Clinical and bronchoscopic diagnosis of suspected pneumonia related to AIDS.

In a series of 25 patients with suspected pneumonia related to the acquired immune deficiency syndrome (AIDS) the first 12 underwent routine fibreoptic bronchoscopy and bronchoalveolar lavage with or without transbronchial biopsy before treatment. Eight were found to have Pneumocystis carinii pneumonia and had typical clinical presentations with a prolonged history of symptoms, including a dry cough, and bilateral diffuse alveolar or interstitial shadowing in chest radiographs. Among the subsequent 13 cases, 11 had similar clinical presentations and were treated with high doses of intravenous co-trimoxazole without bronchoscopy first. Bronchoscopy was performed in those who deteriorated at any stage or failed to improve by the fifth day of treatment. Nine patients recovered and were discharged. In two patients who died P carinii pneumonia was confirmed in one but no diagnosis was made in the other. The early and late survival in both groups of patients was similar. In patients at high risk for AIDS who have clinical features suggestive of P carinii pneumonia starting treatment with intravenous co-trimoxazole is justified. The few patients who deteriorate or fail to respond should undergo bronchoscopy with bronchoalveolar lavage and transbronchial biopsy.     

Cell population obtained by bronchoalveolar lavage in Pneumocystis carinii pneumonitis

In the course of bronchoalveolar lavages performed in 115 immunocompromised patients in order to investigate the occurrences of pneumonitis, Pneumocystis carinii pneumonia was diagnosed by demonstration of cysts in bronchoalveolar lavage specimens from 11 patients. The cellular phenomena associated with P. carinii infection at the level of the alveolar space were evaluated. Differential cell counts on bronchoalveolar lavage preparations stained by the May-Grünwald-Giemsa method were performed in immunocompromised patients and in ten nonimmunocompromised patients without any respiratory disease. A decrease in the alveolar macrophage count associated with an increase in the polymorphonuclear neutrophil count and the presence of plasma cells and/or immunoblasts was highly suggestive of P. carinii pneumonia. These cellular changes in bronchoalveolar lavage specimens are discussed in relation to the pathologic features usually described in P. carinii pneumonia.     

Attempts at in vitro cultivation of Pneumocystis carinii from human bronchoalveolar lavage fluids without feeder cells.

We attempted to cultivate Pneumocystis carinii obtained from two bronchoalveolar lavage fluids of AIDS patients with P. carinii pneumonia, in a system wherein cysteine and 2-mercaptoethanol were substituted for the feeder cells. The presence of P. carinii cysts was monitored for 11 days under conditions of continuous culture. Moderate increase in cyst forms was observed until day 11. Further study with this system would be required to determine if the observed increase in cyst numbers is reproducible and whether the cyst form is a response to adverse in vitro conditions or is a manifestation of growth.     

Detection of Candida antigen in bronchoalveolar lavage fluid

While bronchoalveolar lavage is frequently performed to evaluate immunocompromised hosts for infection, the significance of rare yeasts found on the cytologic examination of lavage fluid is unclear. This study used the latex agglutination method to test lavage fluids for Candida antigen to assess its usefulness in distinguishing Candida pneumonia from Candida colonization of the respiratory tract or oral contamination of the lavage specimen. Ninety-seven specimens from 87 patients were categorized on the basis of historical, microbiologic, cytologic and serologic data. Bronchoalveolar lavage fluids were positive for Candida antigen in 0 of 20 specimens from normal controls, 0 of 14 specimens from patient controls, 5 (36%) of 14 specimens from patients with Pneumocystis carinii pneumonia, 0 of 5 specimens from patients with gastrointestinal candidiasis, 0 of 9 specimens contaminated by oral-derived yeasts, 2 (10%) of 19 specimens from patients with probable Candida colonization and 15 (94%) of 16 specimens from patients with clinical and laboratory evidence of Candida pneumonia. We conclude that this test assists in the differentiation of Candida pneumonia from other situations in which yeasts are recovered by bronchoalveolar lavage.     

Cytomorphology of Alternaria in bronchoalveolar lavage specimens

Review of the bronchoalveolar lavage specimens from 326 patients resulted in the identification of Alternaria in 28 (8.6%) of the specimens. On Papanicolaou-stained Millipore filters, the most common finding was a yellow-brown-pigmented muriform conidium with characteristic transverse and longitudinal septations. Four of the patients had floccose branched and septated hyphae of Alternaria in addition to conidia. Budding yeast or yeast forms were also present in the lavage fluid of 14 of the patients with Alternaria. Two patients had concurrent Pneumocystis carinii pneumonia, and one patient had cytomegalovirus pneumonitis. No patient developed clinical features of systemic Alternaria infection, and autopsy of four patients did not reveal pneumonia. Alternaria conidia in a bronchoalveolar lavage fluid will usually represent laboratory contaminants or nonpathogenic saprophytes, and their significance lies in distinguishing them from other fungi. However, the expanded use of immunosuppressive therapy and the increasing prevalence of acquired immune deficiency syndrome may render such saprophytes clinically important.     

Pneumocystis carinii pneumonia: detection of parasites in sputum and bronchoalveolar lavage fluid by monoclonal antibodies.

Diagnosis of pneumocystis pneumonia is based on identifying Pneumocystis carinii cytochemically in material from the lung. The silver methenamine staining methods most commonly used are technically difficult and lack specificity. The diagnostic value of immunocytological identification of the parasite was evaluated by using mouse monoclonal antibody 3F6, specific for human pneumocystis, to identify P carinii in bronchoalveolar lavage fluid and sputum by immunofluorescence and was compared with that of other variables. Bronchoalveolar lavage was performed on 25 patients positive for HIV antibody with clinically suspected pneumocystis pneumonia and 40 patients negative for HIV antibody who presented with interstitial disorders of the lung. Lavage fluid showed pneumocystis only in the patients positive for antibody, the parasite being detected in 19 by immunofluorescence and in 17 by a modified silver methenamine staining method. Chest x ray films obtained at the time of bronchoscopy showed interstitial or alveolar shadowing in 17 of the 19 patients, but clinical symptoms and the presence of antibodies to pneumocystis did not seem to be predictive. Sputum samples were collected during 43 episodes of clinically suspected pneumocystis pneumonia in patients positive for HIV antibody. Pneumocystis was detected consistently more commonly by immunofluorescence than the silver strain in sputum collected routinely and induced by inhalation of saline. In 17 patients bronchoalveolar lavage followed sputum collection, and the sensitivity of detection of pneumocystis in immunofluorescence in sputum compared with lavage fluid was 57% (8/14). Immunofluorescence was suitable for specimens fixed in ethanol and seemed highly specific and more sensitive than the standard cytochemical methods for identifying pneumocystis.     

Serum lactic dehydrogenase predicts mortality in patients with AIDS and Pneumocystis pneumonia.

Serum lactic dehydrogenase (LDH) activity was compared with mortality in patients with the acquired immunodeficiency syndrome (AIDS) and Pneumocystis carinii pneumonia during the first four days of admission to assess the test''s predictive value. In 30 admissions, 29 patients who survived an episode of Pneumocystis pneumonia had a mean LDH value of 385 IU, with five values greater than 520 IU. Eight with pneumonia who died had a mean value of 926 IU: all had values higher than 520 IU. The mean LDH values for 20 patients with AIDS (35 admissions) who survived and 4 who died of non-Pneumocystis disease were 240 IU and 350 IU, respectively; these patients were the control population. The positive and negative predictive values for survival using 520 IU as the threshold are 61% and 100%. Thus, LDH measurements in the first days of admission for P carinii pneumonia predict mortality and are useful in guiding future management.     

Bronchoalveolar lavage fluid cytology in patients with Pneumocystis carinii pneumonia

OBJECTIVE: To evaluate bronchoalveolar lavage (BAL) cytology and organism burden in patients with Pneumocystis carinii pneumonia (PCP) who were infected with the human immunodeficiency virus (HIV) and in those with other immunodeficiencies. STUDY DESIGN: BAL fluid samples from patients with PCP were selected (HIV-infected patients, n = 15; patients with other immunodeficiencies, n = 11). May-Grünwald-Giemsa-stained cytocentrifuge preparations were evaluated. Foamy alveolar casts (FACs) and P carinii clusters were counted. RESULTS: The numbers of FACs and P carinii clusters in BAL fluid samples of HIV-infected patients were significantly higher as compared to those in samples from patients with other immunodeficiencies. Striking cytologic findings observed in half the samples from both patient groups included the presence of foamy alveolar macrophages, activated lymphocytes, plasma cells and reactive type II pneumocytes. Furthermore, a peculiar cell type, "nonidentified cell" (NIC), was observed almost exclusively in BAL fluid samples from HIV-infected patients. CONCLUSION: BAL fluid samples from HIV-infected patients with PCP displayed higher organism burdens as compared to those from patients with other immunodeficiencies. Moreover, cytologic findings suggestive of noninfectious lung conditions were common in BAL fluid samples obtained from patients with PCP. Further study is required to elucidate the identity of the NIC cell type.     

Generalized immune response to Pneumocystis carinii infection in the lung.

We studied inflammatory cells retrieved by bronchoalveolar lavage (BAL) from immunocompromised patients with or without Pneumocystis carinii pneumonia (PCP). Twenty-four patients with PCP, and 20 patients without PCP underwent lavages of both an uninvolved lobe and the lobe involved in pulmonary infection. Patients without P. carinii, had a significant increase (p less than 0.02) in the percentages of neutrophils (22 +/- 7.1%, mean +/- SEM) and lymphocytes (16 +/- 3.8%) in the involved lobe compared to those in the uninvolved area (neutrophils: 9 +/- 4.8%; lymphocytes: 10 +/- 2.4%). Patients with PCP, had no differences between the % neutrophils or % lymphocytes in the involved vs. uninvolved lobes. Patients with PCP had more (p less than 0.01) P. carinii in the upper lobe (23 +/- 4.6 P. carinii clusters/500 cells) than the middle lobe (11 +/- 3.6). In PCP, despite regional infections, there was a diffuse inflammatory response.     

艾滋病合并肺孢子菌肺炎1例

本文报道1例通过肺组织活检明确诊断的艾滋病合并肺孢子菌肺炎(Pneumocystis carinii pneumonia,PCP)病例,结合文献复习,分析艾滋病合并PCP的病理学特点及临床诊治措施。本例患者经实验室检查确诊为艾滋病,通过气管镜肺活检取得肺组织标本,组织病理学诊断为PCP,给予复方磺胺甲唑治疗后病情好转。PCP多见于艾滋病等免疫缺陷患者,临床上表现为间质性肺炎,提高对该病的认识并尽早进行病原学检测是确诊的关键。尽早使用复方磺胺甲唑等有效药物是改善预后的主要措施。     

Pneumocystis carinii pneumonia and AIDS

An infection with Pneumocystis carinii with clinical symptoms of pneumonia is particularly frequent in patients with AIDS. The authors discuss current knowledge on Pneumocystis carinii pneumonia, including clinical course, possibility of diagnosis, and chemotherapy in patients with AIDS.     

Phenotypic analysis of bronchoalveolar lavage lymphocytes from acquired immunodeficiency patients with and without Pneumocystis carinii pneumonia.

A study was performed to reveal possible differences in lymphocyte subpopulations from bronchoalveolar lavage (BAL) of acquired immunodeficiency patients with and without Pneumocystis carinii pneumonia. Forty-one consecutive human immunodeficiency virus-seropositive patients were studied. Pneumocystis carinii infection was detected in the BAL fluid from 18 patients. The BAL lymphocyte subpopulations were determined by surface marker analysis with the immunoperoxidase slide assay. No significant differences in the percentage of CD4+ and CD8+ lymphocytes were found between the two groups. The percentage of CD57+ natural killer (NK) cells was significantly higher in the Pneumocystis carinii-negative group than in the -positive group. Since NK cells protect from microbial infections, it is conceivable that the loss of CD57+ NK cells may be one of the phenomena leading to the immunodeficiency state that underlies the pulmonary complications characteristic of the acquired immunodeficiency syndrome.     

Cytology of extrapulmonary Pneumocystis carinii infection in the acquired immunodeficiency syndrome.

Rare cases of extrapulmonary Pneumocystis carinii (EPPC) have been seen in patients with acquired immunodeficiency syndrome (AIDS). We report seven such diagnoses of nonpulmonary P carinii (PC) from four AIDS patients between 1986 and 1989. The specimens included fine needle aspirate of liver, spleen, periarticular tissue and pleura as well as ankle fluid, pleural fluid and ascites. In some, but not all, cases the patients had concurrent or previous episodes of PC pneumonia. In all cases the typical granular, eosinophilic aggregates of PC cysts were noted on routine Papanicolaou staining, leading to the definitive detection of PC cysts with Grocott silver stain. In most cases, evidence for granulomalike and neovascularized tissue reaction was present in cytologic material. One specimen demonstrated concurrent acid fast bacilli. In the setting of AIDS, cytology of effusions and masses should include an evaluation for EPPC.     

Open-label efficacy and safety trial of 42 days of 566C80 for Pneumocystis carinii pneumonia in AIDS patients.

Pneumocystis carinii pneumonia continues to be a cause of morbidity and mortality in AIDS patients. Current therapies have a high rate of toxicity and failure. Compound 566C80 is a 1-4,hydroxynaphthoquinone with potent antiprotozoal activity which shows good efficacy and safety in 21-day treatment trials of P. carinii pneumonia (PCP) in AIDS patients. Because there is a generally high recurrence rate after treatment of PCP and there may be a possible advantage in decreasing the P. carinii burden in the lung with extended anti-Pneumocystis therapy, we performed an open label-trial of the safety and efficacy of 42-day therapy with 566C80 for PCP in AIDS patients. Ten patients were enrolled and one was lost to follow-up. Eight of the remaining nine patients successfully completed 42 days of therapy with minimal toxicity. This trial suggests that 566C80 for 42 days can be an effective, safe, and well-tolerated oral therapy for PCP in AIDS patients.     

Bronchoalveolar lavage in liver transplant patients

Because immunosuppression is required to control rejection, liver allograft recipients are susceptible to a variety of opportunistic pathogens. A total of 191 bronchoalveolar lavage (BAL) specimens from 89 patients (53 adults and 36 children) who underwent orthotopic liver transplantation was reviewed. One case each of cytomegalovirus (CMV), staphylococcal and Enterobacter pneumonia was diagnosed with the aid of pretransplant BAL. The pretransplant BAL in 62 patients showed rare yeasts in 24.2%; these probably represent oropharyngeal contaminants since the patients involved had no symptoms of Candida pneumonia. Among 54 patients who developed respiratory symptoms and underwent posttransplant BAL, 23 (42.6%) were infected with opportunistic pathogens, including Pneumocystis carinii (22.2%), CMV (22.2%) and herpes simplex virus (HSV) (7.4%). Frequently, infection with multiple organisms was present. Adults constituted 100% of the HSV-infected group, 69.2% of the CMV-infected group and 16.6% of the group infected with P carinii. The diagnosis of these infections was aided by a combination of cytology, microbial culture and in situ hybridization techniques. Although BAL permitted the diagnosis and treatment of opportunistic infections, high mortality (62.5%) occurred with CMV and HSV pneumonia. Further studies into methods that permit earlier diagnoses of these infections are necessary.     

Role of special stains in the diagnosis of Pneumocystis carinii infection from bronchial washing specimens in patients with the acquired immune deficiency syndrome

Fifty bronchial washing specimens from 36 patients with acquired immune deficiency syndrome (AIDS) were retrospectively reviewed to assess the sensitivity of the various special stains used to diagnose Pneumocystis carinii. In 76% of the cases, the Diff-Quik stain was positive; it was the easiest and most rapid of the special stains used. The sensitivity was increased to 92%, 96% and 100%, respectively, by also doing cresyl echt violet, Grocott's Gomori methenamine silver and both the cresyl violet and Grocott stains in addition to the Diff-Quik stain. We conclude that the Diff-Quik stain is a fairly reliable and rapid screening procedure for making the diagnosis of Pneumocystis infection in bronchial washings from AIDS patients. The routine Papanicolaou stain gave less sensitive results in the smears of the washing specimens, but does give a markedly improved yield in bronchoalveolar lavage specimens.     

Reactive type II pneumocytes in bronchoalveolar lavage fluid

OBJECTIVE: To evaluate the prevalence of reactive type II pneumocytes (RPII) in bronchoalveolar lavage (BAL) fluid samples obtained from patients with various pulmonary disorders. STUDY DESIGN: Consecutive BAL fluid samples were screened for the presence of RPII on May-Grünwald-Giemsa-stained cytocentrifuge preparations. BAL fluid samples with and without RPII were compared with regard to prevalence, associated clinical diagnoses and cytologic findings. RESULTS: RPII were generally large cells with a high nuclear:cytoplasmic ratio and deeply blue-stained, vacuolated cytoplasm. Most RPII occurred in cohesive cell groups, and the vacuoles tended to be confluent. Cytologic findings associated with RPII were foamy alveolar macrophages, activated lymphocytes and plasma cells. RPII were present in 94 (21.7%) of 433 included BAL fluid samples. The highest prevalences were noted in patients with systemic inflammatory response syndrome and alveolar hemorrhage. In addition, RPII tended to occur more frequently in ventilator-associated pneumonia, Pneumocystis carinii pneumonia, extrinsic allergic alveolitis and drug-induced pulmonary disorders. In contrast, RPII were not observed in BAL fluid samples obtained from patients with sarcoidosis. CONCLUSION: RPII were prevalent in about 20% of BAL fluid specimens. They were associated mainly with conditions of acute lung injury and not observed in sarcoidosis.     

Detection of Pneumocystis carinii in serum of AIDS patients with Pneumocystis pneumonia by the polymerase chain reaction.

Amplification of DNA by the polymerase chain reaction (PCR) offers a highly sensitive and specific method for detecting DNA sequences in biological samples. We applied this technology to develop an assay for the P. carinii dihydrofolate reductase (DHFR) gene. This assay was found to be sensitive enough to detect as little as 1 organism-'equivalent' of DHFR DNA. In rats with experimentally-induced P. carinii pneumonia, DHFR DNA amplification demonstrated the presence of pulmonary P. carinii 2 wk prior to the onset of histopathological changes. When rat serum was analyzed by PCR, serum P. carinii DNA was found in 5 of 14 experimental rats. Finally, P. carinii DNA was detected in the serum of 7 of 18 patients (39%) with AIDS and active P. carinii pneumonia. These results suggest that circulating serum P. carinii DNA can be detected frequently in the course of pulmonary infection and may represent a blood-borne phase of infection. The PCR detection of P. carinii DNA provides a useful tool to study the natural history of P. carinii infection and may offer a non-invasive diagnostic procedure in some patients with P. carinii pneumonia.     

The Diagnosis of Pneumocystis Carinii Pneumonia By Cytologic Evaluation of Papanicolaou and Leishman-Stained Bronchoalveolar Specimens In Patients With the Acquired Immunodeficiency Syndrome

The presence of foamy alveolar casts or flocculent material in Papanicolaou and Leishman-stained smears of bronchoalveolar lavage (BAL) fluid is said to be indicative of infection with Pneumocystis carinii. We have investigated the sensitivity and specificity of this method of diagnosing pneumocystis pneumonia in patients with the acquired immunodeficiency syndrome (AIDS). Patients (n= 114) with diffuse lung infiltrates were submitted to fibreoptic broncoscopy and BAL. Seventy of them were patients with AIDS. the other 44 individuals were not infected by the human immunodeficiency virus (HIV). Pneumocystis carinii organisms were identified on Grocott's methenamine silver (GMS)-stained BAL smears in 30 patients with AIDS. Flocculent material was present in the Papanicolaou and Leishman-stained smears from all of these cases. Conversely, P. carinii were not seen on GMS-stained smears in the remaining 84 individuals with or without AIDS. No flocculent material was observed in Papanicolaou or Leishman-stained smears in these 84 patients. We concluded that the presence of flocculent material in Papanicolaou or Leishman-stained smears of BAL fluid is indicative of P. carinii pneumonia in patients with AIDS. La présence de cylindres alvéolaires spumeux ou de matériel floculé dans les étalements de liquide de lavage bronchoalvéolaire (LBA) colorés selon Papanicolaou ou Leishman est considérée comme symptomatique d'une infection par Pneumocystis carinii. Nous avons étudié la sensibilité et la spécificité de cette méthode de diagnostic de l'infection par Pneumocystis carinii chez des patients atteints de syndrome de déficience immunitaire acquise (SIDA). Cent quatorze malades avec des infiltrats pulmonaires diffus ont subi une fibroscopie bronchique et un lavage broncho-alvéolaire. Soixante dix d'entre eux edtaient atteints de SIDA, 44 n'étaient pas infectés par le Virus de l'Immunodéficience Humaine (VIH). Le Pneumocystis carinii a été identifiié par la coloration de Grocott chez 30 patients atteints de SIDA. Chez ces patients, la présence d'un matériel floculé est constante sur les étalements colorés au Papanicolaou et au Leishman. A l'inverse, Pneumocystis carinii n'a pas été retrouvé chez les 84 autres malades, atteints ou non du SIDA et les étalements de LBA ne contenaient pas de matériel floculé. En conclusion, la présence de matériel floculé dans les étalements de LBA colorés selon Papanicolaou ou Leishmanest associée à une pneumpathie àPneumocystis carinii chez les patients atteints de SIDA. Sensitivität und Spezifität des Nachweises schaumiger oder flockiger Alveolarausgüsse bei Pneumocystis carinii wurden in 114 Fällen diffuser Lungeninfiltrate untersucht. 70 Patienten waren an AIDS erkrankt, 44 weitere waren HIV-negative. In 30 der AIDS-Fälle wurde P. carinii mit der Grocott'schen Färbung nachgewiesen. Die typischen Eiweißniederschläge waren in all diesen Fällen nachweisbar. Umgekehrt ergab die Grocottfärbung in 84 Fällen mit oder ohne AIDS ein negatives Ergebnis. In all diesen Fällen war kein Eiweißniederschlag nachweisbar. Daraus ergibt sich, daß die Eiweißniederschläge in Präparaten, die nach Papanicolaou oder Leishman gefärbt wurden, kennziechned sind für die P. carinii Pneumonie.     

Soluble Vascular Cell Adhesion Molecule-1 (sVCAM-1) Is Elevated in Bronchoalveolar Lavage Fluid of Patients with Acute Respiratory Distress Syndrome

Introduction

Pulmonary vascular endothelial activation has been implicated in acute respiratory distress syndrome (ARDS), yet little is known about the presence and role of endothelial activation markers in the alveolar space in ARDS. We hypothesized that endothelial activation biomarkers would be differentially expressed in bronchoalveolar lavage fluid from patients with ARDS compared with healthy volunteers, and that biomarker concentrations would be associated with ARDS severity.

Methods

We performed a cross-sectional analysis of data from 26 intubated patients with ARDS undergoing evaluation for clinically suspected ventilator-associated pneumonia and five healthy volunteers. Patients underwent bronchoalveolar lavage a median of five days after intubation. Healthy volunteers also underwent bronchoalveolar lavage. Endothelial activation biomarkers (soluble vascular cell adhesion molecule-1 [sVCAM-1], soluble endothelial selectin [sESEL], angiopoietin-1 [Ang-1] and angiopoietin-2 [Ang-2]) were measured in bronchoalveolar lavage fluid. Clinically suspected ventilator-associated pneumonia was confirmed with microbiologic culture data.

Results

Patients with ARDS had significantly higher median sVCAM-1 concentrations in the bronchoalveolar lavage fluid compared with healthy volunteers (985 vs 119 pg/mL, p = 0.03). Additionally, there was a trend toward greater bronchoalveolar lavage fluid sVCAM-1 concentrations among patients with moderate/severe compared to mild ARDS (1395 vs 209 pg/mL, p = 0.06). We did not detect significant differences in bronchoalveolar lavage fluid levels of sESEL, Ang-1 or Ang-2 between patients with ARDS and healthy volunteers. Median bronchoalveolar lavage fluid biomarker levels did not differ between patients with and without microbiologically-confirmed ventilator-associated pneumonia.

Conclusions

sVCAM-1 concentrations were significantly higher in the bronchoalveolar lavage fluid of patients with ARDS compared to healthy controls, and tended to be higher in moderate/severe ARDS compared to mild ARDS. Our findings add to the growing evidence supporting the concept that endothelial activation plays an important mechanistic role in the pathogenesis of ARDS. Further studies are necessary to characterize the role and/or clinical significance of sVCAM-1 and other endothelial activation markers present in the alveolar space in ARDS.