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Ntiamoah P, Biehl M, Ruesch V, Mehta AC, Farha S. Corticosteroid treatment for persistent pulmonary infiltrates following COVID-19 infection: Clearing the fog? Ann Thorac Med 2024; 19:74-80. [PMID: 38444989 PMCID: PMC10911237 DOI: 10.4103/atm.atm_121_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/10/2023] [Accepted: 10/23/2023] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Systemic corticosteroids have been shown to improve outcomes in severe coronavirus disease 2019 (COVID-19) pneumonia; however, their role in post-COVID-19 persistent lung abnormalities is not well defined. Here, we describe our experience with corticosteroids in patients with persistent lung infiltrates following COVID-19 infection. RESEARCH QUESTION What is the efficacy of systemic corticosteroids in improving lung function and radiological abnormalities in patients following COVID-19 pneumonia? STUDY DESIGN AND METHODS This is a single-center retrospective study evaluating patients with persistent respiratory symptoms and abnormal chest computed tomography findings. Patients were divided into two groups based on treatment with corticosteroids: "steroid group" and "nonsteroid group." Clinical data were collected from the electronic medical records. RESULTS Between March 2020 and December 2021, 227 patients were seen in the post-COVID-19 pulmonary clinic, of which 75 were included in this study. The mean age was 56 years, 63% were female, and 75% were white. The main physiologic deficit was reduced Diffusing capacity of the Lungs for Carbon Monoxide (DLCO) at 72% (±22). On chest imaging, the most common findings were ground-glass opacities (91%) and consolidation (29%). Thirty patients received corticosteroid (steroid group) and 45 did not (nonsteroid group). Patients treated with corticosteroids had lower DLCO (DLCO [%]: steroid group 63 ± 17, nonsteroid group 78 ± 23; P = 0.005) and all had ground-glass opacities on imaging compared to 84% in the nonsteroid group (P = 0.04). At follow-up, patients in the steroid group (n = 16) had a significant improvement in spirometry and DLCO. In addition, there was a significant improvement with resolution of ground-glass opacities in both the groups (P < 0.05). CONCLUSION The use of systemic corticosteroids in patients with persistent respiratory symptoms and radiological abnormalities post-COVID-19 was associated with significant improvement in pulmonary function testing and imaging. Prospective studies are needed to confirm whether these findings are the effect of corticosteroid therapy or disease evolution over time.
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Affiliation(s)
- Prince Ntiamoah
- Department of Pulmonary and Critical Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Michelle Biehl
- Department of Pulmonary and Critical Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Victoria Ruesch
- Department of Medicine, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Atul C. Mehta
- Department of Pulmonary and Critical Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Samar Farha
- Department of Pulmonary and Critical Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Atef M, Eid H, Amin M, Shehata M, Shaarawy A, Nabawy O, Wahba A, Aboseif A, Rakha M, Zaki M, Mohammed E, Albalsha A, Nour S, Rezk A, Shaheen M, Kabil A. Assessment of C-reactive protein levels as an indicator for lung infiltrates in patients with COVID-19 pneumonia. J Med Life 2023; 16:1028-1031. [PMID: 37900075 PMCID: PMC10600661 DOI: 10.25122/jml-2023-0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/31/2023] [Indexed: 10/31/2023] Open
Abstract
Lung infiltrates are frequently observed in patients with COVID-19 infection and require specialized management. Identifying reliable laboratory parameters to reduce the need for chest CT scans in non-desaturation patients is of great interest. This study aimed to investigate the potential of C-reactive protein (CRP) as an indicator to identify the presence of lung infiltrates in early COVID-19 infection. The study was conducted at Al-Azhar University hospitals from May 2021 to March 2022 and included 210 patients with COVID-19 infection confirmed by positive PCR, all of whom were previously healthy, non-smokers, and non-hypoxemic. CRP levels were assessed and correlated with lung infiltrates observed in CT chest examinations. The mean value of CRP was 40.3±14.3 mg/L in males and 36.6±15.2 mg/L among females. One hundred sixty-two patients had pneumonic infiltrates, while 48 had no infiltrates. The mean value of CRP was 45.02±10.2 mg/L in patients with radiological infiltrates and 18.8±7.8 mg/L in patients without radiological infiltrates. Based on our findings, a CRP value greater than 29.8 mg/L was suggested as a cut-off value to indicate the presence of lung infiltrates. CRP is a simple laboratory marker that, at certain limits, may point to the presence of pneumonic infiltrates in early non-hypoxemic patients with COVID-19 infection.
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Affiliation(s)
- Moaz Atef
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Hoda Eid
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohammad Amin
- Department of Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamad Shehata
- Department of Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Shaarawy
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Osama Nabawy
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Wahba
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Aboseif
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Rakha
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Zaki
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Eid Mohammed
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Abdullah Albalsha
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Sameh Nour
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Amr Rezk
- Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Shaheen
- Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Kabil
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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Sofia S, Orlandi P, Bua V, Imbriani M, Cecilioni L, Caruso A, Schiavone C, Boccatonda A, Cianci A, Spampinato MD. Lung Ultrasound and High-Resolution Computed Tomography in Suspected COVID-19 Patients Admitted to the Emergency Department: A Comparison. J Diagn Med Sonogr 2023; 39:332-346. [PMID: 38603205 PMCID: PMC9892814 DOI: 10.1177/87564793221147496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/30/2022] [Indexed: 04/13/2024]
Abstract
Objective To analyze the diagnostic accuracy of lung ultrasonography (LUS) and high-resolution computed tomography (HRCT), to detect COVID-19. Materials and Methods This study recruited all patients admitted to the emergency medicine unit, due to a suspected COVID-19 infection, during the first wave of the COVID-19 pandemic. These patients also who underwent a standardized LUS examination and a chest HRCT. The signs detected by both LUS and HRCT were reported, as well as the sensitivity, specificity, positive predictive value, and negative predictive value for LUS and HRCT. Results This cohort included 159 patients, 101 (63%) were diagnosed with COVID-19. COVID-19 patients showed more often confluent subpleural consolidations and parenchymal consolidations in lower lung regions of LUS. They also had "ground glass" opacities and "crazy paving" on HRCT, while pleural effusion and pulmonary consolidations were more common in non-COVID-19 patients. LUS had a sensitivity of 0.97 (95% CI 0.92-0.99) and a specificity of 0.24 (95% CI 0.07-0.5) for COVID-19 lung infections. HRCT abnormalities resulted in a 0.98 sensitivity (95% CI 0.92-0.99) and 0.1 specificity (95% CI 0.04-0.23) for COVID-19 lung infections. Conclusion In this cohort, LUS proved to be a noninvasive, diagnostic tool with high sensitivity for lung abnormalities that were likewise detected by HRCT. Furthermore, LUS, despite its lower specificity, has a high sensitivity for COVID-19, which could prove to be as effective as HRCT in excluding a COVID-19 lung infection.
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Affiliation(s)
- Soccorsa Sofia
- Department of Emergency, Azienda USL di Bologna, Bologna, Italy
| | - Paolo Orlandi
- Radiology Department, Azienda USL di Bologna, Bologna, Italy
| | - Vincenzo Bua
- Department of Emergency, Azienda USL di Bologna, Bologna, Italy
| | | | - Laura Cecilioni
- Department of Emergency, Azienda USL di Bologna, Bologna, Italy
| | | | - Cosima Schiavone
- Internistic Ultrasound Unit, “S. S. Annunziata” Hospital, “G. d’Annunzio” University, Chieti, Italy
| | - Andrea Boccatonda
- Internal Medicine, Internal and Vascular Ultrasound Centre of Bentivoglio Hospital, Azienda USL di Bologna, Bologna, Italy
| | - Antonella Cianci
- School of Emergency Medicine, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Aljishi A, Alalbdulhadi D, Alabbadi G, Ali MH, Ivey MK, Almusa Z, Abdulqawi R. Diagnostic Utility of Bronchoalveolar Lavage in Immunocompromised Patients with Lung Infiltrates. Saudi J Med Med Sci 2023; 11:169-174. [PMID: 37252024 PMCID: PMC10211421 DOI: 10.4103/sjmms.sjmms_363_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/29/2022] [Accepted: 03/16/2023] [Indexed: 05/31/2023]
Abstract
Introduction Lung infections are associated with a high mortality rate in immunocompromised patients. Achieving an accurate and rapid diagnosis is vital to help guide management, and thus improve survival. Objective To establish the diagnostic yield, clinical value, and safety of bronchoscopy with bronchoalveolar lavage (BAL) in immunocompromised adult patients with pulmonary infiltrates. Methods This retrospective study included all immunocompromised adult patients who underwent bronchoscopy with BAL for investigation of radiologically confirmed pulmonary infiltrates at a tertiary care hospital between January 01, 2014, and June 30, 2021. Clinically significant findings of BAL were defined as a positive microbiological result of a potential pathogen determined using routine culture, acid-fast bacilli smear, mycobacterial culture, tuberculosis PCR, fungal culture, Aspergillus antigen, and multiplex PCR panel and/or positive cytology. Results A total of 103 unique patients were included (mean ± SD age: 44.5 ± 14.1 years), of which the majority were male (60.2%). The BAL diagnostic yield was 52.4% (95% CI: 42.6-62.2%). In the multiple logistic regression model, positive BAL was predicted by symptom of sputum (aOR 4.01, 95% CI: 1.27-12.70, P = 0.018). Almost half of the procedures (43.7%, 95% CI: 33.9-53.4%) resulted in a change in the management plan, with positive BAL findings more than twice as likely to result in a change (OR 2.39, 95% CI: 1.07-5.33, P = 0.033). Only three (2.9%) procedures resulted in complications and required ventilator support and/or oxygen escalation. Conclusions BAL is a safe clinical tool that can be useful in impacting clinical management in a significant proportion of immunocompromised patients with pulmonary infiltrates.
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Affiliation(s)
- Ahmed Aljishi
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Deemah Alalbdulhadi
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ghadeer Alabbadi
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Mohammed Hashim Ali
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | | | - Zainab Almusa
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Rayid Abdulqawi
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
- Lung Health Centre, Organ Transplant Centre of Excellence, King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
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Manek G, Gupta M, Congrete S, Datta D. Submassive Pulmonary Embolism in Mild COVID-19 Without Lung Infiltrates. Cureus 2021; 13:e13978. [PMID: 33880305 PMCID: PMC8053007 DOI: 10.7759/cureus.13978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 66-year-old man who had been diagnosed with mild coronavirus 2019 (COVID-19) infection nine days prior presented to the emergency room with acute-onset chest pain and shortness of breath. Chest CT angiogram (CTA) revealed pulmonary emboli (PE) in the right and left pulmonary arteries with right heart strain; lung parenchyma showed no infiltrates. Although severe COVID-19 infection is associated with thrombotic complications, data regarding the occurrence of PE in mild cases of COVID-19 is scarce. However, even mild cases of COVID-19 are reported to have revealed lung infiltrates, particularly ground-glass opacities, on imaging. The possibility of the lungs being the primary source of COVID-19-associated coagulopathy has been raised. We report an uncommon case of submassive PE occurring in mild COVID-19, without any associated lung infiltrates. This case indicates that mild COVID-19, without significant lung parenchymal involvement, can also cause a hypercoagulable state, resulting in venous thromboembolism (VTE).
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Affiliation(s)
- Gaurav Manek
- Department of Internal Medicine, University of Connecticut Health, Farmington, USA
| | - Manasvi Gupta
- Department of Internal Medicine, University of Connecticut Health, Farmington, USA
| | - Soontharee Congrete
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut Health, Farmington, USA
| | - Debapriya Datta
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut Health, Farmington, USA
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Abstract
The use of electronic cigarettes among the young adult and adolescent population has increased over the past decade. Vaping is the process of inhaling an aerosol that is produced by heating a liquid or wax containing substances, such as nicotine, cannabinoids (e.g., tetrahydrocannabinol (THC), cannabidiol), flavoring, and additives (e.g., glycerol, propylene glycol) using an e-cigarette. A multistate epidemic associated with vaping prompted the Centers for Disease Control and Prevention (CDC) to issue an official health advisory on e-cigarette or vaping product use-associated lung injury (EVALI). EVALI is a diagnosis of exclusion with no specific diagnostic test. We present a case of EVALI before the COVID-19 pandemic time in a 23-year-old immunocompetent male student with an eight-year history of vaping. He presented to the emergency department with fever, shortness of breath, tachypnea, nausea, and diarrhea. The patient had no past medical history. The patient denied illicit drug abuse or known drug allergies. The patient was admitted with a diagnosis of sepsis and pneumonia. The patient’s urine drug screen was positive for cannabinoids with a history of vaping. Community-acquired pneumonia due to Legionella, Pneumococcal, Mycoplasma bacteria was ruled out. Influenza A/B, Parainfluenza, Rhino, and Adenoviruses were negative. A computed tomographyscan of the chest showed bilateral infiltrates. He was treated with high dose steroids, empiric antibiotics, high flow oxygen and managed in ICU for seven days. The patient was discharged on tapering doses of steroid and counseled to quit vaping. EVALI outbreak is strongly linked to vitamin E acetate in vaping products. EVALI is a diagnosis of exclusion with a history of vaping and responds well to steroids.
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Affiliation(s)
- Ramesh Adhikari
- Hospital Medicine, Franciscan Health, Lafayette, USA.,Geriatrics, Brown University, Providence, USA
| | | | - Raghavender Gotur
- Internal Medicine, Cape Fear Valley Harnett Hospitalist Group, Lillington, USA
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Abstract
Pulmonary infiltrates are a significant cause of morbidity and mortality in immunocompromised patients and remain a diagnostic challenge due to the broad range of etiologies that include infection and malignancy. Empiric therapy may be sub-optimal and can adversely impact outcome. Therefore, a confirmed diagnosis is necessary and flexible bronchoscopy with bronchoalveolar lavage (BAL) may be a useful diagnostic tool. Samples are obtained for microbiological and cytological testing, but the procedure carries risk of complications including the adverse events related to moderate sedation. A review of published literature on BAL in immunocompromised patients from the year 2000 was undertaken focusing on diagnostic yield, complication rate, mortality as well as factors impacting these outcomes. Studies in which the majority of patients were supported on mechanical ventilation were excluded. A total of 23 studies (7 prospective and 16 retrospective) met inclusion criteria. This covered 3,395 procedures in 3,192 patients with a mean age of 47.4 years; 60.3% male gender. Diagnostic yield ranged from 26% to 69% with no clear association between diagnostic yield and etiology of immunosuppression or clinical/radiological presentation. Post BAL modification of treatment as an indicator for clinical utility ranged from 11% to 84%; and complication rate ranged from 1% to 52%. No specific factors were associated with increased adverse event rate. This review provides a summary of the data on the use of BAL for diagnosis of pulmonary infiltrates in immunocompromised patients, highlighting the heterogeneity of patients, significant variation in findings reported and the need for more data to optimize patient selection.
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Affiliation(s)
- Randall Choo
- Duke-NUS Medical School, Singapore.,Singapore Health Services, Singapore
| | - Devanand Anantham
- Singapore Health Services, Singapore.,Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
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8
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Berger N, Nichols J, Datta D. Idiopathic pulmonary haemosiderosis with celiac disease (Lane-Hamilton syndrome) in an adult - a case report. Clin Respir J 2016; 10:661-5. [PMID: 25586081 DOI: 10.1111/crj.12258] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 01/09/2015] [Indexed: 11/30/2022]
Abstract
Idiopathic pulmonary haemosiderosis (IPH) is a rare disorder of unknown cause characterised by haemoptysis, diffuse alveolar infiltrates and iron-deficiency anaemia. IPH predominantly affects children; it is rare in adults, in whom it usually manifests before 30 years. In adults, course is protracted with a better prognosis, in contrast to children. Even rarer is the Lane-Hamilton syndrome, a condition in which IPH is associated with celiac disease. Only 15 cases of Lane-Hamilton syndrome affecting adults are reported in literature. Treatment of IPH is based on anecdotal case reports and case series because of its rare occurrence. High-dose steroids reportedly reduce morbidity and mortality and delays or stops disease progression; more effectively in adults than children. In Lane-Hamilton syndrome, a gluten-free diet for the celiac disease in addition to steroids for IPH, is the mainstay of therapy. The optimal treatment duration of steroid therapy is not known but anecdotally a more prolonged course results in improved outcome. We report a case of a young woman who presented with exertional dyspnoea, intermittent haemoptysis, severe anaemia and lung infiltrates but no gastrointestinal complaints. After extensive work-up, she was diagnosed with Lane-Hamilton syndrome based on a diagnosis of IPH made from lung biopsy and concomitant celiac disease because of positive anti-gliadin antibody and endomyosial antibody and jejunal biopsy. She was treated with sustained low-dose steroid therapy for a year and a gluten-free diet with resolution of her symptoms, anaemia and lung infiltrates. At 4 years of follow-up, she remains stable, without recurrence.
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Affiliation(s)
- Natalie Berger
- Division of Pulmonary-Critical Care Medicine, University of CT Health Center, Farmington, CT, USA
| | - Julianne Nichols
- Division of Pulmonary-Critical Care Medicine, University of CT Health Center, Farmington, CT, USA
| | - Debapriya Datta
- Division of Pulmonary-Critical Care Medicine, University of CT Health Center, Farmington, CT, USA.
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Selimovic A, Mujicic E, Milisic S, Pejicic T, Rancic M, Mesihovic-Dinarevic S, Lukic-Bilela L, Moro M. The Significance of Bronchoalveolar Lavage Fluid Cytology in Diagnosing Lung Infiltrates in Children. Med Arch 2016; 70:27-30. [PMID: 26980927 PMCID: PMC4779357 DOI: 10.5455/medarh.2016.70.27-30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/05/2015] [Indexed: 11/03/2022] Open
Abstract
AIM The aim of this research is to show why is it important in diagnosing children with lung infiltrates. METHODS Our study included 50 children with lung infiltrates during period 2005-2012, and was conducted on Pediatric Clinic of the University Clinical Center Sarajevo. We sent all cytological BAL analyses to the University Clinical Center Sarajevo. Cytology was performed by direct microscopy. BAL cytology was performed by the principle of sending samples for centrifuging, 12000 revolutions during a 10 min Shandon-cyto spin. Then the centrifuged sample is dried in the air during 1-2 hours, and is then dyed under the May-Grünwald-Giemsa staining, and analyzed under the Olympus BX41 microscope. RESULTS Nosocomial pneumonia has occurred in 32% children, acquired pneumonia in 38%, and 30% children had a lung infiltrates. 6 (12%) of children were younger then 1 year old, 23 (46%) children were between 1 to 5 years, 14 (28%) of children were between 5 to 10 ages, and 7 (14%) of children were between 10-15 ages. The most of the changes in observed children took place on the right lung, 34%, while 26% occurred on the left side, 22% were normal and 18% changes have affected both lungs, right and left. Percentage of cells in cytological smear in children with BAL were: cylindrical cells 28%, lung macrophage 26%, lymphocytes 17%, detritus 17% and phlegm 12%. Erythrocyte sedimentation rate (ESR) in children with BAL was up to 10-52%, to 50-30%, while ESR after first hour was above 50-18 %. CONCLUSION Clinical parameters and local inflammation of the affected lobe are associated with positive bronchoalveolar cytology lavage findings.
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Affiliation(s)
- Amina Selimovic
- Pediatric Clinic of the University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Ermina Mujicic
- Department for Cardioanesthesiology, Clinic for anesthesiology, reanimatology and intensive care of the University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Selma Milisic
- Sarajevo Medical School, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
| | - Tanja Pejicic
- Clinic for Lung Diseases and TB "Knez Selo", Clinical Center Niš, Serbia
| | - Milan Rancic
- Clinic for Lung Diseases and TB "Knez Selo", Clinical Center Niš, Serbia
| | | | - Lada Lukic-Bilela
- Department of Biology, Faculty of Science, University of Sarajevo, Sarajevo, Bosnia and Hezegovina
| | - Mahir Moro
- Department of Orthopedic Surgery, General Hospital "Prim.dr.Abdulah Nakaš", Sarajevo, Bosnia and Herzegovina
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Maschmeyer G, Donnelly JP. How to manage lung infiltrates in adults suffering from haematological malignancies outside allogeneic haematopoietic stem cell transplantation. Br J Haematol 2016; 173:179-89. [PMID: 26729577 PMCID: PMC7161791 DOI: 10.1111/bjh.13934] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 12/13/2015] [Indexed: 12/20/2022]
Abstract
Pulmonary complications affect up to 40% of patients with severe neutropenia lasting for more than 10 d. As they are frequently associated with fever and elevation of C‐reactive protein or other signs of inflammation, they are mostly handled as pneumonia. However, the differential diagnosis is broad, and a causative microbial agent remains undetected in the majority of cases. Pulmonary side effects from cytotoxic treatment or pulmonary involvement by the underlying malignancy must always be taken into account and may provide grounds for invasive diagnostic procedures in selected patients. Pneumocystis jirovecii (in patients not receiving co‐trimoxazole as prophylaxis), multi‐resistant gram‐negative bacilli, mycobacteria or respiratory viruses may be involved. High‐risk patients may be infected by filamentous fungi, such as Aspergillus spp., but these infections are seldom proven when treatment is initiated. Microorganisms isolated from cultures of blood, bronchoalveolar lavage or respiratory secretions need careful interpretation as they may be irrelevant for determining the aetiology of pulmonary infiltrates, particularly when cultures yield coagulase‐negative staphylococci, enterococci or Candida species. Non‐culture based diagnostics for detecting Aspergillus galactomannan, beta‐D‐glucan or DNA from blood, bronchoalveolar lavage or tissue samples can facilitate the diagnosis, but must always be interpreted in the context of clinical and imaging findings. Systemic antifungal treatment with mould‐active agents, given in combination with broad‐spectrum antibiotics, improves clinical outcome when given pre‐emptively. Co‐trimoxazole remains the first‐line treatment for Pneumocystis pneumonia, while cytomegalovirus pneumonia will respond to ganciclovir or foscarnet in most cases. The clinical outcome of acute respiratory failure can also be successful with proper intensive care, when indicated.
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Affiliation(s)
- Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - J Peter Donnelly
- Department of Haematology, Radboud University Medical Centre, Nijmegen, The Netherlands
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11
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Maschmeyer G, Carratalà J, Buchheidt D, Hamprecht A, Heussel CP, Kahl C, Lorenz J, Neumann S, Rieger C, Ruhnke M, Salwender H, Schmidt-Hieber M, Azoulay E. Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients (allogeneic SCT excluded): updated guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Oncol 2015; 26:21-33. [PMID: 24833776 PMCID: PMC4269340 DOI: 10.1093/annonc/mdu192] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 04/29/2014] [Accepted: 05/02/2014] [Indexed: 12/13/2022] Open
Abstract
Up to 25% of patients with profound neutropenia lasting for >10 days develop lung infiltrates, which frequently do not respond to broad-spectrum antibacterial therapy. While a causative pathogen remains undetected in the majority of cases, Aspergillus spp., Pneumocystis jirovecii, multi-resistant Gram-negative pathogens, mycobacteria or respiratory viruses may be involved. In at-risk patients who have received trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis, filamentous fungal pathogens appear to be predominant, yet commonly not proven at the time of treatment initiation. Pathogens isolated from blood cultures, bronchoalveolar lavage (BAL) or respiratory secretions are not always relevant for the etiology of pulmonary infiltrates and should therefore be interpreted critically. Laboratory tests for detecting Aspergillus galactomannan, β-D-glucan or DNA from blood, BAL or tissue samples may facilitate the diagnosis; however, most polymerase chain reaction assays are not yet standardized and validated. Apart from infectious agents, pulmonary side-effects from cytotoxic drugs, radiotherapy or pulmonary involvement by the underlying malignancy should be included into differential diagnosis and eventually be clarified by invasive diagnostic procedures. Pre-emptive treatment with mold-active systemic antifungal agents improves clinical outcome, while other microorganisms are preferably treated only when microbiologically documented. High-dose TMP/SMX is first choice for treatment of Pneumocystis pneumonia, while cytomegalovirus pneumonia is treated primarily with ganciclovir or foscarnet in most patients. In a considerable number of patients, clinical outcome may be favorable despite respiratory failure, so that intensive care should be unrestrictedly provided in patients whose prognosis is not desperate due to other reasons.
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Affiliation(s)
- G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany.
| | - J Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | - D Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Mannheim
| | - A Hamprecht
- Institution for Medical Microbiology, Immunology and Hygiene, University Hospital Cologne, Cologne
| | - C P Heussel
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, University Hospital, Heidelberg
| | - C Kahl
- Department of Hematology and Oncology, Klinikum Magdeburg, Magdeburg
| | - J Lorenz
- Department of Pneumology, Infectious Diseases, Sleep Medicine and Intensive Care, Klinikum Lüdenscheid, Lüdenscheid
| | - S Neumann
- Medical Oncology, AMO MVZ, Wolfsburg
| | - C Rieger
- Department of Medicine III, University Hospital Großhadern, München
| | - M Ruhnke
- Department of Medical Oncology and Hematology, Charité University Medicine Campus Mitte, Berlin
| | - H Salwender
- Department of Hematology, Oncology, Stem Cell Transplantation, Asklepios Klinik Altona, Hamburg
| | - M Schmidt-Hieber
- Department of Hematology, Oncology and Tumor Immunology, Helios-Klinikum Berlin-Buch, Berlin, Germany
| | - E Azoulay
- AP-HP, Hopital Saint-Louis, Service de Réanimation Médicale, Université Paris-Diderot, Sorbonne Paris-Cité, Faculté de Médecine, Paris, France
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