Answer
Answer
Acute rejection
Acute rejection may occur at any time (days to years) following transplantation, but it is primarily seen between 2 and 9 months. The diagnosis is based on the presence of perivascular or airway inflammatory infiltrates that are composed mainly of activated lymphocytes but also contain few eosinophils, neutrophils, and plasma cells. The intensity and the distribution of the infiltrate form the basis of the histologic grade. With multiple foci of rejection, the grade reflects the most advanced pattern of rejection rather than the predominant or average pattern.
It is imperative to note evidence of aspiration (see image below) or concomitant infection, because these may precipitate rejection. Clinical findings play no role in the histopathologic grading of lung transplant rejection.
Lung transplantation-related pathology. Intraalveolar multinucleated giant cell indicates microaspiration in this posttransplant transbronchial biopsy specimen (hematoxylin and eosin [H&E], 200x)
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Media Gallery
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Lung transplantation-related pathology. Intraalveolar multinucleated giant cell indicates microaspiration in this posttransplant transbronchial biopsy specimen (hematoxylin and eosin [H&E], 200x)
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Lung transplantation-related pathology. This image depicts minimal acute cellular rejection with incomplete perivascular cuff of inflammatory cells (grade A1) (hematoxylin and eosin [H&E], 200x).
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Lung transplantation-related pathology. This image shows mild acute perivascular rejection with a thick complete cuff around a blood vessel (grade A2) (hematoxylin and eosin [H&E], 200x).
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Lung transplantation-related pathology. Moderate acute perivascular rejection is revealed: The inflammation extends into adjacent alveolar walls and is accompanied by fibrinous exudates (grade A3) (hematoxylin and eosin [H&E], 200x).
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Lung transplantation-related pathology. Note the minimal acute airway rejection shown: There is focal inflammation in the submucosa (grade B1) (hematoxylin and eosin [H&E], 200x).
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Lung transplantation-related pathology. This image demonstrates mild acute airway rejection: There is a bandlike infiltrate in the submucosa (grade B2) (hematoxylin and eosin [H&E], 200x).
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Lung transplantation-related pathology. Moderate acute airway rejection is revealed: The inflammatory infiltrate extends into the overlying epithelium (grade B3) (hematoxylin and eosin [H&E], 200x).
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Lung transplantation-related pathology. This image shows bronchial-associated lymphoid tissue (BALT): A collection of small mature lymphocytes is present which is associated with pigment. Although no airway is seen in this figure, the morphologic appearance is not that of rejection (hematoxylin and eosin [H&E], 100x).
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Lung transplantation-related pathology. Bronchiolitis obliterans (chronic rejection) is revealed: The patient underwent retransplantation for chronic rejection, which is seen here as eccentric fibrosis partially occluding the airway lumen. Note the presence of scant inflammatory cells and plump fibroblasts in the lesion (hematoxylin and eosin [H&E], 100x).
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Lung transplantation-related pathology. This image demonstrates bacterial infection: The presence of mostly neutrophils in both the submucosa and mucosa is most suggestive of an infection (hematoxylin and eosin [H&E], 200x).
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Lung transplantation-related pathology. The image reveals cytomegalovirus (CMV) infection by immunohistochemical (IHC) staining: Both enlarged nuclei and normal-sized infected nuclei stain positively. This feature is helpful when viral inclusions are not readily apparent on hematoxylin and eosin (H&E) stain. (IHC stain using antibody against immediate early antigen, 200x)
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Lung transplantation-related pathology. This image demonstrates posttransplant lymphoproliferative disorder (PTLD): There is a diffuse infiltrate of atypical lymphoid cells, obliterating the lung architecture, with a foci of necrosis, as would be seen in a large-cell lymphoma (hematoxylin and eosin [H&E], 200x).
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