Evaluation of bronchoalveolar lavage for differentiating between Pneumocystis jiroveci pneumonia and drug-induced pulmonary parenchymal disease after chemotherapy for solid tumors

Yoshihisa Hiraishi, Takehiro Izumo, Yuji Matsumoto, Christine Chavez, Shinji Sasada, Takaaki Tsuchida


Background: Differentiating between Pneumocystis jiroveci pneumonia (PCP) and drug-induced pulmonary parenchymal disease (DIPPD) is difficult after chemotherapy for solid tumors. The aim of this study was to evaluate the utility of bronchoalveolar lavage fluid (BALF) analysis for the diagnosis of PCP and DIPPD.

Methods: We evaluated patients who underwent bronchoscopy at our institution from April 2012 to December 2014. Patients’ characteristics, comorbidity, previous treatment of solid tumor, and BALF findings were examined from the medical records.

Results: From a total of 2625 consecutive patients who underwent bronchoscopy, 89 underwent BALF examination; among these, 33 cases had prior chemotherapy for malignancy. PCP was diagnosed in 6 patients and DIPPD was diagnosed in 21 patients. Six patients were diagnosed to have other pathologies or were undiagnosed. The white blood cell count in BALF (PCP (median (%) (range), DIPPD (median (%) (range)) consisted of macrophages (24.7 (6.9-46.1), 26.5 (2.1-86.0)), lymphocytes (71.3 (49.6-84.8), 57.0 (4.3-96.4)), neutrophils (4.6 (1.0-14.0), 5.0 (0.5-69.8)), and eosinophils (0.3 (0-1.3), 2.5 (0-37.0)). Only the proportion of eosinophils in the BALF of DIPPD patients was significantly higher (p = 0.016) than that of PCP patients. BAL was performed without serious complications.

Conclusions: BALF differential count, especially eosinophils, may be useful in distinguishing between PCP and DIPPD to avoid unnecessary treatment. Further prospective studies would be needed to confirm this benefit of BAL.


Bronchoalveolar lavage fluid (BALF); Pneumocystis jiroveci pneumonia (PCP); Drug-induced pulmonary parenchymal disease (DIPPD); Chemotherapy; Solid tumor

Full Text:

 Subscribers Only


Meyer KC, Raghu G, Baughman RP, et al. An official American Thoracic Society clinical practice guideline: the clinical utility of bronchoalveolar lavage cellular analysis in interstitial lung disease. Am J Respir Crit Care Med. 2012;185:1004-14.

Prasad R, Gupta P, Singh A, et al. Drug induced pulmonary parenchymal disease. Drug Discov Ther. 2014;8:232-7.

Ratjen F, Costabel U, Griese M, et al. Bronchoalveolar lavage fluid findings in children with hypersensitivity pneumonitis. Eur Respir J. 2003;21:144-8.

Yoshizawa Y, Ohtani Y, Hayakawa H, et al. Chronic hypersensitivity pneumonitis in Japan: a nationwide epidemiologic survey. J Allergy Clin Immunol. 1999;103:315-20.

Allen JN, Davis WB, Pacht ER. Diagnostic significance of increased bronchoalveolar lavage fluid eosinophils. Am Rev Respir Dis. 1990;142:642-7.

Sitbon O, Bidel N, Dussopt C, et al. Minocycline pneumonitis and eosinophilia. A report on eight patients. Arch Intern Med. 1994;154:1633-40.

Fontenot AP, Schwarz, M.I. Diffuse alveolar hemorrhage. Interstitial Lung Disease. 2003;3:632–56.

Sepkowitz KA. Opportunistic infections in patients with and patients without Acquired Immunodeficiency Syndrome. Clin Infect Dis. 2002;34:1098-107.

Zahar JR, Robin M, Azoulay E, et al. Pneumocystis carinii pneumonia in critically ill patients with malignancy: a descriptive study. Clin Infect Dis. 2002;35:929-34.

Mahindra AK, Grossman SA. Pneumocystis carinii pneumonia in HIV negative patients with primary brain tumors. J Neurooncol. 2003;63:263-70.

De Castro N, Neuville S, Sarfati C, et al. Occurrence of Pneumocystis jiroveci pneumonia after allogeneic stem cell transplantation: a 6-year retrospective study. Bone Marrow Transplant. 2005;36:879-83.

Iikuni N, Kitahama M, Ohta S, et al. Evaluation of Pneumocystis pneumonia infection risk factors in patients with connective tissue disease. Mod Rheumatol. 2006;16:282-8.

Camus P, Fanton A, Bonniaud P, et al. Interstitial lung disease induced by drugs and radiation. Respiration. 2004;71:301-26.

Steinberg KP, Mitchell DR, Maunder RJ, et al. Safety of bronchoalveolar lavage in patients with adult respiratory distress syndrome. Am Rev Respir Dis. 1993;148:556-61.

Hertz MI, Woodward ME, Gross CR, et al. Safety of bronchoalveolar lavage in the critically ill, mechanically ventilated patient. Crit Care Med. 1991;19:1526-32.

Hiwatari N, Shimura S, Takishima T, et al. Bronchoalveolar lavage as a possible cause of acute exacerbation in idiopathic pulmonary fibrosis patients. Tohoku J Exp Med. 1994;174:379-86.

Kim DS, Park JH, Park BK, et al. Acute exacerbation of idiopathic pulmonary fibrosis: frequency and clinical features. Eur Respir J. 2006;27:143-50.

Simpson FG, Arnold AG, Purvis A, et al. Postal survey of bronchoscopic practice by physicians in the United Kingdom. Thorax. 1986;41:311-7.

Utz JP, Ryu JH, Douglas WW, et al. High short-term mortality following lung biopsy for usual interstitial pneumonia. Eur Respir J. 2001;17:175-9.

Nevez G, Raccurt C, Jounieaux V, et al. Pneumocystosis versus pulmonary Pneumocystis carinii colonization in HIV-negative and HIV-positive patients. AIDS. 1999;13:535-6.

Huang L, Crothers K, Morris A, et al. Pneumocystis colonization in HIV-infected patients. J Eukaryot Microbiol. 2003;50 Suppl:616-7.

Vargas SL, Pizarro P, Lopez-Vieyra M, et al. Pneumocystis colonization in older adults and diagnostic yield of single versus paired noninvasive respiratory sampling. Clin Infect Dis. 2010;50:e19-21.

Morris A, Wei K, Afshar K, et al. Epidemiology and clinical significance of pneumocystis colonization. J Infect Dis. 2008;197:10-7.

Lu Y, Ling G, Qiang C, et al. PCR diagnosis of Pneumocystis pneumonia: a bivariate meta-analysis. J Clin Microbiol. 2011;49:4361-3.

Azoulay E, Bergeron A, Chevret S, et al. Polymerase chain reaction for diagnosing pneumocystis pneumonia in non-HIV immunocompromised patients with pulmonary infiltrates. Chest. 2009;135:655-61.

Fischer S, Gill VJ, Kovacs J, et al. The use of oral washes to diagnose Pneumocystis carinii pneumonia: a blinded prospective study using a polymerase chain reaction-based detection system. J Infect Dis. 2001;184:1485-8.

Helweg-Larsen J, Jensen JS, Benfield T, et al. Diagnostic use of PCR for detection of Pneumocystis carinii in oral wash samples. J Clin Microbiol. 1998;36:2068-72.

Huggett JF, Taylor MS, Kocjan G, et al. Development and evaluation of a real-time PCR assay for detection of Pneumocystis jirovecii DNA in bronchoalveolar lavage fluid of HIV-infected patients. Thorax. 2008;63:154-9.

Fan LC, Lu HW, Cheng KB, et al. Evaluation of PCR in bronchoalveolar lavage fluid for diagnosis of Pneumocystis jirovecii pneumonia: a bivariate meta-analysis and systematic review. PLoS One. 2013;8:e73099.

Tamai K, Tachikawa R, Tomii K, et al. Prognostic value of bronchoalveolar lavage in patients with non-HIV pneumocystis pneumonia. Intern Med. 2014;53:1113-7.

Chou CW, Lin FC, Tsai HC, et al. The impact of concomitant pulmonary infection on immune dysregulation in Pneumocystis jirovecii pneumonia. BMC Pulm Med. 2014;14:182.

DOI: http://dx.doi.org/10.18103/imr.v2i11.239


  • There are currently no refbacks.
Copyright 2016. All rights reserved.