Khalid Usman, Akram Muhammad J, Butt Faheem M, Ashraf Mohammad B, Khan Faheem
Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK.
Cureus. 2020 Sep 6;12(9):e10268. doi: 10.7759/cureus.10268.
Introduction Febrile neutropenia (FN) is a dreaded complication of cancer chemotherapy and frequently associated with respiratory infections. Flexible bronchoscopy (FB) serves as a useful diagnostic tool in this regard. Objective To determine the diagnostic yield, safety and clinical implications of bronchoalveolar lavage (BAL) in cancer patients with FN, having lung infiltrates on radiographic chest imaging. Methods We reviewed medical records of FN patients who underwent FB at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, from July 2015 till July 2018. The culture yield of BAL, resultant change of management and outcome over the subsequent 30 days were retrospectively analysed. Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY) was used for data analysis. Results Ninety FN patients, with mean age 26 ± 18 years and predominantly males (65.6%, n = 59) were included in the study. Seventy-seven (85.6%) had hematological and 13 (14.4%) solid organ malignancy. The mean absolute neutrophil count was 0.20 +/- 0.36/ µL. BAL cultures were diagnostic in 40 (44%) patients; the etiology was bacterial, fungal and mixed in 25 (62.5%), 14 (35%) and one (2.5%) patient, respectively. All patients were on empirical antibiotics prior to bronchoscopy: 32 (35.6%) on antibacterial alone and 58 (64.4%) on antibacterial plus antifungal therapy. Change of management occurred in 51 (56.7%) patients after BAL results, including de-escalation from dual antibiotics in 28 (55%) and initiation of new culture sensitive antibiotic in 23 (45%). FB-associated complications developed in three (5.6%) non-intensive care patients (ICU), including transient hypoxia in two and minor hemoptysis in one patient, while five (14.8%) mechanically ventilated patients in ICU experienced worsening of oxygenation parameters within 48 hours. Overall, 24 (26.7%) patients died. Mortality was 3.7% in non-ICU and 69% in ICU setting and significantly higher in patients with fungal pneumonias (p-value 0.01) and with prolonged neutropenia (p-value 0.001). Conclusions BAL is a safe diagnostic tool for FN patients with lung infiltrates, with minimal complications and sufficient diagnostic yield to improve diagnosis and management of such patients.
发热性中性粒细胞减少症（FN）是癌症化疗可怕的并发症，常与呼吸道感染相关。在这方面，可弯曲支气管镜检查（FB）是一种有用的诊断工具。目的：确定支气管肺泡灌洗（BAL）对胸部影像学有肺部浸润的FN癌症患者的诊断率、安全性及临床意义。方法：我们回顾了2015年7月至2018年7月在拉合尔绍卡特·汗姆纪念癌症医院和研究中心接受FB检查的FN患者的病历。对BAL的培养结果、随后30天内治疗方案的改变及结局进行回顾性分析。使用社会科学统计软件包（SPSS）20版（IBM公司，纽约州阿蒙克）进行数据分析。结果：90例FN患者纳入研究，平均年龄26±18岁，以男性为主（65.6%，n = 59）。77例（85.6%）为血液系统恶性肿瘤，13例（14.4%）为实体器官恶性肿瘤。平均绝对中性粒细胞计数为0.20 +/- 0.36/µL。BAL培养对40例（44%）患者有诊断价值；病因分别为细菌感染、真菌感染及混合感染，各有25例（62.5%）、14例（35%）和1例（2.5%）患者。所有患者在支气管镜检查前均接受经验性抗生素治疗：仅使用抗菌药物的有32例（35.6%），使用抗菌药物加抗真菌药物治疗的有58例（64.4%）。根据BAL结果，51例（56.7%）患者的治疗方案发生改变，包括28例（55%）从联合抗生素降级治疗和23例（45%）开始使用新的培养敏感抗生素。3例（5.6%）非重症监护病房（ICU）患者出现与FB相关的并发症，包括2例短暂性低氧血症和1例轻度咯血，而5例（14.8%）ICU机械通气患者在48小时内氧合参数恶化。总体而言，24例（26.7%）患者死亡。非ICU患者死亡率为3.7%，ICU患者死亡率为69%，真菌性肺炎患者和中性粒细胞减少持续时间较长的患者死亡率显著更高（p值分别为0.01和0.001）。结论：BAL对于有肺部浸润的FN患者是一种安全的诊断工具，并发症极少，诊断率足以改善此类患者的诊断和治疗。
