Bronchoalveolar lavage and lung biopsy in patients with cancer and hematopoietic stem-cell transplantation recipients: a systematic review and meta-analysis

Acute Respiratory Failure in the Oncologic Patient: New Era, New Issues

Recent decades have seen an increase in the number of patients living with cancer. This trend has resulted in an increase in intensive care unit (ICU) utilization across this population [1]. Acute respiratory failure is the most frequent medical complication leading to critical illness in oncologic patients [2–4]. Historically, there had been a reluctance to admit cancer patients to the ICU given their poor outcomes, particularly in the setting of hematologic malignancy and invasive mechanical ventilation [5]. ICU treatment limitations or refusal of admission was advocated [6]. Major advances in oncologic care, critical care and more meticulous attention to where the conditions overlap, have resulted in marked improvement in short-term survival in this population [1, 7, 8]. Despite these major advances, acute respiratory failure in this population remains complex with unique challenges surrounding diagnosis and management compared to the general ICU population. This chapter provides a comprehensive overview of acute respiratory failure in the oncologic population and highlights specific considerations for the intensivist. We will focus on the important differences between the immunocompromised oncologic patient and general intensive care population, the spectrum of causes of acute respiratory failure with a specific focus on toxicities related to newer cancer therapies, diagnostic approach, management and an up-to-date overview of prognosis.

Managing pulmonary complications in allogeneic hematopoietic stem cell transplantation

Introduction: Progress in allogeneic hematopoietic stem cell transplantation (HSCT) procedures has been associated with improved survival in HSCT recipients. However, they have also brought to light organ-specific complications, especially pulmonary complications. In this setting, pulmonary complications are consistently associated with poor outcomes, and improved management of these complications is required. Areas covered: We review the multiple infectious and noninfectious lung complications that occur both early and late after allogeneic HSCT. This includes the description of these complications, risk factors, diagnostic approach and outcome. A literature search was performed using PubMed-indexed journals. Expert commentary: Multiple lung complications after allogeneic HSCT can be diagnosed concomitantly and require a multidisciplinary approach. A specific clinical evaluation including a precise analysis of a lung CT scan is necessary. Management of these lung complications, especially the noninfectious ones, is impaired by the lack of prospective, randomized control trials, suggesting preventive strategies should be developed.

18F-FDG PET/CT for invasive fungal infection in immunocompromised patients

BACKGROUND

Opportunistic invasive fungal infections (IFIs) comprise a heterogeneous spectrum of pathogens, whose early diagnosis remains challenging. Candida spp. and Aspergillus spp, the most frequent pathogens in immunocompromised patients, frequently affect lungs, liver, bone and skin.

AIM

To evaluate the impact of 18F-FDG PET/CT in the management of immunocompromised patients with IFI.

DESIGN

A single-center retrospective study included 51 immunocompromised patients with IFI diagnosis undergoing 83 18F-FDG PET/CTs.

METHODS

Twenty-nine 18F-FDG PET/CTs were performed for primary work-up in 29 treatment-naïve patients. Fifty-four PET/CTs were performed during follow-up to confirm IFI suspicion in 22 patients who had anti-fungal drug therapy before PET/CT. When available, histological and/or microbiological criteria were used to assess IFI diagnosis.

RESULTS

Aspergillus spp. and Candida spp. were the most frequent microorganisms responsible for IFI in our population. 18F-FDG PET/CT sensitivity, specificity, positive and negative predictive values, and global accuracy were 93%, 81%, 95%, 72% and 90%, respectively. 18F-FDG PET/CT influenced the diagnostic work-up at primary staging in 16/29 patients (55%) by assessing the extent of infection and targeting the diagnostic procedure. 18F-FDG PET/CT results during treatment induced anti-fungal drugs dosage increase and/or new drugs addition in 8/54 cases (15%) and contributed to the reduction of anti-fungal drugs dosage or treatment withdraws in 17 cases (31%).

CONCLUSIONS

We recommend the utilization of 18F-FDG PET/CT to improve the primary staging work-up of immunocompromised patients with IFI and to assess treatment effectiveness or disease relapse. Both 18F-FDG PET/CT and conventional imaging should be integrated into a well-defined imaging diagnostic algorithm considering the clinical context and both strengths and limitations of each diagnostic modality.

The challenge of avoiding intubation in immunocompromised patients with acute respiratory failure

INTRODUCTION

A growing number of immunocompromised (IC) patients with acute hypoxemic respiratory failure (ARF) is admitted to the intensive care unit (ICU) worldwide. Areas covered: This review provides an overview of the current knowledge of the ways to prevent intubation in IC patients with ARF. Expert commentary: Striking differences oppose ARF incidence, characteristics, etiologies and management between IC and non-IC patients. Survival benefits have been reported with early admission to ICU in IC patients. Then, while managing hypoxemia and associated organ dysfunction, the identification of the cause of ARF will be guided by a rigorous clinical assessment at the bedside, further assisted by an invasive or noninvasive diagnostic strategy based on clinical probability for each etiology. Finally, the initial respiratory support aims to avoid mechanical ventilation for the many yet recognizing those patients for whom delaying intubation expose them to suboptimal management. We advocate for not using noninvasive ventilation (NIV) in this setting. A proper evaluation of High-flow nasal cannula oxygen (HFNC)  is required in IC patients as to demonstrate its superiority compared to standard oxygen therapy. Day-to-day decisions must strive to avoid delayed intubation, and make every effort to identify ARF etiology.

Lung histopathology of non-infectious pulmonary complications after allogeneic haematopoietic stem cell transplantation

AIMS

Non-infectious pulmonary complications (NIPCs) occur frequently following allogeneic haematopoietic stem cell transplantation (HSCT). As there is no consensus on the description of the related pulmonary pathological lesions, pathologist reports and clinical conclusions are largely inconsistent in routine practice. The aim of our study was to provide an accurate overview of post-allogeneic HSCT NIPCs from a large number of lung biopsies.

METHODS AND RESULTS

We reviewed 61 lung biopsies in patients with an NIPC, including 51 surgical lung biopsies, four post-mortem biopsies and six lung explants. We found both bronchiolar (n = 59) and alveolar/interstitial pathologies (n = 27). We describe two types of bronchiolar lesions: bronchiolectasies (n = 37) and fibrous and cellular lesions with luminal narrowing (n = 43). We found a wide spectrum of airway/interstitial pathologies that were labelled using the terminology of the 2013 American Thoracic Society and European Respiratory Society (ATS/ERS) classification of idiopathic interstitial pneumonias (IIPs), including the following: organising pneumonia (OP, n = 8), non-specific interstitial pneumonia (NSIP, n = 9), diffuse alveolar damage (DAD, n = 6), lymphoid interstitial pneumonia (LIP, n = 1) and pleuroparenchymal fibroelastosis (PPFE, n = 2), as well as one instance of associated PPFE and NSIP.

CONCLUSIONS

Interstitial pathology was associated with bronchiolar lesions in 41% of the cases reviewed (n = 25). Lung airway and interstitial inflammation was still present in lung explants from patients who underwent lung transplantation for post-allogeneic HSCT end-stage respiratory insufficiency. Herein, we describe a wide spectrum of pathological lung lesions encountered in post-allogeneic HSCT NIPCs.

Adjunctive interferon-γ immunotherapy in a pediatric case of Aspergillus terreus infection

Aspergillus terreus causes invasive aspergillosis (IA) in immunocompromised patients. Treatment is complicated by intrinsic resistance to amphotericin B and thereby contributing to a high mortality. Therefore, we conducted in vitro studies to investigate the effectivity of adjunctive recombinant interferon-γ immunotherapy. We describe a pediatric patient with A. terreus IA who received adjunctive recombinant interferon-γ (rIFNγ) immunotherapy. In vitro studies were conducted to investigate the capacity of rIFNγ to improve antifungal host defense in terms of fungal killing ability and the release of pro-inflammatory cytokines in cells of the patient as well as healthy controls. An 8-year-old female pediatric patient with leukemia developed A. terreus IA. She clinically deteriorated and had high serum galactomannan levels despite broad antifungal therapy. Therefore, adjunctive immune stimulatory therapy with rIFNγ was initiated. After 3 weeks of treatment, galactomannan levels decreased and the patient clinically showed improvement. Addition of rIFNγ boosted the capacity of monocytes of healthy volunteers to mount TNFα and IL-1β cytokine responses to Escherichia coli LPS, and increased TNFα response to both A. terreus and Aspergillus fumigatus. Monocytes isolated from the patient's blood demonstrated a similar augmented cytokine induction in response to rIFNγ. In addition, rIFNγ increased the capacity of monocytes from healthy volunteers as well as monocytes from the patient to kill A. terreus spores. Adjuvant immunotherapy with rIFNγ might be a promising additional treatment strategy that could be used to improve outcome in patients with refractory invasive A. terreus infections or other resistant invasive Aspergillus infections.

The evolving landscape of new diagnostic tests for invasive aspergillosis in hematology patients: strengths and weaknesses

PURPOSE OF REVIEW

The diagnosis of invasive aspergillosis in hematologic patients is a complex composite of clinical preconditions and features, imaging findings, biomarker combinations from appropriate clinical samples and microbiological and/or histological findings.

RECENT FINDINGS

Recent developments in the evolving landscape of diagnostic tests for invasive aspergillosis in adult hematology patients are highlighted.

SUMMARY

Novel approaches and tools are currently under development. Focusing optimized diagnostic performance, in particular the combination of biomarkers from appropriate clinical samples, improved diagnostic performance distinctly.

Diagnostic Approaches for Invasive Aspergillosis-Specific Considerations in the Pediatric Population

Invasive aspergillosis (IA) is a major cause of morbidity and mortality in children with hematological malignancies and those undergoing hematopoietic stem cell transplantation. Similar to immunocompromised adults, clinical signs, and symptoms of IA are unspecific in the pediatric patient population. As early diagnosis and prompt treatment of IA is associated with better outcome, imaging and non-invasive antigen-based such as galactomannan or ß-D-glucan and molecular biomarkers in peripheral blood may facilitate institution and choice of antifungal compounds and guide duration of therapy. In patients in whom imaging studies suggest IA or another mold infection, invasive diagnostics such as bronchoalveolar lavage and/or bioptic procedures should be considered. Here we review the current data of diagnostic approaches for IA in the pediatric setting and highlight the major differences of performance and clinical utility of the tests between children and adults.

Lung Infections

A review of pulmonary infections of all types with diagnostic and morphological features.

The utility and safety of flexible bronchoscopy in critically ill acute leukemia patients: a retrospective cohort study

PURPOSE

Flexible bronchoscopy with bronchoalveolar lavage (BAL) is commonly performed in immunocompromised patients. Nevertheless, it remains unclear whether bronchoscopy with BAL leads to changes in medical management or is associated with procedural complications among critically ill acute leukemia (AL) patients.

METHODS

We evaluated 71 AL patients who underwent diagnostic bronchoscopy with BAL in the intensive care unit (ICU) between 1 January 2007 and 31 December 2012. We recorded baseline characteristics, vital signs (before, during, and after the procedure), changes in medical management following the procedure, and procedural complications. Using a multivariable logistic regression model, we explored the relationship between patient characteristics and whether bronchoscopy changed management or caused complications. Patient characteristics included as predictors in the regression model were age, sex, immunosuppression status (those undergoing active chemotherapy), and the Acute Physiology And Chronic Health Evaluation II score.

RESULTS

The most common indication for ICU admission was respiratory failure (51 patients, 72%), followed by sepsis (14 patients, 20%). Overall, the results obtained from bronchoscopy with BAL were associated with a change in management in 32 patients (45%), most commonly a change in antimicrobial therapy as a result of an infectious pathogen being identified (17 patients, 24%). Complications were documented in nine patients (13%) and included post-procedural hypoxia (six patients, 8%), the need for intubation (one patient, 9% of non-intubated patients), and tracheal perforation (one patient, 1%). No clinically significant changes in patient vital signs were observed during or immediately following the procedure. Patient characteristics did not predict whether bronchoscopy was associated with changes in medical management or procedural complications in multivariable analyses.

CONCLUSIONS

Flexible bronchoscopy with BAL is relatively safe and helps to guide medical management among patients with AL admitted to the ICU.

Utility of flexible bronchoscopy with polymerase chain reaction in the diagnosis and management of pulmonary infiltrates in allogeneic HSCT patients

Objectives

Pulmonary infiltrates in allogeneic hematopoietic stem cell transplant (allo‐HSCT) patients are potentially life‐threatening and require early diagnosis and treatment. We aimed to retrospectively explore the clinical efficacy of polymerase chain reaction (PCR) in conjunction with flexible bronchoscopy (FB) in allo‐HSCT patients with pulmonary infiltrates.

Patients and methods

We retrospectively reviewed all patients undergoing FB after allo‐HSCT at the Peking University Institute of Hematology from January 2013 to December 2016. We used PCR to detect various viruses in FB specimens, particularly for 27 viruses.

Results

One hundred forty‐nine diagnostic FBs were performed in 130 patients. The overall diagnostic yield was 58%. Eighty‐nine percent of the patients with a positive FB result were diagnosed with a pulmonary infection. Viruses were the most common infectious diagnosis (70%), followed by fungi (48%), bacteria (38%), and Pneumocystis jirovecii (12%). Multivariate analyses showed that a chest computed tomography (CT) finding of diffuse pulmonary infiltrates (P = .012) and positive results in assisted microbiological and serological analyses (P = .000) predicted a positive FB result. FB results prompted a treatment modification in 61% of cases.

Conclusions

FB in conjunction with PCR is efficient in the rapid diagnosis and management of pulmonary infiltrates in allo‐HSCT patients.

Diagnostic Evaluation of Pulmonary Abnormalities in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation

Pulmonary complications (PC) of hematologic malignancies and their treatments are common causes of morbidity and mortality. Early diagnosis is challenging due to host risk factors, clinical instability, and provider preference. Delayed diagnosis impairs targeted treatment and may contribute to poor outcomes. An integrated understanding of clinical risk and radiographic patterns informs a timely approach to diagnosis and treatment. There is little prospective evidence guiding optimal modality and timing of minimally invasive lung sampling; however, a low threshold for diagnostic bronchoscopy during the first 24 to 72 hours after presentation should be a guiding principle in high-risk patients.

Transbronchial biopsy in the management of pulmonary complications of hematopoietic stem cell transplantation

The utility of transbronchial biopsy in the management of pulmonary complications following hematopoietic stem cell transplantation has shown variable results. Herein, we examine the largest case series of patients undergoing transbronchial biopsy following hematopoietic stem cell transplantation. We performed a retrospective analysis of 130 transbronchial biopsy cases performed in patients with pulmonary complications post-hematopoietic stem cell transplantation. Logistic regression models were applied to examine diagnostic yield, odds of therapy change and complications. The most common histologic finding on transbronchial biopsy was a non-specific interstitial pneumonitis (n= 24 cases, 18%). Pathogens identified by transbronchial biopsy were rare, occurring in < 5% of cases. A positive transbronchial biopsy significantly increased the odds of a subsequent change in corticosteroid therapy (OR=3.12, 95% CI 1.18–8.23; p=0.02) but was not associated with a change in antibiotic therapy (OR=1.01, 95% CI 0.40–2.54; p=0.98) or changes in overall therapy (OR=1.92, 95% CI 0.79–4.70; p=0.15). Patients who underwent a transbronchial biopsy had increased odds of complications related to the bronchoscopy (OR=3.33, 95% CI 1.63–6.79; p=0.001). In conclusion, transbronchial biopsy may contribute to the diagnostic management of non-infectious lung injury post-hematopoietic stem cell transplantation, while its utility in the management of infectious pulmonary complications of HSCT remains low.

Bronchiolitis Obliterans Syndrome and Other Late Pulmonary Complications After Allogeneic Hematopoietic Stem Cell Transplantation

As more individuals survive their hematologic malignancies after allogeneic hematopoietic stem cell transplantation (HSCT), there is growing appreciation of the late organ complications of this curative procedure for malignant and nonmalignant hematologic disorders. Late noninfectious pulmonary complications encompass all aspects of the bronchopulmonary anatomy. There have been recent advances in the diagnostic recognition and management of bronchiolitis obliterans syndrome, which is recognized as a pulmonary manifestation of chronic graft-versus-host disease. Organizing pneumonia and other interstitial lung diseases are increasingly recognized. This article provides an update on these entities as well as pleural and pulmonary vascular disease after allogeneic HSCT.

Linking the generation of DNA adducts to lung cancer

Worldwide, lung cancer is the leading cause of cancer death. DNA adducts are considered a reliable biomarker that reflects carcinogen exposure to tobacco smoke, but the central question is what is the relationship of DNA adducts and cancer? Therefore, we investigated this relationship by a meta-analysis of twenty-two studies with bronchial adducts for a total of 1091 subjects, 887 lung cancer cases and 204 apparently healthy individuals with no evidence of lung cancer. Our study shows that these adducts are significantly associated to increase lung cancer risk. The value of Mean Ratio_lung-cancer (MR) of bronchial adducts resulting from the random effects model was 2.64, 95% C.I. 2.00-3.50, in overall lung cancer cases as compared to controls. The significant difference, with lung cancer patients having significant higher levels of bronchial adducts than controls, persisted after stratification for smoking habits. The MR_lung-cancer value between lung cancer patients and controls for smokers was 2.03, 95% C.I. 1.42-2.91, for ex-smokers 3.27, 95% C.I. 1.49-7.18, and for non-smokers was 3.81, 95% C.I. 1.85-7.85. Next, we found that the generation of bronchial adducts is significantly related to inhalation exposure to tobacco smoke carcinogens confirming its association with volatile carcinogens. The MR_smoking estimate of bronchial adducts resulting from meta-regression was 2.28, 95% Confidence Interval (C.I.) 1.10-4.73, in overall smokers in respect to non-smokers. The present work provides strengthening of the hypothesis that bronchial adducts are not simply relate to exposure, but are a cause of chemical-induced lung cancer.

The Intensive Care Medicine research agenda on critically ill oncology and hematology patients

Over the coming years, accelerating progress against cancer will be associated with an increased number of patients who require life-sustaining therapies for infectious or toxic chemotherapy-related events. Major changes include increased number of cancer patients admitted to the ICU with full-code status or for time-limited trials, increased survival and quality of life in ICU survivors, changing prognostic factors, early ICU admission for optimal monitoring, and use of noninvasive diagnostic and therapeutic strategies. In this review, experts in the management of critically ill cancer patients highlight recent changes in the use and the results of intensive care in patients with malignancies. They seek to put forward a standard of care for the management of these patients and highlight important updates that are required to care for them. The research agenda they suggest includes important studies to be conducted in the next few years to increase our understanding of organ dysfunction in this population and to improve our ability to appropriately use life-saving therapies or select new therapeutic approaches that are likely to improve outcomes. This review aims to provide more guidance for the daily management of patients with cancer, in whom outcomes are constantly improving, as is our global ability to fight against what is becoming the leading cause of mortality in industrialized and non-industrialized countries.

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

BACKGROUND

The 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.

METHODS

A 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.

RESULTS

In 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.

CONCLUSIONS

In 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.

SUMMARY

A 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.

A prediction model for distinguishing lung squamous cell carcinoma from adenocarcinoma

Accurate classification of squamous cell carcinoma (SCC) from adenocarcinoma (AC) of non–small cell lung cancer (NSCLC) can lead to personalized treatments of lung cancer. We aimed to develop a miRNA-based prediction model for differentiating SCC from AC in surgical resected tissues and bronchoalveolar lavage (BAL) samples. Expression levels of seven histological subtype-associated miRNAs were determined in 128 snap-frozen surgical lung tumor specimens by using reverse transcription-polymerase chain reaction (RT-PCR) to develop an optimal panel of miRNAs for acutely distinguishing SCC from AC. The biomarkers were validated in an independent cohort of 112 FFPE lung tumor tissues, and a cohort of 127 BAL specimens by using droplet digital PCR for differentiating SCC from AC. A prediction model with two miRNAs (miRs-205-5p and 944) was developed that had 0.988 area under the curve (AUC) with 96.55% sensitivity and 96.43% specificity for differentiating SCC from AC in frozen tissues, and 0.997 AUC with 96.43% sensitivity and 96.43% specificity in FFPE specimens. The diagnostic performance of the prediction model was reproducibly validated in BAL specimens for distinguishing SCC from AC with a higher accuracy compared with cytology (95.69 vs. 68.10%; P < 0.05). The prediction model might have a clinical value for accurately discriminating SCC from AC in both surgical lung tumor tissues and liquid cytological specimens.

Usefulness of bronchoalveolar lavage and flow cytometry in patients with hematological malignancies and respiratory failure

BACKGROUND AND OBJECTIVES

Strategies to improve the efficiency of bronchoalveolar lavage (BAL) are needed. We conducted a study to establish the diagnostic value of BAL in patients with hematological malignancies and pulmonary infiltrates.

PATIENTS AND METHODS

The correlation of cytologic and flow cytometric study of BAL with the microbiological findings and the clinical evolution was determined.

RESULTS

Seventy BAL were performed and flow cytometric study was analyzed in 23 of them. Fifty-three patients did not present any adverse event attributable to BAL. Anti-infectious therapy was modified in 64 (91%) patients. T lymphocyte count >0.3×10⁹/l in peripheral blood was associated with longer OS at 3 years (53 vs. 22%, p=.009). Higher CD4 (>20/μL) and CD8 (>35/μL) lymphocyte counts in the BAL were associated with a longer OS at 3 years: 82 vs. 21% (p=.030) and 80 vs. 23% (p=.059).

CONCLUSIONS

Our study confirms the clinical value of BAL for treatment decision making in patients with hematological malignancies and acute respiratory failure.

Current Algorithms in Fungal Diagnosis in the Immunocompromised Host

Invasive fungal diseases (IFDs) are a major cause of morbidity and mortality in immunocompromised patients such as patients with hematological malignancies or allogeneic hematopoietic stem cell transplant recipients. Whereas the definite diagnosis of IFD requires invasive diagnostic procedures, imaging and noninvasive diagnostic assays may help in decision making with regard to the institution and the choice of antifungal agents, the duration of therapy, surgical intervention, and monitoring of fungal manifestations.Unfortunately, signs and symptoms of IFD are often nonspecific in the immunocompromised patient. Therefore, in immunocompromised patients with suspected IFD, all samples collected need to be cultured for fungi, and, in the case of specimens obtained by invasive diagnostic procedures, also microscopically examined. For high sensitivity of the cultural and microscopic approaches, specific media and stains, respectively, are crucial. Non-culture based method such as the detection of galactomannan or ß-d-glucan and molecular tools such as polymerase chain reaction may help in the early diagnosis of IFD. Imaging studies may be indicative for IFD, but invasive diagnostics such as bronchoalveolar lavage and/or biopsy should be pursued in order to identify the causative pathogen. This chapter summarizes the current knowledge on diagnosing IFD and proposes practical help in the use of diagnostic tools.

Fulminant Laryngeal-tracheobronchial-pulmonary Aspergillosis: A Rare and Fatal Complication in Allogeneic Hematopoietic Stem Cell Transplantation Recipients

A 23-year-old man who had previously undergone allogeneic hematopoietic stem cell transplantation (allo-HSCT) for severe aplastic anemia was diagnosed with invasive laryngeal-tracheobronchial-pulmonary aspergillosis after presenting with a persistent dry cough at six months post-transplantation based on the findings of laryngoscopy and fiberoptic bronchoscopy. A fiberoptic bronchoscope was used to remove the obstructive material from the patient's airway and posaconazole plus caspofungin were administered to successfully to treat the patient. Our report suggests that laryngoscopy and fiberoptic bronchoscopy should be considered as alternative approaches to the diagnosis and treatment of allo-HSCT recipients with persistent respiratory symptoms when invasive laryngeal aspergillosis and invasive tracheobronchial aspergillosis are suspected.

Viral Pneumonia in Patients with Hematologic Malignancy or Hematopoietic Stem Cell Transplantation

Viral pneumonias in patients with hematologic malignancies and recipients of hematopoietic stem cell transplantation cause significant morbidity and mortality. Advances in diagnostic techniques have enabled rapid identification of respiratory viral pathogens from upper and lower respiratory tract samples. Lymphopenia, myeloablative and T-cell depleting chemotherapy, graft-versus-host disease, and other factors increase the risk of developing life-threatening viral pneumonia. Chest imaging is often nonspecific but may aid in diagnoses. Bronchoscopy with bronchoalveolar lavage is recommended in those at high risk for viral pneumonia who have new infiltrates on chest imaging.

Safety and Benefits of Bronchoalveolar Lavage and Lung Biopsy in the Management of Pulmonary Infiltrates in Children With Leukemia

BACKGROUND

Children with leukemia are at risk of developing life-threatening opportunistic pulmonary infections. The role of bronchoalveolar lavage (BAL) and lung biopsy (BX) in the management of these patients is controversial. In this study, we evaluate the yield and safety of BAL and BX in children with leukemia.

PROCEDURE

We reviewed the records of all children with leukemia who underwent either BAL or BX between 1997 and 2007 at the St Jude Children's Research Hospital.

RESULTS

A total of 64 patients were included, of whom 35 (55%) had BX and 29 (45%) had BAL. Positive results were obtained in 69% of BAL cohort and in 46% of BX cohort. Both procedures resulted in change in antimicrobial coverage (77% in BX, 83% in BAL). Pulmonary hemorrhage occurred in 2 patients, and transient hypoxia was the most frequent complication. All resolved without negatively impacting the clinical course.

CONCLUSIONS

Both BAL and BX are safe and useful in the management of children with leukemia and pulmonary disease.

Lower Respiratory Tract Infections

This review will focus on the infectious etiologies and more common noninfectious causes of lower respiratory tract syndromes among major immunosuppressed populations. The changing epidemiology of infections in the era of highly active antiretroviral therapy (HAART) in the case of HIV-positive patients and the impacts of both newer immune-suppressant therapies and anti-infective prophylaxis for other immunocompromised hosts will be discussed, with emphasis on diagnostic approaches and practice algorithms.

Decline in the Use of Surgical Biopsy for Diagnosis of Pulmonary Disease in Hematopoietic Cell Transplantation Recipients in an Era of Improved Diagnostics and Empirical Therapy

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Use of biopsy for diagnosis of post-HCT lung disease has declined significantly.

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Improved testing and increased azole use are associated with this decrease.

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Less invasive methods have improved diagnostics for respiratory pathogens.

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We outline an algorithm for appropriate use of lung biopsy in these patients.

Historically, diagnosis of enigmatic pulmonary disease after hematopoietic cell transplantation (HCT) required lung biopsy, but recent advancements in diagnosis and therapy for respiratory infections have changed how clinicians approach pulmonary abnormalities. We examined temporal trends in the use of lung biopsy after HCT. We retrospectively reviewed patients who underwent their first allogeneic HCT at the Fred Hutchinson Cancer Research Center between the years 1993 to 1997, 2003 to 2007, and 2013 to 2015 and subsequently underwent surgical lung biopsy for any reason. Lung biopsy between cohorts were analyzed using a Cox proportional hazards model with death and relapse considered competing risks. Of 1418 patients, 52 (3.7%) underwent 54 post-HCT surgical lung biopsies during 1993 to 1997 compared with 24 (2.1%) and 25 biopsies in the 2003 to 2007 cohort; 2 cases of surgical lung biopsies out of 786 HCT recipients occurred during the 2013 to 2015 cohort (.25%). The median time to biopsy post-HCT was 71.5 days (IQR, 31 to 89) for the early cohort and 97 days (IQR, 42 to 124) for the late cohort, for an overall biopsy incidence of .15 and .075 per 1000 patient days in the first year after HCT, respectively. Patients in the 2003 to 2007 cohort were less likely to undergo a lung biopsy (adjusted HR, .50; 95% CI, .29 to .83; P = .008) when compared with patients in the early cohort, but more patients in the early cohort underwent lung biopsy without antecedent bronchoscopy (25/54 [46%] versus 3/25 [12%], P = .005). Although infections were a more common finding at biopsy in the early cohort (35/1418 versus 8/1148, P < .001), the number of biopsies demonstrating noninfectious lesions was similar between the two cohorts (19/1418 versus 17/1148, P = .76). Fungal infections were the major infectious etiology in both cohorts (32/35 [91%] versus 5/8 [63%], P = .07), but there was a significant reduction in the number of Aspergillus species found at biopsy between the cohorts (30/54 versus 1/25, P < .001). A similar percentage underwent biopsy with therapeutic intent for invasive fungal disease in the 2 cohorts (8/54 [15%] versus 4/25 [16%]). Surgical evaluation of lung disease in HCT recipients significantly declined over a span of 2 decades. The decline from the years 1993 to 1997 compared with 2003 to 2007 was because of a reduction in the number of biopsies for post-transplant infections due to aspergillosis, which is temporally related to improved diagnostic testing by minimally invasive means and the increased use of empiric therapy with extended-spectrum azoles. This practice of primary nonsurgical diagnostic and treatment approaches to pulmonary disease post-HCT have continued, shown by low numbers of surgical biopsies over the last 3 years.

Molecular and Culture-Based Bronchoalveolar Lavage Fluid Testing for the Diagnosis of Cytomegalovirus Pneumonitis

Background.  Cytomegalovirus (CMV) is a major cause of morbidity and mortality in immunocompromised patients, with CMV pneumonitis among the most severe manifestations of infection. Although bronchoalveolar lavage (BAL) samples are frequently tested for CMV, the clinical utility of such testing remains uncertain. Methods.  Retrospective analysis of adult patients undergoing BAL testing via CMV polymerase chain reaction (PCR), shell vial culture, and conventional viral culture between August 2008 and May 2011 was performed. Cytomegalovirus diagnostic methods were compared with a comprehensive definition of CMV pneumonitis that takes into account signs and symptoms, underlying host immunodeficiency, radiographic findings, and laboratory results. Results.  Seven hundred five patients underwent 1077 bronchoscopy episodes with 1090 BAL specimens sent for CMV testing. Cytomegalovirus-positive patients were more likely to be hematopoietic cell transplant recipients (26% vs 8%, P < .0001) and less likely to have an underlying condition not typically associated with lung disease (3% vs 20%, P < .0001). Histopathology was performed in only 17.3% of CMV-positive bronchoscopy episodes. When CMV diagnostic methods were evaluated against the comprehensive definition, the sensitivity and specificity of PCR, shell vial culture, and conventional culture were 91.3% and 94.6%, 54.4% and 97.4%, and 28.3% and 96.5%, respectively. Compared with culture, PCR provided significantly higher sensitivity and negative predictive value (P ≤ .001), without significantly lower positive predictive value. Cytomegalovirus quantitation did not improve test performance, resulting in a receiver operating characteristic curve with an area under the curve of 0.53. Conclusions.  Cytomegalovirus PCR combined with a comprehensive clinical definition provides a pragmatic approach for the diagnosis of CMV pneumonitis.

Pneumonia After Hematopoietic Stem Cell Transplantation

Pneumonia is the main cause of morbidity and mortality after hematopoietic stem cell transplantation. Two thirds of pneumonias observed after both autologous and allogeneic stem cell transplantations are of infectious origin, and coinfections are frequent. One third is due to noninfectious process, such as alveolar hemorrhage, alveolar proteinosis, or alloimmune pulmonary complications such as bronchiolitis obliterans or idiopathic interstitial pneumonitis. Most of these noninfectious complications may require treatment with corticosteroids which may be deleterious in infection. On the other hand, these complications either mimic or may be complicated with infections. Therefore, a precise diagnosis of pneumonia is of crucial importance to decide of the optimal treatment. CT scan is the best procedure for imaging of the lung. Although several indirect biomarkers, such as serum or plasma galactomannan or (1-3) β(beta)-G-glucan, can help in the etiological diagnosis, only direct invasive investigations provide the best chance to identify the cause(s) of pneumonia. Bronchoalveolar lavage (BAL) under fiberoptic bronchoscopy is the procedure of choice to identify the cause of pulmonary infection. It is safe and reproducible, and its diagnostic yield is around 50 % if the BAL fluid is processed at the laboratory according to a prespecified protocol established between the transplanter, the infectious diseases’ specialist, the pneumologist, and the laboratory, allowing the identification of the most likely hypotheses. Transbronchial biopsy does not provide significant additional information to BAL in most cases and more often complicates with bleeding and pneumothorax. In case of a noncontributory BAL, the decision to proceed to a second BAL, a transthoracic biopsy, or a surgical biopsy should be cautiously weighted in a multidisciplinary approach in regard to the benefits and risks of invasive procedures versus empirical treatment.