Pulmonary complications in adult blood and marrow transplant recipients: Autopsy findings

Study objective: To describe the pulmonary findings at autopsy of blood and bone marrow transplant (BMT) recipients. Design: Retrospective. Setting: An academic medical center. Patients: Seventy-one deceased adult BMT recipients. Interventions: None. Measurements: Antemortem and postmortem pulmonary findings. Results: The transplants were allogeneic in 39 patients (55%), with a peripheral stem cell source in 43 patients (61%). Death occurred at a median of 1.30 months after transplant. Ninety-six pulmonary complications were noted in 63 patients (89%); 27 infectious (bacterial bronchopneumonia, n = 13; pulmonary aspergillosis, n = 11; cytomegalovirus pneumonia, n = 2; and Candida bronchopneumonia, n = 1) and 69 noninfectious (diffuse alveolar damage, n = 35; diffuse alveolar hemorrhage [DAH], n = 10; amyloidosis, n = 9; pulmonary embolism, n = 5; lymphoma/leukemia, n = 4; bronchiolitis obliterans, n = 2; bronchiolitis obliterans organizing pneumonia, n = 1; pulmonary alveolar proteinosis, n = 1; aspiration pneumonia, n = 1; and acute and organizing pneumonia, n = 1). Twenty-seven of the 96 complications (28%) were diagnosed antemortem. Infectious complications were more likely to be diagnosed antemortem compared to noninfectious complications (48% vs 20%, p = 0.006). Six of the 13 patients with bronchopneumonia (46%), 5 of the 11 patients with pulmonary aspergillosis (45%), and 7 of the 8 patients with DAH (88%) at autopsy were not receiving treatment for these conditions at the time of death. Ten patients being treated for suspected pulmonary aspergillosis, 7 patients treated for suspected pulmonary cytomegalovirus infection, 22 patients treated for suspected bacterial pneumonia, 2 patients treated for suspected Pneumocystis carinii pneumonia, and 12 patients treated for DAH at the time of death had no evidence of these conditions at autopsy. The most common immediate cause of death was respiratory failure (n = 37, 52%). Conclusions: Pulmonary complications, the majority not diagnosed antemortem, are the most common cause of death in BMT recipients. As the result of underdiagnosis, BMT recipients may not receive appropriate therapy for potentially treatable pulmonary complications.