Oktay ALVER, Ahmet ÖZMEN, Reşit MISTIK, Funda COŞKUN, Esra UZASLAN, Ahmet URSAVAŞ

Bronkoalveoler lavaj (BAL) ve bronşiyal lavaj yapılan hastalardaki Pneumocystis jirovecii kolonizasyonu ve tanıda kullanılan yöntemlerin karşılaştırması

Giriş: Pneumocystis jirovecii'nin neden olduğu Pneumocystis pnömonisi (PCP) bağışıklık sistemi baskılanmış hastalarda en sık ve ciddi olarak gözlenen fırsatçı infeksiyonlardan biridir. Çalışmamızda göğüs hastalıkları anabilim dalı tarafından klinik ya da poliklinik ortamında takip edilen ve tanı amaçlı bronkoskopi yapılan toplam 100 hastaya ait bronkoalveoler lavaj (BAL) ve bronşiyal lavaj örnekleri değerlendirildi.Materyal ve Metod: Alınan BAL ve bronşiyal lavaj örnekleri metenamin gümüş (Gomori/Grocott), toluidin mavisi O, Wright-Giemsa, boyamaları ve immün floresans antikor (IFA), nested polimeraz zincir reaksiyonu (PCR) ile değerlendirildi.Bulgular: BAL ve bronşiyal lavaj örneklerinde metenamin gümüş (Gomori/Grocott), toluidin mavisi O, Wright-Giemsa boyamaları ile etken saptanmadı. IFA testiyle 13 hastada P. jirovecii'nin kistleri saptanırken; nested PCR ile 16 hastada P. jirovecii'nin DNA'sı saptandı. Hem PCR hem IFA testi ile P. jirovecii saptanan toplam 8 hasta mevcuttu. P. jirovecii saptanan hasta örnekleri incelendiğinde bu örneklerin 13'ünün BAL olduğu ve 8'inin bronşiyal lavaj olduğu görüldü. Olgu gruplarında bakılan yaş, cinsiyet, sigara kullanımı, hipertansiyon, diabetes mellitus, kronik obstrüktif akciğer hastalığı (KOAH), serebrovasküler olay (SVO), konjestif kalp yetmezliği (KKY), son üç ayda hastanede yatma öyküsü, antibiyotik kullanımı ve radyolojik bulguları açısından değerlendirildiğinde P. jirovecii pozitifliğiyle aralarında istatistiksel olarak anlamlılık saptanmadı. Olgu grupları PCR ve IFA pozitifliklerine göre gruplara ayrılarak değerlendirme yapıldığında IFA veya PCR pozitif olgularda immünsüpresyon açısından anlamlı farklılık saptandı (p= 0.003). Pozitif olguların %28.6'sı immünsüpresif saptanırken, PCR veya IFA negatif olguların %3.8'i immünsüpresifti. PCR yöntemi tanıda altın standart olarak kabul edilen IFA ile duyarlılık ve özgüllük açısından kıyaslandığında duyarlılık %61.5 ve özgüllük %90.8 olarak belirlendi. McNemar testiyle IFA ve PCR tanı testi sonuçlarının uyumlu oldukları saptandı (p= 0.581).Sonuç: Bursa bölgesinde yapılan bu çalışmada HIV negatif olgularda immünsüprese hastalarda P. jirovecii göstermeye yönelik boyama yöntemlerinin duyarlılığı düşük olduğu ayrıca IFA ile nested PCR yönteminin paralel sonuçlar vermediği görülmüştür.

The Pneumocystis jirovecii colonization in bronchoalveolar lavage (BAL) and bronchial washing and the comparison of methods which are used in diagnosis

Introduction: Pneumocystis pneumonia (PCP) which is caused by Pneumocystis jirovecii is usually seen in the patients whose immune system is supressed. It is seriously seen an opportunist infection. In our study; totally 100 bronchoalveolar lavage (BAL) and bronchial washing samples collected by pulmonary disease department. Which belong to the patients in the clinics, and out patient clinic of the bronchoscopy material were evaluated.Materials and Methods: The BAL and bronchial washing were evaluated by the help of methenamine silver stain (Gomori/Grocott), toluidine blue O stain, Wright-Giemsa stain, immun fluorescent antibody (IFA) stain, nested polymerase chain reaction (PCR).Results: In the BAL and bronchial washing samples the agent couldn't be shown by the help of methenamine silver (Gomori/Grocott), toluidine blue O, Wright-Giemsa staining. In 13 patients with IFA test the cysts of P. jirovecii were determined. In 16 patients with nested PCR; the DNA of P. jirovecii were determined. In 8 patients by using PCR and IFA test P. jirovecii was determined. When the samples which had P. jirovecii were analyzed; 13 of them were BAL and 8 of them were bronchial washing. When the phenomenon groups were evaluated according to age, gender, smoking, hypertension, diabetes mellitus, chronic obstructive pulmonary disease (COPD), cerebrovascular accident (CVA), congestive cardiac failure (CCF), staying in the hospital in the last three months, using antibiotics and radiological findings; there wasn't a statistical meaningful relation between P. jirovecii positivity and these situations. When the phenomenon groups were evaluated according to PCR and IFA positivity; in IFA and PCR positive patients for immunosupressive there was a meaningful differances (p= 0.003). The positive 28.6 % of cases were immunosuppressed and the 3.8% of PCR or IFA negative cases were immunosupressed. When PCR method was compared with IFA which is called gold standard for sensitivity and specificity; sensitivity was found 61.5% and specificity was found 90.8%. IFA and PCR diagnosis test results were compatible (With McNemar test p= 0.581).Conclusion: Diagnostic sensitivity of staining methods for P. jirovecii in immunocompromised HIV negative patients are found to be low and it was shown that IFA and nested PCR methods have not parallel results.

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