Computed tomography findings of postoperative complications in lung transplantation*, **

Transcription

1 Review Article Computed tomogrphy findings of postopertive complictions in lung trnsplnttion*, ** Achdos tomográficos ns complicções pós-opertóris do trnsplnte pulmonr Bruno Hochhegger, Klus Loureiro Irion, Edson Mrchiori, Rodrigo Bello, José Moreir, José Jesus Cmrgo Astrct Due to the incresing numer nd improved survivl of lung trnsplnt recipients, rdiologists should e wre of the imging fetures of the postopertive complictions tht cn occur in such ptients. The erly tretment of complictions is importnt for the long-term survivl of lung trnsplnt recipients. Frequently, HRCT plys centrl role in the investigtion of such complictions. Erly recognition of the signs of complictions llows tretment to e initited erlier, which improves survivl. The im of this pictoril review ws to demonstrte the CT scn ppernce of pulmonry complictions such s reperfusion edem, cute rejection, infection, pulmonry thromoemolism, chronic rejection, ronchiolitis oliterns syndrome, cryptogenic orgnizing pneumoni, posttrnsplnt lymphoprolifertive disorder, ronchil dehiscence nd ronchil stenosis. Keywords: Tomogrphy, X-ry computed; Lung trnsplnttion; Postopertive complictions. Resumo Com o número cd vez mior e um melhor sorevid dos pcientes sumetidos o trnsplnte pulmonr, os rdiologists devem estr cientes ds diverss possiiliddes de complicções ssocids o trnsplnte de pulmão. O trtmento precoce ds complicções é importnte pr sorevid longo przo dos receptores de trnsplnte pulmonr. Com frequênci, TCAR desempenh um ppel centrl n investigção de tis complicções. O reconhecimento precoce dos sinis de complicções proporcion um trtmento rápido e melhor sorevid. O ojetivo dest revisão pictóric foi proporcionr um visão sore s complicções mis prevlentes n TC, tis como edem de reperfusão, rejeição gud, infecção, tromoemolismo pulmonr, rejeição crônic, síndrome d ronquiolite oliternte, pneumoni em orgnizção criptogênic, doenç linfoprolifertiv pós-trnsplnte, deiscênci rônquic e estenose rônquic Descritores: Tomogrfi computdorizd por rios X; Trnsplnte de pulmão; Complicções pós-opertóris. Lung trnsplnttion hs ecome n estlished technique for the tretment of end-stge pulmonry diseses in dults. (1,2) The numer of trnsplnttions performed nnully nd the numer of centers performing lung trnsplnttions continue to increse. (1,2) Although single lung trnsplnttion ws previously more common, doule lung trnsplnttion is currently the preferred option for ll ptients with end-stge pulmonry disese, due to the etter long-term survivl of ptients sumitted to the ltter procedure. (2,3) Survivl fter lung trnsplnttion hs lso gretly improved s result of dvnces in surgicl technique, creful hrvesting/preservtion of donor orgns, improvements in immunosuppressive therpy nd erlier recognition of complictions with the use of vrious imging techniques. The reported one-, five-, ten- nd fifteen-yer survivl rtes re 75%, 50%, 35% nd 25%, respectively. (3,4) The most common cuse of mortlity in the first 6 months is cteril infection, which is therefter supplnted y chronic grft dysfunction. (3) The clinicl nd rdiologicl mnifesttions of postopertive complictions cn e nonspe- * Study crried out under the uspices of the Postgrdute Progrm in Respirtory Sciences of the Universidde Federl do Rio Grnde do Sul UFRGS, Federl University of Rio Grnde do Sul Porto Alegre, Brzil nd of the Postgrdute Progrm in Rdiologicl Sciences of the Universidde Federl do Rio de Jneiro UFRJ, Federl University of Rio de Jneiro Rio de Jneiro, Brzil. Correspondence to: Bruno Hochhegger. Ru João Alfredo, 558/301, Cidde Bix, CEP , Porto Alegre, RS, Brsil. Tel E-mil: runorgs@mil.ufsm.r Finncil support: None. Sumitted: 28 Octoer Accepted, fter review: 20 Jnury **A versão complet em português deste rtigo está disponível em

2 Computed tomogrphy findings of postopertive complictions in lung trnsplnttion 267 cific nd t times confusing. The im of this pper ws to descrie the most common postopertive complictions in dult recipients of lung trnsplnts, sed on retrospective evlution of cses t our institution nd review of literture. We hve grouped the most prevlent complictions y type: reperfusion edem; cute rejection; infections; pulmonry emolism nd infrction; cryptogenic orgnizing pneumoni; chronic rejection (due to ronchiolitis oliterns syndrome); ronchil nstomosis complictions (including ronchil dehiscence nd stenosis); nd post-trnsplnt lymphoprolifertive disorder. These cn lso e ctegorized temporlly s follows: immedite complictions (occurring within the first 24 h fter trnsplnttion), which re relted to respirtory mechnics (e.g., pneumothorx); erly complictions (occurring within the first 2 postopertive months), which include reperfusion edem, cute rejection, infection, ronchil dehiscence nd pulmonry thromoemolism; nd lte complictions (occurring fter postopertive month 2), which include chronic rejection (ronchiolitis oliterns syndrome), cryptogenic orgnizing pneumoni, post-trnsplnt lymphoprolifertive disorder nd ronchil stenosis. (5) Reperfusion edem Reperfusion edem (ischemi-reperfusion injury) is noncrdiogenic pulmonry edem tht typiclly develops more thn 24 h fter trnsplnttion, peks in severity on postopertive dy 4 nd generlly improves y the end of the first postopertive week. This condition lso referred to s the pulmonry reimplnttion response. The edem cn persist for up to 6 months fter trnsplnttion. However, in most lung trnsplnt recipients, it will hve resolved completely y postopertive month 2. (6) Although chest X-ry is the most common form of rdiologicl investigtion, CT scns cn provide vlule dditionl informtion (Figure 1). At pek severity, reperfusion edem ppers, in the upper, middle nd lower lung zones, s reticulr interstitil disese in 19%, 33% nd 34% of cses, respectively, or s irspce disese in 31%, 61% nd 57% of cses, respectively. (7) Reperfusion edem hs een reported to e symmetric in nerly 20% of ptients undergoing doule lung trnsplnttion. (7) The CT fetures re nonspecific nd cn include perihilr ground-glss opcities, perironchil/perivsculr thickening, pleurl effusion (Figure 1) nd reticulr interstitil/irspce opcities locted predominntly in the middle nd lower lung loes. (7) Acute rejection Acute rejection fter trnsplnttion is common occurrence. Nerly 95% of ptients present t lest two episodes within the first month fter surgery. Histologiclly, cute rejection is chrcterized y predominntly lymphocytic perivsculr infiltrte, with or without ronchiolr involvement. (8) Symptoms re generlly nonspecific, including low-grde Figure 1 - Reperfusion edem in recipient of doule lung trnsplnt due to emphysem. Imges on postopertive dy 3: HRCT scns of the chest demonstrting right pleurl effusion with perironchil/ perivsculr nd interloulr septl thickening in the lower zones of the grft lungs; the hert is norml in size, shpe nd position. By postopertive week 2, the lungs were unremrkle.

3 268 Hochhegger B, Irion KL, Mrchiori E, Bello R, Moreir J, Cmrgo JJ fever, rethlessness nd ftigue. Most ptients experience t lest one episode of cute rejection within the first 3 weeks nd remin t high risk for this compliction for the first 100 dys fter trnsplnttion. (5) Chest X-ry findings re norml in up to 50% of cses. (6) The most common findings re perihilr nd lower-loe opcities, s well s interloulr septl thickening nd pleurl effusion (Figure 2). (9) The HRCT fetures re reltively nonspecific nd include ground-glss opcities (often with sl distriution), perironchil cuffing, septl thickening (interloulr nd intrloulr) nd new or more extensive pleurl effusion. (10) This compliction cn e lmost completely excluded if there re no ground-glss opcities. (9) Acute rejection is treted with intrvenous corticosteroids nd typiclly responds quite well fter 24 h of this tretment. A drmtic reduction in norml rdiologicl fetures fter 48 h of intrvenous dministrtion of methylprednisolone is indictive of dignosis of cute rejection. (9,10) Infections Pulmonry infections, which constitute leding cuse of moridity nd mortlity, cn occur t ny time fter trnsplnttion. (3) The direct communiction etween the trnsplnted lung nd the tmosphere fcilittes infection. This is compounded y impired mucociliry clernce nd filure of the cough reflex. (11) The mjority (65%) of trnsplnt recipients develop infectious complictions, 30% of which re extrpulmonry. (5) Most such infections involve the trnsplnted lung. (12) Bcteri nd fungi re mjor cuses of infection within the first postopertive month, wheres virl infections re more prevlent in postopertive months 2 nd 3. (6) Severe cteril pneumoni ccounts for more thn 60% of post-trnsplnt infections nd is typiclly cused y Stphylococcus ureus, enteroctericee, Pseudomons eruginos or other grm-negtive orgnisms. (12) Although the incidence of cteril pneumoni is highest in the first month fter trnsplnttion, cteril pneumoni continues to e potentil mjor infectious compliction throughout the life of the ptient. (12,13) The incidence of serious cteril pneumoni in the immedite postopertive period fter lung trnsplnttion hs een reduced y the routine prophylctic use of rod-spectrum ntiiotics. (13) In lung trnsplnt recipients, the rdiologicl mnifesttions of cteril pneumoni, which include lor or diffuse consolidtion, cvittions nd lung nodules, re similr to those seen in other hospitlized ptients with cteril pneumoni. (13) In this context, CT might e helpful in confirming the presence of sutle rdiogrphic normlities, therey directing the clinicin to the most pproprite loe t ronchoscopy. For some infections, the CT ppernce cn suggest c Figure 2 - Acute rejection in recipient of single lung trnsplnt due to emphysem. Imges t postopertive week 2: () coronl multidetector CT reconstruction showing res of ground-glss opcity ccompnied y liner telectsis; nd (/c) xil HRCT slices etter demonstrting the interloulr septl thickening.

4 Computed tomogrphy findings of postopertive complictions in lung trnsplnttion 269 Figure 3 - CMV infection in recipient of single lung trnsplnt due to emphysem, presenting dyspne, fever nd leukopeni on postopertive dy 36. Imges: () xil HRCT scn of the chest demonstrting groundglss opcities in the middle loe ccompnied y mild interloulr septl thickening nd sprse res of cinr consolidtion; nd () coronl reconstruction showing tht the findings re locted in the middle loe only. The dignosis ws confirmed y iopsy. moni, chest X-ry findings cn e norml, nd norml findings, when present, re often nonspecific. (11) Cytomeglovirus (CMV) is the most common opportunistic infection mong such ptients. (14) The incidence of CMV infection peks etween 1 nd 2 months fter trnsplnttion, most cses occurring etween postopertive months 1 nd 12. (11,14) Infection with CMV cn e primry nd secondry. Primry infection occurs in over 90% of CMV seronegtive ptients receiving CMV seropositive specific infectious gent. (5) The following re the most common CT findings in cses of infection fter lung trnsplnttion: telectsis; ronchocentric opcities; susegmentl, segmentl or lor irspce consolidtion; rnching nodulr nd liner opcities ( tree-in-ud ppernce); interloulr septl thickening; nd pleurl effusion. (13-15) Opportunistic infection occurs in 34-59% of lung trnsplnt recipients. (13) Unfortuntely, in ptients with new opportunistic pneu c Figure 4 - Aspergillosis in recipient of single lung trnsplnt due to emphysem, presenting dyspne nd fever t 3 months fter trnsplnttion. Imges: (/) HRCT scns showing multifocl nodulr nd mss-like regions in the lower zones of the trnsplnted lung; (c) HRCT scn showing mss-like region surrounded y ground-glss opcity (hlo sign).

5 270 Hochhegger B, Irion KL, Mrchiori E, Bello R, Moreir J, Cmrgo JJ donor lung nd ecomes severe in 50-60% of such cses. (11) Secondry infection results from exposure to different CMV strin or from rectivtion of ltent infection in the recipient nd is usully less severe thn is primry infection. (11) Clinicl mnifesttions of CMV infection include dyspne, fever, mlise nd leukopeni, lthough mny ptients with histologiclly proven CMV pneumoni re symptomtic. (15) A dignosis of CMV pneumoni is typiclly confirmed only fter roncholveolr lvge nd trnsronchil iopsy. The rdiologic mnifesttions of CMV pneumoni include, s shown in Figure 3, ground-glss opcities, interloulr septl thickening nd consolidtion, s well s diffuse reticulr or reticulonodulr opcities, nodules nd smll res of effusion. (14) In lung trns Figure 5 - Cryptogenic orgnizing pneumoni in recipient of single lung trnsplnt due to idiopthic interstitil pneumoni. Imges: () HRCT scn t 4 months fter trnsplnttion showing irspce consolidtion, reticulr opcities, ronchiectsis nd lung volume loss; nd () HRCT scn fter corticosteroid tretment. plnt recipients with ctive CMV infection, chest X-ry findings cn e norml, (11) CT scns etter depicting the rdiologicl mnifesttions of the infection, which lmost exclusively ffects the llogrft. The most common CT mnifesttions re ground-glss opcities, tree-in-ud opcities, irspce consolidtion, nodules, interloulr septl thickening, pleurl effusions, thickened/ enlrged pleur nd ronchiectsis. (11-15) Other common virl pulmonry pthogens ffecting this popultion include herpes simplex virus, denovirus nd respirtory syncytil virus. (11) In lung trnsplnt recipients, fungl pneumoni, which is typiclly cused y Aspergillus spp. or Cndid spp., is less common thn is CMV pneumoni ut is ssocited with higher mortlity. (11,16,17) Fungl pneumoni most often Figure 6 - Chronic rejection in recipient of single lung trnsplnt due to emphysem, presenting, t postopertive month 15, decline in FEV 1 in reltion to the postopertive seline vlue. Imges: (/) HRCT scns showing ronchiectsis, ronchil wll thickening, nodulr nd liner rnching opcities, interloulr septl thickening nd perironchovsculr infiltrtes.

6 Computed tomogrphy findings of postopertive complictions in lung trnsplnttion 271 Bronchiolitis oliterns syndrome (BOS) is defined s clinicl syndrome of progressive, irreversile irwy ostruction in the pulmonry llogrft cused y the presence of constrictive (olitertive) ronchiolitis, (5) which results from eosinophilic firous scrring of the smll irwys. The term BOS is used to descrie less specific grft dysfunction feturing physiologic irflow ostruction nd decline in FEV 1 in reloccurs within the first 2 months fter trnsplnttion. (11) Infection with Aspergillus spp. cn present either s n indolent pneumoni or s fulminnt invsive infection with systemic dissemintion. (16,17) Aspergillus infection cn lso cuse ulcertive trcheoronchitis tht is often rdiogrphiclly occult nd cn led to nstomotic dehiscence. (11,17) Although Cndid spp. frequently colonize the irwys, invsive pulmonry infection is rre. (11) Fungl nstomotic infection or pneumoni is suspected on the sis of positive smers/cultures of roncholveolr lvge smples. However, since these orgnisms cn colonize the donor lung, definitive dignosis of invsive fungl infection might require trnsronchil iopsy. (11) Typicl fetures on HRCT imges include the following: focl nodulr nd mss-like regions of consolidtion; cvittion; nodules (solitry or multiple) with surrounding rim of ground-glss opcity, referred to s the hlo sign (Figure 4); nd pleurl thickening. (16,17) Pulmonry emolism nd infrction In lung trnsplnt recipients, pulmonry thromoemolic events tend to occur within the first 4 months fter trnsplnttion. (18) The incidence of such events hs een reported to e 27%. (18) Rdiogrphic findings re reltively nonspecific nd indirect; the most common eing pleurl effusion. Pulmonry CT ngiogrphy is the dignostic method of choice in suspected cses of pulmonry thromoemolic disese. The CT findings include centrl rteril filling defects, loclized rteril distention nd rupt rteril occlusion. Nonvsculr findings include wedge-shped consolidtion, mosic hypoperfusion (mosic oligemi), telectsis nd pleurl effusion. (18) Cryptogenic orgnizing pneumoni The prevlence of cryptogenic orgnizing pneumoni mong lung trnsplnt recipients is 10-28%. (19) This clinicopthologic syndrome chrcterized cliniclly y sucute or chronic respirtory illness nd pthologiclly y polypoid msses of grnultion tissue in the lumen of smll irwys, lveolr ducts, nd some lveoli is ssocited with vrile degree of interstitil nd irspce infiltrtion y mononucler cells nd fomy mcrophges. (19) An HRCT scn often revels irspce consolidtion, ground-glss opcities, nodulr or mss-like consolidtion nd liner or reticulr opcities (Figure 5). Additionl findings include ronchiectsis, ronchiolectsis, firosis, lung volume loss nd ir trpping. (19) Chronic rejection c R d P E Figure 7 - Bronchil stenosis in recipient of single lung trnsplnt due to emphysem. Imges t 5 months fter trnsplnttion: () xil HRCT scn with focused field of view showing stenosis of the right min ronchus; () volume rendering showing the evident right stenosis; (c) virtul endoscopy of the stenosis; nd (d) multiplnr reconstruction. OL

7 272 Hochhegger B, Irion KL, Mrchiori E, Bello R, Moreir J, Cmrgo JJ tion to the postopertive seline vlue. Chronic llogrft rejection remins the principl lte compliction of lung trnsplnttion; ffecting t lest 50% of recipients within 5 yers, irrespective of specific risk fctors. (20) The rdiogrphic mnifesttions of BOS re nonspecific nd include susegmentl telectsis, decresed peripherl vsculr mrkings nd perironchil cuffing, s well s reduced or incresed lung volumes. (20) The CT findings of chronic rejection include, s shown in Figure 6, ronchil wll thickening, nodulr/liner rnching opcities, interloulr septl thickening nd perironchovsculr infiltrtes, s well s ronchiectsis, ir trpping, regionl volume expnsion/contrction, mosic lung ttenution nd decresed/ distorted peripherl rteries. (20) Dilted ronchi nd ronchiectsis, s well s ir trpping (which is pronounced in the lower loes), re etter demonstrted through HRCT imging studies. Bronchil nstomosis complictions Complictions t the ronchil nstomosis occur in pproximtely 15% of lung trnsplnt recipients. Such complictions include ronchil stenosis (Figure 7), dehiscence, ronchomlci, exophytic grnultion tissue formtion nd nstomotic infection. (5) In 50% of cses, lloon dilttion or ronchil stent plcement is required. (5) Donor ronchus ischemi cused y disruption of the ntive ronchil circultion is key fctor underlying irwy complictions. (6) Pulmonry infection is n dditionl excerting fctor. In the erly postopertive period, ischemi cn result in ronchil dehiscence or fistul. (5) Bronchil dehiscence typiclly occurs within the first month fter lung trnsplnttion. Anstomotic dehiscence is identified sed on CT findings of ronchil wll defect, ronchil nrrowing (fixed or dynmic), ronchil wll irregulrity or extrluminl ir. (21) Multiplnr nd three-dimensionl CT reconstructions provide precise informtion regrding the extent of these complictions. Indirect fetures of ronchil nstomosis compliction include ir lek, mnifesting s pneumothorx, pneumomedistinum or stenosis nd resulting in poor llogrft expnsion, s evidenced y ipsilterl lung volume loss. (21) Unfortuntely, CT does not relily depict mucosl necrosis, which is the erliest sign nd useful predictor of dehiscence. When CT findings re negtive in ptients presenting clinicl or indirect fetures, direct ronchoscopy should e performed in order to identify possile mucosl necrosis. (21) Bronchil nstomotic stenosis nd ronchomlci re usully seen within the first 4 months fter lung trnsplnttion. However, the overll incidence of irwy complictions is decresing due to improvements in preservtion methods, surgicl techniques nd immunosuppressive therpy. Bronchil nrrowing due to stricture, with significnt stenosis, defined s reduction of more thn 50% in ronchil dimeter, (21) cn e seen on CT scns. In cses of ronchomlci, irwy collpse or trnsient nrrowing of the nstomosis (or of other irwy segments) cn e detected through expirtory CT or dynmic CT during respirtion. (21) Bronchomlci cn lso e detected t ronchoscopy during spontneous rething. (21) Figure 8 - Lymphoprolifertive disorder in recipient of doule lung trnsplnt. Imges t 8 months fter trnsplnttion: () xil HRCT scn showing multiple ilterl pulmonry nodules nd right pleurl effusion; nd () xil CT scn of the domen showing retroperitonel lymphdenomegly.

8 Computed tomogrphy findings of postopertive complictions in lung trnsplnttion 273 Post-trnsplnt lymphoprolifertive disorder Post-trnsplnt lymphoprolifertive disorder (PTLD) is n uncommon ut serious compliction of immunosuppressive therpy following solid orgn trnsplnttion. It hs een shown to occur in up to 5% of ptients, depending on the type of orgn trnsplnted, s well s on the type nd durtion of immunosuppressive therpy. (22) It is much more common for PTLD to occur fter lung trnsplnttion thn fter liver or kidney trnsplnttion. (22) The presenttion of PTLD consists of spectrum of lymphoid neoplsms tht re primrily of B-cell origin. (22) Approximtely 90% of ptients with PTLD re infected with Epstein- Brr virus. Seronegtive sttus for Epstein-Brr virus prior to trnsplnttion is thought to e mjor risk fctor for the development of PTLD, the incidence of which vries from 2.8% to 6.1% t 1 yer fter trnsplnttion. (22) When the disorder ppers in the erly postopertive period, it tends to follow enign course nd responds fvorly to ntivirl therpy nd reduction of immunosuppression. Lte disese, which cn develop more thn 1 yer fter trnsplnttion nd is predominntly ccompnied y extrthorcic involvement, is most often treted with chemotherpy nd irrdition. (22) The rdiogrphic mnifesttions of PTLD include multiple pulmonry nodules, predominntly in the peripherl nd sl zones (Figure 8). Other less common ptterns of involvement include ir spce consolidtion, medistinl/ hilr lymphdenopthy, msses (in the pleur or chest wll), effusion (pericrdil or pleurl) nd thymus enlrgement. (22) Finl considertions In summry, the most common nd significnt complictions of lung trnsplnttion re reperfusion edem, cute rejection, chronic rejection, CMV infection nd cryptogenic orgnizing pneumoni, s well s dehiscence or stenosis of the ronchil nstomosis. In lung trnsplnt recipients, finding of pulmonry infiltrtes, medistinl shift, pleurl effusion, pneumothorx or pneumomedistinum demnds further investigtion. References 1. Unilterl lung trnsplnttion for pulmonry firosis. Toronto Lung Trnsplnt Group. N Engl J Med. 1986;314(18): Hdjilidis D, Chprro C, Gutierrez C, Steele MP, Singer LG, Dvis RD, et l. Impct of lung trnsplnt opertion on ronchiolitis oliterns syndrome in ptients with chronic ostructive pulmonry disese. Am J Trnsplnt. 2006;6(1): de Perrot M, Chprro C, McRe K, Wddell TK, Hdjilidis D, Singer LG, et l. Twenty-yer experience of lung trnsplnttion t single center: Influence of recipient dignosis on long-term survivl. J Thorc Crdiovsc Surg. 2004;127(5): Trulock EP, Edwrds LB, Tylor DO, Boucek MM, Mohcsi PJ, Keck BM, et l. The Registry of the Interntionl Society for Hert nd Lung Trnsplnttion: Twentieth Officil dult lung nd hert-lung trnsplnt report J Hert Lung Trnsplnt. 2003;22(6): Wrd S, Müller NL. Pulmonry complictions following lung trnsplnttion. Clin Rdiol. 2000;55(5): Krishnm MS, Suh RD, Tomsin A, Goldin JG, Li C, Brown K, et l. Postopertive complictions of lung trnsplnttion: rdiologic findings long time continuum. Rdiogrphics. 2007;27(4): Kundu S, Hermn SJ, Winton TL. Reperfusion edem fter lung trnsplnttion: rdiogrphic mnifesttions. Rdiology. 1998;206(1): Yousem S. A perspective on the Revised Working Formultion for the grding of lung llogrft rejection. Trnsplnt Proc. 1996;28(1): King-Biggs MB. Acute pulmonry llogrft rejection. Mechnisms, dignosis, nd mngement. Clin Chest Med. 1997;18(2): Loueyre P, Revel D, Delignette A, Loire R, Mornex JF. High-resolution computed tomogrphic findings ssocited with histologiclly dignosed cute lung rejection in hert-lung trnsplnt recipients. Chest. 1995;107(1): Ersmus JJ, McAdms HP, Tpson VF, Murry JG, Dvis RD. Rdiologic issues in lung trnsplnttion for end-stge pulmonry disese. AJR Am J Roentgenol. 1997;169(1): Medin LS, Siegel MJ, Glzer HS, Anderson DJ, Semenkovich J, Bejrno PA, et l. Dignosis of pulmonry complictions ssocited with lung trnsplnttion in children: vlue of CT vs histopthologic studies. AJR Am J Roentgenol. 1994;162(4): Duer JH, Prdis IL, Dummer JS. Infectious complictions in pulmonry llogrft recipients. Clin Chest Med. 1990;11(2): Shreeniws R, Schulmn LL, Berkmen YM, McGregor CC, Austin JH. Opportunistic ronchopulmonry infections fter lung trnsplnttion: clinicl nd rdiogrphic findings. Rdiology. 1996;200(2): Anderson DC. Role of the imging specilist in the detection of opportunistic infection fter lung trnsplnttion: re we out of the loop? Rdiology. 1996;200(2): Knj SS, Welty-Wolf K, Mdden J, Tpson V, Bz MA, Dvis RD, et l. Fungl infections in lung nd hert-lung trnsplnt recipients. Report of 9 cses nd review of the literture. Medicine (Bltimore). 1996;75(3): Guillemin R, Lvrde V, Amrein C, Chevlier P, Guinvrc h A, Glotz D. Invsive spergillosis fter trnsplnttion. Trnsplnt Proc. 1995;27(1): Burns KE, Icono AT. Pulmonry emolism on postmortem exmintion: n under-recognized

9 274 Hochhegger B, Irion KL, Mrchiori E, Bello R, Moreir J, Cmrgo JJ compliction in lung-trnsplnt recipients? Trnsplnttion. 2004;77(5): Arkw H, Kurihr Y, Niimi H, Nkjim Y, Johkoh T, Nkmur H. Bronchiolitis oliterns with orgnizing pneumoni versus chronic eosinophilic pneumoni: high-resolution CT findings in 81 ptients. AJR Am J Roentgenol. 2001;176(4): Skeens JL, Fuhrmn CR, Yousem SA. Bronchiolitis oliterns in hert-lung trnsplnttion ptients: rdiologic findings in 11 ptients. AJR Am J Roentgenol. 1989;153(2): Semenkovich JW, Glzer HS, Anderson DC, Arcidi JM Jr, Cooper JD, Ptterson GA. Bronchil dehiscence in lung trnsplnttion: CT evlution. Rdiology. 1995;194(1): Scrsrook AF, Wrkulle DR, Dttni M, Trill Z. Post-trnsplnttion lymphoprolifertive disorder: the spectrum of imging ppernces. Clin Rdiol. 2005;60(1): Aout the uthors Bruno Hochhegger Resident. Snt Cs Sisters of Mercy Hospitl Complex, Porto Alegre, Brzil. Klus Loureiro Irion Consultnt Rdiologist. The Crdiothorcic Centre NHS Trust nd The Royl Liverpool nd Brodgreen University Hospitls, Liverpool, Englnd. Edson Mrchiori Professor of Rdiology. Fluminense Federl University, Niterói, Brzil. Rodrigo Bello Rdiologist. Snt Cs Sisters of Mercy Hospitl Complex, Porto Alegre, Brzil. José Moreir Full Professor of Pulmonology. Universidde Federl do Rio Grnde do Sul UFRGS, Federl University of Rio Grnde do Sul Porto Alegre, Brzil. José Jesus Cmrgo Physicin. Snt Cs Sisters of Mercy Hospitl Complex, Porto Alegre, Brzil.