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CASE REPORT
Year : 2020 | Volume
: 22
| Issue : 2 | Page : 245-249
First lung transplant recipient of Indian armed forces
Manjit Sharad Tendolkar1, Rahul Tyagi2, Apar Jindal3, Sandeep Attawar4, Ajay Handa5
1 Graded Specialist (Pulmonary Medicine), INHS Asvini, Mumbai, India
2 Classified Specialist (Pulmonary Medicine), Study Leave at AIIMS, New Delhi, India
3 MD (Pulmonary Medicine), Consultant Pulmonary Medicine at Gleaneagles Global Hospital, Chennai, India
4 MCh (Cardiovascular and Thoracic Surgery), Director of Lung Transplant Programme at Gleaneagles Global Hospital, Chennai, India
5 Senior Consultant (Pulmonary Medicine), Sakra World Hospital, Bangalore, Karnataka, India
Correspondence Address:
Surg Lt Cdr Manjit Sharad Tendolkar
Department of Respiratory Medicine, INHS Asvini, Colaba, Mumbai - 400 005, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jmms.jmms_26_20
In 2010, a 22-year-old female presented with progressive breathlessness and multiple joint pain in bilateral knee and wrist joints. She was diagnosed with rheumatoid arthritis (RA) based on the clinical as well as serological criteria, and her breathlessness was attributable to RA-associated interstitial lung disease. Despite being on immunosuppressants, her lung involvement continued to progress as she got dependent on oxygen at home for 2011 and required domiciliary noninvasive ventilatory support for 2017. The prognosis was grave as the disease continued to affect her lungs relentlessly despite all possible medical therapies. Our experience with lung transplants in service hospitals was nonexistent as it was not a common practice to refer patients for lung transplant because of inadequate data of its success in our country and the mammoth cost involved. However, in view of the emerging reports of successful lung transplantation and the risk benefit ratio favoring the patient, she was referred to a lung transplant center. The patient chose to have the lung transplantation at a hospital in Chennai. On May 22, 2018, the patient underwent a successful bilateral lung transplant. She is being managed with triple immunosuppression and antimicrobial prophylaxis at her home. Over the past 1½ year, the patient has developed one episode of bacterial pneumonia which was successfully managed with antibiotics. The patient continues regular visit at our hospital as she is able to work independently of any ventilatory support. We intend to narrate the experience of first-lung transplant recipient among our clientele.
Keywords: India, interstitial lung disease, lung transplant, pneumonia, rheumatoid arthritis
Lung transplantation in India has taken giant leaps over the past decade. Although the criteria of referral for lung transplantation are clear in the literature, the number of patients being referred for lung transplant in India are miniscule. We report the first-lung transplant referral from Army Medical Corps to receive a bilateral lung transplant and our experience in management of the patient.
Case ReportIn 2010, a 22-year-old lady, homemaker of a serving soldier presented to the outpatient department (OPD) of a command hospital with complaints of progressive breathlessness (Modified Medical Research Council [mMRC] Grade III), bilateral joint pain involving wrists and knees for 6 months duration. She was a known case of hypothyroidism. She had no other comorbidities and no significant past or family history. She is a mother of a healthy daughter. Clinical examination showed Grade II clubbing and bilateral fine crackles were heard over all areas of the chest. She had mild hypoxemia with oxygen saturation of 92% at room air in the resting state. On serological evaluation, her ESR was raised, rheumatoid factor was 384 IU/ml (normal: <40 IU/ml), and anticitrullinated peptide antibody (CCP) was 40 IU/ml (normal: 0–15 IU/ml). ANA by immunofluorescence was mildly raised (1:100); however, ANA blot was negative for its subtypes. Her total leukocyte count, liver enzymes, and creatinine were within the normal limits. Her chest X-ray was suggestive of low volume lungs and bilateral reticular shadows [Figure 1] and high-resolution computed tomography (HRCT) chest revealed evidence of interstitial lung disease with a usual interstitial pneumonia (UIP) pattern [Figure 2]. Spirometry documented restrictive pattern, and her DLCO was low. Echocardiography showed no evidence of pulmonary hypertension with a normal ejection fraction. In view of multiple joint pain associated with raised rheumatoid factor and antiCCP, she was diagnosed with rheumatoid arthritis (RA) as per 2010 ACR/EULAR criteria (Ref). Lung involvement was diagnosed to be interstitial lung disease (UIP) secondary to RA. She was managed with immunosuppression and DMARDs (prednisolone + hydroxychloroquine) and vaccination against influenza and pneumococcus.
Figure 1: Chest X-ray (posteroanterior view) at the initial presentation of the patient in 2010. Bilateral reticular shadows with low volume of lungs are noted
Figure 2: High-resolution computed tomography chest (2011). Subpleural cystic changes with æhoneycombingæ and interseptal thickening is noted. Radiologically suggestive of a usual interstitial pneumoniaDespite treatment, her lung disease progressed significantly, and the patient was dependent on domiciliary oxygen for 2011. She required multiple admissions over the next 6 years and had developed pulmonary hypertension. ILD had progressed as evident by the clinical and radiological findings [Figure 3]. Ventilatory failure had set in as suggested by rising PaCO2. She was using noninvasive ventilation at home and had become bed bound because of mMRC Grade IV breathlessness.
Figure 3: High-resolution computed tomography chest (2017) showing progression of disease over 6 years. Increase in the size and number of cystis is noted with interseptal thickening and traction bronchiectasis. Apico basal gradient is evidentAs patient was meeting the criteria for lung transplant referral, she was referred to a Lung Transplant Center in April 2018. The patient opted for a Lung Transplant Center in Chennai. She underwent a successful bilateral lung transplant on May 22, 2018. Postoperatively, she was managed with ventilatory support and immunosuppression. Within 7 days of transplant, the patient developed bilateral lung infiltrates and had evidence of diffuse alveolar damage which was confirmed with bronchoscopy and biopsy. It was consistent with acute cellular rejection. She received a pulse regimen of methylprednisolone for its management. In view of prolonged invasive ventilatory support, she was tracheostomized after 2 weeks posttransplant. Over the next 3 months at the lung transplant center, the patient continued her rehabilitation with chest physiotherapy and breathing exercises as she was weaned off ventilation and tracheostomy was decannulated. While at the transplant center in August 18, she underwent bronchial stenting of bilateral main bronchi in view of dynamic major airways collapse [Figure 4].
Figure 4: Three months postbilateral lung transplant. Lung parenchyma is clear. Endobronchial stents are noted bilaterallyIn view of satisfactory improvement in her general condition, the patient was discharged to home on 17 Aug 18 and was advised regular follow-up to rule out the signs of graft rejection by periodic transbronchial lung biopsies. The patient has undergone regular surveillance bronchoscopies to rule out graft rejection at 1 week, 4 weeks, 3 months, 6 months, 9 months, 12 months, and 15 months. With no evidence of graft rejection after the 1st week, the patient is on triple immunosuppression in the form of tablet Prednisolone 5 mg OD, tablet tacrolimus 2.5 mg BD (to target recommended trough level as per posttransplant period) and tablet mycophenolate mofetil 180 mg BD. She is receiving antimicrobial prophylaxis with tablet cotrimoxazole (single strength) OD, tablet voriconazole 200 mg OD, nebulized tobramycin 300 mg three times per week.
Over the next year, the patient had significant improvement in her lifestyle and has been visiting Pulmonology OPD at Command Hospital regularly without requiring any ventilatory or physical assistance. In Oct 19, the patient developed left lung pneumonia [Figure 5] which was confirmed by bronchoscopy as a bacterial pneumonia. The secretions of pneumonia had led to clogging of the left bronchial stent with secondary collapse of the left lung which opened up on clearing the secretions [Figure 6]. Culture grew Pseudomonas and Klebsiella which were sensitive to only Colistin among all the classes of antibiotics. She had an uneventful recovery with 14 days course of Carbapenems and Colistin.
Figure 5: High-resolution computed tomography chest (October 2019) Left lower lobe pneumonia. Bronchial wash isolated klebsiella and pseudomonas
Figure 6: Chest X-ray (posteroanterior view) Left Side Image: Left lung collapse due to clogging of stent by the secretions from underlying community-acquired pneumonia. Right Side Image: left lung expanded after bronchoscopy and pneumonia resolved after 2 weeks of antibioticsPatient continues regular follow-up at Pulmonology OPD in Command Hospital as well as the Lung Transplant Center.
DiscussionA glimpse into the history of human lung transplant takes us to the 1963 when lung transplant was first attempted by J D Hardy for squamous cell carcinoma of the lung where the patient survived for 18 days to die of renal failure.[1] Between 1963 and 1978, approximately 38 single-lung transplant, heart lung transplant, or lobe transplant were done. One patient got discharged,[2] and 9 survived beyond 2 weeks.[3] Most deaths were attributable to the leak of bronchial anastomosis in the 3rd postoperative week.[3] The first successful heart lung transplant took place in 1981 in a 45-year-old lady of primary pulmonary hypertension.[4] In 1983 Dr. Cooper et al. led a successful single-lung transplant in a case of idiopathic pulmonary fibrosis who survived for 7 years and died of renal failure.[5] The first successful double-lung transplant was done in 1986 in a case of alpha 1 antitrypsin deficiency.[6]
India's first heart lung transplant was done by Dr. Cherian at Madras Medical Mission, Chennai.[7] As per the reports in Indian Media, between 1999 and 2011, five foreigners have undergone lung transplant at various hospitals in South India. The first Indian to undergo a single-lung transplant was a 17-year-old girl suffering from an ILD, who underwent the transplant in a private hospital in Mumbai.[8] The data of lung transplant and its success in India are limited. The private sector of the southern part of India has a head start in lung transplantation. The statistics of lung transplants in Tamil Nadu as per the government registry are as presented here [Table 1] and [Figure 7]. The first-lung transplant in the public sector in India was a double-lung transplant done at PostGraduate Institute of Medical Education and Research on July 11, 2017, in a case of chronic extrinsic allergic alveolitis who died on the 14th postoperative day because of septic shock secondary to hospital-acquired pneumonia.[9] The lack of a national lung transplant registry in India limits our the analysis of postoperative survival among the lung transplant recipients. The published literature is yet to document the long-term survival statistics among transplant recipients in India. Indian data from the published literature are presented[7],[9],[10],[11][Table 2].
Table 1: Data from years 2008-2018 showing increasing number of lung transplants. Source: Transplant Authority of Tamil Nadu
Figure 7: Rising trend in the number of lung transplant over the years. Source: Transplant Authority of Tamil Nadu
Table 2: Indian case reports of patients receiving lung transplant. (Published literature reviewed till Oct 2019, present case is included)The patient reported above is Army Medical Corps first case to receive lung transplant. Her survival and healthy life beyond 18 months of transplant makes us optimistic for the future of lung transplantation as further referrals get lined up.
The number of lung transplantations in India is growing exponentially. As our expertise grows, an improved survival data among lung transplant recipients is expected in the coming years.[12] The improved survival data in turn are expected to increase the number of referrals exponentially as well. The costs involved for lung transplant are often more than half a crore rupee. Army medical corps is yet to have a lung transplantation programmed operationalized. Given the improved outlook toward lung transplant and the huge costs of referral we may soon have to develop our own lung transplant program to provide optimal treatment to our patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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