PURPOSE: Pulmonary complications are common in HSCT patients, occurring early and late, with a broad differential of infectious, non-infectious processes. Delay in diagnosis, lack of uniform approach lead to uneven treatment and outcome. We believe a coordinated Multidisciplinary approach following a strict protocol will improve timeliness in evaluation and effectiveness in management.
METHODS: Various clinical and laboratory services jointly developed an algorithm for rapid assessment of HSCT patients with new pulmonary infiltrates. Bronchoscopy with lavage of most involved segments and transbronchial biopsies when feasible are performed within 24 hours of consultation. Protocolized sample collection and standardized order sets allow uniform testing by microbiology, cytology and histopathology services. Results are used for clinical decision-making regarding therapy. Non-diagnostic bronchoscopy lead to surgical consultation for Open Lung Biopsy within 48 hours.
RESULTS: In the 9 months after establishment of protocol, 26 HSCT patients underwent 32 bronchoscopies. Non-diagnostic bronchoscopies led to 3 Open-Lung Biopsies. 13 infectious diagnosis and 5 non-infectious diagnosis were found. These include 4 Invasive Aspergillosis (IA) cases, 1 case each of Cryotococcus neoformans and Scedosporium apiospermum, 1 case of Pneumocystis jirovecii, 4 cases of viral pathogens (adenovirus, RSV, HSV-1, Parainfluenza), 1 case of BOOP, 3 cases of Diffuse Alveolar Damage and 1 case of Obliterative Bronchiolitis. Treatment changes included change and de-escalation of antimicrobial coverage, initiation of steroid therapy for BOOP and OB. 2 of 5 patients who died had a follow-up autopsy confirming IA in one and MRSA-DAD in the second. There remains a reluctance to refer all patients onto Open Lung Biopsies because of perceived morbidity of the procedure.
CONCLUSION: A Multidisciplinary protocol developed for evaluation of pulmonary infiltrates in HSCT patients is valuable in expediting and unifying diagnostic evaluation, targeting and refining empiric therapy in this patient group. Our approach provided a microbiologic or pathologic diagnosis in >60% of our bronchoscopies.
CLINICAL IMPLICATIONS: This or a similar bronchoscopy algorithm may be easily adapted to facilitate the diagnosis and management of HSCT and other immunosuppressed patient groups with pulmonary complications.
DISCLOSURE: Rex Yung, None.