1
|
López-Fernández S, Molino JA, Soler-Palacín P, Mendoza-Palomar N, Uria Oficialdegui ML, Martos Rodríguez M, López M, Guillén G. Surgical treatment of invasive pulmonary fungal infections in immunocompromised pediatric patients: Aspergillus spp. and other emerging fungi. Pediatr Surg Int 2024; 40:263. [PMID: 39367968 DOI: 10.1007/s00383-024-05851-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2024] [Indexed: 10/07/2024]
Abstract
PURPOSE Invasive Pulmonary Fungal Infections (IPFIs) represent a diagnostic and therapeutic challenge. The exact role of surgery is not well defined. This study analyzes our experience with surgical treatment of IPFI in immunocompromised pediatric patients and, secondarily, compares IPFI caused by Aspergillus spp. with other fungal infections. METHODS This is a retrospective review (2000-2019) of patients with IPFI surgically treated at our pediatric institution. Statistical analysis was used to compare data between Aspergillus spp. and non-Aspergillus IPFI. RESULTS Twenty-five patients (64% female) underwent 29 lung resections. Median age at surgery was 7.19 years (1.63-19.14). The most frequent underlying condition (64%) was acute leukemia. Surgical indications included persistence or worsening of symptoms and pathological image findings (52%) or asymptomatic suspicious lesions in patients scheduled for intensive cytotoxic treatments or hematopoietic stem cell transplantation (48%). All patients underwent atypical lung resections, except one lobectomy. Aspergillus spp. was the most frequently isolated pathogen (68%). Follow-up was 4.07 years (0.07-18.07). Surgery-related mortality was 0%, but 4 patients died in the 100 days following surgery (2 due to disseminated fungal infection); the remaining 21 did not show signs of IPFI recurrence. Non-specific consolidations on CT scan were more frequent in non-Aspergillus IPFI (p < 0.05). CONCLUSION Surgical treatment of IPFI should be considered as a part of the treatment in selected pediatric immunocompromised patients, and it may have both diagnostic and therapeutic advantages over non-surgical management. When there is clinical suspicion of IPFI but CT scan shows unspecific alterations, the possibility of a non-Aspergillus IPFI should be considered.
Collapse
Affiliation(s)
- Sergio López-Fernández
- Pediatric Surgical Oncology Unit, Department of Pediatric Surgery, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron 119, 08035, Barcelona, Spain.
| | - José Andrés Molino
- Pediatric Surgical Oncology Unit, Department of Pediatric Surgery, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron 119, 08035, Barcelona, Spain
| | - Pere Soler-Palacín
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Natalia Mendoza-Palomar
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
| | | | - Marta Martos Rodríguez
- Pediatric Surgical Oncology Unit, Department of Pediatric Surgery, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron 119, 08035, Barcelona, Spain
| | - Manuel López
- Pediatric Surgical Oncology Unit, Department of Pediatric Surgery, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron 119, 08035, Barcelona, Spain
| | - Gabriela Guillén
- Pediatric Surgical Oncology Unit, Department of Pediatric Surgery, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron 119, 08035, Barcelona, Spain
| |
Collapse
|
2
|
Shanthikumar S, Gower WA, Srinivasan S, Rayment JH, Robinson PD, Bracken J, Stone A, Das S, Barochia A, Charbek E, Tamae-Kakazu M, Reardon EE, Abts M, Blinman T, Calvo C, Cheng PC, Cole TS, Cooke KR, Davies SM, De A, Gross J, Mechinaud F, Sheshadri A, Siddaiah R, Teusink-Cross A, Towe CT, Walkup LL, Yanik GA, Bergeron A, Casey A, Deterding RR, Liptzin DR, Schultz KR, Iyer NP, Goldfarb S. Detection of Bronchiolitis Obliterans Syndrome after Pediatric Hematopoietic Stem Cell Transplantation: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2024; 210:262-280. [PMID: 38889365 DOI: 10.1164/rccm.202406-1117st] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 06/18/2024] [Indexed: 06/20/2024] Open
Abstract
Background: Many children undergo allogeneic hematopoietic stem cell transplantation (HSCT) for the treatment of malignant and nonmalignant conditions. Unfortunately, pulmonary complications occur frequently post-HSCT, with bronchiolitis obliterans syndrome (BOS) being the most common noninfectious pulmonary complication. Current international guidelines contain conflicting recommendations regarding post-HSCT surveillance for BOS, and a recent NIH workshop highlighted the need for a standardized approach to post-HSCT monitoring. As such, this guideline provides an evidence-based approach to detection of post-HSCT BOS in children. Methods: A multinational, multidisciplinary panel of experts identified six questions regarding surveillance for, and evaluation of, post-HSCT BOS in children. A systematic review of the literature was undertaken to answer each question. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of recommendations. Results: The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Recommendations addressing the role of screening pulmonary function testing and diagnostic tests in children with suspected post-HSCT BOS were made. Following a Delphi process, new diagnostic criteria for pediatric post-HSCT BOS were also proposed. Conclusions: This document provides an evidence-based approach to the detection of post-HSCT BOS in children while also highlighting considerations for the implementation of each recommendation. Further, the document describes important areas for future research.
Collapse
|
3
|
Pulmonary Infectious Complications in Children with Hematologic Malignancies and Chemotherapy-Induced Neutropenia. Diseases 2020; 8:diseases8030032. [PMID: 32824956 PMCID: PMC7564221 DOI: 10.3390/diseases8030032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/04/2020] [Accepted: 08/17/2020] [Indexed: 11/16/2022] Open
Abstract
Infections frequently complicate the treatment course in children with hematologic malignancies undergoing chemotherapy. Febrile neutropenia (FN) remains a major cause of hospital admissions in this population, and respiratory tract is often proven to be the site of infection even without respiratory signs and symptoms. Clinical presentation may be subtle due to impaired inflammatory response. Common respiratory viruses and bacteria are widely identified in these patients, while fungi and, less commonly, bacteria are the causative agents in more severe cases. A detailed history, thorough clinical and basic laboratory examination along with a chest radiograph are the first steps in the evaluation of a child presenting signs of a pulmonary infection. After stratifying patient’s risk, prompt initiation of the appropriate empirical antimicrobial treatment is crucial and efficient for the majority of the patients. High-risk children should be treated with an intravenous antipseudomonal beta lactam agent, unless there is suspicion of multi-drug resistance when an antibiotic combination should be used. In unresponsive cases, more invasive procedures, including bronchoalveolar lavage (BAL), computed tomography (CT)-guided fine-needle aspiration or open lung biopsy (OLB), are recommended. Overall mortality rate can reach 20% with higher rates seen in cases unresponsive to initial therapy and those under mechanical ventilation.
Collapse
|
4
|
Utility of bronchoscopy in immunocompromised paediatric patients: Systematic review. Paediatr Respir Rev 2020; 34:24-34. [PMID: 32247829 DOI: 10.1016/j.prrv.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/21/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE The objective of this study was to describe the diagnostic yield and safety of bronchoalveolar lavage (BAL) in the evaluation of pulmonary lesions in immunocompromised children. METHODS We conducted a systematic review of literature published during the past 20 years, searching Medline, Medline EPub, EMBASE, and Scopus. Studies included involved paediatric patients (<18 years) on treatment for an oncological diagnosis or other immune compromise who underwent BAL for evaluation of pulmonary lesions. Only English language publications were included. RESULTS In all, 272 studies were screened and 19 included. All were observational studies with moderate (11/19) or serious (8/19) risk of bias. BAL yielded a potential pathogen in 43% of cases (496/1156). Two papers reported improved diagnostic yield with early BAL (less than 3 days of presentation). A change in patient management after BAL was reported in 53% of cases (275/519). Adverse events were reported in 19% of cases following BAL (193/993) but were generally mild with no procedure-related mortality reported. CONCLUSION BAL appears to be useful for evaluation of pulmonary lesions in immunocompromised children with generally acceptable safety, though included studies had at least moderate risk of bias. Future prospective studies may provide more definitive estimates of benefit, timing and risk of BAL in this population.
Collapse
|
5
|
Surgical lung biopsy in children after hematopoietic cell transplantation. J Pediatr Surg 2018; 53:1129-1133. [PMID: 29602553 DOI: 10.1016/j.jpedsurg.2018.02.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 02/27/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Pulmonary complications are some of the leading causes of morbidity and mortality in immunocompromised pediatric patients. We sought to assess the value of surgical lung biopsy (SLB) in hematopoietic cell transplantation (HCT) pediatric patients. METHODS A retrospective review of patients who underwent SLB within one year of HCT between 1999 and 2015 was performed. RESULTS Twenty-nine patients (15 females, 14 males) with a median age of 10years (range, 0.6-23) were identified. Median interval between HCT and SLB was 114.8days (range, 16-302). At surgery, 11 (38%) patients were intubated, and 7 (24%) were receiving supplemental oxygen. The most common histological finding was cryptogenic organizing pneumonia in 8 cases (27%), followed by infection in 7 (24%). Perioperative complications (17%) included bronchopleural fistula (n=2), splenic laceration from a trocar injury (n=2), and hemothorax (n=1). Changes in therapy occurred in 25 patients (86%). Twenty-four (83%) patients survived more than 30days post SLB, and the overall survival rate was 41% with a median follow-up of 8.5years (range, 1-13). CONCLUSION SLB appears to be safe and informative in pediatric patients after HCT and led to changes in therapy in most patients. However, long-term survival after this procedure was <50%, reinforcing the fact that pulmonary complications are some of the leading causes of mortality in these patients. TYPE OF STUDY Retrospective analysis. LEVEL OF EVIDENCE Level IV.
Collapse
|
6
|
Nadimpalli S, Foca M, Satwani P, Sulis ML, Constantinescu A, Saiman L. Diagnostic yield of bronchoalveolar lavage in immunocompromised children with malignant and non-malignant disorders. Pediatr Pulmonol 2017; 52:820-826. [PMID: 28052585 PMCID: PMC7167680 DOI: 10.1002/ppul.23644] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 08/02/2016] [Accepted: 11/06/2016] [Indexed: 02/04/2023]
Abstract
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.
Collapse
Affiliation(s)
- Sruti Nadimpalli
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Stanford University Medical Center, Palo Alto 94305, California
| | - Marc Foca
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Prakash Satwani
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Maria Luisa Sulis
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Andrei Constantinescu
- Division of Pediatric Pulmonology, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Lisa Saiman
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Columbia University Medical Center, New York, New York.,Department of Infection Prevention and Control, NewYork-Presbyterian Hospital, New York, New York
| |
Collapse
|
7
|
Grannis FW, Ito J, Sandoval AJ, Wilczynski SP, Hogan JM, Erhunmwunsee L. Diagnostic Approach to Life-Threatening Pulmonary Infiltrates. SURGICAL EMERGENCIES IN THE CANCER PATIENT 2017. [PMCID: PMC7123707 DOI: 10.1007/978-3-319-44025-5_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diagnosis of pulmonary disease is typically based upon consideration of presenting symptoms, physical examination, and pulmonary function testing in combination with classification of radiographic features, to guide diagnostic tests and initiate empiric treatment. When diagnostic efforts and/or empiric treatment fails, thoracic surgeons have traditionally been called upon to perform surgical biopsy of the lung to aid in the diagnosis of indeterminate, life-threatening pulmonary disease. Such biopsy has been requested specifically in the case of diffuse lung disease among patients receiving treatment for solid-organ or hematologic cancers, particularly when symptoms of respiratory failure progress and when noninvasive diagnostic tests and empiric treatments fail to halt progression. In such circumstances, radiologists, pulmonologists, and thoracic surgeons may be consulted and asked to provide tissue specimens that will allow rapid, accurate diagnosis leading to specific treatment. It is imperative that biopsy take place before respiratory failure supervenes [1], and that the specimens provided to clinical laboratories, pathologists, and microbiologists are comprehensive and properly preserved.
Collapse
|
8
|
Safety and Benefits of Bronchoalveolar Lavage and Lung Biopsy in the Management of Pulmonary Infiltrates in Children With Leukemia. J Pediatr Hematol Oncol 2016; 38:597-601. [PMID: 27467366 PMCID: PMC5699503 DOI: 10.1097/mph.0000000000000644] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
|
9
|
Acker SN, Gonzales D, Ross JT, Dishop MK, Deterding RR, Partrick DA. Factors that increase diagnostic yield of surgical lung biopsy in pediatric oncology patients. J Pediatr Surg 2015; 50:1490-2. [PMID: 25957864 DOI: 10.1016/j.jpedsurg.2015.03.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 03/13/2015] [Accepted: 03/21/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Recent data demonstrate that surgical lung biopsy in immunocompromised children, including oncology patients, alters therapy in only 50% of cases. We hypothesized that there are factors identifiable preoperatively which can predict the patients who will or will not benefit from surgical biopsy. METHODS We reviewed the medical records of all children with malignancy who underwent surgical lung biopsy between 2004 and 2013 at a single institution, excluding those children who had previously undergone a solid organ or bone marrow transplant. RESULTS Eighty lung wedge biopsies were performed (median age 13 years, IQR 5.25-16; 63% male, n=50) 53 (66%) of which led to a change in patient management. The majority of biopsies were performed to diagnose a new mass or differentiate infection from metastases (mass group) (n=68, 85%), and 12 biopsies (15%) were performed to diagnose a known infection for antibiotic guidance (infection group). Children in the infection group were more likely to be febrile preoperatively, were more likely to be an inpatient preoperatively, and had a lower absolute neutrophil count at the time of biopsy. Patients in the infection group had higher postoperative mortality rates and higher rates of major complications. CONCLUSION In pediatric oncology patients, surgical lung biopsy has a lower diagnostic yield and higher complication rate when performed for antibiotic guidance. Prior to proceeding with biopsy in this high-risk patient population, surgeons and oncologists should carefully weigh the potential risks and benefits.
Collapse
Affiliation(s)
- Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Danielle Gonzales
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - James T Ross
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Megan K Dishop
- Department of Pediatric Pathology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Robin R Deterding
- Department of Pediatric Pulmonology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - David A Partrick
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| |
Collapse
|
10
|
Chellapandian D, Lehrnbecher T, Phillips B, Fisher BT, Zaoutis TE, Steinbach WJ, Beyene J, Sung L. Bronchoalveolar lavage and lung biopsy in patients with cancer and hematopoietic stem-cell transplantation recipients: a systematic review and meta-analysis. J Clin Oncol 2015; 33:501-9. [PMID: 25559816 DOI: 10.1200/jco.2014.58.0480] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The objective of this study was to describe the diagnostic yield and complication rate of bronchoalveolar lavage (BAL) and lung biopsy in the evaluation of pulmonary lesions in patients with cancer and recipients of hematopoietic stem-cell transplantation (HSCT). METHODS We conducted a systematic literature review and performed electronic searches of Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Studies were included if patients had cancer or were recipients of HSCT, and if they underwent BAL or lung biopsy for the evaluation of pulmonary lesions. Only English language publications were included. RESULTS In all, 14,148 studies were screened; 72 studies of BAL and 31 of lung biopsy were included. The proportion of procedures leading to any diagnosis was similar by procedure type (0.53 v 0.54; P = .94) but an infectious diagnosis was more common with BAL compared with lung biopsy (0.49 v 0.34; P < .001). Lung biopsy more commonly led to a noninfectious diagnosis (0.43 v 0.07; P < .001) and was more likely to change how the patient was managed (0.48 v 0.31; P = .002) compared with BAL. However, complications were more common with lung biopsy (0.15 v 0.08; P = .006), and procedure-related mortality was four-fold higher for lung biopsy (0.0078) compared with BAL (0.0018). CONCLUSION BAL may be the preferred diagnostic modality for the evaluation of potentially infectious pulmonary lesions because of lower complication and mortality rates; thus, choice of procedure depends on clinical suspicion of infection. Guidelines to promote consistency in the approach to the evaluation of lung infiltrates may improve clinical care of patients.
Collapse
Affiliation(s)
- DeepakBabu Chellapandian
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - Thomas Lehrnbecher
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - Bob Phillips
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - Brian T Fisher
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - Theoklis E Zaoutis
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - William J Steinbach
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - Joseph Beyene
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - Lillian Sung
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC.
| |
Collapse
|
11
|
Maschmeyer G, Carratalà J, Buchheidt D, Hamprecht A, Heussel CP, Kahl C, Lorenz J, Neumann S, Rieger C, Ruhnke M, Salwender H, Schmidt-Hieber M, Azoulay E. Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients (allogeneic SCT excluded): updated guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Oncol 2015; 26:21-33. [PMID: 24833776 PMCID: PMC4269340 DOI: 10.1093/annonc/mdu192] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 04/29/2014] [Accepted: 05/02/2014] [Indexed: 12/13/2022] Open
Abstract
Up to 25% of patients with profound neutropenia lasting for >10 days develop lung infiltrates, which frequently do not respond to broad-spectrum antibacterial therapy. While a causative pathogen remains undetected in the majority of cases, Aspergillus spp., Pneumocystis jirovecii, multi-resistant Gram-negative pathogens, mycobacteria or respiratory viruses may be involved. In at-risk patients who have received trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis, filamentous fungal pathogens appear to be predominant, yet commonly not proven at the time of treatment initiation. Pathogens isolated from blood cultures, bronchoalveolar lavage (BAL) or respiratory secretions are not always relevant for the etiology of pulmonary infiltrates and should therefore be interpreted critically. Laboratory tests for detecting Aspergillus galactomannan, β-D-glucan or DNA from blood, BAL or tissue samples may facilitate the diagnosis; however, most polymerase chain reaction assays are not yet standardized and validated. Apart from infectious agents, pulmonary side-effects from cytotoxic drugs, radiotherapy or pulmonary involvement by the underlying malignancy should be included into differential diagnosis and eventually be clarified by invasive diagnostic procedures. Pre-emptive treatment with mold-active systemic antifungal agents improves clinical outcome, while other microorganisms are preferably treated only when microbiologically documented. High-dose TMP/SMX is first choice for treatment of Pneumocystis pneumonia, while cytomegalovirus pneumonia is treated primarily with ganciclovir or foscarnet in most patients. In a considerable number of patients, clinical outcome may be favorable despite respiratory failure, so that intensive care should be unrestrictedly provided in patients whose prognosis is not desperate due to other reasons.
Collapse
Affiliation(s)
- G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany.
| | - J Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | - D Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Mannheim
| | - A Hamprecht
- Institution for Medical Microbiology, Immunology and Hygiene, University Hospital Cologne, Cologne
| | - C P Heussel
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, University Hospital, Heidelberg
| | - C Kahl
- Department of Hematology and Oncology, Klinikum Magdeburg, Magdeburg
| | - J Lorenz
- Department of Pneumology, Infectious Diseases, Sleep Medicine and Intensive Care, Klinikum Lüdenscheid, Lüdenscheid
| | - S Neumann
- Medical Oncology, AMO MVZ, Wolfsburg
| | - C Rieger
- Department of Medicine III, University Hospital Großhadern, München
| | - M Ruhnke
- Department of Medical Oncology and Hematology, Charité University Medicine Campus Mitte, Berlin
| | - H Salwender
- Department of Hematology, Oncology, Stem Cell Transplantation, Asklepios Klinik Altona, Hamburg
| | - M Schmidt-Hieber
- Department of Hematology, Oncology and Tumor Immunology, Helios-Klinikum Berlin-Buch, Berlin, Germany
| | - E Azoulay
- AP-HP, Hopital Saint-Louis, Service de Réanimation Médicale, Université Paris-Diderot, Sorbonne Paris-Cité, Faculté de Médecine, Paris, France
| |
Collapse
|
12
|
Goldstein G, Keller N, Bilik R, Bielorai B, Toren A. Do immunocompromised children benefit from having surgical lung biopsy performed? Acta Haematol 2014; 133:205-9. [PMID: 25358357 DOI: 10.1159/000366262] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 08/04/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surgical lung biopsy is considered a gold standard for the evaluation of pulmonary disease in immunocompromised children. However, in the literature, its accuracy and the rate of complications vary. OBJECTIVE We aimed to evaluate the yield of surgical lung biopsies in the management of persistent pulmonary findings in immunocompromised children. METHODS We performed a retrospective review of clinical records of immunocompromised children who underwent surgical lung biopsies, and evaluated the impact that preoperative factors had on outcomes. RESULTS Twenty-five patients underwent 27 surgical lung biopsies. The underlying immunodeficiency included allogeneic stem cell transplantation (n = 12), chemotherapy for solid tumors (n = 6), hematologic malignancy (n = 4), primary immunodeficiency (n = 4) and chronic steroid use (n = 1). Biopsies provided a specific histopathologic or microbiologic diagnosis in 10 cases (37%). No preoperative factor predicted a diagnostic biopsy. Five of the 27 biopsies were beneficial for the patients (18%). A major complication related to the procedure was reported for 1 biopsy (4%). CONCLUSIONS We conclude that surgical lung biopsy in pediatric immunocompromised patients appears to be safe, but has a relatively low diagnostic yield and an even lower yield with regards to the benefit it provides.
Collapse
Affiliation(s)
- Gal Goldstein
- Pediatric Hemato-Oncology and Bone Marrow Transplantation, The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | | | | | | | | |
Collapse
|
13
|
The utility of surgical lung biopsy in immunocompromised children. J Pediatr 2013; 162:133-6.e1. [PMID: 22817907 DOI: 10.1016/j.jpeds.2012.06.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 05/07/2012] [Accepted: 06/07/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the utility of lung biopsy in immunocompromised pediatric patients with suspected infectious lung disease and to evaluate the risks and benefits of biopsy in the era of minimally invasive thoracic surgery. STUDY DESIGN We reviewed charts for 50 immunocompromised patients who underwent surgical lung biopsy between January 2000 and July 2011 at a free-standing, tertiary care, urban children's hospital. The primary outcome variable was "benefit from biopsy," defined as change in therapy based on biopsy results. The secondary outcome variable was survival to discharge. The χ(2) analysis was used for categorical variables and Student t test for continuous variables. RESULTS Biopsy provided a definitive histopathologic or microbiologic diagnosis in 25 patients (50%), the most common diagnosis being fungal infection (22%). Diagnostic and nondiagnostic biopsy results yielded benefit in 25 surviving patients (50%) for whom the biopsy results were used to tailor treatment. Taking more than one biopsy specimen did not improve diagnostic yield. Six patients (12%) had a major morbidity including reinsertion of chest tube after initial chest tube removal (3), prolonged air leak (1), and a new requirement for mechanical ventilation postoperatively (2). Two patients died postoperatively, but the mortalities were not clearly related to surgery. Underlying diagnoses included hematologic malignancy (64%), primary immunodeficiency (12%), organ transplant recipient (12%), and solid malignancy (10%). Twelve patients (24%) had undergone stem cell transplantation. CONCLUSION Lung biopsy in immunocompromised pediatric patients alters therapy in 50% of cases, but predictably carries identifiable morbidities. This study is limited by its retrospective nature.
Collapse
|
14
|
García Salido A, Nieto Moro M, Casado Flores J. Dificultad respiratoria en el niño sometido a trasplante de médula ósea. Med Intensiva 2011; 35:569-77. [DOI: 10.1016/j.medin.2011.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Accepted: 06/09/2011] [Indexed: 12/28/2022]
|
15
|
Maschmeyer G. Diagnosis and Antimicrobial Therapy of Lung Infiltrates in Febrile Neutropenic Cancer Patients. Curr Infect Dis Rep 2011; 13:510-6. [DOI: 10.1007/s11908-011-0219-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
|
16
|
Latham GJ, Greenberg RS. Anesthetic considerations for the pediatric oncology patient--part 3: pain, cognitive dysfunction, and preoperative evaluation. Paediatr Anaesth 2010; 20:479-89. [PMID: 20337952 DOI: 10.1111/j.1460-9592.2010.03261.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In part three of this three-part review, we continue with discussion of the effects of tumor and its therapy as they impact neurocognitive functioning, psychosocial issues of the patient and family, and the mechanisms and experience of pain in the child with cancer. A discussion of preanesthetic testing and evaluation in this patient population is next presented for the reader, focusing on the factors which pose the commonest and greatest risks to the child undergoing surgery. Lastly, an algorithmic approach to evaluating and managing key components of the medical history of pediatric patients is presented.
Collapse
Affiliation(s)
- Gregory J Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA 98105, USA.
| | | |
Collapse
|
17
|
Prospective monitoring for invasive aspergillosis using galactomannan and polymerase chain reaction in high risk pediatric patients. J Pediatr Hematol Oncol 2009; 31:920-6. [PMID: 19855303 DOI: 10.1097/mph.0b013e3181b83e77] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The diagnosis of invasive aspergillus remains a challenge in the care of high-risk patients. Outcomes are improved when invasive aspergillus is diagnosed early, prompting the initiation of appropriate antifungal therapy. We evaluated the utility of prospective monitoring for invasive aspergillosis (IA) using biomarkers such as serum galactomannan (GM) and/or blood polymerase chain reaction (PCR) in high-risk pediatric patients. METHODS Patients with high-risk leukemia (HRL) or allogenic hematopoietic cell transplant (HCT) recipients were prospectively monitored twice weekly for IA using GM and PCR for Aspergillus species. RESULTS Sixty-eight patients had collected >or=2 specimens. The 1086 specimens were collected; 627 from HRL (58%) and 459 (42%) from HCT recipients. Median specimens/patient was 11.0 (2 to 58), and median follow-up/patient was 98.5 days (14 to 437). Fifty-six percent of samples were obtained from patients receiving mold-active agents; 32% HRL and 89% HCT. There were no proven, 3 probable, and 20 possible episodes of IA. Thirteen specimens (1.2%) from 4 patients (5%) were GM+. None were positive by PCR. CONCLUSIONS The prospective use of GM and PCR in this high-risk pediatric population did not identify cases of proven IA. A high false positive rate was not detected. It is speculated that changes in clinical practice, such as early use of empiric and/or prophylactic mold-active agent and frequent imaging studies have impacted the epidemiology of IA. In a population with low incidence of IA, the use of these assays as a screening device on blood may not further enhance current outcomes.
Collapse
|
18
|
Maschmeyer G, Beinert T, Buchheidt D, Cornely OA, Einsele H, Heinz W, Heussel CP, Kahl C, Kiehl M, Lorenz J, Hof H, Mattiuzzi G. Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients: Guidelines of the infectious diseases working party of the German Society of Haematology and Oncology. Eur J Cancer 2009; 45:2462-72. [DOI: 10.1016/j.ejca.2009.05.001] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Revised: 04/27/2009] [Accepted: 05/01/2009] [Indexed: 12/15/2022]
|
19
|
Bibliography. Current world literature. Hematology and oncology. Curr Opin Pediatr 2008; 20:107-13. [PMID: 18197049 DOI: 10.1097/mop.0b013e3282f572b6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
20
|
Armenian SH, Hoffman JA, Butturini AM, Kapoor N, Mascarenhas L. Invasive diagnostic procedures for pulmonary infiltrates in pediatric hematopoietic stem cell transplant recipients. Pediatr Transplant 2007; 11:736-42. [PMID: 17910650 DOI: 10.1111/j.1399-3046.2007.00733.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To evaluate the role of BAL, CTB, and OLB in the management of pulmonary infiltrates in pediatric HSCT recipients, we conducted a retrospective review of clinical records of pediatric HSCT recipients. Data were analyzed using Chi-square for dichotomous and anova for continuous variables. Logistic regression was used to adjust confounding variables for diagnostic yield. Forty patients underwent 44 separate procedures. Infections were the prevailing cause of infiltrates with a positive diagnostic yield (96%). CTB and OLB were performed more often in patients with focal infiltrates compared with BAL (100%, 71% vs. 22%; p < 0.01). Adverse events were not significantly different across the three procedures. OLB more often yielded information that led to change in medical management (71% vs. 0%, 34%; p < 0.05) compared with CTB and BAL. Patients who had a positive diagnostic yield had no apparent survival advantage when compared with those in whom a procedure yielded no information. Logistic regression demonstrated that focal infiltrate was the only independently predictive variable for identifying a cause of pulmonary infiltrate. In conclusion, all three invasive diagnostic procedures were safe. Having a focal infiltrate was independently and significantly associated with having a positive diagnostic yield.
Collapse
Affiliation(s)
- Saro H Armenian
- Division of Hematology/Oncology, Childrens Hospital Los Angeles, Los Angeles, CA, USA
| | | | | | | | | |
Collapse
|