Answer
Antibody-mediated rejection
Antibody-mediated rejection, also called humoral or hyperacute rejection, is not included in the ISHLT classification owing to the scarcity of reports in the literature. There is no consensus on its recognition and diagnosis by either histopathologic or immunologic methods, nor on its significance and treatment.
Antibody-mediated rejection is characterized by the activation of inflammatory pathways along with the complement and coagulation cascades due to the binding of preformed antibody to endothelial cells. Progressive respiratory failure within minutes to hours after transplantation suggests antibody-mediated rejection. It is also thought to occur weeks or months after transplantation upon development of serum antibodies. Histologic evaluation reveals diffuse alveolar damage (DAD), fibrin thrombi, vasculitis, intraalveolar hemorrhage, and interstitial neutrophilia.
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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).
