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

• Published in: Thorax 2001-05, Vol.56 (5), p.379-387
• Main Authors: Rañó, A, Agustí, C, Jimenez, P, Angrill, J, Benito, N, Danés, C, González, J, Rovira, M, Pumarola, T, Moreno, A, Torres, A
• Format: Article
• Language: English
• Subjects: Adult; AIDS-Related Opportunistic Infections - complications; AIDS-Related Opportunistic Infections - diagnosis; Anti-Bacterial Agents - therapeutic use; Antibiotic Prophylaxis; Antibiotics; Antigens; Antiviral Agents - therapeutic use; Bacterial Infections - diagnosis; Bacterial Infections - drug therapy; Biological and medical sciences; bronchoalveolar lavage; Bronchoalveolar Lavage Fluid - microbiology; Bronchoscopy - methods; Complications and side effects; Diagnosis; Diagnostic tests; Female; Hematology; HIV infection; HIV Infections - complications; Hospitals; Humans; immunocompromised; Immunocompromised Host; Immunodeficiencies; Immunodeficiencies. Immunoglobulinopathies; Immunopathology; Infection; Lavage; Leukemia; Lung Diseases - diagnosis; Lung Diseases - drug therapy; Lung Diseases - microbiology; Lung Diseases, Fungal - diagnosis; Lung Diseases, Fungal - drug therapy; lung infection; Lungs; Male; Medical sciences; nasopharyngeal wash; Neutropenia; Opportunistic infections; Original; Physiology; Prognosis; Prospective Studies; Stem cell transplantation; Streptococcus infections; tracheobronchial aspirate; Ventilation
• ISSN: 0040-6376; 1468-3296
• DOI: 10.1136/thorax.56.5.379

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), andPseudomonas 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