Flexible bronchoscopy in the diagnosis of Pneumocystis carinii pneumonia in patients with acquired immune deficiency syndrome

Seventy-seven patients with acquired immune deficiency syndrome (AIDS) and suspected of having Pneumocystis carinii pneumonia (PCP) had flexible bronchoscopy. The diagnosis was established in 52 of the 54 patients (96%) who proved to have PCP. There was one false-positive result. The remaining 22 patients and the patient with the false-positive diagnosis had diseases other than PCP, or no diagnosis. Flexible bronchoscopy is a safe and sensitive diagnostic procedure in patients with PCP complicating AIDS, and is recommended as the first invasive diagnostic procedure when patients at risk for AIDS have acute pulmonary complications.     

Safety, diagnostic yield, and therapeutic implications of flexible bronchoscopy in patients with febrile neutropenia and pulmonary infiltrates

OBJECTIVE: To evaluate the safety, diagnostic yield, and therapeutic implications of flexible bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy in patients with febrile neutropenia and pulmonary infiltrates. PATIENTS AND METHODS: We retrospectively reviewed the medical records of all patients with neutropenic fever and pulmonary infiltrates evaluated by flexible bronchoscopy and BAL between January and December 2002 at the Mayo Clinic in Rochester, Minn. Appropriate demographic, clinical, microbiological, and histological data and procedure-related complications were summarized. Therapeutic decisions implemented based on Information obtained by bronchoscopy, and 28-day mortality were determined. RESULTS: Thirty-five patients with febrile neutropenia and associated pulmonary infiltrates were identified. Flexible bronchoscopy, including 35 BALs and 9 transbronchial biopsies, was performed safely (3 complications). The diagnostic yield of BAL was 49%. Sputum analysis was underused (only 34%) but complementary to BAL. The combined diagnostic yield of BAL and sputum analysis was 63%. Transbronchial biopsy provided additional information to BAL and sputum analysis In only 1 patient and did not substantially increase the combined diagnostic yield. The most common diagnoses identified were fungal pneumonias (15/35 [43%]) and diffuse alveolar hemorrhage (5/35 [14%]). Bronchoscopic findings resulted in management changes in 51% of patients. The 28-day mortality rate was 26% and was highest in patients who required mechanical ventilatory assistance before bronchoscopy. CONCLUSION: The favorable safety record, good diagnostic yield, and frequent therapeutic implications support the routine use of BAL for the evaluation of pulmonary inflitrates in neutropenic patients. Bronchoalveolar lavage should be combined with the analysis of several sputum specimens. Transbronchial biopsy did only change the management of 1 patient.     

Spectrum of invasive pulmonary aspergillosis in immunocompetent patients with chronic obstructive pulmonary disease

Invasive pulmonary aspergillosis is a well-recognized complication in immunocompromised patients, especially those with neutropenia. We report four cases of invasive pulmonary aspergillosis in patients whose main underlying disease was chronic obstructive pulmonary disease (COPD). Two patients had an acute fatal course, one had chronic necrotizing pulmonary aspergillosis ending in an acute fatal course, and the other had a semiacute disease that responded to amphotericin B. Autopsy on three patients showed invasive pulmonary aspergillosis in both lungs, and tissue invasion was documented by transbronchial biopsy in the patient who survived. Retrospective review of all cultures that grew Aspergillus species from bronchoscopic specimens showed no false-positive results, and this procedure proved to be the most useful maneuver in making the diagnosis. Invasive pulmonary aspergillosis should be in the differential diagnosis in patients with COPD and unexplained pulmonary infiltrates.     

Utility of Transbronchial Biopsy in the Immunocompromised Host With New Pulmonary Radiographic Abnormalities

ObjectiveTo assess how often transbronchial biopsy (TBBx) added unique positive findings apart from other synchronous bronchoscopic sampling techniques including the bronchoalveolar lavage–immunocompromised host (BAL-ICH) panel that justified changes in management in an array of immunocompromised patients with new pulmonary radiographic abnormalities.MethodsWe retrospectively reviewed all bronchoscopies performed at Mayo Clinic Rochester between January 2012 and December 2017; on the basis of the physician’s selection of a BAL-ICH panel, we identified 192 immunocompromised patients who underwent bronchoscopy with both a BAL-ICH panel and TBBx. The results of the BAL-ICH panel and TBBx were compared and subsequent management decisions analyzed from clinical notes. We identified changes in immunosuppressive agents, antibiotics, chemotherapy, goals of care, and decisions on further evaluation and procedures. We assessed whether the TBBx findings added information not identified on the BAL-ICH panel and other bronchoscopic sampling methods performed during the same procedure that justified subsequent management changes.ResultsOf 192 bronchoscopic procedures performed on immunocompromised patients with acute and subacute pulmonary radiographic abnormalities, management changes justified by the unique positive results of the TBBx occurred 28% (51/192) of the time. Those immunocompromised by solid malignant neoplasms and receiving active immunosuppressive therapy had management changes justified 62.1% (18/29) of the time by the TBBx results. No additional fungal organisms were identified on TBBx that were accounted for on the BAL-ICH panel.ConclusionTransbronchial biopsy may add information to other bronchoscopic findings in immunocompromised patients, especially those with solid malignant neoplasms receiving active immunosuppressive treatment. These potential benefits must be weighed against the risks inherent to the procedure.     

Bronchoscopy and tuberculostearic acid assay in the diagnosis of sputum smear-negative pulmonary tuberculosis: a prospective study with the addition of transbronchial biopsy.

A prospective study of the efficacy of bronchoscopy and tuberculostearic acid assay in the diagnosis of sputum smear-negative pulmonary tuberculosis (TB) was carried out in 39 patients with symptoms and radiographic changes suggestive of active pulmonary TB. The diagnosis of TB was confirmed in 15 patients, probable TB was diagnosed in eight and 16 patients did not have TB. An early diagnosis of TB was made by bronchoscopy in six patients (40 per cent). Culture of sputum obtained before bronchoscopy was positive in nine patients (60 per cent) while combined with bronchoscopy specimens, a positive mycobacterial culture was obtained in 12 patients (80 per cent). Mycobacteria were cultured from transbronchial biopsy specimens from five patients (33 per cent) but none of these was exclusively positive. Histological examination of transbronchial biopsy tissue was diagnostic of TB in four patients and it was the exclusive means of early diagnosis in two. Transbronchial biopsy also provided an alternative diagnosis in four other patients. Tuberculostearic acid assay had a sensitivity of 0.40 in bronchial aspirate, 0.80 in bronchoalveolar lavage fluid, and 0.27 in transbronchial biopsy specimens: the combined result was 0.87. In nine patients with pulmonary TB in whom an early diagnosis could not be made, the tuberculostearic acid assay was positive in seven (78 per cent). We conclude that bronchoscopy with bronchoalveolar lavage and transbronchial biopsy is helpful in providing early diagnosis and positive culture results. Assay of tuberculostearic acid in bronchoalveolar lavage fluid is a useful adjunct to early diagnosis. However, mycobacterial culture and assay of tuberculostearic acid in transbronchial biopsy specimens have little diagnostic value.     

Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome: diagnosis using minilavage samples

Over a 30-month period, we evaluated 74 patients with acquired immunodeficiency syndrome (AIDS) for suspected opportunistic pulmonary infection. All had abnormal findings on chest roentgenogram. Sixty patients (81%) were found to have Pneumocystis carinii pneumonia (PCP). We assessed the yield of various diagnostic methods, and found that bronchoalveolar lavage samples obtained by the instillation of 20 to 50 ml of normal saline (minilavage) contained detectable organisms in 51 of 53 patients (sensitivity of 96%) when the samples were embedded in plastic, cut in thick sections (1 micron), stained with toluidine blue O, and evaluated by light microscopy. In comparison, the diagnostic yield was 94% for lung biopsy, 85% for touch preparation of lung tissue, 32% for bronchial washing, and 14% for brush biopsy. It is significant that minilavage samples embedded in plastic were positive in all seven patients who did not have transbronchial lung biopsy because they were at high risk for complications. We conclude that the process of embedding minilavage samples in plastic and evaluating thick sections stained with toluidine blue O is a sensitive method of diagnosing PCP in patients with AIDS.     

周边型肺部病变的内镜诊断

周边型肺部病变是临床上常见的疾病,支气管肺癌、肺转移瘤、肺结核等多种疾病均可表现为相似的影像学表现。周边型肺部病变常规支气管镜难以探及,对于距离胸壁较远或周围有大血管等重要脏器的病灶经皮穿刺也难以实施。合理利用细（或超细）支气管镜、经支气管镜肺活检、径向气道内超声引导肺活检术、支气管肺泡灌洗以及支气管镜导航等新技术可以提高周边型肺部病变的确诊率,便于指导临床早期治疗,以期获得较好的预后。     

Bronchoscopy and Tuberculostearic Acid Assay in the Diagnosis of Sputum Smear-negative Pulmonary Tuberculosis: A Prospective Study with the Addition of Transbronchial Biopsy

A prospective study of the efficacy of bronchoscopy and tuberculostearicacid assay in the diagnosis of sputum smear-negative pulmonarytuberculosis (TB) was carried out in 39 patients with symptomsand radiographic changes suggestive of active pulmonary TB.The diagnosis of TB was confirmed in 15 patients, probable TBwas diagnosed in eight and 16 patients did not have TB. An earlydiagnosis of TB was made by bronchoscopy in six patients (40per cent). Culture of sputum obtained before bronchoscopy waspositive in nine patients (60 per cent) while combined withbronchoscopy specimens, a positive mycobacterial culture wasobtained in 12 patients (80 per cent). Mycobacteria were culturedfrom transbronchial biopsy specimens from five patients (33per cent) but none of these was exclusively positive. Histologicalexamination of transbronchial biopsy tissue was diagnostic ofTB in four patients and it was the exclusive means of earlydiagnosis in two. Transbronchial biopsy also provided an alternativediagnosis in four other patients. Tuberculostearic acid assayhad a sensitivity of 0.40 in bronchial aspirate, 0.80 in bronchoalveolarlavage fluid, and 0.27 in transbronchial biopsy specimens: thecombined result was 0.87. In nine patients with pulmonary TBin whom an early diagnosis could not be made, the tuberculostearicacid assay was positive in seven (78 per cent). We concludethat bronchoscopy with bronchoalveolar lavage and transbronchialbiopsy is helpful in providing early diagnosis and positiveculture results. Assay of tuberculostearic acid in bronchoalveolarlavage fluid is a useful adjunct to early diagnosis. However,mycobacterial culture and assay of tuberculostearic acid intransbronchial biopsy specimens have little diagnostic value.     

The importance of bronchoscopy in the comprehensive examination and treatment of patients with deforming bronchitis

5-year experience gained in three Moscow hospitals with bronchoscopic examinations of tracheobronchial lesions is analyzed. Out of 10809 procedures performed 337 were indicative of deforming bronchitis. Diagnostic evidence was furnished by x-ray, bronchography, fiber bronchoscopy with biopsy, radiologic evaluation of the lungs. Local bronchoscopic treatment was delivered to 209 patients. As a rule, the course involved 5-6 therapeutic bronchoscopies and was repeated on demand. The response was achieved in 97.6% of the patients.     

Bronchoscopy in the community hospital

A new Pulmonary Medicine-Thoracic Surgery service was established in a community hospital in July 1974. This report details the experience of 409 bronchoscopies performed from July 1, 1974 through Dec 31, 1976. There were no deaths and four complications--one aspiration and three pneumothoraces resulting from transbronchial lung biopsy. Final diagnoses for which bronchoscopy was done were as follows: cancer--141; infectious disease--97; interstitial disease--33; obstructive lung disease--58; hemoptysis--35; miscellaneous--45. In the cancer group, a cytohistologic diagnosis was made in 82 patients by bronchoscopy alone, 31 additional diagnoses were made by scalene node biopsy or mediastinoscopy, and the remainder by surgical exploration and/or resection. In 268 patients with benign disease, bronchoscopy established the diagnosis in 87% of the cases. Pulmonary Medicine tended not to repeat nondiagnostic bronchoscopy but rather to refer immediately for a definitive surgical procedure. Thoracic Surgery tended not to reduplicate bronchoscopy for the purpose of "confirmation." A conjoint medical-surgical approach to bronchial disease, at the community level and based on a mutual understanding of capability and limitation, is feasible, productive, and economical.     

Utility of fiberoptic bronchoscopy in neutropenic patients admitted to the intensive care unit with pulmonary infiltrates

OBJECTIVE: To analyze the impact of fiberoptic bronchoscopy and bronchoalveolar lavage (BAL) on guiding the treatment and intensive care unit (ICU) clinical outcome in neutropenic patients with pulmonary infiltrates admitted to the ICU. DESIGN: Prospective collection of data. SETTING: Medical ICU in a teaching hospital. PATIENTS: During a 6-yr period, we analyzed the results of 93 fiberoptic bronchoscopies plus BALs performed in 93 consecutive neutropenic ICU patients. We separated the patients into two groups according to the cause of neutropenia (high-dose chemotherapy [n = 41] or stem cell transplantation [SCT; n = 52]). RESULTS: Of the 93 BALs, 53 were performed to evaluate diffuse infiltrates and 42 were performed on mechanically ventilated patients. Forty-nine percent of BALs (46 patients) were diagnostic, with a significantly better yield in ICU patients with high-dose chemotherapy-induced neutropenia (26 of 41 BALs). The number of cases of proven infectious pneumonia was significantly higher in this group of ICU neutropenic patients. In patients who underwent SCT, diffuse infiltrates were statistically correlated with a negative result of BAL. Twenty-six patients who underwent diagnostic BALs changed therapy. Sixteen complications (17%) occurred with only two intubations. The overall mortality rate in the ICU and the mortality rate in mechanically ventilated neutropenic patients were 71% and 93%, respectively. In neutropenic patients who underwent SCT, the mortality rate was statistically higher in patients in whom no diagnosis was established. Patients who had a diagnostic BAL that changed therapy did not have an increased probability of survival compared with patients who had a BAL that did not change therapy. CONCLUSIONS: The use of routine diagnostic BAL in ICU neutropenic patients with pulmonary infiltrates is difficult to establish, even if BAL is helpful in the management of these critically ill patients. BAL in our ICU neutropenic patient population had an acceptable overall diagnostic yield (49%), which was higher in ICU patients with chemotherapy-induced neutropenia. Nevertheless, in the ICU, if BAL had a low complication rate, it had infrequently led to changed treatment and was not associated with improved patient survival.     

Fluorescence bronchoscopic surveillance in patients with a history of non-small cell lung cancer

Background Second lung primaries occur at a rate of 2% per patient per year after curative resection for non-small cell lung carcinoma (NSCLC). The aim of this study was to evaluate the role of fluorescence bronchoscopy using the Xillix((R)) LIFE-Lung Fluorescent Endoscopy System(TM) (LIFE-Lung system) in the surveillance of patients for second NSCLC primaries after resection or curative photodynamic therapy (PDT).Methods NSCLC patients who were disease-free following resection or endobronchial PDT were identified and recruited to participate in a LIFE bronchoscopy surveillance program. All suspicious areas were biopsied; areas of apparent normal mucosa served as negative controls. Biopsy specimens were reviewed by a single pulmonary pathologist.Results Thirty-six patients underwent 53 surveillance LIFE bronchoscopies and 6/112 biopsies revealed intraepithelial neoplasia (IEN) or invasive carcinoma in 6/36 (17%) of patients. The overall relative sensitivity of LIFE versus conventional bronchoscopy was 165% with a negative predictive value of 0.96, for the post-resection subset of patients these values increased to 200% and 0.97, respectively.Conclusions Surveillance LIFE bronchoscopy identified intraepithelial or invasive lesions in 17% of patients previously thought to be disease-free. These data support future multicenter trials on fluorescence bronchoscopic surveillance of NSCLC patients after curative surgical resection or PDT.     

骨髓移植后肺部弥漫性病变纤维支气管镜诊断

为了评估骨髓移植术后肺部弥漫性病变诊断中纤维支气管镜检（fibroptic bronchoscopy，FB）的应用价值，对2003年11月-2006年3月间18例骨髓移植术后出现肺部弥漫性病变、短期经验治疗效果欠佳的患者行FB，并做支气管肺泡灌洗（BAL）及刷检涂片，其中3例条件许可者加支气管镜肺活检（TBLB）。结果发现，18例骨髓移植术后患者10例为肺部感染，8例为非感染性肺部并发症。10例肺部感染患者9例通过FB明确诊断，包括细菌性肺炎3例，真菌感染2例，卡氏肺囊虫3例，病毒性肺炎1例。1例接受2次BAL，无阳性结果，开胸肺活检确诊为结核。8例非感染性肺部并发症患者中2例通过TBLB明确诊断。结论：FB特别是BAL是一种安全、有效的检查方法，对白血病骨髓移植后肺部并发症尤其感染性肺部并发症的诊断率高；奈件许可者应尽可能行TBLB，以提高移植后非感染并发症诊断，减少开胸肺活检。     

Pulmonary diagnostic procedures in the critically ill

When faced with a critically ill patient with new pulmonary infiltrates on chest roentgenograms, the physician must choose the appropriate diagnostic procedure on the basis of the expected yields versus the potential complications. The first steps in any patient should include discontinuation of any nonessential medications, careful evaluation of fluid status to exclude cardiogenic pulmonary edema, and a review of likely diagnoses based on the patient's underlying disease. Although not likely to be of immediate utility, obtaining cultures of blood and other body fluids or sites and serologic testing may provide helpful information when combined with other procedures. Bronchoscopy is a reasonable first step in patients with a slow progression of disease or in those in whom the pulmonary process is discovered early in its course. As these patients often present with several of the known risk factors for complications with bronchoscopy, the decision to perform this procedure should not be made lightly. Transbronchoscopic lung biopsy adds additional risk to bronchoscopy but also increases the diagnostic yield considerably over lavages, brushing, and bronchial washings. Open lung biopsy offers high diagnostic yields and relatively low rates of serious complications. Because of the invasive nature of the procedure, there is often reluctance to perform it. In patients with rapidly progressive disease or conditions that make the risk of bronchoscopy unacceptably high, such as severe hypoxemia, bleeding diathesis, or cardiac compromise, prompt diagnosis requires that the physician consider open lung biopsy as a first diagnostic procedure. The physician must also consider whether making a specific diagnosis will be of benefit to the patient. Potential benefits of a specific diagnosis include stopping unnecessary empirical (and potentially toxic) therapies, instituting correct and specific therapy, and thus decreasing morbidity and mortality. The impact of specific diagnosis on morbidity and survival is often difficult to demonstrate. Discouraging notes have been sounded by studies of the effect of bronchoscopic or surgical diagnosis on the ultimate outcome for patients. For bronchoscopy with transbronchoscopic lung biopsy, although the overall diagnostic rate was 60 per cent, no difference in survival was noted between patients in whom a diagnosis was made and those in whom the nature of the pulmonary process remained unknown. Similarly, in a series of patients who underwent open lung biopsy, although the results of biopsy led to a therapeutic change in 70 per cent of the patients, only 16.5 per cent of the patients benefited from this change.(ABSTRACT TRUNCATED AT 400 WORDS)     

肺癌癌性空洞纤维支气管镜检查分析

目的：探讨纤维支气管镜（纤支镜）对肺癌癌性空洞的诊断价值。方法：回顾性分析27例肺癌癌性空洞的纤支镜检查情况，结果：27例中鳞癌17例，腺癌2例，腺鳞癌1例，大细胞癌1例，未能分型6例，纤支镜检查确诊21例，阳性率77．8％，镜下表现，新生物型4例，粘膜浸润型12例，外压型3例，大致正常型8例，4例新生物型直视下活检均阳性，刷检3例阳性，7例粘膜浸润型直视下活检阳性2例，刷检阳性3例，其中1例活检刷检均阳性，纤支镜检查阳性率57．1％（4／7），余16例中经支气管肺活检阳性11例，经支气管刷检阳性6例，其中4例活检刷检均阳性，阳性率81．3（13／16），结论：纤支镜检查对肺癌癌性空洞的确诊率高，应予重视，对镜下未见新生物者，应积极采用经支气管肺活检及经支气刷检。     

Pneumocystis carinii pneumonia in renal transplant recipients--clinical and radiographic features, diagnosis and complications of treatment

Six episodes of Pneumocystis carinii pneumonia in five renal transplant patients on low dose maintenance prednisolone are described. The infection was rare, occurring in 3 per cent of the recipients transplanted between 1978 and 1984. Diagnosis and treatment were not straightforward. Fever was the earliest evidence of illness, and in three episodes the chest radiograph was normal at presentation. At diagnosis, two to 16 days later, all had pulmonary infiltrates and severe hypoxia. Diagnosis was confirmed by cytological examination of bronchial lavage (two), transbronchial biopsy (one), open lung biopsy (one), and for two episodes clinically, from the rapid and complete resolution of fever, pulmonary infiltrates and hypoxia following a therapeutic trial of high dose cotrimoxazole. Pneumocystis antibody titres were low during the illness and in convalescence and did not contribute to diagnosis. Three patients had serological evidence of recent cytomegalovirus infection. All episodes responded to treatment with high dose cotrimoxazole. All the patients survived the illness but one died a year after recovery. The major complications of treatment were thrombocytopenia (three cases) and neutropenia (two cases) which did not respond to folinic acid.     

纤维支气管镜检查在抗酸杆菌阴性肺结核诊断中的应用价值

目的:评价纤维支气管镜(纤支镜)检查在痰涂片抗酸杆菌阴性(菌阴)肺结核诊断中的作用.方法:对应用纤支镜检查确诊的92例菌阴且临床表现不典型肺结核病例资料进行回顾性分析.结果:本组39例纤支镜下见支气管黏膜有异常改变,其中29例(74.4%)刷检涂片找抗酸杆菌阳性,活检有结核病理改变23例(59.0%);另外53例病灶位于外周部位,纤支镜下未见明显异常,经支气管肺活检(TBLB)抗酸杆菌阳性42例(79.2%),刷检涂片抗酸杆菌阳性24例(45.3%),支气管肺泡灌洗液涂片检查抗酸杆菌阳性15例(28.3%).结论:对痰涂片抗酸杆菌阴性肺结核,尤其是临床表现不典型者,纤支镜检查有助于明确诊断.     

Increased radiotracer uptake on positron emission tomography after invasive thoracic procedures: a case series

OBJECTIVE: To investigate the hypothesis that tissue changes induced by invasive thoracic procedures may be associated with increased fluorine 18-labeled fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET) scans, potentially leading to these tissue changes being mistaken for malignancies. PATIENTS AND METHODS: We retrospectively reviewed the records of all patients undergoing bronchoscopies and FDG-PET at Mayo Clinic Jacksonville from February 2002 to September 2004 and identified patients who had undergone computed tomography (CT) of the chest and bronchoscopy before FDG-PET. We identified and reviewed the imaging studies of patients who had increased FDG uptake on PET scans and whose CT scans showed no corresponding abnormalities suggestive of malignancy. RESULTS: Eighty-one patients had undergone both bronchoscopy and PET within the defined study period. Of these, 45 (56%) underwent PET within 4 weeks after bronchoscopy, and 13 (29%) of these 45 patients had increased FDG uptake on PET scans that did not correlate with pathological findings on CT. We judged that increased uptake on 3 (23%) of the 13 PET scans was most likely related to the bronchoscopic procedure. Additionally, 2 patients who had undergone thoracoscopy after bronchoscopy but before PET had discordant CT and PET findings. CONCLUSION: Invasive thoracic procedures may cause an increased uptake of radiotracer on PET scans that could be mistakenly interpreted as evidence of malignancy. To avoid clinical misjudgment, clinicians should perform PET before invasive thoracic procedures.     

Diagnosis of pulmonary infections in immunocompromised patients

In an immunocompromised patient with fever and pulmonary infiltrates, it frequently is difficult to decide which invasive procedure, if any, to use to obtain a definitive diagnosis. Because most lung infiltrates in immunosuppressed patients are caused by bacteria and sputum usually is readily available for examination, empiric therapy with potent, safe, broad spectrum, antibacterial drugs often is successful. Invasive procedures that prove a diagnosis may result in substantive changes in therapy in perhaps as few as 10 to 20 per cent of patients, and the procedure itself may harm the patient. In a unique study in which patients with acute pneumonitis without neutropenia were randomized to either empiric antibiotic treatment or treatment based on results of open lung biopsy, patients with open lung biopsy had a worse outcome, possibly related to morbidity of open lung biopsy. Furthermore, no diagnoses were provided by open lung biopsy that were not treated by the empiric regimen. A missed treatable disease may be tragic, however. A thoughtful clinician must evaluate each patient with careful consideration of the history in light of the underlying disease and its treatment, rapidity of clinical course, physical examination, and laboratory data, particularly the chest radiograph, sputum examination, and bleeding parameters. Fiberoptic bronchoscopy with washings and brushings is very safe; the addition of transbronchial biopsy adds diagnostic power at the price of some complications. Bronchoalveolar lavage is a very promising technique that probably will find widespread use. However, none of the foregoing techniques is completely sensitive. When no diagnosis is established and bronchoscopy studies are negative, open lung biopsy must be considered, especially when the chest radiograph or computed tomography scan suggests focal disease or lymphadenopathy. Needle aspiration can be used, particularly if local experience is favorable and lung disease is peripheral. When evaluating a procedure, local experience must be considered rather than reliance on published diagnostic yields and complication rates. New diagnostic and therapeutic developments may change decision analysis in the near future. At present, cultures for viruses and fungi and serologic techniques have little application at most medical centers, and decisions on data from invasive procedures pivot on interpretation of histology and smears. Development of assays for antigen (for example, Aspergillus) and rapid culture techniques (for example, cytomegalovirus and the shell vial method), coupled with new, effective antimicrobials, may demand maximum effort for a definitive diagnosis in every patient.     

Pneumocystis carinii Pneumonia in Renal Transplant Recipients - Clinical and Radiographic Features, Diagnosis and Complications of Treatment

Six episodes of Pneumocystis carinis pneumonia in five renaltransplant patients on low dose maintenance prednisolone aredescribed. The infection was rare, occurring in 3 per cent ofthe recipients transplanted between 1978 and 1984. Diagnosisand treatment were not straightforward. Fever was the earliestevidence of illness, and in three episodes the chest radiographwas normal at presentation. At diagnosis, two to 16 days later,all had pulmonary infiltrates and severe hypoxia. Diagnosiswas confirmed by cytological examination of bronchial lavage(two), transbronchial biopsy (one), open lung biopsy (one),and for two episodes clinically, from the rapid and completeresolution of fever, pulmonary infiltrates and hypoxia followinga therapeutic trial of high dose cotrimoxazole. Pneumocystisantibody titres were low during the illness and in convalescenceand did not contribute to diagnosis. Three patients had serologicalevidence of recent cytomegalovirus infection. All episodes respondedto treatment wth high dose cotri-moxazole. All the patientssurvived the illness but one died a year after recovery. Themajor complications of treatment were thrombocytopenia (threecases) and neutropenia (two cases) which did not respond tofolinic acid.