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Emergency lung biopsy: friend or foe of the immunosuppressed child?
Insights
Open lung biopsy in immunosuppressed children with pneumonia offers diagnosis but limited survival benefit. While 82% received a diagnosis, only 23% experienced improved outcomes, highlighting challenges in pediatric respiratory infections.
Area of Science:
- Pediatric Pulmonology
- Immunocompromised Host Research
- Diagnostic Pathology
Background:
- Immunosuppressed children with acute pneumonia face significant diagnostic and therapeutic hurdles.
- These patients often have poor tolerance to infections, complicating management.
- Open lung biopsy is a potential method for rapid diagnosis in such cases.
Purpose of the Study:
- To evaluate the diagnostic yield and clinical benefit of open lung biopsy in immunosuppressed children with acute respiratory symptoms and interstitial pulmonary infiltrates.
- To assess the impact of biopsy findings on patient survival and treatment changes.
Main Methods:
- A retrospective review of 56 immunosuppressed children who underwent lung biopsy between 1974 and 1985 for acute respiratory symptoms.
- Analysis of underlying diagnoses, determined etiology, operative morbidity, mortality, and clinical benefit post-biopsy.
Main Results:
- A specific etiology was identified in 82% of patients, with acute lymphocytic leukemia being the most common underlying diagnosis (60%).
- Operative morbidity occurred in 52% of patients. Overall mortality was 34%, with higher rates in solid tumor patients and those requiring postoperative ventilation.
- Only 23% of patients derived clinical benefit (diagnosis leading to treatment change and survival), despite 69% having a specific infectious etiology diagnosed.
Conclusions:
- Open lung biopsy provides a high diagnostic yield in immunosuppressed children with pneumonia but offers limited clinical benefit and survival.
- The procedure is associated with significant morbidity and mortality, necessitating careful consideration in this vulnerable population.
- Early diagnosis of infections like Pneumocystis carinii is crucial, but treatment changes based on biopsy results do not always ensure survival.
Abstract:
An acute pneumonic process in an immunosuppressed child poses a diagnostic and therapeutic challenge. These patients tolerate infection poorly. An open lung biopsy may provide prompt diagnosis. Nevertheless, a beneficial change in therapy that results in survival does not necessarily follow. Fifty-six immunosuppressed children with acute respiratory symptoms and interstitial pulmonary infiltrates underwent lung biopsy from 1974 to 1985. The most common underlying diagnosis was acute lymphocytic leukemia (60%). A specific etiology was determined in 46 (82%). Operative morbidity in 52% included prolonged intubation, recurrent pneumothorax, and hemorrhage. Overall, mortality was 34%. Those patients with solid tumor and those who required postoperative ventilation had a statistically significant higher mortality than all others. We defined biopsy "patient benefit" as follows: (1) the biopsy yielded an etiology for which a change of treatment was required; and (2) the child survived this acute illness. Despite the successful diagnostic results of this procedure, only 13 (23%) of the patients derived clinical benefit. Even though a specific infectious etiology was diagnosed in 39 (69%) patients only ten (18%) of these improved and survived after an appropriate change in therapy. Eight of these had Pneumocystis carinii. One survivor benefited from the treatment of documented radiation pneumonitis. Another was successfully treated for graft v host reaction but this diagnosis also was made by skin biopsy. One half of the biopsies were performed very early in the course of the illness, specifically to exclude Pneumocystis carinii of which we saw a peak incidence in 1978 to 1979.(ABSTRACT TRUNCATED AT 250 WORDS)