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Thorat J, Bhat S, Sengar M, Baheti A, Bothra S, Bhaskar M, Tandon SP, Biswas SK, Salunke GV, Karimundackal G, Tiwari VK, Pramesh C, Sharma N, Kapu V, Eipe T, Bagal BP, Nayak L, Bonda A, Janu A, Shetty A, Jain H. Clinical Utility of Stepwise Bronchoalveolar Lavage Fluid Analysis in Diagnosing and Managing Lung Infiltrates in Leukemia/Lymphoma Patients With Febrile Neutropenia. JCO Glob Oncol 2024; 10:e2300292. [PMID: 38301183 PMCID: PMC10846792 DOI: 10.1200/go.23.00292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/28/2023] [Accepted: 11/20/2023] [Indexed: 02/03/2024] Open
Abstract
PURPOSE Febrile neutropenia (FN) is a serious complication in hematologic malignancies, and lung infiltrates (LIs) remain a significant concern. An accurate microbiological diagnosis is crucial but difficult to establish. To address this, we analyzed the utility of a standardized method for performing bronchoalveolar lavage (BAL) along with a two-step strategy for the analysis of BAL fluid. PATIENTS AND METHODS This prospective observational study was conducted at a tertiary cancer center from November 2018 to June 2020. Patients age 15 years and older with confirmed leukemia or lymphomas undergoing chemotherapy, with presence of FN, and LIs observed on imaging were enrolled. RESULTS Among the 122 enrolled patients, successful BAL was performed in 83.6% of cases. The study used a two-step analysis of BAL fluid, resulting in a diagnostic yield of 74.5%. Furthermore, antimicrobial therapy was modified in 63.9% of patients on the basis of BAL reports, and this population demonstrated a higher response rate (63% v 45%; P = .063). CONCLUSION Our study demonstrates that a two-step BAL fluid analysis is safe and clinically beneficial to establish an accurate microbiological diagnosis. Given the crucial impact of diagnostic delays on mortality in hematologic malignancy patients with FN, early BAL studies should be performed to enable prompt and specific diagnosis, allowing for appropriate treatment modifications.
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Affiliation(s)
- Jayashree Thorat
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Surabhi Bhat
- Hematological Cancer Consortium, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Akshay Baheti
- Department of Radio-diagnosis, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Sweta Bothra
- Department of Radio-diagnosis, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Maheema Bhaskar
- Department of Pulmonary Medicine, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Sandeep Prakashnarain Tandon
- Department of Pulmonary Medicine, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Sanjay K. Biswas
- Department of Microbiology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Gaurav V. Salunke
- Department of Microbiology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | | | - Virendra Kumar Tiwari
- Department of Thoracic Surgical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - C.S. Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Neha Sharma
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Venkatesh Kapu
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Thomas Eipe
- Department of Clinical Pharmacology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Bhausaheb Pandurang Bagal
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Lingaraj Nayak
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Avinash Bonda
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Amit Janu
- Department of Radio-diagnosis, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Alok Shetty
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Hasmukh Jain
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
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Jahn K, Karakioulaki M, Schumann DM, Hirsch HH, Leuzinger K, Grize L, Aliberti S, Sotgiu G, Tamm M, Stolz D. Impact of bronchoalveolar lavage on the management of immunocompromised hosts. Eur J Intern Med 2024; 120:52-61. [PMID: 37722932 DOI: 10.1016/j.ejim.2023.09.007] [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] [Received: 08/05/2023] [Revised: 08/25/2023] [Accepted: 09/07/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Respiratory infections are an important cause of morbidity and mortality in immunocompromised individuals. Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is an important tool to detect infectious agents in immunocompromised patients with low respiratory tract infections (LRTI). RESEARCH QUESTION BAL changes the management of immunocompromised patients with suspected LRTI. STUDY DESIGN AND METHODS Immunocompromised patients with a suspicion of LRTI underwent diagnostic BAL. The primary composite outcome consisted of pre-defined modifications in the management of the immunocompromised patients following BAL. We quantified the impact of bronchoscopy up to 30 days after the procedure. RESULTS A total of 2666 visits from 1301 patients were included in the study and immunosuppression was classified as haematological (n = 1040; 544 patients), solid organ transplantation (n = 666; 107 patients) and other causes (n = 960; 650 patients). BAL led to a change in management in 52.36% (n = 1396) of all cases. This percentage, as well as the 30-day mortality differed significantly amongst the three groups. Age, C-reactive protein and aetiology of infection determined significantly the risk of 30-day mortality in all patients. In 1.89% (n = 50) of all cases, a combination of 2 respiratory viral agents was identified and 24.23% (n = 646) were diagnosed with a single respiratory viral agent. INTERPRETATION BAL leads to changes in management in the majority of immunosuppressed patients. There is a high prevalence of multimicrobial infections and respiratory viral infections in immunocompromised patients with respiratory symptoms. Individual virus infection is associated with diverse risk of a negative outcome.
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Affiliation(s)
- Kathleen Jahn
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital, Basel, Switzerland
| | - Meropi Karakioulaki
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital, Basel, Switzerland; Clinic of Respiratory Medicine, Faculty of Medicine, University of Freiburg, Germany
| | - Desiree M Schumann
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital, Basel, Switzerland
| | - Hans H Hirsch
- Clinical Virology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland University Hospital, Basel, Switzerland; Transplantation & Clinical Virology, Department Biomedicine, University of Basel, Basel Switzerland; Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Karoline Leuzinger
- Clinical Virology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland University Hospital, Basel, Switzerland; Transplantation & Clinical Virology, Department Biomedicine, University of Basel, Basel Switzerland
| | - Leticia Grize
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital, Basel, Switzerland
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; IRCCS Humanitas Research Hospital, Respiratory Unit, Rozzano, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Michael Tamm
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital, Basel, Switzerland
| | - Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital, Basel, Switzerland; Clinic of Respiratory Medicine, Faculty of Medicine, University of Freiburg, Germany.
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Shen Z, Wang Y, Bao A, Yang J, Sun X, Cai Y, Wan L, Huang C, Xu X, Niu J, Xia X, Shen C, Wei Y, Qiu H, Zhou K, Zhang M, Tong Y, Song X. Metagenomic Next-Generation Sequencing for Pathogens in Bronchoalveolar Lavage Fluid Improves the Survival of Patients with Pulmonary Complications After Allogeneic Hematopoietic Stem Cell Transplantation. Infect Dis Ther 2023; 12:2103-2115. [PMID: 37541984 PMCID: PMC10505113 DOI: 10.1007/s40121-023-00850-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 07/14/2023] [Indexed: 08/06/2023] Open
Abstract
INTRODUCTION Unbiased metagenomic next-generation sequencing (mNGS) has been used for infection diagnosis. In this study, we explored the clinical diagnosis value of mNGS for pulmonary complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT). METHODS From August 2019 to June 2021, a prospective study was performed to comparatively analyze the pathogenic results of mNGS and conventional tests for bronchoalveolar lavage fluid (BALF) from 134 cases involving 101 patients with pulmonary complications after allo-HSCT. RESULTS More pathogens were identified by mNGS than with conventional tests (226 vs 120). For bacteria, the diagnostic sensitivity (P = 0.144) and specificity (P = 0.687) were similar between the two methods. For fungus except Pneumocystis jirovecii (PJ), conventional tests had a significantly higher sensitivity (P = 0.013) with a similarly high specificity (P = 0.109). The sensitivities for bacteria and fungi could be increased with the combination of the two methods. As for PJ, both the sensitivity (100%) and specificity (99.12%) of mNGS were very high. For viruses, the sensitivity of mNGS was significantly higher (P = 0.021) and the negative predictive value (NPV) was 95.74% (84.27-99.26%). Pulmonary infection complications accounted for 90.30% and bacterium was the most common pathogen whether in single infection (63.43%) or mixed infection (81.08%). The 6-month overall survival (OS) of 88.89% in the early group (mNGS ≤ 7 days) was significantly higher than that of 65.52% (HR 0.287, 95% CI 0.101-0.819, P = 0.006) in the late group (mNGS > 7 days). CONCLUSIONS mNGS for BALF could facilitate accurate and fast diagnosis for pulmonary complications. Early mNGS could improve the prognosis of patients with pulmonary complications after allo-HSCT. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT04051372.
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Affiliation(s)
- Zaihong Shen
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
- Department of Hematology, Taizhou First People's Hospital, Huangyan Hospital of Wenzhou Medical University, Taizhou City, 318020, Zhejiang Province, China
| | - Ying Wang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Aihua Bao
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Jun Yang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Xi Sun
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Yu Cai
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Liping Wan
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Chongmei Huang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Xiaowei Xu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Jiahua Niu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Xinxin Xia
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Chang Shen
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Yu Wei
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Huiying Qiu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Kun Zhou
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Min Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Yin Tong
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Xianmin Song
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China.
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Yavuz S, Sherif A, Saif S, Alzamar A, Alawad D, Abdelwahab A, Nabawi MN, Amirrad M, Francis N. Indications, Efficacy, and Complications of Pediatric Bronchoscopy: A Retrospective Study at a Tertiary Center. Cureus 2023; 15:e40888. [PMID: 37492847 PMCID: PMC10364458 DOI: 10.7759/cureus.40888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2023] [Indexed: 07/27/2023] Open
Abstract
Background Bronchoscopy is an essential procedure for evaluating, diagnosing, and treating pediatric respiratory diseases. In this study, we demonstrate the indications and contraindications of bronchoscopy done in a tertiary referral hospital, Al Qassimi Woman's and Children's Hospital (AQWCH) in Sharjah, United Arab Emirates (UAE), in order to achieve better service. This study aims to evaluate patients' characteristics, diagnostic and therapeutic indications, and complications of bronchoscopy. Material and method This retrospective chart review included children aged between one day and 13 years, admitted to AQWCH, who underwent bronchoscopy (rigid or flexible) procedures between January 2018 and December 2019. All patients were identified by using a computerized search of hospital discharge diagnosis, which was codified as "pediatric bronchoscopy, flexible, rigid, bronchoalveolar lavage". The main study outcome measure was to evaluate patients' characteristics, diagnostic or therapeutic indications, bronchoalveolar lavage (BAL) analysis, as well as complications of bronchoscopy at AQWCH. Results There were 72 pediatric bronchoscopies (rigid and flexible) performed in patients aged less than 13 years old; the reason for bronchoscopy procedure was diagnostic in 51% and both diagnostic and therapeutic in 49%. Cough was the most common symptom (n=53; 74%), and chest recession was the most common clinical finding (n=46; 64%). Foreign body aspiration was the main indication (n=23; 32%), followed by stridor (26%). Consolidation was the most common radiological finding. Foreign body was the common finding, seen in 25% of bronchoscopies, followed by tracheomalacia in 17%. The suspected diagnosis was confirmed in 89%, and management change was needed in 54% of patients. The main complication during the procedure was desaturation (26%), and cough was the main post-bronchoscopy complication (14%). BAL was done for 28 (39%) patients, in which BAL culture was positive in 75%. Rigid bronchoscopy was done when foreign body aspiration was suspected based on positive history in 70%, abnormal physical examination in 60%, and chest X-ray abnormalities in 39% of patients. Sensitivity and specificity for patient history, physical examination, and chest X-ray were 80% and 83%, 66% and 60%, and 40% and 66 %, respectively. Conclusion Bronchoscopy is an important tool for evaluating, diagnosing, and treating pediatric respiratory diseases. While it is a safe procedure, it still needs a careful selection of patients as it is invasive.
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Affiliation(s)
- Sinan Yavuz
- Pediatrics/Pediatric Pulmonology, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Amal Sherif
- Pediatrics, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Safiya Saif
- Pediatrics/Pediatric Pulmonology, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Asma Alzamar
- Pediatrics, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Doaa Alawad
- Pediatrics, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Ahmed Abdelwahab
- Pediatrics, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Maged N Nabawi
- Pediatrics/Pediatric Intensive Care, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Maryam Amirrad
- Education, Uinversity of Ottawa, Ottawa, CAN
- Pediatrics, Royal College of Pediatrics & Child Health, London, GBR
- Pediatrics, Ajman University, Ajman, ARE
| | - Nader Francis
- Pediatrics/Pediatric Pulmonology, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
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Ghandili S, von Kroge PH, Simon M, Henes FO, Rohde H, Hoffmann A, Lindeman NB, Bokemeyer C, Fiedler W, Modemann F. Diagnostic Utility of Bronchoalveolar Lavage in Patients with Acute Leukemia under Broad-Spectrum Anti-Infective Treatment. Cancers (Basel) 2022; 14:cancers14112773. [PMID: 35681753 PMCID: PMC9179550 DOI: 10.3390/cancers14112773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 05/26/2022] [Accepted: 05/30/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary Infections of bacterial, viral, or fungal origin pose a major threat to patients with acute leukemia. Empiric antibiotic and antifungal treatment is a commonly used approach in leukemia patients with febrile neutropenia. To investigate the utility of flexible bronchoscopy (FB) with bronchoalveolar lavage (BAL) in acute leukemia (AL) patients with pneumonia who were already treated with broad-spectrum antibiotics and antifungal agents, we investigated bronchoalveolar samples of 88 patients. Our results indicate that despite broad-spectrum anti-infective treatment, in approximately half of all patients, pathogens could still be isolated in bronchoalveolar samples. Nevertheless, the detection of pathogens does not lead to frequent changes in anti-infective treatments, with most changes performed in patients with herpes simplex and influenza virus detection, and these pathogens might also be detected in less invasive examinations. The need for FB with BAL in patients with AL who are already receiving broad-spectrum empiric anti-infective treatment should therefore be weighed carefully. Abstract Despite therapeutic advances in the prevention and treatment of febrile neutropenia, acute leukemia (AL) patients still have considerable febrile neutropenia-related mortality. However, the diagnostic yield of flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) in acute leukemia patients is unclear. In this retrospective single-center study, we analyzed 88 BAL samples of patients with acute leukemia and pulmonary infiltrates in spite of treatment with broad-spectrum anti-infective agents. The aim was to investigate the impact of FB with BAL on detecting causative organisms, which would result in a change in treatment regimens. The median age was 59 years, and 86% had acute myeloid leukemia. In 47%, pathogens were detectable in BAL fluid (pathogen bacteria, viruses, and fungi in 2, 15, and 18%, respectively), with Aspergillus fumigatus detected most frequently. BAL-guided anti-infective therapy changes were performed in 15%. The detection of herpes simplex and influenza viruses were the main reasons for treatment changes. Despite broad-spectrum anti-infective treatment, in approximately half of all patients, pathogens could still be isolated in BAL samples. However, consecutive changes in anti-infective treatment were considerably less frequent, with most changes performed in patients with Herpes simplex virus and Influenza A detection. The need for FB with BAL in patients with AL receiving broad-spectrum empiric anti-infective treatment should therefore be weighed carefully.
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Affiliation(s)
- Susanne Ghandili
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (S.G.); (M.S.); (N.B.L.); (C.B.); (W.F.)
| | - Philipp H. von Kroge
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany;
| | - Marcel Simon
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (S.G.); (M.S.); (N.B.L.); (C.B.); (W.F.)
| | - Frank O. Henes
- Department for Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany;
| | - Holger Rohde
- The Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (H.R.); (A.H.)
| | - Armin Hoffmann
- The Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (H.R.); (A.H.)
| | - Nick Benjamin Lindeman
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (S.G.); (M.S.); (N.B.L.); (C.B.); (W.F.)
| | - Carsten Bokemeyer
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (S.G.); (M.S.); (N.B.L.); (C.B.); (W.F.)
| | - Walter Fiedler
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (S.G.); (M.S.); (N.B.L.); (C.B.); (W.F.)
| | - Franziska Modemann
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (S.G.); (M.S.); (N.B.L.); (C.B.); (W.F.)
- Mildred Scheel Cancer Career Center, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Correspondence:
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Ahn H, Lee R, Cho SY, Lee DG. Advances in prophylaxis and treatment of invasive fungal infections: perspectives on hematologic diseases. Blood Res 2022; 57:101-111. [PMID: 35483934 PMCID: PMC9057668 DOI: 10.5045/br.2022.2022036] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 11/26/2022] Open
Abstract
Invasive fungal infections (IFIs) are common causes of mortality and morbidity in patients with hematologic diseases. Delayed initiation of antifungal treatment is related to mortality. Aspergillus sp. is the leading cause of IFI followed by Candida sp. Diagnosis is often challenging owing to variable conditions related to underlying diseases. Clinical suspect and prompt management is important. Imaging, biopsy, and non-culture-based tests must be considered together. New diagnostic procedures have been improved, including antigen-based assays and molecular detection of fungal DNA. Among hematologic diseases, patients with acute myeloid leukemia, myelodysplastic syndrome, recipients of hematopoietic stem cell transplantation are at high risk for IFIs. Antifungal prophylaxis is recommended for these high-risk patients. There are continuous attempts to achieve ideal management of IFIs. Scoring system for quality control has been developed with important recommendations of current guidelines. Higher adherence to guidelines is related to decreased mortality in IFIs.
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Affiliation(s)
- Hyojin Ahn
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Raeseok Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
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7
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Milliken EJT, Davis JS. Pro: Bronchoscopy is essential for pulmonary infections in patients with haematological malignancies. Breathe (Sheff) 2020; 16:200228. [PMID: 33447295 PMCID: PMC7792850 DOI: 10.1183/20734735.0228-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Up to 60% of patients with haematological malignancy will develop pulmonary infiltrates at some point in their disease course. Bronchoscopy should be used early in patients without respiratory failure as diagnostic yield is highest in the first 1–2 days of illness. Perceptions that patients with haematological malignancy are at higher risk of complications from bronchoscopy has led to a reluctance to perform the procedure. However, cohort studies have not demonstrated any increase in complications for this specific patient group. Common concerns include mucosal injury, respiratory impairment and haemorrhage. However, prospective cohort studies demonstrate that this patient group do not experience a higher than baseline level of complications. Specific pathogen diagnosis reduces morbidity and mortality in lung infection. Additionally, complex infections with multidrug-resistant organisms, the increasing prevalence of which is largely driven by empirical antibiotic use, make specific diagnosis more crucial than ever if we are to maintain our ability to manage myelosuppressive therapies and stem cell transplant. Early bronchoscopy reduces morbidity and mortality in haematological malignancy patients with pulmonary infiltratehttps://bit.ly/302uqYv
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Affiliation(s)
| | - Joshua S Davis
- Dept of Infectious Diseases, John Hunter Hospital, Newcastle, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Menzies School of Health Research, Darwin, Australia
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8
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Ing MK, Williamson JP. Con: Bronchoscopy is essential for pulmonary infections in patients with haematological malignancies. Breathe (Sheff) 2020; 16:200210. [PMID: 33447292 PMCID: PMC7792854 DOI: 10.1183/20734735.0210-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Whilst some patients with haematological malignancy and pulmonary infection may benefit from a bronchoscopy, this uniform approach is not justified by the literature and more studies are required to fill the void in our understanding of this areahttps://bit.ly/3bfUfs7
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Affiliation(s)
- Matthew K Ing
- Dept of Respiratory Medicine, Liverpool Hospital, Sydney, Australia
| | - Jonathan P Williamson
- Dept of Respiratory Medicine, Liverpool Hospital, Sydney, Australia.,South Western Sydney Clinical School, Liverpool Hospital, The University of New South Wales, Sydney, Australia.,MQ Health Respiratory and Sleep, Macquarie University Hospital, Sydney, Australia
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9
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Gaddam M, Paff S, Venkatram S, Diaz-Fuentes G. Outcomes of patients with a non-diagnostic initial bronchoscopy for suspected thoracic malignancy. Medicine (Baltimore) 2020; 99:e22772. [PMID: 33120787 PMCID: PMC7581055 DOI: 10.1097/md.0000000000022772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Lung cancer is 1 of the leading causes of cancer-related deaths and bronchoscopy is an essential tool for the diagnosis. The diagnostic yield varies based on the characteristics of the lesion and bronchoscopic techniques employed. There is limited data regarding outcomes of patients suspected of thoracic malignancies with a non-diagnostic initial bronchoscopy. The goal of the study was to evaluate the outcomes of patients with a non-diagnostic bronchoscopy for suspected thoracic malignancies and to evaluate variables predictive of a diagnostic bronchoscopy.Retrospective analysis of adult patients at BronxCare Hospital Center who underwent bronchoscopy for suspected thoracic malignancy. The study period was January 2012 to February 2019. Exclusion criteria included patients who underwent only inspection bronchoscopy or bronchoalveolar lavage as the diagnostic yield for malignancy with these techniques is low. All other bronchoscopic procedures were included that is, endobronchial biopsies, transbronchial biopsies, and endobronchial ultrasound guided-transbronchial needle aspiration. Bronchoscopy was considered diagnostic when a specific histopathological diagnosis was established.311 patients underwent bronchoscopy to rule out malignancy. A diagnosis was obtained in 153 (49.2%) patients, 81 (52.9%) had primary lung cancer and 14 (9.15%) other malignancies. 158 (50.8%) patients had initial non-diagnostic bronchoscopy; 86 (54.43%) were lost to follow up. Of the remaining 72 (45.57%) patients, radiological resolution or stability was observed in 51 (70.8%) patients. Primary lung cancer was found in 13 (18.05%) patients and other malignancies in 5 (6.94%). Predictive of a diagnostic bronchoscopy was the performance of endobronchial biopsies and endobronchial ultrasound guided-transbronchial needle aspiration.This study highlights some of the barriers to the timely diagnosis of thoracic malignancies. Following patients with a non-diagnostic procedure as well as all those patients with diagnosed malignancies it of the utmost importance. In patients available for follow up, close to 25% of additional cases with treatable malignancy could be identified and patients diagnosed with cancer could receive timely treatment.
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Affiliation(s)
- Maneesh Gaddam
- Pulmonary Fellow, Division of Pulmonary and Critical Care Medicine
| | | | - Sindhaghatta Venkatram
- Associate Professor of Clinical Medicine, Division of Pulmonary and Critical Care Medicine, BronxCareHealth System, 1650 Grand Concourse, Bronx, NY 10457, Affiliated with Icahn School of Medicine at Mount Sinai
| | - Gilda Diaz-Fuentes
- Associate Professor of Clinical Medicine, Division of Pulmonary and Critical Care Medicine, BronxCareHealth System, 1650 Grand Concourse, Bronx, NY 10457, Affiliated with Icahn School of Medicine at Mount Sinai
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10
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Khalid U, Akram MJ, Butt FM, Ashraf MB, Khan F. The Diagnostic Utility and Clinical Implications of Bronchoalveolar Lavage in Cancer Patients With Febrile Neutropenia and Lung Infiltrates. Cureus 2020; 12:e10268. [PMID: 33042706 PMCID: PMC7538025 DOI: 10.7759/cureus.10268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Febrile neutropenia (FN) is a dreaded complication of cancer chemotherapy and frequently associated with respiratory infections. Flexible bronchoscopy (FB) serves as a useful diagnostic tool in this regard. Objective To determine the diagnostic yield, safety and clinical implications of bronchoalveolar lavage (BAL) in cancer patients with FN, having lung infiltrates on radiographic chest imaging. Methods We reviewed medical records of FN patients who underwent FB at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, from July 2015 till July 2018. The culture yield of BAL, resultant change of management and outcome over the subsequent 30 days were retrospectively analysed. Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY) was used for data analysis. Results Ninety FN patients, with mean age 26 ± 18 years and predominantly males (65.6%, n = 59) were included in the study. Seventy-seven (85.6%) had hematological and 13 (14.4%) solid organ malignancy. The mean absolute neutrophil count was 0.20 +/- 0.36/ µL. BAL cultures were diagnostic in 40 (44%) patients; the etiology was bacterial, fungal and mixed in 25 (62.5%), 14 (35%) and one (2.5%) patient, respectively. All patients were on empirical antibiotics prior to bronchoscopy: 32 (35.6%) on antibacterial alone and 58 (64.4%) on antibacterial plus antifungal therapy. Change of management occurred in 51 (56.7%) patients after BAL results, including de-escalation from dual antibiotics in 28 (55%) and initiation of new culture sensitive antibiotic in 23 (45%). FB-associated complications developed in three (5.6%) non-intensive care patients (ICU), including transient hypoxia in two and minor hemoptysis in one patient, while five (14.8%) mechanically ventilated patients in ICU experienced worsening of oxygenation parameters within 48 hours. Overall, 24 (26.7%) patients died. Mortality was 3.7% in non-ICU and 69% in ICU setting and significantly higher in patients with fungal pneumonias (p-value 0.01) and with prolonged neutropenia (p-value 0.001). Conclusions BAL is a safe diagnostic tool for FN patients with lung infiltrates, with minimal complications and sufficient diagnostic yield to improve diagnosis and management of such patients.
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Affiliation(s)
- Usman Khalid
- Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Muhammad J Akram
- Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Faheem M Butt
- Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Mohammad B Ashraf
- Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Faheem Khan
- Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
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11
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Heo JW, Yeo CD, Park CK, Kim SK, Kim JS, Kim JW, Kim SJ, Lee SH, Kang HS. Smoking is associated with pneumonia development in lung cancer patients. BMC Pulm Med 2020; 20:117. [PMID: 32357887 PMCID: PMC7195765 DOI: 10.1186/s12890-020-1160-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/20/2020] [Indexed: 02/07/2023] Open
Abstract
Background Various host factors can promote pneumonia susceptibility of lung cancer patients. However, data about risk factors for pneumonia in lung cancer patients receiving active treatments such as chemotherapy, radiotherapy, and surgical intervention are limited. Thus, the purpose of this study was to identify risk factors for pneumonia development in lung cancer patients. Methods The present study used a lung cancer cohort of the Catholic Medical Center at the Catholic University of Korea from January 2015 to December 2018. Pneumonia was defined by the presence of a new or progressive infiltration on chest imaging together with any of the following: new onset purulent sputum, change in character of chronic sputum, and fever. We ruled out noninfectious infiltration such as drug or radiation toxicity and hydrostatic pulmonary edema. We especially excluded those if computed tomography revealed sharp demarcation consolidation or ground glass opacity limited radiation field. Results A total of 413 patients were enrolled in this study. Pneumonia occurred in 118 (28.6%) patients. The pneumonia group had significantly worse overall survival (OS) than the non-pneumonia group (456.7 ± 35.0 days vs. 813.4 ± 36.1 days, log rank p < 0.001). In patients with pneumonia, OS was shorter in ex-smokers and current smokers than in never smokers (592.0 ± 101.0 days vs. 737.0 ± 102.8 days vs. 1357.0 days, log rank p < 0.001). Age (hazard ratio [HR]: 1.046; 95% confidence interval [CI]: 1.019–1.074; p = 0.001), clinical stage IV (HR: 1.759; 95% CI: 1.004–3.083; p = 0.048), neutropenia (HR: 2.620; 95% CI: 1.562–4.396; p < 0.001], and smoking (HR: 2.040; 95% CI: 1.100–3.784; p = 0.024) were independent risk factors of pneumonia development in lung cancer patients in multivariate analysis. In subgroup analysis for patients treated with chemotherapy, age (HR: 1.043; 95% CI: 1.012–1.074; p = 0.006), neutropenia (HR: 3.199; 95% CI: 1.826–5.605; p < 0.001), and smoking (HR: 2.125; 95% CI: 1.071–4.216; p = 0.031) were independent risk factors of pneumonia development. Conclusions Smoking and neutropenia were risk factors affecting pneumonia development in the total group and subgroup of patients with lung cancer.
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Affiliation(s)
- Jung Won Heo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chang Dong Yeo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chan Kwon Park
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Kyoung Kim
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Sang Kim
- Division of Pulmonary, Critical Care and Sleep Allergy, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Woo Kim
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Joon Kim
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Haak Lee
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye Seon Kang
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 327, Sosa-ro, Bucheon-si, Gyeonggi-do, 14647, Republic of Korea.
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12
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Clinical Usefulness of Bronchoalveolar Lavage in the Management of Pulmonary Infiltrates in Adults with Hematological Malignancies and Stem Cell Transplantation. Mediterr J Hematol Infect Dis 2020; 12:e2020025. [PMID: 32395214 PMCID: PMC7202335 DOI: 10.4084/mjhid.2020.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/04/2020] [Indexed: 01/04/2023] Open
Abstract
Introduction Pulmonary complications are frequent in patients with hematologic malignancies and stem cell transplantation. Regardless of the microbiological usefulness of bronchoalveolar lavage (BAL), little information exists on both its benefits as a guide for therapeutic decisions and its impact on patients’ clinical outcome. Methods A prospective observational single-center study was performed between July 2011 and July 2016. Consecutive episodes of pulmonary infiltrates were analyzed in subjects over 18 years of age who presented hematologic malignancies and underwent chemotherapy or stem cell transplantation. Results Ninety-six episodes of pulmonary infiltrates were analyzed. Acute leukemia was the most frequent underlying condition. Thirty-seven patients (38.5%) received a stem cell transplant. Sixty-one (62.9%) were neutropenic at the moment of inclusion in the study. A definitive etiologic diagnosis was obtained in 41 cases (42.7%), where infection accounted for the vast majority of cases (33 cases, 80.5%). Definitive diagnosis was reached by non-invasive methods in 13 cases (13.5%). BAL was performed in 47 cases and led to a diagnosis in 40.4% of the cases. BAL results led to therapeutic changes in 27 cases (57.4%), including the addition of new antimicrobials to empiric treatments in 10. Regarding BAL’s safety, two patients experienced minor adverse events and one a severe adverse event; no procedure-related deaths were observed. Conclusions Infection was the leading cause of pulmonary infiltrates in patients with hematologic malignancies and stem cell transplantation. BAL was a useful decision-making diagnostic tool, with minor adverse events.
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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.
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14
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Boch T, Spiess B, Heinz W, Cornely OA, Schwerdtfeger R, Hahn J, Krause SW, Duerken M, Bertz H, Reuter S, Kiehl M, Claus B, Deckert PM, Hofmann WK, Buchheidt D, Reinwald M. Aspergillus specific nested PCR from the site of infection is superior to testing concurrent blood samples in immunocompromised patients with suspected invasive aspergillosis. Mycoses 2020; 62:1035-1042. [PMID: 31402465 DOI: 10.1111/myc.12983] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 12/16/2022]
Abstract
Invasive aspergillosis (IA) is a severe complication in immunocompromised patients. Early diagnosis is crucial to decrease its high mortality, yet the diagnostic gold standard (histopathology and culture) is time-consuming and cannot offer early confirmation of IA. Detection of IA by polymerase chain reaction (PCR) shows promising potential. Various studies have analysed its diagnostic performance in different clinical settings, especially addressing optimal specimen selection. However, direct comparison of different types of specimens in individual patients though essential, is rarely reported. We systematically assessed the diagnostic performance of an Aspergillus-specific nested PCR by investigating specimens from the site of infection and comparing it with concurrent blood samples in individual patients (pts) with IA. In a retrospective multicenter analysis PCR was performed on clinical specimens (n = 138) of immunocompromised high-risk pts (n = 133) from the site of infection together with concurrent blood samples. 38 pts were classified as proven/probable, 67 as possible and 28 as no IA according to 2008 European Organization for Research and Treatment of Cancer/Mycoses Study Group consensus definitions. A considerably superior performance of PCR from the site of infection was observed particularly in pts during antifungal prophylaxis (AFP)/antifungal therapy (AFT). Besides a specificity of 85%, sensitivity varied markedly in BAL (64%), CSF (100%), tissue samples (67%) as opposed to concurrent blood samples (8%). Our results further emphasise the need for investigating clinical samples from the site of infection in case of suspected IA to further establish or rule out the diagnosis.
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Affiliation(s)
- Tobias Boch
- University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Birgit Spiess
- University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Oliver A Cornely
- First Department of Internal Medicine and ZKS Köln, BMBF 01KN1106, University Hospital Cologne, Deutsches Zentrum für Infektionsforschung, Cologne, Germany
| | | | - Joachim Hahn
- Regensburg University Hospital, Regensburg, Germany
| | | | - Matthias Duerken
- Department of Pediatric Hematology, Mannheim University Hospital, Mannheim, Germany
| | | | | | | | - Bernd Claus
- Ludwigshafen General Hospital, Ludwigshafen, Germany
| | | | | | - Dieter Buchheidt
- University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Mark Reinwald
- Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
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15
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Eroglu-Ertugrul NG, Yalcin E, Oguz B, Ocal T, Kuskonmaz B, Emiralioglu N, Dogru-Ersoz D, Ozcelik U, Tezcan I, Kiper N. The value of flexible bronchoscopy in pulmonary infections of immunosuppressed children. CLINICAL RESPIRATORY JOURNAL 2019; 14:78-84. [PMID: 31710418 PMCID: PMC7162225 DOI: 10.1111/crj.13103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/30/2019] [Accepted: 10/30/2019] [Indexed: 11/28/2022]
Abstract
Objectives To demonstrate the value of flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) when determining causes of lung infection in immunocompromised children; to investigate differences in causes and radiological features of lung infections following bone marrow transplantation (BMT) compared to other immunosuppressive conditions; to evaluate the reliability of radiological findings when predicting the pathogen. Methods We retrospectively evaluated 132 immunosuppressed children who underwent FB and BAL because pulmonary complications between January 1999 and May 2014 at the Hacettepe University Hospital Pediatric Pulmonology Unit. Two groups, Group I (n = 106) and Group II (n = 26), consisted of patients who had primary or secondary immunodeficiency and those who were immunosuppressed because BMT, respectively. Radiological findings before FB and macroscopic and microscopic findings of the procedure were evaluated. Results FB and BAL were diagnostic in 86/132 patients (65.1%) and the antimicrobial treatment changed for 75/132 patients (56.8%). The most common pathogen was bacteria (Streptococcus pneumoniae was the leading one). Bacteria were more frequent in Group I than Group II (P = .008). No significant difference in radiological findings between Groups I and II was found. Considering all patients, a significant association was detected between viral pathogens and radiologically interstitial infiltration and a ground‐glass appearance (P = .003). However, no significant association was detected between bacterial and fungal pathogens and the radiological findings. Conclusion In immunosuppressed patients, FB and BAL should be evaluated early for clarifying the causative agents. Then, appropriate treatments can be utilised and the side effects and high cost of unnecessary treatment may be mitigated.
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Affiliation(s)
| | - Ebru Yalcin
- Division of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Berna Oguz
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Turgay Ocal
- Department of Anesthesiology and Reanimation, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Baris Kuskonmaz
- Division of Pediatric Hematology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nagehan Emiralioglu
- Division of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Deniz Dogru-Ersoz
- Division of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ugur Ozcelik
- Division of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ilhan Tezcan
- Division of Pediatric Immunology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nural Kiper
- Division of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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16
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Diagnostic Performance and Safety of Bronchoalveolar Lavage in Thrombocytopenic Haematological Patients for Invasive Fungal Infections Diagnosis: A Monocentric, Retrospective Experience. Mediterr J Hematol Infect Dis 2019; 11:e2019065. [PMID: 31700590 PMCID: PMC6827601 DOI: 10.4084/mjhid.2019.065] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/14/2019] [Indexed: 01/11/2023] Open
Abstract
Background Although bronchoalveolar lavage (BAL) measurements of galactomannan antigen (GM) seems to be more sensitive than serum testing to detect invasive fungal infection (IFI), a consensus on the most appropriate diagnostic threshold of the BAL GM test is still unclear. Moreover, there is uncertainty as to whether BAL is a safe procedure in patients with hematological malignancies (HM) and thrombocytopenia. Objectives Based on this background, 102 adult patients with HM and associated thrombocytopenia were retrospectively analyzed with the dual aim of 1) determining whether BAL is a safe and feasible procedure; and, 2) identifying the most appropriate threshold for GM positivity in the diagnosis of IFI. Patients/Methods each BAL was considered as one case/patient. One hundred twelve BALs were carried out in 102 HM patients: at the time of the BAL, the median platelet count (PLTs) in all patients was 47×109/L (1–476), and 31 patients (27%) had PLTs< 20×109/L. Results complications from the BAL were infrequent (3.5%) and mild. No bleeding was reported. The BAL GM cut off of >0.8 was associated with the best diagnostic accuracy (sensitivity 72.97% and specificity 80%). Antifungal treatment of patients with BAL GM >0.8 resulted in a clinical-radiological improvement in 35/41 patients (85%). Conclusions BAL was a safe procedure also in thrombocytopenic patients, permitting an IFI diagnosis not otherwise identifiable using EORTC/MSG criteria. Our data suggest that a BAL GM value of>0.8 represents the most useful cut-off in terms of sensibility and specificity. Further prospective studies on a more significant number of patients are needed to confirm these results.
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17
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Marchesi F, Cattaneo C, Criscuolo M, Delia M, Dargenio M, Del Principe MI, Spadea A, Fracchiolla NS, Melillo L, Perruccio K, Alati C, Russo D, Garzia M, Brociner M, Cefalo M, Armiento D, Cesaro S, Decembrino N, Mengarelli A, Tumbarello M, Busca A, Pagano L. A bronchoalveolar lavage-driven antimicrobial treatment improves survival in hematologic malignancy patients with detected lung infiltrates: A prospective multicenter study of the SEIFEM group. Am J Hematol 2019; 94:1104-1112. [PMID: 31321791 DOI: 10.1002/ajh.25585] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/08/2019] [Accepted: 07/13/2019] [Indexed: 12/15/2022]
Abstract
Bronchoalveolar lavage (BAL) is recommended for diagnosing lung infiltrates (LI) in patients with hematologic malignancy (HM). Prospective data on the impact of BAL on survival are still lacking. We conducted a prospective observational study on patients who performed BAL for LI among 3055 HM patients hospitalized from January to September 2018. The BAL was performed in 145 out of 434 patients who developed LI, at a median time of four days from LI detection. The median age was 60 (1-83). Most patients had an acute myeloid leukemia/myelodisplastic syndrome (81), followed by lymphoma (41), acute lymphoblastic leukemia (27), and other types of HM (36). A putative causal agent was detected in 111 cases (76%), and in 89 cases (61%) the BAL results provided guidance to antimicrobial treatment. We observed a significantly improved outcome of LI at day +30 in patients who could receive a BAL-driven antimicrobial treatment (improvement/resolution rate: 71% vs 55%; P = .04). Moreover, we observed a significantly improved outcome in 120-day overall survival (120d-OS) (78% vs 59%; P = .009) and 120-day attributable mortality (120d-AM) (11% vs 30%; P = 0.003) for patients who could receive a BAL-driven treatment. The multivariate analysis showed that BAL-driven antimicrobial treatment was significantly associated with better 120d-OS and lower 120d-AM. We did not observe any severe adverse events. In conclusion BAL allows detection of a putative agent of LI in about 75% of cases, it is feasible and well tolerated in most cases, demonstrating that a BAL-driven antimicrobial treatment allows improvement of clinical outcome and survival.
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Affiliation(s)
- Francesco Marchesi
- Hematology and Stem Cell Transplant UnitIRCCS Regina Elena National Cancer Institute Rome Italy
| | - Chiara Cattaneo
- Hematology DivisionASST‐Spedali Civili di Brescia Brescia Italy
| | - Marianna Criscuolo
- Fondazione Policlinico Universitario Agostino Gemelli – IRCCS Rome Italy
| | - Mario Delia
- Hematology and Bone Marrow Transplantation Unit, Department of Emergency and Organ TransplantationUniversity of Bari Bari Italy
| | - Michelina Dargenio
- Hematology and Stem Cell Transplantation Unit'Vito Fazzi' Hospital Lecce Italy
| | | | - Antonio Spadea
- Hematology and Stem Cell Transplant UnitIRCCS Regina Elena National Cancer Institute Rome Italy
| | | | - Lorella Melillo
- UO of Hematology, Foundation IRCSS Casa Sollievo della Sofferenza Hospital San Giovanni Rotondo Italy
| | - Katia Perruccio
- Pediatric Hematology OncologyUniversity Hospital Santa Maria della Misericordia Perugia Italy
| | - Caterina Alati
- Hematology UnitBianchi‐Melacrino‐Morelli Hospital Reggio Calabria Italy
| | - Domenico Russo
- Bone Marrow Transplant UnitUniversity of Brescia and ASST‐Spedali Civili Brescia Italy
| | | | - Marco Brociner
- Division of HematologyFoundation IRCCS Policlinico San Matteo, University of Pavia Pavia Italy
| | | | - Daniele Armiento
- Hematology and Stem Cell Transplantation UnitUniversity Campus Bio‐Medico Rome Italy
| | - Simone Cesaro
- Pediatric Hematology OncologyAzienda Ospedaliera Universitaria Integrata Verona Italy
| | - Nunzia Decembrino
- Pediatric Hematology OncologyIRCCS Policlinico San Matteo, University of Pavia Pavia Italy
| | - Andrea Mengarelli
- Hematology and Stem Cell Transplant UnitIRCCS Regina Elena National Cancer Institute Rome Italy
| | - Mario Tumbarello
- Fondazione Policlinico Universitario Agostino Gemelli – IRCCS Rome Italy
- Istituto di Malattie Infettive, Università Cattolica del Sacro Cuore Rome Italy
| | - Alessandro Busca
- Stem Cell Transplant Center, AOU Citta' della Salute e Della Scienza Turin Italy
| | - Livio Pagano
- Fondazione Policlinico Universitario Agostino Gemelli – IRCCS Rome Italy
- Istituto di Ematologia, Università Cattolica del Sacro Cuore Rome Italy
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BAL fluid analysis in the identification of infectious agents in patients with hematological malignancies and pulmonary infiltrates. Folia Microbiol (Praha) 2019; 65:109-120. [PMID: 31073843 PMCID: PMC7090732 DOI: 10.1007/s12223-019-00712-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 04/25/2019] [Indexed: 11/02/2022]
Abstract
The present study aims to evaluate the diagnostic yield of bronchoalveolar lavage (BAL) fluid in patients with hematological malignancies and describe the most common pathogens detected in BAL fluid (BALF.) An analysis of 480 BALF samples was performed in patients with hematological malignancies over a period of 7 years. The results of culture methods, PCR, and immunoenzymatic sandwich microplate assays for Aspergillus galactomannan (GM) in BALF were analyzed. Further, the diagnostic thresholds for Aspergillus GM and Pneumocystis jiroveci were also calculated. Microbiological findings were present in 87% of BALF samples. Possible infectious pathogens were detected in 55% of cases; 32% were classified as colonizing. No significant difference in diagnostic yield or pathogen spectrum was found between non-neutropenic and neutropenic patients. There was one significant difference in BALF findings among intensive care units (ICU) versus non-ICU patients for Aspergillus spp. (22% versus 9%, p = 0.03). The most common pathogens were Aspergillus spp. (n = 86, 33% of BAL with causative pathogens) and Streptococcus pneumoniae (n = 46, 18%); polymicrobial etiology was documented in 20% of cases. A quantitative PCR value of > 1860 cp/mL for Pneumocystis jirovecii was set as a diagnostic threshold for pneumocystis pneumonia. The absorbance index of GM in BALF of 0.5 was set as a diagnostic threshold for aspergillosis. The examination of BAL fluid revealed the presence of pathogen in more than 50% of cases and is, therefore, highly useful in this regard when concerning pulmonary infiltrates.
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Venkatram S, Pena D, Bajantri B, Diaz-Fuentes G. Outcomes of patients with non-diagnostic bronchoscopy: A clinico-radiological comparison of patients with diagnostic and non-diagnostic bronchoscopy. Medicine (Baltimore) 2019; 98:e15585. [PMID: 31083241 PMCID: PMC6531116 DOI: 10.1097/md.0000000000015585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Bronchoscopy is one of the most common diagnostic procedures in pulmonary practice. Data on the outcome of patients following a non-diagnostic bronchoscopy are sparse. Diagnostic yield depends on indication, the characteristics of patients, and the chest imaging. The aim of this study was to evaluate the outcomes of patients with a non-diagnostic bronchoscopy and to compare patients who had a diagnostic with those that had a non-diagnostic bronchoscopy.Retrospective, single-center study of adult patients who underwent bronchoscopy with transbronchial biopsy (TBBX) and/or endobronchial biopsy (EBBX), endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA), or brushing. A strict definition for a "diagnostic" bronchoscopy was used. Univariate and multivariate analyses were performed.A total of 684 patients were identified, 350 (51%) had a diagnostic procedure. Of the 334 patients with a non-diagnostic bronchoscopy, 196 (58.6%) were followed, but only 172 (88%) completed 1 year of follow-up. Most of the patients (57.8%) had resolution or stabilization of the condition; in the remaining patients, malignancy was most commonly diagnosed after further investigation followed by diffuse lung diseases and infections. Pulmonary tuberculosis was diagnosed in 8 patients. EBUS-TBNA and EBBX were the procedures associated with a diagnostic bronchoscopy. Presence of bilateral interstitial infiltrates predicted a non-diagnostic bronchoscopy.A significant number of patients with non-diagnostic bronchoscopy may have serious treatable disease that is identified upon further investigation. Close follow up of patients with a non-diagnostic procedure is warranted. Our study found no clear clinical or radiological predictors of diagnostic bronchoscopy.
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Buckley SA, Mark NM, Othus M, Estey EH, Patel K, Walter RB. Diagnostic utility of bronchoscopy in adults with acute myeloid leukemia and other high-grade myeloid neoplasms. Leuk Lymphoma 2019; 60:2304-2307. [PMID: 30856024 DOI: 10.1080/10428194.2019.1581933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Sarah A Buckley
- Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | - Nicholas M Mark
- Department of Medicine, Division of Pulmonary, Care, and Critical Sleep Medicine, University of Washington , Seattle , WA , USA
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | - Elihu H Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,Department of Medicine, Division of Hematology, University of Washington , Seattle , WA , USA
| | - Kevin Patel
- Department of Medicine, Division of Pulmonary, Care, and Critical Sleep Medicine, University of Washington , Seattle , WA , USA
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,Department of Medicine, Division of Hematology, University of Washington , Seattle , WA , USA.,Department of Pathology, University of Washington , Seattle , WA , USA
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21
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Choo R, Naser NSH, Nadkarni NV, Anantham D. Utility of bronchoalveolar lavage in the management of immunocompromised patients presenting with lung infiltrates. BMC Pulm Med 2019; 19:51. [PMID: 30808314 PMCID: PMC6390608 DOI: 10.1186/s12890-019-0801-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/04/2019] [Indexed: 02/08/2023] Open
Abstract
Background Bronchoalveolar lavage (BAL) is utilized for diagnosing lung infiltrates in immunocompromised. There is heterogeneity in the data and reported diagnostic yields range from 26 to 69%. Therefore, selection criteria for BAL to maximize yield and minimize complications are unclear. Objectives of this study were to determine the diagnostic yield and complication rate of BAL in immunocompromised patients presenting with lung infiltrates, and identify factors impacting these outcomes. Exploratory aims included characterization of pathogens, rate of treatment modification and mortality. Methods Retrospective study from January 2012 to December 2016. Patients on mechanical ventilation were excluded. Positive diagnostic yield was defined as confirmed microbiological or cytological diagnosis. Results A total of 217 patients were recruited (70.1% male and mean age: 51.7 ± 14.6 years). Diagnostic yield was 60.8% and complication rate 14.7%. Complications (hypoxemia and endobronchial bleeding) were all sell-limiting. Treatment modification based on BAL results was 63.3%. In 97.0% an infectious aetiology was identified. HIV infection (OR 5.304, 95% CI 1.611–17.458, p = 0.006) and severe neutropenia (OR 4.253, 95% CI 1.288–14.045, p = 0.018) were associated with positive yield. Leukemia (OR 0.317, 95% CI 0.102–0.982, p = 0.047) was associated with lower yield. No factors impacted complication rate. Overall mortality (90-day) was 17.5% and in those with hematologic malignancy, it was 28.3%. Conclusion BAL retains utility in diagnosis of immunocompromised patients with lung infiltrates. However, patients with hematologic malignancy have a high mortality and alternative sampling should be considered because of poor results with BAL. Trial registration ClinicalTrials.gov identifier NCT01374542. Registered June 16, 2011.
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Affiliation(s)
- Randall Choo
- Duke-NUS Medical School, Singapore, Singapore.,Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Academia Building Level 3, 20 College Road, S169856, Singapore, Singapore
| | - Naser Salman Hamza Naser
- Salmaniya Medical Complex, Manama, Bahrain.,Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Academia Building Level 3, 20 College Road, S169856, Singapore, Singapore
| | | | - Devanand Anantham
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Academia Building Level 3, 20 College Road, S169856, Singapore, Singapore.
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22
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Choo R, Anantham D. Role of bronchoalveolar lavage in the management of immunocompromised patients with pulmonary infiltrates. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:49. [PMID: 30906753 DOI: 10.21037/atm.2019.01.21] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pulmonary infiltrates are a significant cause of morbidity and mortality in immunocompromised patients and remain a diagnostic challenge due to the broad range of etiologies that include infection and malignancy. Empiric therapy may be sub-optimal and can adversely impact outcome. Therefore, a confirmed diagnosis is necessary and flexible bronchoscopy with bronchoalveolar lavage (BAL) may be a useful diagnostic tool. Samples are obtained for microbiological and cytological testing, but the procedure carries risk of complications including the adverse events related to moderate sedation. A review of published literature on BAL in immunocompromised patients from the year 2000 was undertaken focusing on diagnostic yield, complication rate, mortality as well as factors impacting these outcomes. Studies in which the majority of patients were supported on mechanical ventilation were excluded. A total of 23 studies (7 prospective and 16 retrospective) met inclusion criteria. This covered 3,395 procedures in 3,192 patients with a mean age of 47.4 years; 60.3% male gender. Diagnostic yield ranged from 26% to 69% with no clear association between diagnostic yield and etiology of immunosuppression or clinical/radiological presentation. Post BAL modification of treatment as an indicator for clinical utility ranged from 11% to 84%; and complication rate ranged from 1% to 52%. No specific factors were associated with increased adverse event rate. This review provides a summary of the data on the use of BAL for diagnosis of pulmonary infiltrates in immunocompromised patients, highlighting the heterogeneity of patients, significant variation in findings reported and the need for more data to optimize patient selection.
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Affiliation(s)
- Randall Choo
- Duke-NUS Medical School, Singapore.,Singapore Health Services, Singapore
| | - Devanand Anantham
- Singapore Health Services, Singapore.,Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
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23
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Bronchoscopy and Bronchoalveolar Lavage in the Diagnosis and Management of Pulmonary Infections in Immunocompromised Children. J Pediatr Hematol Oncol 2018; 40:532-535. [PMID: 30102649 DOI: 10.1097/mph.0000000000001283] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Immunocompromised children are at high risk of rapid deterioration and of developing life-threatening pulmonary infections. Etiologies in this setting are diverse, including those that are infectious and noninfectious, and many etiologies may coexist. Accurate diagnosis is required for the rational use of medications. Fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) can identify infectious causes in this population. OBJECTIVES The aims of this study were to evaluate diagnostic rate, safety, and changes in treatment following FOB with BAL, when applied with advanced laboratory diagnostic techniques. PATIENTS AND METHODS We reviewed the records of children who underwent FOB with BAL during the period spanning from 2006 to 2014 in the Hematology-Oncology Department. BAL samples were processed in microbiology, virology, cytology, and molecular laboratories. RESULTS Antimicrobials were initiated in 91 of 117 children. BAL yielded an infectious etiology in 55 episodes. Management was altered in 74 patients following a positive (40/55) or a negative (30/54) result (4 patients had missing data). No severe complications associated with the procedures occurred. CONCLUSIONS Most immunocompromised patients with pulmonary manifestations are treated empirically with multiple medications. Evaluation FOB/BAL is a useful diagnostic tool, and seems to have changed the course of therapy in more than half of patients, by initiation or cessation of treatment. FOB/BAL is a safe diagnostic tool for the evaluation of pulmonary manifestations in this setting.
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24
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Ullmann AJ, Aguado JM, Arikan-Akdagli S, Denning DW, Groll AH, Lagrou K, Lass-Flörl C, Lewis RE, Munoz P, Verweij PE, Warris A, Ader F, Akova M, Arendrup MC, Barnes RA, Beigelman-Aubry C, Blot S, Bouza E, Brüggemann RJM, Buchheidt D, Cadranel J, Castagnola E, Chakrabarti A, Cuenca-Estrella M, Dimopoulos G, Fortun J, Gangneux JP, Garbino J, Heinz WJ, Herbrecht R, Heussel CP, Kibbler CC, Klimko N, Kullberg BJ, Lange C, Lehrnbecher T, Löffler J, Lortholary O, Maertens J, Marchetti O, Meis JF, Pagano L, Ribaud P, Richardson M, Roilides E, Ruhnke M, Sanguinetti M, Sheppard DC, Sinkó J, Skiada A, Vehreschild MJGT, Viscoli C, Cornely OA. Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline. Clin Microbiol Infect 2018; 24 Suppl 1:e1-e38. [PMID: 29544767 DOI: 10.1016/j.cmi.2018.01.002] [Citation(s) in RCA: 828] [Impact Index Per Article: 138.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 02/06/2023]
Abstract
The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.
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Affiliation(s)
- A J Ullmann
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J M Aguado
- Infectious Diseases Unit, University Hospital Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - S Arikan-Akdagli
- Department of Medical Microbiology, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D W Denning
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; European Confederation of Medical Mycology (ECMM)
| | - A H Groll
- Department of Paediatric Haematology/Oncology, Centre for Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - K Lagrou
- Department of Microbiology and Immunology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lass-Flörl
- Institute of Hygiene, Microbiology and Social Medicine, ECMM Excellence Centre of Medical Mycology, Medical University Innsbruck, Innsbruck, Austria; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R E Lewis
- Infectious Diseases Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - P Munoz
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - P E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - F Ader
- Department of Infectious Diseases, Hospices Civils de Lyon, Lyon, France; Inserm 1111, French International Centre for Infectious Diseases Research (CIRI), Université Claude Bernard Lyon 1, Lyon, France; European Respiratory Society (ERS)
| | - M Akova
- Department of Medicine, Section of Infectious Diseases, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M C Arendrup
- Department Microbiological Surveillance and Research, Statens Serum Institute, Copenhagen, Denmark; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R A Barnes
- Department of Medical Microbiology and Infectious Diseases, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK; European Confederation of Medical Mycology (ECMM)
| | - C Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland; European Respiratory Society (ERS)
| | - S Blot
- Department of Internal Medicine, Ghent University, Ghent, Belgium; Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia; European Respiratory Society (ERS)
| | - E Bouza
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R J M Brüggemann
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG)
| | - D Buchheidt
- Medical Clinic III, University Hospital Mannheim, Mannheim, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Cadranel
- Department of Pneumology, University Hospital of Tenon and Sorbonne, University of Paris, Paris, France; European Respiratory Society (ERS)
| | - E Castagnola
- Infectious Diseases Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - A Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India; European Confederation of Medical Mycology (ECMM)
| | - M Cuenca-Estrella
- Instituto de Salud Carlos III, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - G Dimopoulos
- Department of Critical Care Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece; European Respiratory Society (ERS)
| | - J Fortun
- Infectious Diseases Service, Ramón y Cajal Hospital, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J-P Gangneux
- Univ Rennes, CHU Rennes, Inserm, Irset (Institut de Recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Garbino
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - W J Heinz
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R Herbrecht
- Department of Haematology and Oncology, University Hospital of Strasbourg, Strasbourg, France; ESCMID Fungal Infection Study Group (EFISG)
| | - C P Heussel
- Diagnostic and Interventional Radiology, Thoracic Clinic, University Hospital Heidelberg, Heidelberg, Germany; European Confederation of Medical Mycology (ECMM)
| | - C C Kibbler
- Centre for Medical Microbiology, University College London, London, UK; European Confederation of Medical Mycology (ECMM)
| | - N Klimko
- Department of Clinical Mycology, Allergy and Immunology, North Western State Medical University, St Petersburg, Russia; European Confederation of Medical Mycology (ECMM)
| | - B J Kullberg
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lange
- International Health and Infectious Diseases, University of Lübeck, Lübeck, Germany; Clinical Infectious Diseases, Research Centre Borstel, Leibniz Center for Medicine & Biosciences, Borstel, Germany; German Centre for Infection Research (DZIF), Tuberculosis Unit, Hamburg-Lübeck-Borstel-Riems Site, Lübeck, Germany; European Respiratory Society (ERS)
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Confederation of Medical Mycology (ECMM)
| | - J Löffler
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Lortholary
- Department of Infectious and Tropical Diseases, Children's Hospital, University of Paris, Paris, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Maertens
- Department of Haematology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Marchetti
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland; Department of Medicine, Ensemble Hospitalier de la Côte, Morges, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - L Pagano
- Department of Haematology, Universita Cattolica del Sacro Cuore, Roma, Italy; European Confederation of Medical Mycology (ECMM)
| | - P Ribaud
- Quality Unit, Pôle Prébloc, Saint-Louis and Lariboisière Hospital Group, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M Richardson
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece; Hippokration General Hospital, Thessaloniki, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Ruhnke
- Department of Haematology and Oncology, Paracelsus Hospital, Osnabrück, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Sanguinetti
- Institute of Microbiology, Fondazione Policlinico Universitario A. Gemelli - Università Cattolica del Sacro Cuore, Rome, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D C Sheppard
- Division of Infectious Diseases, Department of Medicine, Microbiology and Immunology, McGill University, Montreal, Canada; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Sinkó
- Department of Haematology and Stem Cell Transplantation, Szent István and Szent László Hospital, Budapest, Hungary; ESCMID Fungal Infection Study Group (EFISG)
| | - A Skiada
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M J G T Vehreschild
- Department I of Internal Medicine, ECMM Excellence Centre of Medical Mycology, University Hospital of Cologne, Cologne, Germany; Centre for Integrated Oncology, Cologne-Bonn, University of Cologne, Cologne, Germany; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; European Confederation of Medical Mycology (ECMM)
| | - C Viscoli
- Ospedale Policlinico San Martino and University of Genova (DISSAL), Genova, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O A Cornely
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; CECAD Cluster of Excellence, University of Cologne, Cologne, Germany; Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM); ESCMID European Study Group for Infections in Compromised Hosts (ESGICH).
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25
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The utility and safety of flexible bronchoscopy in critically ill acute leukemia patients: a retrospective cohort study. Can J Anaesth 2017; 65:272-279. [PMID: 29256064 DOI: 10.1007/s12630-017-1041-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/08/2017] [Indexed: 10/18/2022] Open
Abstract
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.
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26
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Harris B, Geyer AI. Diagnostic Evaluation of Pulmonary Abnormalities in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation. Clin Chest Med 2017; 38:317-331. [PMID: 28477642 PMCID: PMC7172342 DOI: 10.1016/j.ccm.2016.12.008] [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] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Bianca Harris
- Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Alexander I Geyer
- Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
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27
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Makita K, Mikami Y, Matsuzaki H, Narumoto O, Takai D, Yatomi Y, Nagase T. Utility of bronchoscopy in the definitive diagnosis of patients with haematological malignancies presenting with radiological abnormalities. CLINICAL RESPIRATORY JOURNAL 2017; 12:1381-1388. [PMID: 28752537 DOI: 10.1111/crj.12666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 06/12/2017] [Accepted: 07/10/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patients with haematological malignancies usually have a plethora of respiratory complications. Bronchoscopy is one of the most important procedures used to diagnose respiratory complications. Despite enormous benefit, patients should be carefully selected for bronchoscopy as the process is invasive; however, there are only few reports evaluating the contributing factors of bronchoscopy that result in the definitive diagnosis of respiratory complications in these patients. OBJECTIVE This study aimed to elucidate and identify the contributing factors of bronchoscopy for definitive diagnosis in patients with haematological malignancies. METHODS We retrospectively analysed 275 patients with haematological malignancies who later showed respiratory complications, requiring consultation with pulmonologists. We found that 62 patients underwent bronchoscopy. Our data analysis focused on this particular subset of patients to identify the factors crucial for definitive diagnosis via bronchoscopy. RESULTS Bronchoscopy provided definitive diagnosis for 25 patients (diagnostic yield = 40.3%). We determined that nodular shadow was associated with high diagnostic yields by multivariate logistic regression [odds ratio (OR): 6.6 (2.1-23)]. Furthermore, in several bronchoscopic procedures, biopsy also contributed to definitive diagnosis of patients with nodular shadow [OR: 17 (1.5-180)]. Life-threatening complications were not observed due to bronchoscopy in our study. CONCLUSIONS Our study demonstrated that patients with haematological malignancies who showed lung nodular shadows are more likely to be definitively diagnosed by bronchoscopy, whereas transbronchial biopsy may also be beneficial for these patients.
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Affiliation(s)
- Kosuke Makita
- Department of Respiratory Medicine, Graduate school of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yu Mikami
- Department of Respiratory Medicine, Graduate school of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Clinical Laboratory Medicine, Graduate school of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirotaka Matsuzaki
- Department of Respiratory Medicine, Graduate school of Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Narumoto
- Department of Respiratory Medicine, Graduate school of Medicine, The University of Tokyo, Tokyo, Japan
| | - Daiya Takai
- Department of Respiratory Medicine, Graduate school of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Clinical Laboratory Medicine, Graduate school of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Yutaka Yatomi
- Department of Clinical Laboratory Medicine, Graduate school of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Takahide Nagase
- Department of Respiratory Medicine, Graduate school of Medicine, The University of Tokyo, Tokyo, Japan
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Young AY, Leiva Juarez MM, Evans SE. Fungal Pneumonia in Patients with Hematologic Malignancy and Hematopoietic Stem Cell Transplantation. Clin Chest Med 2017; 38:479-491. [PMID: 28797490 DOI: 10.1016/j.ccm.2017.04.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Fungal pneumonias cause unacceptable morbidity among patients with hematologic malignancies (HM) and recipients of hematopoietic stem cell transplantation (HSCT). The high incidence of fungal pneumonias in HM/HSCT populations arises from their frequently severe, complex, and persistent immune dysfunction caused by the underlying disease and its treatment. The cytopenias, treatment toxicities, and other immune derangements that make patients susceptible to fungal pneumonia frequently complicate its diagnosis and increase the intensity and duration of antifungal therapy. This article addresses the host factors that contribute to susceptibility, summarizes diagnostic recommendations, and reviews current guidelines for management of fungal pneumonia in patients with HM/HSCT.
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Affiliation(s)
- Alisha Y Young
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The University of Texas Health Sciences Center, 6431 Fannin Street, MSB 1.434, Houston, TX 77030, USA
| | - Miguel M Leiva Juarez
- Division of Internal Medicine, Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1100, Houston, TX 77030, USA
| | - Scott E Evans
- Division of Internal Medicine, Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1100, Houston, TX 77030, USA.
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29
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Prise en charge du patient neutropénique en réanimation (nouveau-nés exclus). Recommandations d’un panel d’experts de la Société de réanimation de langue française (SRLF) avec le Groupe francophone de réanimation et urgences pédiatriques (GFRUP), la Société française d’anesthésie et de réanimation (Sfar), la Société française d’hématologie (SFH), la Société française d’hygiène hospitalière (SF2H) et la Société de pathologies infectieuses de langue française (SPILF). MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1278-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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30
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Svensson T, Lundström KL, Höglund M, Cherif H. Utility of bronchoalveolar lavage in diagnosing respiratory tract infections in patients with hematological malignancies: are invasive diagnostics still needed? Ups J Med Sci 2017; 122:56-60. [PMID: 27739337 PMCID: PMC5361433 DOI: 10.1080/03009734.2016.1237595] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Patients treated for hematological malignancies have an increased risk of serious infections. Diagnosis and prompt initiation of therapy are essential. Bronchoalveolar lavage (BAL) is a well-established investigation for identifying the cause of pulmonary infiltrates in immunocompromised patients. The aim of the study was to determine the diagnostic yield of BAL in patients treated for hematological malignancies and how often it contributed to a modification of the anti-infectious therapy. METHODS We reviewed records from 151 consecutive BAL procedures in 133 adult patients with hematological malignancies, treated at a tertiary hematology unit from 2004 to 2013. Extensive microbiological work-ups on BAL samples had been performed according to a standardized protocol. RESULTS A microbiological finding causing the infectious episode could be identified in 59 (39%) cases. In 44 (29%) of the cases, results from BAL had an impact on clinical management either by contributing to a specific diagnosis (25%) or by leading to cessation of ongoing microbiological therapy. The most common diagnoses were invasive pulmonary aspergillosis (IPA) and Pneumocystis jirovecii pneumonia (PJP). Diagnoses of IPA and PJP were based on results from BAL in 65% and 93% of cases, respectively. Several microbiological tests on BAL samples rendered no positive results. Complications were few and mainly mild. CONCLUSION BAL is still important for either verifying or excluding some of the most important respiratory tract pathogens in patients with hematological malignancies, particularly IPA and PJP. Standardized procedures for BAL sampling should be continually revised to exclude unnecessary microbiological tests.
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Affiliation(s)
- Tobias Svensson
- Department of Medical Sciences, Section of Hematology, Uppsala University, Uppsala, Sweden
- CONTACT Tobias Svensson Department of Medical Sciences, Section of Hematology, Uppsala University Hospital, SE-751 85 Uppsala, Sweden
| | | | - Martin Höglund
- Department of Medical Sciences, Section of Hematology, Uppsala University, Uppsala, Sweden
| | - Honar Cherif
- Department of Medical Sciences, Section of Hematology, Uppsala University, Uppsala, Sweden
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31
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Gerritsen MG, Willemink MJ, Pompe E, van der Bruggen T, van Rhenen A, Lammers JWJ, Wessels F, Sprengers RW, de Jong PA, Minnema MC. Improving early diagnosis of pulmonary infections in patients with febrile neutropenia using low-dose chest computed tomography. PLoS One 2017; 12:e0172256. [PMID: 28235014 PMCID: PMC5325310 DOI: 10.1371/journal.pone.0172256] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 02/02/2017] [Indexed: 12/26/2022] Open
Abstract
We performed a prospective study in patients with chemotherapy induced febrile neutropenia to investigate the diagnostic value of low-dose computed tomography compared to standard chest radiography. The aim was to compare both modalities for detection of pulmonary infections and to explore performance of low-dose computed tomography for early detection of invasive fungal disease. The low-dose computed tomography remained blinded during the study. A consensus diagnosis of the fever episode made by an expert panel was used as reference standard. We included 67 consecutive patients on the first day of febrile neutropenia. According to the consensus diagnosis 11 patients (16.4%) had pulmonary infections. Sensitivity, specificity, positive predictive value and negative predictive value were 36%, 93%, 50% and 88% for radiography, and 73%, 91%, 62% and 94% for low-dose computed tomography, respectively. An uncorrected McNemar showed no statistical difference (p = 0.197). Mean radiation dose for low-dose computed tomography was 0.24 mSv. Four out of 5 included patients diagnosed with invasive fungal disease had radiographic abnormalities suspect for invasive fungal disease on the low-dose computed tomography scan made on day 1 of fever, compared to none of the chest radiographs. We conclude that chest radiography has little value in the initial assessment of febrile neutropenia on day 1 for detection of pulmonary abnormalities. Low-dose computed tomography improves detection of pulmonary infiltrates and seems capable of detecting invasive fungal disease at a very early stage with a low radiation dose.
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Affiliation(s)
- M. G. Gerritsen
- Department of Haematology, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
- Department of Haematology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - M. J. Willemink
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - E. Pompe
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Respiratory Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - T. van der Bruggen
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A. van Rhenen
- Department of Haematology, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - J. W. J. Lammers
- Department of Respiratory Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - F. Wessels
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R. W. Sprengers
- Department of Radiology, Meander Medical Center, Amersfoort, the Netherlands
| | - P. A. de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M. C. Minnema
- Department of Haematology, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
- * E-mail:
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Balasubramaniam P, Nampoothiri RV, Gupta N, Malhotra P. Lung consolidation responding to chemotherapy. BMJ Case Rep 2017; 2017:bcr2016218304. [PMID: 28154156 PMCID: PMC5293983 DOI: 10.1136/bcr-2016-218304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2017] [Indexed: 11/04/2022] Open
Abstract
Consolidations in the pulmonary parenchyma are mostly infective, although they can rarely be due to autoimmune and neoplastic processes. Consolidations, especially in the setting of underlying immunosuppressive haematological malignancy, are usually presumed infective by the treating physician. Pulmonary involvement in chronic lymphocytic leukaemia presenting as consolidations and type 1 respiratory failure, responding to systemic chemotherapy, is a rare and uncommon presentation.
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MESH Headings
- Aged
- Antineoplastic Agents/therapeutic use
- Cough/etiology
- Diagnosis, Differential
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnostic imaging
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lung Neoplasms/diagnostic imaging
- Lung Neoplasms/pathology
- Male
- Respiratory Insufficiency/complications
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Affiliation(s)
| | | | | | - Pankaj Malhotra
- Department of Internal Medicine, PGIMER, Chandigarh, India
- Department of Hematology, PGIMER, Chandigarh, India
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33
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Leiten EO, Martinsen EMH, Bakke PS, Eagan TML, Grønseth R. Complications and discomfort of bronchoscopy: a systematic review. Eur Clin Respir J 2016; 3:33324. [PMID: 27839531 PMCID: PMC5107637 DOI: 10.3402/ecrj.v3.33324] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/20/2016] [Indexed: 01/19/2023] Open
Abstract
Objective To identify bronchoscopy-related complications and discomfort, meaningful complication rates, and predictors. Method We conducted a systematic literature search in PubMed on 8 February 2016, using a search strategy including the PICO model, on complications and discomfort related to bronchoscopy and related sampling techniques. Results The search yielded 1,707 hits, of which 45 publications were eligible for full review. Rates of mortality and severe complications were low. Other complications, for instance, hypoxaemia, bleeding, pneumothorax, and fever, were usually not related to patient characteristics or aspects of the procedure, and complication rates showed considerable ranges. Measures of patient discomfort differed considerably, and results were difficult to compare between different study populations. Conclusion More research on safety aspects of bronchoscopy is needed to conclude on complication rates and patient- and procedure-related predictors of complications and discomfort.
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Affiliation(s)
| | | | - Per Sigvald Bakke
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tomas Mikal Lind Eagan
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Rune Grønseth
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
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34
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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.
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Schnell D, Azoulay E, Benoit D, Clouzeau B, Demaret P, Ducassou S, Frange P, Lafaurie M, Legrand M, Meert AP, Mokart D, Naudin J, Pene F, Rabbat A, Raffoux E, Ribaud P, Richard JC, Vincent F, Zahar JR, Darmon M. Management of neutropenic patients in the intensive care unit (NEWBORNS EXCLUDED) recommendations from an expert panel from the French Intensive Care Society (SRLF) with the French Group for Pediatric Intensive Care Emergencies (GFRUP), the French Society of Anesthesia and Intensive Care (SFAR), the French Society of Hematology (SFH), the French Society for Hospital Hygiene (SF2H), and the French Infectious Diseases Society (SPILF). Ann Intensive Care 2016; 6:90. [PMID: 27638133 PMCID: PMC5025409 DOI: 10.1186/s13613-016-0189-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 08/29/2016] [Indexed: 02/07/2023] Open
Abstract
Neutropenia is defined by either an absolute or functional defect (acute myeloid leukemia or myelodysplastic syndrome) of polymorphonuclear neutrophils and is associated with high risk of specific complications that may require intensive care unit (ICU) admission. Specificities in the management of critically ill neutropenic patients prompted the establishment of guidelines dedicated to intensivists. These recommendations were drawn up by a panel of experts brought together by the French Intensive Care Society in collaboration with the French Group for Pediatric Intensive Care Emergencies, the French Society of Anesthesia and Intensive Care, the French Society of Hematology, the French Society for Hospital Hygiene, and the French Infectious Diseases Society. Literature review and formulation of recommendations were performed using the Grading of Recommendations Assessment, Development and Evaluation system. Each recommendation was then evaluated and rated by each expert using a methodology derived from the RAND/UCLA Appropriateness Method. Six fields are covered by the provided recommendations: (1) ICU admission and prognosis, (2) protective isolation and prophylaxis, (3) management of acute respiratory failure, (4) organ failure and organ support, (5) antibiotic management and source control, and (6) hematological management. Most of the provided recommendations are obtained from low levels of evidence, however, suggesting a need for additional studies. Seven recommendations were, however, associated with high level of evidences and are related to protective isolation, diagnostic workup of acute respiratory failure, medical management, and timing surgery in patients with typhlitis.
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Affiliation(s)
| | | | | | - Benjamin Clouzeau
- Medical Intensive Care Unit, Pellegrin University Hospital, Bordeaux, France
| | - Pierre Demaret
- Paediatric Intensive Care Unit, Centre Hospitalier Chrétien, Liège, Belgium
| | - Stéphane Ducassou
- Pediatric Hematological Unit, Bordeaux University Hospital, Bordeaux, France
| | - Pierre Frange
- Microbiology Laboratory & Pediatric Immunology - Hematology Unit, Necker University Hospital, Paris, France
| | - Matthieu Lafaurie
- Department of Infectious Diseases, Saint-Louis University Hospital, Paris, France
| | - Matthieu Legrand
- Surgical ICU and Burn Unit, Saint-Louis University Hospital, Paris, France
| | - Anne-Pascale Meert
- Thoracic Oncology Department and Oncologic Intensive Care Unit, Institut Jules Bordet, Brussels, Belgium
| | - Djamel Mokart
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmette, Marseille, France
| | - Jérôme Naudin
- Pediatric ICU, Robert Debré University Hospital, Paris, France
| | | | - Antoine Rabbat
- Respiratory Intensive Care Unit, Cochin University Hospital Hospital, Paris, France
| | - Emmanuel Raffoux
- Department of Hematology, Saint-Louis University Hospital, Paris, France
| | - Patricia Ribaud
- Department of Stem Cell Transplantation, Saint-Louis University Hospital, Paris, France
| | | | | | - Jean-Ralph Zahar
- Infection Control Unit, Angers University Hospital, Angers, France
| | - Michael Darmon
- University Hospital, Saint-Etienne, France. .,Medical-Surgical Intensive Care Unit, Saint-Etienne University Hospital, Avenue Albert Raymond, 42270, Saint-Etienne, Saint-Priest-En-Jarez, France.
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Oren I, Hardak E, Zuckerman T, Geffen Y, Hoffman R, Yigla M, Avivi I. Does molecular analysis increase the efficacy of bronchoalveolar lavage in the diagnosis and management of respiratory infections in hemato-oncological patients? Int J Infect Dis 2016; 50:48-53. [PMID: 27484225 DOI: 10.1016/j.ijid.2016.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/17/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES The identification of the specific pathogen responsible for a respiratory infection in patients with hematological malignancies (HM) would ensure relevant treatment and prevent toxicity associated with anti-infective therapy. This large-scale study aimed to explore the clinical impact of fiberoptic bronchoscopy with bronchoalveolar lavage (FOB-BAL) in conjunction with molecular analysis on the diagnosis and management of respiratory infections in hemato-oncological patients. METHODS All consecutive patients with HM and pulmonary infiltrates, who underwent FOB-BAL between January 2008 and January 2013, were included in the analysis. Clinical characteristics, FOB-BAL results, and treatment adjustments were recorded, and factors predicting a positive BAL were assessed. RESULTS Four hundred and twenty-five FOB-BAL procedures were analyzed. BAL revealed a specific diagnosis in 219 (51.5%) patients, 208 of them with a pulmonary infection. Infectious etiological agents found were mainly Aspergillus spp (n=142), bacterial species (n=44), and Pneumocystis jirovecii (n=34). Multivariate analysis showed that a lymphoproliferative disease, ≥2 symptoms (dyspnea/cough/hemoptysis/pleuritic pain), and less than 4 days between symptom appearance and FOB-BAL, predicted a positive FOB-BAL result. BAL results prompted a treatment modification in 48% of subjects. CONCLUSIONS FOB-BAL in conjunction with molecular assays is efficient in the rapid detection of life-threatening infections, allowing for adjustment of anti-infective therapy, which may result in better outcomes and reduce treatment-related toxicity.
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Affiliation(s)
- Ilana Oren
- Unit of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel; The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Emilia Hardak
- The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Division of Pulmonary Medicine, Rambam Health Care Campus, 8 Ha'Aliya Street, Haifa 31096, Israel.
| | - Tsila Zuckerman
- The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Yuval Geffen
- Clinical Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - Ron Hoffman
- The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Mordechai Yigla
- The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Division of Pulmonary Medicine, Rambam Health Care Campus, 8 Ha'Aliya Street, Haifa 31096, Israel
| | - Irit Avivi
- Department of Hematology and Bone Marrow Transplantation, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
ABSTRACT
Filamentous mycoses are often associated with significant morbidity and mortality. Prompt diagnosis and aggressive treatment are essential for good clinical outcomes in immunocompromised patients. The host immune response plays an essential role in determining the course of exposure to potential fungal pathogens. Depending on the effectiveness of immune response and the burden of organism exposure, fungi can either be cleared or infection can occur and progress to a potentially fatal invasive disease. Nonspecific cellular immunity (i.e., neutrophils, natural killer [NK] cells, and macrophages) combined with T-cell responses are the main immunologic mechanisms of protection. The most common potential mold pathogens include certain hyaline hyphomycetes, endemic fungi, the
Mucorales
, and some dematiaceous fungi. Laboratory diagnostics aimed at detecting and differentiating these organisms are crucial to helping clinicians make informed decisions about treatment. The purpose of this chapter is to provide an overview of the medically important fungal pathogens, as well as to discuss the patient characteristics, antifungal-therapy considerations, and laboratory tests used in current clinical practice for the immunocompromised host.
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Boch T, Buchheidt D, Spiess B, Miethke T, Hofmann WK, Reinwald M. Direct comparison of galactomannan performance in concurrent serum and bronchoalveolar lavage samples in immunocompromised patients at risk for invasive pulmonary aspergillosis. Mycoses 2015; 59:80-5. [PMID: 26627577 DOI: 10.1111/myc.12434] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 10/21/2015] [Accepted: 10/21/2015] [Indexed: 02/02/2023]
Abstract
Invasive pulmonary aspergillosis (IPA) is a life-threatening infection mainly affecting immunocompromised patients. Early diagnosis is critical, but the diagnostic gold standard (histopathology and culture) is time consuming and cannot offer early confirmation of IPA. Fungal biomarkers like galactomannan (GM) are a promising extension to the diagnostic repertoire. However, it still remains under discussion if biomarker analysis from the site of the infection is superior to testing blood samples. We retrospectively evaluated the diagnostic performance of concurrent serum GM and bronchoalveolar lavage (BAL) GM (obtained within 24 h) of immunocompromised patients at high risk of IPA. Twenty-six proven/probable patients and eight patients with no IPA according to the EORTC/MSG 2008 criteria were included in this study. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic odds ratio were for BAL GM: 85%, 88%, 96%, 64% and 38.5, and for serum GM: 23%, 88%, 88%, 26% and 2.1 respectively. BAL GM proved to be significantly more sensitive for the detection of IPA compared to same-day serum GM in patients at high risk of IPA (P < 0.0001). Our data show that BAL GM testing is significantly superior to serum GM implying that diagnostic efforts should focus on specimens from the site of infection.
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Affiliation(s)
- Tobias Boch
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Birgit Spiess
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Thomas Miethke
- Institute of Medical Microbiology and Hygiene, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Wolf-Karsten Hofmann
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Mark Reinwald
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
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Murro D, Slade JM, Gattuso P. Cytologic findings of hematologic malignancies in bronchoalveolar lavage fluid. J Am Soc Cytopathol 2015; 4:267-275. [PMID: 31051764 DOI: 10.1016/j.jasc.2015.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 02/05/2015] [Accepted: 02/05/2015] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Bronchoalveolar lavage (BAL) is often performed in leukemia and lymphoma patients with pulmonary infiltrates, mainly to rule out infection. However, malignant hematopoietic infiltrates are uncommon and a comprehensive cytologic study has not yet been performed. MATERIALS AND METHODS We retrospectively reviewed all BAL samples from our institution for the past 22 years (November 1992-October 2014). RESULTS There were 37 cases of hematologic malignancies identified on BAL specimens (21 female patients and 16 male patients, age 22-80 years). Eighteen patients (49%) had pneumonia-like symptoms at the time of initial diagnosis of their malignancy, including fever, dyspnea, respiratory distress/hypoxia, and cough. The biopsy-proven cases were 25 leukemia (12 acute myeloid leukemia, 6 acute promyelocytic leukemia, 2 acute monocytic leukemia, 2 acute myelomonocytic leukemia, 1 chronic myeloid leukemia in blast phase, 1 large granular leukemia, and 1 plasma cell leukemia), 11 lymphoma (8 diffuse large B-cell lymphoma, 1 mantle cell lymphoma, 1 natural killer/T-cell lymphoma, and 1 T-cell lymphoma), and 1 multiple myeloma. Chest X-ray findings included opacities, consolidation, and interstitial edema. Four patients had BAL specimens with concomitant microorganisms. Eighteen patients subsequently died (2 days to 4 years), 15 were alive (3 weeks to 8 years of follow-up), and 4 were lost to follow-up. CONCLUSIONS BAL is especially important in distinguishing inflammatory/infectious processes from neoplastic disorders because many patients with hematologic malignancies can have pneumonia-like symptoms as part of their initial disease presentation. Causative pathogens are identified in only a minority of malignant BAL specimens from these patients. Lung involvement in patients with hematologic malignancies carries a poor prognosis.
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Affiliation(s)
- Diana Murro
- Rush University Medical Center, 1750 W. Harrison Street, Chicago, Illinois.
| | | | - Paolo Gattuso
- Rush University Medical Center, 1750 W. Harrison Street, Chicago, Illinois
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40
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Caniza MA, Odio C, Mukkada S, Gonzalez M, Ceppi F, Chaisavaneeyakorn S, Apiwattanakul N, Howard SC, Conter V, Bonilla M. Infectious complications in children with acute lymphoblastic leukemia treated in low-middle-income countries. Expert Rev Hematol 2015. [PMID: 26211675 DOI: 10.1586/17474086.2015.1071186] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Infections are the most important cause of morbidity and mortality in children treated for acute lymphoblastic leukemia (ALL). The rates of infection-associated mortality are up to 10-times higher in low- and middle-income countries (LMIC) than in high-income countries. The prevention, early recognition and management of infectious complications is especially challenging in LMIC because of disease and poverty-related factors, as well as the shortage of trained personnel, supplies, diagnostic tools and adequate organizational infrastructure. Children in LMIC with ALL, who are frequently underweight, are at increased risk of community-acquired pathogens, nosocomial multidrug-resistant pathogens and opportunistic microorganisms. This review summarizes the challenges of managing the major categories of infections in children receiving treatment for ALL and provides updated practical recommendations for preventing and managing these infections in LMIC.
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Affiliation(s)
- Miguela A Caniza
- a 1 Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
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Ambasta A, Carson J, Church DL. The use of biomarkers and molecular methods for the earlier diagnosis of invasive aspergillosis in immunocompromised patients. Med Mycol 2015; 53:531-57. [DOI: 10.1093/mmy/myv026] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 04/08/2015] [Indexed: 12/15/2022] Open
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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.
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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.
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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.
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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
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Kim SW, Rhee CK, Kang HS, Lee HY, Kang JY, Kim SJ, Kim SC, Lee SY, Kim YK, Lee JW. Diagnostic value of bronchoscopy in patients with hematologic malignancy and pulmonary infiltrates. Ann Hematol 2014; 94:153-9. [PMID: 25062720 DOI: 10.1007/s00277-014-2172-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 07/16/2014] [Indexed: 11/25/2022]
Abstract
Pulmonary infections are a major cause of morbidity and mortality in patients with hematologic malignancy. Bronchoscopy is at present still the traditional first investigation in immunosuppressed patients that have developed pulmonary infiltrates. There is limited data available on the validity of fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) to determine the etiology of pulmonary infiltrates with concurrent hematologic malignancy. We retrospectively analyzed the microbiological results of 206 bronchoscopic examinations and treatment changes used in 187 patients with hematologic malignancy and pulmonary infiltrates. Bacteria, fungi, and viruses were found in 85 (41.3 %), 49 (23.8 %), and 55 (28.6 %) of cases, respectively, and overall yield of bronchoscopy was 65.0 %. We compared the microbiological findings with respect to neutropenia, hematopoietic stem cell transplantation (HSCT) status, and the type of malignancy. There were significantly more bacterial and viral infections detected in post-HSCT patients, and more viruses were detected in patients without neutropenia. Galactomannan (GM) was measured in 149 BAL samples. With a GM index threshold of ≥0.5, the sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) of the BAL GM assay were 93.94 %, 86.21 %, 65.96 %, and 98.04 %, respectively. Treatment was modified in 62 cases (30.1 %). There was no significant relationship of treatment modification with the underlying disease, HSCT, or neutropenia. Bronchoscopy with BAL is a valuable diagnostic tool to determine the etiology and appropriate treatment in patients with hematologic malignancy and pulmonary infiltrates. A BAL GM test is recommended when invasive pulmonary aspergillosis is suspected.
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Affiliation(s)
- Sei Won Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, School of Medicine, Catholic University of Korea, Seoul, South Korea
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Ben-Ami R, Halaburda K, Klyasova G, Metan G, Torosian T, Akova M. A multidisciplinary team approach to the management of patients with suspected or diagnosed invasive fungal disease. J Antimicrob Chemother 2013; 68 Suppl 3:iii25-33. [DOI: 10.1093/jac/dkt390] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Buchheidt D, Spiess B, Hofmann WK, Reinwald M. Galactomannan-Based and PCR-Based Assays in Bronchoalveolar Lavage to Diagnose Invasive Aspergillosis: Current Status and Future Prospects. CURRENT FUNGAL INFECTION REPORTS 2013. [DOI: 10.1007/s12281-013-0141-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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O'Leary M, Cantley RL, Kluskens L, Gattuso P. Cytologic findings of acute leukemia in bronchoalveolar lavage fluid. Diagn Cytopathol 2012; 41:613-6. [PMID: 23161838 DOI: 10.1002/dc.22920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 08/03/2012] [Indexed: 12/22/2022]
Abstract
Bronchoalveolar lavage (BAL) is often performed in patients with acute leukemia developed with respiratory failure or pulmonary infiltrates. Patients usually undergo BAL to rule out infection. Occasionally, however, leukemic infiltrate may be detected. We present a series of 11 cases in which the diagnosis of leukemia was made on the BAL material. We retrospectively reviewed all BAL samples from January 1, 2006 to December 31, 2008. There were a total of 1,130 cases, of which 139 showed malignant cytology, including 10 with leukemia. Sixteen samples were unsatisfactory and 904 were benign, of which 32 had identifiable microorganisms. In additional to the 10 leukemia cases identified, two more were reviewed after the search criteria. The 12 patients (seven men, five women) ranged from 22 to 75 years old. All patients had previously biopsy-proven leukemia [two acute myelomonocytic leukemia, two acute promyelocytic leukemia, two acute myeloid leukemia (AML) with inv16, two therapy-related AML, one acute monocytic leukemia, one chronic myeloid leukemia in blast face, one AML with maturation, one myelodysplastic syndrome with excess blasts, and one large granular leukemia]. Four had a prior diagnosis of myelodysplastic syndrome. The time from initial diagnosis of leukemia to BAL ranged from 1 to 233 days, with 8 of 10 occurring within 8 days of diagnosis. Symptoms that prompted BAL included shortness of breath/hypoxia (8), fever (3), chest pain (2), and cough (2). Chest X-rays in all cases revealed opacities or consolidations mimicking an inflammatory process. Seven patients subsequently died, while three were alive, and, in remission, and two were lost to follow-up. The presence of a leukemic infiltrate can mimic infection. BAL is a relatively safe and useful diagnostic tool in this setting for differentiating a leukemic infiltrate from an infection/inflammatory infiltrate. The prognosis of patients with lung involvement of acute leukemia is poor.
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Affiliation(s)
- Michelle O'Leary
- Department of Pathology, Rush University Medical Center, Chicago, IL 60612, USA
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Abstract
Pulmonary complications in children with leukemia often display nonspecific clinical and radiologic manifestations that lead to a delay in diagnosis. The role of fiberoptic bronchoscopy (FOB) and the proper time for its performance are controversial. The aim of our study was to evaluate the frequency and nature of specific diagnoses revealed by FOB. Children with leukemia submitted to FOB because of suspicion of pulmonary involvement (mainly pneumonia) were retrospectively analyzed. A total of 33 FOB procedures performed in 31 patients (20 males) with an average age of 9.4 years (range, 3.5 to 15 y) were evaluated. Microorganisms isolated from 21 (63.6%) bronchoalveolar lavage samples were mainly fungi including Candida in 13 cases (39.4%) and Aspergillus in 3 cases (9.1%). Isolation rate in 10 procedures performed within the first 3 days was 90%. Tracheobronchitis was present in > 50% of patients, pulmonary hemorrhage was seen in 7 (21.0%) patients, and leukemic infiltration was demonstrated in 2 patients (6.1%), among other conditions visualized by FOB. Complications of FOB were minimal and transient. Our study suggests that FOB is a useful and safe procedure in patients with leukemia and pulmonary infiltrates. The earlier the FOB was performed, the higher the isolation rate of causative agents. In addition, this procedure allowed the identification of noninfectious airway comorbidities. Further studies in regard to this issue are warranted.
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49
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How I manage pulmonary nodular lesions and nodular infiltrates in patients with hematologic malignancies or undergoing hematopoietic cell transplantation. Blood 2012; 120:1791-800. [DOI: 10.1182/blood-2012-02-378976] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Abstract
Pulmonary nodules and nodular infiltrates occur frequently during treatment of hematologic malignancies and after hematopoietic cell transplantation. In patients not receiving active immunosuppressive therapy, the most likely culprits are primary lung cancer, chronic infectious or inactive granulomata, or even the underlying hematologic disease itself (especially in patients with lymphoma). In patients receiving active therapy or who are otherwise highly immunosuppressed, there is a wider spectrum of etiologies with infection being most likely, especially by bacteria and fungi. Characterization of the pulmonary lesion by high-resolution CT imaging is a crucial first diagnostic step. Other noninvasive tests can often be useful, but invasive testing by bronchoscopic evaluation or acquisition of tissue by one of several biopsy techniques should be performed for those at risk for malignancy or invasive infection unless contraindicated. The choice of the optimal biopsy technique should be individualized, guided by location of the lesion, suspected etiology, skill and experience of the diagnostic team, procedural risk of complications, and patient status. Although presumptive therapy targeting the most likely etiology is justified in patients suspected of serious infection while evaluation proceeds, a structured evaluation to determine the specific etiology is recommended. Interdisciplinary teamwork is highly desirable to optimize diagnosis and therapy.
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Kim ES, Kim EC, Lee SM, Yang SC, Yoo CG, Kim YW, Han SK, Yim JJ. Bacterial yield from quantitative cultures of bronchoalveolar lavage fluid in patients with pneumonia on antimicrobial therapy. Korean J Intern Med 2012; 27:156-62. [PMID: 22707887 PMCID: PMC3372799 DOI: 10.3904/kjim.2012.27.2.156] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 09/30/2011] [Accepted: 12/20/2011] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Early diagnosis and appropriate antimicrobial choice are crucial when managing pneumonia patients, and quantitative culture of bronchoalveolar lavage (BAL) fluid is considered a useful method for identifying pneumonia pathogens. We evaluated the quantitative yield of BAL fluid bacterial cultures in patients being treated with antimicrobials and attempted to identify factors predictive of positive BAL cultures. METHODS Patients over 18 years old and whose BAL fluid was subjected to quantitative culture to identify the organism causative of pneumonia between January 1, 2005, and December 31, 2009, were included. We reviewed the results of BAL fluid bacterial cultures and the clinical records, laboratory tests, and radiographic findings of the patients. RESULTS BAL was performed on 340 patients with pneumonia. A positive BAL culture, defined as isolation of more than 10(4) colony forming units/mL bacteria, was documented in 18 (5.29%) patients. Of these, 9 bacteria isolated from 10 patients were classified as probable pathogens. The most frequently isolated bacteria were methicillin-resistant Staphylococcus aureus, Acinetobacter baumannii, and Pseudomonas aeruginosa. No independent predictive factor for positive BAL cultures was identified. CONCLUSIONS The yield of quantitative BAL fluid bacterial culture in patients already on antimicrobials was low. Clinicians should be cautious when performing a BAL culture in patients with pneumonia who are already on antimicrobials.
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Affiliation(s)
- Eun Sun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Eui-Chong Kim
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Seok-Chul Yang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Chul-Gyu Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Young Whan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Koo Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
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