Evaluation of three assays on alveolar lavage fluid in the diagnosis of cytomegalovirus pneumonitis after bone marrow transplantation

Pneumonia After Hematopoietic Stem Cell Transplantation

Pneumonia is the main cause of morbidity and mortality after hematopoietic stem cell transplantation. Two thirds of pneumonias observed after both autologous and allogeneic stem cell transplantations are of infectious origin, and coinfections are frequent. One third is due to noninfectious process, such as alveolar hemorrhage, alveolar proteinosis, or alloimmune pulmonary complications such as bronchiolitis obliterans or idiopathic interstitial pneumonitis. Most of these noninfectious complications may require treatment with corticosteroids which may be deleterious in infection. On the other hand, these complications either mimic or may be complicated with infections. Therefore, a precise diagnosis of pneumonia is of crucial importance to decide of the optimal treatment. CT scan is the best procedure for imaging of the lung. Although several indirect biomarkers, such as serum or plasma galactomannan or (1-3) β(beta)-G-glucan, can help in the etiological diagnosis, only direct invasive investigations provide the best chance to identify the cause(s) of pneumonia. Bronchoalveolar lavage (BAL) under fiberoptic bronchoscopy is the procedure of choice to identify the cause of pulmonary infection. It is safe and reproducible, and its diagnostic yield is around 50 % if the BAL fluid is processed at the laboratory according to a prespecified protocol established between the transplanter, the infectious diseases’ specialist, the pneumologist, and the laboratory, allowing the identification of the most likely hypotheses. Transbronchial biopsy does not provide significant additional information to BAL in most cases and more often complicates with bleeding and pneumothorax. In case of a noncontributory BAL, the decision to proceed to a second BAL, a transthoracic biopsy, or a surgical biopsy should be cautiously weighted in a multidisciplinary approach in regard to the benefits and risks of invasive procedures versus empirical treatment.

Bronchoalveolar lavage and lung biopsy in patients with cancer and hematopoietic stem-cell transplantation recipients: a systematic review and meta-analysis

PURPOSE

The objective of this study was to describe the diagnostic yield and complication rate of bronchoalveolar lavage (BAL) and lung biopsy in the evaluation of pulmonary lesions in patients with cancer and recipients of hematopoietic stem-cell transplantation (HSCT).

METHODS

We conducted a systematic literature review and performed electronic searches of Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Studies were included if patients had cancer or were recipients of HSCT, and if they underwent BAL or lung biopsy for the evaluation of pulmonary lesions. Only English language publications were included.

RESULTS

In all, 14,148 studies were screened; 72 studies of BAL and 31 of lung biopsy were included. The proportion of procedures leading to any diagnosis was similar by procedure type (0.53 v 0.54; P = .94) but an infectious diagnosis was more common with BAL compared with lung biopsy (0.49 v 0.34; P < .001). Lung biopsy more commonly led to a noninfectious diagnosis (0.43 v 0.07; P < .001) and was more likely to change how the patient was managed (0.48 v 0.31; P = .002) compared with BAL. However, complications were more common with lung biopsy (0.15 v 0.08; P = .006), and procedure-related mortality was four-fold higher for lung biopsy (0.0078) compared with BAL (0.0018).

CONCLUSION

BAL may be the preferred diagnostic modality for the evaluation of potentially infectious pulmonary lesions because of lower complication and mortality rates; thus, choice of procedure depends on clinical suspicion of infection. Guidelines to promote consistency in the approach to the evaluation of lung infiltrates may improve clinical care of patients.

Successful management of sequential pulmonary infections in a cardiac transplant recipient

A case of a cardiac allograft recipient who had an initial combined pulmonary infection with cytomegalovirus, Aspergillus fumigatus and Nocardia asteroides, successfully treated with liposomal amphotericin B and sulfisoxazole and followed by an episode of respiratory syncytial virus pneumonitis, is presented. This case illustrates the role of computed tomographic imaging in the recognition, diagnosis and monitoring of complex opportunistic pulmonary infections and the benefits of liposomal amphotericin B in the treatment of aspergillosis.

Minimally Invasive Diagnostic Strategy in Immunocompromised Patients with Pulmonary Infiltrates

Acute respiratory failure (ARF) is the main reason for ICU admission in patients with haematological malignancies. High mortality rates of up to 50% are reported in this situation, and mortality is highest when mechanical ventilation is needed. Rapid and accurate diagnostic methods are needed in these vulnerable patients to ensure the prompt initiation of effective treatment. However, the broad array of possible cause of ARF raises diagnostic challenges. In this review, we discuss the DIRECT strategy, which identifies the most plausible diagnosis in each patient based on the type of immune deficiency and clinical presentation. We will focus on non-invasive laboratory tests developed in recent years, discussing their sensitivity and specificity. We also discuss the usefulness in cancer patients with specific organ dysfunctions of biomarkers introduced over the past few years.

[Viral pneumonia in immunocompetent patients]

Les infections virales respiratoires communautaires sont fréquentes et le plus souvent bénignes. Beaucoup d'agents différents comme les virus influenza, ou para-influenza, le virus respiratoire syncitial, les rhinovirus, coronavirus, adénovirus et les herpès virus peuvent être isolés chez les patients immunocompétents. Parmi ces virus, le cytomégalovirus (CMV) peut être responsable de pneumonie nosocomiale en réanimation. Le diagnostic des infections virales est difficile car les signes cliniques sont non spécifiques et l'isolement du virus responsable difficile. Cependant, une symptomatologie clinique associant fièvre, myalgies, céphalées, pharyngite est fréquente dans les infections à Inflenza qui peuvent aboutir à des tableaux sévères. Enfin, le virus plus récent responsable d'infection respiratoire est un virus nouvellement découvert de la famille des coronavirus, le SRAS-CoV qui a été responsable d'une épidémie d'infections respiratoires sévères. Les pneumonies virales sont fréquentes mais probablement non diagnostiquées chez les patients immunocompétents. Cependant le diagnostic est nécessaire car pour la plupart des pathogènes il existe un traitement efficace. Le diagnostic repose sur l'histologie mais de nouvelles techniques comme la PCR doivent devenir d'utilisation courante pour améliorer le rendement diagnostique.

Diagnosis and treatment approaches of CMV infections in adult patients

BACKGROUND

Cytomegalovirus (CMV) infections are very common in the general population. Clinical CMV disease, particularly CMV pneumonitis, greatly impacts the morbidity and mortality of immunosuppressed patients.

OBJECTIVE

To present an overview of the basic aspects of the biology, epidemiology, and clinical features of CMV in relation to the available diagnostic and therapeutic approaches in adult patients.

METHODS

Review of the medical literature on cytomegalovirus infection and disease in adult hosts, with a focus on approaches to diagnosis and treatment of CMV respiratory disease in immunosuppressed hosts.

CONCLUSIONS

Cytomegalovirus infections are likely to remain a significant cause of morbidity and mortality among immunosuppressed patients. Important aspects of the biological events underlying the transition from infection to clinical disease remain unclear. Despite that, considerable progress has been made in the design of improved diagnostic techniques and the development of antiviral agents. Preventive and particularly preemptive therapeutic approaches demand further technical improvements in diagnostic testing. At present, the emphasis in the search for improved diagnostic testing rests on the development of quantitative methods for early detection of the increased viral replicative activity that presumably precedes the onset of CMV disease in infected individuals.

Bronchoalveolar lavage in the diagnosis of pulmonary complications of bone marrow transplant patients

Bronchoalveolar lavage (BAL) has proved valuable in the diagnosis of pulmonary complications in immunosuppressed patients. We evaluated the diagnostic yield of BAL in pulmonary complications in bone marrow transplantation (BMT) recipients. We reviewed sequentially the records of 89 patients during an 18-month period. BAL was diagnostic in 42 patients (47%). The most common pulmonary complication diagnosed by BAL was diffuse alveolar hemorrhage (n = 15); followed by bacterial pneumonia (n = 10), respiratory syncytial virus (n = 8), aspergillosis (n = 6), Pneumocystis carinii pneumonia (n = 5), cytomegalovirus (CMV) (n = 4), and others (n = 4). The final diagnoses in the BAL non-diagnostic group were: bacterial pneumonia (n = 6), CMV (n = 6), idiopathic pneumonia syndrome (n = 5), cancer recurrence (n = 4), cardiogenic pulmonary edema (n = 4), and others (n = 9). We conclude that BAL is a useful diagnostic tool in BMT-related pulmonary complications.

Clinical features and outcomes of HIV-related cytomegalovirus pneumonia

OBJECTIVE

To describe the characteristics and outcomes of HIV-infected patients with biopsy-proven cytomegalovirus (CMV) pneumonia.

DESIGN

Retrospective study.

SETTING

A 900-bed acute facility in New York City.

PATIENTS

Eighteen HIV-infected patients with pathologically confirmed CMV inclusions in lung tissue without other pathogens and 36 control patients with biopsy-proven Pneumocystis carinii pneumonia (PCP) selected for comparisons by computer-generated random sequential numbers.

MAIN OUTCOME MEASURES

Demographic, clinical, laboratory, radiological findings, and in-hospital mortality.

RESULTS

Eighteen HIV-infected patients were found to have CMV lung infection alone. Pathologic findings were pneumonitis (n = 11); pneumonitis and pulmonary vasculitis (n = 1); and CMV inclusions alone (n = 6). All presented with respiratory symptoms (cough or dyspnea), 89% had fever, 83% had radiological abnormalities, and 56% had severe hypoxemia. The pulmonary presentation was similar except for higher lactate dehydrogenase (median, 449 versus 329 IU/l; P = 0.03) and presence of pleural effusions (33 versus 0%; P = 0.001) in CMV patients. Multivariate analysis showed that CD4 counts < or = 12 x 10(6)/l (odds ratio; 9.2; P = 0.029) and extrapulmonary CMV (odds ratio, 20.4; P = 0.039) were independently associated with CMV pneumonia. Seventeen patients received specific anti-CMV therapy for a mean of 22 +/- 13 days. In-hospital mortality was higher in patients with CMV pneumonia (odds ratio, 11.9; P = 0.002). The median time from admission to death was 31 days.

CONCLUSIONS

CMV lung infection was seen in severely immunosuppressed HIV-positive patients and associated with clinical pneumonitis with high early mortality. Although the clinical features resemble PCP, the presence of extrapulmonary CMV disease should suggest the diagnosis of CMV pneumonia.

Extracorporeal life support for the treatment of viral pneumonia: collective experience from the ELSO registry. Extracorporeal Life Support Organization

Viral pneumonia is the most common indication for pediatric extracorporeal life support (ECLS). Despite this fact, no previous studies have directly stratified patient outcome according to viral etiology.

METHODS

Using the Extracorporeal Life Support Organization (ELSO) registry database, the authors reviewed the national experience of patients undergoing ECLS with culture or serologically demonstrated viral pneumonia and compared outcome parameters according to viral etiology.

RESULTS

Patients differed with respect to age and weight according to the viral type. Patients with respiratory syncytial virus (RSV, median age 3 months), herpes simplex virus (HSV, 0.13 months), cytomegalovirus (CMV, 2.5 months), and adenovirus (0.6 months) were younger than those with other viruses (5.5 months). The patient groups did not significantly differ with respect to pre-ECLS Pao2 mean airway pressure (MAP), oxygenation index (OI), mode, or duration of ECLS. The overall survival of patients with viral pneumonia was 57%, although patients with RSV or CMV were found to have a 67% survival. Patients infected with HSV and adenovirus had a significantly lower survival rate (31% and 25%, respectively) when compared with those with RSV. In addition RSV pneumonia was associated with fewer cardiovascular complications than several of the other viral types. When comparison was made between survivors and nonsurvivors, a higher last pre-ECLS MAP and increased incidence of elevated creatinine and renal failure requiring dialysis were noted among nonsurvivors.

CONCLUSION

ECLS remains an important modality in the treatment of neonatal and pediatric patients with respiratory failure secondary to viral pneumonia. The survival rate of these patients varies according to the type of viral infection.

Bronchoscopic diagnosis of pneumonia

Lower respiratory tract infections are characterized by significant morbidity and mortality but also by a relative inability to establish a specific etiologic agent on clinical grounds alone. With the recognized shortcomings of expectorated or aspirated secretions toward establishing an etiologic diagnosis, clinicians have increasingly used bronchoscopy to obtain diagnostic samples. A variety of specimen types may be obtained, including bronchial washes or brushes, protected specimen brushings, bronchoalveolar lavage, and transbronchial biopsies. Bronchoscopy has been applied in three primary clinical settings, including the immunocompromised host, especially human immunodeficiency virus-infected and organ transplant patients; ventilator-associated pneumonia; and severe, nonresolving community- or hospital-acquired pneumonia in nonventilated patients. In each clinical setting, and for each specimen type, specific laboratory protocols are required to provide maximal information. These protocols should provide for the use of a variety of rapid microscopic and quantitative culture techniques and the use of a variety of specific stains and selective culture to detect unusual organism groups.

The diagnosis of anal ulcers in AIDS patients

Recent reports have suggested that routine microscopic evaluation of anal ulcer tissue from AIDS patients is not the most accurate way to diagnose viral infection. This study was undertaken to determine if either viral culture (VC) or immunohistochemistry (IHC) can improve the diagnostic accuracy as compared with routine hematoxylin and eosin (H&E) staining. Specifically, we sought to identify inclusion bodies of cytomegalovirus (CMV) or herpes simplex virus (HSV) to assist in the diagnosis of CMV or HSV. All patients had clinical evidence of an anal ulcer or a nonhealing anal fissure. Duration of symptoms ranged from 1 week to 3 months with a mean of 6 weeks. All specimens were submitted for viral culture in addition to routine H&E staining; immunohistochemistry was also performed. Twenty-five paraffin-embedded anal ulcer biopsies from 23 male patients (age range 27-73; mean 37.4 years) with the diagnosis of AIDS or AIDS-related complex (ARC) were reviewed over a 4 year period (1988-1992). Routine H&E staining revealed 6 (22%) specimens with CMV inclusions. Four of these 6 reacted positively with IHC (67%) and one was positive on viral culture (17%). In the remaining 19 specimens that did not reveal infection with CMV (78%), IHC was positive in 2 patients (10%) and viral culture was positive in 1 patient (5%). Although HSV was not seen in any of the specimens on H&E staining, IHC was positive in one patient (3.5%) and viral culture reacted positively in 8 (29%) specimens. Thus IHC is a good confirmatory test for CMV inclusions and can be used to achieve a definitive diagnosis in equivocal cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Cytomegaloviral virus infection in bone marrow transplantation recipients: strategies for prevention and treatment

Cytomegalovirus is major infectious pathogen following allogeneic bone marrow transplantation. In infected recipients, the virus is generally detected between 4 and 10 weeks after transplantation. Historically, CMV disease developed in 30-40% of seropositive recipients, the predominante manifestation being interstitial pneumonitis, which was generally lethal. Therapeutic interventions are discussed with special reference to the use of antiviral therapy for both treatment and prevention of CMV disease. The strategies developed in the bone marrow transplantation population to treat or prevent the development of CMV disease can be extrapolated to other patients groups who are immunosuppressed and at risk for developing clinical manifestations of CMV infection.

Diagnosis of cytomegalovirus in bronchoalveolar lavage by polymerase chain reaction, in comparison with virus isolation and detection of viral antigen

Bronchoalveolar lavage (BAL) products from 52 immunocompromised patients with symptoms of pulmonary infection was examined for cytomegalovirus (CMV) by virus isolation, polymerase chain reaction (PCR) and detection of CMV antigen by immunofluorescence or immunoperoxidase staining after short-term incubation in tissue culture and directly in BAL cells. We found that PCR detected all cases positive by virus isolation (15/52 samples) and the result was obtained within 5 h. PCR detected more cases of CMV than did virus isolation (22/52 samples). Positive PCR and negative virus isolation were consistent with probable CMV infection in 3/7 patients when other clinical and laboratory parameters of CMV infection were considered. The negative predictive value of PCR was high; none of 30 patients negative by PCR developed CMV pneumonia within the subsequent 2 months. Detection of CMV antigen after short-term incubation was rapid enough to be used in clinical practice, specific (100%) and with a sensitivity of 60%. Demonstration of CMV antigen in alveolar cells was highly specific (100%) but had too low a sensitivity (26.7%) to be used as the only rapid method. Our conclusion is that a combination of PCR and detection of CMV antigen after short-term incubation and directly in alveolar cells is optimal for rapid identification of CMV.

Monitoring of patients for cytomegalovirus after organ transplantation by centrifugation culture and PCR

A modified centrifugation culture technique and a polymerase chain reaction (PCR) is described for detection of early antigen and IE antigen DNA, respectively, for rapid and sensitive monitoring of active cytomegalovirus (HCMV) infection after organ transplantation. In a preliminary study, 541 clinical specimens (blood, urine, bronchoalveolar lavage, pharyngeal wash, sputum) from 59 organ recipients were assayed for HCMV antigen by centrifugation culture; 144 samples were tested by PCR simultaneously. Antigenemia detected by centrifugation culture correlated strongly with active HCMV infection and clinical symptoms and proved useful for monitoring the efficacy of antiviral therapy. PCR was more sensitive in an earlier phase of infection when centrifugation culture was still negative. The clinical usefulness of both methods is discussed.

Diagnosis of cytomegalovirus pneumonitis on bronchoalveolar lavage fluid: comparison of cytology, immunofluorescence, and in situ hybridization with viral isolation

Forty-three bronchoalveolar lavage (BAL) specimens from 40 immunocompromised patients were studied for the presence of cytomegalovirus (CMV) by rapid diagnostic methods. DNA in situ hybridization, cytology, and immunofluorescence were compared to conventional cell culture. Eleven (25%) of the 43 BAL samples grew CMV in culture. In situ hybridization detected 6 of these 11 for sensitivity, specificity, and predictive values of positive and negative of 55%, 94%, 75%, and 86%, respectively. Cytology had a sensitivity of 73% and specificity of 100%. Six Papanicolaou-stained cytospins were screened cytologically versus one hybridization cytospin, and the higher sensitivity of cytology may reflect this extensive sampling. The immunofluorescent method had a sensitivity equal to that of cytology (73%): however, the specificity (72%) was significantly less than that of either the probe or cytology. These data suggest that although in situ hybridization can be a rapid, useful method for detecting CMV in BAL specimens, cytology appears to be a more sensitive method.

Detection of cytomegalovirus in bronchoalveolar lavage specimens. Spin amplification and staining with a monoclonal antibody to the early nuclear antigen for diagnosis of cytomegalovirus pneumonia

To diagnose cytomegalovirus pneumonia in a hetergeneous population of patients, three methods for detection of CMV in bronchoalveolar lavage specimens were compared as follow: (1) spin amplification followed by staining with a monoclonal antibody to the early nuclear antigen (EA-assay); (2) conventional tissue cell culture; and (3) cytology. Cell differentials were performed on most specimens. Cytomegalovirus was detected by one or more method in 55 BAL specimens from 39 patients. Cytomegalovirus (CMV) pneumonia was diagnosed by lung tissue (primarily autopsy) histologic findings and conventional culture results or the presence of CMV in extrapulmonary tissue, fulfillment of specific clinical and radiographic criteria plus failure to recover a pathogen other than CMV from a respiratory specimen. Probable CMV pneumonia was diagnosed if only the latter two criteria were met. The EA-assay was positive in all patients with proven or probable CMV pneumonia and in 92 percent of those without documented pneumonia. Cytologic findings were positive only in patients with CMV pneumonia but were negative in one-third of those patients. As a diagnostic test for CMV pneumonia, the EA-assay, conventional culture, and cytology had positive predictive values of 45, 57, and 100 percent, respectively. Lymphocyte percentages in BAL specimens from patients with CMV pneumonia were significantly decreased compared with those of patients without CMV pneumonia (p less than 0.005). Although the EA-assay should not be used alone as a diagnostic test for CMV pneumonia in our patient population, the combination of alveolar lymphopenia and a positive BAL CMV EA-assay was highly suggestive of disease.

Bronchoalveolar lavage findings in patients seropositive for the human immunodeficiency virus (HIV)

To evaluate bronchoalveolar lavage (BAL) findings in patients infected with human immunodeficiency virus (HIV), 39 patients seropositive for the virus but with no history of opportunistic infection were studied. Opportunistic organisms such as Pneumocystis carinii were not found in any of the 35 BAL fluids sent for special stains and cultures. Three of 16 (18 percent) BAL fluids sent for HIV culture were positive compared with a 60.9 percent blood HIV culture positivity in the same group. To evaluate cellular recovery, the patients were divided into Walter Reed (WR) groups 1 and 2 (blood CD4 greater than or equal to 400/cu mm) and WR3 to WR5 (blood CD4 less than 400/cu mm). Compared with ten nonsmoking healthy controls, the WR1 and WR2 group had a greater overall cellular recovery but this was not statistically significant when the smokers were excluded. There was no difference in macrophage or lymphocyte percentages in either patient group compared with controls. T-cell subset analysis of a small group of WR1 to WR5 patient BAL fluids revealed no difference in CD4 numbers or the CD4/CD8 rate between WR1 and WR2 and WR3 to WR5 patients. We conclude that opportunistic pulmonary infection is unlikely in HIV-seropositive patients with normal chest roentgenograms despite symptoms of dyspnea on exertion. Also, HIV can be isolated from BAL fluid from these patients although not as often as from blood. Finally, there appears to be no distinct progression in BAL cellular findings before the onset of acquired immunodeficiency syndrome.

Rapid detection of cytomegalovirus in bronchoalveolar lavage specimens from marrow transplant patients: evaluation of a direct fluorescein-conjugated monoclonal antibody reagent

An FITC-conjugated monoclonal antibody reagent containing three CMV-specific monoclonal antibodies was evaluated for the rapid detection of CMV in bronchoalveolar lavage (BAL) cytospin preparations by direct IF (DFA). Eighty-six BAL samples from 72 marrow transplant patients were inoculated into both centrifugation and standard cell culture. CMV was detected in 49/86 (57%) BAL samples. DFA detected 37/46 (80%) samples which were positive in centrifugation culture. While DFA staining lacked the sensitivity (overall sensitivity 38/49, 78%) to replace either standard or centrifugation culture, the total laboratory time needed to complete the DFA was only 1.5 h and its concurrent use with centrifugation culture can provide rapid specific diagnosis of CMV pneumonia.

Cytomegalovirus retinitis

Cytomegalovirus retinitis is a frequent and serious complication of various conditions, including diseases characterized by impaired immunity, such as the acquired immunodeficiency syndrome. Due to recent advances in the treatment of cytomegalovirus retinitis, accurate diagnosis and management have become increasingly important. In this review, the authors present the epidemiology, clinical features, diagnostic testing, treatment with complications, and prognosis of cytomegalovirus retinitis. A differential diagnosis is presented and the characteristic ocular lesions are illustrated.

Open lung biopsy diagnosis of diffuse pulmonary infiltrates after marrow transplantation

The results were reviewed of 111 open lung biopsies (OLB) performed on 109 marrow transplantation recipients with diffuse pulmonary infiltrates between January 1983 and July 1987. We determined the frequency and types of infections identified, and the relationship to time after transplantation. Infection was found in 70 of the 111 cases (63 percent) and cytomegalovirus (CMV) was present in 90 percent of all cases with infection. Infection was identified in only five of 26 (19 percent) cases within the first 30 days after transplant, and when present, was viral. The prevalence of infection after 30 days (over 75 percent of 85 cases) was significantly higher (chi 2 = 26.2, p = 0.00001). Bacterial or yeast infections were found in only four cases (4 percent) (two cases each), and Pneumocystis carinii in six cases (6 percent). Simultaneous infection with two or more organisms was found in four cases (4 percent). Four of 25 autopsies performed within ten days after OLB revealed fungal infections with Aspergillus not detected at OLB. Thus, the prevalence of infection detected by OLB is low within the first 30 days after marrow transplantation among patients receiving broad spectrum antibiotics. CMV infection is found in most transplantation recipients who undergo OLB with diffuse infiltrates between days 30 and 180.

Chronic cytomegalovirus infection

Cytomegalovirus infects about 60% of persons in developed countries and may cause significant disease in immunosuppressed patients. Serology has no role in the diagnosis of CMV disease in such patients yet detection of the virus in diseased parts of the body can be used to monitor the course of disease and antiviral measures. Detection of viral proteins (alpha or beta proteins) by monoclonal antibodies in cell cultures infected by urine, saliva or blood samples from patients allows a positive diagnosis within 24 h (DEAFF test). Monoclonal antibodies against CMV can also be used to stain cells obtained directly from the infected patients.

Evaluation of centrifugation cultures of bronchoalveolar lavage fluid for the diagnosis of cytomegalovirus pneumonitis

Cytomegalovirus (CMV) pneumonitis is one of the most severe manifestations of CMV disease among immunocompromised patients. The diagnosis of CMV pneumonitis traditionally has required the use of invasive procedures such as lung biopsy. In this retrospective study, we evaluated a centrifugation culture method in samples of bronchoalveolar fluid for the noninvasive diagnosis of CMV pneumonitis. During a 9-mo period, 75 bronchoalveolar lavage samples were collected from 58 patients with pneumonitis. We analyzed the data from 21 patients in whom lung tissue samples were obtained within 14 days of the bronchoalveolar lavage. Centrifugation cultures of bronchoalveolar fluid were positive for CMV in 12 cases. CMV pneumonitis was confirmed in samples of lung tissue from five (42%) of the 12 patients, whereas no evidence of CMV pneumonitis was found in the remaining seven (58%) cases. Of nine patients with negative centrifugation cultures, CMV pneumonitis was confirmed in two (22%). When compared with conventional cultures, we found bronchoalveolar lavage fluid centrifugation cultures to be highly sensitive (100%) and specific (92%) for the detection of CMV infection. However, detection of CMV by centrifugation culture proved to be only moderately sensitive (71%) and nonspecific (50%) for the diagnosis of CMV pneumonitis.

Comparative sensitivity of three methods for the diagnosis of cytomegalovirus lung infection

Conventional cell culture (CCC), an immunofluorescent assay for the rapid detection of CMV-induced early antigens (DEAFF) in infected fibroblasts and an immunofluorescent assay for the detection of CMV-infected cells obtained directly from clinical material were compared prospectively for their ability to detect CMV in bronchoalveolar lavage (BAL) material. CMV was detected by at least one method in 47 of 139 BALs (33.8%). The mean sensitivities of each of the three assays were 93% for DEAFF, 46% for CCC and 22% for the direct method. The mean time to diagnosis was 24 h, 15 days and 4 h for each of the methods, respectively. The use of monoclonal antibodies in the DEAFF test on BAL specimens provided a simple and rapid method for the diagnosis of CMV lung infection and was shown to be more reliable than conventional culture methods in achieving a diagnosis from BAL specimens.

DNA hybridization for detection of human cytomegalovirus in bronchoalveolar lavage and pharynx biopsy

A simplified hybridization procedure was used for detection of cytomegalovirus (CMV) in human specimens. The probe was a 32P-labelled cloned DNA fragment of CMV strain AD169. This probe did not hybridize to DNA from uninfected cells or other herpesviruses (herpes simplex virus, Epstein-Barr virus). Specific hybridization was obtained with unselected bronchoalveolar lavage specimens, but the sensitivity of the test (33%) was lower than that of culture (80%) and immunofluorescence (60%) assays which are routinely performed in our laboratory. The detection procedure was also carried out with pharynx biopsy specimens which had been kept frozen at -70 degrees C. CMV DNA was detected in 14% of tumour specimens and only in 1.7% of control specimens (p less than 0.05). The indications of DNA hybridization for CMV diagnosis are discussed.