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The Treatment of Refractory Pneumothorax in Diffuse Panbronchiolitis by Intravenous Administration of Coagulation Factor XIII Concentrate

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The Treatment of Refractory Pneumothorax in Diffuse Panbronchiolitis by Intravenous Administration of Coagulation Factor XIII Concentrate !Report on Experiments and Clinical Cases! The Treatment of Refractory Pneumothorax in Diffuse Panbronchiolitis by Intravenous Administration of Coagulation Factor XIII Concentrate Akira Murata, Ayumi Kouno, Kazuo Yamamoto, Hiroko Yoshioka, Kozui Kida and Shoji Kudoh Department of Pulmonary Medicine, Infection and Oncology, Nippon Medical School Abstract This case report presents a patient with advanced diffuse panbronchiolitis accompanied by chronic respiratory failure, marked cachexia, and refractory spontaneous pneumothorax. Because instillation of a pleurodesis agent and thoracoscopy were considered highly risky and invasive, we instead treated the patient with intravenous administration of a coagulation factor XIII concentrate, and the pneumothorax resolved. This case suggests refractory pneumothorax in a restrictive ventilatory disorder can be effectively treated with noninvasive intravenous administration of coagulation factor XIII concentrate. (J Nippon Med Sch 2006; 73: 89!92) Key words: coagulation factor XIII, persistent air leak, intravenous administration, refractory peumothorax bronchial fistula is present, we usually start Introduction treatment with long-term tube thoracostomy and instillation of a pleurodesis agent. Thoracoscopy will Diffuse panbronchiolitis ( DPB ) was first be considered only when theses treatments are distinguished from chronic obstructive pulmonary unsuccessful. However surgery itself poses a disease in the early1960s and was recorded as a new significant risk for patients whose physical condition clinicopathologic entity. This disease is observed and lung function have deteriorated. mostly among East Asians and is characterized by Coagulation factor XIII stabilizes fibrin at the final chronic sinobronchial infection and diffuse bilateral stage of homeostasis, stabilizes fibrinogen, and stops micronodular lesions consisting of inflammatory cells. bleeding. It is also an important factor for restoring The current data suggest that the patholosiology of organization and wound healing1. Therefore, a fall in DPB is similar to that of cystic fibrosis and the activity of coagulation factor XIII is an obstacle bronchiectasis. End-stage DPB is occasionally to the wound healing and is a cause of prolonged air complicated by pneumothorax, which makes leakage in refractory pneumothorax. treatment more difficult. We report on a patient with refractory In cases of prolonged air leakage in which a fistula peumothorax, a poor general condition, and a on the surface of lung dose not close and no decreased pulmonary function who we successfully Correspondence to Akira Murata, Department of Pulmonary Medicine, Infection and Oncology, Nippon Medical School, JPR Ichigaya Building 8F, 4!7!15 Kudan-minami, Chiyoda-ku, Tokyo 102!0074, Japan E-mail: [email protected] Journal Website (http:!!www.nms.ac.jp!jnms!) J Nippon Med Sch 2006; 73 (2) 89 A. Murata, et al Fig. 1 Plain chest roentgenograms The left side (A) shows peumothorax with a drainage tube, and the right side (B) shows the re-expanded lung after infusion of factor XI I I . treated with infusion of coagulation factor XIII pleurodesis agent and thoracoscopy were considered concentrate. highly risky for this patient because of advanced DPB , severe hypoxemia , hypercapnia , and Case Report emaciation (Fig. 2). On the 19th hospital day, activity of coagulation A 49-year-old Japanese woman with a 6-year factor XIII decreased to 48% (normal, >70%), and history of advanced DPB was treated with coagulation factor XIII concentrate (6 vials!day, erythromycin, 600 mg daily, and had received Fibrogammin P, Aventispharma Co., Ltd.) was oxygen therapy over the previous 2 years. She was administered intravenously for 5 days, from the 20th th th admitted to our hospital because of hypercapnia! ( O2 to the 24 day. Air leakage resolved on the 25 day, 2L!min., nasal inhalation" pH 7.359; PaCO2, 72.9 the pneumothorax decreased, and the collapsed lung ! mmHg; PaO2, 52.1 mmHg; HCO3 , 40.1 mmol!l;base was re-expanded. However, just after starting excess, 12.0 mEq!l;arterialO2 saturation !SaO2", rehabilitation, the patient caught a cold and 85.2%) and severe pulmonary dysfunction (vital complained of a low-grade fever and persistent capacity!VC",1.07L;%VC,41.3%;forcedexpiratory cough. Air leakage occurred again on the 37th day. volume 1 sec !FEV1",0.59L;FEV1%, 67.8%; %FEV1, When treatment of the cold began, the symptoms 85.2%; residual volume!total lung capacity, 57.8%) disappeared. The change was confirmed from the with marked emaciation (body height, 152 cm; body blood test result; c-reactive protein level was weight, 32.6 kg; body mass index, 14.1; serum improved to the normal level. Because the activity of albumin, 3.7 g!dl). Sputum culture was positive for coagulation factor XIII remained low at 56%, Pseudomonas aeruginosa. coagulation factor XIII concentrate was again given On the second day of hospitalization (Day 2), the intravenously for 5 days, from the 51st to the 55th patient complained of right-side chest pain and day. Air leakage resolved on the 55th day. The rd worsening dyspnea (pH, 7.305; PaCO2, 81.6 mmHg; drainage tube was clamped on the 63 day and was ! PaO2, 47.6 mmHg; HCO3 39.4 mmol!l;SaO2, 78.9%). removed 2 days later (Fig. 1-B). The patient then Chest X-ray films demonstrated a large started rehabilitation because of generalized muscle pneumothorax (Fig. 1-A). Air leakage continued atrophy during hospitalization. She was discharged despite tube thoracostomy. Instillation of a on the 79th day. The activity of coagulation factor 90 J Nippon Med Sch 2006; 73 (2) The Treatment of Refractory Pneumothorax in DPB Fig. 2 Clinical course The pneumothorax occurred on the second day of hospitalization. The coagulation factor X I I I concentrate was first administered intravenously from the 20th to the 24th day. Leakage resolved on the 25th day, and the lung expanded. Air leakage occurred again on the 37th day. Because the activity of factor XI I I was low at 56%, coagulation factor XI I I concentrate was again given intravenously for 5 days, from the 51st to the 55th day. Air leakage resolved on the 55th day. The drainage tube was clamped on the 63rd day and was removed 2 days later. The patient was discharged on the 79th day. XIII was 83% at the time of discharge. enhances binding to fibrin4. Therefore, wound healing becomes slower when levels of coagulation Discussion factor XIII decrease, for example, in congenital factor XIII deficiency disease, after surgery in Secondary spontaneous pneumothorax in DPB is severe liver dysfunction, and blood diseases5!8. rare2. However, for patients with advanced DPB, Duckert et al have reported one case of congenital prolonged pneumothorax accompanied by air coagulation factor XIII deficiency in which wound leakage is occasionally refractory because of severe healing was delayed9. More recent reports indicate hypoxemia , malnutrition , frequent bronchiolar that hemorrhagic tendency can be controlled by infections with resistant strains of bacteria, or a poor replacement therapy with a small amount of general condition. The treatment of pneumothorax coagulation factor XIII10. associated with DPB , cystic fibrosis , or However, a large amount of coagulation factor bronchiectasis is similar to that for pneumothorax XIII is needed to enhance wound healing11,12.Other associated with chronic obstructive pulmonary reports have also recognized the beneficial effects of disease3. factor XIII replacement therapy in patients with The failure of a fistula on the surface of lungs to acute therapy-resistant ulcerative colitis 13 and close causes prolonged air leakage and is affected by Crohns disease fistulas14. many factors: age, sex, condition of the wound, Therefore, we administered coagulation factor infection, the patients general condition and XIII intravenously to a patient with refractory nutrition level, and activity of coagulation factor pneumothorax and advanced DPB. XIII. Of these factors, coagulation factor XIII has the We were able to stop the prolonged air leakage most important role in wound healing, because it is and treat refractory pnemothorax with a coagulation present in the blood and in many kinds of tissue4. factor XIII concentrate. Therefore, we recommend Coagulation factor XIII activates coagulation coagulation intravenous administration of factor XIII factor XIII, interferes with enzymatic function, and concentrate (3"6 vials!day, 5 days) with the J Nippon Med Sch 2006; 73 (2) 91 A. Murata, et al following guidelines. The indications and contraindications we have References presented in this study are new perception. We believe that coagulation factor XIII concentrate is 1!Lorand L, Losowsky MS, Miloszewski KJM: Human not always effective for every patient with factor XIII: Fibrin-stabilizing factor. Prog Hemost Thromb 1980; 5: 245"290. pneumothorax because several factors can delay 2!Kudoh S, Keicho N: Diffuse Panbronchiolitis. wound healing. There are also well-established Seminars in Respiratory and Critical Care Medicine " treatments that are tried before coagulation factor 2003; 24: 607 617. 3!Miller AC, Harvey JE: Guidelines for the XIII concentrate is administered. For example, even management of spontaneous pneumothorax . though the activity of coagulation factor XIII is less Standard of Care Committee. British Thoracic Society. BMJ 1993; 307: 114"116. than 70% of the normal value, infection causing 4!Ueda H, Iwasaki A, Kusano T, et al.: Use of Plasma severe pneumonia, sepsis, and pyothorax, and
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