Detección de autoanticuerpos en el lavado broncoalveolar en pacientes con enfermedad pulmonar intersticial difusa

IntroductionSerum autoantibodies support the diagnosis of interstitial lung disease (ILD) related to systemic autoimmune diseases (SAD-ILD). Nevertheless, their presence in the bronchoalveolar lavage (BAL) has not been explored.ObjectivesTo demonstrate the presence of autoantibodies in the BAL of ILD patients at onset of clinical evaluation, its relation with serum autoantibodies and to analyze clinical features of patients with autoantibodies in BAL.MethodsAutoantibodies against extractable nuclear antigens (ENAs) were analyzed by immunoblot in the BAL of 155 patient with suspected diagnosis of ILD and 10 controls.ResultsSeven ENAs were detected in the BAL of 19 patients (Anti-Ro52, Anti-Ro60, CENP-B, Anti-La, Jo-1, Sm/RNP and Anti-SL70). The most frequent ENA was anti-Ro52 (13 patients; 68,4% of positives ones). Seven patients presented more than one ENAs. Fourteen were diagnosed of SAD-ILD, 3 of interstitial pneumonia with autoimmune features, one of non-specific idiopathic pneumonia and other of silicosis. In 10 cases (52%) IgA autoantibodies were also detected. The autoantibodies observed in BAL were also detected in the serum of 17 patients (90%). There were no significant clinical differences with the patients with SAD-ILD or interstitial pneumonia with autoimmune features with patients with negative BAL.ConclusionThe study of ENAs in BAL is feasible and can be a useful tool in the ILD initial algorithm, specifically sustaining the suspected diagnosis of SAD-ILD.     

Development and validation of a Pneumocystis jirovecii real-time polymerase chain reaction assay for diagnosis of Pneumocystis pneumonia

BACKGROUND:Pneumocystis jirovecii (PJ), a pathogenic fungus, causes severe interstitial Pneumocystis pneumonia (PCP) among immunocompromised patients. A laboratory-developed real-time polyermase chain reaction (PCR) assay was validated for PJ detection to improve diagnosis of PCP.METHODS:Forty stored bronchoalveolar lavage (BAL) samples (20 known PJ positive [PJ+] and 20 known PJ negative [PJ−]) were initially tested using the molecular assay. Ninety-two sequentially collected BAL samples were then analyzed using an immunofluorescence assay (IFA) and secondarily tested using the PJ real-time PCR assay. Discrepant results were resolved by retesting BAL samples using another real-time PCR assay with a different target. PJ real-time PCR assay performance was compared with the existing gold standard (ie, IFA) and a modified gold standard, in which a true positive was defined as a sample that tested positive in two of three methods in a patient suspected to have PCP.RESULTS:Ninety of 132 (68%) BAL fluid samples were collected from immunocompromised patients. Thirteen of 92 (14%) BALs collected were PJ+ when tested using IFA. A total of 40 BAL samples were PJ+ in the present study including: all IFA positive samples (n=13); all referred PJ+ BAL samples (n=20); and seven additional BAL samples that were IFA negative, but positive using the modified gold standard. Compared with IFA, the PJ real-time PCR had sensitivity, specificity, and positive and negative predictive values of 100%, 91%, 65% and 100%, respectively. Compared with the modified gold standard, PJ real-time PCR had a sensitivity, specificity, and positive and negative predictive values of 100%.CONCLUSION:PJ real-time PCR improved detection of PJ in immunocompromised patients.     

Synovial C-reactive protein features high negative predictive value but is not useful as a single diagnostic parameter in suspected periprosthetic joint infection (PJI)

ObjectivesSynovial fluid C-reactive protein (syCRP) has been recently described as a new biomarker in preoperative diagnostics to identify periprosthetic joint infections (PJI). The aim of this study was to evaluate syCRP in a large cohort of patients with suspected PJI and to calculate the optimal cut-off to diagnose PJI.MethodsBetween September 2015 and June 2017, we prospectively included patients with suspected PJI, in which syCRP was additionally measured along with routine preoperative diagnostic serum and synovial biomarkers. We analysed the sensitivity and specificity of syCRP using receiver operating characteristic curves.ResultsWe included 192 cases (hip n = 80, knee n = 91, shoulder n = 21) with a final diagnosis of PJI in 26 cases (14.0%). Combined for all joints, the syCRP values were significantly higher in the PJI group than in the no PJI group (median: 13.8 vs. 0 mg/l; p < 0.001). The optimal cut-off (Youden Index: 0.71) for the PJI diagnosis combined for all joints was at a syCRP value of 2.9 mg/l with a sensitivity of 88%, a specificity of 82%, and a negative predictive value of 98%.ConclusionsSyCRP features high negative predictive value but is not useful as a single diagnostic parameter in suspected periprosthetic joint infection (PJI).     

Clinical usefulness of tomographic standards for COVID-19 pneumonia diagnosis: Experience from a Brazilian reference center

BackgroundCOVID-19 is a new disease and the most common complication is pneumonia. The Radiological Society of North America (RSNA) proposed an expert consensus for imaging classification for COVID-19 pneumonia.ObjectiveTo evaluate sensitivity, specificity, accuracy, and reproducibility of chest CT standards in the beginning of the Brazilian COVID-19 outbreak.MethodsCross-sectional study performed from March 1st to April 14th, 2020. Patients with suspected COVID-19 pneumonia submitted to RT-PCR test and chest computed tomography (CT) were included. Two thoracic radiologists blinded for RT-PCR and clinical and laboratory results classified every patient scan according to the RSNA expert consensus. A third thoracic radiologist also evaluated in case of discordance, and consensus was reached among the three radiologists. A typical appearance was considered a positive chest CT for COVID-19 pneumonia. Sensitivity, specificity, positive and negative predictive values were calculated. Cohen’s kappa coefficient was used to evaluate intra- and inter-rater agreements.ResultsA total of 159 patients were included (mean age 57.9 ± 18.0 years; 88 [55.3%] males): 86 (54.1%) COVID-19 and 73 (45.9%) non-COVID-19 patients. Eighty (50.3%) patients had a positive CT for COVID-19 pneumonia. Sensitivity and specificity of typical appearance were 88.3% (95%CI, 79.9–93.5) and 94.5% (95%CI, 86.7–97.8), respectively. Intra- and inter-rater agreement were assessed (Cohen’s kappa = 0.924, P = 0.06; Cohen’s kappa=0.772, P = 0.05, respectively).ConclusionChest CT categorical classification of COVID-19 findings is reproducible and demonstrates high level of agreement with clinical and RT-PCR diagnosis of COVID-19. In RT-PCR scarcity scenarios or in equivocal cases, it may be useful for attending physicians in the evaluation of suspected COVID-19 pneumonia patients attended at the emergency unit.     

Detection of non-infectious conditions mimicking pneumonia in the intensive care setting: usefulness of bronchoalveolar fluid cytology.

The present study investigated the usefulness of bronchoalveolar (BAL) fluid cytology in the identification of non-infectious pulmonary conditions in patients hospitalized in the intensive care unit (ICU) and suspected of pneumonia. A total of 182 BAL fluid samples obtained during a 27-month period from 130 ICU patients with suspected pneumonia were quantitatively cultured and investigated for opportunistic pathogens. Cytocentrifuged preparations stained with the May-Grünwald Giemsa and Perls's methods were reviewed. A non-infectious aetiology was considered when cultures yielded micro-organisms in quantities < 10(3) colony-forming units (CFU) per ml, in the absence of any other pathogen and in conjunction with one or more of the following cytological findings: > 20% haemosiderin macrophages, > 10% lymphocytes, the presence of activated lymphocytes, plasma cells, > 5% eosinophils, a preponderance of foamy macrophages, reactive type II pneumocytes or malignant cells. Patients' clinical records were reviewed to identify a clinical diagnosis for these episodes. In thirty-five (19.2%) BAL fluid samples from 26 patients, the cytological findings pointed to a non-infectious origin. An alternative diagnosis was ascertained in 20 of 26 patients. Diagnoses included: drug-induced pneumonitis (n = 7), aspiration of gastric contents (n = 2), pulmonary emboli (n = 3), adult respiratory distress syndrome (n = 4), lung contusion (n = 1), cardiogenic pulmonary oedema (n = 1), and carcinomatous lymphangitis (n = 2). The BAL fluid cytological findings were readily discernable and proved to be useful in the diagnostic work-up of samples obtained from ICU patients with suspected pneumonia.     

Role of Gene Xpert in smear negative pulmonary tuberculosis

BackgroundTuberculosis is a major health problem contributing to significant morbidity and mortality. Early diagnosis and treatment is the key for TB control. Sputum microscopy is a rapid and inexpensive test but due to low and variable sensitivity, many cases can be missed. Culture is considered to be the gold standard but is time consuming. Gene Xpert is a novel and rapid cartridge based nucleic acid amplification test (CBNAAT) that can be used for prompt diagnosis.AimTo compare the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of Gene Xpert with culture in diagnosing tuberculosis in sputum smear negative patients.MethodsThe study is a prospective observational study conducted from December 2017 to January 2019 on 189 patients, who were sputum smear negative but had signs and symptoms suggestive of tuberculosis. Their respiratory samples were taken (either sputum or bronchoalveolar lavage) and sent for Gene Xpert. The results were compared with culture, which was taken as the gold standard, and diagnostic accuracy was assessed.ResultA total of 189 patients were included in the study. In 25 patients sputum was taken and in 164 patients BAL was taken (which included 22 patients in whom sputum Gene Xpert was negative but there was high clinical suspicion of tuberculosis). The sensitivity, specificity, PPV and NPV of Gene Xpert in diagnosing smear negative pulmonary tuberculosis was found to be 96.3%, 81.3%, 87.5% and 94.2% respectively.ConclusionGene Xpert can be used as a rapid diagnostic tool in patients who are sputum smear negative but have clinical features highly suggestive of tuberculosis. It additionally helps in detecting rifampicin resistance. But every Gene Xpert positive case does not necessarily mean an active disease, therefore, past history of tuberculosis along with radiological signs of disease activity are to be considered. In case of negative Gene Xpert but high clinico-radiological suspicion of TB, patients should be followed up on regular intervals, while awaiting their culture.     

微量支气管肺泡灌洗在菌阴肺结核诊断中的应用

目的　探讨微量支气管肺泡灌洗对菌阴肺结核的诊断价值。方法　对 18例临床高度怀疑肺结核的痰菌阴性患者行灌洗液为 4 0 ml的微量支气管肺泡灌洗 ,并对回收液涂片做抗酸杆菌检查、普通细菌培养、细胞学检查及术后痰涂片检查抗酸杆菌。并于术后 1周至 1月复查胸片。结果　微量支气管肺泡灌洗液 (BAL F)检查抗酸杆菌阳性率为 5 0 % ,联合术后痰涂片检查抗酸杆菌阳性率为 71.4 % ,与术前相比 ,差异有显著性 (P<0 .0 1)。术后无 1例出现并发症。结论　微量支气管肺泡灌洗对菌阴肺结核的诊断是一种安全实用的检查方法。     

Clinical and computed tomographic features of Legionella pneumonia with negative urine antigen test results

BackgroundLegionella spp. can cause severe pneumonia and most Legionella pneumonia (LP) cases are diagnosed using the urine antigen test (UAT). However, diagnosis of LP with negative UAT results (LPNUAT) is challenging. We investigated the clinical and radiological features of LPNUAT.MethodsWe retrospectively collected LP cases with positive UAT (LPPUAT) and cases of suspected LP with negative UAT that were examined by Legionella culture between July 2014 and March 2020. We investigated the clinical and CT findings for LP that showed negative UAT results and was diagnosed by culture and compared these findings with those for other pneumonias suspicious for LP with negative results in UAT and Legionella culture (OPSLP).ResultsEight LPNUAT, 20 LPPUAT, and 19 OPSLP cases were included in this study. There were no significant differences in the clinical and CT findings between LPPUAT and LPNUAT when examined by UAT. In LPNUAT, dyspnea, renal dysfunction, liver dysfunction, and bilateral lesions were more commonly observed and inflammatory changes and the number of affected lobes were significantly higher when examined by culture than when examined by UAT. Comparison to OPSLP, LPNUAT did not show such differences, but rather showed disturbances in consciousness, hyponatremia and rhabdomyolysis. Furthermore, lobar consolidation was observed more frequently and bronchial wall thickening and centrilobular nodules were observed less frequently in LPNUAT.ConclusionsLP characteristics such as disturbance of consciousness, hyponatremia, rhabdomyolysis, lobar consolidation, and less bronchial wall thickening and centrilobular nodule contribute to the diagnosis of LP in patients with negative UAT results.     

Diagnostic accuracy of bronchoalveolar lavage samples in immunosuppressed patients with suspected pneumonia: analysis of a protocol

BACKGROUND: Fast and accurate etiologic diagnosis of pneumonia in immunocompromised patients is essential for a good outcome. Utility of bronchoalveolar lavage (BAL) samples has already been established, but studies about them are scarce and limited to few countries. We aimed to evaluate the accuracy of a diagnostic protocol, emphasizing on local epidemiology, rapidity, and yield of different techniques. METHODS: One year prospective study of 101 consecutive immunosuppressed patients admitted with suspected pneumonia to a university hospital. They all had bronchoscopic BAL (n=109) and respiratory sampling. Conventional microbiological studies, cytomegalovirus pp65 antigenemia and transbronchial biopsy (TBB), whenever considered pertinent, were done. Results were analyzed along with other diagnostic procedures, clinical course and final outcome. RESULTS: HIV/AIDS infection was the most frequent cause of inclusion (n=80). Infections accounted for 79 out of 122 final diagnoses (64.8%). Our protocol identified 60 infectious and 3 noninfectious pathologies (general yield: 51.6%). Sensitivity in pulmonary infections was 75.9% (IC95%: 64.8-84.6%), specificity 86.0% (72.6-93.7%), positive predictive value 89.6% (79.1-95.3%), negative predictive value 69.4% (56.2-80.1%), accuracy 79.8% (71.7-86.2%). Mycobacterium spp. (n=27), bacteria (n=19), Pneumocystis jirovecii (n=18) and other fungi (histoplasmosis: 6, aspergillosis: 5, cryptococosis: 3) were the most common infectious pathogens. Direct microscopy allowed an early definite/presumptive diagnosis in 36/49 fungal and mycobacterial infections (73.5%). Up to 30% of mycobacterial infections were missed. CONCLUSIONS: Systematical study of BAL samples has a high diagnostic yield in our immunocompromised patients with suspected pneumonia. As economical and epidemiological conditions of regions are different, it should be tried everywhere.     

Integrated approach to bronchoalveolar lavage cytology to distinguish interstitial lung diseases

BackgroundBroncho-alveolar lavage (BAL) is a safe diagnostic procedure, useful for differentiating fibrotic lung disorders and for excluding malignancy and infection. A recent multicenter study demonstrated a new, relatively sensitive, and specific index called Bronchoalveolar Cytology Threshold (BCT), useful for distinguishing healthy individuals from patients with lung diseases.ObjectivesIn our study, BCT was applied for the first time to the analysis of interstitial lung diseases (ILDs), investigating its potential for differential diagnosis. Combinations of BAL cells that improve diagnostic accuracy for ILDs were studied and are proposed.MethodsA retrospective analysis of BAL samples was performed. We considered more than 1000 BAL samples from patients investigated for ILD, performed at Siena University Hospital.The samples enrolled for the study included 468 patients: 413 with and 55 without ILD. BAL was performed for diagnostic purposes in line with international guidelines. BCT were calculated according to available literature.ResultsAmong ILDs, patients with fibrotic hypersensitivity pneumonitis, idiopathic pulmonary fibrosis (IPF) and sarcoidosis showed significantly lower BCTs than unclassified ILD. Asbestosis patients showed significantly lower BCTs than nonspecific interstitial pneumonia (NSIP), cryptogenic organizing pneumonia (COP), connective tissue disease related ILD (CTD-ILD), sarcoidosis and unclassified ILD patients. COP patients showed significantly higher BCT than IPF, f-HP and sarcoidosis. Moreover, COP patients were best distinguished by BCT.ConclusionThe analysis of BAL features is currently included in the diagnostic algorithm of ILDs. BAL cell patterns and BCT index can provide useful information for distinguishing ILDs, reducing the need for invasive procedures. Integrated approaches to BAL analysis can improve the interpretation of results without further cost or loss of time.     

Antibiotic utilization and outcomes for patients with clinically suspected ventilator-associated pneumonia and negative quantitative BAL culture results

OBJECTIVE: To evaluate antibiotic utilization and clinical outcomes among patients with clinically suspected ventilator-associated pneumonia (VAP) and culture-negative BAL (CNBAL). DESIGN: Prospective observational cohort study. SETTING: A medical ICU from a university-affiliated urban teaching hospital employing a previously described antibiotic discontinuation guideline for the management of VAP. PATIENTS: One hundred one patients with a clinical suspicion of VAP and CNBAL were evaluated between July 2002 and December 2004. INTERVENTIONS: Prospective patient follow-up and data collection. Antibiotic discontinuation was determined by the clinical guideline and not the results of BAL cultures. RESULTS: The average age of the patients was 60.4 +/- 17.9 years and the mean APACHE II score was 23.2 +/- 8.7 (+/- SD). The mean duration of mechanical ventilation prior to clinically suspected VAP was 2.9 +/- 1.9 days. Nineteen patients (18.8%) received antibiotics for other indications prior to BAL. Empiric antibiotic therapy for VAP was begun in 65 patients (64.4%) following BAL. The duration of empiric antibiotic treatment following BAL was 2.1 +/- 0.8 days. None of these patients received antibiotics for > 3 days (median, 2 days; range, 1 to 3 days). Six patients (5.9%) were treated with antibiotics for a secondary episode of VAP or hospital-acquired pneumonia developing at least 72 h after the CNBAL was performed and discontinuation of the empiric antibiotic therapy prescribed for the initially suspected episode of VAP. Overall, 35 patients (34.7%) died during hospitalization. Two deaths occurred in patients with a secondary episode of VAP following CNBAL and discontinuation of empiric antimicrobial therapy. Neither of these two deaths was attributed to VAP. CONCLUSIONS: Although the decision to discontinue antibiotic treatment was based on clinical criteria and not BAL culture results, this study suggests that patients with a clinical suspicion of VAP and CNBAL can have empiric antimicrobial therapy safely discontinued within 72 h or in some cases withheld altogether. Prospective studies are needed to determine the safety of employing CNBAL as the primary criterion for the discontinuation of empirically begun antibiotic treatment for VAP.     

Bronchoalveolar lavage as the exclusive diagnostic modality for Pneumocystis carinii pneumonia. A prospective study among patients with acquired immunodeficiency syndrome

Pneumocystis carinii pneumonia (PCP) is the most common life-threatening opportunistic infection among patients with the acquired immunodeficiency syndrome (AIDS). Because retrospective studies suggested that bronchoalveolar lavage (BAL) compared favorably to lung biopsy in the diagnosis of PCP, we prospectively evaluated the utility of BAL in 40 consecutive patients with AIDS or risk of AIDS who presented with respiratory complaints. The BAL revealed P carinii in 36 of 42 episodes of pneumonia (86 percent) among 40 patients. Clinical follow-up of the six patients whose BAL was negative for PCP suggested only one possible false negative BAL for PCP. Therefore, BAL detected PCP in 36 of 37 patients for a sensitivity of 97 percent. BAL detected cytomegalovirus in 15 of 38 patients, as well as Mycobacterium avium-intracellulare and Cryptococcus (each in one patient). By virtue of accuracy and lack of morbidity demonstrated in our study, BAL should supplant lung biopsy techniques in the evaluation of AIDS patients with pulmonary symptoms.     

Diagnostic yield of bronchoalveolar lavage in pneumonitis occurring after allogeneic bone marrow transplantation

Fifty-two bronchoalveolar lavages (BAL) were performed in order to investigate 46 episodes of pneumonitis that occurred after allogeneic bone-marrow transplantation. No complications have been attributed to this procedure. A specific etiologic diagnosis was obtained in 24 of 46 episodes (52%) by 26 of 52 BAL (50%). Cytomegalovirus (CMV), diagnosed by the presence of typical inclusions, was the pathogen most frequently identified by BAL (13 of 46 episodes) and was associated with other causes of pneumonia in 4 patients. The other causes of pneumonitis diagnosed by BAL were: giant-cell pneumonia: 1, aspergillosis alone: 3, Pneumocystis carinii: 1, Hemophilus influenzae: 3, isolated pulmonary hemorrhage: 3. One false negative (aspergillosis, n = 1) was diagnosed at autopsy. The overall mortality rate of these episodes was 24%. Thus, BAL appears to be a rapid and reproducible diagnostic method for monitoring pneumonitis in grafted patients, particularly CMV pneumonitis, and may avoid the need for surgical biopsy.     

Therapeutic implication of BAL in patients with neutropenia

Bronchoalveolar lavage (BAL) is a practicable procedure establishing the etiology of pneumonia. In patients with neutropenia, empirical antimicrobial treatment is mandatory immediately after diagnosis of infection, usually before results of BAL are available. We evaluated the impact of BAL on treatment and outcome of pneumonia in immunocompromised patients with a special regard to neutropenia. Bronchoscopy with BAL was performed in 58 episodes of clinical documented pneumonia in patients with hematological malignancies (88%) or solid tumors (12%), in 30 cases patients had neutropenia, in 28 cases patients had no neutropenia. In 93% of cases, BAL was performed under empirical antimicrobial treatment. BAL fluid was cultivated for bacteria, fungi, and tested for Pneumocystis jirovecii and cytomegalovirus (CMV). BAL revealed positive bacterial results in 67% of cases. Gram-positive microorganisms were detected in 95% of positive BAL results, gram-negative microorganisms in 23%, mixed bacterial cultures occurred in 41%. Positive fungi cultures were found in 59%. P. jirovecii was detected in 5% of cases tested and CMV in 8%. There was no significant difference between neutropenic and non-neutropenic patients. BAL results directed a change of therapy in only six of 58 episodes (5%). Overall mortality related to pneumonia was 16%. In this patient setting, the yield of BAL rarely has a significant influence on treatment and outcome of pneumonia. The early beginning of antimicrobial treatment reduces the diagnostic yield of BAL. In patients with pneumonia during neutropenia, its use should be well considered.     

Hypersensitivity Pneumonitis and (Idiopathic) Pulmonary Fibrosis Due to Feather Duvets and Pillows

IntroductionExposure to feather bedding may be an unnoticed cause of hypersensitivity pneumonitis (HP) and idiopathic pulmonary fibrosis (IPF). Thus, an in-depth clinical study of the diagnosis of patients with suspected HP and IPF is required in order to determine their etiologies. The objective of the present study is to raise awareness of HP and pulmonary fibrosis due to exposure to feather bedding, and to study the prevalence and describe long-term outcomes.MethodsWe describe a series of 33 patients diagnosed with HP and pulmonary fibrosis due to feather bedding exposure and followed over a 10-year period. The patients were from a subgroup of 127 individuals with HP undergoing in-depth evaluation using a diagnostic protocol at a regional referral center.ResultsEleven (33%) patients were clinically diagnosed with acute HP and 22 (67%) with chronic HP. Ten (45%) chronic HP patients showed a high resolution computed tomography (HRCT) pattern of usual interstitial pneumonia (UIP) with suspected IPF. The prevalence of HP was 6.2/100 000 feather bedding users (compared with 54.6 per 100 000 bird-breeders). The survival rates of patients over the 10-year period was 100% for acute HP and 64% for chronic HP.ConclusionsIn a series of HP patients, the diagnosis was attributed to feather bedding exposure in 26%. UIP pattern on HRCT was present in nearly half of the chronic cases. The survival of patients with chronic HP at ten years was 64%, despite avoiding further exposure.     

A retrospective observational study of benign anthracotic lymphadenitis and its association with PET avid lymph nodes in patients undergoing cancer evaluation

BackgroundAccurate staging of newly diagnosed or recurrent malignancy is essential for effective treatment. An important first step in staging involves the use of PET/CT to identify areas of FDG avidity. PET/CT however has limitations, including false positive FDG uptake from benign causes. In this paper we characterize an uncommon yet clinically important cause of false positive PET/CTs, that of benign anthracotic lymphadenitis (BAL). We examine the clinical, radiographic and histologic characteristics of BAL in patients referred for endobronchial ultrasound (EBUS) guided biopsies and discuss its context in relation to existing literature.MethodsWe performed a retrospective observational case series of 20 patients who were referred for EBUS guided biopsies of PET positive mediastinal and hilar lymph nodes during the work-up or treatment of suspected malignancy.ResultsTo be included, all patients received PET imaging as well as an EBUS guided biopsy of FDG avid lymph nodes which demonstrated anthracotic pigment as the only histologic abnormality. The key findings were that 90% of patients in this cohort were born outside of the US, 90% had bilateral FDG avid lymph nodes with an average standardized uptake value (SUV) of 7.9±2.2. Most patients, based on their history, had a likely exposure to biomass fuel or urban pollution.ConclusionsBAL may be an underrecognized cause for PET positive lymph nodes in patients undergoing work-up for malignancy. These findings support the importance of sampling mediastinal and hilar lymph nodes even when SUVs are highly suggestive of malignancy.     

Detection of cryptococcal antigen in bronchoalveolar lavage fluid: a prospective study of diagnostic utility.

Cryptococcal pneumonia is associated with significant morbidity and mortality in immunocompromised patients. We examined the utility of screening bronchoalveolar lavage (BAL) fluid for cryptococcal antigen. In a pilot study, we found that cryptococcal antigen was always positive in unprocessed BAL specimens of seven patients with cryptococcal pneumonia and negative in 44 patients with other granulomatous diseases who acted as the control subjects. A prospective study was done of 220 immunocompromised patients (188 with human immunodeficiency virus infection, 32 with other causes of immunosuppression) undergoing BAL for fever and pulmonary symptoms. The eventual diagnosis of cryptococcal pneumonia was made in eight patients. All eight patients had a cryptococcal antigen titer greater than or equal to 1:8. There were four patients without cryptococcal pneumonia who had cryptococcal antigen titers of 1:8, there were none with higher titers. For a titer of cryptococcal antigen titer of greater than or equal to 1:8, there was 100% sensitivity, 98% specificity, a positive predictive value of 67%, and a negative predictive value of 100%. The measurement of cryptococcal antigen in the BAL can be a rapid, simple way to make a diagnosis of cryptococcal pneumonia in immunosuppressed patients with pneumonia.     

Safety of withholding anticoagulant therapy in patients with suspected pulmonary embolism with a negative multislice computed tomography pulmonary angiography

BackgroundTo assess the safety of withholding anticoagulant therapy in patients with clinically suspected pulmonary embolism with a negative multislice computed tomography pulmonary angiography (MCTPA).MethodsThree hundred and eighty six patients who were consecutively assessed in the emergency room of our institution for suspected pulmonary embolism were eligible for our study. Patients with either a low or an intermediate clinical probability of pulmonary embolism according to the Wells score and a negative MCTPA for pulmonary embolism were enrolled. Patients with anticoagulant therapy for other medical conditions were excluded from this study. We assessed the percentage of patients in whom venous thromboembolic events or death related to this condition within three months after the negative CT.ResultsTwo hundred and forty two patients were included in our series [mean age ± standard deviation (SD) (63.1 ± 18.1)]. Only one patient (0.41% [95% confidence interval ?0.4%–1.22%]) showed a non-fatal pulmonary embolism during the three-month follow-up period after an initial negative CT scan (negative predictive value, 99.58%). Eleven patients died during the follow-up period due to conditions unrelated to venous thromboembolic disease (pneumonia [n = 5], lung cancer [n = 2], wasting syndrome [n = 1], acute myocardial infarction [n = 1], leiomyosarcoma [n = 1], and severe pulmonary hypertension [n = 1]).ConclusionsWithholding anticoagulant therapy in patients with suspected venous thromboembolic disease with a negative result on MCTPA seems to be safe in our clinical setting.     

Prognostic value of dynamic soluble triggering receptor expressed on myeloid cells in bronchoalveolar lavage fluid of patients with ventilator-associated pneumonia

Background and objective: The aim of this study was to investigate the time course, and correlation with prognosis, of BAL fluid concentrations of soluble triggering receptor expressed on myeloid cells (sTREM‐1) in patients with ventilator‐associated pneumonia (VAP). Methods: The study included 35 patients with clinically diagnosed VAP, eight of whom were BAL fluid culture‐negative and 27 BAL fluid culture‐positive (16 survivors, 11 non‐survivors). sTREM‐1 levels were measured in BAL fluid of these mechanically ventilated patients, at the time of diagnosis, on days 4–5 and on days 7–9. The time course of this biomarker and its prognostic value for outcome in patients with culture‐positive VAP were assessed. Results: sTREM‐1 concentrations were significantly greater in culture‐positive VAP patients than in culture‐negative VAP patients. sTREM‐1 levels decreased significantly with time in surviving patients with culture‐positive VAP, but increased significantly with time in non‐survivors. In contrast, PaO₂/fraction of inspired oxygen (FiO₂) increased significantly with time in survivors and decreased significantly with time in non‐survivors. At a cut‐off value of ?10 pg/mL 7–9 days after initial diagnosis, sTREM levels had a sensitivity of 90% and a specificity of 87.5% for predicting mortality. Conclusions: sTREM‐1 concentrations in BAL fluid are of potential prognostic value in patients with VAP.     

Agreement between quantitative cultures of postintubation tracheal aspiration and plugged telescoping catheter, protected specimen brush, or BAL for the diagnosis of nosocomial pneumonia

BACKGROUND: The diagnosis of ventilator-associated pneumonia relies on protected specimen brush (PSB), BAL, and plugged telescoping catheter (PTC) procedures. In the particular setting of nosocomial pneumonia (NP) occurring in non-mechanically ventilated patients, no consensus exists on their use. When mechanical ventilation (MV) becomes mandatory, postintubation tracheal aspiration (PITA) could be a simple, fast, and cheap diagnostic tool. Our aim was to compare the diagnostic accuracy of PITA to that of PSB, BAL, or PTC in patients requiring MV for suspected NP. METHODS: Patients with a prior hospital stay of > or = 48 h who required MV for suspicion of NP were prospectively enrolled in the study. PITA was performed by sterile suction. Within 2 h, pulmonary samples were obtained by PSB, BAL, or blinded PTC, which are referred to hereafter as "reference methods" (RMs). The definite diagnosis of NP was made using a composite item of clinical, radiologic, and bacteriologic (ie, blood or pleural fluid cultures) patterns. The agreement between the quantitative microbiological results obtained with PITA and those of the RMs was assessed by the kappa-statistic. The sensitivity, specificity, and positive and negative likelihood ratios of PITA and RMs were calculated taking the definite diagnosis of NP as the reference. RESULTS: There were 44 cases (63.8%) of confirmed NP. The kappa-statistic was 0.71. The sensitivity, specificity, and positive and negative likelihood ratios were 77%, 84%, 4.80, and 0.27, respectively, for PITA, and 75%, 88%, 6.25, and 0.28, respectively, for RMs. CONCLUSIONS: PITA may be a reliable alternative to RMs in the particular setting of NP in newly mechanically ventilated patients.