title: How to manage lung infiltrates in adults suffering from haematological malignancies outside allogeneic haematopoietic stem cell transplantation.
abstract: Pulmonary complications affect up to 40% of patients with severe neutropenia lasting for more than 10 d. As they are frequently associated with fever and elevation of C-reactive protein or other signs of inflammation, they are mostly handled as pneumonia. However, the differential diagnosis is broad, and a causative microbial agent remains undetected in the majority of cases. Pulmonary side effects from cytotoxic treatment or pulmonary involvement by the underlying malignancy must always be taken into account and may provide grounds for invasive diagnostic procedures in selected patients. Pneumocystis jirovecii (in patients not receiving co-trimoxazole as prophylaxis), multi-resistant gram-negative bacilli, mycobacteria or respiratory viruses may be involved. High-risk patients may be infected by filamentous fungi, such as Aspergillus spp., but these infections are seldom proven when treatment is initiated. Microorganisms isolated from cultures of blood, bronchoalveolar lavage or respiratory secretions need careful interpretation as they may be irrelevant for determining the aetiology of pulmonary infiltrates, particularly when cultures yield coagulase-negative staphylococci, enterococci or Candida species. Non-culture based diagnostics for detecting Aspergillus galactomannan, beta-D-glucan or DNA from blood, bronchoalveolar lavage or tissue samples can facilitate the diagnosis, but must always be interpreted in the context of clinical and imaging findings. Systemic antifungal treatment with mould-active agents, given in combination with broad-spectrum antibiotics, improves clinical outcome when given pre-emptively. Co-trimoxazole remains the first-line treatment for Pneumocystis pneumonia, while cytomegalovirus pneumonia will respond to ganciclovir or foscarnet in most cases. The clinical outcome of acute respiratory failure can also be successful with proper intensive care, when indicated.
authors.affiliation: Department of Haematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany.
authors.forename: Georg
authors.initials: G
authors.lastname: Maschmeyer
authors.affiliation: Department of Haematology, Radboud University Medical Centre, Nijmegen, The Netherlands.
authors.forename: J Peter
authors.initials: JP
authors.lastname: Donnelly
mesh_terms: D000890:Anti-Infective Agents / Q000627:therapeutic use; D015415:Biomarkers / Q000378:metabolism; D003422:Critical Care; D003937:Diagnosis, Differential; D003952:Diagnostic Imaging / Q000379:methods; D016179:Granulocyte Colony-Stimulating Factor / Q000627:therapeutic use; D019337:Hematologic Neoplasms / Q000150:complications*; D018380:Hematopoietic Stem Cell Transplantation / Q000009:adverse effects; D006801:Humans; D008171:Lung Diseases / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D009503:Neutropenia / Q000150:complications; D011657:Pulmonary Eosinophilia / Q000209:etiology; D012017:Referral and Consultation; D012141:Respiratory Tract Infections / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D014182:Transplantation, Autologous / Q000009:adverse effects
chemical_list: D000890:Anti-Infective Agents; D015415:Biomarkers; D016179:Granulocyte Colony-Stimulating Factor
keywords: diagnosis; fever; lung infiltrates; neutropenia; pneumonia