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

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 diVerent 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. , 10%), and the most frequent pathogens were Aspergillus fumigatus (n=29), Staphylococcus aureus (n=17), and Pseudomonas aeruginosa (n=12). Among the noninfectious aetiologies, pulmonary oedema (16/37, 43%) and diVuse 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 diVerent 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. Methods-The

Utility of early versus late fiberoptic bronchoscopy in the evaluation of new pulmonary infiltrates following hematopoietic stem cell transplantation

“…When reported, FOB typically occurred 4 or more days following the initiation of empiric antibiotics. 11,12,25,27,28 Thus, our findings corroborate previous observations that link diagnostic delays to poor patient outcome and underscore the futility of late FOBguided antimicrobial adjustments in offsetting mortality among HSCT recipients with suspected pneumonia. A notable difference in our study compared with previousreports, however, is the significantly lower mortality rate associated with antibiotic modifications following early FOB.…”

Is BAL useful in patients with acute myeloid leukemia admitted in ICU for severe respiratory complications?

“…In these patients, reported diagnostic yields range from 35 to 60%. 8,9,11,12,15,17,[18][19][20][21][22][23][24] We found comparable results in our patients with lymphoid malignancies, with a diagnostic yield of 50%. The much lower diagnostic yield of FOB-BAL in our AML patients with ARF admitted in ICU raises several issues, dominated by the differences in studied populations between available reports.…”

Retrospective utility of bronchoscopy after hematopoietic stem cell transplant

“…In our review, 20% of ventilated patients lived more than 60 days from bronchoscopy in comparison to 43% in non-intubated patientsthis supports other published reports that only autograft recipients intubated for uncomplicated lung injury 24 and allograft recipients intubated at the time of engraftment 25 should be expected to survive to hospital discharge. Rano et al 23 showed that a delay greater than 5 days in the identification of the cause of the pulmonary infiltrates increased the risk of death threefold, but we found that survival was not statistically different after a diagnostic or non-diagnostic bronchoscopy; this difference may be accounted for by our focus on only HSCT patients. This suggests that other variables such as the extent or severity of graft-versus-host disease (GVHD), the forced expiratory volume in 1 s to forced vital capacity ratio, or cumulative steroid treatment may better predict patients more likely to die from an opportunistic pulmonary infection.…”

“…In the largest study of bronchoscopy in non-human immunodeficiency virus immunocompromised patients with pulmonary infiltrates, Rano et al 23 (27% HSCT recipients) described three variables that predicted mortality: increasing severity of illness, need for mechanical ventilation and delay in diagnosis. In our review, 20% of ventilated patients lived more than 60 days from bronchoscopy in comparison to 43% in non-intubated patientsthis supports other published reports that only autograft recipients intubated for uncomplicated lung injury 24 and allograft recipients intubated at the time of engraftment 25 should be expected to survive to hospital discharge.…”