Table 3.
Diagnostic workup of bronchoalveolar lavage (BAL) samples from febrile neutropenic patients with lung infiltrates
| Recommended diagnostic program | Evidence level |
|---|---|
| Cytospin preparations for distinguishing intracellular from extracellular pathogens and identifying infiltration by underlying malignancy | B |
| Gram stain | B |
| Giemsa or May-Grünwald-Giemsa stain (assessment of macrophages, ciliated epithelium, leukocytes) | B |
| Mycobacterium tuberculosis (M. tuberculosis) polymerase chain reaction (PCR) | A |
| PCR for Pneumocystis jirovecii (P. jirovecii); quantitative if possible | A |
| Calcofluor white or equivalent (assessment of fungi and P. jirovecii) | A |
| Direct immunofluorescence test for P. jirovecii (confirmatory) | A |
| Aspergillus antigen (Galactomannan Sandwich ELISA) | A |
| Bacteriological cultures (Quantitative or semi-quantitative): dilutions of 10−2 and 10−4; culture media: blood agar, MacConkey/Endo, Levinthal/blood (bacterial culture), Legionella-BCYE or equivalent (Legionella spp.), for mycobacteria at least one solid and one liquid medium (e.g. Löwenstein–Jensen agar and Middlebrook 7H9 broth or equivalent), Sabouraud/Kimmig or equivalent (fungal culture) | A |
| Optional program | |
| Enrichment culture (Brain–Heart Infusion broth, dextrose broth) | C |
| Legionella PCR | B |
| PCR for cytomegalovirus (CMV), Respiratory Syncytial Virus, influenza A/B, parainfluenza 1-3, metapneumovirus and adenovirus | B |
| Quantitative PCR for Varicella Zoster Virus | B |
| Panfungal or Aspergillus PCR | B |
| Peripheral blood cultures 1 h after bronchoscopy to detect transient bacteremia | C |
| Throat swab to assess oral flora in comparison with BAL | C |