The purpose of the present study was to validate the quantitative culture and cellularity of bronchoalveolar lavage (BAL) for the diagnosis of ventilator-associated pneumonia (VAP). A prospective validation test trial was carried out between 1992 and 1997 in a general adult intensive care unit of a teaching hospital. Thirty-seven patients on mechanical ventilation with suspected VAP who died at most three days after a BAL diagnostic procedure were submitted to a postmortem lung biopsy. BAL effluent was submitted to Gram staining, quantitative culture and cellularity count. Postmortem lung tissue quantitative culture and histopathological findings were considered to be the gold standard exams for VAP diagnosis. According to these criteria, 20 patients (54%) were diagnosed as having VAP and 17 (46%) as not having the condition. Quantitative culture of BAL effluent showed 90% sensitivity (18/20), 94.1% specificity (16/17), 94.7% positive predictive value and 88.8% negative predictive value. Fever and leukocytosis were useless for VAP diagnosis. Gram staining of BAL effluent was negative in 94.1% of the patients without VAP (16/17). Regarding the total cellularity of BAL, a cut-off point of 400,000 cells/ml showed a specificity of 94.1% (16/17), and a cut-off point of 50% of BAL neutrophils showed a sensitivity of 90% (19/20).In conclusion, BAL quantitative culture, Gram staining and cellularity might be useful in the diagnostic investigation of VAP. Correspondence

Objective: To evaluate the frequency of the real association between paracoccidioidomycosis (PCM) and tuberculosis (TB) as well as the rate of previous TB misdiagnosis in individuals with PCM among the patients treated in the Pulmonology Division of the State University of Campinas Hospital das Clínicas, Campinas, Brazil. Methods: A retrospective study of 227 adult patients with PCM (chronic form) treated between 1980 and 2005. Results: Of the 227 patients studied, 36 (15.8%) had been previously treated for TB. However, only 18 (7.9%) presented positive sputum smear microscopy results. The remaining 18 (7.9%) neither presented positive sputum smear microscopy nor showed improvement after receiving specific anti-TB treatment. Conclusion: Although the existence of an association between PCM and TB has been documented in the literature, misdiagnosis is common due to the superimposition of and the similarity between their clinical and radiographic presentations, thereby warranting the need for bacteriological diagnosis before initiating specific treatment.

Bronchoalveolar lavage (BAL) is an established diagnostic tool in diffuse parenchyma lung disease. The objective of the present study was designed to investigate whether immunophenotyping affects BAL results and improves diagnostic accuracy. BAL from 61 patients was included in the study. The patients were also submitted to transbronchial biopsy, with a final diagnosis of granulomatous disease [tuberculosis (TB), n = 20; sarcoidosis (SARC), n = 3; and hypersensitivity pneumonitis (HP), n = 4]; idiopathic interstitial pneumonias (IIPs) [idiopathic pulmonary fibrosis (IPF), n = 9; organizing pneumonia (OP), n = 17]; and lung cancer (LC), n = 8. Immunohistochemistry and histomorphometry were used to identify and quantify type 1 and type 2 alveolar epithelial cells, macrophages, CD3+T-cells, CD4+T-cells, CD8+T-cells, and CD20+B-cells in BAL. These markers were correlated with a database and pulmonary function tests. The cellular, inflammatory, and immune components of BAL varied among the diagnostic groups and were negatively correlated with age and smoking history. An increased quantity of lymphocyte surface markers CD3 (P < 0.05) and CD20 (P = 0.01) was seen in IIPs. Patients with a pattern of OP had a higher proportion of type 2 alveolar epithelial cells; patients with SARC had a higher density of CD20+B-cells and CD4+T-helper cells; and patients with HP had a higher proportion of CD8+T-cytotoxic cells. A positive association was found between the density of type I alveolar epithelial cells and forced vital capacity. The immunophenotyping affects the cellular, inflammatory, or immune constituents of BAL and improved the diagnostic accuracy in diffuse parenchymal lung disease.

Paracoccidioidomycosis (PCM) is a systemic infection caused by the fungus Paracoccidioides brasiliensisand is believed to be the leading cause of fungal pulmonary infection. In this study, we used an inhibition enzyme-linked immunosorbent assay to diagnose pulmonary PCM based on the detection of 43-kDa and 70-kDa molecules in bronchoalveolar lavage fluids. The results were compared with results obtained by classical methods for antibody detection.Paracoccidioidomycosis (PCM) is a systemic endemic mycosis caused by the dimorphic fungus Paracoccidioides brasiliensis that affects rural workers in Latin American countries (1,6,9). It has a wide spectrum of clinical manifestations, ranging from mild pulmonary lesions to severe disseminated forms involving many organs, especially the mucosae, skin, lymph nodes, adrenals, and central nervous system (6, 9). The primary pulmonary infection is unapparent or oligosymptomatic in most cases, and individuals may remain infected throughout their lives without ever developing PCM. In most cases, symptomatic patients develop the disease years after acquiring the infection as a result of reactivation of the quiescent foci (chronic form) (3, 9, 10). Clinical findings in these patients generally include severe pulmonary involvement, followed by extrapulmonary dissemination. In PCM, lung destruction involves the alveoli, interstitium, and bronchial tree, resulting in fibrosis, ventilatory dysfunction, and hypoxemia (22). Tobón et al. (23) recently reported that late diagnosis and disseminated lung involvement are two conditions associated with a higher rate of pulmonary sequelae.Definitive diagnosis of pulmonary PCM is based on the visualization of fungal elements characteristic of P. brasiliensis in biopsy material, respiratory secretion, or sputum culture. However, processing respiratory secretion for direct examination is time-consuming. Culture is difficult because sputum is contaminated with bacteria and other yeasts such as Candida sp. that inhibit the growth of P. brasiliensis, a fastidious organism, and bronchoscopy and lung biopsy may be difficult to perform in patients with severe respiratory dysfunction. Hence, serological methods based on antibody or antigen detection may be useful tools for diagnosis of the disease. Marques-daSilva et al. (15-18) recently described an antigen detection assay (the inhibition enzyme-linked immunosorbent assay [inh-ELISA]) for the gp43 and gp70 molecules of P. brasiliensis with good potential for use in diagnosis and follow-up of patients with PCM. The detection of P. brasiliensis antigens in body fluids might facilitate early diagnosis of PCM even in patients with pulmonary involvement.In the present study, gp43 and gp70 antigens of P. brasiliensis were detected in bronchoalveolar lavage (BAL) fluid samples from patients with pulmonary PCM using an inh-ELISA. The results were compared with those obtained for anti-P. brasiliensis antibodies detected by immunodiffusion (ID) tests and ELISA.BAL fluid and serum samples were obtained from 27 ...

To investigate the local immune response, the cellular infiltrate and cytokine levels were analysed in bronchoalveolar lavage (BAL) from patients with pulmonary paracoccidioidomycosis. The group consisted of 19 patients aged 34-65 yrs. The diagnosis was confirmed by demonstration of the fungus in the sputum or BAL fluid and by serological tests.Cytospin preparations showed an increased number of lymphocytes and neutrophils in BAL. A higher number of CD8z lymphocytes were observed in BAL compared with peripheral blood. Alveolar macrophages (AM) expressed approximately three-fold more major histocompatibility class II, intercellular adhesion molecule-1 and B7-2 molecules on their surfaces than their circulating counterparts, indicating that they had differentiated into activated macrophages inside the lungs.Cultured AM produced higher levels of interleukin (IL)-6, tumour necrosis factor (TNF)-a and macrophage inflammatory protein (MIP)-1a than peripheral blood monocytes. BAL fluid contained low but detectable amounts of IL-6, TNF-a and MIP1a, and specific antibodies to Paracoccidioides brasiliensis, mainly of the immunoglobulin G 2 isotype.As macrophage inflammatory protein-1a was shown to selectively attract CD8z Tcells and this population was elevated in bronchoalveolar lavage, the data suggest that, besides macrophages, CD8z T-cells may have an important role in the pathogenesis of pulmonary paracoccidioidomycosis. Eur Respir J 2003; 22: 895-899.