However, no patient in the present series had this organism demonstrated by smear or culture. Since the present report includes only patients with diffuse radiologic infiltrates, we excluded two cases of M avium-intracellulare presenting with localized infiltrates during the period of study. buy antibiotics online
Nevertheless, in all such cases the pneumonia was effectively treated without therapy directed toward the virus. Also, autopsies on five patients who had cytomegalovirus cultured from their BAL failed to reveal histologic changes consistent with cytomegalovirus pneumonia or viral inclusions in lung tissue. However, most of the cytomegalovirus was in AIDS patients with Pneumocystis (13/21), and the two transplant patients with cytomegalovirus had no Pneumocystis attributed to this virus. buy flovent inhaler
Although others* have described invasive candidal pneumonia in some patients in whom Candida sp were isolated from BALs, we found no clinical or pathologic evidence that Candida sp were respiratory pathogens in our series. The positive correlation between oral candidiasis and a positive BAL culture for Candida sp suggests that many instances of Candida in BALs represent contamination from the upper respiratory tract. Aspergillus sp similarly can colonize the tracheobronchial tree, as was the case in one AIDS patient whose BAL showed growth of Aspergillus sp and contained Pneumocystis. Continue reading
The 12 cases (20 percent) of fungal infection in 60 BALs in the current series is higher than has been reported previously (see Table 3). This is primarily due to the seven cases of coccidioidomycosis, a number that was not surprising in view of the fact that the patient population comes from the endemic area for this disease. In five of the seven cases, the diagnosis was made by BAL, either immediately, by cytologic examination of the Pap-stained BAL, or several days later, by culture. In one instance in which the diagnosis was missed, the BAL fluid was of small quantity and contained few alveolar macrophages, indicating a somewhat inadequate specimen. The other case involved a patient with myelodysplasia who died shortly after the bronchoscopy with pneumonia and pulmonary hemorrhage. Continue reading
The differential diagnosis of diffuse pulmonary infiltrates in the immunocompromised patient is difficult at best. In addition to a large variety of infectious agents, one must also consider that recurrence of the primary disease, drug toxicity, the adult respiratory distress syndrome, and toxic reactions to radiation therapy that may produce similar clinical and roent-genographic findings. Even when all these possibilities have been exhausted, one is often left with a small number of patients with interstitial disease of unknown cause. Continue reading
Noninfectious Causes of Infiltrates
Radiation pneumonitis was an eventual diagnosis in five patients by open lung biopsy in two patients, autopsy in one, and clinical course in the remaining two. In three of these, BAL cytologic study demonstrated reactive atypia of epithelial cells consistent with radiation. In two other cases, the final diagnosis was rejection of transplanted lungs, and the “negative” BAL was clinically important in making this distinction. The BAL was also appropriately negative in two cases of adult respiratory distress syndrome and three cases of pneumonitis due to drug toxicity. Two cases of pulmonary infiltrates due to drug reaction responded quickly to corticosteroid therapy and drug withdrawal alone, while another with a skin rash as well cleared rapidly following discontinuance of the drug therapy. Continue reading
Of the 57 of 60 BALs cultured for bacteria, bacterial pathogens grew from eight: these included three cases of coagulase-positive Staphylococcus aureus, and one each of Streptococcus pneumoniae, Chlamydia trachomatis, Legionella pneumophila, Haemophilus influenzae, and Pseudomonas aeruginosa. Of the three isolates of S aureus, one was regarded clinically as a pathogen in an elderly man with severe chronic obstructive pulmonary disease and AIDS; the patient was treated for this infection but died shortly thereafter; an autopsy was not performed. In another patient with AIDS and Pneumocystis, C trachomatis was regarded as a pathogen and treated while the S aureus isolated was not treated. A patient with Hodgkins disease and S aureus was treated for this infection; autopsy showed pneumonia that could have been staphylococcal. Legionella pneumophila pneumonia was confirmed at autopsy. Continue reading
Cytomegalovirus was demonstrated by direct immunofluorescence with monoclonal antibodies and/or culture in 21 of the 59 BALs studied. Likewise, herpes simplex virus was identified in five specimens and parainfluenza type 3 was identified in one. Intranuclear viral inclusions were seen cytologically in only two cases, one of cytomegalovirus and one of herpes. In only one patient who had treated acute myelogenous leukemia was cytomegalovirus believed clinically to be a cause of progressive pneumonia. In 13 cases, cytomegalovirus was isolated from AIDS patients with Pneumocystis pneumonia, but clinically it was not responsible for disease.
Hemorrhagic necrotizing aspergillosis was diagnosed both cytologically and by culture from a BAL and confirmed by transbronchial biopsy. However, a case of granulomatous aspergillosis was not detected by BAL, but it was diagnosed subsequently by open lung biopsy. Aspergillus sp was also grown from a BAL in one AIDS patient with Pneumocystis pneumonia, but there was no evidence of pulmonary infection clinically or in a transbronchial biopsy specimen. Fungi consistent with Candida sp, including Toru-lopsis glabrata and yeast not otherwise identified (not Cryptococcus) were detected cytologically in nine BALs and cultured in 23. The ability to culture the Candida-like organism from BAL was positively correlated with the presence of thrus h (x2 = 6.61; p = 0.01). However, in no case was it apparent, clinically or pathologically, that Candida was a cause of lower respiratory tract infection. Continue reading
In 12 of the 60 episodes, fungi were identified as the cause of the pulmonary infiltrates (Table 2), C immitis being found in seven cases. This fungus was grown from culture of five BALs, three of which had previously shown the organism cytologically (Fig 1).
One additional case was diagnosed at autopsy and the other was diagnosed from blood and bronchial brush-ings. Only one of the seven cases of coccidioidomycosis occurred in an AIDS patient. Serologic studies for coccidioidomycosis were obtained during 46 of the 60 episodes, including all seven of those in which such a diagnosis was ultimately confirmed. Continue reading