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. 2001 May;56(5):379–387. doi: 10.1136/thorax.56.5.379

Pulmonary infiltrates in non-HIV immunocompromised patients: a diagnostic approach using non-invasive and bronchoscopic procedures

A Rano 1, C Agusti 1, P Jimenez 1, J Angrill 1, N Benito 1, C Danes 1, J Gonzalez 1, M Rovira 1, T Pumarola 1, A Moreno 1, A Torres 1
PMCID: PMC1746047  PMID: 11312407

Abstract

BACKGROUND—The development of pulmonary infiltrates is a frequent life threatening complication in immunocompromised patients, requiring early diagnosis and specific treatment. In the present study non-invasive and bronchoscopic diagnostic techniques were applied in patients with different non-HIV immunocompromised conditions to determine the aetiology of the pulmonary infiltrates and to evaluate the impact of these methods on therapeutic decisions and outcome in this population.
METHODS—The non-invasive diagnostic methods included serological tests, blood antigen detection, and blood, nasopharyngeal wash (NPW), sputum and tracheobronchial aspirate (TBAS) cultures. Bronchoscopic techniques included fibrobronchial aspirate (FBAS), protected specimen brush (PSB), and bronchoalveolar lavage (BAL). Two hundred consecutive episodes of pulmonary infiltrates were prospectively evaluated during a 30 month period in 52 solid organ transplant recipients, 53 haematopoietic stem cell transplant (HSCT) recipients, 68 patients with haematological malignancies, and 27 patients requiring chronic treatment with corticosteroids and/or immunosuppressive drugs.
RESULTS—An aetiological diagnosis was obtained in 162 (81%) of the 200 patients. The aetiology of the pulmonary infiltrates was infectious in 125 (77%) and non-infectious in 37 (23%); 38 (19%) remained undiagnosed. The main infectious aetiologies were bacterial (48/125, 24%), fungal (33/125, 17%), and viral (20/125, 10%), and the most frequent pathogens were Aspergillus fumigatus (n=29), Staphylococcus aureus (n=17), and Pseudomonas aeruginosa (n=12). Among the non-infectious aetiologies, pulmonary oedema (16/37, 43%) and diffuse alveolar haemorrhage (10/37, 27%) were the most common causes. Non-invasive techniques led to the diagnosis of pulmonary infiltrates in 41% of the cases in which they were used; specifically, the diagnostic yield of blood cultures was 30/191 (16%); sputum cultures 27/88 (31%); NPW 9/50 (18%); and TBAS 35/55 (65%). Bronchoscopic techniques led to the diagnosis of pulmonary infiltrates in 59% of the cases in which they were used: FBAS 16/28 (57%), BAL 68/135 (51%), and PSB 30/125 (24%). The results obtained with the different techniques led to a change in antibiotic treatment in 93 cases (46%). Although changes in treatment did not have an impact on the overall mortality, patients with pulmonary infiltrates of an infectious aetiology in whom the change was made during the first 7 days had a better outcome (29% mortality) than those in whom treatment was changed later (71% mortality; p=0.001).
CONCLUSIONS—Non-invasive and bronchoscopic procedures are useful techniques for the diagnosis of pulmonary infiltrates in immunocompromised patients. Bronchial aspirates (FBAS and TBAS) and BAL have the highest diagnostic yield and impact on therapeutic decisions.



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Selected References

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  1. Agustí C., Ramirez J., Picado C., Xaubet A., Carreras E., Ballester E., Torres A., Battochia C., Rodriguez-Roisin R. Diffuse alveolar hemorrhage in allogeneic bone marrow transplantation. A postmortem study. Am J Respir Crit Care Med. 1995 Apr;151(4):1006–1010. doi: 10.1164/ajrccm/151.4.1006. [DOI] [PubMed] [Google Scholar]
  2. Baughman R. P. The lung in the immunocompromised patient. Infectious complications Part 1. Respiration. 1999;66(2):95–109. doi: 10.1159/000029349. [DOI] [PubMed] [Google Scholar]
  3. Campbell J. H., Blessing N., Burnett A. K., Stevenson R. D. Investigation and management of pulmonary infiltrates following bone marrow transplantation: an eight year review. Thorax. 1993 Dec;48(12):1248–1251. doi: 10.1136/thx.48.12.1248. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Crawford S. W. Noninfectious lung disease in the immunocompromised host. Respiration. 1999;66(5):385–395. doi: 10.1159/000029418. [DOI] [PubMed] [Google Scholar]
  5. Denning D. W. Therapeutic outcome in invasive aspergillosis. Clin Infect Dis. 1996 Sep;23(3):608–615. doi: 10.1093/clinids/23.3.608. [DOI] [PubMed] [Google Scholar]
  6. Dunagan D. P., Baker A. M., Hurd D. D., Haponik E. F. Bronchoscopic evaluation of pulmonary infiltrates following bone marrow transplantation. Chest. 1997 Jan;111(1):135–141. doi: 10.1378/chest.111.1.135. [DOI] [PubMed] [Google Scholar]
  7. Ettinger N. A., Trulock E. P. Pulmonary considerations of organ transplantation. Part 3. Am Rev Respir Dis. 1991 Aug;144(2):433–451. doi: 10.1164/ajrccm/144.2.433. [DOI] [PubMed] [Google Scholar]
  8. Ewig S., Torres A., Riquelme R., El-Ebiary M., Rovira M., Carreras E., Raño A., Xaubet A. Pulmonary complications in patients with haematological malignancies treated at a respiratory ICU. Eur Respir J. 1998 Jul;12(1):116–122. doi: 10.1183/09031936.98.12010116. [DOI] [PubMed] [Google Scholar]
  9. Horvath J. A., Dummer S. The use of respiratory-tract cultures in the diagnosis of invasive pulmonary aspergillosis. Am J Med. 1996 Feb;100(2):171–178. doi: 10.1016/s0002-9343(97)89455-7. [DOI] [PubMed] [Google Scholar]
  10. Hughes W. T., Armstrong D., Bodey G. P., Brown A. E., Edwards J. E., Feld R., Pizzo P., Rolston K. V., Shenep J. L., Young L. S. 1997 guidelines for the use of antimicrobial agents in neutropenic patients with unexplained fever. Infectious Diseases Society of America. Clin Infect Dis. 1997 Sep;25(3):551–573. doi: 10.1086/513764. [DOI] [PubMed] [Google Scholar]
  11. Leland D. S., Emanuel D. Laboratory diagnosis of viral infections of the lung. Semin Respir Infect. 1995 Dec;10(4):189–198. [PubMed] [Google Scholar]
  12. Maertens J., Verhaegen J., Demuynck H., Brock P., Verhoef G., Vandenberghe P., Van Eldere J., Verbist L., Boogaerts M. Autopsy-controlled prospective evaluation of serial screening for circulating galactomannan by a sandwich enzyme-linked immunosorbent assay for hematological patients at risk for invasive Aspergillosis. J Clin Microbiol. 1999 Oct;37(10):3223–3228. doi: 10.1128/jcm.37.10.3223-3228.1999. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Marquette C. H., Georges H., Wallet F., Ramon P., Saulnier F., Neviere R., Mathieu D., Rime A., Tonnel A. B. Diagnostic efficiency of endotracheal aspirates with quantitative bacterial cultures in intubated patients with suspected pneumonia. Comparison with the protected specimen brush. Am Rev Respir Dis. 1993 Jul;148(1):138–144. doi: 10.1164/ajrccm/148.1.138. [DOI] [PubMed] [Google Scholar]
  14. Mayaud C., Cadranel J. A persistent challenge: the diagnosis of respiratory disease in the non-AIDS immunocompromised host. Thorax. 2000 Jun;55(6):511–517. doi: 10.1136/thorax.55.6.511. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. McWhinney P. H., Kibbler C. C., Hamon M. D., Smith O. P., Gandhi L., Berger L. A., Walesby R. K., Hoffbrand A. V., Prentice H. G. Progress in the diagnosis and management of aspergillosis in bone marrow transplantation: 13 years' experience. Clin Infect Dis. 1993 Sep;17(3):397–404. doi: 10.1093/clinids/17.3.397. [DOI] [PubMed] [Google Scholar]
  16. Murray P. R., Washington J. A. Microscopic and baceriologic analysis of expectorated sputum. Mayo Clin Proc. 1975 Jun;50(6):339–344. [PubMed] [Google Scholar]
  17. Niederman M. S. Is "crop rotation" of antibiotics the solution to a "resistant" problem in the ICU? Am J Respir Crit Care Med. 1997 Oct;156(4 Pt 1):1029–1031. doi: 10.1164/ajrccm.156.4.ed-14. [DOI] [PubMed] [Google Scholar]
  18. Papazian L., Thomas P., Garbe L., Guignon I., Thirion X., Charrel J., Bollet C., Fuentes P., Gouin F. Bronchoscopic or blind sampling techniques for the diagnosis of ventilator-associated pneumonia. Am J Respir Crit Care Med. 1995 Dec;152(6 Pt 1):1982–1991. doi: 10.1164/ajrccm.152.6.8520766. [DOI] [PubMed] [Google Scholar]
  19. Riddell S. R. Pathogenesis of cytomegalovirus pneumonia in immunocompromised hosts. Semin Respir Infect. 1995 Dec;10(4):199–208. [PubMed] [Google Scholar]
  20. Robbins R. A., Linder J., Stahl M. G., Thompson A. B., 3rd, Haire W., Kessinger A., Armitage J. O., Arneson M., Woods G., Vaughan W. P. Diffuse alveolar hemorrhage in autologous bone marrow transplant recipients. Am J Med. 1989 Nov;87(5):511–518. doi: 10.1016/s0002-9343(89)80606-0. [DOI] [PubMed] [Google Scholar]
  21. Stover D. E., Zaman M. B., Hajdu S. I., Lange M., Gold J., Armstrong D. Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host. Ann Intern Med. 1984 Jul;101(1):1–7. doi: 10.7326/0003-4819-101-1-1. [DOI] [PubMed] [Google Scholar]
  22. Tamm M. The lung in the immunocompromised patient. Infectious complications part 2. Respiration. 1999;66(3):199–207. doi: 10.1159/000029377. [DOI] [PubMed] [Google Scholar]
  23. Wendt C. H., Weisdorf D. J., Jordan M. C., Balfour H. H., Jr, Hertz M. I. Parainfluenza virus respiratory infection after bone marrow transplantation. N Engl J Med. 1992 Apr 2;326(14):921–926. doi: 10.1056/NEJM199204023261404. [DOI] [PubMed] [Google Scholar]
  24. Whimbey E., Bodey G. P. Viral pneumonia in the immunocompromised adult with neoplastic disease: the role of common community respiratory viruses. Semin Respir Infect. 1992 Jun;7(2):122–131. [PubMed] [Google Scholar]
  25. White P., Bonacum J. T., Miller C. B. Utility of fiberoptic bronchoscopy in bone marrow transplant patients. Bone Marrow Transplant. 1997 Oct;20(8):681–687. doi: 10.1038/sj.bmt.1700957. [DOI] [PubMed] [Google Scholar]
  26. Wimberley N. W., Bass J. B., Jr, Boyd B. W., Kirkpatrick M. B., Serio R. A., Pollock H. M. Use of a bronchoscopic protected catheter brush for the diagnosis of pulmonary infections. Chest. 1982 May;81(5):556–562. doi: 10.1378/chest.81.5.556. [DOI] [PubMed] [Google Scholar]
  27. Xaubet A., Torres A., Marco F., Puig-De la Bellacasa J., Faus R., Agusti-Vidal A. Pulmonary infiltrates in immunocompromised patients. Diagnostic value of telescoping plugged catheter and bronchoalveolar lavage. Chest. 1989 Jan;95(1):130–135. doi: 10.1378/chest.95.1.130. [DOI] [PubMed] [Google Scholar]
  28. Yousuf H. M., Englund J., Couch R., Rolston K., Luna M., Goodrich J., Lewis V., Mirza N. Q., Andreeff M., Koller C. Influenza among hospitalized adults with leukemia. Clin Infect Dis. 1997 Jun;24(6):1095–1099. doi: 10.1086/513648. [DOI] [PubMed] [Google Scholar]
  29. el-Ebiary M., Torres A., Fàbregas N., de la Bellacasa J. P., González J., Ramirez J., del Baño D., Hernández C., Jiménez de Anta M. T. Significance of the isolation of Candida species from respiratory samples in critically ill, non-neutropenic patients. An immediate postmortem histologic study. Am J Respir Crit Care Med. 1997 Aug;156(2 Pt 1):583–590. doi: 10.1164/ajrccm.156.2.9612023. [DOI] [PubMed] [Google Scholar]
  30. el-Ebiary M., Torres A., González J., de la Bellacasa J. P., García C., Jiménez de Anta M. T., Ferrer M., Rodriguez-Roisin R. Quantitative cultures of endotracheal aspirates for the diagnosis of ventilator-associated pneumonia. Am Rev Respir Dis. 1993 Dec;148(6 Pt 1):1552–1557. doi: 10.1164/ajrccm/148.6_Pt_1.1552. [DOI] [PubMed] [Google Scholar]
  31. von Eiff M., Roos N., Schulten R., Hesse M., Zühlsdorf M., van de Loo J. Pulmonary aspergillosis: early diagnosis improves survival. Respiration. 1995;62(6):341–347. doi: 10.1159/000196477. [DOI] [PubMed] [Google Scholar]

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