Pneumocystitis carinii pneumonia: percutaneous lung biopsy and review of literature

Pulmonary abnormalities in inflammatory bowel disease

Extraintestinal manifestations of inflammatory bowel disease (IBD) is a common clinical problem affecting up to half of all IBD patients; pulmonary disease, however, ranks among less common extraintestinal manifestations of IBD. Pulmonary disease in patients with IBD is most frequently drug induced due to treatment with sulfasalazine or mesalamine leading to eosinophilic pneumonia and fibrosing alveolitis or due to treatment with methotrexate leading to pneumonitis. Recently, various opportunistic infections have been shown to be a further important cause of pulmonary abnormalities in those IBD patients who are treated with immunosuppressants such as anti TNF-α monoclonal antibodies, methotrexate, azathioprine or calcineurin antagonists. In not drug related pulmonary disease a wide spectrum of disease entities ranging from small and large airway dysfunction to obstructive and interstitial lung disorders exist. Patients with lung disorders and inflammatory bowel disease should be evaluated for drug-induced lung disease and opportunistic infections prior to considering pulmonary disease as an extraintestinal manifestation of inflammatory bowel disease.

Pneumonias in the compromised host

The choice of diagnostic modality depends on the patient's status, the expertise of the operator and pathologic resources of the hospital, and is a decision that should be guided by the infectious disease consultant and the clinicians involved in the care of the patient. Although the diagnosis must be tissue based, every attempt must be made to arrive at a tissue diagnosis as soon as possible in order to start specific therapy as soon as possible. It is as important to determine that the cause of the patient's pulmonary infiltrate is noninfectious versus infectious. Pulmonary embolic disease, CHF, ARDS, pulmonary hemorrhage, and pulmonary drug reactions may be reversible and require nonantimicrobially based therapies to treat the patient. Often clinicians are overwhelmed by differential diagnostic possibilities of exotic infectious disease pathogens and overlook easily treatable noninfectious disease mimics of pneumonia. Although differential diagnostic possibilities are great in the compromised host, clinicians should not be overwhelmed by diagnostic possibilities. Instead, clinicians should try to approach the patient syndromically, taking into account the degree and type of immunosuppression, the appearance and behavior of the infiltrates on the chest radiograph and the nature of the host defense defects and time relationships that will limit the differential diagnosis to relatively few diagnostic possibilities. The clinician can then treat empirically patients with presumed bacterial pneumonias and devise a diagnostic plan designed to arrive at a specific tissue diagnosis as soon as possible in patients who are likely to have nonbacterial infection of the lungs.

Lung biopsy in immunocompromised patients: one institution's experience and an approach to management of pulmonary disease in the compromised host

The authors report on their institution's experience with 53 lung biopsies, including 26 open, 22 transbronchial, and five trephine air drill biopsies, performed in immunocompromised patients with roentgenographic pulmonary infiltrates. Open biopsy was far more likely to provide a specific etiologic diagnosis (81%, P less than 0.001) than transbronchial biopsy (32%), or trephine biopsy (20%). Infection (17 biopsies), neoplastic disease, (7) or drug-related pneumonitis (2) were identified most frequently. Patients with myeloproliferative disease, granulocytopenia, or those who had not received prior immunosuppressive therapy were most likely to have a nondiagnostic biopsy (P less than 0.05 for each factor). The overall complication rate of biopsy procedures was 15% and was comparable with all three methods. Survival in this series was not significantly lower if a specific etiologic diagnosis could not be established, but correlated with the respiratory rate (less than 20 per minute), pO2 (greater than 60 torr), and the roentgenographic pattern (other than bilateral diffuse disease) at the time of biopsy (P less than 0.05 for each factor). There were 18 cases (34%) in which a clearcut etiologic diagnosis would not be established at the time of biopsy; based on serologic tests performed ex post facto, 2 of 12 of these cases (17%) were Legionnaire's disease. Lung biopsies were helpful in the management of the majority of the cases, although nondiagnostic biopsies continue to be a problem. The authors propose an approach to the management of compromised patients with pulmonary infiltrates.

Transbronchial lung biopsy via the fiberoptic bronchoscope. Experience with 107 consecutive cases and comparison with bronchial brushing

Transbronchial lung biopsy (TBB) was performed during fiberoptic bronchoscopy under fluoroscopic guidance in 107 patients. TBB was diagnostic in 17 of 21 (81 percent) cases with localized malignant lesions greater than 4 cm in diameter and bronchial brushing was positive in 12 (57 percent). TBB was diagnostic in 14 of 24 (58 percent) cases with localized malignant lesions equal to or less than 4 cm in diameter, whereas brush biopsy was positive in 7 (29 percent). In 13 cases with suspected Pneumocystis carinii pneumonia, the combination of TBB and brush biopsy was diagnostic of P carinii pneumonia in all 11 patients; TBB was diagnostic in 10 and brush biopsy diagnostic in 5. Cytomegalovirus pneumonitis was diagnosed in the other two cases. In 20 patients with localized infiltrates or nodules, a TBB diagnosis of acute or chronic inflammation excluded malignancy in 15 of 18 cases (follow-up 3 to 24 months) and tuberculosis was diagnosed in 2. Malignancy was found in one patient with acute inflammation on TBB. TBB accurately diagnosed 23 of 29 (79 percent) cases of diffuse lung disease. Following TBB, one patient had pneumothorax and nine patients had hemoptysis not requiring treatment. TBB and bronchial brushing via the flexible fiberoptic bronchoscope offer good diagnostic accuracy and a low complication rate in both diffuse and localized lung diseases.

Transbronchial forceps lung biopsy through the fiberoptic bronchoscope. tdiagnosis of diffuse pulmonary disease

Transbronchial forceps biopsy through the fiberoptic bronchoscope was performed in 37 patients. Tissue was technically inadequate for examination in two cases. A pathologic diagnosis was obtained in 26 (72 percent) and in five additional critically ill patients, direct histologic examination of lung tissue allowed exclusion of certain entities, thus significantly influencing therapy. Overall, the procedure was of value in 31 of 35 patients (90 percent). There was no significant hemorrhage and there was one 15 percent pneumothorax. The safety and high diagnostic yield of this technique in the diagnosis of diffuse lung disease is proved.

Direct fluorescent-antibody method for the diagnosis of Pneumocystis carinii pneumonitis from sputa or tracheal aspirates from humans

A direct fluorescent antibody (DFA) method was applied to sputum or tracheal aspirate from 68 patients with clinical or radiological evidence suggesting Pneumocystis carinii pneumonitis, and to 50 control patients. P. carinii was detected by DFA in specimens from 33 of the 69 clinical cases and 3 of the 50 controls. Specimens of lung from 11 of 33 DFA-positive cases were examined histologically, and 9 were positive. Four of 35 DFA-negative cases were examined histologically, and all were negative. Sputa or tracheal aspirates from 6 patients who were positive by both DFA and histological examination were examined also by methenamine silver staining; none could be diagnosed conclusively by this method. The results indicate that the DFA method is a sensitive and dependable procedure for the laboratory diagnosis of P. carinii pneumonitis in man.