Diagnostic Yield Of Bronchoalveolar Lavage Research Articles

Diagnostic Yield of Bronchoalveolar Lavage in Nepalese Patients Presenting with Chronic Cough with Normal Radiological Imaging in Tertiary Care Hospital

Background: Cough is one of the most common symptoms that lead patients to seek medical attention. The diagnosis of chronic cough is complex and challenging. In our setting, a large proportion of patients with cough are treated empirically without a definite diagnosis. Despite investigation and treatment, fiberoptic bronchoscope with bronchoalveolar lavage (BAL) has been shown to be a useful technique in a selected group of patients with unexplained chronic persistent cough. The aim of the study was to determine the diagnostic yield of bronchoalveolar lavage in Nepalese patients presenting with chronic cough with normal radiological imaging. Methods: This was a hospital based cross sectional study. The patients presenting with chronic cough (>8 weeks) with normal radiological imaging were enrolled in the study. Results: 1 patient (2.6%) sputum sample for AFB was negative however BAL sample of the same patient sent for Gene xpert came positive for Mycobacterium Tuberculosis, 5 patients (12.8%) had positive BAL culture, 29 patients (74.4%) had normal cellular pattern in BAL Cytology. Conclusion: Diagnostic yield of BAL was very low for chronic cough in our study. Patient presenting with eosinophilic pattern in BAL had cough variant asthma suffer from non-productive cough in the absence of other asthma symptoms such as dyspnea and wheezing. Thus, though fiberoptic bronchoscope with BAL is indicated in chronic cough of unknown etiology, its diagnostic yield is low

Diagnostic Role of Bronchoalveolar Lavage in Patients with Suspected SARS-CoV-2 Pneumonia and Negative Upper Respiratory Tract Swab: A Systematic Review and Meta-Analysis.

The added role of bronchoalveolar lavage (BAL) in SARS-CoV-2 detection in hospitalized patients with suspected COVID-19 pneumonia and at least one negative nasopharyngeal swab (NPS) has yet to be definitively established. We aimed to provide a systematic review and meta-analysis to summarize data from the literature on the diagnostic yield of BAL in this context. We searched Medline and Embase for all studies reporting outcomes of interest published up to October 2021. Two authors reviewed all titles/abstracts and retrieved the selected full texts according to predefined selection criteria. The summary estimate was derived using the random-effects model. Thirteen original studies, involving 868 patients, were included. The summary estimate of proportions of SARS-CoV-2 positivity in BAL fluid in patients with at least one previous negative NPS was 20% (95% confidence interval [CI]; 11–30%). Moreover, microbiological tests of BAL fluid led to the identification of other pathogens, mainly bacteria, in up to two-thirds of cases. BAL plays a crucial role in the diagnostic work-up of patients with clinical suspicion of COVID-19 and previous negative NPS, as it allowed to detect the infection in a significant proportion of subjects, who would have been otherwise misclassified, with relevant implications in the prevention of disease spread, especially in hospital settings.

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.

BAL fluid analysis in the identification of infectious agents in patients with hematological malignancies and pulmonary infiltrates.

The present study aims to evaluate the diagnostic yield of bronchoalveolar lavage (BAL) fluid in patients with hematological malignancies and describe the most common pathogens detected in BAL fluid (BALF.) An analysis of 480 BALF samples was performed in patients with hematological malignancies over a period of 7 years. The results of culture methods, PCR, and immunoenzymatic sandwich microplate assays for Aspergillus galactomannan (GM) in BALF were analyzed. Further, the diagnostic thresholds for Aspergillus GM and Pneumocystis jiroveci were also calculated. Microbiological findings were present in 87% of BALF samples. Possible infectious pathogens were detected in 55% of cases; 32% were classified as colonizing. No significant difference in diagnostic yield or pathogen spectrum was found between non-neutropenic and neutropenic patients. There was one significant difference in BALF findings among intensive care units (ICU) versus non-ICU patients for Aspergillus spp. (22% versus 9%, p = 0.03). The most common pathogens were Aspergillus spp. (n = 86, 33% of BAL with causative pathogens) and Streptococcus pneumoniae (n = 46, 18%); polymicrobial etiology was documented in 20% of cases. A quantitative PCR value of > 1860 cp/mL for Pneumocystis jirovecii was set as a diagnostic threshold for pneumocystis pneumonia. The absorbance index of GM in BALF of 0.5 was set as a diagnostic threshold for aspergillosis. The examination of BAL fluid revealed the presence of pathogen in more than 50% of cases and is, therefore, highly useful in this regard when concerning pulmonary infiltrates.Electronic supplementary materialThe online version of this article (10.1007/s12223-019-00712-4) contains supplementary material, which is available to authorized users.

Improving Microbiological Diagnostic Yield of Bronchoalveolar Lavage (BAL) Specimens in Pediatric Allogeneic Hematopoietic Stem Cell Transplant (AlloHSCT) Recipients

Background Pulmonary complications, including both infectious and noninfectious etiologies, are a frequent cause of morbidity and mortality in pediatric alloHSCT patients from the immediate post-transplant period to 5 years post-transplant. Early detection and initiation of appropriate antimicrobial therapy improve survival. However, present techniques for identifying infectious organisms are limited by pretreatment with antimicrobial therapies and the need for a priori knowledge of likely viral pathogens, greatly decreasing the yield of BAL. Our group has published the results of 193 pediatric HSCT patients and found a 43% probability of need for BAL in the year following stem cell transplant with only a 40% yield of identifying an infectious organism. Massively parallel sequencing (MPS) has the potential to mitigate these limitations, by identifying the genetic sequence of all DNA or RNA in a sample without the need for viable organisms or microbe specificity. Methods Pediatric alloHSCT patients with new pulmonary findings on imaging underwent BAL by the pediatric pulmonary service at MFCH as a pilot study (NYMC-181). BAL was performed per standard WMC clinical practice methods and lavage fluid sent for bacterial, fungal, and viral cultures, aspergillus galactomannan, βD-glucan, and PCRs for CMV, EBV, and adenovirus, and other tests as indicated. Excess BAL fluid was preserved in Trizol prior to RNA isolation. cDNA libraries were generated from each sample and sequenced on the Illumina NextSeq platform. Sequence reads were de novo assembled using the Trinity assembler and classified using Kraken and a custom-built database. Results from MPS and clinical testing were compared. Results 9 patients underwent 10 BALs (1 patient underwent 2 BALs) from July 2016 through December 2017 and had sufficient BAL fluid for inclusion in this study (Figure 1). Clinical microbiological testing identified infections in 6 patients (60%), 3 with bacterial infections (2 Staphylococcus haemolyticus & 1 Streptococcus viridans), 3 with viral pathogens (1 CMV, 1 EBV, and 1 RSV), and 1 fungal infection (Candida). MPS identified infections in 5 patients, one fewer than the clinical testing. Results were wholly concordant in 2 patients (Staph haemolyticus and RSV) and partly concordant in 1 patient (Candida detected, but different viruses found on clinical and sequencing testing). CMV, EBV, S. haemolyticus, and S. viridans (1 patient each) were detected on clinical testing, but not using sequencing. Haemophilus influenza, rhinovirus, and enterovirus (1 patient each) were detected using sequencing, but not clinical testing. Conclusions RNA based massively parallel sequencing techniques can serve as an adjunct to standard clinical testing of BAL fluid for improved detection of infections (especially polymicrobial) in pediatric recipients of alloHSCT.

Main findings and diagnostic yield of bronchoalveolar lavage, bronchial brushing and transbronchial biopsy in HIV-positive patients.

ABSTRACTBronchoalveolar lavage, bronchial brushing and transbronchial biopsy are of fundamental importance in the diagnosis of pathologies affecting the lungs of immunosuppressed patients, especially those infected with HIV. This was a descriptive and retrospective study, in which the results of bronchoalveolar lavages, bronchial brushings and transbronchial biopsies of HIV-positive patients attended at the Clinical Hospital of the Federal University of Triangulo Mineiro from 1999 to 2015 were reviewed to determine the most frequent findings in these patients, to evaluate the diagnostic accuracy of these procedures and to correlate bronchoscopy results with clinical and radiological findings. Serological tests for HIV were confirmed and cases with negative or unverified serology were excluded. Medical records were reviewed for correlation with clinical and radiological findings. A total of 1,423 patients with a mean age of 50 years were initially selected; 727 cases had no serology for HIV; 696 had serology for HIV and 64 were positive. Of these, 47 were men, aged 24 to 84 years, and 17 women, aged 31 to 69 years. Biopsies and cytological tests were positive in 20 (31.25%) of the 64 patients and the most frequent diagnosis was pneumocystosis, found in 8 cases (12.5%). Of the 20 bronchofibroscopy-positive patients, only 2 did not show agreement between histopathological and clinical-radiological diagnoses. The analysis of the cytological tests and biopsy specimens obtained by bronchofibroscopy seems to be valuable for the etiological diagnosis of pulmonary infections in HIV- positive patients; however, negative results do not always exclude the diagnosis. In these cases, clinical symptoms and imaging findings may help to guide the best therapy.

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.

Diagnostic yield of bronchoalveolar lavage in immunocompromised children with malignant and non-malignant disorders.

SummaryBackgroundThe diagnostic yield of bronchoalveolar lavage (BAL) in the Immunocompromised pediatric population has ranged from 28% to 68%. We hypothesized that the diagnostic yield of BALs would be higher in more recent years due to new diagnostic assays.MethodsA retrospective case series was performed among immunocompromised children ≤18 years old who underwent BALs from 2001 to 2012, to assess the yield of microbiologic diagnostic studies and to determine the impact of BAL findings on antimicrobial management.ResultsIn all, 123 subjects underwent 174 BALs (mean age 9.9 years). Underlying diagnoses included both malignant (n = 79) and non‐malignant (n = 44) disorders, and 75 (61.0%) subjects were hematopoietic stem cell transplant (HSCT) recipients. Fifty‐four (31.0%) of 174 BAL were positive for ≥1 potential pathogen (n = 58 microorganisms). The diagnostic yield of BALs performed from 2001 to 2006 versus2007–2012 was similar (40.5% vs. 26.6%, respectively, P = 0.07). Most subjects (86.2%) were on ≥1 antimicrobial at the time of BAL. Most (65.8%) negative BALs were associated with narrowing antimicrobial therapy, while most (74.1%) positive BALs were associated with continuing or changing to targeted antimicrobial therapy.ConclusionsIn this study population, the diagnostic yield of BAL was similar to that previously described and unchanged in more recent years. Both negative and positive BALs were associated with changes in antimicrobial management.SummaryA 10‐year retrospective review of bronchoalveolar lavage in 123 immunocompromised children determined that the rate of isolation of potential pathogens was 31% in this population. The majority of BAL was associated with a change in antimicrobial therapy. Pediatr Pulmonol. 2017;52:820–826. © 2017 Wiley Periodicals, Inc.

Utility of bronchoalveolar lavage in diagnosing respiratory tract infections in patients with hematological malignancies: are invasive diagnostics still needed?

Background: Patients treated for hematological malignancies have an increased risk of serious infections. Diagnosis and prompt initiation of therapy are essential. Bronchoalveolar lavage (BAL) is a well-established investigation for identifying the cause of pulmonary infiltrates in immunocompromised patients. The aim of the study was to determine the diagnostic yield of BAL in patients treated for hematological malignancies and how often it contributed to a modification of the anti-infectious therapy.Methods: We reviewed records from 151 consecutive BAL procedures in 133 adult patients with hematological malignancies, treated at a tertiary hematology unit from 2004 to 2013. Extensive microbiological work-ups on BAL samples had been performed according to a standardized protocol.Results: A microbiological finding causing the infectious episode could be identified in 59 (39%) cases. In 44 (29%) of the cases, results from BAL had an impact on clinical management either by contributing to a specific diagnosis (25%) or by leading to cessation of ongoing microbiological therapy. The most common diagnoses were invasive pulmonary aspergillosis (IPA) and Pneumocystis jirovecii pneumonia (PJP). Diagnoses of IPA and PJP were based on results from BAL in 65% and 93% of cases, respectively. Several microbiological tests on BAL samples rendered no positive results. Complications were few and mainly mild.Conclusion: BAL is still important for either verifying or excluding some of the most important respiratory tract pathogens in patients with hematological malignancies, particularly IPA and PJP. Standardized procedures for BAL sampling should be continually revised to exclude unnecessary microbiological tests.

Diagnostic Value of Bronchoalveolar Lavage for Diagnosis of Suspected Peripheral Lung Cancer

BackgroundThere is a paucity of data concerning the benefit of bronchoalveolar lavage (BAL) for the diagnosis of suspected peripheral lung cancer (PLC). The aim of this study was to investigate the diagnostic value of BAL for the diagnosis of suspected PLC. Patients and MethodsAll flexible bronchoscopies that included BAL among other modalities (brush, forceps, washing) for the diagnosis of a suspected PLC performed between 2009 and 2013 were analyzed in this retrospective study. ResultsA total of 260 patients were included. Malignancy was present in 61%. BAL's sensitivity for the diagnosis of malignancy was 29%, and overall diagnostic yield of BAL was 46%. However, only 1% of cancer diagnoses would have been missed in the absence of BAL. In the multivariable analysis, the size of lesion (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.02–1.33; P = .023), the presence of bronchus sign (OR, 4.73; 95% CI, 1.06–21.08; P = .042), and the presence of mediastinal/hilar lymphadenopathy (OR, 3.37; 95% CI, 1.53–7.41; P = .002) were associated with improved BAL true-positive ratio relating to diagnosis of malignancy. However, the effect of lesion size on sensitivity was small (area under the curve, 0.31; 95% CI, 0.23–0.40; P < .001). Ground-glass lesions were not associated with improved BAL diagnostic value. The number needed to test for BAL for the diagnosis of malignancy or pulmonary infection was 37. ConclusionConventional BAL has a low diagnostic value for the diagnosis of suspected PLC, and the low number needed to test does not qualify BAL as a recommended routine investigation for the diagnosis of suspected PLC for either solid or ground-glass lesions.

The Diagnostic Yield of Bronchoalveolar Lavage and Transbronchial Lung Biopsy in Pulmonary Lymphangitic Carcinomatosis

The Diagnostic Yield of Bronchoalveolar Lavage and Transbronchial Lung Biopsy in Pulmonary Lymphangitic Carcinomatosis

Polymerase‐chain‐reaction‐based diagnosis of viral pulmonary infections in immunocompromised children

AimViral pneumonia is a serious complication in immunocompromised children. Its aetiology is difficult to identify owing to the limitations of conventional microbiological tests. The aim of this study was to determine whether polymerase chain reaction (PCR) assays for respiratory viruses increase the diagnostic yield of bronchoalveolar lavage (BAL) in immunocompromised children.MethodsBAL samples obtained from immunocompromised children hospitalized with pneumonia were processed for respiratory viruses by viral culture, rapid antigen test and PCR (for CMV, adenovirus, influenza, parainfluenza, herpesvirus, RSV and hMPV).ResultsThe study group included 42 patients (mean age 7.2 ± 5.1 years) with 50 episodes of clinical pneumonia (50 BAL samples). Forty viral pathogens were identified in 30 episodes (60%). PCR increased the diagnostic rate by fourfold (75% identified by PCR alone, p < 0.0001). When viral culture and rapid antigen test were used as the gold standard, PCR was found to have high sensitivity (86–100% when assessed) and specificity (80–96%). The PCR results prompted the initiation of specific antiviral therapy and the avoidance of unnecessary antibiotic treatment in 17 (34%) episodes.Conclusion PCR‐based diagnosis from BAL may increase the rate of pathogen detection in immunocompromised children, decrease the time to diagnosis and spare patients unnecessary antimicrobial treatment.

Factors Affecting Diagnostic Yield of Bronchoalveolar Lavage in Immunocompromised Patients

Factors Affecting Diagnostic Yield of Bronchoalveolar Lavage in Immunocompromised Patients

Performance of a standardized bronchoalveolar lavage protocol in a comprehensive cancer center

Flexible bronchoscopy with bronchoalveolar lavage (BAL) is performed widely for the diagnosis of pulmonary infections in patients with cancer, but there is no consensus regarding the technical parameters of the lavage procedure in this setting. The authors evaluated the mechanics (instilled and recovered volumes), diagnostic yield, and safety of a standardized BAL protocol in 284 patients with cancer who underwent bronchoscopy for the evaluation of new radiologic infiltrates. Physician adherence to the BAL protocol was > 90%. The most common protocol deviations were reductions in the saline volume instilled because of actual or anticipated oxyhemoglobin desaturation during the procedure. The mean volume instilled was 121.5 ± 13.9 mL, the mean volume recovered was 68.7 ± 18.1 mL, and the mean ratio of volume instilled to that recovered was 56.7% ± 14.5%. The overall diagnostic yield of BAL was 33.8% and was higher in the nonhematologic malignancy group (42.3% vs 29.4%; P = .021). The diagnostic yield in neutropenic patients was significantly higher than in non-neutropenic patients (41.5% vs 24.6%; P = .019). No major complications were encountered. In summary, the diagnostic performance of a standardized BAL protocol was comparable to that of nonprotocolized BAL reported in the literature with few complications. Adherence to a standardized BAL protocol may improve clinical and laboratory comparisons between studies, potentially facilitating research into the diagnosis and management of pneumonia in patients with cancer.

Diagnostic Yield of Bronchoalveolar Lavage Is Low in Allogeneic Hematopoietic Stem Cell Recipients Receiving Immunosuppressive Therapy or with Acute Graft-versus-Host Disease: The St. Jude Experience, 1990-2002

Management of pulmonary complications after hematopoietic stem cell transplantation (HSCT) often includes bronchoalveolar lavage (BAL), but the diagnostic yield of BAL remains unclear in pediatric HSCT patients. We reviewed the records of 78 allogeneic and 11 autologous transplant recipients who underwent BAL after HSCT at St. Jude Children’s Research Hospital (1990-2002). We analyzed donor and recipient information, clinical variables, adverse events during bronchoscopy, outcome, and medical management at the time of the procedure to determine the diagnostic yield of BAL and factors that affect its success. Seventy-eight allogeneic and 11 autologous transplant recipients underwent BAL at a median of 68 days (range, 6-528 days) and 23 days (range, 6-705 days) after HSCT, respectively. The median age at the time of BAL was 12.2 years (0.8-23.5 years) in allogeneic patients and 16.9 years (4.8-26.2 years) in autologous patients. The most common indications for BAL in both populations were fever, hypoxia, and abnormality on chest auscultation. BAL identified an etiology in 53 allogeneic (67.9%) and 7 autologous (63.6%) patients (BAL positive); only 1 etiology was identified in 30 of the 53 allogeneic patients (56.6%). The most common finding was bacterial infection in both allogeneic (59.0%) and autologous (71.4%) patients. Of 39 allogeneic patients who had concurrent extrapulmonary infection, 30 (76.9%) had a positive BAL. Seven (9.0%) allogeneic patients experienced hypoxia (generally transient) during bronchoscopy. Approximately 68% of those with a positive BAL were receiving immunosuppressive therapy, whereas 96% of patients with a negative BAL were receiving immunosuppressive therapy ( P = .008). Further, 26.4% of the BAL-positive cohort had grade II-IV acute graft-versus-host disease (aGVHD), whereas 60% of the BAL-negative group had grade II-IV aGVHD ( P = .004). In our experience, the safety and diagnostic yield of BAL in this set of patients is relatively high, but the likelihood of informative findings is reduced among allogeneic recipients with grade II-IV aGVHD and those receiving immunosuppressive therapy.

The Yield of Bronchoalveolar Lavage in the Diagnosis of Pulmonary Involvement Among Immune-suppressed Patients With Hematologic Disorders

Background Pulmonary complications are a major cause of morbidity and mortality among patients with hematologic malignancies and bone marrow transplantation (BMT) recipients. This study retrospectively evaluated the diagnostic yield of bronchoalveolar lavage (BAL) in this setup. Methods A total of 115 BAL procedures were performed on 94 patients with hematologic malignancies (n=28) and BMT recipients (n=87) for the diagnosis of lung infiltrates. BAL was considered effective if it provided a specific diagnosis or ruled out a suspected diagnosis that led to a change in therapy. The yield of the BAL and the distribution of the etiologies were compared among 3 subgroups of patients; hematologic malignancies (n=28), allogeneic BMT (n=50), and autologous BMT (n=37). Results A specific diagnosis was obtained in 30.4% [infectious: 22.6%; diffuse alveolar hemorrhage (DAH): 7.8%] and, in addition a therapeutic change was followed in 21.8%, producing a yield of 52.2%. Bacteria accounted for 54% and fungi for 30.8% of the infectious etiology. The yield of the BAL and the distribution of the etiologies to the lung infiltrates were similar in the 3 subgroups. Only 3 minor complications occurred during BAL. Conclusions This study has shown the effectiveness of BAL in providing a specific diagnosis or leading to a change in management in half the patients with hematologic malignancies or in BMT recipients with lung infiltrates. The relatively low rate of specific diagnosis may be explained by the changing spectrum of pulmonary diseases related to prophylaxis and early empiric therapy against respiratory pathogens.

Diagnostic yield of bronchoalveolar lavage following renal transplantation.

Organ transplant recipients are at high risk of infectious pulmonary complications. In this retrospective study, the diagnostic yield of bronchoalveolar lavage (BAL) was evaluated in renal transplant recipients. The results were analysed in special regard to the clinical presentation of pulmonary infections and the possible impact of new immunosuppressive agents. Over a 5-year period 91 BAL were performed in 71 renal transplant recipients. Microorganisms were isolated from 69% of BAL (63/91): bacteria 32%; cytomegalovirus (CMV) 27%; Pneumocystis carinii (PC) 22%; other viruses 9% (HSV; EBV, RSV, adenovirus, HHV8); Aspergillus fumigatus 1%. Total cell counts and neutrophil counts in BAL were significantly elevated in bacterial infection, whereas BAL positive for PC showed eosinophilia (P<0.05). There was no association between clinical symptoms and the radiological pattern of infiltrates and the type of infection. Immunosuppression containing tacrolimus or mycophenolate mofetil was associated with a significantly higher percentage of PC and CMV infections compared to cyclosporin-based immunosuppression (65% vs. 30%, P<0.005). A considerable number of PC and CMV infections occurred beyond 6 months after transplantation. In conclusion, BAL has a high diagnostic yield in renal transplant recipients. Infection with CMV and PC should also be considered beyond 6 months after transplantation, and prophylaxis for opportunistic infections should be given if the immunosuppression is intensified.

Utilidad del lavado broncoalveolar en el paciente trasplantado renal con sospecha de infección respiratoria

In this retrospective study we aimed to assess the diagnostic yield of bronchoalveolar lavage (BAL) in kidney transplant patients who were suspected of having severe respiratory infection or in whom empirical antibiotic treatment had failed. All BAL procedures performed on kidney transplanted patients suspected of having respiratory infections between January 1, 1988 and July 31, 1996 were analyzed. BAL was carried out in the standard way and samples were sent for cytologic and bacteriologic study. Thirty-three patients with a mean age of 48.5 years were enrolled. All had been receiving immunosuppressive treatment and the mean time following transplantation was 320 days. Thirty-one had received antibiotic treatment before BAL. BAL was positive for 21 of the 33 patients (64%). Twenty-two pathogens were identified: 6 Pneumocystis carinii, 4 Cytomegalovirus, 3 Mycobacterium tuberculosis, 2 Aspergillus fumigatus, 2 Herpes simplex type I, 1 Streptococcus pneumoniae, 1 Staphylococcus aureus, 1 Streptococcus mitis, 1 Legionella pneumophila, 1 Legionella longbeachae. BAL was negative for 12 patients, of whom 8 were tentatively diagnosed of bacterial infection, 3 of acute pulmonary edema and one of pulmonary infarction. Based on the results, therapy was changed for 20 patients (61%), 19 (58%) because an unsuspected pathogen was identified and 1 because treatment could be simplified. The diagnostic yield of BAL is high (64%) in kidney transplant patients suspected of respiratory infection and is useful for managing such cases, as evidenced by the fact that a high proportion (19/33) of our patients were infected by pathogens not covered by empirical treatment.

Diagnostic value of bronchoalveolar lavage and postbronchoscopic sputum cytology in peripheral lung cancer.

The objective of this study was to evaluate the value of bronchoalveolar lavage (BAL) and postbronchoscopic sputum cytology in diagnosing peripheral lung cancer. We performed a prospective study in 55 patients with lesions on chest radiographs who were suspected of having lung cancer and had non-endoscopically visible lesions on fiberoptic bronchoscopy. The sequence of procedures in all cases was BAL and transbronchial forceps biopsy. The final diagnosis of these patients were primary lung cancer in 30 patients, metatastic lung cancer in five and benign diseases in 20. In the primary lung cancer group, BAL was positive for malignant cells in 14 of the 30 patients (46.7%). In seven (50%) of these patients, the cell type diagnosed by BAL agreed with the final diagnosis. The diagnostic yield of BAL was influenced by the size and segmental location of the lesion. Bronchoalveolar lavage provided a higher diagnostic yield (46.7%) than transbronchial biopsy (16.7%). In five patients with metastatic lung cancer and 20 patients with benign disease, BAL gave negative results in all. Postbronchoscopic sputum cytology was positive in only two of the 26 patients (7.7%) from whom samples could be obtained. Bronchoalveolar lavage cytology proved to be a valuable diagnostic tool in detecting peripheral, primary lung cancer. Postbronchoscopic sputum cytology provided no significant additional information.

Differential Lobe Lavage for Diagnosis of Acute Pneumocystis carinii Pneumonia in Patients Receiving Prophylactic Aerosolized Pentamidine Therapy

The diagnostic yield of bronchoalveolar lavage (BAL) for Pneumocystis carinii pneumonia (PCP) in patients infected with human immunodeficiency virus has been reported to be 95 percent, but falls to 62 percent in patients receiving aerosolized pentamidine. Because aerosolized pentamidine appears to be preferentially deposited in the middle and lower lobes, we postulated that an upper lobe lavage would have a higher diagnostic yield than the standard middle/lower lobe lavage in patients receiving aerosolized pentamidine. Twenty-five patients receiving aerosolized pentamidine suspected of having acute PCP underwent separate BAL of an upper lobe and lower lobe as well as transbronchial biopsy. Fifteen of the 25 (60 percent) were diagnosed as having PCP. Of the 15, one had the samples inadvertently combined. In the remaining 14, BAL was positive for P carinii organisms in 12 lavages of the lower lobe and 14 of the upper lobe. Upper lobe lavage had statistically significantly more P carinii organisms by semiquantitative technique than the lower lobe. In patients receiving aerosolized pentamidine, who develop acute PCP, an upper lobe lavage may have a higher diagnostic yield than the standard middle/lower lobe lavage. In addition, the transbronchial biopsy specimen offered no treatable diagnosis that was not made by lavage alone in the 25 patients. This raises the question of the utility of transbronchial biopsies in these patients.