Frailty, defined as a state of decreased physiologic reserve, has been correlated with poorer outcomes after hospitalization or surgery. Studies in lung transplant patients have associated frailty with an increased risk of post-transplant mortality; however, a unified approach is lacking. The identification of frail patients can help clinicians pre-emptively target modifiable risk factors and may facilitate risk stratification. The Frailty Risk Score (FRS) is a chart review-based approach based on eight symptoms and four laboratory biomarkers. We applied this method in a retrospective study to investigate its utility in predicting post-transplant lung outcomes. Eighty-four lung transplant recipients were evaluated, including 51 older (≥ 60) and 33 younger (< 60) patients.Median FRS score was 3.9, with 63 categorized as frail (75%) and 21 as non-frail (25%), using a previously published cut-off of ≥3 to define frailty. A high FRS was associated with readmission in the first year after transplantation and with the number of readmissions. There was also an association between FRS score and death (p = .047). FRS may be a viable tool in the assessment of lung transplant candidates. Frail patients may benefit from earlier referral and targeted therapy prior to transplant, as well as close post-transplant follow-up.

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INTRODUCTION: Inflammatory bowel disease (IBD) is an idiopathic disease that causes inflammation of the gastrointestinal tract and includes ulcerative colitis and Crohn's disease. Overt respiratory manifestations of IBD are unusual, but bronchiectasis, organizing pneumonia, and eosinophilic pneumonia have been reported. Cavitary lung nodules are rarely seen in IBD. In this report, we present a case of Crohn's disease-associated pulmonary necrobiosis. CASE PRESENTATION:A 67-year-old woman with Crohn's disease on adalimumab presented with four weeks of cough, hemoptysis, and dyspnea. Computed tomography (CT) of the chest revealed nodular cavities with consolidation (Fig. 1). Laboratory evaluation for Cryptococcus, Aspergillus, Coccidioides, Histoplasma, and Mycobacterium tuberculosis was unrevealing. Autoimmune serologies (antinuclear antibody, anti-neutrophil cytoplasmic antibodies, rheumatoid factor, and SSA/SSB) were negative. A bronchoscopy with bronchoalveolar lavage was performed with negative bacterial, fungal and mycobacterial cultures. An initial CT-guided biopsy did not reveal any organisms or malignant cells. Video-assisted thoracoscopic surgery (VATS) biopsy of the right middle and lower lobes was performed, with pathology showing airway-centered inflammation with secondary granulomas, abscess formation, and necrosis (Fig. 2), consistent with a diagnosis of pulmonary necrobiosis. She was started on infliximab, which caused an infusion reaction. She was then placed on prednisone and mycophenolate mofetil, with resolution of the cavitary lesions.DISCUSSION: Extra-intestinal manifestations of IBD are not commonly seen in the lung, and pulmonary necrobiosis has only been described in isolated case reports. Necrobiotic lung nodules are sterile nodules that can cavitate and histologically are composed of abscesses filled with necrotic debris and inflammatory cells. The association between bowel disease activity and the lung lesions has been controversial in the literature, as the nodules have been reported to precede, be coincident with, or follow the diagnosis of IBD. Pulmonary necrobiosis responds well to corticosteroids though the duration of treatment remains unknown.CONCLUSIONS: There should be a high index of suspicion for the development of pulmonary disease in the setting of IBD, and IBD should be considered in the differential of cavitary lung nodules.