FOLLOW-UP BRONCHOALVEOLAR LAVAGE IN AIDS PATIENTS WITH PNEUMOCYSTIS-CARINII PNEUMONIA - PNEUMOCYSTIS-CARINII BURDEN PREDICTS EARLY RELAPSE

We performed an analysis of the value of repeat bronchoalveolar lavage (BAL) at 21 days to identify patients at risk for early relapse with Pneumocystis carinii pneumonia. Patients with P. carinii pneumonia and the acquired immunodeficiency syndrome (AIDS) were asked to participate in this study. All patients had P. carinii identified on methenamine silver stain of BAL fluid. BAL fluid was also stained with a modified Wright-Glemsa technique. The Wright-Glemsa stain was done to determine the cell differential count, and the number of P. carinii clusters associated with 500 nucleated cells was used as an estimate of P. carinii burden in the BAL. Initial and follow-up lavage was performed in 56 patients. Patients were classified based on their clinical response to anti-P. carinii therapy at 21 days. Nonresponders were patients with persistent or worsening symptoms. Responders were patients who improved and had therapy discontinued. Responders were further classified as responders with relapse if P. carinii pneumonia recurred within 6 months of the initial episode or responders without relapse if they remained disease free during the follow-up period. Responders without relapse reduced P. carinii cluster counts more than 50% in 24 of 25 cases. In responders with relapse P. carinii cluster counts were unchanged. The responders as a group had a significant decrease in the percentage of neutrophils in the BAL, with only 2 of 32 still having increased neutrophils in the follow-up lavage compared to 17 of 24 nonresponders (p < 0.0001). Nonresponders were classified as those in whom an alternative reason for respiratory failure was found at follow-up lavage (14 patients) and those who only had P. carinii (10 patients). Of the 10 patients with P. carinii alone all had more than 50% of the initial amount of P. carinii found in the follow-up lavage. We conclude that BAL at 21 days can be useful in identifying patients at increased risk for early relapse and in evaluating patients not responding to anti-P. carinii therapy.