Medicine of the Future in America

Detection of Fungi and Other Pathogens in Immunocompromised Patients by Bronchoalveolar Lavage: Discussion (Part 2)

Detection of Fungi and Other Pathogens in Immunocompromised Patients by Bronchoalveolar Lavage: Discussion (Part 2)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. Cultures of blood and urine were also negative, as was the serologic test. The diagnosis was made only at autopsy, with the identification of fibrotic granulomas that were limited in extent and only minimally active. Among those patients with active pulmonary involvement in whom an adequate BAL specimen is obtained, the diagnostic yield of this procedure approaches 100 percent. buy asthma inhaler
The yield from serologic studies for coccidioidomycosis was similar to that of BAL (five to seven). Unfortunately, serologic results are often not available for up to seven days at a time when immediate therapeutic intervention is required. Thus, the fact that the BAL Pap-stained cytologic test result is available within hours from the time of collection represents a distinct clinical advantage. Of particular interest in this series was the fact that only one of the 31 AIDS patients (36 BALs) was found to have coccidioidomycosis. This contrasts sharply with a previous report of a 25 percent prevalence of this disease in AIDS patients living in this area.

Table 3—Identification of Fungi in BAL Fluid

Source, yr

Number of BALS

Type of Patient

% of BALs with Pathogenic Fungi

Aspergillus

sp

Candida

sp

Coccidioides

immitis

Crypto

coccus

neoformans

Other

Cases Missed by BAL

Stover et al,1984

97

Non-AIDS

5

4

0

0

1

0

1

Stover et al,1984

72

AIDS

0

0

0

0

0

0

0

Young et al,1984

30

Non-AIDS

20

2

3

0

0

It

0

Broaddus et al, 1985

276

AIDS

2

0

0

1

4

0

3

Orenstein et al, 1986

78

AIDS

3

0

0

0

2

0

1

Francis et al,1987

120

AIDS

2

0

o (3)

0

1

2

Linder et al, 1987

604

Non-AIDS

-1

5

1671

0

1

26

0

Martin et al,1987

100

Mostly non-AIDS

3

1 (1)

1 (2)

0

1

0

1

Present study

60

60% AIDS

11

1 (1)

0 (24)

5

1

0

5

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