AJR 2000; 175:235-238
© American Roentgen Ray Society
The Value of CT-Guided Percutaneous Needle Aspiration in Immunocompromised Patients with Suspected Pulmonary Infection
Sung Su Hwang1,
Hak Hee Kim2,
Seog Hee Park2,
Jung Im Jung3 and
Hye Suk Jang2
1
Department of Radiology, St. Vincent's Hospital, The Catholic University of
Korea, 93 Chi-dong, Paldal-ku, Suwon, Kyunggi-do, 442-723, Korea.
2
Department of Radiology, Kangnam St. Mary's Hospital, The Catholic University
of Korea, 505 Banpo-dong, Seocho-ku, Seoul, 137-040, Korea.
3
Department of Radiology, St. Mary's Hospital, The Catholic University of
Korea, #62, Youido-dong, Yongdungpo-gu, Seoul, 150-019, Korea.
Received September 14, 1999;
accepted after revision December 20, 1999.
Address correspondence to H. H. Kim.
Abstract
OBJECTIVE. We evaluated the diagnostic efficacy of CT-guided
percutaneous needle aspiration in immunocompromised patients with suspected
pulmonary infection.
SUBJECTS AND METHODS. We reviewed the findings and yields of 24
CT-guided percutaneous needle aspirations in 21 immunocompromised patients.
Cytologic evaluation and culture for aerobes, anaerobes,
Mycobacterium species, and fungus were performed in all
aspirates.
RESULTS. We identified one or more etiologic microorganisms in 19
(79.2%) of 24 CT-guided percutaneous needle aspirations. Of 19 aspirates with
positive findings, single causal microorganisms were identified in 18.
Staphylococcus aureus was found in four aspirates, and
Aspergillus fumigatus in seven; these microorganisms were the
principal bacterial (4/11) and fungal (7/9) causative organisms. One of the 19
aspirates with positive findings yielded two microorganisms. In the remaining
five aspirates, no microorganisms were identified and cytologic examination
revealed nonspecific inflammatory cells. No major complications were observed
during or after the procedure.
CONCLUSION. CT-guided percutaneous needle aspiration is a safe and
useful diagnostic method for the identification of specific microorganisms in
immunocompromised patients with suspected pulmonary infection.
Introduction
Immunocompromised hosts are predisposed to various infections. Pulmonary
infections remain a significant cause of morbidity and mortality for
immunocompromised patients. In some clinical situations, the causative
microorganism of pulmonary infection can be predicted. However, the use of
antibiotics to treat expected microorganisms can be potentially harmful to
immunocompromised patients
[1,2,3].
Although CT-guided percutaneous needle aspiration has become a
well-established diagnostic tool for detecting malignant lung lesions, the
yield and effectiveness of this technique in the identification of pathogens
in immunocompromised patients with pulmonary infection have not been
emphasized. We evaluated the diagnostic efficacy of CT-guided percutaneous
needle aspiration in immunocompromised patients with suspected pulmonary
infection.
Subjects and Methods
From January 1997 to July 1999, 21 immunocompromised patients (14 men and
seven women; age range, 19-85 years) with suspected pulmonary infection
underwent 24 CT-guided percutaneous needle aspirations at our institution.
Before the procedure, platelet counts and clotting parameters were assessed;
platelet counts above 100,000/mm3, bleeding times of less than 8
min, prothrombin times within 3 sec of the control value, and partial
thromboplastin times within 6 sec of the control value were considered
satisfactory conditions for the procedure. The procedure was performed using
20-gauge Chiba needles (Cook, Bloomington, IN) under CT (Somatom plus 1;
Siemens, Erlangen, Germany) guidance. The CT-guided technique we used is
similar to that used by many radiologists for the diagnosis of pulmonary
lesions [4]. After preparing
the skin with alcohol and iodine, physicians anesthetized the patients with 2%
xylocaine. After placing the Chiba needle at the edge of the pleura, it was
inserted into the target area during a single breath-hold. The target lesion
was aspirated using a 20-ml syringe during gentle breathing. Aspirated
materials were visually inspected and the procedure was repeated in cases of
inadequate aspiration. Usually, less than three aspirations were required.
Cytologic evaluation and culture for aerobes, anaerobes,
Mycobacterium species, and fungus were performed on all aspirates.
After the procedure, follow-up chest radiographs were obtained over a 24-hr
period to detect possible pulmonary complications, such as pneumothorax.
To evaluate the relationship between the duration of the empiric antibiotic
therapy and the yield of the procedure, we assessed the patients' medical
records. The presence and duration of empiric antibiotic therapy before the
procedure were recorded. All patients were assigned to positive and negative
yield groups. Statistical analysis was performed using the Wilcoxon's rank sum
test.
Results
Underlying conditions of immunocompromised patients and identified
pathogens are summarized in Tables
1 and
2. On CT scans, pulmonary
parenchymal changes of the suspected lung infection included single or
multiple foci of parenchymal consolidation with or without cavitation (lobar,
segmental, or subsegmental involvement). Identification of one or more
specific pathogens was confirmed in 19 (79.2%) of 24 aspirations
(Fig. 1). Five aspirates
(20.8%) revealed nonspecific inflammatory cells on cytologic examination, and
no growth of pathogen was observed on culture. Findings were confirmed at
surgery in one patient (Aspergillus species), sputum culture in one
(tuberculosis), and lesion resolution in three during follow-up (no specific
pathogen was identified) (Fig.
2A,2B,2C).
Of 19 aspirates with positive findings, Staphylococcus aureus was
identified in four and Aspergillus fumigatus in seven; these
microorganisms were identified as predominant pathogens in bacterial (4/11)
and fungal (7/9) infections, respectively. One of 19 aspirates with positive
findings yielded two microorganisms: S. aureus and Pseudomonas
aeruginosa. In three patients, we successfully identified six pathogens
with CT-guided percutaneous needle aspiration. A small asymptomatic
ipsilateral pneumothorax developed in one patient. No catheter or tube
drainage was required. Three patients had transient chest pain at the site of
aspiration. However, no major complications such as symptomatic pneumothorax
or hemorrhage occurred in any patient after the procedure.
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Fig. 1. —33-year-old man with acute lymphocytic leukemia. Contrast-enhanced
CT scan of chest shows well-defined thick-walled cavitary lesion filled with
low-density slough in superior segment of left lower lobe. Note adjacent
pleural thickening. CT-guided percutaneous needle aspiration (not shown)
revealed Aspergillus fumigatus.
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Fig. 2A. —18-year-old woman with acute myelocytic leukemia. Posteroanterior
chest radiograph shows homogeneous lobar consolidation in right upper lobe.
Note central venous catheter. Aspirate obtained with CT-guided percutaneous
needle aspiration (not shown) revealed nonspecific inflammatory cells on
cytologic examination and no growth of pathogen in culture.
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Fig. 2B. —18-year-old woman with acute myelocytic leukemia. Follow-up chest
radiograph obtained 10 days after A reveals partial resolution of
pneumonic consolidation. Note round low-density cavitary lesion in right upper
lobe. Patient underwent empiric therapy.
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Fig. 2C. —18-year-old woman with acute myelocytic leukemia. Follow-up chest
radiograph obtained 18 days after B shows remaining thin-walled
cavitary lesion (arrows) in right upper lobe, despite near-complete
resolution of pneumonic consolidation.
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All patients were on empiric antibiotic therapy before the procedure. The
duration of antibiotic therapy ranged from 5 to 28 days (mean, 10.3 days) in
the positive yield group and from 6 to 38 days (mean, 14.1 days) in the
negative yield group. However, statistical analysis revealed no significant
difference between the two groups.
Discussion
In recent years, the number of immunocompromised hosts has increased
because of increased numbers of organ or bone marrow transplantations and the
wide spread of HIV infection. The risk of infection by a wide variety of
microorganisms remains high. Pulmonary infections are one of the most frequent
complications in immunocompromised patients and remain a significant cause of
morbidity and mortality [1].
Two articles reported that infectious microorganisms can be predicted on the
basis of the nature and severity of the immune defect, past patient exposures,
dose and duration of corticosteroid therapy, and type of chemotherapy
[2,
3]. However, empiric therapy
initiated against commonly suspected organisms may be harmful to
immunocompromised patients because of superinfections that may develop
resulting from the suppression of normal flora. Additionally, side effects or
drug toxicity may occur in various organs. Therefore, the identification of a
specific pathogen is important for the targeted and adequate treatment of
pulmonary infection in immunocompromised patients.
Several diagnostic methods have been used to obtain specimens for culture
or staining when identifying pathogens that cause pulmonary infection.
Specimens obtained from the sputum or nasopharyngeal secretions have limited
value because of the presence of normal flora and variable results obtained
for the detection of anaerobic infection. Fiberoptic bronchoscopy with
bronchoalveolar lavage is also a well-established technique. Although this
technique may play an important role in the diagnosis of pulmonary infection,
it is moderately invasive and requires deep sedation or anesthesia, especially
in younger children. The yield of bronchoalveolar lavage is also variable, and
the obtained specimen may be contaminated during the passage of the
bronchoscope through the upper airways
[4,5,6,7].
Open lung biopsy is also an important diagnostic procedure. Two reports have
revealed the overall diagnostic yield of open lung biopsy at 81%
[8,
9]. However, open lung biopsy
has relatively high complication rates of 8-20% in comparison with radiologic
interventional procedures, such as percutaneous needle aspiration
[10].
In practice, many physicians have difficulties when empiric antibiotic
therapy used for a suspected organism is ineffective and the causative
pathogen remains unknown, despite the use of several diagnostic techniques.
The typical radiographic appearances of pulmonary infections, such as
angioinvasive fungal infections, have been documented
[11,
12]. However, our cases of
pulmonary infection, including fungal infection, revealed nonspecific
pulmonary consolidation, areas that should be aspirated to identify causative
pathogens. Percutaneous needle aspiration using fluoroscopy, sonography, and
CT is an alternative method of obtaining specimens. With the accurate
targeting of a pulmonary lesion, specimens and positive results provide
reliable clues for the identification of specific organisms.
Several articles reported variable diagnostic yields (11.7-73%) for
percutaneous needle aspiration for the identification of specific organisms
[13,14,15,16,17,18].
In our series, the diagnostic yield for identifying specific pathogens was
79.2%. In comparison with previous studies, our data show relatively high
diagnostic yields. Our findings show that CT-guided percutaneous needle
aspiration is also useful in the diagnosis of mixed pulmonary infection (we
identified one patient with S. aureus and P. aeruginosa
infection). When percutaneous needle aspiration reveals positive results, it
can eliminate the need for more invasive procedures and provide important
information for specific antibiotic treatment.
Although the diagnostic rate of pulmonary malignancy was high (>90%),
the reported yields of pulmonary infection including our data are relatively
low. Several factors have been suggested to explain the relatively low yield
in the diagnosis of benign pulmonary disease, including infection. Diagnosis
of benign pulmonary disease requires more tissue than that for malignancy;
therefore, it is more difficult to establish correct diagnoses using
percutaneous needle aspiration
[14]. Two reports revealed low
diagnostic yields (44-42%) for the diagnosis of pulmonary infection in
hematologic malignancy patients who underwent open lung biopsy
[1,
8]. In our study, specific
pathogens were identified in only six (66%) of nine aspirates in patients with
underlying hematologic malignancy. These findings may be caused by the prior
use of empiric antibiotics and the presence of a nonspecific pneumonitis
syndrome in our patients with hematologic malignancies
[19].
Concerning the correlation of antibiotic therapy duration and aspiration
yield, our data revealed no significant difference between the positive and
the negative yield groups. However, these findings are affected by factors
such as the different antibiotics used and the duration of symptoms before
empiric therapy. Therefore, the shorter duration of antibiotic therapy in the
positive yield group may suggest that early aspiration improves yield
results.
A limitation of our study is the lack of steps for the identification of
nonbacterial or nonfungal pulmonary infection, such as virus or
Pneumocystis carinii infection. Although the five patients with
negative aspirate findings had no suggestive clinical and cytologic findings
of virus or P. carinii infection, virus or P. carinii
infection cannot be ruled out as possible factors responsible for the
relatively low yields of percutaneous needle aspiration.
Reported complications of percutaneous needle aspiration are minor and
include pneumothorax and hemoptysis. A large series studying patients
undergoing percutaneous needle aspiration reported a 1.1% complication rate
[20]. Two articles reported
increased complication rates with increased needle size
[21,
22]. No complications, such as
symptomatic pneumothorax or hemoptysis, occurred in our patients. Although a
small ipsilateral pneumothorax developed in one patient (detected on a
postaspiration chest radiograph), the patient did not complain of any
respiratory symptoms. In three patients with mild chest pain at the site of
the aspiration, the pain was transient and resolved spontaneously.
In conclusion, CT-guided percutaneous needle aspiration is a safe and
useful diagnostic method for the identification of specific organisms in
immunocompromised patients with pulmonary infection. If necessary,
percutaneous aspiration should be performed as soon as is practically possible
because antibiotic therapy before aspiration may decrease the diagnostic yield
of the aspiration.
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Abstract
Introduction
