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Query: UMLS:C0023241 (Legionella)
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The reliability of bronchoscopy with transbronchial biopsies for the diagnosis of acute graft rejection has recently been questioned. We present our experience with 59 transbronchial and bronchial biopsies and two open-lung biopsies from 12 patients that underwent lung transplantation. The diagnosis of acute rejection was established in 14 biopsies based on the absence of infection and presence of one or more of the following features: perivascular lymphoid infiltrates, usually associated with endothelial swelling; bronchial "acute on chronic" inflammation; and/or angiitis. Problems and potential pitfalls in the diagnosis of acute graft rejection in lung transplant patients are discussed. The biopsies were also sensitive for the diagnosis of cytomegalovirus pneumonitis and fungal infections but were not helpful for the diagnosis of bacterial pneumonias. Indeed, one patient died with Legionella sp. pneumonia diagnosed only on open-lung biopsy after two negative transbronchial biopsies. The significance of other histologic changes, such as nonspecific interstitial pneumonitis, diffuse alveolar damage, acute alveolitis, goblet cell hyperplasia of the bronchial mucosa, and pulmonary infarction, is discussed.
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PMID:Lung transplantation: the pathologic diagnosis of pulmonary complications. 164 51

Choosing appropriate antimicrobial therapy for patients with pneumonia requires knowledge of the etiologic agents seen in specific kinds of patients at specific times and places. For community-acquired pneumonia, there is an important difference in the agents seen in the normal and the compromised host. The normal host most often presents with viral, mycoplasmal, or pneumococcal pneumonia. The exact place of Chlamydia pneumoniae is still under study. A normal host who aspirates is at risk of anaerobic pneumonia. Normal hosts with influenza may acquire superinfection with Streptococcus pneumoniae, Haemophilus influenzae, or Staphylococcus aureus. Under specific epidemiologic conditions, community-acquired pneumonia may be due to Legionella species, Yersinia pestis, Francisella tularensis, Coxiella burnetii, Chlamydia psittaci, a mycotic agent, or tuberculosis. Patients with chronic bronchitis and emphysema are predisposed to H. influenzae, Moraxella catarrhalis, and S. pneumoniae infections. HIV-infected patients are likely to have Pneumocystis carinii pneumonia and pneumonia due to cytomegalovirus, S. pneumoniae, and H. influenzae. Patients with diabetes, nursing-home patients, hospitalized patients, immuno-compromised patients, and patients with recent antibiotic therapy are predisposed to pneumonia due to Gram-negative aerobic bacilli of enteric and environmental origin. Initial therapy should be directed at the likely organism or organisms based on hospital susceptibility surveillance. In the normal host with community-acquired pneumonia, the therapy will often be penicillin G or erythromycin. In the patient predisposed to Gram-negative pneumonia, a third-generation cephalosporin with or without an aminoglycoside is the usual choice.
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PMID:Pneumonia. Patient profiles, choice of empiric therapy, and the place of third-generation cephalosporins. 173 Jan 86

Bronchoalveolar washout was performed in 130 patients with pneumonia during a period of 28 months. Microbiological investigation involved common bacteria, Legionella, fungi, viruses (Cytomegalovirus, herpes, RSV), Mycobacterium, and Pneumocystis carinii. Infection HIV was present in 75% of patients. The remaining patients had malignant diseases or severe pneumonia. The overall sensitivity of the technique was 65.4% and the positive predictive value was 92%. The technique was less sensitive in cases of bacterial pneumonia (sensitivity = 34.4%). This was attributed to the fact that 82.8% of these cases received antibiotic therapy. Pneumocystis carinii and Mycobacterium tuberculosis were the most common agents (44.8% and 34.5%, respectively). In seven instances the clinical picture was related to cytomegalovirus, although this diagnosis can not be easily done.
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PMID:[Evaluation of bronchoalveolar lavage in the microbiological diagnosis of pneumonia in patients at risk]. 186 7

A rapid diagnostic team was formed to facilitate the diagnosis of pulmonary infections in solid organ transplant recipients. Seventy-seven renal and three liver transplant recipients developed 86 episodes of pneumonitis between 6 and 2,410 days posttransplant (median, 117 days). A diagnosis was established in all but seven patients. More than one diagnosis was established in 25. Cytomegalovirus (CMV) occurred in 51 episodes, bacterial pneumonia in 16 episodes, Pneumocystis carinii (PCP) in 11 episodes, fungal or Nocardia in 10 episodes, and Legionellosis in six episodes. Over half of the episodes of pneumonitis occurred in the period 1 to 4 months posttransplant. Bacterial pneumonia occurred significantly later than pneumonitis caused by PCP, Legionella, or CMV. Death occurred in 24 transplant recipients (31%) including 19 of 49 patients (39%) with CMV. Diffuse disease was the most common abnormality noted on initial chest roentgenogram (79 of 111, 71%). Interstitial infiltrates were the most common type of radiographic lesion observed, accounting for 62 of 111 (56%). Fiberoptic bronchoscopy was performed in 69 transplant recipients. Thirty-six of the 65 diagnoses made were established early, within 24 hours after bronchoscopy. Of the remaining diagnoses established later than 24 hours, all but one case of CMV was included. Bronchial alveolar lavage alone established 31 of the diagnoses. Bronchial brushings alone established only six cases, including five episodes of bacterial pneumonia and one case of CMV. We conclude that a team approach relying on fiberoptic bronchoscopy is useful in establishing the diagnosis of pulmonary infections in solid organ transplant recipients.
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PMID:The rapid diagnosis of pulmonary infections in solid organ transplant recipients. 216 Jul 17

Approximately 4% of recipients of solid organ transplants in the United States develop bacterial pneumonia in the posttransplant period, often in the first 3 months following transplantation. The incidence of bacterial pneumonia is highest in recipients of heartlung (22%) and liver transplants (17%), intermediate in recipients of heart transplants (5%), and lowest in renal transplant patients (1 to 2%). The crude mortality of bacterial pneumonia in solid organ transplantation has exceeded 40% in most series. Beyond those risk factors identified for nosocomial pneumonia, the occurrence of primary cytomegalovirus (CMV) infection, graft rejection, maintenance antirejection therapy with prednisone, azathioprine, and antilymphocyte globulin, antirejection therapy with high-dose corticosteroids or OKT3 and splenectomy have been associated with a significantly increased risk of bacterial pneumonia in these patients. In the first 3 months posttransplant, gram-negative bacilli, Staphylococcus aureus and Legionella predominate and mortality is very high, in excess of 60%. Thereafter, bacterial pneumonias are caused primarily by Streptococcus pneumoniae and Hemophilus influenzae, with considerably lower mortality. Bacterial pneumonia must be suspected in any transplant patient presenting with fever and cough, especially associated with dyspnea or infiltrates on chest radiograph. If large numbers of bacteria and polymorphonuclear leukocytes are not visualized in respiratory secretions the work-up should proceed directly to fiberoptic bronchoscopy with bronchoalveolar lavage and/or protected brush specimen to establish the microbiologic diagnosis as accurately as possible. For presumptive gram-negative bacillary pneumonia, the initial regimen must be effective against Pseudomonas aeruginosa. Prevention of bacterial pneumonia in transplant patients must begin with immunization against S pneumoniae and Influenza A, and include precautions taken to prevent nosocomial pneumonia. It further may include measures to prevent CMV infection and the use of trimethoprim/sulfamethoxazole prophylaxis during the first year posttransplantation. Ultimately, novel technologies such as selective antimicrobial decontamination and/or protective isolation during the early postoperative period may prove effective.
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PMID:Bacterial pneumonia in solid organ transplantation. 218 17

Pulmonary infection is a frequent and serious complication following kidney transplantation. Increased susceptibility to infection is due to a decrease in the patient's immunological response caused by immunosuppression through drug administration, and by other influences. The majority of bacterial sources are gram-negative, often hospital strains. The most important gram-positive bacterium is Staphylococcus aureus. Lung tb occurs with a 10-25 times higher frequency than in the rest of the population. Nocardial and Legionella pneumonias are no exception. Candida and Aspergillus are the most common fungus infections. They affect patients weakened by previous bacterial or virus infections. Cytomegalovirus is the most serious among the latter. The disease is usually accompanied by fever, leukopenia, thrombocytopenia and hepatitis. Pneumocystic pneumonia is characterized by a rapid progression of hypoxemia without any marked skiagraphical changes. Disseminated toxoplasmosis affects also the central nervous system simultaneously with the lungs, and the clinical picture shows a combination of interstitial pneumonia and a focal neurological finding with consciousness impairment.
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PMID:[Lung infection after kidney transplantation. I. Etiology, pathogenesis and clinical picture]. 236 54

Overwhelming Pneumocystis carinii pneumonia (PCP) in patients with acquired immunodeficiency syndrome (AIDS) carries a poor prognosis. Patients who require mechanical ventilation have up to a 90% mortality rate despite vigorous treatment. Although there are theoretic contraindications to steroid use in severely immunocompromised individuals, case reports of AIDS patients with PCP either inadvertently or intentionally given steroids have shown benefit. We report a series of seven patients whose AIDS and PCP worsened with conventional therapy and who subsequently received high-dose intravenous steroid therapy. All patients required intubation or a high inspired oxygen concentration. Four patients with uncomplicated PCP had a rapid and sustained response to steroids. Three patients with mixed infections (cytomegalovirus, Legionella pneumophila, and Pneumococcus) had transient improvement in gas exchange, though two of these patients subsequently died. Our experience is similar to that of others and suggests that corticosteroids may be of benefit in patients with AIDS and overwhelming PCP. We postulate that pulmonary inflammation is a major determinant of the severity of PCP in AIDS, and that this inflammation may be diminished by high-dose corticosteroid therapy.
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PMID:High-dose corticosteroid therapy for Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome. 266 Feb 89

In acquired immunodeficiency syndrome (AIDS) the pulmonary opportunistic infections are due to the depression of cellular immunity and they are found in more than 50% of patients. Most frequently the infection is due to Pneumocystis carinii, Cytomegalovirus, Cryptococcus neoformans and Mycobacterium avium-intracellulare. Non-opportunistic infections in AIDS are mostly due to the Mycobacterium tuberculosis and Legionella pneumophila. In Kaposi sarcoma in AIDS the lungs may be involved into pulmonary manifestations of the syndrome. In this paper the diagnostics of pulmonary disturbances in AIDS is briefly evaluated together with the therapy of most frequent pulmonary infections.
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PMID:[Pulmonary manifestations in patients with AIDS]. 279 62

Certain types and causes of pneumonia are unique to the immunocompromised host. The most frequent causes are cytomegalovirus, Pneumocystis carinii, varicella zoster virus, Candida species and Aspergillus species. Lymphoid interstitial pneumonia has recently been recognized in children with the acquired immunodeficiency syndrome. With the exception of varicella-zoster pneumonitis, an invasive procedure, such as open lung biopsy, is required to establish a definitive diagnosis. Infrequent causes of pneumonitis in immunocompromised children include Toxoplasma gondii; Cryptosporidium; Herpes simplex; adenovirus, gram-negative bacillary infections (Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Legionella pneumophilia); Nocardia spp; zygomycetes, and Cryptococcus neoformans. The discovery of any of the aforementioned pneumonias suggests the patient may have a serious underlying immunodeficiency.
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PMID:Pneumonia in the immunocompromised child. 282 16

The acquired immunodeficiency syndrome (AIDS) is a devastating new disease caused by the human immunodeficiency virus (HIV). This retrovirus causes profound immunoincompetence in its infected hosts, who are thereafter susceptible to develop myriad severe and relapsing protozoal, fungal, bacterial, viral, and arthropodal opportunistic infections, as well as unusual malignancies. The more than 50,000 patients who have developed AIDS in the United States have produced a sudden unexpected deluge of diagnostic dilemmas that are stressing laboratories of pathology everywhere. This paper describes the gross and microscopic pathology of the numerous complications in patients infected by HIV: (a) the prodromal AIDS-related complex with persistent generalized lymphadenopathy, (b) lymphoid infiltration of salivary gland and lung, including the complex of lymphoid interstitial pneumonitis-pulmonary lymphoid hyperplasia, (c) extranodal non-Hodgkin's lymphomas, (d) multifocal mucocutaneous and visceral Kaposi's sarcoma, (e) small cell undifferentiated (oat cell) carcinomas, (f) protozoal infections caused by Pneumocystis carinii, Toxoplasma gondii, Acanthamoeba, Cryptosporidium species (sp.), and Isospora belli, (g) the causes of chronic enteritis, (h) mycotic infections caused by Candida sp., Cryptococcus neoformans, Histoplasma capsulatum, Coccidioides immitis, and Sporothrix schenckii, (i) bacterial infections caused by Mycobacterium avium-intracellulare, M. tuberculosis, M. kansasii, Nocardia sp., Listeria monocytogenes, Legionella sp., Treponema pallidum, and others, (j) viral infections caused by cytomegalovirus, herpes simplex and zoster, polyomavirus (progressive multifocal leukoencephalopathy), hepatitis B, molluscum contagiosum, and papillomavirus, (k) oral hairy leukoplakia, (l) subacute encephalopathy, and (m) Norwegian scabies.
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PMID:The pathology of AIDS. 283 78


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