Respiratory Medicine (2007) 101, 317–325
Bronchoscopic diagnosis of pulmonary infiltrates in
granulocytopenic patients with hematologic
malignancies: BAL versus PSB and PBAL
Wim G. Boersmaa,?, Zoran Erjavecb, Tjip S. van der Werfc,
Hilly G. de Vries-Hosperd, Annette S.H. Gouwe, Willem L. Mansonf
aDepartment of Pulmonary Diseases, Medical Center Alkmaar, P.O. Box 501, 1800 AM Alkmaar,
bDepartment of Hematology, University Hospital Groningen, Groningen, The Netherlands
cDepartment of Pulmonary Diseases, University Hospital Groningen, Groningen, The Netherlands
dDepartment of Medical Microbiology, University Hospital Groningen, Groningen, The Netherlands
eDepartment of Pathology and Laboratory Medicine, University Hospital Groningen, Groningen,
fRegional Public Health Laboratory, Groningen, The Netherlands
Received 30 December 2005; accepted 24 April 2006
Background: 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.
Objectives: In a prospective study the combination of protected specimen brush
(PSB) and protected bronchoalveolar lavage (PBAL) was compared with bronchoal-
veolar lavage (BAL) for evaluated feasibility and diagnostic yield in granulocytopenic
patients with hematologic malignancies and pulmonary infiltrates.
Methods: 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.
Results: 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 broncho-
scopic 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.
ARTICLE IN PRESS
0954-6111/$-see front matter & 2006 Elsevier Ltd. All rights reserved.
?Corresponding author. Tel.: +317252482750; fax: +31725482167.
E-mail address: firstname.lastname@example.org (W.G. Boersma).
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
Conclusions: 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.
& 2006 Elsevier Ltd. All rights reserved.
Respiratory infections, particularly pneumonia,
constitute a major threat to the immunocompro-
mised patient. Patients with hematologic malig-
nancies and prolonged neutropenia are at the
highest risk for acquiring invasive infections,
associated with a high mortality. In these patients,
diagnostic problems due to several factors such as
the patient’s critical condition, the presence of
multiple infections, and the previous use of
empirical antibiotic therapy, are frequently ob-
served. Febrile episodes are a rule rather than the
exception in patients being intensively treated for
leukaemia and lymphoma.1Boggs and Friedland2
reported 3.9 febrile episodes per 100 days of
hospitalization in adults with leukaemia. The over-
all risk for developing a febrile episode during a
treatment-induced period of neutropenia varies
between 30% and 80%, depending on the duration
of neutropenia.1The extent and the duration of
neutropenia are proportional to infectious compli-
cations. Empirical antibiotic therapy is often
warranted, yet as a consequence of its use the
cause of fever cannot be identified in the majority
of the patients.3Approximately 60% of granulocy-
topenic patients will develop a lung infiltrate at
some time during the course of the disease.4,5
Besides infection, the most common causes of lung
infiltrates in these patients are leukemic infiltra-
tion, congestive heart failure, hemorrhage, and
Since sputum is seldom being produced, many
clinicians use bronchoscopy to establish the exact
aetiology of the lung infiltrate. Several investiga-
tions have shown that bronchoalveolar lavage (BAL)
is a valuable method in the diagnosis of pulmonary
infections in the immunocompromised host.8–12
The diagnostic yield of BAL has been found to
vary between 15% and 60% in hematologic patients
with lung infiltrates.10,13–15Combining different
bronchoscopic techniques may increase the diag-
In immunocompromised patients BAL-fluid (BALF)
may be contaminated by microbial flora from the
upper airways, especially Gram-positive bacteria,
yeasts and fungi. In order to reduce the orophar-
yngeal contamination during sampling, protected
bronchoscopic techniques such as protected speci-
men brush (PSB) and protected bronchoalveolar
lavage (PBAL) were developed. In ventilator-asso-
ciated pneumonia these techniques seem to be of
additive value, especially in those patients not
receiving antibiotic treatment.17
This prospective study was designed to com-
pare the diagnostic yield of the conventional BAL
versus new techniques such as PSB and PBAL in
patients with hematologic malignancies and lung
A prospective study was undertaken in patients
admitted to the University Hospital Groningen with
hematologic malignancies during a period of 24
months. After written informed consent was ob-
tained, 65 patients with 70 episodes of pulmonary
infiltrates were included in the study. None of them
were mechanically ventilated.
The inclusion criteria for entering the study
protocol were: (1) new intrapulmonary abnormal-
ities on the chest radiograph(s) and/or new
respiratory symptoms and signs; (2) fever or
previous period of fever; (3) the presence of a
hematologic malignancy; (4) neutropenia defined
as a neutrophil count of o500 or o1000/mm3with
predicted decline to o500/mm3.
Patients were excluded from the study if: (1) the
hemodynamic and/or respiratory condition was
unstable; (2) the platelet count was o15?109/l
despite platelet transfusion; (3) the pO2was o7.5
kPa despite supplemental O2.
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W.G. Boersma et al. 318
From all included patients recent (p24h) chest
radiographs, frontal and lateral view, were ob-
tained. The extent of the radiographic abnormal-
ities and the radiographic types were classified
before the bronchoscopic procedure. Patients were
alternately included in one of the two groups.
Broncnoscopic procedures were carried out by two
experienced respiratory physicians (W.B. and T.W.)
according to the standard protocol.
All patients fasted for at least 8h prior to
bronchoscopy. Premedication consisted of codeine
(30mg) taken orally 2h before bronchoscopy and
subcutaneous atropine (0.25mg) given 15min be-
fore the procedure. Ten minutes before broncho-
scopy 10ml of lidocaine (4%) was nebulized at tidal
volume breathing. Maximally 5ml of lidocaine (1%)
was applied to the nose, throat, and vocal cords.
was usedas needed
sedation. Patients with severe thrombocytopenia
(o20?109/l) received a pooled platelet transfu-
sion just before the procedure. Supplemental
oxygen (4–6l/min) was administered during the
procedure, while oxygen saturation and pulse rate
were monitored by pulse oxymetry.
For the PSB–PBAL procedure two large channel
bronchoscopes (Olympus BF 1T-20 or Olympus XT
20; Olympus, Paes, The Netherlands) were avail-
able. Several types of flexible bronchoscope (FB)
were used to perform the conventional BAL
The FB was gently introduced via the nose or
mouth. When using the protected techniques,
lidocaine (2%, to a maximum of 2ml) was instilled
through the suction channel of the FB. During
introduction and inspection, suction of bronchial
secretion was avoided. If additional local anes-
thetic was required to control coughing, this was
given and the bronchoscope then replaced. The FB
was also replaced if the amount of bronchial
secretion was a disturbing factor for optimal
visualization; with the first FB all secretions were
removed. Using the chest radiographs (frontal and
lateral view) as guidance, the FB was advanced to
the chosen segmental or subsegmental bronchus.
Selection of the correct bronchial region could also
be influenced by visible intrabronchial abnormal-
ities such as purulent secretions or mucosal
changes. PSB and PBAL were always performed in
the same segmental or subsegmental bronchus.
The tip of the FB was wedged into the segmental
bronchus corresponding to the area of radiographic
abnormality. BAL was then performed by sequen-
tially instilling and suctioning 50ml of normal saline
four times. The first aliquot obtained was consid-
ered to be bronchial secretion. This specimen was
therefore considered to be non-representative,
because of potential contamination with orophar-
yngeal flora. The other BALF aliquots were pooled
and further processed in both the microbiology and
Protected specimen brush
The PSB catheter (Microbiology Brush, Mill-Rose
Laboratory Inc., OH, USA) was introduced into the
selected segmental or subsegmental bronchus and
advanced 3cm out of the bronchoscope. The inner
catheter was protruded to eject the distal wax plug
into a large airway, and the catheter was advanced
into the desired subsegment. If purulent secretion
was visualized, the brush was rotated into them. In
the absence of purulent secretions, the brush was
advanced to a wedge position with gentle rotation.
After specimen collection, the brush was retracted
into the inner catheter, the inner catheter pulled
back into the outer catheter, and the whole
system removed. The distal parts of both inner
and outer catheter were separately and conse-
cutively wiped clean with 70% alcohol. The brush
was then advanced and a small quantity of
secretion was smeared onto two sterile micro-
scope slides for additional staining. Subsequently,
the brush was aseptically placed into a tube
containing 2ml of normal saline. The tube and
one smear were immediately delivered to the
microbiology laboratory. The other smear and the
remaining part of the solution were used for
Protected bronchoalveolar lavage
After the removal of the PSB catheter from the
Bronchoalveolar Lavage Balloon Catheter, Mill-Rose
Laboratory Inc., OH, USA) was introduced and
advanced 2cm into the selected segmental or
subsegmental bronchus. The balloon was inflated
with 2ml of air for optimal occlusion of the
bronchial lumen. The distal plug was ejected by
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Bronchoscopic diagnosis of pulmonary infiltrates in granulocytopenic patients319
instilling 2ml of sterile normal saline through the
irrigation lumen. Subsequently, PBAL was per-
formed by sequentially instilling and gently suc-
tioning five 30ml aliquots of normal saline at 371C.
The balloon was deflated and the entire catheter
was retracted. PBAL fluid obtained after the first
aliquot was discarded. The remaining PBAL fluid
was divided equally for microbial and cytological
Laboratory processing of specimens
The BALF was vortexed for 60s. From this suspen-
sion 0.05ml was plated out on sheep blood agar,
chocolate agar, McConkey 3 agar, and Saboraud’s
agar (Oxoid, Basingstoke, UK). All plates were
incubated for maximally 4 days at 371C. Another
0.05ml was inoculated onto a Brucella Blood
Agar (BBA) plate and incubated anaerobically
for 5 days. Semiquantitative cultures were per-
formed according to generally accepted methods.
The number of colony-forming units (cfu) was
counted, with growth in the first quadrant only
considered to be less than 104cfu/ml. Growth
intothe second quadrant
104–105cfu/ml, and into the third quadrant as
more than 105cfu/ml. Microorganisms were identi-
fied by standard methods.
Five hundred microlitres of BALF was suspended
in GLY medium for viral culture. Twenty millilitres
of suspension was centrifuged at 2000rpm for
10min. The supernatant was decanted, and the
cell pellet was re-suspended in 2ml of normal
saline. If the specimen contained blood, the pellet
was re-suspended in 10ml of sterile H2O at 41C in
order to haemolyse the red blood cells. Subse-
quently, the same procedure of centrifugation and
re-suspension with 2ml of normal saline was
performed. From this pellet slides were prepared
for staining by Gram, Giemsa, toluidine-blue and
calcofluor. From the re-suspended pellet cultures
for Legionella sp. and mycobacteria were also
BALF was sent for cytological analysis and was
fixed in an equal volume of alcohol-polyethylene-
glycol (50–2%). Smears obtained after centrifuga-
tion (1000rpm for 10min.) and cytocentrifuge
preparation (Cytospin III, Shandon Southern Instru-
ments, Sewickly, PA, USA) were stained by Papani-
colaou, Grocott methenamine silver, auramine–
for viral, fungal, and parasitic infections, and used
for the detection of siderophages and malignant
was defined as
Protected specimen brush
The diluted PSB specimen (2ml) was mechanically
vortexed for 60s. From this solution a Gram stain
and a Ziehl–Neelsen stain was prepared. Two
dilutions (0.1 and 0.001ml) of the original speci-
men were plated out on different media (see BAL)
for quantitative cultures. If growth occurred,
colony counts were performed, and identification
obtained for each microorganism. Five hundred
microlitres of the initial dilution was diluted in 1ml
normal saline for Lo ¨wenstein culture for mycobac-
teria. If indicated, 0.2ml was used for Legionella
culture. Another 0.1ml was inoculated in GLY
medium for viral culture. Cytological analysis was
similar to BAL.
Protected bronchoalveolar lavage
The microbiological and cytological analysis of
PBAL was almost similar to the BAL analysis. From
the original suspension of PBAL one 100-fold dilu-
tion was made. Aliquots of 0.1ml each were plated
onto the different media (see BAL). In contrast to
BAL, quantitative cultures were performed.
The definite etiologies of the pulmonary infiltrates
were established by combining the results of
positive blood cultures, microbiological and cyto-
logical examination of the bronchoscopic samples,
open lung biopsy, and/or outcome of autopsy.
Probable etiologies were defined as the presence
of characteristic abnormal radiographic signs (e.g.
halo or air-crescent sign observed on CT-scan which
is very suggestive for invasive pulmonary apsergil-
losis), isolation of a pathogen from sputum,
abnormal serological test(s) such as complement
fixation (respiratory pathogens), enzyme-linked
immunosorbent assay (IgG to Aspergillus fumiga-
tus, immunodiffusion (A. fumigatus), and the result
of antimicrobial treatment.
Detection of microorganisms that are not nor-
mally present in the oropharyngeal area, or the
presence of malignant cells in one of the stains was
considered to be a proven aetiology. In BAL,
bacterial growth of X104cfu/ml from the original
respiratory secretions was considered to be diag-
nostic. For PSB and PBAL samples the threshold for
detection of a single pathogen was X103and
X104cfu/ml of the original secretions, respectively.
All continuous variables were tested for normal
distribution with the Kolmogorov–Smirnov test for
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W.G. Boersma et al. 320
normal distribution. The independent samples
T-test was used for normally distributed variables
and the w2-test for dichotomous variables. The
software package SPSS 11.5 for Windows (SPSS Inc.,
Chicago, IL, USA) was used for statistical analysis. A
P-value of o0.05 was used to assess statistical
significance of all tests.
Sixty-five patients with hematologic malignancies
participated in the study and were subjected to 70
bronchoscopic procedures; 35 conventional BAL
procedures and 35 protected techniques (PSB and
PBAL) procedures. In seven cases the protected
techniques were not well or not completely carried
out. Therefore, the results of 35 conventional BAL
procedures and 28 PSB and PBAL procedures were
studied. Patient characteristics are summarized in
Table 1. The majority of the patients had acute
myeloid leukaemia as an underlying disease with
In both groups, alveolar consolidation was the
predominant radiographic finding on the chest
X-ray. Radiographic patterns extended to both
lungs in more than half of the patients. In spite of
progressive respiratory symptoms, no radiological
abnormalities were detected in 4 patients of the
PSB–PBAL group. Cavitation was observed only in
the BAL group (3 cases); in one patient pulmonary
aspergillosis was presumed to be the cause of
Before bronchoscopy various schemes of anti-
microbial treatment were used. Antibiotic treat-
ment was started empirically in almost all patients
at onset of fever. Due to the possibility of a fungal
infection, amphotericin B was used in 10 patients of
the BAL group, and 12 of the PSB–PBAL group,
respectively. Only a small number of patients did
not receive intravenous antimicrobial treatment.
Most patients were also treated with an oral
regimen for selective decontamination of the
Causative pathogens were identified by broncho-
scopic techniques in 17 (27%) of the 63 procedures
(Table 2). In both groups A. fumigatus was the
pathogen most frequently isolated, with no differ-
ence in diagnostic yield between the two techni-
ques. Viruses were cultured from the BALF in 4
cases. Bacterial pathogens with growth above the
defined detection threshold were cultured by PSB
in 2 cases, by PBAL in 1 case and by BAL in none of
the cases (Table 3). Leukemic cells were detected
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Patient characteristics in BAL group and PSB–PBAL group.
BAL groupPSB–PBAL group
Episodes with pulmonary infiltrates (n)?
Acute myeloid leukemia (n)z
Non-Hodgkin’s lymphoma (n)
Hodgkin’s lymphoma (n)
Burkitt’s lymphoma (n)
Other hematologic malignancies (n)y
Duration of fever (days)z,z
Platelet count (109/l)z,z
Duration of neutropenia (days)z,z
28 ( 1–340)
?Some patients had more than one episode of pneumonia.
yMedian (range), P ¼ 0:01.
zStatistically not significant.
yBAL group: myelodysplastic syndrome, acute lymphoblastic leukemia, and refractory ¼ anaemia with an excess of blasts in
transformation; PSB–PBAL group: hairy cell leukemia, acute lymphoblastic leukemia, and aplastic anaemia.
zMedian (range), before bronchoscopy.
Bronchoscopic diagnosis of pulmonary infiltrates in granulocytopenic patients 321
in BALF in two patients; however, contamination
with blood could not be excluded.
The overall diagnostic yield was 26% with con-
ventional BAL procedure and 14% each with PSB and
PBAL (Table 2). By combining both protected
techniques the diagnostic yield increased to 29%.
The aetiology of pneumonia was detected by blood
cultures in five patients (Table 4). In these patients
bronchoscopic specimens were negative; one of the
pathogens was detected in BALF in a growth density
of o103cfu/ml (Table 3).
Combining all diagnostic tests such as microbio-
logical and serological tests, radiography, and
histological examinations (including post-mortem)
a definite diagnosis was made in 40% and 64% of
cases of the BAL group and the PSB–PBAL group,
respectively (Table 4). Pulmonary aspergillosis
especially was underdiagnosed in both groups; only
4 of 15 (27%) cases were detected by invasive
bronchoscopic techniques. Probable invasive asper-
patients, bronchoscopy and computed tomography
(CT) scanning in 1 patient, CTscanning and Magnetic
Resonance Imaging in 5 patients, and serology in 1
patient. The remaining 2 patients were diagnosed as
proven invasive aspergillosis by histology. Treatment
was adapted to the results in those patients with
P. carinii and A. fumigatus infections in 8 patients.
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BAL (n ¼ 35)PSB (n ¼ 28) PBAL (n ¼ 28)PSB+PBAL (n ¼ 28)
A. fumigatus+Mucor sp.
A.fumigatus+Herpes simplex virus
Respiratory syncytial virus
Parainfluenzae 3 virus
Coagulase-negative staphylococci (cfu/ml)
Lactobacillus sp. (cfu/ml)+HSV
4 (14%)9 (26%)y
?The two patients in whom A. fumigatus was detected by PSB are not the same two patients in whom it was detected by
yProbably false positive result of acid-fast staining. Mycobacterial cultures were negative.
zNo statistical difference between BAL group and PSB–PBAL group.
yIn two patients leukemic cells were demonstrated in BALF.
The growth density of isolated bacteria by BAL, PSB, and PBAL.
Growth BAL (n ¼ 35)
PSB (n ¼ 28) PBAL (n ¼ 28)
?Specimens yielding multiple bacteria consistent with oropharyngeal flora were considered to be unrepresentative specimens
and are therefore excluded from the table.
yCoagulase negative staphylococci, considered contaminants.
zLactobacillus sp. (see also Table 4).
zIncluding C. albicans (BAL: 5, PSB: 1, PBAL: 1).
??Additiontional stains were also negative.
W.G. Boersma et al.322
Assessment and complications of the
The majority of the patients had an oxygen
desaturation (o90%) during the bronchoscopic
procedure. Severe coughing was a frequently
recorded symptom. PSB caused no severe bleeding;
none of the patients needed a transfusion with
platelets directly after bronchoscopy. Coughing and
bleeding caused by PSB procedure resulted in a
more complex positioning of the PBAL catheter.
Partial luxation of the balloon of the PBAL catheter
by coughing, leading to leakage of the PBAL fluid,
was regularly observed.
The recovery of the instilled fluid (150ml) by PBAL
catheter was disappointing; in most patients the
recovered volume of PBAL fluid was less than 10ml.
No pneumothorax, severe bleeding or other compli-
cations were observed in any of 63 bronchoscopic
procedures. One patient died within 24h after
bronchoscopy due to fulminant P. carinii pneumonia.
Invasive techniques such as bronchoscopy are often
used for the identification of the causative patho-
gen(s) in immunocompromised patients. Various
bronchoscopic techniques, such as BAL, PSB and
PBAL, have been used in patients with hematologic
diseases and were compared in this study. The
sensitivity of BAL to diagnose the cause of
pulmonary infiltrates in these patients from 15%
In the present study, the diagnostic yield of BAL
(26%) was superior to PSB (14%) and PBAL (14%)
individually, however the results of the combina-
tion of both protected procedures was almost
identical to that of BAL. In other studies, the
combination strategy was superior to the individual
methods.22,23The higher diagnostic yield reported,
compared to the present study, may be explained
by two factors. First, the patient groups reported
were different from those in the present study;
most non-granulocytopenic patients had AIDS or
were transplant recipients.20,21,24Secondly, the
rate of patients that did not received antimicrobial
treatment before bronchoscopy was lower in the
other studies, whereas the duration of antibiotic
pretreatment was shorter.
In another study the diagnostic yield of all
endoscopic procedures (BAL, telescoping plugged
catheter, PSB) was 53% in the granulocytopenic
group and 61% in the non-granulocytopenic group.15
Differences in underlying diseases, i.e. acute
leukaemia type, and duration of antimicrobial
treatment, may be reasons for the relatively high
This was illustrated by Ewig25studying patients
with hematologic malignancies and pulmonary
complications in the ICU. Pathogens were retrieved
by BAL in 31% and PSB in 20% of the patients,
whereas blood cultures and tracheobronchial aspi-
rate revealed a positive result in 30% and 6%,
respectively. In only 37 (42%) cases infectious
aetiology was diagnosed during patient’s lifetime
or at necropsy. Remarkable was the low percentage
of infection with Aspergillus spp. (3 cases).
ARTICLE IN PRESS
(including post-mortem) examinations.
Presumptive aetiology of pulmonary infiltrates based on microbial, radiological, and pathological
AetiologyBAL group (n ¼ 35)
PSB–PBAL group (n ¼ 28)
Definite Aspergillus pneumonia
Probable Aspergillus pneumonia
C. albicans pneumonia
P. jerovicii pneumonia
?Co-infection with Herpes simplex virus.
yCo-infection with Lactobacillus spp.
zPositive blood culture.
zS. pneumoniae, S. aureus, and a-hemolytic streptococcus (positive blood culture).
??Coagulase-negative staphylococcus (positive blood culture).
Bronchoscopic diagnosis of pulmonary infiltrates in granulocytopenic patients 323
The clinical significance of culture results just
under the threshold level, especially during an
antibiotic regimen, is unclear. Data obtained from
patients with ventilator-associated pneumonia sug-
gest borderline results should be carefully inter-
preted. It might imply that bronchoscopy should be
repeatedif clinical suspicion
high.26,27The results of quantitative cultures in
the present study indicate that contamination also
occurred with the protected techniques.
Invasive aspergillosis is often seen in granulocy-
topenic patients and bone marrow transplantation
recipients.28Mortality in these high-risk groups may
approach 90%. Much of this high mortality may
reflect the difficulty in establishing a correct
diagnosis in an early stage. BAL analysis by Kahn
et al.29demonstrated invasive pulmonary aspergil-
losis in 9 of the 17 (53%) immunocompromised
patients; in patients without aspergillosis BAL had a
specificity of 92%. The low sensitivity was con-
firmed by others,30,31whereas the values of the
specificity were conflicting. PSB, as shown in our
results and as also found by others, provides a low
diagnostic yield of invasive aspergillosis.30
Other methods, such as CTscanning and galacto-
mannan-based antigen detection diagnosing pul-
monary aspergillosis, may be complementary. CT
features considered consistent with angioinvasive
aspergillosis are the halo sign and air-crescent
sign.32In the present study, CT scanning diagnosed
approximately half of the patients with probable
aspergillosis. Moreover, a CT scan might serve as
guidance for the optimal timing, type and site of
The diagnostic accuracy of chest radiograph in
the evaluation of acute pulmonary complications in
granulocytopenic patients is generally low.4As
shown in our study the radiographic presentation
(often alveolar consolidation) is neither typical nor
specific for any of the diagnoses (e.g. hemorrhage,
infection, tumor infiltration, etc.) nor typical for a
specific pathogen. A recent study indicated that
chest CT scanning provides more specific informa-
tion in the immunocompromised host.33
If all diagnostic examinations remain negative,
tissue examination should be considered and can be
of additive value.21However, bronchoscopic biopsy
procedures are often contraindicated because of
the presence of coagulopathies. In our study, with
transfusion of platelets before the bronchoscopic
procedure, no severe bleeding was observed.
Bronchoscopy in bone marrow transplantation
recipients led to 18% minor complications (desa-
turation, minor bleeding, hypotension, and stridor)
and 8% major complications (severe bleeding,
death).34In our study bleeding initiated by PSB
sometimes partially obstructed the lumen of the
PBAL catheter leading to a lower BALF recovery.
Therefore, video-assisted thoracoscopic surgery or
open lung biopsy are often performed and may
provide a more specific diagnosis compared to
This study illustrates that the application of
modern techniques does not necessarily improve
diagnostic results. In this group of hematologic
patients with granulocytopenia and pulmonary
infiltrates, the diagnostic value of all bronchoscopic
techniques during antibiotic treatment was low. No
difference in diagnostic yield was found between
PSB–PBAL and BAL. Especially in this group of
patients the combination of PSB and PBAL, although
safe, required more skills and effort from the
bronchoscopist. Although we did not time the
duration of the procedures, they might require
more time than the conventional BAL, which would
conceivably impact on discomfort experienced by
patients. If appropriate imaging like early chest CT
is combined with an appropriate bronchoscopic
diagnostic technique such as BAL, we expect that
the diagnostic yield will be improved. Further
studies are needed to evaluate this.
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