Professor of Medicine
Medical Director of the Lung and Transplant Program
Director of the Advanced Lung Disease/ILD Program
Mount Sinai School of Medicine
New York, New York

Question: I recently moved my practice to New Mexico. I keep getting lung biopsy results which say "foreign polarizable material and noncaseating granulomas." I'm unfamiliar with this nomenclature and haven't been able to contact the pathologist. Is this finding known by another name? All cultures and serologies are negative. Any thoughts on what I should do about these patients?

Answer: "Foreign polarizable material" is a descriptive term that further characterizes the nature of noncaseating granulomas on tissue biopsies. It refers to the presence of birefringent material revealed by polarizing microscopy at sites of granuloma formation. It should alert clinicians to the possibility of inhaled or circulating foreign substances such as talc, mica, aluminum, calcium, beryllium, etc that may provide a clue to the diagnosis. Endogenous material (calcium silicate or carbonate) may also polarize and not represent true "foreign material." It is sometimes possible to identify the polarizing material, particularly if it is abundant. Electron probe microanalysis can be used for this purpose.

Question: I have a patient with IPF whose condition has worsened over the past few weeks. I believe that "acute exacerbations of IPF" describes my patient well; she has a rapid deterioration of PFTs and quality of life and is requiring higher concentration of oxygen. What can be done to help her or slow the decline?

Answer: Patients in all stages (early, moderate, advanced) of IPF are at risk of developing acute decompensation of their clinical condition. They may present with progressive dyspnea, cough, and/or low grade fever.

Question: I am treating a patient with IPF who is showing signs of depression. As a pulmonologist, I am reticent to treat this comorbidity but I believe she would benefit from therapy. Who would be the best point person to manage her psychiatric issues?

Answer: Idiopathic Pulmonary Fibrosis, a progressive illness leading to respiratory insufficiency, is well known to affect patient's quality of life in the physical as well as emotional domains.

Question: Recently I referred a patient with IPF for evaluation for lung transplantation. The center prefers to perform only single lung transplants. I have heard that other centers would consider bilateral lung transplantation for this condition. What is the current best practice for IPF lung transplantation, and are the considerations the same for all the major ILDs?

Answer: This is an interesting question that touches upon several aspects of lung transplantation. The increasing numbers of candidates awaiting lung transplantation far outstrip the supply of available organs. To optimize the use of this resource, single lung transplantation would serve the greatest number of recipients. However, another principle of lung transplantation is to improve survival and quality of life for the recipients. Suppurative lung diseases, such as cystic fibrosis or diffuse bronchiectasis, are absolute indications for bilateral lung transplantation, but for most diseases data on the ideal procedure are not that clear.

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