Evaluation Of Pulmonary Infiltrates Research Articles

The clinical impact of pneumocystis and viral PCR testing on bronchoalveolar lavage in immunosuppressed patients.

IntroductionPulmonary infiltrates in immunosuppressed patients are common. Yields from bronchoscopy with bronchoalveolar lavage (BAL) has been reported to be between 31 and 65%. The clinical impact of pneumocystis and viral Polymerase chain reaction (PCR) testing on BAL has not been extensively evaluated in a mixed immunosuppressed patient population.MethodsWe performed a retrospective chart review of immunosuppressed adults with pulmonary infiltrates who underwent BAL at the University of Rochester Medical Center. Only one BAL per patient was included. We compared the rate of positive PCR testing to conventional testing. We then investigated factors associated with positive PCR testing. Finally, we assessed for changes in antimicrobial therapy after bronchoscopy.ResultsThree hundred and fifty-nine patients underwent BAL with 249 patients having pneumocystis PCR testing and 142 having viral PCR testing. Pneumocystis identification occurred in 43 patients and viral species identification occurred in 56 patients. PCR testing increased pneumocystis identification compared to microscopy, 14% vs. 5%, p = 0.01, and viral identification compared to culture, 25% vs. 6%, p = 0.0001. Of the patients with positive pneumocystis PCR testing 49% had antibiotics stopped, 66% were started on anti-pneumocystis therapy, and only 6% did not receive treatment. There was no difference in the number of patients with antibiotics stopped based on viral PCR testing results.DiscussionPCR testing increases BAL yield in immunosuppressed patients compared to conventional testing. Pneumocystis identified by PCR only may cause a self-limited infection and may not require antimicrobial therapy. PCR testing should be included in the evaluation of pulmonary infiltrates in immunosuppressed patients.

Utility of Flexible Bronchoscopy in the Evaluation of Pulmonary Infiltrates in the Hematopoietic Stem Cell Transplant Population – A Single Center Fourteen Year Experience

IntroductionPulmonary infiltrates are common within the hematopoietic stem cell transplant (HSCT) population and unfortunately portend an increased mortality. Bronchoscopy is often utilized as an initial diagnostic tool, but the literature supporting its diagnostic utility and effect on clinical management varies significantly. The aim of this study was to investigate the diagnostic ability, complication rate, and clinical impact of flexible bronchoscopy (FB) in evaluating pulmonary infiltrates in a large HSCT population. Patients and methodRetrospective review of all patients undergoing FB after HSCT in the Bone Marrow Transplant Unit from 1996 to 2009. ResultsFB was performed 162 times in 144 patients with pulmonary infiltrates yielding positive results in 52.5%. The most common positive results were bacterial pneumonia (31%), fungal pneumonia (15%), and alveolar hemorrhage (11%). Treatment changes occurred in 44% of patients after FB. Treatment changes included antibiotic modification (59%), addition of corticosteroids (21%), antifungal modification (12%), and antiviral modification (7%). The overall complication rate associated with FB was 30%, although 84% of these complications were considered minor. ConclusionsFB in patients with pulmonary infiltrates after HSCT should still be considered a valuable tool in the evaluation and management of pulmonary infiltrates in the HSCT population. Future prospective, multicenter randomized studies are needed to evaluate the overall clinical impact that bronchoscopic results and management changes have in this unique population.

Cáncer, neutropenia febril e imágenes pulmonares: Hallazgos en el lavado broncoalveolar en niños

Lung infections are a serious complication in children with cancer. Bronchoalveolar lavage (BAL) has been demonstrated to be an effective procedure for achieving etiologic diagnosis.We did a retrospective analysis of BAL data performed between November 2005 and October 2008 in children with cancer, severe neutropenia and lung infiltrates for assessing its performance, clinical utility and safety. Thirty-seven BAL were evaluated in 35 patients.Focal infiltrates were demonstrated in imaging studies associated with 19/37 BAL; in 8 an infectious agent was found. Interstitial pattern was observed in 15/37, in which there were 4 positive studies, proving a higher microbiological performance in BAL associated with focal lesions. BAL yielded significant microbiological findings in 32.4% (12/37). Sixteen microorganisms were identified in the study: bacteria in 8 cases, Mycobacterium tuberculosis (n: 2), Pseudomonas aeruginosa (n: 2), Acinetobacter baumannii (n: 1), A. Iwoffii (n: 1), group viridans Streptococcus (n: 1), Mycoplasma pneumoniae (n: 1); viruses in 3 cases, metapneumovirus (n: 2) cytomegalovirus (n: 1) and fungal infection in 5 cases, Pneumocystis jiroveci (n: 2) Aspergillus fumigatus (n: 1), Aspergillus niger (n: 1), Candida albicans (n: 1). Therapeutic adjustments were done in 6/37 episodes (16.2%).BAL has a significant role in the evaluation of pulmonary infiltrates in pediatric oncological patients, requiring a prompt and safe diagnosis, which is crucial for the survival with minimal morbidity. Our results suggest that BAL by fiberbronchoscopy should be considered as an initial diagnostic tool in these patients.

Evaluation of pulmonary infiltrates in patients after stem cell transplantation

Hematopoietic stem cell transplantation is potentially curative therapy that has become the standard of care for many hematologic malignancies. Pulmonary complications occur in about 50% of stem cell transplant recipients and no other organ dysfunction has a higher mortality. Unfortunately the diagnosis of these infiltrates is hampered by the poor yield from routine studies and this patient population is rarely able to tolerate more risky procedures that will obtain tissue for microscopy and culture. A bronchoalveolar lavage (BAL) is usually insufficient to make a diagnosis of invasive fungal, significant bacterial, or pathogenic viral infections in patients that will still benefit from a change in therapy. In this review we discuss the infectious etiologies of pulmonary infiltrates post hematopoietic stem cell transplant, the non-infectious causes of infiltrates such as diffuse alveolar hemorrhage, engraftment syndrome, and idiopathic pneumonia syndrome, and the yield of newer diagnostic procedures ranging from peripheral blood galactomannan to cytomegalovirus antigenemia, and report on new technologies that promise more accurate and timely diagnoses of these infiltrates.

The Findings of Surgical Lung Biopsy in HIV Patients in the Era of Highly Active Antiretroviral Therapy

Surgical lung biopsy (SLB) is rarely necessary in the evaluation of pulmonary infiltrates in patients with human immunodeficiency virus (HIV). The aim of this study is to describe the findings of SLB in a recent cohort of HIV-infected patients with unexplained pulmonary infiltrates, and determine the impact of this procedure on management and outcome of these patients. We used a retrospective review of medical records for this study. Twenty-six patients who underwent SLB where evaluated. The procedure was performed either by video-assisted thoracoscopy, in 42% of the cases, or by thoracotomy in 58%. Eleven patients (42%) had focal infiltrates, and 15 (58%) had diffuse infiltrates. There were 31 diagnoses in the 26 patients; 26 (84%) were specific and 5(16%) were nonspecific. The most common specific diagnoses were infection (58%), malignancy (16%), and inflammatory conditions (10%). Pneumocystis carinii, alone or in combination with other conditions, was the most common diagnosis of all biopsies (34%). Surgical lung biopsy led to a change in management in 17 patients (65%), and was associated with complications in 4 patients (15%). The in-hospital mortality rate was 27%. Surgical lung biopsy is a relatively safe procedure, and provides a specific diagnosis in the majority of patients with HIV infection and unexplained pulmonary infiltrates. Pneumocystis carinii alone or in combination with other conditions is the most common finding.

Open lung biopsy in bone marrow transplant recipients has a poor diagnostic yield for a specific diagnosis.

The diagnostic yield of open lung biopsy (OLB) in bone marrow transplantation (BMT) recipients having pulmonary infiltrates has not been evaluated recently. Therefore, we reviewed our 2-year experience (1998-99) with such patients at The University of Texas M. D. Anderson Cancer Center. We found 12 BMT recipients who underwent OLB analysis for the evaluation of pulmonary infiltrates. A treatable infectious etiology leading to the initiation or modification of antimicrobial agent administration was found in only two patients having bilateral nodular disease and one having bilateral parenchymal infiltrates. We conclude that OLB in BMT patients having diffuse pulmonary infiltrates has a low diagnostic yield for treatable infectious etiologies.

Bronchoscopic evaluation of pulmonary infiltrates following bone marrow transplantation

Bronchoscopic evaluation of pulmonary infiltrates following bone marrow transplantation

Differential cytology of bronchoalveolar lavage fluid in immunosuppressed children with pulmonary infiltrates.

Bronchoalveolar lavage (BAL) is a well established technique for the detection of pathogens in immunosuppressed children, but its diagnostic yield is variable. The aim of this study was to investigate whether BAL differential cell counts are helpful in the evaluation of pulmonary infiltrates in immunocompromised children. BAL was performed 28 times in 27 febrile immunocompromised children with pulmonary infiltrates. All patients were pretreated with broad spectrum antibiotics; 11 children also received amphotericin B. BAL was conducted with a flexible bronchoscope wedged in the area of maximal pathology as suggested by the chest radiograph or in the middle lobe in patients with diffuse interstitial radiographic changes. Differential cell counts were performed from cell smears obtained after centrifugation of BAL fluid. Bacterial or fungal organisms were detected in BAL fluid of 12 patients. Patients with bacterial or fungal infections (group 1) had a significantly higher percentage of granulocytes in BAL fluid both compared with patients with sterile BAL cultures (group 2) and with a control group of children without pulmonary disease (p < 0.001, Wilcoxon test). The proportion of lymphocytes was not different from the control group in group 1 but significantly increased in group 2 (p < 0.001, Wilcoxon test). Blood differential cell counts were not different in the two patient groups. Lymphocyte subsets of BAL fluid obtained in a subgroup of patients were not significantly different from controls. These data suggest that BAL differential cell counts may be a useful adjunct in the differential diagnosis of pulmonary infection in immunocompromised children.

Utility of Bronchoscopic Sampling Techniques for Cryptococcal Disease in AIDS

Although cryptococcal pneumonia is a well recognized complication of the acquired immunodeficiency syndrome, optimal diagnostic approaches remain to be defined. During a 32-month period (October 1984 to June 1987), 11 patients were diagnosed with CP at our institution. The diagnosis was established in all 11 patients from specimens obtained via fiberoptic bronchoscopy (ten) and/or double-lumen catheter lavage (one). Direct stains of sedimented bronchoalveolar lavage were positive for organisms characteristic of Cryptococcus neoformans in nine of 11 patients. Transbronchial biopsies were positive (special histologic stains) in six of eight patients; bronchial washings were positive (direct smear) in seven of ten patients, the bronchial brushings were positive on stain in six of nine patients, and in one patient, a Wang transbronchial needle aspirate was positive on stain. Fungal cultures were positive on the BAL in seven of 11 patients, and on the bronchial washings in four of ten patients; the TBBx culture samples were all negative (zero of three). The serum cryptococcal antigen titer was elevated (median = 1:1024) in all eight patients in which it was assayed. Our data suggest that BAL and bronchial washings have a combined sensitivity on smear equal to that of TBBx and superior to that of TBBx fungal culture. The TBBx does not appear to be necessary in this setting. In addition, an elevated serum cryptococcal antigen titer appears to be an important adjunct in the evaluation of pulmonary infiltrates in AIDS.

Evaluation of Pulmonary Infiltrates in Immunocompromised Host : The Use of BAL and Rapid Diagnostic Methods(Special Issue for 13th Annual Congress of the Japan Society for Bronchology)

Evaluation of Pulmonary Infiltrates in Immunocompromised Host : The Use of BAL and Rapid Diagnostic Methods(Special Issue for 13th Annual Congress of the Japan Society for Bronchology)

Evaluation of Pulmonary Infiltrates in Immuno-compromized Host : The Use of BAL and Rapid Diagnostic Methods

Evaluation of Pulmonary Infiltrates in Immuno-compromized Host : The Use of BAL and Rapid Diagnostic Methods

The use of gallium-67 in pulmonary disorders

Imaging of the chest cage with gallium-67 (67Ga) citrate is relatively easier to perform and interpret than imaging of the abdomen, because normally pulmonary concentration is low after 48 hr and physiologic accumulation in bones and breast can be recognized by its distribution. Modern scintillation detectors, particularly large field cameras with multiple pulse-height analyzers, give substantially better gallium images than those available in the past. Because of the nonspecific affinity of gallium through neoplastic and inflammatory processes, its value in the differential diagnosis of pulmonary diseases is limited. However, based on the literature and our own observations in over 1100 patients with established diagnosis of a variety of pulmonary diseases, we feel that the judicious use of 67Ga in selected patients is helpful in answering specific questions. These include preoperative evaluation of hilar and mediastinal involvement in pulmonary neoplasms, differential diagnosis of pulmonary infarctions and bacterial pneumonias, evaluation of pulmonary infiltrates regarding infectious etiology, follow-up of sarcoidosis on corticosteroid treatment, assessment of inflammatory activity in interstitial fibrosis and, in selected cases, early detection of neoplastic and inflammatory diseases before radiography becomes abnormal, such as diffuse carcinomatosis and Pneumocystis carinii infection. Potential large-scale application of pulmonary gallium imaging could be found in the screening of subjects exposed occupationally to noxious dust and in long-term serial follow-up of pulmonary tuberculosis patients for treatment response and reactivation. However, it remains to be seen whether gallium imaging statistically provides essential additional information in these indications when compared to cheaper conventional techniques.