Bronchoalveolar Lavage Results Research Articles

Comparison of the Results of BAL and ETA Culture in Intubated COVID-19 Patients.

The isolation of pathogens using bronchoalveolar lavage (BAL) culture or endotracheal aspirate (ETA) culture may enhance the treatment success for secondary pneumonia due to COVID-19, thereby reducing the risk of morbidity and mortality. This study aimed to retrospectively analyze the results of BAL and ETA cultures in intubated COVID-19 patients and to determine whether BAL has an advantage over ETA. We routinely perform BAL culture via bronchoscopy or ETA culture within the first 48 h after intubation. We retrospectively reviewed cases that underwent BAL and ETA. The patients were divided into two groups: Group B (BAL) and Group E (ETA). Various parameters were evaluated and compared between the two groups. The demographic data and blood test results were similar between the two groups. However, ICU stay, duration of intubation, and culture positivity were significantly higher in Group B. Although not statistically significant, the mortality rate was higher in Group E. The most commonly isolated microorganisms were Candida species. The observed mortality rates were consistent with the existing literature. Since the microorganism isolation rate is higher with BAL, leading to more effective antimicrobial treatment, early deaths were prevented, and ICU stay durations were prolonged. Conversely, these durations were shorter in the ETA group due to higher mortality. In intubated COVID-19 patients, a more effective treatment process can be achieved by clearing the airway with fiberoptic bronchoscopy and tailoring the treatment based on BAL culture results. This approach may positively impact prognosis and mortality rates.

Bronchoscopy-guided antimicrobial therapy for cystic fibrosis.

Bronchoscopy-guided antimicrobial therapy for cystic fibrosis.

The impact of bronchoalveolar lavage on the diagnosis of undifferentiated interstitial lung disease alongside a multidisciplinary discussion.

Cellular analysis of bronchoalveolar lavage (BAL) fluid may aid diagnosis in patients with undifferentiated interstitial lung disease (ILD). The utility of this test in the diagnostic process in conjunction with a multidisciplinary discussion (MDD) is not known. We aim to assess and compare interobserver agreement and diagnostic confidence before and after presenting BAL results in an ILD-MDD. Patients undergoing investigations for ILD at Waikato Hospital were recruited. At the ILD-MDD two respiratory physicians and one respiratory radiologist participated in the discussion, and their diagnosis and diagnostic confidence were assessed at four sequential time points. Assessors were blinded to each others diagnosis and diagnostic confidence scores. The four sequential time points were (1) after clinical and radiology presentation; (2) after subsequent MDD; (3) after reviewing BAL results; (4) after final MDD with all results. Interobserver agreements were calculated using Fleiss κ statistic. 36 patients were recruited, and 77.8% were male. In the first step, the interobserver agreement was substantial κ = 0.622 (95% CI 0.47-0.77), improving in step 2 following MDD to κ = 0.78 (95% CI 0.624-0.935), in step 3 κ = 0.776 (95% CI 0.614-0.937) and step 4 achieved almost perfect agreement of κ = 0.969 (95% CI 0.828-1.11). The diagnostic confidence for individual and group diagnosis increased with the presentation of BAL with and without multidisciplinary MDD. We found that BAL cellular analysis improves interobserver agreement and confidence in diagnosis following MDD, thus aiding decision-making in cases with undifferentiated ILD.

The role of smear microscopy of induced sputum and bronchoalveolar lavage in the diagnosis of pulmonary tuberculosis in patients with initial smear-negative: A prospective study

Several studies have compared the diagnostic value of sputum induction (SI) with flexible fiberoptic bronchoscopy (FOB) in diagnosing pulmonary tuberculosis; however, these investigations yield an inconsistent conclusion. This study aims to evaluate the role of acid-fast bacilli (AFB) testing of SI and bronchoalveolar lavage (BAL) samples in suspected pulmonary tuberculosis cases. A prospective study was conducted at the Department of Pulmonary in Cho Ray Hospital (Ho Chi Minh City, Vietnam) between October 2020 and May 2021. The study comprised 60 patients hospitalized with suspected pulmonary tuberculosis who had at least one negative AFB result from spontaneous sputum or gastric lavage. All participants underwent AFB testing of SI and BAL samples on the same day. Among 60 patients, 25 (41.7%) were diagnosed with pulmonary tuberculosis. Of the patients with pulmonary tuberculosis, 13 had positive AFB results, including four cases with both positive AFB SI and positive AFB BAL results. The sensitivity of AFB SI was significantly lower compared to that of AFB BAL (16% vs. 52%, p = 0.0027). The most common complication associated with the SI method was cough (15%). The proportion of patients able to provide sputum using the SI method was significantly higher than those with spontaneous sputum (p = 0.0499, McNemar test). SI is a safe and effective method for collecting respiratory specimens, even from patients unable to expectorate spontaneous sputum. FOB should be reserved for suspected cases of pulmonary tuberculosis that are negative for AFB in spontaneous sputum, SI, and gastric lavage.

Diagnostic Yield of Bronchoscopy in Children with Leukemia or Post Hematopoietic Stem Cell Transplant

This project was funded, in part, with support from the Indiana Clinical and Translational Sciences Institute funded, in part by UL1TR002529 from the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
 Background: The utilization and diagnostic yield of bronchoscopy with bronchoalveolar lavage (BAL) in immunocompromised children is not well understood. We aim to describe bronchoscopy use and complication rates and to investigate diagnostic yield.
 Project Methods: This is a retrospective cohort study of 60 children with leukemia or post hematopoietic cell transplant who had a bronchoscopy with BAL at Riley Hospital for Children between 2017 and 2021. Existing datasets and the electronic medical record were used to collect data on demographics, transplant and diagnosis information, as well as respiratory and bronchoscopy data. Inferential statistics were used. Comparisons were done with regression analysis.
 Results: Of the 60 bronchoscopies performed, 48 (80%) revealed diagnostic information: 41 (68%) identified a pathogen, 14 (23.3%) found significant secretions/mucus plugging, and 6 (10%) found pulmonary hemorrhage. BAL results led to a change in antimicrobial therapy in 27 (45%) cases. Blood cultures, respiratory viral panels and serum pathogen testing did not always correlate with BAL results. In patients with other infectious workup, 53% of bronchoscopies found a new infectious diagnosis. Of this cohort, 39 (65%) received supplemental oxygen for a median of 3 (IQR: 1-7) days prior to the bronchoscopy. Most patients, 58 (96.7%), had respiratory symptoms for a median of 5 (IQR: 2-18) days prior to bronchoscopy. Antibiotic use prior to bronchoscopy was common with use in 56 (93.3%) patients for a median length of 6 (IQR: 3-14) days. None of these factors were associated with the diagnostic yield. No patient required an escalation of respiratory support post-bronchoscopy. For the 25 (41.7%) children on mechanical ventilation when the bronchoscopy was performed, there was no difference in ventilator settings pre and post-bronchoscopy.
 Conclusion and Implications: Bronchoscopies with BAL are useful, safe, and important in the diagnostic management of pulmonary complications in this cohort of children.

CONSISTENCY BETWEEN BRONCHOALVEOLAR LAVAGE AND ENDOTRACHEAL ASPIRATE IN THE DIAGNOSIS OF VENTILATOR-ASSOCIATED PNEUMONIA

Background 
 Ventilator-associated pneumonia (VAP) is a common nosocomial lung infection. Quick and accurate identification of the causative pathogen is crucial to improve prognosis. To date, the literature is controversial regarding whether endotracheal aspirate (ETA) can be used as an alternative to bronchoalveolar lavage (BAL) in VAP diagnosis.
 Objectives 
 To evaluate the consistency between the results of BAL and ETA in the diagnosis of early- and late VAP and to determine the microbial profiles of the involved microorganisms and their antimicrobial susceptibility. 
 Patients and Methods
 This is a single-centre prospective study that included 50 VAP-suspected patients conducted at Shar Hospital, Sulaimani, Iraq, from July 2021 to February 2022. The patients were categorised into early VAP and late VAP. For each patient, both ETA and BAL techniques were used to obtain samples for microbiological analysis and antimicrobial susceptibility testing.
 Results
 Ten (20%) patients developed early VAP, and 40 (80%) developed late VAP. The culture results of samples obtained by BAL showed microbial growth in 45 (90%) of the cases. Meanwhile, ETA resulted in microbial growth in 40 (80%) patients. In 45 (90%) of the samples, both techniques yielded the same results regarding microbial growth in the cultures. Among the 45 samples with the same growth results, 35 (70%) showed the same type of microbes, and 5 (10%) showed no microbial growth, indicating substantial agreement. In both BAL and ETA, Pseudomonas aeruginosa, Staphylococcus aureus, and Acinetobacter baumannii were the most frequently isolated pathogens. Both early- and late-VAP were associated with a high frequency of multidrug-resistant microorganisms, 6 (75%) and 25 (56.8%), respectively. However, extensively drug-resistant/pan-drug-resistant isolates were much more common in late-VAP patients (12, 27.3%). 
 Conclusion
 ETA can be a reliable, non-invasive alternative to BAL in VAP diagnosis associated with rapid and relatively accurate results.

UTILITY OF BAL FOR EVALUATION OF PULMONARY INFECTIONS IN PATIENTS WITH AUTOIMMUNE DISEASE: A SINGLE CENTER ANALYSIS

UTILITY OF BAL FOR EVALUATION OF PULMONARY INFECTIONS IN PATIENTS WITH AUTOIMMUNE DISEASE: A SINGLE CENTER ANALYSIS

Invasive Pulmonary Aspergillosis in Patients with Haematological Malignancies and Hematopoietic Stem Cell Transplantation:a Single-Center Study.

The aim of this study was to evaluate the clinical significance of Aspergillus Galactomannan antigen (GM) test for the diagnosis of invasive pulmonary aspergillosis (IPA) in patient with hematological malignancies, including patients undergoing hematopoietic stem cell transplantation (HSCT). Between January 2016 and June 2019, ninety patients were tested for GM. A total of 134 blood and 19 bronchoalveolar lavage (BAL) samples were analyzed using Platelia Aspergillus Ag Enzyme-Immuno Assay (Bio-Rad Laboratories). The median age of patients was 63 years (range 25-81). Fifty-six patients (62.2%) were male. All patients were allocated into five groups on the basis of their GM results. A positive GM antigen test was detected in 16 patients (17.7%). Of these, ten had positive serum samples (group I). After re-testing, 1 patient from group I gave a negative result. Five patients with negative serum samples gave positive BAL results (group II). One patient had positive both serum and BAL samples (group III). Fifteen GM positive patients (9 from group I, group II, and III) were categorized as probable IPA. Thirty-six patients (40%) negative for GM (group IV) were considered with a possible IPA. IPA was excluded in 38 patients (42.2%) (group V). Anti-mould therapy was initiated in all 15 patients who were considered to be cases with probable IPA. IPA was the immediate cause of death in 3 cases (25%). Our results demonstrated the clinical applicability of the GM test for screening of IPA in high-risk patients with hematological malignancies and HSCT.

Low utilisation of bronchoscopy to assess COVID-19 respiratory infection: a multicenter experience

ObjectiveFor the diagnosis of COVID-19, the yield of nasopharyngeal (NP) swabs is unclear, and bronchoalveolar lavage (BAL) is obtained to confirm the diagnosis. We assessed the utilisation of bronchoscopy for...

The Utility of Early Broncholaveolar Lavage in Prolonged Neutropenic Patients with Pulmonary Nodules

▪IntroductionManagement of patients with hematologic malignancies (HM) post induction chemotherapy or allogeneic hematopoietic cell transplant (Allo HSCT) is often complicated by neutropenic fever associated with nodular pulmonary infiltrates, and may result in acute respiratory failure and death. The presence of a halo sign in a neutropenic patient with nodular infiltrates is highly suggestive of invasive pulmonary aspergillosis (IPA).Fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) is the preferred procedure for identifying the infectious aetiology of pulmonary infiltrates in post Allo-HSCT or post chemotherapy in HM patients with neutropenic fever. The diagnostic value of FOB with BAL in such patients is controversial, however, it has been suggested that the microbiologic yield from FOB and BAL is higher when bronchoscopy is performed within 24 hours of presentation, allowing subsequent BAL-guided therapeutic adjustment.With a view towards improving health care resource utilization, we re-evaluated this diagnostic strategy.MethodsWe conducted a prospective observational study of 100 participants with the following diagnoses: acute myeloid leukemia (AML), 76%; myelodysplastic syndrome (MDS), 9%; acute lymphoblastic leukemia (ALL), 6%; and acute promyelocytic leukemia (APL), 6%. One hundred sequential patients who underwent FOB after August 2016 and provided informed consent, were enrolled and followed for 30 days. Sixty six percent were admitted for induction chemotherapy; 17% for re-induction chemotherapy; 10% for conditioning pre- Allo- HSCT; 4% for consolidation chemotherapy; and 3% for other therapy.Data collected included patients' demographics, dates of onset of fever and of baseline chest CT scan, findings on CT scan, dates of initiation of empirical antibiotic and antifungal therapy, BAL results, and the impact on antimicrobial choices. Other outcomes included transfer to ICU and death.We assessed the utility of performing early FOB (within 48 hours of performing a low dose chest CT scan) vs Late FOB (after 48 hours from low dose chest CT scan) in post-chemotherapy HM and Allo-HSCT patients.ResultsOf the 100 enrolled participants, 61 and 39 underwent early and late FOB, respectively (Figure-1: Table of results) . A positive BAL Galactomannan was observed in 7 (11.5%) early FOB cases, compared to only 1 (2.6 %) in late FOB case (p=0.15), with a subsequent impact on the choice of antifungal in 6 cases (9.8 %) and 1 case (2.6 %), respectively (p=0.042).BAL culture was positive in 2 cases (3.3%) in the early FOB group, compared to only 1 case (2.6%) in the late FOB group (p=0.99). The choice of antibiotic was influenced by BAL results in 1 of the 2 early FOB cases.Eight (13.3%) and 7 (17.9%) of early and late FOB patients, respectively, were transferred to the ICU (p=0.57); and 6 (9.8%) of the early FOB and 3 (7.7 %) of late FOB patients died (p=0.99).ConclusionThe diagnostic yield of early FOB was greater than that of late FOB, as assessed by GM positivity, and more frequently permitted targeted antifungal therapy. There was no difference in the rate of antibiotic use between the two groups. [Display omitted] DisclosuresGupta:Incyte: Consultancy, Research Funding; Novartis: Consultancy, Honoraria, Research Funding. Schuh:Amgen: Consultancy, Honoraria. Yee:Astex: Research Funding; Oncoethix: Research Funding; Karyopharm: Research Funding; Novartis Canada: Honoraria; Celgene Canada: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Systematic screening for COVID-19 associated invasive aspergillosis in ICU patients by culture and PCR on tracheal aspirate.

BackgroundA high prevalence of COVID‐19 associated pulmonary aspergillosis (CAPA) has been reported, though histopathological evidence is frequently lacking. To assess the clinical significance of Aspergillus species in respiratory samples of mechanically ventilated COVID‐19 patients, we implemented routine screening for Aspergillus in tracheal aspirate (TA).Patients/methodsFrom all adult COVID‐19 patients admitted to the intensive care unit (ICU), TA samples were collected twice a week for Aspergillus screening by PCR and or culture. Bronchoalveolar lavage (BAL) sampling was performed in patients with a positive screening result if possible. Clinical information was obtained from the electronic patient record and patients were categorised according to the recently published consensus case definition for CAPA.ResultsOur study population consisted of 63 predominantly (73%) male patients, with a median age of 62 years and total median ICU stay of 18 days. Aspergillus species were present in TA screening samples from 15 patients (24%), and probable CAPA was diagnosed in 11 (17%) patients. Triazole resistance was detected in one patient (14%). Concordance between TA and BAL was 86%, and all TA culture positives were confirmed in BAL. We were able to withhold treatment in three of fifteen patients with positive screening (20%) but negative BAL results.ConclusionsPositive culture, molecular detection and or antigen detection of Aspergillus species do not equal infection. Until we understand the clinical relevance of Aspergillus species detected in respiratory samples of COVID‐19 patients, minimal‐invasive screening by TA is a feasible method to monitor patients. Positive screening results should be an indication to perform a BAL to rule out upper airway colonisation.

Diagnostic Yield of Bronchoalveolar Lavage in Immunocompromised Children.

Results from early studies in the diagnostic yield of bronchoalveolar lavage (BAL) in immunocompromised adults and children were variable. This prospective study aimed to determine the diagnostic yield of BALs in immunocompromised children over the first 18 months of service at a newly established children's hospital. Relationship between BAL results and changes in antimicrobial management was also studied. Twenty-one bronchoscopic BALs were performed on 18 children; 14 BALs (66.7%) yielded at least 1 pathogen and 7 (33.3%) yielded no pathogen. Two pathogens were found in 2 samples, and 1 pathogen was identified in 12 samples. Bacteria (n = 7 patients), viruses (n = 8 patients) and fungus (Pneumocycstis jirovecii in one patient) were yielded. Of the 21 BALs, 8 (38.1%) were associated with changes in antimicrobial management (Fisher's exact test, p = 0.018). No significant side effects such as pneumothorax or pulmonary hemorrhages were observed in this series. In conclusion, BAL in immunocompromised children is rewarding and has potential to impact on antimicrobial management.

The Diagnostic Utility and Clinical Implications of Bronchoalveolar Lavage in Cancer Patients With Febrile Neutropenia and Lung Infiltrates.

IntroductionFebrile neutropenia (FN) is a dreaded complication of cancer chemotherapy and frequently associated with respiratory infections. Flexible bronchoscopy (FB) serves as a useful diagnostic tool in this regard.ObjectiveTo determine the diagnostic yield, safety and clinical implications of bronchoalveolar lavage (BAL) in cancer patients with FN, having lung infiltrates on radiographic chest imaging.MethodsWe reviewed medical records of FN patients who underwent FB at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, from July 2015 till July 2018. The culture yield of BAL, resultant change of management and outcome over the subsequent 30 days were retrospectively analysed. Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY) was used for data analysis.ResultsNinety FN patients, with mean age 26 ± 18 years and predominantly males (65.6%, n = 59) were included in the study. Seventy-seven (85.6%) had hematological and 13 (14.4%) solid organ malignancy. The mean absolute neutrophil count was 0.20 +/- 0.36/ µL. BAL cultures were diagnostic in 40 (44%) patients; the etiology was bacterial, fungal and mixed in 25 (62.5%), 14 (35%) and one (2.5%) patient, respectively. All patients were on empirical antibiotics prior to bronchoscopy: 32 (35.6%) on antibacterial alone and 58 (64.4%) on antibacterial plus antifungal therapy. Change of management occurred in 51 (56.7%) patients after BAL results, including de-escalation from dual antibiotics in 28 (55%) and initiation of new culture sensitive antibiotic in 23 (45%). FB-associated complications developed in three (5.6%) non-intensive care patients (ICU), including transient hypoxia in two and minor hemoptysis in one patient, while five (14.8%) mechanically ventilated patients in ICU experienced worsening of oxygenation parameters within 48 hours. Overall, 24 (26.7%) patients died. Mortality was 3.7% in non-ICU and 69% in ICU setting and significantly higher in patients with fungal pneumonias (p-value 0.01) and with prolonged neutropenia (p-value 0.001).ConclusionsBAL is a safe diagnostic tool for FN patients with lung infiltrates, with minimal complications and sufficient diagnostic yield to improve diagnosis and management of such patients.

Bronchoalveolar lavage hemosiderosis in dogs and cats with respiratory disease.

Hemosiderophages can be found in bronchoalveolar lavage samples and have been reported in association with a wide range of respiratory and cardiovascular disorders in cats and humans. This study aimed to retrospectively evaluate the presence of hemosiderin in canine and feline bronchoalveolar lavage (BAL) samples. It also aimed to examine the association of BAL hemosiderin with signalment, clinical signs, and historical disease prior to BAL, with prior transthoracic fine-needle aspiration (FNA), with bronchoalveolar lavage duration, and with cytologic interpretation. The medical records of dogs and cats with respiratory disease that underwent BAL between 2007 and 2016 were reviewed. Appropriate medical information and BAL results were available from 171 dogs and 34 cats. Cases were assigned to four disease categories based on BAL cytologic findings: pneumonia, inflammatory disease, neoplasia, or normal airways. The degree of hemosiderosis was classified based on a semi-quantitative scoring scale. Exact logistic regression analysis was used to evaluate the relationship between risk factors and the presence of BAL hemosiderosis on cytology. Hemosiderin was identified in 13/171 (7.6%) canine samples and 18/34 (52.9%) feline samples. Cats were 13.33 times more likely to have pulmonary hemosiderosis on bronchoalveolar lavage cytology compared with dogs (P<0.001). Increased respiratory rates, prolonged bronchoalveolar lavage times, concurrent transthoracic FNAs, and cytologic diagnoses were associated with an increased risk of hemosiderosis in dogs. No specific risk factors associated with pulmonary hemosiderosis in cats were identified. Hemosiderosis is more common in BAL samples from cats than from dogs and is associated with a diverse range of disease conditions.

An Analysis of the Clinical Benefit of 37 Bronchoalveolar Lavage Procedures in Patients with Hematologic Disease and Pulmonary Complications.

ObjectiveSince pulmonary complications are a major cause of mortality in patients with hematologic diseases, their rapid detection and treatment are essential. Bronchoalveolar lavage (BAL) is widely performed to diagnose pulmonary infiltrates not evident with non-invasive investigations; however, reports on its clinical benefits for patients with hematologic diseases are limited. The aim of our study was to investigate the utility of diagnostic bronchoscopy with BAL for those patients. Methods We retrospectively reviewed the clinical records of 37 consecutive BAL procedures in 33 adult patients with hematological diseases and pulmonary infiltrates with at least 6 months of follow-up between August 2013 and September 2017 (total 747 BAL procedures). The BAL results, ensuing treatment modifications, treatment outcomes, survival times, and adverse events were evaluated. Results Microbiological findings were detected in 11 (29.7%), even though wide-spectrum antibiotics and antifungal drugs had been empirically administered to most patients (>70%) prior to the bronchoscopy procedure. Overall, 25 of the 37 BAL procedures (67.6%) had some impact on the diagnosis of pulmonary diseases. Patients without specific diagnostic findings from BAL had a significantly poorer survival than those with diagnostic findings via BAL (30-day survival: 33.3% vs. 92.0%; 180-day survival: 8.3% vs. 64.0%). Four patients (12.1%) experienced complications associated with bronchoscopy; there were no procedure-related deaths. Conclusion BAL seems still important for diagnosing pulmonary infiltrates and/or excluding some of the important respiratory tract pathogens in patients with hematological diseases; furthermore, negative specific diagnostic findings from BAL may be associated with poor prognoses.

DIFFUSE PARENCHYMAL LUNG DISEASE (DPLD) IN PATIENTS WITH RHEUMATOID ARTHRITIS (RA): IMPORTANCE OF DIFFERENTIAL DIAGNOSIS

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: The development of DPLD can be idiopathic or related to infections, autoimmune, or exposures to environmental agents, radiation and drugs. RA as well as Methotrexate(MTX) are well known causes of DPLD. Our case lays importance of differentiating potential causes of DPLD and also unusual presentation of MTX related DPLD in setting of limited risk factors CASE PRESENTATION: A 67 year old female with a two-year history of RA on MTX (7.5 mg weekly) admitted for hypoxic respiratory distress and initially treated empirically for community-acquired pneumonia.CT Scan on admission revealed ground-glass opacities in diffuse lung fields, without any other parenchymal or vascular pathology. Patient had no exposure to tobacco,no travel or sick contacts and her primary care physician confirmed no prior pulmonary complaints including previously negative imaging. Despite antibiotic treatment her symptoms persisted so a Broncho alveolar Lavage(BAL) was performed and fluid samples for sent for cultures and cytology and results were negative. In light of the negative workup, MTX was considered as a possible culprit and was discontinued. She was also started on prednisone and her symptoms improved. At 4 week out patient followup, her symptoms markedly improved, which also correlated with her improved chest x-ray. She remained off the MTX and began a steroid taper DISCUSSION: DPLD is a known complication of RA; the challenge is to exclude other causes before establishing diagnosis in a previously relatively healthy patient with RA, with no known baseline clinical or radiological lung pathology, evaluating causes like infection, neoplasm and drugs is vital. BAL is more helpful in assessing infectious or neoplastic etiology than actually making a definitive diagnosis of drug related pneumonitis, with cessation of the offending agent being the mainstay of management. CONCLUSIONS: DPLD is suspected in 20-30% of patients with RA. Dilemma remains excluding RA related DPLD versus other causes like medications, as most of these patients are on cytotoxic medications. MTX related toxicity is commonly associated with multiple risk factors including age greater than 60, RA- pleuropulmonary involvement, previous use of disease-modifying anti-rheumatic drugs,and higher weekly doses of MTX, pre-existing lung disease and decreased elimination of MTX like in renal insufficiency. Diagnosis of above is typically based on the combination of the appropriate clinical setting, clinical manifestations, radiographic abnormalities and either the response to drug withdrawal or the results of BAL. Our case reports an acute onset MTX induced DPLD in an uncommon setting of limited risk factors with no known RA related pulmonary changes before presentation and dramatic improvement after cessation of MTX. It also lays importance of early diagnosis of drug induced DPLD and early cessation of offending agent for better outcome. Reference #1: Cooper JA Jr, White DA, Matthay RA. Drug-induced pulmonary disease. Part 1: Cytotoxic drugs. Am Rev Respir Dis 1986; 133:321.Lynch JP 3rd, McCune WJ. Immunosuppressive and cytotoxic pharmacotherapy for pulmonary disorders. Am J Respir Crit Care Med 1997; 155:395.Searles G, McKendry RJ. Methotrexate pneumonitis in rheumatoid arthritis: potential risk factors. Four case reports and a review of the literature. J Rheumatol 1987; 14:1164.Lateef O, Shakoor N, Balk RA. Methotrexate pulmonary toxicity. Expert Opin Drug Saf 2005; 4:723.Kremer JM, Alarcón GS, Weinblatt ME, et al. Clinical, laboratory, radiographic, and histopathologic features of methotrexate-associated lung injury in patients with rheumatoid arthritis: a multicenter study with literature review. Arthritis Rheum 1997; 40:1829. DISCLOSURES: No relevant relationships by Malvika Kaul, source=Web Response

Positive Pneumocystis jirovecii Sputum PCR Results with Negative Bronchoscopic PCR Results in Suspected Pneumocystis Pneumonia.

Introduction The diagnostic standard for Pneumocystis jirovecii pneumonia (PCP) is direct microscopic identification; however, in recent years, polymerase chain reaction (PCR) from bronchoalveolar lavage (BAL) samples to detect Pneumocystis nucleic acids has proven to be more sensitive and specific. Sputum samples have been presumed inferior to bronchoscopic samples secondary to variability and adequacy of sample collection. We observed several cases of positive sputum PCP-PCR results with negative PCP-PCR BAL results. The aim of the current study was to further characterize the clinical setting and outcomes in patients with positive sputum PCP-PCR samples and negative BAL PCP-PCR samples. Methods We identified all patients who underwent P. jirovecii-PCR testing at Mayo Clinic between 2011 and 2016. Patients with a positive sputum and negative BAL sample collected within a 14-day time frame were identified and underwent further chart review for demographics, immunocompromised state, and clinical outcome. Results From 2011 to 2016, 4431 respiratory samples from 3021 unique patients were tested for the presence of P. jirovecii by PCR. Fifty-five samples (1.2% of all samples collected) belonging to 24 unique patients (0.79% of patients tested) were identified as having a positive and negative sample collected within 14 days. Of these 24 patients, 10 (46%) patients had a positive sputum or tracheal secretion sample with negative BAL or bronchial washings. Out of these 10 patients, 8 were immunocompromised and 9 underwent treatment for PCP with 6 patients improving. Conclusion Our results suggest that discordant P. jirovecii-PCR testing results from sputum and bronchoscopic specimens are an infrequent occurrence. Patients with positive P. jirovecii-PCR sputum/tracheal secretion samples and negative bronchoscopic samples appear to be clinically infected and respond to PCP treatment. Sputum P. jirovecii-PCR testing may be a viable alternative to invasive testing.

Change in Clinical Management Associated with Flexible Bronchoscopy and Bronchoalveolar Lavage in Hematopoietic Stem Cell Transplant Recipients with New Pulmonary Infiltrates

BackgroundPulmonary complications occur in 60% of hematopoietic stem cell transplant (HSCT) recipients with significant morbidity and mortality. Bronchoscopy with bronchoalveolar lavage (BAL) is an important diagnostic tool, but yield can be variable. The aim of this study was to investigate the utility of BAL in HSCT patients with new pulmonary infiltrates and determine factors associated with higher BAL yield.MethodsRetrospective review of BAL results from January 2014 to July 2016. Included first bronchoscopy for HSCT patients over 18 years of age. Positive BAL determined by positive culture (bacterial, fungal, mycobacteria), viral PCR, elevated aspergillus galactomannan antigen (AGA), and cytology. Logistic regression analysis was performed.Results54 HSCT recipients were included: 93% allogeneic, 34% neutropenic, 39% on prednisone, 59% on supplemental oxygen, 8% receiving mechanical ventilation (MV), 85% with multilobar infiltrates, 92% on antimicrobials (antibacterial 83%, antifungal 92%, antiviral 13%). 65% had positive BAL (23/54 bacterial, 16/54 elevated AGA, 6/54 fungal, 14/54 viral PCR, 1/54 mycobacteria). Median time to BAL from HSCT was 7.5 months. Not on levofloxacin prophylaxis (P = 0.004), not on MV (P = 0.037), or unrelated donor were associated with positive BAL results. Positive bacterial BAL culture was predictive of antibacterial escalation (P < 0.001). Elevated BAL AGA was associated with antifungal escalation and antibacterial de-escalation (P = 0.012). Antiviral initiation was more likely with positive BAL PCR (P = 0.002). Antifungal de-escalation (P = 0.047) and steroid initiation (P = 0.010) were more likely with negative BAL. 6 month mortality was 41%, and more likely with positive bacterial BAL culture (P = 0.046). Overall positive BAL was not predictive of mortality.ConclusionBronchoscopy with BAL assisted in making critical management changes: elevated AGA with antifungal escalation and antibacterial de-escalation; and negative BAL with prednisone initiation and antifungal de-escalation. Unrelated donors, patients not on levofloxacin, or not on MV were more likely to have a positive BAL. Antimicrobial use likely reduced diagnostic yield for bacterial pathogens. Overall 6 month mortality was high, especially among those with bacterial infections.Disclosures All authors: No reported disclosures.

Eosinophilic Lung Disease: Accompanied with 12 Cases.

Eosinophilic lung diseases are a rare group of heterogeneous diseases characterized by the increase of the eosinophil ratio in airways and lung parenchyma. In our clinic, patients diagnosed with eosinophilic lung disease were evaluated with their clinical features and prognoses. In our clinic, 12 cases that were diagnosed and followed up for eosinophilic lung disease [eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss syndrome) (n=4), chronic eosinophilic pneumonia (CEP) (n=7), and simple pulmonary eosinophilia (Löffler's syndrome) (n=1)] were retrospectively evaluated. Of the 12 cases, 8 were females, and the average age was 43 (28-72) years. All cases were undergoing bronchodilator therapy with asthma diagnosis (2 months-40 years). Additionally, 4 of the cases had sinusitis, and 1 had allergic rhinitis. The most common complaints of the patients were difficulty in breathing and coughing, and the duration of complaints was a median of 2 months. Peripheral eosinophilia and total IgE elevation were present during the admission of all cases; additionally, leucocyte elevation was recorded in 10 of them, anemia in 4 of them, and thrombocytosis in 4 of them. Moreover, 43% of the recorded DLCO values were lower than normal. Of the 10 cases that underwent bronchoalveolar lavage (BAL), the eosinophil ratio was above 25% in 7 subjects. Of the 8 cases that underwent transbronchial biopsy, eosinophil-involving infiltration was detected in 6 subjects. Additional findings in cases diagnosed with EGPA were nasal polyposis (n=1), sinusitis (n=2), polyneuropathy (n=1), cardiac involvement (n=2), and skin involvement in biopsy (n=1). Spontaneous recovery was observed in the patient diagnosed with simple pulmonary eosinophilia during the follow-up that was performed based on the history and laboratory and BAL results of the patient. Prednisolone treatment was started for all cases, except for simple pulmonary eosinophilia, and their controls were performed. Relapse was observed in eight cases (EGPA: 4, CEP: 4); during the relapse treatment of one case diagnosed with EGPA, exitus occurred. One case rejected treatment despite the presence of peripheral eosinophilia, and the other cases are being followed-up without medication. Given that the clinical pictures in pulmonary eosinophilia syndromes are on a wide spectrum, a specific diagnosis is important. Progression may differ in each patient, and a close follow-up is necessary during and after the treatment.

Adherence to an established diagnostic threshold for ventilator-associated pneumonia contributes to low false-negative rates in trauma patients.

The diagnosis of ventilator-associated pneumonia (VAP) in our institution has followed an established diagnostic threshold (DT) of equal to or greater than 10 colony-forming units (CFU) per milliliter on bronchoalveolar lavage (BAL) based on our previous study (PS). Because mortality from VAP is related to treatment delay, some have advocated a lower DT. The purpose of the current study (CS) was to evaluate the impact of adherence to this DT for VAP on false-negative (FN) rates and mortality in trauma patients. Consecutive patients over 9 years with VAP (defined as ≥10 CFU/mL in the BAL effluent) subsequent to the PS were identified. Data regarding each BAL performed and the colony counts of each organism identified were recorded. An FN BAL result was defined as any patient who had less than 10 CFU/mL and developed VAP with the same organism up to 7 days after the previous culture. The CS was then compared with the PS. Over 9 years, 1,679 patients underwent 3,202 BALs. Of these, 79% were male, 88% experienced blunt injury, mean age and Injury Severity Score (ISS) were 44 years and 31, respectively. Overall, there were 73 FN BAL results (2.3%) in the CS compared with 3% in the PS (p = 0.092). In those patients with 10 organisms, the FN rate was reduced (7.5% vs. 11%, p = 0.045), and mortality was unchanged (5.4% vs. 8.3%, p = 0.361) in the CS compared with the PS. The use of the threshold equal to or greater than 10 resulted in a cumulative reduction in antibiotic charges of $1.57 million. Continued adherence to the diagnostic threshold of equal to or greater than 10 for quantitative BAL in trauma patients has maintained a low incidence of FN BALs and reduced patient charges without impacting mortality. The purported benefit of a lower threshold is not supported. In addition, the potential sequelae of increased resistant organisms, antibiotic-related complications, and costs associated with prolonged unnecessary antibiotic exposure are minimized. Prognostic study, level III.