Workup considerations of noninfectious lung injury after HCT
| Type . | Test . | Considerations . |
|---|---|---|
| Radiographic | CT-inspiratory | Noncontrast sufficient for most; bronchiectasis, enlarged pulmonary vessels may be seen in some diagnoses |
| CT-added expiratory | Valuable to assess air trapping (BOS or RLD) | |
| MRI/MRA | May identify vascular disease | |
| V/Q scan | Evaluate for PE | |
| Chest x-ray | Less valuable if air trapping is present | |
| BAL | PCP (PJP) PCR Explify PCR Respiratory virus PCR Gram stain/culture Fungal stain/culture Cytology (silver stain) Nocardia culture AFB smear/culture CMV PCR HSV PCR Mycoplasma pneumoniae PCR Legionella pneumophilia culture Galactomannan | PCR tests are increasingly valuable Explify can detect multiple pathogens by NGS and may detect organisms at low levels not evident in culture, which may be most valuable for pretreated patients or distal lesions Blood return that does not clear is diagnostic for DAH Visual inspection can identify fungal lesions or other indicators Because BAL fluid quantity is per kilogram and return is diminished in severe lung injury, it may be important to prioritize tests in children |
| Blood | Blood culture Karius Blood gas | Karius uses NGS and can detect lung organisms with good sensitivity, though data suggest that some pulmonary infections may be missed (eg, fungal nodules) Consider methemoglobin if hypoxic and medications at risk |
| Urine | Histoplasmosis antigen | |
| PFTs | FEV1, FEV1/VC ratio, RV and RV/TLC, DLCO, +/−albuterol | Lung clearance index may be valuable 6 minutes' walk time is a measure of endurance for BOS FEV1 slope of decline can be valuable for prognosis in BOS |
| Lung biopsy | Pathology, stains, and cultures | High morbidity should prompt careful consideration of risk/benefit analysis |
| Echocardiogram/+/−angiography | Pulmonary hypertension | May also identify pericardial effusions |
| Type . | Test . | Considerations . |
|---|---|---|
| Radiographic | CT-inspiratory | Noncontrast sufficient for most; bronchiectasis, enlarged pulmonary vessels may be seen in some diagnoses |
| CT-added expiratory | Valuable to assess air trapping (BOS or RLD) | |
| MRI/MRA | May identify vascular disease | |
| V/Q scan | Evaluate for PE | |
| Chest x-ray | Less valuable if air trapping is present | |
| BAL | PCP (PJP) PCR Explify PCR Respiratory virus PCR Gram stain/culture Fungal stain/culture Cytology (silver stain) Nocardia culture AFB smear/culture CMV PCR HSV PCR Mycoplasma pneumoniae PCR Legionella pneumophilia culture Galactomannan | PCR tests are increasingly valuable Explify can detect multiple pathogens by NGS and may detect organisms at low levels not evident in culture, which may be most valuable for pretreated patients or distal lesions Blood return that does not clear is diagnostic for DAH Visual inspection can identify fungal lesions or other indicators Because BAL fluid quantity is per kilogram and return is diminished in severe lung injury, it may be important to prioritize tests in children |
| Blood | Blood culture Karius Blood gas | Karius uses NGS and can detect lung organisms with good sensitivity, though data suggest that some pulmonary infections may be missed (eg, fungal nodules) Consider methemoglobin if hypoxic and medications at risk |
| Urine | Histoplasmosis antigen | |
| PFTs | FEV1, FEV1/VC ratio, RV and RV/TLC, DLCO, +/−albuterol | Lung clearance index may be valuable 6 minutes' walk time is a measure of endurance for BOS FEV1 slope of decline can be valuable for prognosis in BOS |
| Lung biopsy | Pathology, stains, and cultures | High morbidity should prompt careful consideration of risk/benefit analysis |
| Echocardiogram/+/−angiography | Pulmonary hypertension | May also identify pericardial effusions |
AFB, acid fast bacillus; CMV, cytomegalovirus; DLCO, diffusion capacity of lung for carbon monoxide; HSV, herpes simplex virus; MRA, magnetic resonance angiography; PJP/PCP, Pneumocystis jirovecii pneumonia (formerly Pneumocystis carinii pneumonia); TLC, total lung capacity.