Diagnosis Of Pulmonary Infiltrates Research Articles

Role of fiberoptic bronchoscopy in the diagnosis of pulmonary infiltrates in patients with hematological malignancies

RationalePatients with hematological malignancies are a special challenge to health care providers as they undergo a wide variety of immune-suppressive therapies. Both disease and therapy can cause complications. The lungs may be directly injured through infectious or toxic insults. Early identification of the nature of infiltrates will result in better outcome in the management of these patients. Fiberoptic bronchoscopy (FOB) may be a good tool for indentifying the infiltrate nature by using different diagnostic techniques like transbronchial lung biopsy (TBLB) and bronchoalveolar lavage (BAL).Patients and methodsThis study was performed over 6 months, in Kasr Al-Aini Hospital, Cairo University. It included 30 patients with hematological malignancies presenting with pulmonary infiltrates confirmed by computed tomography of the chest. All patients underwent history taking, clinical examination, and investigations included complete blood count and coagulation profile, BAL for culture and sensitivity, cytology examination, and TBLB.ResultsOverall diagnostic yield of FOB was 73.3% in this study. The diagnostic yield of FOB was higher for infectious (43.3%) than both noninfectious (20%) and mixed (10%) etiologies. The combined diagnostic yield of BAL for bacteriological examination and TBLB was higher than that of BAL for cytology examination. Bacteriological examination revealed a predominance for gram-negative bacteria in 62.5% of total culture and sensitivity.ConclusionThis study supports the role of FOB as the initial procedure of choice for identifying the nature of pulmonary infiltrates in patients with hematological malignancies. Because our results suggest that BAL and TBLB are complementary, we recommend performing TBLB whenever it is deemed safe. On the contrary, cytological examination of BAL fluids was not helpful in reaching a final diagnosis.

Limited Usefulness of Bronchoalveolar Lavage (BAL) in the Diagnosis of Pulmonary Infiltrates After Allogeneic Hematopoietic Stem Cell Transplantation (allo-HCT)

Limited Usefulness of Bronchoalveolar Lavage (BAL) in the Diagnosis of Pulmonary Infiltrates After Allogeneic Hematopoietic Stem Cell Transplantation (allo-HCT)

Distinguishing the Causes of Pulmonary Infiltrates in Patients With Acute Leukemia.

Pulmonary infiltrates are commonly observed in patients with acute leukemia (AL), particularly acute myeloid leukemia, who undergo remission induction therapy. The mortality rate is unacceptably high and depends on 3 factors: the host (performance status, comorbidities, and frailty), the etiology of the infiltrates and the type of response to antileukemic therapy. The approach to the diagnosis of pulmonary infiltrates in patients with AL includes a medical history, thorough physical examination, radiologic pattern of the infiltrates (focal vs. diffuse), and timing of their appearance in relation to the start of antileukemic therapy (early, ie, within the first 2 weeks or late). Localized infiltrates are most commonly caused by bacterial (early) and fungal infections (late). Diffuse early infiltrates might be caused by leukemic infiltration of the lungs, pulmonary hemorrhage and/or edema, diffuse alveolar damage, viral pneumonia, and rarely transfusion-related acute lung injury (TRALI) or the differentiation syndrome. Similar to the early phase, pulmonary edema, viral pneumonia, and rarely TRALI might cause diffuse infiltrates during the late phase, in addition to immune reconstitution and pneumocystosis, particularly among patients with acute lymphoblastic leukemia. Diagnostic tests, invasive and noninvasive, can be particularly useful to establish the diagnosis. Early intervention is critical and is based on the most likely diagnosis with modification when the etiology is confirmed.

Role of bronchoalveolar lavage in the diagnosis of pulmonary infiltrates in immunocompromised patients.

To describe the role of bronchoalveolar lavage (BAL) in the evaluation of pulmonary disease in immunocompromised patients. Recent discoveries in this field are largely in two areas: the array of diagnostic testing performed on BAL fluid and technical details that can enhance the yield from this procedure. Regarding diagnostic testing, the addition of new assays, including Aspergillus galactomannan antigen assay, respiratory viral panels, and Pneumocystis jirovecii PCR, has improved the diagnostic yield of BAL over conventional cultures and stains. To improve the diagnostic yield of the procedure itself, it should be done early in the clinical course, with the BAL in the anatomic area most affected, and with a preprocedural computed tomography of the chest to properly plan the procedure. Bronchoscopic evaluation with BAL can provide important diagnostic information in immunocompromised patients with pulmonary diseases and should be routinely performed when clinically indicated and able to be completed safely.

Detektion pneumonischer Infiltrate bei ambulant erworbener Pneumonie: Übereinstimmung in der Befundung der Röntgen-Thoraxaufnahme

To assess interobserver agreement (IOA) in the diagnosis of pulmonary infiltrates on chest x-rays for patients with community-acquired pneumonia (CAP). From 7/2002 to 12/2005, 806 adults with CAP were included in the multicenter study "CAPNETZ" (7 hospitals). Inclusion criteria were clinical signs of pneumonia and pulmonary opacification on chest x-rays. Each x-ray was reevaluated by two radiologists from the university hospital in consensus reading against the interpreter at the referring hospital in regard to: presence of infiltrate (yes/no/equivocal), transparency (<or=/>50%), localization, and pattern of infiltrates (alveolar/interstitial). The following parameters were documented: digital or film radiography, hospitalization, fever, findings of auscultation, microbiological findings. The overall IOA concerning the detection of infiltrates was 77.7% (n=626; CI 0.75-0.81), the infiltrates were not verified in 16.4% (n=132) by the referring radiologist with equivocal findings in 5.9% (n=48). The IOA of the different clinical centers varied between 63.2% (n=38, CI 0.48-0.78) and 92.3% (n=65, CI 0.86-0.99). The IOA for the diagnosis of infiltrates was significantly higher for inpatients with 82.6% (n=546; CI 0.80-0.85) than for outpatients with 55.2 % (n=80; CI 0.47-0.63), p<0.0001. The IOA of infiltrates with a transparency >50% was 95.1% (n=215; CI 0.92-0.98) versus 80.4% (n=403; CI 0.77-0.84) for infiltrates with a transparency >50% (p<0.0001). In patients with positive auscultation, the IOA was higher (p=0,034). Chest x-rays of patients with antibiotic therapy or an alveolar infiltrate showed more equivocal findings compared to patients without these features. There is considerable interobserver variability in the diagnosis of pulmonary infiltrates on chest radiographs. The IOA is higher in more opaque infiltrates, positive auscultation and inpatients.

Diagnostic value of C-reactive protein in discriminating fungal from nonfungal pulmonary infiltrates in patients with hematologic malignancies

The objective of this study was to assess the utility of C-reactive protein (CRP) on differential diagnosis of pulmonary infiltrates occurring in 143 febrile patients with hematologic malignancies. Serum CRP level, measured on the first day of pneumonia, was significantly higher in patients with fungal lung infiltrates than in those with nonfungal pneumonia (22.3 mg/dl vs 7.3 mg/dl; p<0.0001). Predictive factors for fungal pneumonia were CRP level higher than 10 mg/dl, neutropenia longer than 10 days, and active underlying disease.

The utility of open lung biopsy in critically ill adult patients

Open lung biopsy (OLB) is regarded as the gold standard for the diagnosis of pulmonary infiltrates. This procedure is associated with significant risk of morbidity and mortality in the intensive care unit (ICU) setting. We wished to study the efficacy of open lung biopsies in ICU patients requiring advanced respiratory support associated with bilateral pulmonary infiltrates.

Flexible bronchoscopy in the diagnosis of pulmonary infiltrates following autologous peripheral stem cell transplantation for advanced breast cancer.

Flexible bronchoscopy is an important tool in the diagnosis of pulmonary complications following bone marrow transplantation. However, the value of this procedure in autologous peripheral stem cell transplant (APSCT) recipients with pulmonary complications is not well defined. We retrospectively evaluated the diagnostic yield of 27 consecutive bronchoscopies done on 23 APSCT recipients following high-dose chemotherapy for breast cancer. FB resulted in a positive diagnosis in 16 cases (59%). Broncheoalveolar lavage (BAL) was performed on all patients, and transbronchial biopsies (TBB) were carried out in 14. TBB were diagnostic in 10 (71%), with pulmonary drug toxicity as the most common finding (n = 8), followed by metastatic breast cancer (n = 2). BAL was diagnostic in six (22%): bacterial pneumonia (n = 3), aspergillosis (n = 2), Pneumocystis carinii pneumonia (n = 1) and Influenza B (n = 1). The procedure was well tolerated with no major complications except a small pneumothorax in one patient that did not require chest tube insertion. In conclusion, flexible bronchoscopy is a useful tool in the evaluation of pulmonary complications following APSCT for breast cancer. TBB can be done safely with relatively high diagnostic yield. Pulmonary drug toxicity is the most common pathological finding.

Lung biopsy in immunocompromised children: When, how, and who?

Lung biopsy in immunocompromised children: When, how, and who?

FIBEROPTIC BRONCHOSCOPY FOR DIAGNOSIS AND TREATMENT

Bedside fiberoptic bronchoscopy is a valuable tool in the diagnosis and treatment of various respiratory conditions in critically ill patients. The fiberoptic bronchoscope allows direct airway inspection, facilitating the diagnosis of benign and malignant airway lesions. In addition, pulmonary secretions or tissue samples can be collected using the bronchoscope and techniques that allow sampling of the lower airways with minimal or no upper airway contamination. Collection of lower airway samples is important in the diagnosis of pulmonary infiltrates in immunocompromised patients, in many patients with ventilator-associated pneumonia, and in selected patients with CAP. The fiberoptic bronchoscope can be used for therapeutic interventions, such as insertion of an endotracheal tube, removal of an aspirated foreign body, clearance of tenacious secretions, promotion of hemostasis in patients with hemoptysis, instillation of drugs, and assistance in the placement of tracheobronchial prostheses (i.e., airway stents). If proper preprocedural training and planning are done and the patient is monitored carefully during the procedure, fiberoptic bronchoscopy can be performed quickly and safely at the bedside in most critically ill patients.

Bronchoscopy and Surgical Lung Biopsy for the Diagnosis and Management of Pulmonary Infiltrates in Immunocompromised Hosts

Background: Pulmonary infiltrate in immunocompromised hosts has many infectious and non-infectios etiologies. To evaluate the diagnostic yield and therapeutic implication of two invasive diagnostic methods, such as bronchoscopy and surgical lung biopsy, we performed retrospective analysis of these patients. Methods: All immunocompromised patients admitted to Samsung Medical Center from October 1995 to August 1998 who underwent bronchoscopy and/or surgical lung biopsy for the diagnosis of pulmonary infiltrates were included in this study. Confirmative diagnostic yield, the rate of changed therapeutic plan and patients' survival were investigated. Results: Seventy-five episodes of pulmonary infiltrates developed in 70 patients(M : F=46 : 24, median age 51). Underlying diseases of patients were hematologic malignancy(n=30), organ transplantation(n=11), solid tumor(n= 12), connective tissue disease(n=6) and others. Confirmative diagnosis was made in total 53 cases (70.7%), of which 70.2% had infectious etiology. Diagnostic yields of bronchoscopy, bronchoalveolar lavage(BAL), transbronchiallung biopsy(TBLB) and surgical lung biopsy were 35.0%(21/60), 31.4%(16/51), 25.0%(9/36) and 80.0%(20/25). Therapeutic plan was changed in 40%(24/60) of patients after bronchoscopy and in 36%(9/25) of patients after surgical lung biopsy. More patients survived (84.4% vs 60.5%, p=0.024) when therapeutic plan was changed after invasive diagnostic study. Conclusion: Bronchoscopy and surgical lung biopsy are helpful for the therapeutic implication of pulmonary infiltrates in immunocompromised hosts. Large-scale prospective case-control study may further clarify their limitation and usefulness.

The role of lung biopsy in children with perinatally acquired AIDS.

There is a need for a rapid and efficacious method of diagnosis of pulmonary infiltrates in perinatal HIV infection. However, controversy still exists about which method--open lung biopsy (OLB) versus bronchoscopic techniques--is the best for this population. We present our results with OLB in 24 children with HIV-related lung disease. Over a 6-year period, 27 OLBs were performed on 24 children with diagnosis of HIV infection. The procedures were performed under general anesthesia using a limited anterolateral thoracotomy. Suspicious areas were removed with the autostapler. The specimens were studied for the presence of non-infectious as well as bacterial, viral, fungal, and mycobacterial diseases. There were no operative deaths related to the procedure. Morbidity was limited to prolonged but self-resolving air leaks in two patients (8.3%). Five hospital deaths occurred between 3 and 12 weeks postoperatively and 11 late deaths between 3 months and 6.5 years. All deaths were related to AIDS. Eight patients (33.3%) are still alive 2 to 8 years postoperatively. A total of 43 pathologies were found in 27 specimens. A positive pathologic finding was obtained in all patients, with two patients having nonspecific minimal changes. This resulted in a change of therapy in all but one case. The technique of OLB in children with AIDS is safe and simple. It should be performed early in the course of the disease and, a careful selection of candidates can minimize the incidence of complications.

Transbronchial Biopsy in the Diagnosis of Pulmonary Infiltrates in Immunocompromised Patients

Bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) frequently are performed in the investigation of immunocompromised patients with lung disorders. The risk-benefit ratio of TBB currently is debated, since several authors have found that the less invasive BAL may provide as much information as TBB, with the avoidance of some biopsy-related side effects. We retrospectively evaluated 157 instances of bronchoscopy carried out on 142 immunocompromised patients, with both BAL and TBB performed in every case. Immunosuppressant conditions were HIV infection (79), hematologic malignancies (36), and antirejection therapy in renal transplant recipients (27). Transbronchial biopsy provided a diagnostic yield significantly higher than that obtained by BAL in all categories investigated; diagnostic rates were 77.3% for TBB and 47.6% for BAL (p < 0.001) in patients with HIV infection, 55 and 20% (p < 0.001) in patients with hematologic malignancies, and 57.5 and 27.2% (p < 0.001) in renal transplant recipients. Looking at the whole series, the diagnostic rates of TBB and BAL were 67.5 and 36.3%, respectively (p < 0.001), with a total additional yield of 33% provided by TBB, while in only 2% of cases BAL gave rise to diagnostic information not achieved by TBB. Considering that side effects followed TBB at a negligible rate (2.5%), we believe that TBB should be routinely carried out in these patients once the diagnostic strategy has been oriented to bronchoscopy.

Pulmonary infiltrates with eosinophilia

ABSTRACTA seven‐month‐old collie and a four‐year‐old Jack Russell terrier were presented with coughing and dyspnoea of varying duration. A peripheral and pulmonary eosinophilia was detected in both dogs. After ruling out heartworm disease, lungworms, fungal pneumonia and drug reactions, a diagnosis of pulmonary infiltrates with eosinophilia was made. Dramatic relief of clinical signs, radiographic infiltrate and peripheral eosinophilia occurred after administration of glucocorticoids.

Bronchoalveolar lavage.

The technique of BAL performed through the fiberoptic bronchoscope has, in two decades, provided clinicians and researchers with the ability to safely sample the inflammatory-immune cell milieu of the human lung. Standardized BAL and processing of the lavage constituents provides assistance in determining the optimal care of patients with a variety of lung diseases, and renders diagnosis in selected cases. It has become indispensable in the diagnosis of pulmonary infiltrates in immunocompromised patients, and plays an important role in improving clinical management. Finally, it continues to yield an ever increasing amount of data for the researchers studying the mechanisms and pathogenesis of lung disease. It is likely that BAL will become an even more valuable tool with increasing relevance to the practice of chest medicine in the 1990s.

Role of flexible bronchoscopy in the diagnosis of pulmonary infiltrates in pediatric patients with cancer

We reviewed 60 consecutive flexible bronchoscopies done during a 36-month period in 48 pediatric cancer patients with undiagnosed pulmonary infiltrates. Diagnostic procedures during bronchoscopy included 40 brushings, 50 bronchoalveolar lavages, and 6 transbronchial and mucosal biopsies. A total of 16 specific diagnoses were made by bronchoscopy (27% diagnostic yield), including infection (12), pulmonary leukemia (3), and lymphoma (1). The largest proportion of specific diagnoses came from lavage (14/50) and the smallest from brushings (1/40). Biopsies were also useful for selected patients. The low overall yield for bronchoscopy was probably due to the routine use of empiric broad-spectrum antibiotics and antifungal therapy, as well as trimethoprim-sulfamethoxazole prophylaxis for Pneumocystis carinii pneumonitis. Subsequent specific diagnoses were obtained by other procedures (open biopsy, needle aspiration, or autopsy) for 10 patients with negative bronchoscopy results and 3 patients with diagnostic bronchoscopies. These additional diagnoses included 7 infections (Pneumocystis carinii (1), Candida tropicalis (1), cytomegalovirus (1), and Aspergillus (4), and 6 other diagnoses with nonspecific histologic findings. A positive bronchoscopy result may be useful, but negative bronchoscopy findings do not justify delaying other diagnostic procedures or discontinuing antibiotic and antifungal therapy in children with cancer and pulmonary infiltrates.

Pulmonary Infiltrates in Immunocompromised Patients: Diagnostic Value of Telescoping Plugged Catheter and Bronchoalveolar Lavage

The usefulness of telescoping plugged catheter (TPC) together with bronchoalveolar lavage (BAL) in the same bronchoscopic act in the diagnosis of pulmonary infiltrates was studied in 113 fiberoptic bronchoscopic examinations performed on 96 immunocompromised patients. The TPC cultures detected pulmonary bacterial infections in 25 (22 percent) cases but showed a high frequency of false positive results (12 microorganisms, 27 percent). Bronchoalveolar lavage had an overall diagnostic yield of 49 percent (53 of 113 cases). Combining TPC and BAL diagnostic values, 78 of 113 pulmonary infiltrates (69 percent) were diagnosed. The results obtained by both techniques allowed us to modify the treatment in 35 (31 percent) cases. Combined, TPC and BAL show a good diagnostic yield in immunocompromised patients with pulmonary infiltrates. Both techniques should be performed as the first approach in the evaluation of these patients, and be done in the same bronchoscopic procedure.

Bronchoalveolar Lavage in the Diagnosis of Pulmonary Infiltrates in Patients with Acute Leukemia

The utility of bronchoalveolar lavage (BAL) in determining the causative agent of pulmonary infiltrates in patients with acute leukemia is not known. We retrospectively evaluated the diagnostic yield of BAL in 22 adults with acute leukemia and compared the results with those at autopsy performed within three weeks of BAL. All patients had neutropenia and thrombocytopenia at the time of BAL, were receiving broad-spectrum antibacterial agents, and 15 were also receiving amphotericin B before BAL. The median interval between the detection of pulmonary infiltrates and BAL was seven days (range, 0 to 23 days); the median interval between BAL and autopsy was nine days (range, 1 to 20 days). The diagnostic yield of BAL was 15 percent (3 of 20 specific diseases); all three were Candida pneumonia. The sensitivity of BAL was 75 percent and its specificity 100 percent, for Candida pneumonia. BAL did not result in a specific diagnosis for the 17 remaining diseases, nine of which were Aspergillus pneumonia. In seven patients in whom autopsy was performed within 72 hours of BAL, lavage results correlated with those of autopsy in only one who had Candida pneumonia. All BAL cultures were falsely positive, except in four cases of Candida pneumonia. The therapeutic regimen was not modified according to the BAL results in any of the 22 patients. There were no major complications associated with the procedure.

Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host.

The usefulness of bronchoalveolar lavage in the diagnosis of pulmonary infiltrates in the immunosuppressed patient was studied in 97 patients. In immunosuppressed patients, the available diagnostic procedures are often invasive and have variable yield and a potential for serious complications. Bronchoalveolar lavage had an overall diagnostic yield of 66% (61 of 92 diseases). It was most effective in the diagnosis of opportunistic infections, including infection with Pneumocystis carinii (18 of 22 cases), cytomegalovirus pneumonia (10 of 12 cases), fungal pneumonia (5 of 6 cases), and mycobacterial disease (4 of 5 cases). The technique was also helpful in suspected pulmonary hemorrhage (7 of 9 cases) but was less useful for diagnosing malignancy (10 of 22 cases) and drug-induced toxicity (6 of 15 cases). Findings of bronchoalveolar lavage could be combined with those of transbronchial biopsies, brushings, and washings in the diagnosis of most of the diseases. The procedure was safe, even in thrombocytopenic patients and those requiring mechanical ventilatory support. Bronchoalveolar lavage is a valuable procedure for evaluation of pulmonary disease in the immunosuppressed host.

Role of surgery in the management of pulmonary sporotrichosis

Management of four patients with sporotrichosis is summarized; one was treated medically and three were treated surgically. Thirty-seven cases from the literature are reviewed. The role of surgery in the management of pulmonary sporotrichosis is outlined as follows: (1) diagnosis of pulmonary infiltrates and/or pulmonary cavities of undetermined origin, (2) surgical intervention in patients with persistent infiltrates with cavitary lesions resulting from sporotrichosis, following failed medical treatment, and (3) resection of associated pulmonary cavitary lesions in patients in spite of adequte medical control of sporotrichosis. Surgical principles that must be observed in the management of pulmonary sporotrichosis follows:(1) Resection is the procedure of choice. The magnitude ranges from segmental resection to pneumonectomy. Clean resection is necessary. (2) Antifungal drug therapy--preferably with amphotericin B--is advisable preoperatively and postoperatively, since the major cause of late death is progression of the disease when clean resection has not been feasible. (3) Resection combined with drug therapy can be curative without increased risk in physiologically operable and anatomically resectable disease. (4) Thoracoplasty can be a lifesaving procedure for bilateral cavitary lesions with severe hemoptysis in patients with impaired pulmonary functions.