Chest
ReviewsPulmonary Complications of Leukemia
Section snippets
INFECTION
Infection with bacteria and opportunistic organisms is responsible for the majority of pulmonary infiltrates in leukemic patients. Sixty to 75 percent of reported deaths in leukemia are due to infection.5, 6, 7 In Tenholder and Hooper's1 series of 68 patients with pulmonary infiltrates, 82 percent of focal and 35 percent of diffuse infiltrates had infectious causes. Common bacterial pathogens were responsible for most of the focal infiltrates, whereas opportunistic organisms accounted for most
HEMORRHAGE
Alveolar hemorrhage is often found at autopsy in patients with leukemia.1, 23, 24, 25, 26, 27, 28 It is frequently related to other pulmonary pathologic conditions, particularly pneumonia from invasive aspergillosis, which generally involves blood vessels.23, 28 Alveolar hemorrhage is usually not suspected or diagnosed before death because hemoptysis occurs in less than one-fourth of patients in this setting. The chest roentgenogram may show a well-localized infiltrate(s), a pneumonic pattern,
LEUKEMIC AND LYMPHOMATOUS INVOLVEMENT
Pulmonary leukemic cell infiltrates are found at autopsy in 31 to 66 percent of patients who die of leukemia,23, 29, 30, 31 but symptomatic pulmonary disease due to the leukemic cell infiltrates themselves is uncommon (Fig 2). Leukemic involvement may be parenchymal (both focal and diffuse), pleural, peribronchial, or endobronchial (Fig 3 A and B).31, 32, 33 CLL may convert from a low-grade histologic picture to an aggressive intermediate or high-grade non-Hodgkin's lymphoma, Richter's
LEUKOSTASIS, LEUKEMIC CELL LYSIS, AND HYPERLEUKOCYTIC REACTION
There are three unusual pulmonary complications unique to leukemia: leukostasis, leukemic cell lysis pneumonopathy, and hyperleukocytic reaction (Table 2).
Patients with acute respiratory failure due to increased leukocyte or blast cell counts are common.41, 42, 43, 44, 45, 46, 47, 48, 49 In an autopsy review of 206 patients with acute nonlymphocytic leukemia or chronic myelogenous leukemia, McKee and Collins41 discovered pulmonary vascular “leukostasis” or small vessel infiltration and
ALVEOLAR PROTEINOSIS
PAP must also be included in the differential diagnosis of pulmonary infiltrates in leukemic patients. An association has been made between hematologic malignancies, an increased incidence of PAP, and coexistent opportunistic pneumonias.50, 51, 52, 53 In a review of 260 cases of PAP reported to date, Bedrossian and co-workers51 found 22 patients (8.5 percent) with various hematologic disorders, including nine with leukemia. All had alveolar infiltrates and concurrent infections by opportunistic
ADVERSE DRUG REACTIONS
Adverse drug reactions affecting the lung can mimic opportunistic infection, pulmonary edema, and leukemic infiltration and must always be considered in the differential diagnosis of pulmonary infiltrates in patients with leukemia who are undergoing treatment with chemotherapeutic agents.54, 55, 56
The onset of drug-induced pulmonary disease can be insidious, subacute, or chronic—the last especially with busulfan. Most drug-induced pulmonary disease is associated with fever, but not necessarily
CONCLUSION
Several practical considerations can be derived from this review. Infection is the most common cause of infiltrates, with local infections being more common than diffuse. These can be diagnosed effectively by using blood cultures and specimens from sputum, bronchoalveolar lavage, and open-lung biopsy. Pulmonary infiltrates may be attributable to new pulmonary processes, such as cardiogenic pulmonary edema, pulmonary emboli, and chemotherapeutic drug effect, which are unrelated to the underlying
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