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Bronchoalveolar lavage for the diagnosis of disseminated toxoplasmosis in AIDS patients
The usefulness of cell culture of bro~choa~veo~arlavage fluid for the diagnosis of ~oxo~las~~ffs~s in j~~~~~oco~~~o~ise~ hosts has not been stressed previously. We report an acquired
hted by cell culture. the basis of seroconversion, but i sion may delay or inhibit the an (Pomeroy et al., 1992). More recently, other techniques for T. gondii diagnosis have been introduced:
From the Departments of Medical Microbiology (KG., MC., F.S.) and Internal Medicine (N.B., J&W.), Fundaci6n Jimenez Dfaz. Madrid, Spain. Address reprint requests to Dr. F. Soriano, Department of Medical Microbiology. FundaciBn Jimenez DQz, Avenida de Reyes CatBlicos 2,28040 Madrid, Spain. Received X6 February 1995; revised and accepted 19 June 1995. DIAGN MICROBIOL INFECT 01s 1995;22:339341 0 1995 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
been well until
0732-88~3/~5/$9.5Q SSBI 0732-8893(95)00142-W
risk factors for human immunodeficiency virus (HIV) infection because of a heterosexual relationship some years before with an intravenous drug abuser as partner. She had a history of sulphona-
mide intolerance. On physical examination, the patient was a thin woman who appeared to be aware, oriented, mildly ill, and pale; her temperature was 39.5”C, pulse 120, and blood pressure lOOk mm Wg. General physical examination was otherwise normal except for Candida stomatitis, hairy leukoplakia, and seborrheic dermatitis on her face. Neither lymphadeno~athy nor visceromegaly was observed. Meningeal signs were absent and neurologic examination was normal. On admission, the white cell count was 23501~1 with 80% neutrophils, 14% lymphocytes, 5% monocytes, and 1% eosinqphils; hemoglobin was 10.1 g/dl, hematocrit was 30%, and platelet count was 108,OOO/pl.biochemical values were in the normaI range except for lactate dehydrogenase (851 aspartate aminotransferase (67 U/liter), and aminotransferase (55 U/liter). Arterial blood gasses and urine examination were normal. A chest radiograph showed bilateral, multifocal patchy air-space disease and irregular nodules. The patient was admitted with suspected HIV infection and opportunistic pulmonary infection. Ceftriaxone 1 g every 12 h was prescribed. Routine cultures and Salmonella, Brucella, Treponema pallidurn, T. gondii, and HIV serology studies were performed. Over the next 5 days the patient’s fever and respiratory impairment progressed. Three tures and a urine culture were all negativ rology was positive with anti-env antibodies and anti-gag negative; p24 antigen was positive (91 pg/ ml). Lymphocyte populations were also studied, a total count of SOO/~l with 5761~1 CD2 (72%), 3U~l CD4 (4%), 51Up.1 CD8 (64%), and 40/~1 b-lymphocytes (5%). Toxoplasma gondii serology showed 163 UI Immunoglobulin G (IgG), and IgM was not detected. The other serology studies were all negative. The 5th day after admission, BAL was performed, and empirical pentamidine (4 mg/Kg per day) was added. Microbiologic studies from BAL yielded negative results for bacteria (including Legionella) and fungi; no Pneumocystis carinii (Toluidine blue 0), acid-fast bacilli (Ziehl-Neelsen), or T. gondii tachyzoites (Giemsa) were seen. The specimen was cultured for mycobacteria; the result was negative after 8 weeks of incubation. Virologic GUItureS were also carried out onto human diploid fibroblast (HDF) and Vero cell monolayers, and we observed them during 4 weeks. For this purpose, BAL fluid was added with vancomycin and gentamicin at 100 and 80 ~gIml, respectively and 0.2 ml was seeded onto each monolayer. fight days later (13 days after admission), the
age size in a CT performed 3 weeks later.
wn et al., 1991) inc with AIDS (Pomeroy et al., 1992). CNS toxoplasmosis is another opportunistic complication in immunocompromised patients and a source of substantial morbidity and mortality among patients with AIDS ft et al., 1988). Although CT images are usu racteristic, etiologic confirmation is always , because generally there is no serologic response and cerebral biopsy is not without complications. In our case, T. gondii infection was not suspected until the observation of CNS CT images, and later on confirmed with the appearance of positive BAL culture. Although BAL clearly facilitates the detection of pulmonary toxoplasmosis, its sensitivity is unknown (Pomeroy et al., 1992). It is also unclear how many cases of CNS toxoplasmosis are really disseminated infections with multiorgan involvement, which could be diagnosed by detection of tachyzoites in BAL or blood. However, in some studies, up to one third of the cases of toxoplasmosis that manifested predominantly in extrapulmonary sites also showed evidence of T. ge:onds’t in I the lungs were frequently involved in fatal cases of toxoplasmosis, even when pneumonia was not diagnosed on clinical grounds (Pomeroy et al., 1992). It has been reported (Yermakov et al., 1982) that up to 73% of patients dying of toxoplasmosis had
Basdski VS, Wunderink RG (1994) ronchoscopic diagnosis of pneumonia. Clin Microbial Rev X35-558. Bottone EJ (1991) Diagnosis of acute pulmonary toxoplasmosis by visualization of invasive and in~a~e~u~a~ tachyzoites in Giemsa-stained lavage fluid. J Clin Microbial Brswn NJ, McKenzie S, Decker M fatal pulmonary toxoplasm apy. Am J Med Sci 302152-154. Derouin F, Sarfati C, Beaouvais B, Iliou M-C, Dehen L, Lariviere M (1989) Laboratory diagnosis of pul toxoplasmosis in patients with acquired immunodeficiency syndrome. J CIin Microbial 27:1661-1663. Dupouy-Camet J, Laverada de Souza S, IvIaslo C, Paugam A, Saimot AG, Bernarous R, Tourte-Schaefer C, Derouin F (1993) Detection of Toxoplasma gondii in venous
Infec Dis 11:1177-1181. Yerrnakov V, Rashid IX, Vuletin JC, Pertschuk LP, Isaksson I-I (1982) Disseminated toxoplasmosis. Arc!? Pathol katb Med 1063524528.
hted by cell culture. the basis of seroconversion, but i sion may delay or inhibit the an (Pomeroy et al., 1992). More recently, other techniques for T. gondii diagnosis have been introduced:
From the Departments of Medical Microbiology (KG., MC., F.S.) and Internal Medicine (N.B., J&W.), Fundaci6n Jimenez Dfaz. Madrid, Spain. Address reprint requests to Dr. F. Soriano, Department of Medical Microbiology. FundaciBn Jimenez DQz, Avenida de Reyes CatBlicos 2,28040 Madrid, Spain. Received X6 February 1995; revised and accepted 19 June 1995. DIAGN MICROBIOL INFECT 01s 1995;22:339341 0 1995 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
been well until
0732-88~3/~5/$9.5Q SSBI 0732-8893(95)00142-W
risk factors for human immunodeficiency virus (HIV) infection because of a heterosexual relationship some years before with an intravenous drug abuser as partner. She had a history of sulphona-
mide intolerance. On physical examination, the patient was a thin woman who appeared to be aware, oriented, mildly ill, and pale; her temperature was 39.5”C, pulse 120, and blood pressure lOOk mm Wg. General physical examination was otherwise normal except for Candida stomatitis, hairy leukoplakia, and seborrheic dermatitis on her face. Neither lymphadeno~athy nor visceromegaly was observed. Meningeal signs were absent and neurologic examination was normal. On admission, the white cell count was 23501~1 with 80% neutrophils, 14% lymphocytes, 5% monocytes, and 1% eosinqphils; hemoglobin was 10.1 g/dl, hematocrit was 30%, and platelet count was 108,OOO/pl.biochemical values were in the normaI range except for lactate dehydrogenase (851 aspartate aminotransferase (67 U/liter), and aminotransferase (55 U/liter). Arterial blood gasses and urine examination were normal. A chest radiograph showed bilateral, multifocal patchy air-space disease and irregular nodules. The patient was admitted with suspected HIV infection and opportunistic pulmonary infection. Ceftriaxone 1 g every 12 h was prescribed. Routine cultures and Salmonella, Brucella, Treponema pallidurn, T. gondii, and HIV serology studies were performed. Over the next 5 days the patient’s fever and respiratory impairment progressed. Three tures and a urine culture were all negativ rology was positive with anti-env antibodies and anti-gag negative; p24 antigen was positive (91 pg/ ml). Lymphocyte populations were also studied, a total count of SOO/~l with 5761~1 CD2 (72%), 3U~l CD4 (4%), 51Up.1 CD8 (64%), and 40/~1 b-lymphocytes (5%). Toxoplasma gondii serology showed 163 UI Immunoglobulin G (IgG), and IgM was not detected. The other serology studies were all negative. The 5th day after admission, BAL was performed, and empirical pentamidine (4 mg/Kg per day) was added. Microbiologic studies from BAL yielded negative results for bacteria (including Legionella) and fungi; no Pneumocystis carinii (Toluidine blue 0), acid-fast bacilli (Ziehl-Neelsen), or T. gondii tachyzoites (Giemsa) were seen. The specimen was cultured for mycobacteria; the result was negative after 8 weeks of incubation. Virologic GUItureS were also carried out onto human diploid fibroblast (HDF) and Vero cell monolayers, and we observed them during 4 weeks. For this purpose, BAL fluid was added with vancomycin and gentamicin at 100 and 80 ~gIml, respectively and 0.2 ml was seeded onto each monolayer. fight days later (13 days after admission), the
age size in a CT performed 3 weeks later.
wn et al., 1991) inc with AIDS (Pomeroy et al., 1992). CNS toxoplasmosis is another opportunistic complication in immunocompromised patients and a source of substantial morbidity and mortality among patients with AIDS ft et al., 1988). Although CT images are usu racteristic, etiologic confirmation is always , because generally there is no serologic response and cerebral biopsy is not without complications. In our case, T. gondii infection was not suspected until the observation of CNS CT images, and later on confirmed with the appearance of positive BAL culture. Although BAL clearly facilitates the detection of pulmonary toxoplasmosis, its sensitivity is unknown (Pomeroy et al., 1992). It is also unclear how many cases of CNS toxoplasmosis are really disseminated infections with multiorgan involvement, which could be diagnosed by detection of tachyzoites in BAL or blood. However, in some studies, up to one third of the cases of toxoplasmosis that manifested predominantly in extrapulmonary sites also showed evidence of T. ge:onds’t in I the lungs were frequently involved in fatal cases of toxoplasmosis, even when pneumonia was not diagnosed on clinical grounds (Pomeroy et al., 1992). It has been reported (Yermakov et al., 1982) that up to 73% of patients dying of toxoplasmosis had
Basdski VS, Wunderink RG (1994) ronchoscopic diagnosis of pneumonia. Clin Microbial Rev X35-558. Bottone EJ (1991) Diagnosis of acute pulmonary toxoplasmosis by visualization of invasive and in~a~e~u~a~ tachyzoites in Giemsa-stained lavage fluid. J Clin Microbial Brswn NJ, McKenzie S, Decker M fatal pulmonary toxoplasm apy. Am J Med Sci 302152-154. Derouin F, Sarfati C, Beaouvais B, Iliou M-C, Dehen L, Lariviere M (1989) Laboratory diagnosis of pul toxoplasmosis in patients with acquired immunodeficiency syndrome. J CIin Microbial 27:1661-1663. Dupouy-Camet J, Laverada de Souza S, IvIaslo C, Paugam A, Saimot AG, Bernarous R, Tourte-Schaefer C, Derouin F (1993) Detection of Toxoplasma gondii in venous
Infec Dis 11:1177-1181. Yerrnakov V, Rashid IX, Vuletin JC, Pertschuk LP, Isaksson I-I (1982) Disseminated toxoplasmosis. Arc!? Pathol katb Med 1063524528.