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Objectives: The identification of the specific pathogen responsible for a respiratory infection in patients with hematological malignancies (HM) would ensure relevant treatment and prevent toxicity associated with anti-infective therapy. This large-scale study aimed to explore the clinical impact of fiberoptic bronchoscopy with bronchoalveolar lavage (FOB-BAL) in conjunction with molecular analysis on the diagnosis and management of respiratory infections in hemato-oncological patients. Methods: All consecutive patients with HM and pulmonary infiltrates, who underwent FOB-BAL between January 2008 and January 2013, were included in the analysis. Clinical characteristics, FOB-BAL results, and treatment adjustments were recorded, and factors predicting a positive BAL were assessed. Results: Four hundred and twenty-five FOB-BAL procedures were analyzed. BAL revealed a specific diagnosis in 219 (51.5%) patients, 208 of them with a pulmonary infection. Infectious etiological agents found were mainly Aspergillus spp (n = 142), bacterial species (n = 44), and Pneumocystis jirovecii (n = 34). Multivariate analysis showed that a lymphoproliferative disease, ≥2 symptoms (dyspnea/cough/hemoptysis/pleuritic pain), and less than 4 days between symptom appearance and FOB-BAL, predicted a positive FOB-BAL result. BAL results prompted a treatment modification in 48% of subjects. Conclusions: FOB-BAL in conjunction with molecular assays is efficient in the rapid detection of life-threatening infections, allowing for adjustment of anti-infective therapy, which may result in better outcomes and reduce treatment-related toxicity.

Background: The syndrome of pulmonary hypertension (PHT) in end-stage renal disease (ESRD) has been described in patients on chronic hemodialysis (HD) therapy via arterial-venous (A-V) access. However, the exact timing for the development of the PHT is unknown. This study was designed to evaluate changes in pulmonary artery pressure (PAP) following creation of the vascular access. Patients and Methods: PAP and cardiac-output (CO) values were recorded in 12 pre-dialysis patients without PHT a few months after the access formation, before treatment with HD was started, and the prevalence of PHT was calculated. Clinical data was compared between patients with and without PHT. Results: The systolic PAP values were increased in “ve of the 12 pre-dialysis patients (42%) by 21±9 mm Hg to more than 35 mm Hg. Patients with and without PHT differed only in that CO was signi“cantly higher among the former. Conclusions: The development of PHT following access formation represents a failure of the pulmonary circulation to accommodate the access-mediated elevated CO. Pre-dialysis patients scheduled for access formation should be screened for the presence of sub-clinical PHT. “Positive” patients should proceed to peritoneal dialysis or advance to kidney transplantation; rather than getting access and HD therapy.

O envolvimento pulmonar definido como febre e aparecimento de novos infiltrados são a maior causa de morbilidade e mortalidade entre os doentes com doenças hematológicas malignas e em doentes transplantados de medula óssea (TMO). Os autores decidiram avaliar o valor diagnóstico do lavado broncoalveolar (LBA) neste grupo de doentes. Durante um período de dois anos, de Maio de 2000 a Maio de 2002, realizaram 115 LBA para tentar esclarecer infiltrados pulmonares em 94 doentes com doenças hematológicas malignas (28) e em doentes TMO (87). O BAL foi considerado eficaz desde que tenha feito um diagnóstico específico ou tenha excluído um diagnóstico posto e subsequentemente levado a alteração da terapêutica. O diagnóstico foi conseguido em 30,4% (infecções: 22,6%; hemorragia alveolar: 7,8%) e houve alteração da estratégia terapêutica em 21,8%, produzindo um campo de acção de 52,2%. A etiologia infecciosa foi de 54% de bactérias e de 30,8% de fungos. Houve apenas 3 complicações minor. O estudo destes autores mostrou eficácia do LBA no diagnóstico específico e levou a alterações terapêuticas em metade dos doentes com infiltrados pulmonares. A percentagem relativamente baixa nos diagnósticos específicos, segundo os autores, deve-se à utilização de antibióticos na profilaxia das infecções e na terapêutica empírica usada nestes doentes hematológicos com eventuais sinais de infecção.