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Clinical Investigations: DRUGS |

Pulmonary Infiltrates in Patients Receiving Long-term Glucocorticoid Treatment*: Etiology, Prognostic Factors, and Associated Inflammatory Response

Carlos Agustí, MD, PhD; Ana Rañó, MD, PhD; Xavier Filella, MD, PhD; Juliá González, MD, PhD; Asunción Moreno, MD, PhD; Antoni Xaubet, MD, PhD; Antoni Torres, MD, PhD, FCCP
Author and Funding Information

*From Servei de Pneumologia (Drs. Agustí, Rañó, Xaubet, and Torres), Institut Clínic de Pneumologia i Cirurgía Toràcica; Servei de Microbiologia i Malalties Infeccioses (Drs. Filella, González, and Moreno), Servei de Bioquímica Clínica, Institut Clínic de Infeccions i Inmunitat, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.

Correspondence to: Antoni Torres, MD, PhD, FCCP, Servei de Pneumologia, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain; e-mail: atorres@medicina.ub.es



Chest. 2003;123(2):488-498. doi:10.1378/chest.123.2.488
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Background: Glucocorticoid treatment alters immunoregulatory defense mechanisms and may therefore favor the development of different pulmonary infections.

Methods: The etiology, prognostic factors, and associated inflammatory response of pulmonary infiltrates in 33 patients receiving long-term glucocorticoid treatment (LTGCT) were prospectively evaluated.

Results: Aspergillus spp (n = 9, 31%) and Staphylococcus spp (n = 6, 21%) were the most common causative agents. Using different diagnostic techniques, we obtained a specific diagnosis in 28 of 33 episodes (85%) of pulmonary infiltrates. Bronchoscopic techniques provided the diagnosis in 64% of the cases. Crude mortality was 45%. Variables associated with mortality were as follows: age > 64 years, bilateral radiographic involvement, delay in diagnosis, inappropriate empirical treatment, Simplified Acute Physiology Score (SAPS) II ≥ 25, and requirement for mechanical ventilation (MV). SAPS II ≥ 25 (odds ratio [OR], 16; 95% confidence interval, 1 to 260) and MV requirement (OR, 50; 95% confidence interval, 2 to 360) were also significant on multivariate analysis. Pulmonary infections were associated with an increase in the concentration of relevant inflammatory cytokines such as tumor necrosis factor-α and interleukin-6 both in serum and BAL. This local and systemic inflammatory response was attenuated when compared with the response observed in patients with pulmonary infections but without glucocorticoid treatment or receiving glucocorticoids for a short period of time (< 9 days).

Conclusions: Pulmonary infiltrates in patients receiving LTGCT are often caused by fungi and Gram-positive cocci, and are associated with attenuated local and systemic inflammatory response. Although in most cases, sputum cultures and bronchoscopic techniques are diagnostic, the associated mortality is high, particularly in those requiring MV.

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