Diagnostic Bronchoalveolar Lavage Research Articles

European Respiratory Society guidelines for the Diagnosis and Management of Pulmonary Alveolar Proteinosis.

Pulmonary alveolar proteinosis (PAP) is a rare syndrome caused by several distinct diseases leading to progressive dyspnoea, hypoxemia, risk of respiratory failure and early death due to accumulation of proteinaceous material in the lungs. Diagnostic strategies may include computed tomography (CT) of the lungs, bronchoalveolar lavage, evaluation of antibodies against granulocyte macrophage colony stimulating factor (GM-CSF), genetic testing, and, eventually, lung biopsy. The management options are focused at removing the proteinaceous material by whole lung lavage (WLL), augmentation therapy with GM-CSF, rituximab, plasmapheresis, and lung transplantation. The presented diagnostic and management guideline aim to provide guidance to physicians managing patients with PAP. A European Respiratory Society Task Force committee composed of clinicians, methodologists, and patients with experience in PAP developed recommendations in accordance with the ERS Handbook for Clinical Practice Guidelines and the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach. This included a systematic review of the literature and application of the GRADE approach to assess the certainty of the evidence and strength of recommendations. The committee formulated five PICO (Patients, Intervention, Comparison, Outcomes) questions, and two narrative questions to develop specific evidence-based recommendations. The Task Force committee developed recommendations for five PICOs. These included management of PAP with WLL, GM-CSF augmentation therapy, rituximab, plasmapheresis, and lung transplantation. Also, the committee made recommendations regarding the use of GM-CSF antibody testing, diagnostic bronchoalveolar lavage (BAL) and biopsy based on narrative questions.In addition to the recommendations, the committee provided information on the hierarchy of diagnostic interventions and therapy. The diagnosis of PAP is based on CT and BAL cytology or lung histology, whereas diagnosis of specific PAP-causing diseases requires GM-CSF antibody testing or genetic analysis. There are several therapies including WLL and augmentation therapy with GM-CSF available to treat PAP, but supporting evidence is still limited.

Impact of bronchoalveolar lavage on the management of immunocompromised hosts

BackgroundRespiratory infections are an important cause of morbidity and mortality in immunocompromised individuals. Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is an important tool to detect infectious agents in immunocompromised patients with low respiratory tract infections (LRTI). Research QuestionBAL changes the management of immunocompromised patients with suspected LRTI. Study Design and MethodsImmunocompromised patients with a suspicion of LRTI underwent diagnostic BAL. The primary composite outcome consisted of pre-defined modifications in the management of the immunocompromised patients following BAL. We quantified the impact of bronchoscopy up to 30 days after the procedure. ResultsA total of 2666 visits from 1301 patients were included in the study and immunosuppression was classified as haematological (n = 1040; 544 patients), solid organ transplantation (n = 666; 107 patients) and other causes (n = 960; 650 patients). BAL led to a change in management in 52.36% (n = 1396) of all cases. This percentage, as well as the 30-day mortality differed significantly amongst the three groups. Age, C-reactive protein and aetiology of infection determined significantly the risk of 30-day mortality in all patients. In 1.89% (n = 50) of all cases, a combination of 2 respiratory viral agents was identified and 24.23% (n = 646) were diagnosed with a single respiratory viral agent. InterpretationBAL leads to changes in management in the majority of immunosuppressed patients. There is a high prevalence of multimicrobial infections and respiratory viral infections in immunocompromised patients with respiratory symptoms. Individual virus infection is associated with diverse risk of a negative outcome.

758 Correlation between initial and diagnostic bronchoalveolar lavage isolates among patients with inhalation injury and pneumonia

Abstract Introduction Inhalation injury is associated with increased risk of pneumonia. Bronchoscopy with bronchoalveolar lavage (BAL) is commonly used to diagnose and grade inhalation injury while obtaining a microbiological sample. It has been shown that a quarter of patients with inhalation injury have a single bacteria isolated from initial BAL within 12-48 hours of injury. The clinical significance of this and role of antibiotics in this setting are unknown. We investigated the incidence that bacteria isolated during a pneumonia episode were previously isolated on surveillance BAL among patients with inhalation injury. Methods Among patients with inhalation injury admitted to a large ABA-verified burn center from 2009-2022, microbiological isolates from initial BAL and subsequent culture obtained during a pneumonia episode (BAL, sputum), were extracted from medical records. Abbreviated injury severity score (AIS) was used to grade inhalation injury. Hospital-acquired pneumonia (HAP) was defined using CDC PNU1 criteria, and ventilator-associated pneumonia (VAP) was defined using PNU2 criteria with BAL cutoff >10,000 colony forming units (CFU). Results Two-hundred forty-eight patients with inhalation injury who underwent bronchoscopy for airway inspection and surveillance BAL within 48 hours of injury were included in the analysis. Of the 111 who had a bacterial isolate from initial BAL, 23 (21%) subsequently developed HAP or VAP during the hospitalization. Median (IQR) days between bronchoscopy and pneumonia diagnosis was six (2-8.5). In three of the 11 VAP cases (27%), the organisms identified at pneumonia diagnosis matched the organisms identified on initial BAL. Antibiotic use on admission was not associated with re-culture of initial BAL organism during a subsequent pneumonia episode (p=0.071). Conclusions Among patients with inhalation injury and bacteria isolated on surveillance BAL, 21% developed pneumonia during their hospital stay, usually with different bacteria than those isolated at initial bronchoscopy. There was no association between empiric antibiotic use and incidence of initial BAL organisms re-cultured during subsequent pneumonia episode. Applicability of Research to Practice Findings suggest initial BAL isolates cannot guide empiric coverage of pneumonia for patients with inhalation injury. This remains an important area of future research.

Pulmonary Granuloma Associated with Pneumocystis Jirovecii in a Patient with Peripheral T-Cell Lymphoma: Presentation of a Rare Case with Review of the Literature

Abstract Casestudy: Although Pneumocystis jirovecii (PJ) is a known opportunistic pulmonary infection among immunocompromised patients, it is a rare (<5%) cause of pneumonia in this cohort. Majority of cases are observed in patients with HIV or solid organ transplant recipients. Granuloma formation in patients infected with PJ is even rarer. We present a case of multiple pulmonary granulomas associated with PJ in a non-HIV patient. A 49-year-old female with a history of asthma presented with worsening dyspnea. Initial imaging revealed multifocal bilateral areas of consolidation and a diagnostic bronchoalveolar lavage (BAL) demonstrated PJ organisms. Additional investigation was pursued to determine the etiology of this infection in a seemingly immunocompetent patient. New findings noted during hospitalization included a new maculopapular skin rash, significant weight loss, and lymphopenia. A bone marrow biopsy revealed a clonal proliferation of plasma cells. Subsequent imaging revealed mediastinal adenopathy. There was no improvement in symptoms despite treatment for pneumonia and a month later, a lung wedge biopsy revealed organizing acute lung injury and multiple non-caseating granulomas without lymphoid rimming, asteroid, or Schaumann bodies. Silver stain highlighted numerous PJ organisms within and outside of the granulomas. An inguinal lymph node and skin biopsies eventually revealed involvement by peripheral T-cell lymphoma (PTCL). Repeat BAL revealed clearance of organisms after additional therapy; however, the PTCL was refractory to chemotherapy and palliative care was pursued. To date, we could only find <30 cases of pulmonary PJ granulomas in patients with hematologic malignancies. Most are in patients with B cell lymphomas and just 1 report in a patient with adult T-cell leukemia/lymphoma. In summary, this case highlights that PJ associated pulmonary granulomas are uncommon, can be a harbinger of an underlying immunocompromised state, such as a lymphoma, and are even rarer to be associated with PTCL.

Risk factors for disease-related deterioration following diagnostic bronchoalveolar lavage procedures in diffuse lung disease: a case-control study.

BackgroundAlthough the risk factors for diagnostic bronchoalveolar lavage (BAL)-induced acute exacerbations in patients with idiopathic pulmonary fibrosis (IPF) have been previously reported, no study has assessed these in patients with non-IPF. We aimed to identify the risk factors for BAL-induced disease deterioration (BAL-DD) in all types of diffuse lung disease.MethodsPatients with diffuse lung disease who underwent BAL at our hospital from April 2012 to November 2017 were retrospectively analyzed. The patient information, laboratory data, radiological findings, and BAL fluid analysis results in patients who developed BAL-DDs were compared with those in patients who did not.ResultsBAL-DDs occurred in 14 (3.3%) of the 429 patients included the study. The BAL-DD group had a significantly poorer performance status, higher C-reactive protein level, lower partial pressure of oxygen in the arterial blood at rest, greater proportion of desaturation on exertion and cases having followed a progressive clinical course before BAL, and more extensive consolidation and ground-glass opacity on chest high-resolution computed tomography (HRCT) than the non-BAL-DD group. A high total cell concentration and an increased number of eosinophils in the BAL fluid were more frequently found in patients with BAL-DD than in those without.ConclusionsPatients with decreased physical activity level, increased level of inflammatory markers, low oxygenation status, and extensive lung involvements on chest HRCT and following a progressive clinical course before BAL may be warned of the BAL-DD risk. Elevated eosinophil counts in the BAL fluid could be associated with the triggering of BAL-DDs.

Effect of exogenous surfactant on Paediatric Bronchoalveolar lavage derived macrophages\u2019 cytokine secretion

BackgroundBronchoalveolar lavage is a useful bronchoscopy technique. However, studies in “normal” children populations are few. Furthermore, the anti-inflammatory effects of exogenous pulmonary surfactants on the bronchoalveolar cellular components are limited.MethodsThirty children, aged 3 to 14 years, underwent diagnostic bronchoscopy and bronchoalveolar lavage. Differential cytology, cytokine and chemokine measurements were performed on the fluid after exogenous surfactant exposure. The aim of the study was to investigate the potential anti-inflammatory effects of exogenous surfactants on the bronchoalveolar lavage fluid, specifically alveolar macrophages of healthy South African children.ResultsAlveolar macrophages were the predominant cellular population in normal children. Patients with inflammatory pneumonopathies had significantly more neutrophils. Levels of inflammatory cytokines were significantly lower after exogenous surfactant exposure. Moreover, IL-10 and IL-12 cytokine secretion increased after exogenous surfactant exposure.ConclusionThis study provides the first data on bronchoalveolar lavage of healthy South African children. Bronchoalveolar lavage fluid from patients with pulmonary inflammation was characterised by neutrophilia. Finally, we propose that exogenous surfactant treatment could help alleviate inflammation in diseased states where it occurs in the tracheobronchial tree.

Is it possible to predict, whether BAL salvage is going to be diagnostic?

Bronchoalveolar lavage (BAL) is used in the diagnosis of interstitial lung diseases. BAL is diagnostic when ≥ 60% of the instilled volume is recovered. There are no reliable markers useful to predict whether BAL volume is going to be diagnostic. Our goal was to search for pulmonary function markers which could anticipate whether the recovered volume of instilled fluid would be ≥ 60% of administered volume. BAL volumes and quality were analyzed in the context of disease, medical condition and lung function test results of the subjects hospitalized at the Pulmonology Ward from January 2015 to October 2016. The patients' average age was 61 (29-89). Among 80 procedures, diagnostic BAL (≥ 60%) has been obtained in 58 cases. The analysis of the group of patients with an interstitial lung disease confirmed that there is a correlation between decreasing BAL recovered volume and an increase of RV[%pred] (r = -0.34) and RV/TLC[%pred] (r = -0.41); p < 0.05. There was no significant correlation with DLCO. RV/TLC[%pred] was the parameter with the highest predictive value for an anticipated correct BAL recovery. The curve analysis of the receiver operating characteristic (ROC) showed a diagnostic accuracy (AUC 0.73, 95% CI 0.61-0.86). Pulmonary hyperinflation may have a predictive role in anticipating a proper recovery of the BAL fluid volume.

Regional pulmonary effects of bronchoalveolar lavage procedure determined by electrical impedance tomography

BackgroundThe provision of guidance in ventilator therapy by continuous monitoring of regional lung ventilation, aeration and respiratory system mechanics is the main clinical benefit of electrical impedance tomography (EIT). A new application was recently described in critically ill patients undergoing diagnostic bronchoalveolar lavage (BAL) with the intention of using EIT to identify the region where sampling was performed. Increased electrical bioimpedance was reported after fluid instillation. To verify the accuracy of these findings, contradicting the current EIT knowledge, we have systematically analysed chest EIT data acquired under controlled experimental conditions in animals undergoing a large number of BAL procedures.MethodsOne hundred thirteen BAL procedures were performed in 13 newborn piglets positioned both supine and prone. EIT data was obtained at 13 images before, during and after each BAL. The data was analysed at three time points: (1) after disconnection from the ventilator before the fluid instillation and by the ends of fluid (2) instillation and (3) recovery by suction and compared with the baseline measurements before the procedure. Functional EIT images were generated, and changes in pixel electrical bioimpedance were calculated relative to baseline. The data was examined in the whole image and in three (ventral, middle, dorsal) regions-of-interest per lung.ResultsCompared with the baseline phase, chest electrical bioimpedance fell after the disconnection from the ventilator in all animals in both postures during all procedures. The fluid instillation further decreased electrical bioimpedance. During fluid recovery, electrical bioimpedance increased, but not to baseline values. All effects were highly significant (p < 0.001). The fractional changes in individual regions-of-interest were posture-dependent. The regional fall in electrical bioimpedance was smaller in the ventral and larger in the dorsal regions after the fluid instillation than after the initial disconnection to ambient pressure in supine animals (p < 0.001) whereas these changes were of comparable amplitude in prone position.ConclusionsThe results of this study show a regionally dissimilar initial fall in electrical bioimpedance caused by non-uniform aeration loss at the beginning of the BAL procedure. They also confirm a further pronounced fall in bioimpedance during fluid instillation, incomplete recovery after suction and a posture-dependent distribution pattern of these effects.

Hydropneumothorax following diagnostic bronchoalveolar lavage : A rarest of rare complication.

Hydropneumothorax following diagnostic bronchoalveolar lavage : A rarest of rare complication.

Emerging Side Effects of Programmed Cell Death 1 Ligand Inhibitors: MAC Infection and Nivolumab

SESSION TITLE: Non-Small Cell Lung Cancer SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Mycobacterium Avium Complex (MAC) is a ubiquitous environmental microorganism. In recent years, there has been an increase in disease incidence; it is not clear whether this reflects a real increase in infection rate or greater recognition resulting from more widespread awareness and advanced laboratory techniques. A potential reason for the MAC infection is the weakened immune system in aging population and the rise in the use of immunomodulating drugs. We hereby describe the first known case report of MAC infection in a patient with Non-Small Cell Lung Cancer (NSCLC) receiving Nivolumab (Opdivo) a programmed cell death 1 ligand inhibitor. CASE PRESENTATION: Our patient is an 83 years old gentleman with lung adenocarcinoma diagnosed in June 2011. He had received six cycles of Pemetrexed and Carboplatin and placed on maintenance therapy with Pemetrexed which was discontinued due side effects. The cancer progressed and the patient was placed on Opdivo with great response. At a follow up appointment, the patient presented with progressive fatigue, weight loss, and dry cough. On physical examination, the patient appeared chronically ill, with no specific respiratory exam findings. His chest was clear to auscultation without wheezing, rhonchi or crackles. Additionally, his laboratory results showed normal WBC count and differential. CT scan of the chest showed no progression of his cancer but revealed new nodular and small cavitary lesions with centrilobular nodularity in tree-in-bud distribution (figure 1). Subsequently the patient underwent bronchoscopy with diagnostic bronchoalveolar lavage which returned positive for MAI infection. The patient was placed on triple antibiotics and the Opdivo was placed on hold. At three months follow up, the patient showed significant improvement in his fatigue and weight and his cough had resolved. DISCUSSION: Despite the impressive benefits of the immune checkpoint blockade, its use can be hampered by the occurrence of serious adverse events including immune-related adverse events (irAEs) and opportunistic infections with potentially aggressive course and fatal outcome. With more indications and widespread use of these medications we will be encountering more of their side effects. Prompt diagnosis, discontinuation of the drug and starting antibiotics treatment is the key for successful treatment CONCLUSIONS: It is important to become aware of the possible infections that patient on current treatment with Opdivo (Nivolumab) could develop; it becomes important to keep in mind that MAC infections should be at the top of the list in the differential diagnosis if patient presents with symptoms such as cough, fever, severe fatigue. Reference #1: OPDIVO. Package insert. Princeton, NJ: Bristol Myers Squibb Company; 2016. DISCLOSURE: The following authors have nothing to disclose: Fernando Fuentes, Yousef Al-ahwel No Product/Research Disclosure Information

Effects of positive end-expiratory pressure and 30% inspired oxygen on pulmonary mechanics and atelectasis in cats undergoing non-bronchoscopic bronchoalveolar lavage.

Objectives The objective of this study was to determine if modification of inspired oxygen concentration or positive end-expiratory pressure (PEEP) would alter bronchoalveolar lavage (BAL)-induced changes in pulmonary mechanics or atelectasis, as measured using ventilator-acquired pulmonary mechanics and thoracic CT. Methods Six experimentally asthmatic cats underwent anesthesia and non-bronchoscopic BAL, each under four randomized treatment conditions: 100% oxygen, zero PEEP; 30% oxygen, zero PEEP; 100% oxygen, PEEP 2 cmH2O; and 30% oxygen, PEEP 2 cmH2O. Pulse oximetry was used to estimate oxygen saturation (SpO2). Ventilator-acquired pulmonary mechanics and thoracic CT scans were collected prior to BAL and at 1, 5 and 15 mins post-BAL. Results While receiving 100% oxygen, no cat had SpO2 <91%. Some cats receiving 30% oxygen had decreased saturation immediately post-BAL (mean ± SD 70.8 ± 31%), but 6/8 of these had SpO2 >90% by 1 min later. There was a significant increase in airway resistance and a decrease in lung compliance following BAL, but there was no significant difference between treatment groups. Cats receiving no PEEP and 30% oxygen conserved better aeration of the lung parenchyma in BAL-sampled areas than those receiving no PEEP and 100% oxygen. Conclusions and relevance Alterations in pulmonary mechanics or atelectasis may not be reflected by SpO2 following BAL. The use of 30% inspired oxygen concentration failed to show any significant improvement in pulmonary mechanics but did diminish atelectasis. In some cats, it was also associated with desaturation of hemoglobin. The use of PEEP in this study did not show any effect on our outcome parameters. Further studies using higher PEEP (5-10 cmH2O) and intermediate inspired oxygen concentration (40-60%) are warranted to determine if they would confer clinical benefit in cats undergoing diagnostic BAL.

Clinical course and complications following diagnostic bronchoalveolar lavage in critically ill mechanically ventilated patients.

BackgroundFlexible, fibreoptic bronchoscopy (FFB) and bronchoalveolar lavage (BAL) have been used for diagnostic purposes in critically ill ventilated patients. The additional diagnostic value compared to tracheal aspirations in ventilator-associated pneumonia (VAP) has been questioned. Nevertheless, BAL can provide extra information for the differential diagnosis of respiratory disease and good antibiotic stewardship. These benefits should outweigh potential hazards caused by the invasiveness of this diagnostic technique. The focus of the present study was on the clinical course and complications of patients following BAL procedures up to 24 h.MethodsHundred sixty-four FFB guided BAL procedures for suspected pneumonia were analysed in an observational study. The clinical course of patients was monitored by respiratory and haemodynamic data before BAL, 1 and 24 h after BAL. Complications were defined and registered. Factors associated with complications were analysed by logistic regression.ResultsClinical course: a decrease in average pO2/FiO2 ratio 1 h after BAL from 29 kPa (218 mmHg) to 25 kPa (189 mmHg) (p < 0.05) was observed which fully recovered within 24 h. Respiratory complications: the incidence of procedure related hypo-oxygenation (SaO2 ≤ 88 %) and/or bronchospasm was 9 %; a decrease of >25 % PaO2/FiO2 ratio 1 h after BAL was found in 29 % of patients; no bleeding or pneumothorax were registered. Haemodynamic complications: there were no cases of hypertension and cardiac rhythm disturbances; haemodynamic instability within the first 24 h after BAL was recorded in 22 %; this was correlated with a cardiovascular diagnosis at admission (OR 2.9; 95 % CI 1.2 - 6.7) and the presence of cardiovascular co-morbidity (OR 3.5; 95 % CI 1.5 – 8.3). The incidence of bacteraemia was 7 %. There was no case of procedure related death.DiscussionFrequently occurring haemodynamic and respiratory instability but no cases of cardiac rhythm disturbances, bleeding, pneumothorax or procedure related death were attributable to diagnostic FFB and BAL. The procedures should be conducted under careful supervision by experienced physicians. Only a randomized controlled trial that compares diagnostic FFB and BAL with a non-invasive strategy could ultimately establish the safety profile and clinical utility of these procedures in critically ill ventilated patients.

Alternative diagnosis in the putative ventilator-associated pneumonia patient not meeting lavage-based diagnostic criteria.

The clinical picture of ventilator-associated pneumonia (VAP) can be mimicked by other infectious and non-infectious diseases. The aim of this study was to determine the alternative diagnoses and to develop a diagnostic flow chart for patients suspected of having VAP not meeting the diagnostic broncho-alveolar lavage (BAL) criteria. Adult intensive care patients with a clinical suspicion of VAP and negative BAL results were included. The clinical suspicion of VAP was based on the combination of clinical, radiological, and microbiological criteria. BAL was considered positive if cell differentiation revealed ≥ 2% cells with intracellular organisms and/or quantitative culture results of ≥ 10(4) cfu/ml. The most likely alternative diagnosis of fever and pulmonary densities was retrospectively determined by two authors independently. In all, 110 of 207 patients with suspected VAP did not meet the diagnostic BAL criteria and required further diagnostic evaluation. In 67 patients an alternative diagnosis for fever could be found. In 51 patients an alternative diagnosis of both fever and pulmonary densities could be established. In almost 40% of patients no alternative diagnosis could be provided. Non-bacterial pneumonia was diagnosed in 10 patients with Herpes simplex virus 1 (HSV-1) as the most common pathogen. In eight patients non-infectious pneumonitis was diagnosed. Due to the wide range of alternative diagnoses and applied tests the diagnostic work-up proved to be necessarily individualized and guided by repeated clinical assessment. The most frequently found alternative diagnoses were viral pneumonia and non-infectious pneumonitis.

Stromal cells can be cultured and characterized from diagnostic bronchoalveolar fluid samples obtained from patients with various types of interstitial lung diseases.

Increased proliferation of stromal cells is a typical feature encountered in several lung diseases. The objective of this study was to evaluate the success of standardized process for culturing stromal cells from small volumes of diagnostic bronchoalveolar lavage (BAL) fluid samples collected from various patients and to characterize the cultured cells. Small volumes (average 15 mL) of BAL fluid samples were collected from 98 patients who underwent bronchoscopy and BAL for diagnostic purposes. The cells were cultured in vitro and characterized by immunohistochemistry, electron microscopy, flow cytometry and differentiation tests. Cells could be cultured from 62% of samples with the success rate varying with the disease (p = 0.003). Cultures from samples of the patients with idiopathic pulmonary fibrosis, non-specific interstitial pneumonia, connective tissue disorder associated interstitial lung disease and allergic alveolitis had a higher success rate than samples derived from control lung (p < 0.001, 0.03, 0.03 and 0.044, respectively). Smokers had a higher success rate compared with non-smokers (p = 0.035). The cultured cells were fibroblasts or myofibroblasts, but shared also similarities with progenitor-type cells. The study shows that mesenchymal cells can be cultured and studied from small volumes of diagnostic BAL fluid samples from patients with several different types of lung diseases.

Myofibroblasts in interstitial lung diseases show diverse electron microscopic and invasive features

The characteristic features of myofibroblasts in various lung disorders are poorly understood. We have evaluated the ultrastructure and invasive capacities of myofibroblasts cultured from small volumes of diagnostic bronchoalveolar lavage (BAL) fluid samples from patients with different types of lung diseases. Cells were cultured from samples of BAL fluid collected from 51 patients that had undergone bronchoscopy and BAL for diagnostic purposes. The cells were visualized by transmission electron microscopy and immunoelectron microscopy to achieve ultrastructural localization of alpha-smooth muscle actin (α-SMA) and fibronectin. The levels of α-SMA protein and mRNA and fibronectin mRNA were measured by western blot and quantitative real-time reverse transcriptase polymerase chain reaction. The invasive capacities of the cells were evaluated. The cultured cells were either fibroblasts or myofibroblasts. The structure of the fibronexus, and the amounts of intracellular actin, extracellular fibronectin and cell junctions of myofibroblasts varied in different diseases. In electron and immunoelectron microscopy, cells cultured from interstitial lung diseases (ILDs) expressed more actin filaments and α-SMA than normal lung. The invasive capacity of the cells obtained from patients with idiopathic pulmonary fibrosis was higher than that from patients with other type of ILDs. Cells expressing more actin filaments had a higher invasion capacity. It is concluded that electron and immunoelectron microscopic studies of myofibroblasts can reveal differential features in various diseases. An analysis of myofibroblasts cultured from diagnostic BAL fluid samples may represent a new kind of tool for diagnostics and research into lung diseases.

Pulmonary involvement in sea-blue histiocytosis

Sea-blue histiocytosis is one of the six types of Niemann-Pick disease. It is characterized by childhood onset of hepatosplenomegaly, lack of neurological involvement and diminished sphingomyelinase activity. Pulmonary system is rarely involved sea-blue histiocytosis. In this paper, we present a 39-years-old male who had previously diagnosed as sea-blue histiocytosis at the age of 15. He was admitted to our clinic due to productive cough, hemoptysis, fever and weight loss. His symptoms did not resolve with the antibiotic treatment and further investigations revealed pulmonary involvement of sea-blue histiocytosis. After diagnostic bronchoalveolar lavage, his symptoms were improved, interestingly. This rare entity was discussed with literature survey.

Acute exacerbation of IPF following diagnostic bronchoalveolar lavage procedures

Bronchoalveolar lavage (BAL) is generally regarded as a safe diagnostic procedure. However, acute exacerbation after BAL is increasingly recognized as a specific complication for patients with idiopathic pulmonary fibrosis (IPF). So far little is known about the correlation between BAL and acute exacerbation of IPF (AE-IPF). A cohort of 112 IPF patients at a single institution was analyzed retrospectively. We defined BAL-related AE-IPF as development of AE-IPF within 30 days after the procedure. The incidence rate of AE-IPF per person-month during the post-BAL period was compared with that after the post-BAL period. The relative risk was estimated as the former rate divided by the latter. We also reviewed the previous literature. Four AE-IPF cases occurred during the 201 person-month post-BAL period. The riskofAE-IPF was significantly elevated within 30 days after BAL (rate ratio=4.12; 95% CI=1.03-12.2). None of the 111 initial BAL procedures were followed by AE-IPF within a month. In a post hoc analysis, the relative risk of developing AE after second or later BAL procedures was estimated to be considerably higher (rate ratio=9.10; 95% CI=2.27-26.98). Twelve cases of BAL-induced AE-IPF were found in our study and in the literature review. Among them, nine showed moderate to severe functional impairment, and eight had either findings of leukocytosis, positive C-reactive protein, or neutrophilia in BAL. These results suggest that IPF patients should be carefully monitored after BAL, especially those with functional impairment or active inflammation.

The Etiologic Role of Infectious Antigens in Sarcoidosis Pathogenesis

Sarcoidosis is a disease of unknown etiology, characterized pathologically by noncaseating granulomas that most commonly involve the lung, skin, lymph nodes, and eyes. Syndromes with similar pathological and immunologic features to sarcoidosis such as chronic beryllium disease, hypersensitivity pneumonitis, and tuberculosis illustrate that granulomatous diseases may or may not have an infectious etiology. Although the etiology of sarcoidosis remains unknown, recent molecular, genetic, and immunologic studies strengthen the association of sarcoidosis with infectious antigens. Currently, the strongest agents considered include PROPIONIBACTERIUM and MYCOBACTERIUM species. Independent studies report the presence of microbial nucleic acids and proteins within sarcoidosis specimens. Th-1 immune responses to mycobacterial proteins have been detected within sarcoidosis diagnostic bronchoalveolar lavage (BAL). These proteins are actively secreted by the mycobacterial SecA 2 secretion system and are important to evade the host immune system. Recent discoveries regarding MHC class II alleles provide additional insight regarding the role of microbial antigens in sarcoidosis pathogenesis. Although further investigation is warranted, the recent progress of independent laboratories, using complementary techniques, strengthens the role of microbial antigens in sarcoidosis pathogenesis. These studies lay a strong foundation toward identifying therapeutic targets.

Successful treatment of lipoid pneumonia associated with bowel obstruction by Ascaris lumbricoides

Partial bowel obstruction is a serious complication of ascariasis infestation generally treated with mineral oil. This prospective study aimed to evaluate the efficacy of multiple bronchoalveolar lavages (BAL) as a therapeutic strategy for reducing lung inflammation of lipoid pneumonia associated with ascariasis. The study included five children (mean age 25 months) with partial small-bowel obstruction by Ascaris lumbricoides, who underwent diagnostic bronchoalveolar lavage for assessment of refractory pneumonia. Routine biochemical, microbiological and cytological analysis were carried out in the BAL. Protein, lactate dehydrogenase and tumor necrosis factor-alpha (TNF-α) cytokine levels were determined in the serum before and after treatment. At admission, children consistently had respiratory symptoms, altered hematological function, increased immunoglobulin E serum level and peripheral blood eosinophilia. Chest tomography showed consolidation with air bronchogram (4/4), ground-glass infiltration (3/4) and decreased attenuation in the consolidation areas (2/4). Presence of marked pleocytosis with Sudan positive foamy alveolar macrophages, high protein and lactate dehydrogenase levels in the BAL indicated presence of mixed alveolitis. One child with extensive consolidation and air bronchogram in both lungs died before treatment. Multiple bronchoalveolar lavages efficiently removed alveolar oil deposits, restored BAL cellularity, improved clinical symptoms, radiological parameters and further reduced inflammatory reaction evidenced by marked decrease of the inflammatory cytokine, TNF-α. This study presents a therapeutic strategy for management of lung complications caused by mineral oil administration to treat intestinal bowel obstruction associated with ascariasis.

Performance Characteristics of the Platelia Aspergillus Enzyme Immunoassay for Detection of Aspergillus Galactomannan Antigen in Bronchoalveolar Lavage Fluid

We have evaluated the Platelia Aspergillus enzyme immunoassay for detection of galactomannan in bronchoalveolar lavage (BAL) specimens in solid organ transplant patients with aspergillosis. The precision and reproducibility in serum or BAL to which galactomannan was added were similar. Sensitivity was 81.8% in patients with aspergillosis, and specificity was 95.8% in lung transplant patients who underwent BAL for surveillance for infection or rejection. Among transplant controls, positive results were more common in patients (i) who underwent diagnostic BAL performed for evaluation of symptoms or chest computed tomographic abnormalities, (ii) who had undergone lung transplantation, or (iii) who were colonized with Aspergillus. Galactomannan testing in BAL is useful for diagnosis of aspergillosis in transplant patients. The significance of positive results in patients without confirmed aspergillosis requires further evaluation.