronchoalveolar lavage cultures from the right middle and lower lobes were positive for nontuberculous Mycobacterium. (c) Medium-power photomicrograph (original magnification, x100; H–E stain) shows granulomatous inflammation with giant cells obliterating a bronchiole (arrow). Note the presence of organizing pneumonia with intraalveolar fibrous plugs (*).
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Figure 13b. Mycobacterium infection in a patient with bilateral lung transplants for end-stage pulmonary fibrosis. (a, b) Axial chest CT images, obtained more than 12 weeks after lung transplantation, demonstrate tree-in-bud nodularity and multiple ground-glass opacities (arrows in a) in the middle and lower lobes of the right lung and consolidation (arrow in b) in the lower lobe. Subsequent bronchoalveolar lavage cultures from the right middle and lower lobes were positive for nontuberculous Mycobacterium. (c) Medium-power photomicrograph (original magnification, x100; H–E stain) shows granulomatous inflammation with giant cells obliterating a bronchiole (arrow). Note the presence of organizing pneumonia with intraalveolar fibrous plugs (*).
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Figure 13c. Mycobacterium infection in a patient with bilateral lung transplants for end-stage pulmonary fibrosis. (a, b) Axial chest CT images, obtained more than 12 weeks after lung transplantation, demonstrate tree-in-bud nodularity and multiple ground-glass opacities (arrows in a) in the middle and lower lobes of the right lung and consolidation (arrow in b) in the lower lobe. Subsequent bronchoalveolar lavage cultures from the right middle and lower lobes were positive for nontuberculous Mycobacterium. (c) Medium-power photomicrograph (original magnification, x100; H–E stain) shows granulomatous inflammation with giant cells obliterating a bronchiole (arrow). Note the presence of organizing pneumonia with intraalveolar fibrous plugs (*).
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Figure 14a. Chronic rejection in a patient with bilateral lung transplants for COPD. (a) Inspiratory axial chest CT image shows mosaic attenuation (regions of mixed hypo- and hyperattenuation). (b) Expiratory high-resolution CT image shows a hypoattenuating region (arrow) produced by air trapping, a hallmark of chronic rejection due to bronchiolitis obliterans. (c) Inspiratory high-resolution CT image demonstrates bilateral hypoattenuating regions, nodularity, interlobular septal thickening (arrow), bronchial wall thickening, and patchy regions of ground-glass opacity. (d) Medium-power photomicrograph (original magnification, x100; Masson trichrome stain) of a specimen from a right lung biopsy reveals active bronchiolitis obliterans with fibroblastic proliferation (straight black arrow), mononuclear cell inflammatory infiltration (curved black arrow), and dense fibrous scarring (white arrow) of the lamina propria. The presence of intraalveolar foamy macrophages (*), which in this case are due to obstructive pneumonitis, is nonspecific but usually indicative of small-airway obstruction.
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Figure 14b. Chronic rejection in a patient with bilateral lung transplants for COPD. (a) Inspiratory axial chest CT image shows mosaic attenuation (regions of mixed hypo- and hyperattenuation). (b) Expiratory high-resolution CT image shows a hypoattenuating region (arrow) produced by air trapping, a hallmark of chronic rejection due to bronchiolitis obliterans. (c) Inspiratory high-resolution CT image demonstrates bilateral hypoattenuating regions, nodularity, interlobular septal thickening (arrow), bronchial wall thickening, and patchy regions of ground-glass opacity. (d) Medium-power photomicrograph (original magnification, x100; Masson trichrome stain) of a specimen from a right lung biopsy reveals active bronchiolitis obliterans with fibroblastic proliferation (straight black arrow), mononuclear cell inflammatory infiltration (curved black arrow), and dense fibrous scarring (white arrow) of the lamina propria. The presence of intraalveolar foamy macrophages (*), which in this case are due to obstructive pneumonitis, is nonspecific but usually indicative of small-airway obstruction.
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Figure 14c. Chronic rejection in a patient with bilateral lung transplants for COPD. (a) Inspiratory axial chest CT image shows mosaic attenuation (regions of mixed hypo- and hyperattenuation). (b) Expiratory high-resolution CT image shows a hypoattenuating region (arrow) produced by air trapping, a hallmark of chronic rejection due to bronchiolitis obliterans. (c) Inspiratory high-resolution CT image demonstrates bilateral hypoattenuating regions, nodularity, interlobular septal thickening (arrow), bronchial wall thickening, and patchy regions of ground-glass opacity. (d) Medium-power photomicrograph (original magnification, x100; Masson trichrome stain) of a specimen from a right lung biopsy reveals active bronchiolitis obliterans with fibroblastic proliferation (straight black arrow), mononuclear cell inflammatory infiltration (curved black arrow), and dense fibrous scarring (white arrow) of the lamina propria. The presence of intraalveolar foamy macrophages (*), which in this case are due to obstructive pneumonitis, is nonspecific but usually indicative of small-airway obstruction.
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Figure 14d. Chronic rejection in a patient with bilateral lung transplants for COPD. (a) Inspiratory axial chest CT image shows mosaic attenuation (regions of mixed hypo- and hyperattenuation). (b) Expiratory high-resolution CT image shows a hypoattenuating region (arrow) produced by air trapping, a hallmark of chronic rejection due to bronchiolitis obliterans. (c) Inspiratory high-resolution CT image demonstrates bilateral hypoattenuating regions, nodularity, interlobular septal thickening (arrow), bronchial wall thickening, and patchy regions of ground-glass opacity. (d) Medium-power photomicrograph (original magnification, x100; Masson trichrome stain) of a specimen from a right lung biopsy reveals active bronchiolitis obliterans with fibroblastic proliferation (straight black arrow), mononuclear cell inflammatory infiltration (curved black arrow), and dense fibrous scarring (white arrow) of the lamina propria. The presence of intraalveolar foamy macrophages (*), which in this case are due to obstructive pneumonitis, is nonspecific but usually indicative of small-airway obstruction.
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Figure 15a. Cryptogenic organizing pneumonia in a patient with a right lung transplant for end-stage pulmonary fibrosis secondary to sarcoidosis. (a) Axial chest CT image, obtained more than 16 weeks after lung transplantation, shows patchy ground-glass and airspace opacities predominantly in subpleural regions (black arrows) and bronchiectasis (white arrow) of the right lung. In the native left lung, fibrosis with cicatricial bronchiectasis (arrow) is evident. (b) Low-power photomicrograph (original magnification, x40; H–E stain) shows arborizing polypoid plugs of fibroblastic tissue within the distal airways (arrowheads). The fibroblastic tissue consists of plump spindle cells within a collagen-poor, slightly basophilic extracellular matrix.
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Figure 15b. Cryptogenic organizing pneumonia in a patient with a right lung transplant for end-stage pulmonary fibrosis secondary to sarcoidosis. (a) Axial chest CT image, obtained more than 16 weeks after lung transplantation, shows patchy ground-glass and airspace opacities predominantly in subpleural regions (black arrows) and bronchiectasis (white arrow) of the right lung. In the native left lung, fibrosis with cicatricial bronchiectasis (arrow) is evident. (b) Low-power photomicrograph (original magnification, x40; H–E stain) shows arborizing polypoid plugs of fibroblastic tissue within the distal airways (arrowheads). The fibroblastic tissue consists of plump spindle cells within a collagen-poor, slightly basophilic extracellular matrix.
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Figure 16a. Posttransplantation lymphoproliferative disorder in a patient with a left lung transplant for COPD. (a, b) Axial chest CT images, obtained more than 12 months after lung transplantation, demonstrate a large left hilar mass (arrow in a) and two nodules in the lingula and left lower lobe (arrows in b). (c) High-power photomicrograph (original magnification, x200; H–E stain) of a biopsy specimen shows marked infiltration of the bronchiolar wall with destruction of the smooth-muscle layer by large atypical lymphocytes (arrows).
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Figure 16b. Posttransplantation lymphoproliferative disorder in a patient with a left lung transplant for COPD. (a, b) Axial chest CT images, obtained more than 12 months after lung transplantation, demonstrate a large left hilar mass (arrow in a) and two nodules in the lingula and left lower lobe (arrows in b). (c) High-power photomicrograph (original magnification, x200; H–E stain) of a biopsy specimen shows marked infiltration of the bronchiolar wall with destruction of the smooth-muscle layer by large atypical lymphocytes (arrows).
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Figure 16c. Posttransplantation lymphoproliferative disorder in a patient with a left lung transplant for COPD. (a, b) Axial chest CT images, obtained more than 12 months after lung transplantation, demonstrate a large left hilar mass (arrow in a) and two nodules in the lingula and left lower lobe (arrows in b). (c) High-power photomicrograph (original magnification, x200; H-E stain) of a biopsy specimen shows marked infiltration of the bronchiolar wall with destruction of the smooth-muscle layer by large atypical lymphocytes (arrows).
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Figure 17. Fibrosis in a patient with a right lung transplant for severe centrilobular emphysema related to cigarette smoking. High-resolution CT image, obtained more than 24 months after lung transplantation, demonstrates regions of fibrosis (arrows) in the upper lobe of the allograft.
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Figure 18a. Recurrence of sarcoidosis in a patient with bilateral lung transplants for end-stage pulmonary fibrosis secondary to sarcoidosis. (a) High-resolution CT image, obtained more than 16 weeks after lung transplantation, shows multiple pulmonary nodules (small white arrows), nodularity along the right major fissure (large white arrow), peribronchial thickening, ground-glass opacities, and patchy architectural distortion (black arrow). (b) High-power photomicrograph (original magnification, x200; H–E stain) of a specimen from bronchoscopic biopsy reveals multiple discrete nonnecrotizing granulomas (arrows) in the wall of a bronchiole (*).
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Figure 18b. Recurrence of sarcoidosis in a patient with bilateral lung transplants for end-stage pulmonary fibrosis secondary to sarcoidosis. (a) High-resolution CT image, obtained more than 16 weeks after lung transplantation, shows multiple pulmonary nodules (small white arrows), nodularity along the right major fissure (large white arrow), peribronchial thickening, ground-glass opacities, and patchy architectural distortion (black arrow). (b) High-power photomicrograph (original magnification, x200; H–E stain) of a specimen from bronchoscopic biopsy reveals multiple discrete nonnecrotizing granulomas (arrows) in the wall of a bronchiole (*).
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Figure 19a. Recurrence of pulmonary capillary hemangiomatosis in a patient with bilateral lung transplants for pulmonary hypertension associated with pulmonary capillary hemangiomatosis. (a) High-resolution CT image, obtained more than 16 weeks after transplantation, demonstrates multiple bilateral bronchocentric ground-glass opacities (white arrows) and an enlarged pulmonary trunk (black arrow). Enlargement of the main pulmonary artery to 42 mm is indicative of hypertension. (b) High-power photomicrograph (original magnification, x200; H–E stain) of a bronchoscopic biopsy specimen reveals thickened alveolar septa with proliferating capillaries (arrows), findings indicative of recurrent pulmonary capillary hemangiomatosis.
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Figure 19b. Recurrence of pulmonary capillary hemangiomatosis in a patient with bilateral lung transplants for pulmonary hypertension associated with pulmonary capillary hemangiomatosis. (a) High-resolution CT image, obtained more than 16 weeks after transplantation, demonstrates multiple bilateral bronchocentric ground-glass opacities (white arrows) and an enlarged pulmonary trunk (black arrow). Enlargement of the main pulmonary artery to 42 mm is indicative of hypertension. (b) High-power photomicrograph (original magnification, x200; H–E stain) of a bronchoscopic biopsy specimen reveals thickened alveolar septa with proliferating capillaries (arrows), findings indicative of recurrent pulmonary capillary hemangiomatosis.
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Figure 20a. Bronchogenic carcinoma in a patient with a left lung transplant for COPD. (a) Axial chest CT image of the native right lung, obtained 4 years after transplantation, shows a new spiculated solid pulmonary nodule (arrow) that later was proved to be a non–small cell lung carcinoma. (b) High-power photomicrograph (original magnification, x200; H–E stain) of a specimen from a needle biopsy reveals an admixture of keratinizing squamous cell carcinoma (*) and micropapillary adenocarcinoma.
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Figure 20b. Bronchogenic carcinoma in a patient with a left lung transplant for COPD. (a) Axial chest CT image of the native right lung, obtained 4 years after transplantation, shows a new spiculated solid pulmonary nodule (arrow) that later was proved to be a non–small cell lung carcinoma. (b) High-power photomicrograph (original magnification, x200; H–E stain) of a specimen from a needle biopsy reveals an admixture of keratinizing squamous cell carcinoma (*) and micropapillary adenocarcinoma.
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Figure 21. Focal hematoma after a transbronchial biopsy in a patient with a right lung transplant. High-resolution CT image, obtained 2 days after the biopsy, demonstrates a new solitary nodule (arrow). The nodule later spontaneously resolved.
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Copyright © 2007 by the Radiological Society of North America.
