6 0 6 Grigg et al. The Journal of Pediatrics April 1993

nosis and let them know that they do not have an increased

risk of recurrence.

We thank Donna McDonald-McGinn, MS, for assistance with and referral of patient 1; James J. Kirk, DO, for referral of patient 2; Kathleen E. Richkind, PhD, and Robert C. Miller, PhD, for fi- broblast cytogenetie analysis on patients 1 and 3, respectively; and Fikru Bekele for technical assistance with patient 2.

R E F E R E N C E S

1. Butler N, Claireaux AE. Congenital diaphragmatic hernia as a cause of perinatal mortality. Lancet 1962;1:659-63.

2. Cunniff C, Jones KL, Jones h|C. Patterns of malformation in children with congenital diaphragmatic defects. J PEOIATR 1990;116:258-61.

3. Pallister PD, Meisner LF, Elejalde RE, et al. The Pallister mosaic syndrome. Birth Defects 1977;13(3B):103-10.

4. Killian W, Teschler-Nicola M. Case report 72: mental retar- dation, unusual facial appearance, abnormal hair. Syndrome Identification 1981;7(1):6-7.

5. Wenger SL, Boone LY, Steele MW. Mosaicism in Pallister i(12p) syndrome. Am J Med Genet 1990;35:523-5.

6. Speleman F, Leroy JG, Van Roy N, et al. Pallister-Killian

syndrome: characterization of the isochromosome 12p by flu- orescent in situ hybridization. Am J Med Genet 1991 ;41:381-7.

7. Schinzel A. Tetrasomy 12p (Pallister-Killian syndrome). J Med Genet 1991;28:122-5.

8. Wyatt PR. Pallister-Killian syndrome: an update of a clinical case [Letter]. Am J Med Genet 1988;29:229.

9. Pauli RM, Zeier RA, Sekhon GS. Mosaic isochromosome 12p [Letter]. Am J Med Genet 1987;27:291-4.

10. Warburton D, Anyane-Yeboa K, Francke U. Mosaic trisomy 12p: four new cases, and confirmation of the chromosomal or- igin of the supernumerary chromosome in one of the original Pallister-mosaic syndrome cases. Am J Med Genet 1987;27: 275-83.

i 1. Young ID, Duckett DP, O'Reilly KM. Lethal presentation of mosaic tetrasomy 12p (Pallister-Killian) syndrome. Ann Genet 1989;32(1):62-4.

12. Bresson JL, Arbez-Gindre F, Peltie J, Gouget A. Pallister- Killian-mosaic tetrasomy 12p syndrome: another prenatally diagnosed case. Prenat Diagn 1991;11:271-5.

13. McLeod DR, Wesselman LR, Hoar DI. Pallister-Killian syn- drome: additional manifestations of cleft palate and sacral ap- pendage. J Med Genet 1991;28:541-3.

14. Priest JH, Ust JM, Fernhoff PM. Tissue specificity and stabil- ity of mosaicism in Pallister-Killian +i(12p) syndrome: rele- vance for prenatal diagnosis. Am J Med Genet 1991;42:820-4.

Bilateral fiberoptic bronchoalveolar lavage in acute unilateral lobar pneumonia

Jonathan.Gr igg, MRCP(UK). Carine van den Borre, MD. Anne Malfroot, MD. Denis Pierard, MD. Deyun Wang, MD. and Isi Dab, MD

From the Departments of Pediatric Pulmonology and Cystic Fibrosis. Microbiology, and Otorhi- nolaryngology. Academisch Klnderziekenhuis. Vrije Universiteit Brussel, Brussels. Belgium

Bilateral cultures of bronchoalveolar lavage fluid were obtained from eight children with unilateral lobar pneumonia. In four patients bacterial pathogens were not isolated from lavage of the radiologlcal ly normal side but were sub- sequently cultured from the consolidated segment. This pattern helped to exclude contamination by oropharyngeal flora of bronchoalveolar lavage fluid. Bilateral bronchoalveolar lavage may help in the interpretation of lower respiratory tract cultures obtained by fiberoptic bronchoscopy. (J PEDIAIR 4993; 122:606-8)

Supported by grants from the Nuffield Foundation, Allen and Han- bury, Ltd. (United Kingdom), and the Ministry of the Flemish Community in Belgium (Ministerie van de Vlaamse Gemeenschap). Submitted for publication May 5, 1992; accepted Jan. 4, 1993. Reprint requests: Isi Dab, hiD, Department of Pediatric Pulmonol- ogy and Cystic Fibrosis, Academisch Kinderzienkenhuis, Vrije Universiteit Brussel, Laarbeeklaan 101, B-1090 Brussels, Belgium.

Copyright �9 1993 by Mosby-Year Book, Inc. 0022-3476/93/$1.00+.10 9/22/45339

Blood culture results in acute childhood pneumonia are

frequently negative, so determining the causative organism

is often difficult. 1 The availability of broad-spectrum anti-

biotics allows treatment without a microbiologic diagnosis,

but this approach may be inadequate in the presence of im-

munosuppression or multiply resistant organisms. In adults

with pneumonia, lavage fluid obtained from the consoli-

dated lobe at bronchoscopy often contains the causative or

The Journal of Pediatrics Grigg et aL 6 0 7 Volume 122, Number 4

Table. Pathogens isolated from NP aspirate and BALF

BALF from lung

Patient Consolidated No. NP lavage Normal lung segment

anti-Mycoplasma pneumoniae tiler

1 S. pneumoniae No pathogen 2 H. influenzae (+) No pathogen 3 B-Hemolytic streptococcus /~-Hemolytic streptococcus

(group A) (group A) S. pneumoniae

4 RSV RSV H. influenzae (-)

5 No pathogen No pathogen 6 S. pneumoniae No pathogen 7 H. influenzae (-) No pathogen 8 No pathogen H. hlfluenzae (-)

S, pneumoniae <40 H. influenzae (+) <40 /3-ttemolytic streptococcus <40

(group A) S. pneumoniae RSV ND H. influenzae (-) No pathogen 1280 No pathogen >5120 No pathogen <40 H. influenzae (-) <40

RSV, Respiratory syncytial virus; ND, not done; (+) (-)./~-lactamase activity.

ganism. 2 Unfortunately, the bronchoscope is usually con- taminated by bacteria during its passage through the oropharynx. 2 Organisms grown in unilateral BALF cul- tures by routine microbiologic methods are therefore not

BALF Bronchoalveolar lavage fluid ] NP Nasopharyngeal

representative of lower respiratory tract flora. Quantitation of BALF bacteria may help to separate contaminant from pathogenic organisms, but specialized culture techniques are required. 3 Quantitative cultures may not be necessary if bilateral bronchoalveolar lavage is performed in unilat- eral pneumonia. The BALF from the unaffected lung, when obtained immediately after insertion of the bronchoscope, should contain any contaminating upper respiratory tract bacteria. A pathogen not isolated from initial lavage of the radiologically normal lung, but found in BALF subse- quently lavaged from the consolidated segment, should therefore be significant. We report the results of bilateral bronchoalveolar lavage in a group of children with unilat- eral pneumonia but without prior antibiotic therapy.

M E T H O D S

All children admitted to the Academisch Ziekenhuis, Brussels, during a 12-month period with untreated acute unilateral pneumonia and a normal contralateral radio- graph were eligible for this study. The protocol was ap- proved by the hospital ethics committee and informed parental consent was obtained. Bronchoscopy of eligible children was performed only if clinically indicated. After premedication with rectally administered phenobarbital and intramuscularly administered droperidol with fentanyl (Innovar; Janssen Pharmaceutica, Beerse, Belgium), the airway was anesthetized by nebulized 10% lidocaine and oxybuprocaine (Novesine; Sandoz-Wander Pharma SA,

Berne, Switzerland). Before bronchoscopy, nasopharyngeal lavage was performed by instilling 2 ml 0.9% saline solution into the right nostril and simultaneously aspirating through the left. A 3.8 mm fiberoptic broncboscope with bite block (Olympus Optical Co., Ltd., Tokyo, Japan) was then inserted orally and wedged into a subsegmental bronchus of the radiologically normal side. Four aliquots of 0.25 ml sa- line solution (37 ~ C) per kilogram were then instilled and immediately aspirated into a sputum trap. The broncho- scope was then dislodged and placed into the contralateral primary bronchus. The subsegmental bronchus supplying the infected segment was identified by the presence of pus and an identical lavage performed.

Aliquots of BALF from the two sides were cultured sep- arately. The NP aspirate and BALF were inoculated onto sheep blood agar and McConkey, mannitol sugar, and charcoal yeast-enriched agar. Samples were also screened for respiratory syncytial virus by indirect immunofluores- cence and inoculation onto HEp-2 human cells. Serum anti-Mycoplasma pneumoniae antibodies were detected by passive particle agglutination and seroconversion, or a sin- gle titer of > 1:640 was considered suggestive of ongoing .~L pneumoniae infection. Blood culture specimens were ob- tained before antibiotic therapy was started.

R E S U L T S

Eight children (2 to 7 years of age) underwent bronchos- copy. Bilateral bronchoalveolar lavage was well tolerated and had no significant effect on oxygenation or heart rate. In four cases (patients I to 4; Table) bacterial pathogens were not isolated from the radiologically normal lung but were present in BALF subsequently obtained from the con- solidated segment. The BALF from the normal lung in these children was always contaminated with nonpathogenic bacteria identical to those isolated from the NP aspirate. One child (patient 3) had a concomitant purulent tonsilli-

6 0 8 Grigg et al. The Journal of Pediatrics April 1993

tis, and both B-hemolytic streptococcus group A and Strep- tococcuspneumoniae were isolated from the BALF. In this patient, S. pneuntoniae grew in the blood culture. Results of all other blood cultures were negative.

Bilateral BALF cultures from four children (patients 5 to 8) were not helpful in excluding upper respiratory tract contamination. Two of these children had serologic evi- dence of Mycoplasnta pneumonia (patients 5 and 6), and in the remaining two (patients 7 and 8) no definitive microbi- ologic diagnosis could be made.

D I S C U S S I O N

This study demonstrates that prior lavage of the noncon- solidated lung in acute untreated unilateral pneumonia may help to determine whether bacterial pathogens have entered the lower respiratory tract from the oropharynx during bronchoscopy. Bilateral lavage has been performed in adults to increase the detection of Pneumoc.l'stis carinii in bilateral pulmonary disease 4 but not to exclude pharyngeal contamination. With routine culture methods and lavage of the consolidated segment only, interpretion of BALF cul- tures in this study would have been difficult. The same bac- terial pathogens in the BALF were frequently cultured from the NP aspirate. It would therefore have been impossible to exclude contamination from the upper respiratory tract without culture of lavage specimens from the unaffected lung. The reason that nonpathogenic upper respiratory tract bacteria, and not potential pathogens from the upper respi- ratory tract, contaminated BALF from the radiologically normal lung remains unknown.

Apart from blood culture, there is no "gold standard" for the noninvasive isolation of bacterial pathogens causing pneumonia. In the four patients in whom bilateral BALF cultures suggested a causative pathogen, the organisms were compatible with those described as a cause of either community-acquired pneumonia 5 or coinfection with bac- teria and respiratory syncytial virus. 6 Fortunately, the pos- sibility that fl-hemolytic streptococcus was the significant pathogen in patient 3 was excluded by the isolation of S. pneumoniae from both the blood and from the BALF,

Because of the small number of children referred to us without prior antibiotic therapy, the sensitivity and speci- ficity of bilateral lavage in the diagnosis of pneumonia could not be determined. Bilateral lavage can provide no addi-

tional information when no pathogens can be found in the consolidated lung. The absence of pathogens in cultures of the BALF from the two children with high anti-Mycoplasnta antibodies were to be expected because our routine culture techniques were unable to isolate this organism. Bilateral lavage was therefore diagnostic in four of the six patients in whom positive culture results were possible. However, the isolation of Hentophilus il~uenzae from both the normal and abnormal lung of one child (patient 8) demonstrates that bilateral bronchoalveolar lavage will not always im- prove culture interpretation in the presence of a pathogen.

Fiberoptic bronchoscopy and bronchoalveolar lavage are increasingly being used to diagnose pulmonary infections in children 7.s and appear to be safe in trained hands. 9 The procedure is invasiveand clearly inappropriate for the ma- jority of children with lobar pneumonia. However, if it is important to make a microbiologic diagnosis and examina- tion of BALF seems appropriate, lavage of the radiologi- cally normal lung first can be clinically useful.

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2. Bartlett JG, Alexander J, Mayhew J, Sullivan-Sigler N, Gor- bach SL. Should fiberoptic bronchoscopy aspirates be cul- tured? Am Rev Respir Dis 1976;114:73-8.

3. Khan FW, Jones JM. Diagnosing bacterial respiratory infec- tion by bronchoalveolar lavage. J Infect Dis 1987;155:862-9.

4. Meduri GU, Stover DE, Greeno RA, Nash T, Zaman MB. Bilateral hronchoalveolar lavage in the diagnosis of opportu- nistic pulmonary infections. Chest 1991;100:1272-6.

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6. Korppi K, Leinonen M, Koskela M, M,"ikel/i PH, Launiala K. Bacterial coinfection in children hospitalized with respiratory syncytial virus infections. Pediatr Infect Dis J 1989;8:687- 92.

7. Frankel LR, Smith DW, Lewiston NJ. Bronchoalveolar lavage for the diagnosis of pneumonia in the immunocompromised child. Pediatrics 1988;81:785-8.

8. Springer C, Avital A, Noviski N, et al. Role of infection in the middle lobe syndrome in asthma. Arch Dis Child 1992; 67:592-4.

9. Wood RE, Postma D. Endoscopy of the airway in infants and children. J PEDIATR 1988;122:1-6.