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The Role of BAL in the Diagnosis of Pulmonary Mucormycosis*
Five patients with pulmonary mucormycosis diagnosed during life are described. All had underlying predisposing conditions: either posttransplant or hematologic malignancies. In all cases, the diagnosis was made using fiberoptic bronchoscopy. In three patients, BAL was diagnostic. In two of these patients, the diagnosis was made by identifying the typical hyphae of mucormycosis in the BAL fluid alone. Transbronchial biopsy was diagnostic in three patients. Treatment was based on IV antifungal chemotherapy together with surgical removal of involved lung tissue whenever feasible. The clinical outcome of these patients was dismal and was determined primarily by the underlying condition.
(CHEST 2000,117.279-282)
Key words: BAL; immunocompromised; mucormycosis; neutropenie
Abbreviations: AMB = amphotericin B; BMT = bone marrow transplantation; CSE = corticosteroid; DM = diabetes mellitis; renal-Tx = renal transplantation; RLL = right lower lobe; TBB = transbronchial biopsy
Mucor, a fungus from the class of Zygomycetes, is a ubiquitous saprophyte that resides in soil and decaying organic matter, Humans may be infected with Mucor after inhalation of airborne fungal spores. However, normal macrophage and neutrophil function provides immune protection against Mucor. Therefore, patients with neutrophil dysfunction, such as occurs in diabetes, renal failure, or prolonged steroid therapy, are particularly vulnerable to infections with Mucor. Additionally, neutropenic patients may also develop invasive mucormycosis.
The most frequently observed manifestation of mucormycosis is the characteristic rhinocerebral infection, which may initially mimic bacterial sinusitis, and later extend to involve and destroy the hard palate and the orbit, and further invade the carotid artery. The GI tract and the brain may be involved in disseminated mucormycosis. The lung is more rarely involved by infection with this fungus. Such pulmonary involvement may progress and include invasion of blood vessels.
In reported series of invasive pulmonary mucormycosis, the diagnosis is often made at postmortem or premortem examination by using transbronchial biopsy (TBB) or open lung biopsy. However, many patients at risk for this infection are thrombocytopenic, which precludes the performance of invasive diagnostic procedures. BAL has not been evaluated for the diagnosis of this infection.
We present five patients with pulmonary mucormycosis that was diagnosed during life in our institution; three of the five patients had a diagnostic BAL.
MATERIALS AND METHODS
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