Bronchoscopic diagnosis of pulmonary infiltrates in granulocytopenic patients with hematologic malignancies: BAL versus PSB and PBAL

Article (PDF Available)inRespiratory Medicine 101(2):317-25 · March 2007with20 Reads
DOI: 10.1016/j.rmed.2006.04.021 · Source: PubMed
Abstract
Treatment of patients with hematologic malignancies is often complicated by severe respiratory infections. Bronchoscopy is generally to be used as a diagnostic tool in order to find a causative pathogen. In a prospective study the combination of protected specimen brush (PSB) and protected bronchoalveolar lavage (PBAL) was compared with bronchoalveolar lavage (BAL) for evaluated feasibility and diagnostic yield in granulocytopenic patients with hematologic malignancies and pulmonary infiltrates. All specimens from 63 bronchoscopic procedures (35 BAL and 28 PSB-PBAL) were investigated by cytological examination and various microbiological tests. If clinically relevant and feasible, based on the clinical condition and/or the presence of thrombocytopenia, lung tissue samples were obtained. The majority of the 58 included patients were diagnosed as having acute myeloid leukaemia and developed a severe neutropenia (BAL-group: 27 days; PSB-PBAL group: 30 days). Microbiological and cytological examination of 63 bronchoscopic procedures (35 BAL and 28 PSB-PBAL) yielded causative pathogens in 9 (26%) patients of the BAL-group and 8 (29%) patients of the PSB-PBAL group (PSB and PBAL 4 each). Aspergillus fumigatus was the pathogen most frequently (13%) detected. Using all available examinations including the results of autopsy, a presumptive diagnosis was established in 43% of the patients in the BAL group and 57% of those in the PSB-PBAL group; in these cases microbial aetiology was correctly identified in 67% and 57%, respectively. The complication rate was of these procedures were low, and none of the patients experienced serious complications due to the invasive techniques. Our results showed that modern bronchoscopic techniques such as PSB and PBAL did not yield better diagnostic results compared to BAL in granulocytopenic patients with hematologic malignancies and pulmonary infiltrates. In approximately half of the cases a presumptive diagnosis was made by bronchoscopic procedures.
    • "An evaluation of 249 BAL samples collected from the bronchoscopic examinations of 199 febrile patients with hematological malignancy and pulmonary infiltrates showed the isolation of fungal pathogens in 46 samples [5] . Another study detected fungal pathogens by BAL in 23 of 135 immunocompromised patients with pulmonary infiltrates [8] . In our study, the use of BAL and mini-BAL led to the isolation of Candida albicans in 12 and Aspergillus fumigatus in 1 patient. "
    [Show abstract] [Hide abstract] ABSTRACT: Pneumonia is a major cause of morbidity and mortality in immunocompromised patients. Bronchoalveolar lavage (BAL) is commonly used to help diagnose and characterize pneumonia in these patients. Mini-BAL is a less-invasive, less-costly and less-cumbersome diagnostic tool than BAL. In this study, we compared the diagnostic value of BAL and mini-BAL in the evaluation of pneumonia in immunocompromised patients with respiratory failure. Methods: Sixty-four respiratory samples were collected from 32 immunocompromised patients admitted to our respiratory intensive care unit with a clinical diagnosis of pneumonia and respiratory failure requiring invasive mechanical ventilation. A single BAL sample and a single mini-BAL sample were collected from each patient. Samples were examined for bacteriologic, mycologic, mycobacteriologic, and viral organisms. The mean age of the patients was 56.0 ± 14.4 years. Of the 32 BAL samples, bacterial isolates were detected in 11 patients (34.4%) and on the other hand bacterial isolates were detected in 10 patients (31.3%) of the mini-BAL samples. Fungal isolates were detected in 11 patients (34.4%) from BAL samples and 13 patients (40.6%) from mini-BAL samples. Our analysis demonstrated a strong positive correlation between the results of BAL and mini-BAL testing (r = 0.850 and r = 0.821, respectively). In this study, we demonstrated a strong correlation between the isolation rates of bacteria and fungi in BAL and mini-BAL samples obtained from immunocompromised patients with pneumonia and respiratory failure. The data strongly support the use of mini-BAL sampling in such patients as a less-invasive, less-costly and simpler alternative to traditional BAL.
    Full-text · Article · Feb 2011
    • "This study highlights, in a critical way, the importance of BAL in patients with lung infiltrates and neutropenia. The diagnostic yield of BAL published for neutropenic patients with pneumonia ranged between 13% and 53% [3, 5, 9, 11, 21, 27, 30]. Nearly all of these data were collected in retrospective studies. "
    [Show abstract] [Hide abstract] ABSTRACT: Bronchoalveolar lavage (BAL) is a practicable procedure establishing the etiology of pneumonia. In patients with neutropenia, empirical antimicrobial treatment is mandatory immediately after diagnosis of infection, usually before results of BAL are available. We evaluated the impact of BAL on treatment and outcome of pneumonia in immunocompromised patients with a special regard to neutropenia. Bronchoscopy with BAL was performed in 58 episodes of clinical documented pneumonia in patients with hematological malignancies (88%) or solid tumors (12%), in 30 cases patients had neutropenia, in 28 cases patients had no neutropenia. In 93% of cases, BAL was performed under empirical antimicrobial treatment. BAL fluid was cultivated for bacteria, fungi, and tested for Pneumocystis jirovecii and cytomegalovirus (CMV). BAL revealed positive bacterial results in 67% of cases. Gram-positive microorganisms were detected in 95% of positive BAL results, gram-negative microorganisms in 23%, mixed bacterial cultures occurred in 41%. Positive fungi cultures were found in 59%. P. jirovecii was detected in 5% of cases tested and CMV in 8%. There was no significant difference between neutropenic and non-neutropenic patients. BAL results directed a change of therapy in only six of 58 episodes (5%). Overall mortality related to pneumonia was 16%. In this patient setting, the yield of BAL rarely has a significant influence on treatment and outcome of pneumonia. The early beginning of antimicrobial treatment reduces the diagnostic yield of BAL. In patients with pneumonia during neutropenia, its use should be well considered.
    Full-text · Article · Jun 2009
  • [Show abstract] [Hide abstract] ABSTRACT: Bei Patienten mit AML während zytostatischer Therapie sind invasive Mykosen als eine ernstzunehmende Komplikation zu betrachten. Sie führen nicht nur zu einer Verlängerung des Krankenhausaufenthaltes sondern auch zu einer erheblichen Therapiekostensteigerung. Sie sind potentiell lebensbedrohlich. Fast ein Fünftel der Patienten verstirbt an dieser Komplikation. Die Diagnostik der invasiven Mykosen gestaltet sich schwierig. Bisher gibt es keine Kriterien für den Einsatz im klinischen Alltag.
    Article · · Annals of Hematology
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