Obstrüktif uyku apne sendromu (OUAS) hastalarında vasküler hastalık riski artmıştır. Bu hastalarda kardiyovasküler hastalık gelişimine ait kesin mekanizma bilinmemektedir. Fibrinojen normal plazmanın ana bileşenidir. Akut faz reaktanı olan fibrinojen düzeyleri inflamatuar yanıtın bir parçası olarak yükselmektedir. Fibrinojenin koroner arter hastalığı ve inme için bağımsız risk faktörü olduğu gösterilmiştir. Çalışmamızda yeni orta/ağır OUAS tanısı almış hastalarda ve non-apneik olgularda plazma fibrinojen düzeylerini karşılaştırmayı ve polisomnografi (PSG) parametreleri ile ilişkisini değerlendirmeyi amaçladık. Tüm gece PSG sonrası yeni tanı almış 50 orta ve ağır OUAS olgusu ile 33 nonapneik kontrol olgu çalışmaya dahil edilmiştir. uyku çalışmasının ardından sabah 8.00-9.00 saatleri arasında kan örnekleri alınarak plazma fibrinojen düzeyleri Clauss metodu ile ölçülmüştür. Her iki grup arasında yaş, cinsiyet, sigara alışkanlığı açısından fark saptanmadı. Plazma fibrinojen düzeyleri OUAS grubunda (4.2 ± 0.14 g/L) kontrol grubuna göre anlamlı derecede yüksek bulundu (p<0.028). Plazma fibrinojen düzeyleri; Epworth uykululuk skalası (ESS) skoru (r=0.301, p=0.006), yaş (r=0.327, p=0.003), beden kitle indeksi (BKİ) (r=0.388, p<0.001), ortalama oksijen desaturasyonu (r=0.258, p=0.019), oksijen desaturasyon indeksi (r=0.281, p=0.010), oksijen satürasyonunun % 90’ın altında kalma süresi (r=0.248, p=0.024) ve arousal indeksi (r=0.220, p=0.046) ile pozitif korele idi. Plazma fibrinojen düzeyleri ile uykudaki oksijen saturasyonu arasında (r= -0.254, p=0.029) negatif korelasyon mevcuttu. Çoklu doğrusal regresyon analiz ile EUS skoru ve BKİ’nin, AHİ’den bağımsız olarak, fibrinojen düzeyleri ile ilişkili değişkenler olduğu saptanmıştır. Sonuçta plazma fibrinojen düzeyleri ile ESS ve BKİ’nin ilişkili olduğu bulunmuştur. Fibrinojen düzeyleri ve nokturnal desaturasyon arasındaki ilişki, hipoksi inflamasyon ilişkisini desteklemektedir. Yüksek fibrinojen düzeylerinin OUAS’lı hastalarda vasküler hastalık gelişimi için önemli bir faktör olabileceği sonucuna varılmıştır.

Introduction Chemokine (C-C motif) ligand 18 (CCL-18) has been shown to be elevated in chronic obstructive pulmonary disease (COPD) patients. This study primarily aimed to evaluate whether the serum CCL-18 level differentiates the frequent exacerbator COPD phenotype from infrequent exacerbators. The secondary aim was to investigate whether serum CCL-18 level is a risk factor for exacerbations requiring hospitalization. Materials and methods Clinically stable COPD patients and participants with smoking history but normal spirometry (NSp) were recruited for the study. Modified Medical Research Council Dyspnea Scale, COPD Assessment Test, spirometry, and 6-min walking test were performed. Serum CCL-18 levels were measured with a commercial ELISA Kit. Results Sixty COPD patients and 20 NSp patients were recruited. Serum CCL-18 levels were higher in COPD patients than those in NSp patients (169 vs 94 ng/mL, P<0.0001). CCL-18 level was significantly correlated with the number of exacerbations (r=0.30, P=0.026), although a difference in CCL-18 values between infrequent and frequent exacerbator COPD (168 vs 196 ng/mL) subgroups did not achieve statistical significance (P=0.09). Serum CCL-18 levels were significantly higher in COPD patients who had experienced at least one exacerbation during the previous 12 months. Overall, ROC analysis revealed that a serum CCL-18 level of 181.71 ng/mL could differentiate COPD patients with hospitalized exacerbations from those who were not hospitalized with a 88% sensitivity and 88.2% specificity (area under curve: 0.92). Serum CCL-18 level had a strong correlation with the frequency of exacerbations requiring hospitalization (r=0.68, P<0.0001) and was found to be an independent risk factor for hospitalized exacerbations in the multivariable analysis. Conclusion CCL-18 is a promising biomarker in COPD, as it is associated with frequency of exacerbations, particularly with severe COPD exacerbations requiring hospitalization, as well as with functional parameters and symptom scores.

Interstitial lung disease (ILD) is a negative prognostic factor associated with increased morbidity and mortality in patients with dermatomyositis (DM). Spontaneous pneumomediastinum is a rare complication of DM and it can be fatal. We present a 48-year-old woman with DM and ILD complicated by pneumomediastinum without pneumothorax and subcutaneous emphysema.

Background: Catheter-directed therapy (CDT) for pulmonary embolism (PE) is considered as an alternative to systemic thrombolysis (ST) in patients with hemodynamically unstable acute PE who are considered at high bleeding risk for ST. We aimed to evaluate the efficacy and safety of CDT in the management of acute PE with right ventricular dysfunction (RVD). The primary outcomes were mortality, clinical success, and complications. Secondary outcomes were change in hemodynamic parameters in the first 24 hours following the procedure.Material/Methods: Medical records of consecutive patients diagnosed as having acute massive or submassive PE with accompanying RVD treated by immediate CDT at our institution from January 2007 to January 2014 were reviewed. Patient characteristics, mortality, achievement of clinical success, and minor and major bleeding complications were analyzed in the overall study group, as well as massive vs. submassive PE subgroups. Change in hemodynamic parameters in the second, eighth, and 24th hours after the CDT procedure were also analyzed.Results: The study included 15 consecutive patients (M/F=10/5) with a mean age of 54.2 +/- 16.6 years who underwent immediate CDT. Nine of the patients had submassive PE, and 6 had massive PE. In-hospital mortality rate was 13.3% (95% CI, 0.04-0.38). One major, but not life-threatening, bleeding episode was evident in the whole group. Hemodynamic parameters were stabilized and clinical success was achieved in 14/15 (93.3%; 95% CI, 70.2-98.8) of the patients in the first 24 hours. Notably, the hemodynamic recovery was significantly evident in the first 8 hours after the procedure.Conclusions: CDT is a promising treatment option for patients with acute PE with RVD with no fatal bleeding complication. In experienced centers, CDT should be considered as a first-line treatment for patients with acute PE and RVD and contraindications for ST, with the advantage of providing early hemodynamic recovery.

SESSION TITLE: Diffuse Lung Disease Global Case Reports SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Sarcoidosis and Sjögren's syndrome (SS) are both multisystemic diseases of unknown etiology. Sarcoidosis is a multisystemic granulomatous disease of unknown etiology. Although, lungs and the tracheobronchial tree are the most common involvement sites in sarcoidosis it can rarely effect the salivary and lacrimal glands. On the other hand, SS mainly affects the exocrine glands, but it may also have systemic manifestations. Occasionally some features of sarcoidosis may mimic SS when parotid and/or lacrimal gland involvement is present. Although they are different clinical entities there are several reports suggestive of sarcoidosis and coexisting Sjögren's syndrome in the literature (1, 2). CASE PRESENTATION: A 58 years-old Caucasian female presented with dry cough, exertional dyspnea, progressive dry mouth and dry eyes. Physical examination was unremarkable except dryness of oral mucosa and bilateral basal crackles. Laboratory examinations revealed an increased erythrocyte sedimentation rate, C-reactive protein. Routine hematological laboratory and blood chemistry values were normal. Chest radiograph showed bilateral hilar lymphadenopathy and lower zone reticular infiltrates. Chest computed tomography revealed multiple mediastinal and bilateral hilar lymphadenopathies in addition to bilateral pulmonary nodules with peribronchovascular involvement. A mild restrictive ventilatoty defect and mild reduction in carbon monoxide diffusion capacity was observed on pulmonary function tests. She underwent bronchoscopy. A transbronchial fine needle aspiration biopsy from the right lower paratracheal station revealed non-caseating granulomatous inflammation. Serum angiotensin converting enzyme level was elevated. Antinuclear antibody and antibodies against SS-A / Ro were positive. Bilateral Shirmer's tear test yielded positive. Histopathological examination of minor salivary glands showed periductal lymphocytic infiltration. The patient was diagnosed with coexisting SS and sarcoidosis. Treatment with prednisolon and hidroxychloroquine were started. During a 2 year follow-up clinical symptoms and laboratory findings normalized. Radiographic findings regressed. Corticosteroids were tapered and stopped. Until now, the patient has been treated with hidroxychloroquine with no major symptoms and findings. DISCUSSION: Our patient was considered as sarcoidosis on the basis of compatible clinical, radiological findings and histopathological verification of noncaseating granulomas in mediastinal lymph node biopsy. Elevated serum angiotensin converting enzyme also supported sarcoidosis diagnosis. On the other hand, diagnosis of SS was based on dry eye and dry mouth sympthoms, positive bilateral Schirmer's test, the presence of characteristic autoantibody (anti-Ro/SS-A) in addition to evident lymphocytic sialoadenitis in salivary gland biopsy (3). Sarcoidosis and SS share similar immunologic and histopathological features. Making a differential diagnosis between these two diseases may be difficult in cases that present with common clinical features. On the other hand, it was shown that the frequency of sarcoidosis is higher in patients with SS than in the general population (2). Immunologic profile with a high ANA, RF and anti-Ro/SS-A was shown to have an important role in differentiating between sarcoidosis mimicry or coexistence with SS in addition to biopsy. CONCLUSIONS: We emphasize that both sarcoidosis and SS may coexist as illustrated in our case. Analysis of autoantibodies may be very helpful in making differential diagnosis or deciding their coexistence. Currently, the acceptance of sarcoidosis as an exclusion criteria for SS diagnosis may lead to under-diagnosis of SS in these cases. A revision for exclusion criteria of SS diagnosis might be necessary with this respect. Reference #1: Mansour MJ, et. al. Coexistence of Sjogren's syndrome and sarcoidosis: a report of five cases. J Oral Pathol Med 2007:36:337-341. Reference #2: Ramos-Casals M, et. al. Sarcoidosis or Sjogren Syndrome? Clues to defining mimicry or coexistence in 59 cases. Medicine 2004: 83: 85-95. Reference #3: Vitali C, et. al. Classification criteria for Sjogren's syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis 2002;61:554-558. DISCLOSURE: The following authors have nothing to disclose: Asli Gorek Dilektasli, Ezgi Demirdogen Cetinoglu, Eda Durmus, Esra Uzaslan, Ercument Ege, Mehmet Karadag No Product/Research Disclosure Information

Driving performance is known to be very sensitive to cognitive-psychomotor impairment. The aim of the study was to determine the relationship between obesity, risk of obstructive sleep apnoea (OSA), daytime sleepiness, history of road traffic accident (RTA) and performance on a driving simulator, among commercial drivers.

BACKGROUND :Cathater-directed therapy(CDT)has been considered as an alternative to systemic thrombolysis(ST) in acute pulmonary embolism(PE) in the presence of contraindications for ST.We aimed to evaluate the efficacy and safety of CDT compared to SIT in acute PE management with right ventricular dysfunction(RVD). MATERIAL-METHODS: Acute PE patients with RVD diagnosed between 2007-2013 treated by CDT were included.Afterwards PE patients treated by CDT were matched by age,sex,mean pulmonary artery pressure,and shock index at admission with a PE patient whom recieved ST.The primary,secondary and tertiary outcomes were mortality,complications and the change in haemodynamic parameters in thefirst 24 hours. RESULTS: Thirty-two acute PE patients(58.5±15.3 years old)were included.Seventeen(53%)and fifteen(47%)of the study group were diagnosed as massive and submassive PE, respectively. CDT was performed in six(40%)patients with massive PE and nine(60%)with submassive PE. All-cause mortality,major and minor bleeding complications did not differ among CDT and ST groups(p>0,05). Haemodynamic parameters were stabilized in 93% of CDT group and76.5% of the ST group in thefirst 24 hours(p>0,05).24 th hour systolic blood pressure(116±13mmHg vs.110±23 mmHg,p=0.078)and diastolic blood pressure(72±4mmHg vs.67±9 mmHg,p=0.017)were found to be higher while heart rate(88±16mmHg vs.90±10 mmHg,p=0.068)were found to be lower in the CDT group. CONCLUSION: CDT is a safe and effective treatment option for acute PE with RVD.It should be considered as a first-line treatment for patients having contraindications for ST with acute PE and RVD in experienced centers.

Purpose:ILD patient's oxygenation should be asses at baseline and during follow-up evaluation. The increase in the red cell distribution width (RDW)is independent predictors of coronary thrombus burden and associated with increased mortality risk in patients with respiratory insufficiency.Our aim was to evaluate the correlation between hypoxemia and age, length of stay hospital,biochemical parameters, RDW, in-hospital mortality in patients with ILD. Method:A retrospective study was conducted on 184 patients who hospitalized for diffuse ILD in Pulmonary Department between 2010-2013. Results:The mean age of the patients was 62±13 and 51% were female. Patients were classified according to their partial oxygen pressure (PO2) values; 7% of the patients were severe hypoxemia (< 40mmHg), while 20%were moderate hypoxemia (40-59mmHg), 18% were mild hypoxemia and 23%were non hypoxemic. In patients with severe or moderate hypoxemia white blood cells count was higher and pH values were lower than those who were not hypoxemics(p=0.004,p=0.005,p=0.001,p=0.003respectively). The RDW level had a mean value of 16.7±2.8 and RDW values were significantly higher in severe hypoxemic patients than the patients had no hypoxemia(p=0.009).No significant correlation was observed between PaO2 levels of ILD patients and age, length of stay in hospital, biochemical parameters on admission and in-hospital mortality. Conclusion: Diffuse ILD seems to occur in elderly patients and hypoxemia can be observed during hospitalization. Although no correlation was observed between level of hypoxemia and length of stay in hospital or mortality,high RDW levels in severe hypoxemic patients may be secondary to right heart failure.

BACKGROUND:The aim of the study was to determine the relationship between obesity, berlin questionnaire (BQ), epworth sleepiness scale (ESS), past history of road traffic accident(RTA) and performance on driving simulator among heavy vehicle drivers. MATERIAL-METHODS:We examined 282 heavy vehicle drivers admitted for driving simulator test in psychotechnique driver assessment system.The risk of obstructive sleep apnea(OSA)and excessive daytime sleepiness (EDS)was assessed by BQ and ESS. Computer-based system including tests assessing psychomotor-cognitive skills required for driving was developed by TUBITAK-ODTU and BILTEN. RESULTS:The mean age of the drivers were 45.4±8.8. Thirty drivers were at high risk for OSA with BQ. Median ESS of the group were 2 (0-20). Seventy-two drivers had past history of RTA. 86.9% of the subjects “passed” the simulator test; and 12.4% “failed”. 47%of the subjects at high risk of OSA failed in early reaction time test while 28% of the drivers with low risk of OSA failed(p<0.03). The obese drivers failed the peripheral vision test when compared with BMI<30kg/m2 (p<0.02). ESS was increased in drivers with a past history of RTA when compared with no RTA(p=0.02). CONCLUSION:Cognitive-psycohomotor functions can be impaired in obese subjects and people with high risk of OSA assessed by BQ.Driving performance is very sensitive to cognitive and psycohomotor impairment.We conclude that a risk assessment procedure for screening based on BMI and OSA risk should be applied during the driving licence application procedure of heavy vehicle drivers.

BACKGROUND:Obstructive sleep apnea (OSA) may increase perioperative complications. The aim of this study was to determine the relationship among postoperative pulmonary complication, snoring and STOP questionnaire in patients with ortophaedic surgery. METHODS:1,406 consecutive records of patients who had undergone elective ortophaedic surgery during the period January 2005-December 2008 were investigated retrospectively. Demographic information, sleep symptoms, STOP questionnaire, comorbidities and outcome data were collected. RESULTS:There were 289 (20.5%) snorers and 1,117 (79.5%) non-snorers in the study group. There was no significant difference between snorer and non-snorer patients (p > 0.05) in the prevalence of pneumonia and respiratory failure. But in snorer patients the rate of postoperative atelectasis was significantly higher than in non-snorer group (p < 0.0001). The STOP Questionnaire was given to 1,406 patients and 147 (10.4%) out of them were classified at high risk of OSA. There was no significant difference in the prevalence of pneumonia and respiratory failure between low and high risk group (p > 0.05). However, in high risk patients the occurrence of postoperative atelectasis was significantly higher than in low risk group (p < 0.0001). CONCLUSION:Postoperative atelectasis was significantly more prevalent in the high risk group according to STOP questionnaire.

INTRODUCTION: Intrapleural fibrinolytics are considered as an acceptable treatment modality in selected patients with complicated parapneumonic effusion (CPE) and empyema that may reduce the need for surgery. METHODS: In order to assess the clinical efficacy of streptokinase use, we retrospectively analysed data of patients with empyema and CPE in patients whom were treated with intrapleural streptokinase treatment in last five years. RESULTS: Eighty-eight patients treated with intrapleural streptokinase between 2007-2012 in Uludag University Pulmonology Department were recruited. The mean age of the study group was 54±17 and 74% were male. According to the Light’s pleural effusion classification 30% of the patients were Stage2 while 17% were Stage3, 37% were Stage4, 10% were Stage5, 4% were Stage6 and 2% were Stage7.Hemorrhagic complications were noted in 10 patients.Successful drainage was obtained in 61% in the overall group.75% of the patients recovered without need for surgery in the follow-up period.The pleural fluid lactate dehydrogenase(LDH)and adenosine deaminase(ADA)levels were significantly higher and glucose levels were lower in patients whom recovered with intrapleural streptokinase without surgery when compared with the ones who need surgery(p=004,p=0.03,p=0.03,respectively). CONCLUSION: Intrapleural streptokinase administration improves pleural drainage and may decrease the need for operative intervention. Therefore is considered one of the safe and effective treatment option for patients with parapneumonic effusion and empyema. Furthermore according to our results some biochemical parameters of pleural fluid might help to predict the response to treatment.

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality worldwide. Acute exacerbation of COPD (AECOPD) is associated with increased mortality. Material-Methods: We included COPD patients whom admitted to a tertiary reference center in Southern Marmara Region and hospitalized with acute exacerbation in the last two years. Medical records of the study participants were screened retrospectively in order to analyze in-hospital mortality and affecting factors on mortality in AECOPD patients. Results: We identified a total of 242 patients hospitalized for AECOPD. Of these 86.4% (n=209) were male. The mean age of the group was 66.6±11 years old. 11 patients lost follow-up. 9 % (n=21) of the patients died. The median length of stay for hospitalization was longer in the lost patients (19.5 [min: 1-36] days vs. 10.0 [min: 1-36] days, p<0.05). The median Charlson comorbidity index was 3.0 [min: 0-12] in the overall group and total score was not different among alive and dead patients. On the other hand, mortality rate was higher in patients with concomitant lung cancer (23.8% vs. 7.5%, p<0.05). Comorbid conditions other than lung cancer were not affecting mortality outcome. C-reactive protein levels on admission were significantly higher in patients who died than the alive ones (1.96 [min: 0.3-29.8] mg/dL vs. 5.67[min: 0.3-26.4] mg/dL, p<0.05). Conclusion: The mortality of AECOPD is high. AECOPD patients with lung cancer are at risk for poor outcome. And, high CRP levels during AECOPD episode correlate with short-term prognosis.

Introduction: The prevalence and hospitalization of COPD in women are increasing in developing countries.Little is known about gender differences in acute exacerbations of COPD (AECOPD).Objective: We aimed to evaluate if gender is a risk factor that has effects on clinical characteristics of the patients with AECOPD. Methods: We included patients whom admitted and hospitalized a tertiary reference center with AECOPD between 2011-2013 years.Medical records of the study participants have been screened retrospectively for 24 months. Results :A total of 242 patients (209 males, and 33 females) hospitalized for AECOPD were included. Mean age, clinical findings and routine laboratory tests on admission did not differ between males and females.In arterial blood gas analyzes PaCO2 levels were found to be significantly higher in females than the males [53.8 mmHg (min:28.6-max:102.5) mmHg],[42.4 mmHg (min:24 - max:109.1 mmHg].Also HCO3 and pH levels of females were significantly higher than males. Percentage of the patient more than one comorbidities were significantly higher in females than the males (30% vs 11%).Diabetes mellitus (F/M: 27%/12%, p<0.05), hypertension (F/M: 36% /21%, p=0.07), and obesity (F/M: 21%/1%,p<0.05) were also more prevelant in females with AECOPD. Lung cancer was only detected in males(10%). Gender was not an effecting factor on mortality in patients with AECOPD. Conclusion:Female COPD patients were tend to be more hypercapnic than the males on admission.Although comorbidities are common in hospitalized patients, their relative distribution varies by gender. Therefore the effects of different comorbidities in gender related AECOPD hospitalization needs to be verified with further studies.

Erdheim-Chester disease (ECD) is a rare, non-Largerhans histiocytosis with multisystem involvement. Pulmonary involvement is uncommon. We present a 46-year-old woman who presented with chronic chough, dyspnea and yellowish plaques in the periorbital area. She was previously diagnosed as diabetes insipidus. Chest radiographs showed bilateral diffuse interstitial infiltrates. Symmetric sclerotic bone lesions, dural nevre thickening were defined on imaging studies. Histopathologic examination of the skin lesions revealed infiltration of CD-68 positive foamy histiocytes. She was diagnosed as ECD with pulmonary, pituitary, skeletal, orbita, central nervous system and skin involvement. Following first-line treatment with corticosteroids her syptoms worsened. Treatment with interferon-alpha was started. She had an marked improvemet in symptoms, radiologic findings and skin involvement under this treatment. Conclusion: ECD should be considered in the differential diagnosis of interstitial lung diseases. As there is no standard treatment for this disorder, interferon-alpha can be effective in the treatment of Erdheim-Chester disease.

Obstruktif Uyku Apne Sendromlu (OSAS) hastalarda uyku sirasinda tekrarlayan apne periyodlarinin olmasi santral sinir sistemi uzerinde degisikliklere neden olmaktadir. MR Spektroskopi santral sinir sistemini etkileyen cesitli durumlardaki lokal metabolik degisikliklerin saptanabildigi non invaziv bir magnetik rezonans yontemidir. Bu calismanin amaci orta ve agir OSAS olgularindaki serebral metabolizma degisikliklerini belirlemek ve continious positive airway pressure (CPAP) tedavisi sonrasinda serebral metabolizmada duzelme olup olmadigini arastirmaktir. Calismaya 19 orta ve agir OSAS hastasi alindi. Calisma grubuna polisomnografi, epworth skalasi, MR spektroskopi ve norokognitif testler uygulandi. 3 ay CPAP tedavisi sonrasinda nookognitif testler ve MR spektroskopi tekrarlandi. MR spektroskopide frontal beyaz cevher, frontal korteks, talamus ve hipokampustan N-asetil aspartat (NAA), kolin (Cho) ve kreatinin (Cr) olcumleri yapildi. Olgularin tedavi oncesi ve sonrasi spektroskopik olcumleri degerlendirildiginde frontal korteks Cr duzeyinde anlamli farklilik saptandi (p=0.046). Tedavi sonrasindaki Cr degerleri daha dusuk bulundu. Tedavi oncesi ve sonrasi NAA/Cho, NAA/Cr, Cho/Cr ve NAA/Cho+Cr karsilastirildiginda sadece frontal beyaz cevherde NAA/Cr degerlerinde anlamli farklilik saptandi (p=0.01). Sonuc olarak orta ve agir OSAS olgularinda MR spektroskopi ile serebral metabolizma degisikliklerinin oldugunu ve bu degisikliklere norokognitif testlerin de eslik ettigini saptadik.

Wegener's granulomatosis (WG) is a disorder that causes necrotizing granulomatosis vasculitis particularly of the upper respiratory tract, lung and kidney. A 43-year-old male who had been treated with hemodialysis because of renal insufficiency due to WG underwent live donor renal transplantation. Pulmonary infiltrates were detected on the postoperative 4th day and antibiotic therapy was started with a diagnosis of sepsis and pulmonary infection. Dialysis treatment was also started due to the degradation of renal function for the patient who was intubated during follow-up. Non-invasive mechanical ventilation (BiPAP) treatment was started after extubation. The graft and respiratory function improved during clinical follow-up. Resistant hospital infections, causing respiratory failure and systemic complications, were facilitated by a long history of hospitalization before transplantation, the presence of WG and immunosupression and were successfully treated with a multidisciplinary approach. a