307
DIAGN MICROBIOLINFECTDIS 1990;13:307-310
PARASITOLOGY
Evaluation of Calcofluor White Stain for Detection of Pneumocystis carinii Yoo K. Kim, Shehkar Parulekar, Pauline K.W. Yu, Richard J. Pisani, Thomas F. Smith, and John P. Anhalt
A rapid calcofluor white (CFW) stain for detecting Pneumocystis carinii was evaluated prospectively. Eighty-nine bronchoalveolar lavage (BAL) specimens, 21 open-lung biopsy (OLB) tissues, 2 induced sputums, 1 expectorated sputum, 2 tracheal secretions, and 1 bronchial secretion from 102 patients were examined for P. carinii cysts by both the CFW stain and a modified methenamine silver (MS) stain. Twenty episodes of P. carinii pneumonia were detected: 19 of these episodes were detected by CFW stain, and 16 of those episodes were detected
by MS stain. Discrepancies between the two staining methods were resolved by review of the clinical histories and, in one case, by testing an OLB specimen. Neither staining procedure gave false-positive results with any specimen. More cysts were detected in CFW-stained specimens than in MS-stained specimens (p = 0.05). CFW stain is a simple, rapid, and inexpensive method for detecting P. carinii in clinical specimens and is at least as sensitive as MS stain.
INTRODUCTION
Papanicolaou, and Giemsa can be used to detect P. carinii (Hughes, 1987). A fluorescent stain with a monoclonal antibody against P. carinii also has been developed to identify the organisms (Kovacs et al., 1986; Gill et al., 1987). Calcofluor white (CFW) is a nonspecific fluorochrome stain that binds with betaconfiguration polysaccharides, such as cellulose and chitin, and has been used for detecting fungi in clinical specimens (Monheit et al., 1984). Recently, Baselski and co-workers (1990) showed that P. carinii cysts could be detected with this stain. Our study was designed to compare the CFW stain with a MS stain for detecting P. carinii in clinical specimens.
Pneumocystis carinii pneumonia (PCP) is a major pulmonary complication in immunosuppressed patients, including patients with acquired immunodeficiency syndrome (AIDS) (Murray et al., 1984; Rosenow et al., 1985). Because PCP is amenable to antimicrobial treatment, sensitive and accurate diagnosis of PCP is important. Although a presumptive diagnosis can be based on dinical manifestations and chest x-ray findings, a definite diagnosis of PCP depends on the demonstration of the organisms in the lung tissue or pulmonary exudates. Any of several stains, including Gomori methenamine silver (MS), toluidine blue O, Gram-Weigert,
From the Section of ClinicalMicrobiology,Departmentof LaboratoryMedicineand Pathology(Y.K.K., S.P., P.K.W.Y., T.F.S., J.P.A.) and Department of Internal Medicine, (R.J.P.); Mayo Clinicand Mayo Foundation, Rochester, Minnesota. Address reprint requests to: John P. Anhalt, Ph.D., M.D.; Section of ClinicalMicrobiology;Department of LaboratoryMedicine and Pathology;Mayo Clinicand Mayo Foundation;Rochester, MN 55905. Received January4, 1990; revised and accepted February27, 1990. © 1990ElsevierScience PublishingCo., Inc. 655 Avenue of the Americas, New York, NY 10010 0732-8893/90/$3.50
MATERIALS A N D METHODS Patients The age of the patients ranged from 1 to 85 years; most were non-AIDS patients.
Specimens From February 14, 1989, to June 30, 1989, 136 specimens were submitted to the clinical microbiology
308
laboratory for examination for P. carinii. One hundred and sixteen specimens from 102 patients were evaluated by both CFW and MS stains. The specimens tested included 89 bronchoalveolar lavage (BAL) specimens, 21 open-lung biopsy (OLB) tissues, two induced sputums, one expectorated sputum, two tracheal secretions, and one bronchial secretion. Twenty specimens were excluded from our study because of insufficient sample to permit both staining procedures. Cytospin smears were prepared from BAL specimens, as described previously (Martin et al., 1987). Sputum specimens were digested with sputolysin (Calbiochem, La Jolla, CA) prior to preparing smears for staining. Homogenized lung tissue and tissue impression smears were used to examine OLB tissues (Gay et al., 1985). Smears were allowed to airdry before further processing. Touch preparations of h u m a n lung tissue containing P. carinii were used as positive controls for both CFW and MS staining procedures.
Y.K. Kim et al.
FIGURE 1. Calcofluor white stain of Pneumocystis carinii cysts in bronchoalveolar |avage specimens, x 400.
Staining Procedure Two slides were stained by each method for each specimen. The MS stain was performed by the method of Mahan and Sale (1978), as modified by Yu et al (1989). Smears for CFW staining were fixed by placing slides in 100% methanol for 2 min, followed by airdrying. Six drops of CFW solution A (Fungi-Fluor kit, Polysciences, Warrington, PA) were placed on each smear and spread with a pasteur pipette. Staining was allowed to proceed for 1 min at room temperature, after which slides were rinsed with deionized water, placed under coverslips and examined.
Microscopy Specimens stained with CFW were examined with a fluorescence microscope (Leitz, Orthoplan 2) equipped with an epifluorescent filter (D filter; BP 355-425, RKP 455, LP 460 or G filter; BP 350-460, RKP 510, LP 515) and a 100-W mercury lamp. Smears stained with MS were examined using a bright-field microscope. A low-power objective ( x 20) was used for screening all stained specimens. Potential cyst structures found with screening were verified for appropriate morphology by using high-power ( x 40) or oil-immersion (x 100) objectives. Each slide was examined by two of the authors. Specimens were considered positive for P. carinii when round or oval cysts with a typical double-parenthesis structure were observed in the smears. The number of cysts seen on each smear was recorded. When there was a discordance between the
two staining methods, the negative slides were reexamined and clinical histories were reviewed to resolve remaining discrepancies.
Statistics Statistical evaluations were done by using the McNemar sign test. The average number of cysts detected on both slides with each stain was used in the calculation.
RESULTS Pneumocystis carinii cysts stained by CFW appeared as pale-blue, round or oval structures with a bright, whitish-blue cystic wall w h e n viewed with the Dfilter system (Fig. 1). With the G-filter system, yellowish-green cysts were observed. Most cysts contained a prominent double-parenthesis structure and were easily discernible from yeasts. Clusters of cysts were present in most cases. Of the 116 specimens examined, 19 BAL specimens and one OLB specimen were found to have P carinii cysts (Table 1). The number of P. carinii cysts detected by each staining method was compared (Table 2). In all but two instances, CFW stain detected more P. carinii cysts than MS stain (p = 0.05). It is worth noting that the MS-stained slides for case 17 were initially read as negative. The slides were reexamined after the CFW stain showed P. carinii cysts, and only one cyst on one slide was detected. A summary of clinical findings for cases with a dis-
Calcofluor White Stain for Pneumocystis carinii
T A B L E 1.
309
Comparison of the Calcofluor White (CFW) Stain with the Modified Methenamine Silver (MS) Stain for Detection of Pneumocystis carinii in Clinical Specimens
procedure. For the remaining patient (case 12), clinical findings were suggestive of PCP, and the result of the CFW stain was considered a true positive result.
MS
DISCUSSION
4CFW +
15
-
1
4 96
cordance between staining methods is presented in Table 3. In case 3, diagnosis was confirmed by detection of P. carinii cysts in OLB tissue by both CFW and MS stains. For two patients (cases 5 and 10), clinical histories were consistent with PCP, and these patients responded rapidly to appropriate antimicrobial treatment. Case 20 represents the same patient as case 5, from w h o m a BAL specimen obtained 3 months earlier was positive by the other staining T A B L E 2.
Number of Pneumocystis carinii Cysts Detected on CFW- and MS-Stained Slides No. of Cystsa
Case No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Specimen BALb BAL BAL OLBb BAL BAL BAL BAL BAL BAL BAL BAL BALb BAL BAL BAL BAL BAL BAL BAL
MS
CFW
22 81 0 ND 0 31 1 134 36 0 1 0 11 >200 9 >200 Ia 1 >200 1
NEF 154 4 ND 1 142 5 >200 16 1 2 6 ND >200 23 >200 29 1 >200 0
aAverage of two slides. MS, methenaminesilver; and CFW, calcofluorwhite. bNot included in statisticalanalysis. eND, counting not performed. aMS stain initiallyread as negative; one cyst found on reexamination.
In our study, BAL constituted the majority of the specimens tested. The usefulness of this specimen type in diagnosing PCP from immunocompromised patients has been well documented, with a sensitivity for detecting P. carinii ranging from 82% to 97% (Stover et al., 1984; Broaddus et al., 1985; Golden et al., 1986: Martin et al., 1987). CFW and MS stains were comparable in our laboratory for the detection of P. carinii. CFW staining requires only a few steps and - 10 min to perform. In contrast, MS staining involves many steps and reagents, some of which must be prepared fresh with each use, and requires 45 min to perform. Due to the instabililty of reagents used for the MS stain, both the staining procedure and quality control of reagents are very labor intensive for the laboratory. Although the sensitivity for detecting any cysts in patients with PCP was not significantly different for the two stains (p = 0.20), greater numbers of cysts were evident with the CFW stain than with the MS stain (p = 0.05). We did not attempt to determine w h y there was a difference in the number of cysts detected. The difference could be due to loss of cysts from the slides during the multiple washing steps of the MS staining procedure or simply a reflection of the ease with which the cysts are discernible as very bright objects in the fluorescent staining procedure. In any event, the ability to detect more cysts with the CFW stain might increase sensitivity for diagnosis of PCP in patient populations characterized by low numbers of cysts. In contrast with PCP in AIDS patients, fewer cysts have been reported for immunosuppressed non-AIDS patients with PCP (Limper et al., 1988). Most of the patients included in our study did not have AIDS, and extension of our study for a longer period may have revealed a statistically significant increase in sensitivity for CFW staining; however, this was not the purpose of the study. The CFW stain would be prefered in our laboratory setting, based on simplicity alone and demonstration that it is at least as sensitive as the MS stain. One should note that CFW stain from different vendors may vary in suitability for staining P. carinii cysts (Baselski et al., 1990).
We thank the technologists who prepared the positive control slides and those who performed the modified MS stain.
310
Y.K. K i m et al.
TABLE 3.
Evaluation of D i s c o r d a n t Results b e t w e e n MS a n d CFW Clinical Evaluation b
Laboratory Resulff
Fever
Cough or Dyspnea
Impaired Oxygenation
Compatible CXR Findings
Evidence of Clinical or Radiologic Response to Treatment
+ ND
+ +
+ +
+ +
+ +
ND ND ND
+ +
+ + +
+ UK +
+ +/+/-
Pathologic confirmation Resolution of CXR and symptoms with TMP/SMX Rapid clinical response to TMP/SMX Resolution of CXR with TMP/SMX Resolution of CXR and symptoms with TMP/SMX
Case No.
MS
CFW
OLB
3 5
-
+ +
10 12 20
+
+ + -
a+, cysts detected; and - , cysts not detected. MS, methenamine silver; CFW, calcofluor white; OLB, open-lung biopsy; and ND, not done. b+, sign or symptom present; - , sign or symptom absent; and + / - , sign or symptom not definitely present or absent. UK, unknown; CXR, chest x-ray; and TMP/SMX, trimethoprim-sulfamethoxazole.
REFERENCES Baselski VS, Robison MK, Pifer LW, Woods DR (1990) Rapid detection of Pneumocystis carinii in bronchoalveolar lavage samples by using Cellufluor staining. ] Clin Microbiol 28:393-394. Broaddus C, Dake MD, Stulbarg MS, Blumenfeld W, Hadley WK, Golden JA, Hopewell PC (1985) Bronchoalveolar lavage and transbronchial biopsy for the diagnosis of pulmonary infections in the acquired irnmunodeficiency syndrome. Ann Intern Med 102:747752. Gay JD, Smith TF, Ilstrup DM (1985) Comparison of processing techniques for detection of Pneumocystis carinii cysts in open-lung biopsy specimens. J Clin Microbiol 21:150-151. Gill VJ, Evans G, Stock F, Parrillo JE, Masur H, Kovacs JA (1987) Detection of Pneumocystis carinii by fluorescent-antibody stain using a combination of three monoclonal antibodies. J Clin Microbiol 25:1837-1840. Golden JA, Hollander H, Stulbarg MS, Gamsu G (1986) Bronchoalveolar lavage as the exclusive diagnostic modality for Pneumocystis carinii pneumonia: a prospective study among patients with acquired immunodeficiency syndrome. Chest 90:18-22. Hughes WT (1987) Pneumocystis carinii pneumonia, vol 2. Ed, WT Hughes. Boca Raton, FL: CRC, pp 35-64. Kovacs JA, Gill V, Swan JC, Ognibene F, Shelhamer J, Parrillo JE, Masur M (1986) Prospective evaluation of a monoclonal antibody in diagnosis of Pneumocystis carinii pneumonia. Lancet 2:1-3.
Limper AH, Smith TF, Martin WJ II (1988) Pneumocystis carinii pneumonia: quantitative differences in parasite burden and host inflammatory response in AIDS and non-AIDS patients. Am Rev Respir Dis 137(suppl):356. Mahan CT, Sale GE (1978) Rapid methenamine silver stain for Pneumocystis carinii and fungi. Arch Pathol Lab Med 102:351-352. Martin WJ II, Smith TF, Sanderson DR, Brutinel WM, Cockerill FR, Douglas WW (1987) Role of bronchoalveolar lavage in the assessment of opportunistic pulmonary infections: utility and complications. Mayo Clin Proc 62:549-557. Monheit JE, Cowan DF, Moore DG (1984) Rapid detection of fungi in tissues using calcofluor white and fluorescence microscopy. Arch Pathol Lab Med 108:616-618. Murray JF, Felton CP, Garay SM, Gottlieb MS, Hopewell PC, Stover DE, Teirstein AS (1984) Pulmonary complications of the acquired immunodeficiency syndrome. N Engl J Med 310:1682-1688. Rosenow EC III, Wilson WR, Cockerill FR III (1985) Pulmonary disease in the immunocompromised host. Mayo Clin Proc 60:473-487. Stover DE, White DA, Romano PA, Gellene RA (1984) Diagnosis of pulmonary disease in acquired immune deficiency syndrome (AIDS). Am Rev Respir Dis 130:659662. Yu PKW, Uhl JR, Anhalt JP (1989) Rapid methenamine silver stain. Arch Pathol Lab Med 113:111.
DIAGN MICROBIOLINFECTDIS 1990;13:307-310
PARASITOLOGY
Evaluation of Calcofluor White Stain for Detection of Pneumocystis carinii Yoo K. Kim, Shehkar Parulekar, Pauline K.W. Yu, Richard J. Pisani, Thomas F. Smith, and John P. Anhalt
A rapid calcofluor white (CFW) stain for detecting Pneumocystis carinii was evaluated prospectively. Eighty-nine bronchoalveolar lavage (BAL) specimens, 21 open-lung biopsy (OLB) tissues, 2 induced sputums, 1 expectorated sputum, 2 tracheal secretions, and 1 bronchial secretion from 102 patients were examined for P. carinii cysts by both the CFW stain and a modified methenamine silver (MS) stain. Twenty episodes of P. carinii pneumonia were detected: 19 of these episodes were detected by CFW stain, and 16 of those episodes were detected
by MS stain. Discrepancies between the two staining methods were resolved by review of the clinical histories and, in one case, by testing an OLB specimen. Neither staining procedure gave false-positive results with any specimen. More cysts were detected in CFW-stained specimens than in MS-stained specimens (p = 0.05). CFW stain is a simple, rapid, and inexpensive method for detecting P. carinii in clinical specimens and is at least as sensitive as MS stain.
INTRODUCTION
Papanicolaou, and Giemsa can be used to detect P. carinii (Hughes, 1987). A fluorescent stain with a monoclonal antibody against P. carinii also has been developed to identify the organisms (Kovacs et al., 1986; Gill et al., 1987). Calcofluor white (CFW) is a nonspecific fluorochrome stain that binds with betaconfiguration polysaccharides, such as cellulose and chitin, and has been used for detecting fungi in clinical specimens (Monheit et al., 1984). Recently, Baselski and co-workers (1990) showed that P. carinii cysts could be detected with this stain. Our study was designed to compare the CFW stain with a MS stain for detecting P. carinii in clinical specimens.
Pneumocystis carinii pneumonia (PCP) is a major pulmonary complication in immunosuppressed patients, including patients with acquired immunodeficiency syndrome (AIDS) (Murray et al., 1984; Rosenow et al., 1985). Because PCP is amenable to antimicrobial treatment, sensitive and accurate diagnosis of PCP is important. Although a presumptive diagnosis can be based on dinical manifestations and chest x-ray findings, a definite diagnosis of PCP depends on the demonstration of the organisms in the lung tissue or pulmonary exudates. Any of several stains, including Gomori methenamine silver (MS), toluidine blue O, Gram-Weigert,
From the Section of ClinicalMicrobiology,Departmentof LaboratoryMedicineand Pathology(Y.K.K., S.P., P.K.W.Y., T.F.S., J.P.A.) and Department of Internal Medicine, (R.J.P.); Mayo Clinicand Mayo Foundation, Rochester, Minnesota. Address reprint requests to: John P. Anhalt, Ph.D., M.D.; Section of ClinicalMicrobiology;Department of LaboratoryMedicine and Pathology;Mayo Clinicand Mayo Foundation;Rochester, MN 55905. Received January4, 1990; revised and accepted February27, 1990. © 1990ElsevierScience PublishingCo., Inc. 655 Avenue of the Americas, New York, NY 10010 0732-8893/90/$3.50
MATERIALS A N D METHODS Patients The age of the patients ranged from 1 to 85 years; most were non-AIDS patients.
Specimens From February 14, 1989, to June 30, 1989, 136 specimens were submitted to the clinical microbiology
308
laboratory for examination for P. carinii. One hundred and sixteen specimens from 102 patients were evaluated by both CFW and MS stains. The specimens tested included 89 bronchoalveolar lavage (BAL) specimens, 21 open-lung biopsy (OLB) tissues, two induced sputums, one expectorated sputum, two tracheal secretions, and one bronchial secretion. Twenty specimens were excluded from our study because of insufficient sample to permit both staining procedures. Cytospin smears were prepared from BAL specimens, as described previously (Martin et al., 1987). Sputum specimens were digested with sputolysin (Calbiochem, La Jolla, CA) prior to preparing smears for staining. Homogenized lung tissue and tissue impression smears were used to examine OLB tissues (Gay et al., 1985). Smears were allowed to airdry before further processing. Touch preparations of h u m a n lung tissue containing P. carinii were used as positive controls for both CFW and MS staining procedures.
Y.K. Kim et al.
FIGURE 1. Calcofluor white stain of Pneumocystis carinii cysts in bronchoalveolar |avage specimens, x 400.
Staining Procedure Two slides were stained by each method for each specimen. The MS stain was performed by the method of Mahan and Sale (1978), as modified by Yu et al (1989). Smears for CFW staining were fixed by placing slides in 100% methanol for 2 min, followed by airdrying. Six drops of CFW solution A (Fungi-Fluor kit, Polysciences, Warrington, PA) were placed on each smear and spread with a pasteur pipette. Staining was allowed to proceed for 1 min at room temperature, after which slides were rinsed with deionized water, placed under coverslips and examined.
Microscopy Specimens stained with CFW were examined with a fluorescence microscope (Leitz, Orthoplan 2) equipped with an epifluorescent filter (D filter; BP 355-425, RKP 455, LP 460 or G filter; BP 350-460, RKP 510, LP 515) and a 100-W mercury lamp. Smears stained with MS were examined using a bright-field microscope. A low-power objective ( x 20) was used for screening all stained specimens. Potential cyst structures found with screening were verified for appropriate morphology by using high-power ( x 40) or oil-immersion (x 100) objectives. Each slide was examined by two of the authors. Specimens were considered positive for P. carinii when round or oval cysts with a typical double-parenthesis structure were observed in the smears. The number of cysts seen on each smear was recorded. When there was a discordance between the
two staining methods, the negative slides were reexamined and clinical histories were reviewed to resolve remaining discrepancies.
Statistics Statistical evaluations were done by using the McNemar sign test. The average number of cysts detected on both slides with each stain was used in the calculation.
RESULTS Pneumocystis carinii cysts stained by CFW appeared as pale-blue, round or oval structures with a bright, whitish-blue cystic wall w h e n viewed with the Dfilter system (Fig. 1). With the G-filter system, yellowish-green cysts were observed. Most cysts contained a prominent double-parenthesis structure and were easily discernible from yeasts. Clusters of cysts were present in most cases. Of the 116 specimens examined, 19 BAL specimens and one OLB specimen were found to have P carinii cysts (Table 1). The number of P. carinii cysts detected by each staining method was compared (Table 2). In all but two instances, CFW stain detected more P. carinii cysts than MS stain (p = 0.05). It is worth noting that the MS-stained slides for case 17 were initially read as negative. The slides were reexamined after the CFW stain showed P. carinii cysts, and only one cyst on one slide was detected. A summary of clinical findings for cases with a dis-
Calcofluor White Stain for Pneumocystis carinii
T A B L E 1.
309
Comparison of the Calcofluor White (CFW) Stain with the Modified Methenamine Silver (MS) Stain for Detection of Pneumocystis carinii in Clinical Specimens
procedure. For the remaining patient (case 12), clinical findings were suggestive of PCP, and the result of the CFW stain was considered a true positive result.
MS
DISCUSSION
4CFW +
15
-
1
4 96
cordance between staining methods is presented in Table 3. In case 3, diagnosis was confirmed by detection of P. carinii cysts in OLB tissue by both CFW and MS stains. For two patients (cases 5 and 10), clinical histories were consistent with PCP, and these patients responded rapidly to appropriate antimicrobial treatment. Case 20 represents the same patient as case 5, from w h o m a BAL specimen obtained 3 months earlier was positive by the other staining T A B L E 2.
Number of Pneumocystis carinii Cysts Detected on CFW- and MS-Stained Slides No. of Cystsa
Case No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Specimen BALb BAL BAL OLBb BAL BAL BAL BAL BAL BAL BAL BAL BALb BAL BAL BAL BAL BAL BAL BAL
MS
CFW
22 81 0 ND 0 31 1 134 36 0 1 0 11 >200 9 >200 Ia 1 >200 1
NEF 154 4 ND 1 142 5 >200 16 1 2 6 ND >200 23 >200 29 1 >200 0
aAverage of two slides. MS, methenaminesilver; and CFW, calcofluorwhite. bNot included in statisticalanalysis. eND, counting not performed. aMS stain initiallyread as negative; one cyst found on reexamination.
In our study, BAL constituted the majority of the specimens tested. The usefulness of this specimen type in diagnosing PCP from immunocompromised patients has been well documented, with a sensitivity for detecting P. carinii ranging from 82% to 97% (Stover et al., 1984; Broaddus et al., 1985; Golden et al., 1986: Martin et al., 1987). CFW and MS stains were comparable in our laboratory for the detection of P. carinii. CFW staining requires only a few steps and - 10 min to perform. In contrast, MS staining involves many steps and reagents, some of which must be prepared fresh with each use, and requires 45 min to perform. Due to the instabililty of reagents used for the MS stain, both the staining procedure and quality control of reagents are very labor intensive for the laboratory. Although the sensitivity for detecting any cysts in patients with PCP was not significantly different for the two stains (p = 0.20), greater numbers of cysts were evident with the CFW stain than with the MS stain (p = 0.05). We did not attempt to determine w h y there was a difference in the number of cysts detected. The difference could be due to loss of cysts from the slides during the multiple washing steps of the MS staining procedure or simply a reflection of the ease with which the cysts are discernible as very bright objects in the fluorescent staining procedure. In any event, the ability to detect more cysts with the CFW stain might increase sensitivity for diagnosis of PCP in patient populations characterized by low numbers of cysts. In contrast with PCP in AIDS patients, fewer cysts have been reported for immunosuppressed non-AIDS patients with PCP (Limper et al., 1988). Most of the patients included in our study did not have AIDS, and extension of our study for a longer period may have revealed a statistically significant increase in sensitivity for CFW staining; however, this was not the purpose of the study. The CFW stain would be prefered in our laboratory setting, based on simplicity alone and demonstration that it is at least as sensitive as the MS stain. One should note that CFW stain from different vendors may vary in suitability for staining P. carinii cysts (Baselski et al., 1990).
We thank the technologists who prepared the positive control slides and those who performed the modified MS stain.
310
Y.K. K i m et al.
TABLE 3.
Evaluation of D i s c o r d a n t Results b e t w e e n MS a n d CFW Clinical Evaluation b
Laboratory Resulff
Fever
Cough or Dyspnea
Impaired Oxygenation
Compatible CXR Findings
Evidence of Clinical or Radiologic Response to Treatment
+ ND
+ +
+ +
+ +
+ +
ND ND ND
+ +
+ + +
+ UK +
+ +/+/-
Pathologic confirmation Resolution of CXR and symptoms with TMP/SMX Rapid clinical response to TMP/SMX Resolution of CXR with TMP/SMX Resolution of CXR and symptoms with TMP/SMX
Case No.
MS
CFW
OLB
3 5
-
+ +
10 12 20
+
+ + -
a+, cysts detected; and - , cysts not detected. MS, methenamine silver; CFW, calcofluor white; OLB, open-lung biopsy; and ND, not done. b+, sign or symptom present; - , sign or symptom absent; and + / - , sign or symptom not definitely present or absent. UK, unknown; CXR, chest x-ray; and TMP/SMX, trimethoprim-sulfamethoxazole.
REFERENCES Baselski VS, Robison MK, Pifer LW, Woods DR (1990) Rapid detection of Pneumocystis carinii in bronchoalveolar lavage samples by using Cellufluor staining. ] Clin Microbiol 28:393-394. Broaddus C, Dake MD, Stulbarg MS, Blumenfeld W, Hadley WK, Golden JA, Hopewell PC (1985) Bronchoalveolar lavage and transbronchial biopsy for the diagnosis of pulmonary infections in the acquired irnmunodeficiency syndrome. Ann Intern Med 102:747752. Gay JD, Smith TF, Ilstrup DM (1985) Comparison of processing techniques for detection of Pneumocystis carinii cysts in open-lung biopsy specimens. J Clin Microbiol 21:150-151. Gill VJ, Evans G, Stock F, Parrillo JE, Masur H, Kovacs JA (1987) Detection of Pneumocystis carinii by fluorescent-antibody stain using a combination of three monoclonal antibodies. J Clin Microbiol 25:1837-1840. Golden JA, Hollander H, Stulbarg MS, Gamsu G (1986) Bronchoalveolar lavage as the exclusive diagnostic modality for Pneumocystis carinii pneumonia: a prospective study among patients with acquired immunodeficiency syndrome. Chest 90:18-22. Hughes WT (1987) Pneumocystis carinii pneumonia, vol 2. Ed, WT Hughes. Boca Raton, FL: CRC, pp 35-64. Kovacs JA, Gill V, Swan JC, Ognibene F, Shelhamer J, Parrillo JE, Masur M (1986) Prospective evaluation of a monoclonal antibody in diagnosis of Pneumocystis carinii pneumonia. Lancet 2:1-3.
Limper AH, Smith TF, Martin WJ II (1988) Pneumocystis carinii pneumonia: quantitative differences in parasite burden and host inflammatory response in AIDS and non-AIDS patients. Am Rev Respir Dis 137(suppl):356. Mahan CT, Sale GE (1978) Rapid methenamine silver stain for Pneumocystis carinii and fungi. Arch Pathol Lab Med 102:351-352. Martin WJ II, Smith TF, Sanderson DR, Brutinel WM, Cockerill FR, Douglas WW (1987) Role of bronchoalveolar lavage in the assessment of opportunistic pulmonary infections: utility and complications. Mayo Clin Proc 62:549-557. Monheit JE, Cowan DF, Moore DG (1984) Rapid detection of fungi in tissues using calcofluor white and fluorescence microscopy. Arch Pathol Lab Med 108:616-618. Murray JF, Felton CP, Garay SM, Gottlieb MS, Hopewell PC, Stover DE, Teirstein AS (1984) Pulmonary complications of the acquired immunodeficiency syndrome. N Engl J Med 310:1682-1688. Rosenow EC III, Wilson WR, Cockerill FR III (1985) Pulmonary disease in the immunocompromised host. Mayo Clin Proc 60:473-487. Stover DE, White DA, Romano PA, Gellene RA (1984) Diagnosis of pulmonary disease in acquired immune deficiency syndrome (AIDS). Am Rev Respir Dis 130:659662. Yu PKW, Uhl JR, Anhalt JP (1989) Rapid methenamine silver stain. Arch Pathol Lab Med 113:111.
