Evaluating the Clinical Utility of Staged Bronchoalveolar Lavage (BAL) Fluid Analysis in Adolescent and Adult Acute Leukemia and Lymphoma Patients with Febrile Neutropenia and Lung Infiltrates

• Published in: Blood 2021-11, Vol.138 (Supplement 1), p.4008-4008
• Main Authors: K, Venkatesh, Jain, Dr. Hasmukh, Thorat, Jayshree, Sengar, Dr. Manju, Tandon, Sandeep, Baheti, Akshay, Bothra, Sweta, Bhat, Surabhi, Sharma, Dr. Neha, Biswas, Sanjay, Salunkhe, Gaurav, Karimundackal, George, Bonda, Avinash, Nayak, Lingaraj, Bagal, Dr. Bhausaheb
• Format: Article
• Language: English
• ISSN: 0006-4971; 1528-0020
• DOI: 10.1182/blood-2021-152691

▪ Introduction: Lung infiltrates(LI) are seen in 30-45% of the patients with Febrile neutropenia(FN) in haematological malignancies.In FN patients with LI, accurate/probable microbiological diagnosis is possible in only 30 % with conventional blood culture and serological tests. BAL increases the microbiological diagnostic yield. The battery of microbiological tests done in BAL fluid analysis is not uniform.We evaluated a staged approach while analysing the BAL fluid sample, in the first stage we performed the routine cultures and antigen-based tests and in patients with negative results, we performed Polymerase Chain Reaction(PCR) tests guided by the radiological findings. Methods: This was a prospective observational study initiated after Institutional ethics committee approval and conducted at Tata memorial centre,Mumbai between November 2018 and June 2020.BAL testing was done as per a standard protocol(Sampsonas et al.) in hemodynamically stable patients with Spo2 more than 90% and platelet count above 300x10 9/L.Samples were sent for gram stain & bacterial cultures, ziehl neelsen stain and cultures, fungal stain and cultures and Galactomannan (ELISA) and an extra sample was preserved in an EDTA vacutainer at 10-20 degree C. If none of the initial reports were positive, then stored BAL sample was sent for PCR testing guided by the radiology and clinical picture i.e., with nodular infiltrates(Bacteria,Nocardia,Aspergillus,Mucor,P.Jiroveci,Mycobacterium TB,Atypical Mycobacterium TB) and with diffuse micronodular infiltrates Viruses,Legionella,mycoplasma PCR tests were sent. The causal association of the isolated organism was defined as per AGIHO guidelines(G. Maschmeyer et al.) The Primary objective is proportion of patients with a confirmed microbiological diagnosis using staged BAL analysis. The Secondary Objectives are proportion of patients who had a change in antimicrobial therapy,Feasibility of doing a Bronchoscopy and Proportion of Patients who develop Major or Minor complications during procedure and the 4 and 12weeks Clinical and Radiological Outcomes. A sample size of 130 patients was required for incidence of 50%(40-60%) positivity with 10% variation at 95% confidence interval. Results: A total of 172 patients were eligible of which 50 patients are not enrolled due to physician discretion in 37 patients,9 lost for followup and 2 refused consent and one patient expired and one palliated and 122 patients are enrolled and of these BAL couldn't be