Bronchoscopy with bronchoalveolar lavage in tuberculosis and fungal infections

Prediction of lymph node status in patients with surgically treated head and neck squamous cell carcinoma via neck lavage cytology: A pilot study

BACKGROUND

Neck dissection is a standardized surgical procedure for patients with head and neck squamous cell carcinoma (HNSCC) and plays a critical role in the choice of adjuvant treatment based on histopathological findings. Saline irrigation is routinely performed at the end of surgery. However, this irrigant is not used for diagnostic purposes.

METHODS

Intraoperative irrigation of the neck dissection wound was performed in 56 patients with HNSCC (N = 93 neck dissections), and the cytological suspension obtained was processed via the liquid-based cytology (LBC) technique, Papanicolaou staining, and immunocytochemical staining. Microscopic preparations were screened for the presence of tumor cells and classified as positive, borderline, or negative. These results were correlated with the histopathological and clinical data.

RESULTS

Neck lavage LBC demonstrated high diagnostic value in detecting lymph node metastases (N+) with extracapsular spread (ECS), with a specificity, sensitivity, negative predictive value, and positive predictive value of 93.1%, 100%, 100%, and 80%, respectively. Tumor cells were detected in 4.8% of N- cases, 20% of N+ cases without ECS, and 100% of N+ cases with ECS. Receiver operating characteristic curve analysis showed an area under the curve of 0.8429 for the prediction of N+ (p < .0001) and 0.9658 for the prediction of N+ with ECS (p < .0001).

CONCLUSIONS

Differential lavage cytology can provide valid and rapid information on the lymph node status in patients with HNSCC and showed an excellent correlation with histopathology. Thus, neck lavage LBC may facilitate faster and more reasonable planning of adjuvant treatment and help improve the therapeutic management of patients with HNSCC.

Cytopathological Findings in Bronchoalveolar Lavage from Patients with COVID-19

Information on cellular analysis of bronchoalveolar lavage (BAL) in patients with COVID-19 is limited. Some studies have described an increase in lymphocyte percentage or exuberant plasmacytosis. Some reports addressed the importance of molecular testing on BAL samples to confirm COVID-19 pneumonia, in clinically highly suspected patients with consecutive negative nasopharyngeal swab results. In addition to atypical lymphocytes in the peripheral blood, morphologic findings of atypical lymphocytes in BAL were also reported in a few patients. The objective of this study was to describe the cytopathic characteristics identified, any data presented here are descriptives and intended to trigger further research. Three general aspects have been evaluated in each sample: reactive changes, virus-related pathological changes, and differential leukocyte count. Seventeen samples were collected. All samples were negative for malignancy, with an inflammatory background, predominantly lymphohistiocytic in 5 samples, histiocytic in 9, and 3 with predominantly neutrophilic. Hemosiderin-laden macrophages were observed in 12/17. Nonspecific reactive cell changes were identified in 4 samples, including bronchial, alveolar, and reserve cell hyperplasia. Virus-related pathological changes were observed in 14 samples, such as loss of nuclear chromatin pattern, lymphocytes with atypical nuclei, nuclear and cytoplasmic inclusions, multinucleations in bronchial cells and macrophages, or multinucleated giant cells. The identification of multinucleated giant cells could represent a cytopathic effect induced by the virus, at the same time the nuclear clearance of pneumocytes as a possible direct effect. BAL is a procedure aimed at obtaining cells from the respiratory tract that can provide valuable and rapid information. It is important to collect and describe as many cytopathological findings as possible, which can provide relevant information for future studies.

Use of uncoated magnetic beads to capture Mycobacterium smegmatis and Mycobacterium avium paratuberculosis prior detection by mycobacteriophage D29 and real-time-PCR

Uncoated tosyl-activated magnetic beads were evaluated to capture Mycobacterium smegmatis and Mycobacterium avium subspecies paratuberculosis (MAP) from spiked feces, milk, and urine. Centrifugation and uncoated magnetic beads recovered more than 99% and 93%, respectively, of 1.68 × 10⁷ CFU/mL, 1.68 × 10⁶ CFU/mL and 1.68 × 10⁵ CFU/mL M. smegmatis cells resuspended in phosphate buffer saline. The use of magnetic beads was more efficient to concentrate cells from 1.68 × 10⁴ CFU/mL of M. smegmatis than centrifugation. Likewise, the F57-qPCR detection of MAP cells was different whether they were recovered by beads or centrifugation; cycle threshold (Ct) was lower (p < 0.05) for the detection of MAP cells recovered by beads than centrifugation, indicative of greater recovery. Magnetic separation of MAP cells from milk, urine, and feces specimens was demonstrated by detection of F57 and IS900 sequences. Beads captured no less than 10⁹ CFU/mL from feces and no less than 10⁴ CFU/mL from milk and urine suspensions. In another detection strategy, M. smegmatis coupled to magnetic beads were infected by mycobacteriophage D29. Plaque forming units were observed after 24 h of incubation from urine samples containing 2 × 10⁵ and 2 × 10³ CFU/mL M. smegmatis. The results of this study provide a promising tool for diagnosis of tuberculosis and Johne's disease.

Cellular and Biochemical Analysis of Bronchoalveolar Lavage Fluid from Murine Lungs

Bronchoalveolar lavage (BAL) is a technique used to collect the contents of the airways. The fluid recovered, called BAL fluid (BALF), serves as a dynamic tool to identify various disease pathologies ranging from asthma to infectious diseases to cancer in the lungs. A wide array of tests can be performed with BALF, including total and differential leukocyte counts (DLC), enzyme-linked immunosorbent assays (ELISA) or flow-cytometric quantitation of inflammatory mediators, such as cytokines, chemokines and adhesion molecules, and assessment of nitrate and nitrite content for estimation of nitric oxide synthase (NOS) activity. Here, we describe a detailed procedure for the collection of BALF for a variety of downstream usages, including DLC by cytological and flow-cytometry-based methods, multiplex cytokine analysis by flow cytometry, and NOS activity analysis by determining nitrate and nitrite levels.

Usefulness of CT-Guided Percutaneous Transthoracic Needle Lung Biopsies in Patients with Suspected Pulmonary Infection

Objective

This study aimed to evaluate the clinical benefits and risks of CT-guided percutaneous transthoracic needle lung biopsies (PTNBs) in patients with a suspected pulmonary infection.

Materials and Methods

This study included 351 CT-guided PTNBs performed in 342 patients (mean age, 58.9 years [range, 17–91 years]) with suspected pulmonary infection from January 2010 to December 2016. The proportion of biopsies that revealed the causative organism for pulmonary infection and that influenced patient's treatment were measured. Multivariate analyses were performed to identify factors associated with PTNB that revealed the causative organism or affected the treatment. Finally, the complication rate was measured.

Results

CT-guided PTNB revealed the causative organism in 32.5% of biopsies (114/351). The presence of necrotic components in the lesion (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1–2.7; p = 0.028), suspected pulmonary tuberculosis (OR, 2.0; 95% CI, 1.2–3.5; p = 0.010), and fine needle aspiration (OR, 2.5; 95% CI, 1.1–5.8; p = 0.037) were factors associated with biopsies that revealed the causative organism. PTNB influenced patient's treatment in 40.7% (143/351) of biopsies. The absence of leukocytosis (OR, 1.9; 95% CI, 1.0–3.7; p = 0.049), presence of a necrotic component in the lesion (OR, 2.4; 95% CI, 1.5–3.8; p < 0.001), and suspected tuberculosis (OR, 1.7; 95% CI, 1.0–2.8; p = 0.040) were factors associated with biopsies that influenced the treatment. The overall complication rate of PTNB was 19% (65/351).

Conclusion

In patients with suspected pulmonary infection, approximately 30–40% of CT-guided PTNBs revealed the causative organism or affected the treatment. The complication rate of PTNB for suspected pulmonary infection was relatively low.

Role of bronchoalveolar lavage in diagnosing pulmonary infections and malignancies: Experience from a tertiary care center

BACKGROUND

Bronchoalveolar lavage (BAL), is a safe, minimally invasive procedure to sample the terminal airways and the lung parenchyma. Although frequently used, there is lack of contemporary literature regarding the diagnostic utility of BAL for various pulmonary diseases. This study was conducted to evaluate the utility of BAL in diagnosis of various pulmonary pathologies, both infectious and neoplastic.

METHODS

This was a retrospective study performed over a period of 2 years. All the BAL samples reported on cytology were studied, their clinical details were retrieved, and the corresponding smears were reviewed. Cyto-histopathologic correlation was done, wherever possible.

RESULTS

There were a total of 1835 cases (1153 men, 682 women; age, 8 months to 78 years). Of these, 19 (1%) cases were assessed as inadequate for opinion. In 348 (19%) cases, specific infective cause could be identified on BAL cytology alone. Tuberculosis and fungal infections could be diagnosed in 165 (9%) and 178 (9.7%) cases respectively. There were 46 (2.5%) neoplasms, including adenocarcinoma (n = 20), squamous cell carcinoma (n = 5), small cell carcinoma (n = 2), Langerhans cell histiocytosis (n = 1), suspicious for malignancy (n = 15) and metastatic carcinoma (n = 3). Some rare diagnoses were also reported on BAL cytology, including sarcoidosis, actinomycosis, leishmaniasis, pulmonary alveolar proteinosis and metastatic papillary carcinoma of the thyroid.

CONCLUSION

BAL is a safe and useful procedure for primary diagnosis of infections such as tuberculosis and fungal infections, which has special significance in developing nations where prevalence of such infections is high. In addition, BAL has the potential to diagnose both primary as well as secondary malignant lung lesions.

Pleural tuberculosis

A 35-year-old woman with previously untreated latent tuberculosis was admitted to the hospital for management of a right-sided empyema. After a prolonged hospitalization and several interventions, including chest tubes, bronchoscopy with bronchoalveolar lavage, and a video-assisted thoracoscopic surgery, positive acid-fast bacilli cultures on the initial thoracentesis ultimately led to the diagnosis of pleural tuberculosis. This case highlights the importance of utilizing a combination of diagnostic tests to diagnose pleural tuberculosis, especially in the setting of a negative pleural adenosine deaminase level.

Diagnostic utility of bronchoalveolar lavage

Introduction:

Bronchoalveolar lavage (BAL) is a diagnostic procedure by which cells and other components from bronchial and alveolar spaces are obtained for various studies. One of the main advantages of BAL is that it can be done as a day care procedure. Material obtained by BAL can give a definite diagnosis in conditions such as infections and malignancies.

Aims:

The aims and objective of this study were to assess the utility of BAL as a diagnostic tool to determine the diagnostic accuracy of the material obtained from BAL in various infections and neoplastic lesions to study the limitations of BAL in certain lung disorders.

Materials and Methods:

This study was done in a tertiary care center in Hyderabad. Bronchoscopy was done as an outpatient procedure and lavage fluid obtained analyzed. This is a prospective study done from January 2012 to Jun 2013. Ninety-one BALs were analyzed for total and differential count, microbiological examination and cytological evaluation. Cases selected included nonresolving pneumonias, diffuse lung infiltrates, infiltrates in immunosuppressed hosts and ventilator-associated pneumonias.

Results:

Bronchoalveolar lavage was done in 91 cases over a period of 1½ years. Definite diagnosis was not given in 7 cases. Four cases were inadequate. Tuberculosis was diagnosed in 22 cases, fungal infections in 7 cases. Thirty-eight cases of bacterial pneumonias were diagnosed, Klebsiella was the most common organism. Malignancy was diagnosed in 13 cases.

Conclusion:

Definite diagnosis can be made in tuberculosis, fungal infections, bacterial pneumonias and in malignancies.

Respiratory mechanics and results of cytologic examination of bronchoalveolar lavage fluid in healthy adult alpacas

OBJECTIVE

To evaluate respiratory mechanical function and bronchoalveolar lavage (BAL) cytologic results in healthy alpacas.

ANIMALS

16 client-owned adult alpacas.

PROCEDURES

Measurements of pulmonary function were performed, including functional residual capacity (FRC) via helium dilution, respiratory system resistance via forced oscillatory technique (FOT), and assessment of breathing pattern by use of respiratory inductive plethysmography (RIP) in standing and sternally recumbent alpacas. Bronchoalveolar lavage was performed orotracheally during short-term anesthesia.

RESULTS

Mean ± SD measurements of respiratory function were obtained in standing alpacas for FRC (3.19 ± 0.53 L), tidal volume (0.8 ± 0.13 L), and respiratory system resistance at 1 Hz (2.70 ± 0.88 cm H(2)O/L/s), 2 Hz (2.98 ± 0.70 cm H(2)O/L/s), 3 Hz (3.14 ± 0.77 cm H(2)O/L/s), 5 Hz (3.45 ± 0.91 cm H(2)O/L/s), and 7 Hz (3.84 ± 0.93 cm H(2)O/L/s). Mean phase angle, as a measurement of thoracoabdominal asynchrony, was 19.59 ± 10.06°, and mean difference between nasal and plethysmographic flow measurements was 0.18 ± 0.07 L/s. Tidal volume, peak inspiratory flow, and peak expiratory flow were significantly higher in sternally recumbent alpacas than in standing alpacas. Cytologic examination of BAL fluid revealed 58.52 ± 12.36% alveolar macrophages, 30.53 ± 13.78% lymphocytes, 10.95 ± 9.29% neutrophils, 0% mast cells, and several ciliated epithelial cells.

CONCLUSIONS AND CLINICAL RELEVANCE

Pulmonary function testing was tolerated well in nonsedated untrained alpacas. Bronchoalveolar lavage in alpacas yielded samples with adequate cellularity that had a greater abundance of neutrophils than has been reported in horses.

Study of bronchoalveolar lavage in clinically and radiologically suspected cases of pulmonary tuberculosis

CONTEXT

About 30 to 50 % of pulmonary tuberculosis patients have sputum report negative for acid fast bacilli or present with no expectoration. A lot of research is going on to find methods to establish early and accurate diagnosis of pulmonary tuberculosis (PTB) as institutions of early treatment can have significant effects on morbidity and mortality of patients and also the development of MDR-TB. Samples other than sputum play an important role in the diagnosis of disease in such patients.

AIMS

To assess the significance of bronchoalveolar lavage samples and fiberoptic bronchoscopy (FOB) in the early diagnosis of occult sputum smear negative pulmonary tuberculosis.

SETTINGS AND DESIGN

Study was conducted in a tertiary care hospital. FOB was performed in patients with three consecutive sputum smear negative acid fast bacilli to obtain bronchoalveolar lavage (BAL) samples. Written informed consent was obtained from these patients.

MATERIALS AND METHODS

BAL samples were subjected to Z-N staining and culture on L-J slopes for acid fast bacilli. Sputum samples from the same patients were also cultured.

RESULTS

BAL samples were positive in 82.2% of sputum smear negative samples. Culture positivity of BAL samples was 90.9% as compared to sputum culture positivity which was 26.4%. Overall diagnosis could be established in 86.6% of patients with the help of fiber optic bronchoscopy.

CONCLUSIONS

BAL samples are very useful in early sputum smear negative pulmonary tuberculosis and FOB can play an important role in diagnosis of lower respiratory tract infections with minimal complications in hands of an expert.

Comparison of acid-fast stain and culture for Mycobacterium tuberculosis in pre- and post-bronchoscopy sputum and bronchoalveolar lavage in HIV-infected patients with atypical chest X-ray in Ethiopia

BACKGROUND:

Smear-negative tuberculosis occurs more frequently in human immunodeficiency virus (HIV)-infected patients than in non-HIV-infected patients. Besides, there are substantial numbers of patients who cannot produce sputum, making the diagnosis of pulmonary tuberculosis (PTB) difficult.

AIMS:

To evaluate the relative yield of pre- and post-bronchoscopy sputum and bronchoalveolar lavage (BAL) in ‘sputum smear’-negative, HIV-positive patients.

SETTINGS:

A tertiary care referral hospital in Addis Ababa.

MATERIALS AND METHODS:

Acid-fast stain (AFS) using the concentration technique was done on 85 pre-bronchoscopy sputum and 120 BAL samples. Direct AFS was done on all BAL and 117 post-bronchoscopy sputum samples. Culture for Mycobacterium tuberculosis (MTB) was done for all sputa and BAL.

RESULTS:

MTB was isolated from 26 (21.7%), 23 (19.7%) and 13 (15.3%) of BAL, post- and pre-bronchoscopy sputum cultures respectively. AFS on pre-bronchoscopy sputum using concentration technique and direct AFS on BAL together detected 11 (41%) of the 27 culture-positive cases. In patients who could produce sputum, the sensitivity of pre-bronchoscopy sputum culture (13/85, 15.3%) was comparable to BAL (12/85, 14%) and post-bronchoscopy sputum (12/85, 14%). In patients who could not produce sputum, however, both BAL (12/35, 40%) and post-bronchoscopy sputum (12/32, 31.4%) detected significantly more patients than those who could produce sputum (P=0.002, P=0.028 respectively).

CONCLUSION:

In HIV-infected patients, AFS by concentration method on pre-bronchoscopy sputum and direct AFS on BAL in patients who cannot produce sputum are the preferred methods of making a rapid diagnosis. BAL culture seems to add little value in patients who can produce sputum; therefore, bronchoscopy should be deferred under such circumstances.

The value of fiberoptic bronchoscopy in culture-positive pulmonary tuberculosis patients whose pre-bronchoscopic sputum specimens were negative both for smear and PCR analyses

OBJECTIVE

This study assessed the diagnostic rate of pulmonary tuberculosis (PTB) using fiberoptic bronchoscopy (FBS) in patients with suspected PTB, and negative pre-bronchoscopy smear and polymerase-chain reaction (PCR) in sputum.

PATIENTS AND METHODS

We retrospectively reviewed 201 culture-positive PTB patients that underwent FBS because both smear and PCR results in sputum were negative. The positive rates of smear for acid fast bacilli, PCR for Mycobacterium tuberculosis, the presence of granuloma in transbronchial biopsy (TBB), and culture of M. tuberculosis were analyzed. In addition, the radiographic features, contribution of FBS to rapid and/or definitive diagnosis of PTB, and drug susceptibility results of M. tuberculosis were also reviewed.

RESULTS

There were 136 males and 102 patients under the age of 40 years; non-cavitary (156 cases) and minimal disease (119 cases) on radiographs predominated. The positive rates of FBS were: 44% (smear), 62% (PCR), 61% (TBB), and 87% (culture). These rates increased in smear and PCR examinations when taken from wider spread shadows on radiographs. The combination of the various bronchoscopy samples increased the diagnostic rate to 92% when all examinations were combined. Positive culture results depended on FBS procedures in 80 cases. Twenty-one cases showed resistance to at least one of the major anti-tuberculous agents.

CONCLUSION

This analysis revealed high positive rates of PTB from bronchoscopy samples, providing rapid and definitive ability for PTB diagnosis, and details of drug susceptibility. Therefore, FBS is an important diagnostic procedure in patients with suspected PTB whose sputum specimens were negative both for smear and PCR analyses.

Diagnostic accuracy of in-house PCR for pulmonary tuberculosis in smear-positive patients: meta-analysis and metaregression

In-house PCR (hPCR) could speed differential diagnosis between tuberculosis (TB) and nontuberculous mycobacterial disease in patients with positive smears and pulmonary infiltrates, but its reported accuracy fluctuates across studies. We conducted a systematic review and meta-analysis of hPCR sensitivity and specificity for smear-positive TB diagnosis, using culture as the reference standard. After searching English language studies in MEDLINE and EMBASE, we estimated cumulative accuracy by means of summary receiver operating characteristic analysis. The possible influence of hPCR procedures and study methodological features on accuracy was explored by univariate metaregression, followed by multivariate adjustment of items selected as significant. Thirty-five articles (1991 to 2006) met the inclusion criteria. The pooled estimates of the diagnostic odds ratio, sensitivity, and specificity (random-effect model) were, respectively, 60 (confidence interval [CI], 29 to 123), 0.96 (CI, 0.95 to 0.97), and 0.81 (CI, 0.78 to 0.84), but significant variations (mainly in specificity) limit their clinical applicability. The quality of the reference test, the detection method, and real-time PCR use explained some of the observed heterogeneity. Probably due to the limited study power of our meta-analysis and to the wide differences in both laboratory techniques and methodological quality, only real-time PCR also displayed a positive impact on accuracy in the multivariate model. Currently, hPCR can be confidently used to exclude TB in smear-positive patients, but its low specificity could lead to erroneous initiation of therapy, isolation, and contact investigation. As the inclusion of samples from treated patients could have artificially reduced specificity, future studies should report mycobacterial-culture results for each TB and non-TB sample analyzed.

Current evidence on diagnostic accuracy of commercially based nucleic acid amplification tests for the diagnosis of pulmonary tuberculosis

BACKGROUND

Even though commercial nucleic acid amplification tests (NAATs) have become the most frequently used molecular tests for laboratory diagnosis of pulmonary tuberculosis (TB), published studies report variable estimates of their diagnostic accuracy. We analysed the accuracy of commercial NAATs for the diagnosis of pulmonary TB in smear positive and smear negative respiratory samples using culture as a reference standard.

METHODS

English language studies reporting data sufficient for calculating sensitivity and specificity of commercial NAATs on smear positive and/or smear negative respiratory samples were included. Meta-regression was used to analyse associations with reference test quality, the prevalence of TB, sample and test type. Predictive values for different levels of pre-test probability were quantified using Bayes' approach.

RESULTS

Sixty three journal articles published between 1995 and 2004 met the inclusion criteria. Pooled sensitivity and specificity were 0.96 and 0.85 among smear positive samples and 0.66 and 0.98 among smear negative samples. The number of culture media used as reference test, the inclusion of bronchial samples, and the TB prevalence were found to influence the reported accuracy. The test type had no effect on the diagnostic odds ratio but seemed to be correlated with sensitivity or specificity, probably via a threshold effect.

CONCLUSIONS

Commercial NAATs can be confidently used to exclude TB in patients with smear positive samples in which environmental mycobacteria infection is suspected and to confirm TB in a proportion of smear negative cases. The methodological characteristics of primary studies have a considerable effect on the reported diagnostic accuracy.

Comparative analysis of various cytohistological techniques in diagnosis of lung diseases

A prospective study was conducted on 100 patients divided in two groups who underwent fiberoptic bronchoscopy (FOB). Group I consisted of 60 cases of suspected lung malignancy on clinical and radiological examination, while group II consisted of 40 cases of nonneoplastic lung diseases. Pre-FOB sputum, bronchoalveolar lavage (BAL), and bronchial brushing (BB) were done in all the cases, while forceps biopsy (FB), transbronchial needle aspiration (TBNA), and transthoracic needle aspiration were done in 56, 25, and 15 patients, respectively. BB and FB showed a sensitivity of 70.83 and 70% respectively in the diagnosis of malignancy. BAL was found to be positive in 37.5% patients. TBNA had the highest sensitivity of 83.33% whereas pre-FOB sputum and post-FOB sputum were positive only in 27.58 and 29.06% cases. In nonneoplastic group, BAL showed sensitivity of 80 and 83.33% in diagnosing tuberculosis and fungal diseases whereas BB was positive in 60 and 66.66% patients, respectively. Thus a combination of various cytohistological techniques results in a statistically significant increase in the diagnostic yield of various neoplastic and nonneoplastic lung diseases. BB, FB, and TBNA are complimentary in diagnosis of various lung malignancies whereas BAL is a useful procedure in detection of infectious diseases.

The diagnosis of tuberculosis

Diagnostic testing for tuberculosis has remained unchanged for nearly a century, but newer technologies hold the promise of a true revolution in tuberculosis diagnostics. New tests may well supplant the tuberculin skin test in diagnosing latent tuberculosis infection in much of the world. Tests such as the nucleic acid amplification assays allow more rapid and accurate diagnosing of pulmonary and extrapulmonary tuberculosis. The appropriate and affordable use of any of these tests depends on the setting in which they are employed.

Fungal infections as a complication of therapy for sarcoidosis

BACKGROUND

Treatment of symptomatic sarcoidosis usually includes systemic immunosuppressive agents. These agents may render the patient more susceptible to opportunistic infections. In addition, the fungal infection may be difficult to distinguish from the underlying sarcoidosis.

AIM

To examine the presentation and management of invasive fungal infections in sarcoidosis patients.

DESIGN

Retrospective record review.

METHODS

We reviewed the notes of all sarcoidosis patients (n = 753) seen at our clinic over an 18-month period.

RESULTS

Seven patients (0.9%) with previously diagnosed sarcoidosis developed fungal infections: two each with Histoplasma capsulatum and Blastomyces dermatitidis and three others with Cryptococcus neoformans. No cases of invasive aspergillus or tuberculosis were identified. The diagnosis of fungal infection was made by bronchoscopy (four cases), open-lung biopsy (one case), bone-marrow aspirate (one case), and spinal fluid examination (one case). All patients were receiving corticosteroids at the time of worsening chest X-ray or clinical status. Four patients were also receiving methotrexate prior to infection. No patient with systemic fungal infection was receiving either infliximab or cyclophosphamide. All patients responded to anti-fungal therapy and a reduction in immunosuppression.

DISCUSSION

Fungal infections occur rarely in treated patients with sarcoidosis. Deterioration of chest X-ray, especially a localized infiltrate, warrants investigation.

Pulmonary sarcoidosis

Pulmonary sarcoidosis is one of the most common causes of idiopathic interstitial lung disease. Clinical presentation can range from asymptomatic to respiratory failure. Although some patients never require therapy, many patients with pulmonary sarcoidosis become symptomatic enough to require therapy. Treatment options include corticosteroids.In the past few years, alternatives to corticosteroids have been developed,especially for patients with a chronic condition.

Urban Tuberculosis: The New Face of an Old Problem

Tuberculosis (TB) persists as a worldwide health crisis. Nearly one third of the world's population is infected with TB and it remains a critical public health issue. In the past two decades, international efforts have focused on improving identification of those infected with TB as well as supporting molecular microbiologists in developing better diagnostic techniques. Furthermore, implementation of programs such as directly observed therapy have assisted more patients in receiving and completing therapy. This review aims to identify some of the more relevant findings in the field of TB over the past few years with a special emphasis on TB in urban communities.

Adenosine deaminase activity in bronchoalveolar lavage in Turkish patients with smear negative pulmonary tuberculosis

The sputum smear-negative patients have been a diagnostic challenge for health professionals. Adenosine deaminase (ADA) activity has been shown to rise in various body fluids of patients with tuberculosis (Tb). A prospective clinical trial was conducted to determine the diagnostic value of ADA activity in bronchoalveolar lavage (BAL) in sputum smear-negative subjects highly suggestive for pulmonary Tb. Nineteen (M/F: 15/4, mean age 46.8 +/- 16.5 years) sputum smear-negative patients highly suggestive for pulmonary Tb constituted Group I. Acid fast bacilli (AFB) grew on sputum and/or BAL culture of all subjects in this group. Twenty-nine patients (M/F: 19/10, mean age 55.7 +/- 8.0 years) with non-tuberculous pulmonary diseases constituted Group II. Ten of them had interstitial lung disease, nine lung cancer, five pneumonia and five COPD. Twelve subjects (M/F: 7/5, mean age 48.4 +/- 12.8 years) constituted the controls (Group III) undergoing fiberoptic bronchoscopy (FOB) for various indications and the lungs were found to be normal eventually. Albumin and ADA activity levels were measured in plasma and BAL in all the subjects. LocalADA was calculated. PlasmaADA and BALADA of Group I was significantly higher (P < 0.001) than that of the other groups. LocalADA was also the highest in Group I when compared with the others (P < 0.001) but that of Group II was also higher (P < 0.01) when compared with controls. With a cut-off value derived from the control subjects, sensitivity of BALADA was 100% and specificity 85.3%. Sputum PCR results are available in a couple of days whereas that of BALADA are available in a couple of hours and BALADA costs cheaper than PCR in our country. Therefore, we conclude that BALADA may be a useful, cheaper and faster diagnostic test in sputum smear-negative patients highly suggestive for pulmonary Tb. LocalADA need not be calculated as it is also significantly higher in Group II subjects and thus not as reliable as BALADA.

Role of bronchoalveolar lavage in interstitial lung disease

Bronchoalveolar lavage remains an important research tool in understanding ILD. It is still an important part of the clinical management of patients with ILD. It is most useful in detecting unusual forms of ILD. It helps the clinician narrow down the possible causes of the interstitial pattern. It also can confirm a clinical impression of certain conditions. Although rarely diagnostic, it is often supportive. In conjunction with high-resolution CT scan, most patients with ILD can be diagnosed using relatively noninvasive methods.

Sterols of Pneumocystis carinii hominis organisms isolated from human lungs

The opportunistic pathogen Pneumocystis carinii causes pneumonia (P. carinii pneumonia, or PCP) in immunocompromised individuals such as AIDS patients. Rat-derived P. carinii carinii organisms have distinct sterols which are not synthesized by mammals and not found in other microbes infecting mammalian lungs. The dominant sterol present in the organism is cholesterol (which is believed to be scavenged from the host), but other sterols in P. carinii carinii have an alkyl group at C-24 of the sterol side chain (C(28) and C(29) 24-alkylsterols) and a double bond at C-7 of the nucleus. Recently, pneumocysterol (C(32)), which is essentially lanosterol with a C-24 ethylidene group, was detected in lipids extracted from a formalin-fixed human P. carinii-infected lung, and its structures were elucidated by gas-liquid chromatography, mass spectrometry, and nuclear magnetic resonance spectrometry in conjunction with analyses of chemically synthesized authentic standards. The sterol composition of isolated P. carinii hominis organisms has yet to be reported. If P. carinii from animal models is to be used for identifying potential drug targets and for developing chemotherapeutic approaches to clear human infections, it is important to determine whether the 24-alkylsterols of organisms found in rats are also present in organisms in humans. In the present study, sterol analyses of P. carinii hominis organisms isolated from cryopreserved human P. carinii-infected lungs and from bronchoalveolar lavage fluid were performed. Several of the same distinct sterols (e.g., fungisterol and methylcholest-7-ene-3beta-ol) previously identified in P. carinii carinii were also present in organisms isolated from human specimens. Pneumocysterol was detected in only some of the samples.

Detection of non-infectious conditions mimicking pneumonia in the intensive care setting: usefulness of bronchoalveolar fluid cytology

The present study investigated the usefulness of bronchoalveolar (BAL) fluid cytology in the identification of non-infectious pulmonary conditions in patients hospitalized in the intensive care unit (ICU) and suspected of pneumonia. A total of 182 BAL fluid samples obtained during a 27-month period from 130 ICU patients with suspected pneumonia were quantitatively cultured and investigated for opportunistic pathogens. Cytocentrifuged preparations stained with the May-Grünwald Giemsa and Perls's methods were reviewed. A non-infectious aetiology was considered when cultures yielded micro-organisms in quantities < 10(3) colony-forming units (CFU) per ml, in the absence of any other pathogen and in conjunction with one or more of the following cytological findings: > 20% haemosiderin macrophages, > 10% lymphocytes, the presence of activated lymphocytes, plasma cells, > 5% eosinophils, a preponderance of foamy macrophages, reactive type II pneumocytes or malignant cells. Patients' clinical records were reviewed to identify a clinical diagnosis for these episodes. In thirty-five (19.2%) BAL fluid samples from 26 patients, the cytological findings pointed to a non-infectious origin. An alternative diagnosis was ascertained in 20 of 26 patients. Diagnoses included: drug-induced pneumonitis (n = 7), aspiration of gastric contents (n = 2), pulmonary emboli (n = 3), adult respiratory distress syndrome (n = 4), lung contusion (n = 1), cardiogenic pulmonary oedema (n = 1), and carcinomatous lymphangitis (n = 2). The BAL fluid cytological findings were readily discernable and proved to be useful in the diagnostic work-up of samples obtained from ICU patients with suspected pneumonia.

BAL fluid cytology in the assessment of infectious lung disease

The need for rapid laboratory results has marked the application of bronchoalveolar lavage (BAL) fluid cytology as a valuable tool in the assessment of infectious lung conditions. The techniques of BAL fluid processing presented here can be performed in a microbiological laboratory. The diagnostic value of BAL fluid cytology for the prediction of ventilator-associated pneumonia is discussed.

[Usefulness of routine investigation of fungal infections through bronchoscopy in HIV-infected and non-HIV-infected patients in a general hospital, reference to AIDS]

The diagnostic yields and the spectrum of pulmonary fungal-infection obtained in samples collected by fiberoptic bronchoscopy from HIV-positive and HIV-negative patients were evaluated from 1990 to 1995. A total of 1943 bronchoscopies were performed during this period, 47% in the HIV-positive group and 53% in the HIV-negative group. Of 908 HIV-positive patients, 38 (4%) had a fungus isolated from the pulmonary sample whereas of 1035 HIV-negative patients, only 4 (0.2%) had a fungus isolated. Histoplasmosis and Cryptococcosis were more frequently found in HIV-positive than in HIV-negative patients (p < 0.001). Paracoccidioides brasiliensis was found in only 3 patients, all of them immunocompetent. The study demonstrated that, despite the low yields, the HIV-positive group may benefit from routine screening for fungal elements in specimens obtained by fiberoptic bronchoscopy.

Comparison of bronchoalveolar lavage cell findings in complete-resolution pneumonia and delayed-resolution pneumonia

BACKGROUND

In some patients with bacterial pneumonia, the resolution of chest radiograph shadows are delayed. There have been many clinical and pathological studies on delayed-resolution pneumonia (DR). However, there are no reports concerning inflammatory cell findings of bronchoalveolar lavage (BAL) fluid in patients with DR. We compared the BAL fluid cell findings in patients with DR with those in patients with complete-resolution pneumonia (CR).

METHODS

The subjects included six patients whose chest radiograph shadows were completely resolved within 2 weeks after an appropriate antibiotic administration (CR), and nine patients whose chest radiograph shadows were unresolved more than 2 weeks after the treatment (DR). BAL was done 2-3 weeks after the antibiotic treatment in both groups. We compared differential counts and lymphocyte subsets in BAL fluid among patients with CR, patients with DR, and asymptomatic subjects.

RESULTS

There were no significant differences in BAL fluid cell findings between CR groups and asymptomatic groups. On the other hand, the percentages of lymphocytes, neutrophils and eosinophils in DR group were significantly increased compared with those in CR and normal groups. There was no significant difference in the CD4+/CD8+ ratio of BAL lymphocytes among the three groups.

CONCLUSIONS

It is suggested that infiltration of inflammatory cells in the lung exists in DR, despite the disappearance of inflammatory reaction in the peripheral blood.

Detection of Mycobacterium tuberculosis in bronchoalveolar lavage from patients with sputum smear-negative pulmonary tuberculosis using a polymerase chain reaction assay

The objective of this study was to evaluate the utility of a polymerase chain reaction (PCR) assay in detecting Mycobacterium tuberculosis in bronchoalveolar lavage (BAL) specimens of patients suspected of having active pulmonary tuberculosis (TB) but who were sputum smear-negative. Patients undergoing investigation for suspected pulmonary TB at the University Hospital, Kuala Lumpur, and who were sputum smear-negative underwent fibreoptic bronchoscopy and BAL. One portion of each lavage specimen was submitted for smear examination for acid-fast bacilli and mycobacterial culture and the other portion assayed by PCR for the presence of a 562-base pair DNA segment belonging to the insertion sequence IS986, unique to the M. tuberculosis complex. As controls, lavage specimens from patients with other lung lesions were also similarly tested. The PCR assay gave a positivity rate of 80.9% (55 of 68) compared with 8.8% of smear examination and 7.4% of culture for detecting M. tuberculosis in BAL specimens. The assay was positive in two of 45 BAL specimens from 35 control subjects. The PCR assay was more sensitive than smear and culture in detecting M. tuberculosis in BAL specimens of patients with sputum smear-negative pulmonary TB.

Diagnosis of lower respiratory tract infections: what we have and what would be nice

STUDY OBJECTIVES

To review the various methods used to diagnose lower respiratory tract infections.

DESIGN

Review of literature with appropriate references to various techniques proposed to diagnose pneumonia.

INTERVENTION

Compare and contrast different proposed approaches to diagnose pneumonia.

RESULTS

Bronchoscopic techniques appear more clear cut for certain nonbacterial pathogens. Their role in immunocompromised patients is more clear cut, while in the nonimmunocompromised patient, invasive diagnostic techniques probably provide a higher certainty of the final diagnosis of the patient. Recent interest has focused on nonbronchoscopic techniques for the mechanically ventilated patient. None of these techniques has been demonstrated to change clinical outcome.

CONCLUSIONS

Diagnosis of lower respiratory tract infection has to be tailored for the individual patient. Decision about which procedure to do is influenced by the patient's underlying immune status, level of illness, and response to empiric therapy.

Local immune responses correlate with presentation and outcome in tuberculosis

Local cellular immune responses may affect presentation and outcome in tuberculosis (TB). To investigate this hypothesis, we performed bronchoalveolar lavage (BAL) on 30 patients with untreated pulmonary tuberculosis and assessed the type of cellular inflammatory response and cytokine production. We then correlated BAL findings and cytokine production with clinical findings. We also performed BAL on a subset of patients to examine changes in cytokine production by BAL cells over time. We found that at presentation patients with less clinically and radiographically advanced TB (smear-negative, noncavitary disease) had a local immune response characterized by a predominance of lymphocytes. Furthermore, BAL cells from these patients secreted interferon (IFNgamma), and not Interleukin-4, suggesting a Th 1-type lymphocytic response. In patients with smear-positive and/or cavitary disease, macrophages or polymorphonuclear leukocytes were the predominant BAL cell type, but with treatment and clinical improvement these patients went on to recruit IFNgamma producing cells to the lung. We conclude that the type of cellular immune response that occurs locally in the lung may affect presentation and outcome in pulmonary TB, and an understanding of the development of this response may lead to insights into pathogenesis and novel therapies for TB.

Cytological analysis of bronchoalveolar lavage fluid in the diagnosis of spontaneous respiratory tract disease in dogs: a retrospective study

Results of cytological analysis of bronchoalveolar lavage (BAL) fluid were compared with clinical diagnoses in dogs that presented with signs of respiratory disease to referral hospitals. Of 68 dogs in which a clinical diagnosis was possible, BAL cytological findings were considered definitive for the diagnosis in 17 cases (25%), supportive of the diagnosis in 34 cases (50%), and not helpful in 17 cases (25%). Findings were most often considered supportive of or definitive for the clinical diagnosis in dogs with alveolar or bronchial radiographic patterns, or the presence of pulmonary masses. BAL results among lung lobes differed in 23 of 63 dogs (37%) with diffuse radiographic patterns. Tracheal wash cytology differed from BAL fluid cytology in 45 of 66 dogs (68%). Bronchoalveolar lavage was a clinically useful procedure for the diagnostic evaluation of dogs with signs of respiratory disease.

Diagnostic role of fiberoptic bronchoscopy in suspected smear negative pulmonary tuberculosis

Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) was performed in 40 patients suspected to have pulmonary tuberculosis, in whom chest roentgenogram revealed minimal infiltration and sputum smears were negative for acid-fast bacilli. Bronchoscopic procedures provided overall diagnostic yields in 47.5% (19/40) of patients. The diagnostic yield of overall bronchoscopic procedures for tuberculosis in this study was 32.5% (13/40) of patients. It consisted of positive BAL smear in 7.5% (3/40) of patients, positive for mycobacterial culture in 15% (6/40) of patients and TBB revealing granuloma in 17.5% (7/40) of patients. Non-tuberculosis conditions were diagnosed by the bronchoscopic method in six patients (15%). These results suggest that in an area with a high prevalence of tuberculosis, bronchoscopic procedures should be performed in those cases in which other diagnoses such as malignancy must be ruled out. Transbronchial biopsy has a major role for early diagnosis and should be performed in all cases, if possible.

Value of bronchoalveolar lavage and gastric lavage in the diagnosis of pulmonary tuberculosis in children

OBJECTIVE

The aim of our study was to find out if bronchoalveolar lavage (BAL) would be better than gastric lavage for the isolation of Mycobacterium tuberculosis from pediatric patients with suspected pulmonary tuberculosis.

DESIGN

50 children with suspected pulmonary tuberculosis at a mean age of 5.1 years (range 7 months to 12 years) were studied. Early morning gastric lavage was collected. Flexible bronchoscopy and bronchoalveolar lavage was performed under local anaesthesia after obtaining informed consent from the parents. The BAL fluid and gastric lavage specimens were subjected to smear examination for acid-fast bacilli (AFB) and culture for mycobacteria using established methods.

RESULTS

Of the 50 cases, M. tuberculosis was grown in 6 BAL samples (12%) and 16 gastric lavage samples (32%) making a total of 17 culture proven cases (34%). Out of the 6 BAL positive cases, gastric lavage was also positive in 5 cases.

CONCLUSION

We conclude that gastric lavage is better than BAL for bacteriologic confirmation of pulmonary tuberculosis in children. The overall bacteriologic yield combining both procedures was 34% while gastric lavage alone was positive in 32% of the cases.

Tuberculosis in the AIDS era

A resurgence of tuberculosis has occurred in recent years in the United States and abroad. Deteriorating public health services, increasing numbers of immigrants from countries of endemicity, and coinfection with the human immunodeficiency virus (HIV) have contributed to the rise in the number of cases diagnosed in the United States. Outbreaks of resistant tuberculosis, which responds poorly to therapy, have occurred in hospitals and other settings, affecting patients and health care workers. This review covers the pathogenesis, epidemiology, clinical presentation, laboratory diagnosis, and treatment of Mycobacterium tuberculosis infection and disease. In addition, public health and hospital infection control strategies are detailed. Newer approaches to epidemiologic investigation, including use of restriction fragment length polymorphism analysis, are discussed. Detailed consideration of the interaction between HIV infection and tuberculosis is given. We also review the latest techniques in laboratory evaluation, including the radiometric culture system, DNA probes, and PCR. Current recommendations for therapy of tuberculosis, including multidrug-resistant tuberculosis, are given. Finally, the special problem of prophylaxis of persons exposed to multidrug-resistant tuberculosis is considered.

The continuing utility of bronchoalveolar lavage to diagnose opportunistic infection in AIDS patients

PURPOSE

To determine whether bronchoalveolar lavage (BAL) remains a useful technique in assessing human immunodeficiency virus (HIV)-infected patients with pulmonary symptoms.

PATIENTS AND METHODS

All HIV-infected patients with pulmonary symptoms referred to a university hospital-based pulmonary service underwent bronchoscopy and BAL within 24 hours of referral. All samples were handled in a standardized fashion. The results of the lavage were compared with chest roentgenograms and clinical results.

RESULTS

A total of 894 lavages were performed on HIV-infected patients over a 7-year period. The overall diagnostic yield was 60%, with 420 patients having Pneumocystis carinii. Infections other than P carinii were found in 185 cases, including 75 lavages with P carinii and another infection. The other infections included Mycobacterium tuberculosis (17 patients), Mycobacterium kansasii (15 patients), Histoplasma capsulatum (24 patients), Cryptococcus neoformans (17 patients), and bacterial infection (103 patients). For 364 lavages, no diagnosis was made. Chest roentgenograms were not useful in predicting what infection would be diagnosed. There was no difference in the yield of BAL over the 7-year period, despite the introduction of aerosol pentamidine prophylaxis and antiretroviral therapy.

CONCLUSION

Bronchoscopy with BAL continues to have a role in the evaluation of HIV-infected patients with pulmonary symptoms.