Bronchoscopy in the diagnosis of pulmonary histoplasmosis

Disseminated Histoplasmosis as AIDS-presentation. Case Report and Comprehensive Review of Current Literature

Progressive disseminated histoplasmosis (PDH) is an AIDS-defining illness with a high lethality rate if not promptly treated. The wide range of its possible clinical manifestations represents the main barrier to diagnosis in non-endemic countries. Here we present a case of PDH with haemophagocytic syndrome in a newly diagnosed HIV patient and a comprehensive review of disseminated histoplasmosis focused on epidemiology, clinical features, diagnostic tools and treatment options in HIV-infected patients.

Adrenal Histoplasmosis

An 89-year-old woman presented with seizure and hyponatremia. CT and MRI demonstrated mass-like enlargement of the adrenal glands and multiple pulmonary nodules. PET/CT performed to evaluate for metastatic disease demonstrated intense F-FDG uptake within enlarged adrenal glands. Given mild uptake in the pulmonary nodules, the differential diagnosis for the adrenal uptake included lymphoma, granulomatous infection, and less likely, metastatic lung cancer.

Tracheal and endobronchial involvement in disseminated histoplasmosis: a case report

Histoplasmosis is an endemic fungal infection that can involve any organ when disseminated. Although oral, pharyngeal, laryngeal, and endobronchial involvement have been described, direct tracheal involvement has not been reported. We describe the first case of disseminated histoplasmosis with direct involvement of the trachea. The endobronchial manifestations of histoplasmosis are reviewed.

Redefining the clinical spectrum of chronic pulmonary histoplasmosis: a retrospective case series of 46 patients

Chronic pulmonary histoplasmosis is a disorder caused by Histoplasma capsulatum infection that is classically described as cavitary disease in male smokers with underlying chronic obstructive pulmonary disease (COPD). This clinical description relies on previous studies conducted mainly on cohorts from tuberculosis sanatoriums and United States Department of Veterans Affairs hospitals. Patients in earlier series were often selected either after being suspected of having Mycobacteria tuberculosis or by the presence of cavitary disease on chest radiograph. These early studies therefore may overrepresent the true proportion of males, smokers, and the percentage with cavitary disease in the general population. We sought to define the clinical spectrum of chronic pulmonary histoplasmosis in a mixed-sex inpatient and outpatient population. We conducted a retrospective chart review from 1976 to 2000 on all adults with a diagnosis of histoplasmosis with symptoms suggestive of pulmonary histoplasmosis for > or =6 weeks and either significantly positive serum H. capsulatum antibody titers or positive cultures (without evidence of disseminated disease). Participants included 46 patients, with a median age of 56 years. Notable differences were found between our study population and those in previously reported studies. First, nearly half of our patients were women (48%), and one-quarter were life-long nonsmokers (27%). Only 39% had cavitary disease and only 20% had COPD. It is noteworthy that there were no positive cultures from those patients who had never smoked. Major differences existed between male and female participants. Female patients had a lower presence of cavities, a decreased number of smokers and extent of smoking exposure, a decreased number of positive cultures, and an absence of underlying COPD. To our knowledge, this study is the first to report on a large number of outpatients with chronic pulmonary histoplasmosis. In contrast to previous studies, the current study included 48% female patients, 27% never smokers, and only 39% of patients with cavitary disease, representing a noticeably different spectrum of disease compared to previous studies.

Bronchial lavage in tropical pneumonias

PURPOSE OF REVIEW

In developing countries, where resources are scarce, it is paramount that the clinician be familiar with the most cost-effective diagnostic and therapeutic modalities available. The fiberoptic bronchoscope is an expensive piece of equipment, but can be an economical diagnostic tool in tropical pneumonias. The role of bronchoalveolar lavage is discussed in this review.

RECENT ADVANCES

Since its introduction in the 1970s, particularly in developing countries, bronchoalveolar lavage has become an important tool for diagnosis, assessing the activity and monitoring a large number of pulmonary diseases. The importance of bronchoalveolar lavage is becoming even more apparent since the emergence of the HIV/AIDS epidemic, which has changed the face of many pulmonary diseases, especially tropical ones.

SUMMARY

Bronchoalveolar lavage is useful in developed and developing countries alike, for assessing many bacterial, fungal, and parasitic pulmonary diseases.

[Disseminated histoplasmosis and AIDS. The role of culture medium for the bronchoscopic clinical specimens]

Fiberoptic bronchoscopy is a useful procedure in the diagnosis of histoplasmosis, when the clinical material is adequately processed. Ten cases of disseminated histoplasmosis in patients with AIDS are presented here, with a mycological evaluation in culture, Mycosel and Sabouraud's chloramphenicol agar of clinical specimens obtained through fiberoptic bronchoscopy. The yield of Mycosel culture was 60%, while in Sabouraud's chloramphenicol agar it was 20%, supporting the importance of selective medium in the isolation of Histoplasma capsulatum var capsulatum from potentially contaminated clinical specimens, as well as the importance of clinical information for the laboratory as the key for a correct diagnosis.

The cytopathology of infectious diseases

Utilizing abrasive, exfoliative, and fine-needle aspiration techniques to diagnose infectious organisms by cytopathologic means is common practice. The increase in the number of immunosuppressed patients in conjunction with the relative ease with which specimens are procured has resulted in the need for rapid interpretation to ensure prompt and adequate treatment. Although some organisms cannot be definitively classified on cytologic preparations, morphologic clues that can guide the pathologist toward rendering a diagnosis helpful to clinicians are often present. In addition, some fungi and parasites rarely identified in cytopathology in the past are more frequently found in cytologic specimens today. This review focuses on organisms found in the United States. Special attention is paid to the morphologic findings on routine Papanicolaou- and Diff Quik-stained cytologic preparations and readily available special stains.

Richter's transformation presenting as an obstructing endobronchial lesion

A 60-year-old man with chronic lymphocytic leukemia presented to our institution with a recurring lingular pneumonia. On fiberoptic bronchoscopy, the patient was found to have an endobronchial mass obstructing the lingula and left upper lobe. Biopsy specimens of the mass demonstrated anaplastic large cell lymphoma consistent with Richter's transformation. Only one case of endobronchial Richter's transformation has been previously reported in the literature. This was described as peribronchial and endobronchial leukemic infiltrates within the bronchial mucosa. We report the first case of an obstructive endobronchial mass secondary to Richter's transformation. The endobronchial mass was treated with a Nd-YAG laser to maintain airway patency while the patient underwent chemotherapy, resulting in complete resolution of the mass within the airway.

Pneumonia in the compromised host including cancer patients and transplant patients

Pneumonia remains a major cause of morbidity and mortality in the immunocompromised host. The type and timing of immunosuppression will predispose the patient to infections with certain pathogens. This article discusses the types of immunosuppression and their infectious and noninfectious implications. Key points of the most commonly involved pathogens are mentioned. Finally, an approach to diagnosis and empiric therapy is discussed.

Approach to the patient with pulmonary disease

The approach to the HIV-infected patient with pulmonary disease is summarized by the algorithms in Figures 3 and 4. These are not intended to be followed in a rigid step-wise fashion. Rather, the practitioner's knowledge of the patient with his or her accompanying medical risks influences the path taken, including the depth and the speed of the evaluation. For example, the patient with cough who is afebrile and breathing at 18 breaths a minute, with a normal chest radiograph and a CD4 count of 350 cells/mm3, is reasonably treated with a macrolide or cephalosporin for bacterial bronchitis and clinical follow-up while awaiting cultures (see Fig. 4). A febrile patient with a cough productive of thin mucus, but known to have a CD4 count of 60 cells/mm3 should be started on anti-PCP therapy while being evaluated for PCP with an induced sputum and if nondiagnostic, a bronchoscope despite a normal chest radiograph. Screening can be as simple as placing an oximeter on the patient's finger in the clinic. If the oxygen saturation of a patient with a normal chest radiograph is low, then the patient should be hospitalized and begun on treatment for PCP while diagnostic evaluation is initiated. If the oxygen saturation is normal, the patient can be exercised to elicit desaturation. If there is no desaturation, PCP is unlikely. If the results are equivocal (i.e., a decrease in saturation, but less than 3%), rest and exercise arterial blood gases can be performed, along with a Dlco-Gallium scanning can be done in patients known to have abnormal Dlco or those who cannot exercise. Patients with focal infiltrates who have acute onset of symptoms (see Fig. 4) commonly have bacterial infections, but the possibility of PCP or TB should not be dismissed. Induced sputum should be examined if TB or PCP is suspected. Patients who are severely ill might go quickly to bronchoscopy without awaiting improvement on empiric therapy. The patient with diffuse infiltrates (see Fig. 4) needs no screening because the presence of disease is apparent from the radiograph. The diagnostic part quickly leads to bronchoscopy for these patients and the initiation of therapy for PCP when suspected. In patients with known pulmonary KS, gallium scanning can be helpful to rule out acute infection, but bronchoscopy is warranted if the patient is severely ill, or at high risk for PCP. This approach should avoid unnecessary procedures in patients with simple bacterial infections, without missing opportunistic infections and tumors.

Bronchoscopic findings in a case of bronchopulmonary histoplasmosis

At bronchoscopic examination extensive areas of fibrinous slough covering bronchial mucosal inflammation and ulceration were seen in a case of progressive diffuse bronchopulmonary histoplasmosis. Rigid bronchoscopy was needed to obtain sufficient biopsy material for specific histological diagnosis.

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.

Acute histoplasmosis in a hyperreactive individual

Acute histoplasmosis usually is asymptomatic and most commonly occurs in children. Symptomatic acute pulmonary infections range from mild to severe. Extrapulmonary lesions are common and oftentimes most prominent. In this report, we describe a patient with acute histoplasmosis with pulmonary findings as well as striking lesions within the liver and spleen.

Bronchoscopy with bronchoalveolar lavage in tuberculosis and fungal infections

STUDY OBJECTIVE

To determine the utility of bronchoscopy with bronchoalveolar lavage for diagnosing M tuberculosis and fungal infections.

DESIGN

Retrospective review of patients over a six-year period.

SETTING

In- and outpatients of one University hospital and affiliated Veterans Administration Medical Center.

PATIENTS

Those who were subsequently found to have either M tuberculosis or fungal infections.

INTERVENTIONS

Bronchoscopy with bronchoalveolar lavage specimens were compared to prebronchoscopy sputum, when available. Specimens were sent for smear and culture for both acid-fast bacilli and fungi. In the case of lavage, an aliquot also was studied for cellular differential.

MEASUREMENTS AND RESULTS

For TB, sputum was smear-positive in 6/47 (34 percent) and culture positive in 24/47 (51 percent), while bronchoscopy was smear positive in 34/50 (68 percent) and culture positive in 46/50 (92 percent). For fungal infections, no sputum was smear-positive and only 1/22 (5 percent) was sputum culture-positive, while bronchoscopy was smear-positive in 14/41 (34 percent) and culture positive in 35/41 (85 percent). Bronchoscopy washings and BAL provided complementary specimens. Eighty-three patients had adequate lavages and the cellularity was significantly different from controls (lymphocytes: TB 18 +/- 11.2 percent [mean +/- SD]; fungal: 13 +/- 11.1 percent; controls 6 +/- 3.1 percent; p less than 0.001; neutrophils: TB 9 +/- 11.5 percent; fungal: 6 +/- 9.1 percent controls: 2 +/- 1.5 percent, p less than 0.01); however, there was overlap and no pattern was characteristic for TB or fungal infections.

CONCLUSION

Bronchoscopy with BAL is useful in diagnosing tuberculosis and fungal infections.