Pathologic characteristics of drug-induced lung disease
Section snippets
Clinical scenarios relevant to the surgical pathologist
Pulmonary drug reactions result from either direct or indirect effects of a drug. Indirect effects include drug-induced thrombocytopenia, central nervous system depression, and drug-induced immunosuppression with subsequent pulmonary hemorrhage, aspiration pneumonia, or opportunistic infection, respectively [3], [4], [5]. The latter consequence is most important because many of the histologic patterns that are seen in drug-induced pulmonary disease also are seen in bacterial, fungal, viral, and
Methods of diagnosis
Histologic changes for most drug reactions are nonspecific and diagnosis rests on correlation with clinical, laboratory, and radiologic information. Some type of lung sampling often is required to help establish a diagnosis. Although a surgical (open or thoracoscopic) lung biopsy might allow the pathologist to give a more complete description of the pulmonary process, a minimally-invasive procedure, such as bronchoalveolar lavage (BAL) or bronchoscopic biopsy, can contribute valuable data and
Criteria for diagnosis of drug reaction
Irey [2] defined a set of criteria for the diagnosis of drug reactions (Box 2). One must identify correctly the drug in question; was the patient taking the drug, and, if so, in what dosage for what duration? Other primary or secondary lung diseases must be excluded, such as infection or pulmonary involvement by collagen vascular disease. The issue of temporal eligibility must be considered; some drugs have well-established latency periods from initiation of therapy to onset of pulmonary
Lung injury patterns associated with drug reactions
The spectrum of clinical syndromes and diseases that is associated with pulmonary drug reactions involves all anatomic compartments of the lung. The major histologic patterns are listed in Box 3. The interstitium, airspaces, vasculature, and pleura may be involved preferentially, but one should be aware that the lung's response to injury is limited to several recognized reaction patterns; drugs may affect more than one compartment and, thus, lead to overlapping histologic patterns of disease. A
Summary
The surgical pathologist's role in the diagnosis of adverse pulmonary and pleural drug effect requires an appreciation of the clinico-radiologic scenario and particular knowledge of morphologic patterns of lung injury. Bronchoscopic biopsies may be helpful in some cases of DAD, eosinophilic pneumonia, or OP. Extrapolating patterns of lung involvement from small biopsies and cytologic preparations often is difficult and surgical lung biopsy is required. Although lung biopsies are not
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