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Colbenson GA, Olson EM, Nelson DR. 61-Year-Old Man With Shortness of Breath and Cough. Mayo Clin Proc 2021; 96:2243-2247. [PMID: 34226026 DOI: 10.1016/j.mayocp.2020.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/26/2020] [Accepted: 11/30/2020] [Indexed: 10/20/2022]
Affiliation(s)
- Gretchen A Colbenson
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Emily M Olson
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Darlene R Nelson
- Advisor to residents and Consultant in Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Baikunje N, Gangaramajalu S, Hosmane GB. Melioidosis: A Fulminant Infection in a Patient with Uncontrolled Diabetes. JOURNAL OF HEALTH AND ALLIED SCIENCES NU 2020. [DOI: 10.1055/s-0040-1721232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractMelioidosis is an endemic infection in Southeast Asia and Northern Australia commonly manifesting with pneumonia and localized skin infection. Though most exposures do not lead to severe illness, a fulminant infection can occur among patients with risk factors. A 59-year-old male presented with cough with expectoration and fever for 1 week. He had diabetes for 10 years with poorly controlled blood sugars. Contrast-enhanced computerized tomography (CECT) of thorax showed right upper lobe consolidation with diffuse ground-glass opacities in right upper lobe along with microabscesses in liver and spleen. Sputum culture and Xpert mycobacterium tuberculosis complex and resistance to rifampin (MTB/RIF) for tuberculosis were negative. Bronchoalveolar lavage culture grew Burkholderia pseudomallei. He was treated with initial intensive therapy with injection amoxicillin-clavulanic acid for 2 weeks and subsequently started on eradication therapy with tablet trimethoprim-sulfamethoxazole. Diagnosis of melioidosis should be considered in a patient of pneumonia with multiorgan involvement in an endemic area, especially with underlying risk factors.
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Affiliation(s)
- Nandakishore Baikunje
- Department of Pulmonary Medicine, K.S. Hegde Medical Academy, NITTE (Deemed to be University), Mangaluru, Karnataka, India
| | - Suresh Gangaramajalu
- Department of General Medicine, K.S. Hegde Medical Academy, NITTE (Deemed to be University), Mangaluru, Karnataka, India
| | - Giridhar Belur Hosmane
- Department of Pulmonary Medicine, K.S. Hegde Medical Academy, NITTE (Deemed to be University), Mangaluru, Karnataka, India
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Kim HJ, Lee JH, Yoon SH, Kim SA, Kim MS, Choi SM, Lee J, Lee CH, Han SK, Yim JJ. Nontuberculous mycobacterial pulmonary disease diagnosed by two methods: a prospective cohort study. BMC Infect Dis 2019; 19:468. [PMID: 31126235 PMCID: PMC6534935 DOI: 10.1186/s12879-019-4078-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/10/2019] [Indexed: 11/18/2022] Open
Abstract
Background Microbiological criteria for diagnosing nontuberculous mycobacterial pulmonary disease (NTM-PD) include positive culture results from at least two separately expectorated sputum specimens or one bronchial washing or lavage. However, the clinical similarities and differences between patients diagnosed by these two methods remain unclear. We compared clinical features and prognoses of patients with NTM-PD diagnosed from both specimen types. Methods We analysed data from patients who participated in the Seoul National University Hospital NTM-PD cohort (ClinicalTrials.gov identifier: NCT01616745). Baseline demographics, symptoms, radiographic findings, disease progression, and treatment responses were summarized and compared between patients diagnosed from sputum specimens and patients diagnosed from bronchoscopic specimens. Results Three hundred forty-seven patients were included in the analyses. Of these, 279 (80.4%) were diagnosed from two separately expectorated sputum specimens, and 68 (19.6%) were diagnosed from bronchoscopic specimens. Patients diagnosed from sputum specimens had more frequent and severe cough, sputum, postnasal drip, and high St. George’s Respiratory Questionnaire scores. However, the extent and severity of the radiographic lesions, disease progression, and treatment responses were similar for both groups. Further analysis based on the following three groups (sputum culture positive, sputum culture negative/bronchoscopy, and scanty sputum/bronchoscopy groups) suggested that the scanty sputum/bronchoscopy group appeared to have the worst prognosis in terms of both time to progression and time to culture conversion. Conclusions Although some symptoms and quality of life were worse in patients with NTM-PD diagnosed from sputum specimens, their prognoses were similar to those of patients diagnosed by bronchoscopic specimen. We recommend bronchoscopic sampling for patients in whom NTM-PD is suspected clinically or radiographically, especially those who have no or scanty sputum. Electronic supplementary material The online version of this article (10.1186/s12879-019-4078-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro Jongno-Gu, 03080, Seoul, Republic of Korea
| | - Jong Hyuk Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soon Ho Yoon
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung A Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro Jongno-Gu, 03080, Seoul, Republic of Korea
| | - Myoung Sil Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro Jongno-Gu, 03080, Seoul, Republic of Korea
| | - Sun Mi Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro Jongno-Gu, 03080, Seoul, Republic of Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro Jongno-Gu, 03080, Seoul, Republic of Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro Jongno-Gu, 03080, Seoul, Republic of Korea
| | - Sung Koo Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro Jongno-Gu, 03080, Seoul, Republic of Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro Jongno-Gu, 03080, Seoul, Republic of Korea.
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Michael CW, Faquin W, Jing X, Kaszuba F, Kazakov J, Moon E, Toloza E, Wu RI, Moreira AL. Committee II: Guidelines for cytologic sampling techniques of lung and mediastinal lymph nodes. Diagn Cytopathol 2018; 46:815-825. [PMID: 30195266 DOI: 10.1002/dc.23975] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 04/25/2018] [Accepted: 04/27/2018] [Indexed: 12/19/2022]
Abstract
The Papanicolaou Society of Cytopathology has developed a set of guidelines for pulmonary cytology including indications for bronchial brushings, washings, and endobronchial ultrasound guided transbronchial fine-needle aspiration (EBUS-TBNA), technical recommendations for cytological sampling, recommended terminology and classification schemes, recommendations for ancillary testing and recommendations for post-cytological management and follow-up. All recommendations are based on the expertise of the authors, an extensive literature review and feedback from presentations at national and international conferences. This document selectively presents the results of these discussions. The present document summarizes recommendations regarding techniques used to obtain cytological and small histologic specimens from the lung and mediastinal lymph nodes including rapid on-site evaluation (ROSE), and the triage of specimens for immunocytochemical and molecular studies.
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Affiliation(s)
- C W Michael
- Department of Pathology and Laboratory Medicine, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, Ohio
| | - W Faquin
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - X Jing
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - F Kaszuba
- Division of Pulmonary, Critical Care and Sleep Medicine, H. Lee Moffitt Cancer Center/University of South Florida, Tampa, Florida
| | - J Kazakov
- Department of Internal Medicine, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, Ohio
| | - E Moon
- Department of Internal Medicine, University of Pennsylvania Health System and Perelman School of Medicine, Philadelphia, Pennsylvania
| | - E Toloza
- Department of Thoracic Oncology, H. Lee Moffitt Cancer Center/University of South Florida, Tampa, Florida
| | - R I Wu
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Health system and Perelman School of Medicine, Philadelphia, Pennsylvania
| | - A L Moreira
- Department of Pathology, New York University Langone Health, New York, New York
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Athlin S, Lidman C, Lundqvist A, Naucler P, Nilsson AC, Spindler C, Strålin K, Hedlund J. Management of community-acquired pneumonia in immunocompetent adults: updated Swedish guidelines 2017. Infect Dis (Lond) 2017; 50:247-272. [PMID: 29119848 DOI: 10.1080/23744235.2017.1399316] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Based on expert group work, Swedish recommendations for the management of community-acquired pneumonia in adults are here updated. The management of sepsis-induced hypotension is addressed in detail, including monitoring and parenteral therapy. The importance of respiratory support in cases of acute respiratory failure is emphasized. Treatment with high-flow oxygen and non-invasive ventilation is recommended. The use of statins or steroids in general therapy is not found to be fully supported by evidence. In the management of pleural infection, new data show favourable effects of tissue plasminogen activator and deoxyribonuclease installation. Detailed recommendations for the vaccination of risk groups are afforded.
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Affiliation(s)
- Simon Athlin
- a Department of Infectious Diseases , Örebro University Hospital , Örebro , Sweden.,b Faculty of Medicin and Health , Örebro University , Örebro , Sweden
| | - Christer Lidman
- c Unit of Infectious Diseases, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Anders Lundqvist
- e Department of Infectious Diseases , Södra Älvsborgs Hospital , Borås , Sweden
| | - Pontus Naucler
- c Unit of Infectious Diseases, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Anna C Nilsson
- f Infectious Disease Research Unit, Department of Translational Medicine , Lund University , Malmö , Sweden
| | - Carl Spindler
- d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Kristoffer Strålin
- b Faculty of Medicin and Health , Örebro University , Örebro , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden.,g Unit of Infectious Diseases, Department of Medicine Huddinge , Karolinska Institutet , Stockholm , Sweden
| | - Jonas Hedlund
- c Unit of Infectious Diseases, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
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Abstract
Purpose of Review This article reviews the new definitions of pneumonia, discusses risk factors for pneumonia among trauma patients, presents the latest evidence for prevention strategies, discusses the best ways to make the diagnosis, and reviews the microbiology and treatment for trauma patients with pneumonia. Recent Findings Pneumonia can be prevented by decreasing the duration of mechanical ventilation using daily paired spontaneous awakening and breathing trials, but not with early tracheostomy placement. Other useful prevention strategies include semirecumbent positioning and oral care. Mini-BAL is a sensitive and specific means of securing the diagnosis of pneumonia that does not require a physician to be present and is therefore especially useful in busy trauma centers. Summary Pneumonia is a frequent complication among trauma patients. Risk factors are largely unmodifiable. However, trauma centers can institute routine daily paired spontaneous awakening and breathing trials to decrease the duration of ventilation and incidence of pneumonia. Future research is needed to further characterize the microbiology of pneumonia among trauma patients.
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Affiliation(s)
- Morgan Schellenberg
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo St, IPT C5L100, Los Angeles, CA 90033 USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo St, IPT C5L100, Los Angeles, CA 90033 USA
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Abstract
This review will focus on the infectious etiologies and more common noninfectious causes of lower respiratory tract syndromes among major immunosuppressed populations. The changing epidemiology of infections in the era of highly active antiretroviral therapy (HAART) in the case of HIV-positive patients and the impacts of both newer immune-suppressant therapies and anti-infective prophylaxis for other immunocompromised hosts will be discussed, with emphasis on diagnostic approaches and practice algorithms.
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Spindler C, Strålin K, Eriksson L, Hjerdt-Goscinski G, Holmberg H, Lidman C, Nilsson A, Ortqvist A, Hedlund J. Swedish guidelines on the management of community-acquired pneumonia in immunocompetent adults--Swedish Society of Infectious Diseases 2012. ACTA ACUST UNITED AC 2012; 44:885-902. [PMID: 22830356 DOI: 10.3109/00365548.2012.700120] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This document presents the 2012 evidence based guidelines of the Swedish Society of Infectious Diseases for the in- hospital management of adult immunocompetent patients with community-acquired pneumonia (CAP). The prognostic score 'CRB-65' is recommended for the initial assessment of all CAP patients, and should be regarded as an aid for decision-making concerning the level of care required, microbiological investigation, and antibiotic treatment. Due to the favourable antibiotic resistance situation in Sweden, an initial narrow-spectrum antibiotic treatment primarily directed at Streptococcus pneumoniae is recommended in most situations. The recommended treatment for patients with severe CAP (CRB-65 score 2) is penicillin G in most situations. In critically ill patients (CRB-65 score 3-4), combination therapy with cefotaxime/macrolide or penicillin G/fluoroquinolone is recommended. A thorough microbiological investigation should be undertaken in all patients, including blood cultures, respiratory tract sampling, and urine antigens, with the addition of extensive sampling for more uncommon respiratory pathogens in the case of severe disease. Recommended measures for the prevention of CAP include vaccination for influenza and pneumococci, as well as smoking cessation.
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Affiliation(s)
- Carl Spindler
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm.
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Park JY, Park MR, Bui HT, Kwon DN, Kang MH, Oh M, Han JW, Cho SG, Park C, Shim H, Kim HM, Kang MJ, Park JK, Lee JW, Lee KK, Kim JH. α1,3-galactosyltransferase deficiency in germ-free miniature pigs increases N-glycolylneuraminic acids as the xenoantigenic determinant in pig-human xenotransplantation. Cell Reprogram 2012; 14:353-63. [PMID: 22775484 DOI: 10.1089/cell.2011.0083] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In this study, we examined whether Hanganutziu-Deicher (H-D) antigens are important as an immunogenic non-α1,3-galactose (Gal) epitope in pigs with a disrupted α1,3-galactosyltransferase gene. The targeting efficiency of the AO blood genotype was achieved (2.2%) in pig fibroblast cells. A total of 1800 somatic cell nuclear transfer (SCNT) embryos were transferred to 10 recipients. One recipient developed to term and naturally delivered two piglets. The α1,3-galactosyltransferase activity in lung, liver, spleen, and testis of heterozygote α1,3-galactosyltransferase gene knockout (GalT-KO) pigs was significantly decreased, whereas brain and heart showed very low decreasing levels of α1,3-galactosyltransferase activity when compared to those of control. Enzyme-linked lectinosorbent assay showed that the heterozygote GalT-KO pig had more sialylα2,6- and sialylα2,3-linked glycan than the control. Furthermore, the heart, liver, and kidney of the heterozygote GalT-KO pig had a higher N-glycolylneuraminic acid (Neu5Gc) content than the control, whereas the lung of the heterozygote GalT-KO pig had Neu5Gc content similar to the control. Collectively, the data strongly indicated that Neu5Gc is a more critical xenoantigen to overcoming the next acute immune rejection in pig to human xenotransplantation.
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Affiliation(s)
- Jong-Yi Park
- Department of Animal Biotechnology, Konkuk University, Seoul, Republic of Korea
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Taylor DM, Taylor S, Ho J, Cabalag M, Hijazi R, Howden BP, Charles PGP. Effect of Nebulised Acetylcysteine on Sputum Quality and Diagnostic Yield. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2009. [DOI: 10.1002/j.2055-2335.2009.tb00699.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- David McD Taylor
- Austin Health, and Department of Medicine; University of Melbourne
| | | | | | | | | | | | - Patrick GP Charles
- Department of Infectious Diseases, Austin Health, Heidelberg, and Department of Medicine; University of Melbourne; Parkville Victoria
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Strålin K. Usefulness of aetiological tests for guiding antibiotic therapy in community-acquired pneumonia. Int J Antimicrob Agents 2008; 31:3-11. [DOI: 10.1016/j.ijantimicag.2007.06.037] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Accepted: 06/26/2007] [Indexed: 11/30/2022]
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May ML, Robson J. Microbiological diagnostic procedures in respiratory infections: suppurative lung disease. Paediatr Respir Rev 2007; 8:185-93, quiz 194. [PMID: 17868916 DOI: 10.1016/j.prrv.2007.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Pursuing a microbiological diagnosis in suppurative lung disease can enable focused antibiotic therapy, identify pathogens of potential concern for infection control, and in some cases delineate a specific pathological process. Suppurative lung disease can be categorized as acute or chronic. Acute disease most commonly consists of lung abscess or parapneumonic empyema. The vast majority of chronic suppurative lung disease in childhood is due to cystic fibrosis. Samples from the respiratory tract offer the most useful information for diagnosis and management, but adjunctive information can also be obtained from serological methods, blood cultures and molecular techniques. The quality of respiratory tract samples is vital to aid accurate interpretation of results, and this varies according to the technique of collection. Antibiotic sensitivity testing is of particular importance in an era of evolving antibiotic resistance and can be problematical in cystic fibrosis.
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Affiliation(s)
- M L May
- Department of Microbiology, Sullivan Nicolaides Pathology, Brisbane, Australia.
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Hedlund J, Strålin K, Ortqvist A, Holmberg H. Swedish guidelines for the management of community-acquired pneumonia in immunocompetent adults. ACTA ACUST UNITED AC 2006; 37:791-805. [PMID: 16358446 DOI: 10.1080/00365540500264050] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This document presents the evidence-based guidelines of the Swedish Society of Infectious Diseases for the management of adult immunocompetent patients with community-acquired pneumonia (CAP), who are assessed at hospital. The prognostic score 'CURB-65' is recommended for all CAP patients in the emergency room. The score provides an assessment tool for the decision regarding outpatient treatment or level of hospital supervision, the choice of microbiological investigations, and empirical antibiotic treatment. In patients with non-severe CAP (CURB-65 score 0-2) we recommend initial narrow-spectrum antibiotic treatment, orally or intravenously, primarily directed at Streptococcus pneumoniae. In those with CURB-65 score 3, penicillin G or a cephalosporin intravenously is recommended. For CURB-65 score 0-3 atypical pathogens should be covered only when they are suspected on clinical or epidemiological grounds. In patients with CURB-65 score 4-5 intravenous combination therapy with either cephalosporin/macrolide or penicillin G/fluoroquinolone is recommended. Efforts should be made to identify the CAP aetiology in order to support the ongoing antibiotic treatment or to suggest treatment alterations. Recommended measures for prevention of CAP include influenza -- and pneumococcal -- vaccination to risk groups and efforts for smoking cessation.
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Affiliation(s)
- Jonas Hedlund
- Department of Infectious Diseases, Karolinska University Hospital, S-17176 Stockholm, Sweden.
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Abstract
OBJECTIVES To determine the sensitivity of referral guidelines for induced sputum in pulmonary tuberculosis (PTB) case detection and determine the diagnostic yield of the test. METHODS A retrospective analysis of case notes of adult patients referred for induced sputum was carried out at the North Trent Regional Department of Infection and Tropical Medicine, the Royal Hallamshire Hospital, Sheffield, UK. Clinical characteristics were noted on patients referred during a 12-month period in 2001-2002, and of all patients with positive induced sputum results from April 1998 to March 2002. RESULTS Over a 12-month period 114 patients were referred in our unit for induced sputum sampling. Twelve of the 114 patients had positive sputum cultures giving a positive yield for the test of 10.5%. With strict adherence to our referral guidelines, 10 of the 12 positive cases (83.3%) would have been detected. With modification to the referral guidelines, all 12 microbiologically positive cases would have been detected making the guidelines 100% sensitive in detecting microbiologically positive cases among patients referred with a clinical suspicion of PTB who are unable to self-expectorate. The positive yield for the test would have been increased to 13.2%. In the past 4 years 29 patients had positive induced sputum results. Of these, 11 patients (37.9%) had concurrent microbiological proven extra-pulmonary TB (EPTB) and 10 (34.5%) had past histories of TB infection. Seven patients had chest X-rays reported as normal. CONCLUSIONS Induced sputum offers a relatively non-invasive investigation for patients with suspected PTB who are unable to bring up sputum. Induced sputum also offers a means of establishing a microbiological diagnosis in some cases of EPTB. An investigative algorithm is suggested.Summary. In an era of increasing drug resistant disease, establishing a microbiological diagnosis of TB is paramount. Sputum induction can be used as an alternative investigation to bronchoscopy in suspected PTB patients who are able to self-expectorate. Induced sputum is a sensitive investigation for suspected PTB patients but with a low diagnostic yield. Referral guidelines are suggested.
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Affiliation(s)
- David Bell
- Department of Infection and Tropical Medicine, The Royal Hallamshire Hospital, Sheffield, UK
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McWilliams T, Wells AU, Harrison AC, Lindstrom S, Cameron RJ, Foskin E. Induced sputum and bronchoscopy in the diagnosis of pulmonary tuberculosis. Thorax 2002; 57:1010-4. [PMID: 12454293 PMCID: PMC1758793 DOI: 10.1136/thorax.57.12.1010] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Previous studies suggest that bronchoscopy and a single induced sputum sample are equally effective for diagnosing pulmonary tuberculosis. METHODS In a prospective study of subjects with possibly active pulmonary tuberculosis, the diagnostic yield of three induced sputum tests was compared with that of bronchoscopy. Subjects either produced no sputum or (acid fast) smear negative sputum. Bronchoscopy was only performed if at least two induced sputum samples were smear negative. RESULTS Of 129 subjects who completed all tests, 27 (21%) had smear negative and culture positive specimens, 14 (52%) on bronchoscopy and 26 (96%) on induced sputum (p<0.005). One patient was culture positive on bronchoscopy alone compared with 13 on induced sputum alone; 13 were culture positive on both tests. Induced sputum positivity was strikingly more prevalent when chest radiographic appearances showed any features of active tuberculosis (20/63, 32%) than when appearances suggested inactivity (1/44, 2%; p<0.005). Induced sputum costs were about one third those of bronchoscopy, and the ratio of costs of the two tests per case of tuberculosis diagnosed could be as much as 1:6. CONCLUSIONS In subjects investigated for possibly active or inactive tuberculosis who produce no sputum or have smear negative sputum, the most cost effective strategy is to perform three induced sputum tests without bronchoscopy. Induced sputum testing carries a high risk of nosocomial tuberculosis unless performed in respiratory isolation conditions. The cost benefits shown could be lost if risk management measures are not observed.
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Affiliation(s)
- T McWilliams
- Respiratory Services, Green Lane Hospital, Auckland, New Zealand
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Saubolle MA, McKellar PP. Laboratory diagnosis of community-acquired lower respiratory tract infection. Infect Dis Clin North Am 2001; 15:1025-45. [PMID: 11780266 PMCID: PMC7126342 DOI: 10.1016/s0891-5520(05)70185-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This article has focused on the evaluation of outpatients with lower respiratory illness. In large part, the need for microbiological work-up is host-dependent. Healthy patients usually do well, and laboratory data are often unnecessary. The abnormal host requires a different approach and, in general, the more compromised the host, the more aggressive the laboratory evaluation. A renal transplant patient with respiratory symptoms often follows the dictum that "common things happen commonly;" however, the clinician needs that extra level of assurance in this case. Some transplant patients may have respiratory illness caused by strongyloidiasis. Cystic fibrosis is another example of the need for a more comprehensive laboratory evaluation. Specialized selective media and additional susceptibility studies may be needed to evaluate isolates associated with exacerbation of symptoms in these patients. The clinical laboratory should be forewarned of any materials coming from invasive diagnostic techniques, so they can prepare and offer useful advice regarding specimens, transport, and follow-up. Microbiological laboratories are often most knowledgeable regarding what type of testing is appropriate. Direct communication with the laboratory is essential to assure the best patient care.
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Affiliation(s)
- M A Saubolle
- Department of Medicine, University of Arizona College of Medicine, Infectious Diseases Division, Laboratory Sciences of Arizona/Sonora Quest Laboratories, Arizona, USA.
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Sagel SD, Kapsner R, Osberg I, Sontag MK, Accurso FJ. Airway inflammation in children with cystic fibrosis and healthy children assessed by sputum induction. Am J Respir Crit Care Med 2001; 164:1425-31. [PMID: 11704590 DOI: 10.1164/ajrccm.164.8.2104075] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A noninvasive method to characterize inflammation and infection in the airways of nonexpectorating children with cystic fibrosis (CF) is needed for clinical and research purposes. Accordingly, we performed sputum inductions by administering 3% saline to 11 healthy control children and 20 children with CF, composed of 7 sputum producers (capable of spontaneously expectorating sputum) and 13 nonproducers. Induced sputum weights were comparable in each group, whereas the amount of induced sputum collected from the CF producers was over 10-fold higher than the spontaneously expectorated samples. We found a significant increase in indices of airway inflammation, including total cell counts, absolute neutrophil counts, interleukin-8 (IL-8) levels, and neutrophil elastase activity in the CF subjects compared with the healthy control subjects. These same indices in the induced sputum specimens from CF producers were significantly correlated with levels in the matched expectorated sputum specimens. Sputum total protein concentration was elevated in the CF groups, whereas urea and albumin levels were not significantly different. Salivary analysis, performed separately, revealed higher levels of IL-8 and total protein in the CF groups. Airway infection, as assessed by quantitative counts of CF-related bacterial pathogens, was also higher in the CF subjects. The same bacterial pathogens, in similar colony counts, were isolated from both the induced and expectorated sputum samples from the CF producers. We conclude that airway inflammation and infection, assessed through sputum induction, are significantly increased in children with CF as compared with healthy children. Furthermore, induced sputum samples are similar to spontaneously expectorated samples in describing both inflammation and infection in the CF airway.
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Affiliation(s)
- S D Sagel
- Department of Pediatrics, University of Colorado Health Sciences Center, Denver, Colorado, USA.
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Chuard C, Fracheboud D, Regamey C. Effect of sputum induction by hypertonic saline on specimen quality. Diagn Microbiol Infect Dis 2001; 39:211-4. [PMID: 11404062 DOI: 10.1016/s0732-8893(01)00231-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Microbiologic work-up of expectorated material is routinely used to search for the etiology of pulmonary infections, but sputum is often contaminated by saliva. Inhalation of hypertonic saline induces bronchial secretions and theoretically may improve specimen quality. We compared in a laboratory-blinded, randomized study the quality of sputum obtained either with induction by saline or without induction in patients with respiratory tract infection and a history of productive cough. The quality of sputum was considered good if the polymorphonuclear neutrophils (PMNs)/squamous epithelial cells (SECs) ratio was > or = 2 or the Q (quality) score was > or = +1 on Gram stain. Forty-nine and 50 patients were able to expectorate in the induced and spontaneous sputum groups, respectively. PMNs/SECs ratio was > or = 2 in 65% and 74% of the patients in the induced and spontaneous sputum groups (p = 0.47); for the Q score, a value > or = +1 was found in 55% and 66% of the patients of each group (p = 0.37). In conclusion, sputum induction by hypertonic saline inhalation does not improve specimen quality as judged by the PMNs/SECs ratio on Gram stain.
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Affiliation(s)
- C Chuard
- Department of Medicine, Hôpital Cantonal, Fribourg, Switzerland.
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Plouffe JF, McNally C, File TM. Value of noninvasive studies in community-acquired pneumonia. Infect Dis Clin North Am 1998; 12:689-99, ix. [PMID: 9779385 DOI: 10.1016/s0891-5520(05)70205-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Noninvasive diagnostic studies, i.e., sputum gram stain, sputum culture, blood culture and antigen detection assays will assist the clinician in the selection of initial antimicrobial therapy in some patients. These tests may be even more valuable in adjusting treatment regimens to prevent the use of broad spectrum antimicrobial agents as routine therapy.
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Affiliation(s)
- J F Plouffe
- Division of Infectious Diseases, Ohio State University Medical Center, Columbus, USA
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Affiliation(s)
- P A LoBue
- University of California San Diego, USA
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Abstract
Fever is a common sign during the course of HIV infection, usually represents a superimposed opportunistic infection, and is almost always a treatable condition. Proper management generally requires detection of the underlying cause, and the diagnostic evaluation is largely driven by the clinical symptoms, associated conditions such as injection drug use, and stage of disease based largely on the absolute CD4 cell count. This article provides guidelines for the management of fever in the patient with HIV infection.
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Affiliation(s)
- M Sullivan
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Yungbluth M. The Laboratory Diagnosis of Pneumonia: The Role of the Community Hospital Pathologist. Clin Lab Med 1995. [DOI: 10.1016/s0272-2712(18)30330-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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