The role of early open lung biopsy in the diagnosis and treatment of Pneumocystis carinii pneumonia

Analysis of induced sputum in the diagnosis of Pneumocystis carinii pneumonia

Sixty-two patients with possible AIDS-associated Pneumocystis carinii pneumonia (PCP) were studied to determine the diagnostic usefulness of sputum analysis and whether or not the results of sputum analysis are related to severity of disease. Induced sputum was stained with Gomori Methenamine silver and modified Wright Giemsa stains. Indicators of disease severity were: extent of chest roentgenographic infiltrate, serum lactic dehydrogenase activity, alveolar-arterial oxygen tension difference, and total blood lymphocyte count. All patients with sputum negative for Pneumocystis underwent bronchoscopy with bronchoalveolar lavage. Sputum analysis was 71% sensitive and 100% specific for the diagnosis of PCP. The negative predictive value of sputum analysis was 48%. There was no relationship between sputum results and the severity of PCP. This study led to the conclusions that sputum analysis is a sensitive, specific, rapid, and low-cost technique for the diagnosis of PCP, and that the sensitivity of sputum analysis for the detection of PCP is not affected by the severity of PCP.

Open lung biopsy in children with diffuse pulmonary lesions

During the period 1973-81, open lung biopsy was performed in 33 consecutive children, aged 1 month to 13 years, to exclude or diagnose Pneumocystis carinii pneumonia and to differentiate other interstitial pulmonary lesions. Twenty-one of the patients were undergoing immunosuppressive treatment because of their malignant disease. The clinical diagnosis was correct only in 55% of the patients, but open lung biopsy and histological examination gave the final answer in every patient. Pneumocystis carinii was the causative organism in 67% of the immunosuppressed patients. Nine patients had postoperative complications, 5 of which were mild in nature and resolved spontaneously. Three patients had to be reoperated on for postoperative sequelae. There was one death possibly caused by surgical intervention--tension pneumothorax 10 days after surgery. It is concluded that open lung biopsy is the most reliable method in the diagnosis of diffuse interstitial pneumonitis in children. The need of anaesthesia is no contra-indication and the benefits of the biopsy far outweight the risks of its complications.

Emergency open lung biopsy

Twenty-eight patients underwent open lung biopsy on an emergency basis. The clinical course in each case was deteriorating rapidly, and all were in respiratory failure. The correct diagnosis was established in 96% of the biopsies (27 of the 28 patients). The clinical diagnosis prior to biopsy was in error or incomplete in 15 (55%) of the patients. Specific therapy was lifesaving in 12 of the 28 patients. The value of the procedure outweighed the complications. Thrombocytopenia and positive end-expiratory pressure ventilation were not contraindications to biopsy.

Pneumocystis pneumonia: the importance of early open lung biopsy

Pulmonary infection due to Pneumocystis carinii is now recognized as the leading cause of death from infection in patients with a hematologic malignancy who are in remission. Effective treatment requires suspicion of the infection in susceptible patients and rapid identification of the organism. In most patients, open lung biopsy performed through a small anterior thoracotomy provides immediate identification or exclusion of the organism, thus allowing treatment of infected patients and avoidance of inappropriate therapy in patients without the disease. We feel that the use of early thoracotomy, in spite of the fact that it exposes these very ill patients to a major surgical procedure and general anesthesia, is ultimately the safest therapeutic course.