Original article 249

Screening for pulmonary mycosis: sputum versus

bronchoalveolar lavage
Rajesh Guptaa, Puneet Singlaa, Nidhi Goelb, Anupama Guptac,
Pardeep Singha, Raghav Guptad
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Departments of aRespiratory Medicine, Introduction

b
Microbiology, cPhysiology, PGIMS, Rohtak, Prevalence of pulmonary mycosis is increasing because of increase in the number
Haryana, dNDMC, New Delhi, India
of susceptible people, increasing awareness toward these infections, and improved
Correspondence to Anupama Gupta, MBBS, methods of laboratory diagnosis. Inflammation of airway and microbiology of
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/27/2023

MD (PHYSIOLOGY), Department of Physiology,

Pt. B.D. Sharma PGIMS, Rohtak, Haryana,
124001, India Tel: +94 1614 7834;
e-mail: dragupta66@gmail.com
Received: 18 February 2020
Revised: 13 April 2020
Accepted: 13 August 2020
Published: 28 May 2021
The Egyptian Journal of Chest Diseases and
Tuberculosis 2021, 70:249–253
various respiratory infections can be studied using sputum and bronchoalveolar
lavage (BAL). The advantage of sputum examination is that it is a noninvasive
procedure as compared with BAL.
Objective
To explore the pulmonary mycosis and compare the yield of induced sputum and
BAL for detecting pulmonary mycosis.
Patients and methods
The present study was conducted on 98 patients of all age groups and sex who
underwent bronchoscopy in the Department of Respiratory Medicine, in association
with the Department of Microbiology. Sputum/induced sputum and BAL were
collected in sterile vials and sent to the microbiology for examination for fungal
species. In microbiology, sputum/BAL samples were subjected to direct microscopy
and cultured on Sabouraud dextrose agar. Culture was observed daily until 21 days
for any fungal growth.
Discussion
Of 98 patients, 60 were detected with fungal infection via sputum, whereas 64 of 98
patients were detected positive for fungal infection via BAL. Yield of sputum
compared with the BAL for diagnosis of fungal infection showed sensitivity of
85.93%, specificity of 85.29%, positive predictive value of 91.66%, negative
predictive value of 76.31%, and accuracy of 85.71%.
Conclusion
Results were slightly better with BAL, but the difference was not much significant.

Keywords:
bronchoalveolar lavage, pulmonary mycosis, sputum
Egypt J Chest Dis Tuberc 70:249–253
© 2021 The Egyptian Journal of Chest Diseases and Tuberculosis
2090-9950

noninvasive procedure. Bronchoscopy with BAL is

Introduction
Pulmonary mycosis is frequently detected in present
day practice [1] because of increased number of
immunosuppressed and vulnerable people, increasing
knowledge toward such infections, and advancement in
laboratory detection methods [2]. Detection of airway
infections employs sputum sampling, transtracheal
needle aspiration, bronchoalveolar lavage (BAL)
with a bronchoscope, and lung biopsy. Latter three
are invasive but considered to be more representative,
whereas the former is noninvasive but considered to be
contaminated with oropharyngeal normal flora. It may
not be possible to undergo invasive procedure in every
patient or person with mild respiratory symptoms. So,
the study was planned to explore fungus in patients
undergoing bronchoscopy through BAL samples and
sputum sample. Inflammation of airway and
microbiology of respiratory infections can be studied
using sputum and BAL. The advantage of sputum
examination over BAL is that sputum is a
an important tool for diagnosis of pulmonary
infections.
Objective
The objective was to explore fungus in BAL and
sputum samples in patients undergoing fiberoptic
bronchoscopy and compare detection of fungal
infection in various lung diseases by sputum and BAL.
Patients and methods
The present study was conducted in the Department of
Respiratory Medicine, in association with the
Department of Microbiology. A total of 98 patients
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© 2021 The Egyptian Journal of Chest Diseases and Tuberculosis | Published by Wolters Kluwer - Medknow DOI: 10.4103/ejcdt.ejcdt_28_20
 250 The Egyptian Journal of Chest Diseases and Tuberculosis, Vol. 70 No. 2, April-June 2021

of all age groups and sex who underwent bronchoscopy Table 1 Prevalence of fungi in sputum sample
for any reason in the Department of Respiratory Findings Number of patients [n (%)]
Medicine were included in the study. Candida albicans 31 (31.63)
Aspergillus fumigatus 6 (6.12)
Inclusion criteria Aspergillus flavus 3 (3.06)
Patients undergoing fiberoptic bronchoscopy were Fusarium spp. 3 (3.06)
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included. Non- Penicillium marneffei 6 (6.12)

Non-Candida albicans 8 (8.16)
Scedosporium spp. 1 (1.02)
Exclusion criteria
Alternaria spp. 2 (2.04)
Patients who did not gave written consent were
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Nil 38 (38.77)
excluded.

Sample collection Table 2 Prevalence of various fungi in the bronchoalveolar

Sputum and BAL were collected in sterile vials. lavage
Findings Number of patients [n (%)]

Induced sputum Candida albicans 32 (32.65)

Patients, if not expectorating, were subjected to sputum Aspergillus fumigates 7 (7.14)
induction as per guidelines. Patients were first given via Aspergillus flavus 3 (3.06)
Aspergillus niger 1 (1.02)
inhalational route 200 μg of salbutamol or equivalent
Fusarium spp. 4 (4.08)
β2-agonist. Spirometry was done 10 min before and
Non-Penicillium marneffei 6 (6.12)
after giving β2-agonist via inhalation. Approximately Non-albicans candida 10 (10.20)
5 ml of 3% hypertonic saline was given via nebulization Alternaria spp. 1 (1.02)
for about 15 min. Patients expectorated at an interval of Nil 34 (34.69)
5 min or whenever they felt. If drop of FEV1 was
observed by 20%, then procedure was stopped [3]. bacteria. It was inoculated on Sabouraud dextrose agar
slant at 25°C for culture. Put at 25–37°C in biological
Sputum oxygen demand for 3 weeks.
Three consecutive early morning sputum samples, after
mouthwash, were collected in a sterile wide-mouth Culture was observed daily for any fungal growth. If
container from the patients. any fungal growth, then it was identified as per
standard protocol [5].
BAL: BAL was taken by using a fiberoptic
bronchoscope. The bronchoscope was advanced Statistical analysis
through mouth distally into a specific subsegmental At the end of the study, the data were collected, and
bronchus, and if no specific segment, then middle lobe statistical analysis was done using χ 2 test. Descriptive
and/or lingua. A volume of 100-ml sterile saline in statistics were represented by means and SDs.
aliquots of 20 ml each was instilled and then gently
aspirated. Retrieved BAL fluid was sent for Observations
microbiological examination [4]. Observations of the study are shown in tabulated
forms. Table 1 shows the prevalence of various
Transportation fungal species in sputum samples, whereas Table 2
Samples collected were transported to the Microbiology shows the prevalence of fungal species in BAL samples.
Department within 2 h in sterile vials to avoid Figures 1 and 2 shows the prevalence of fungi in
contaminants and to keep viable the causative fungus. sputum and BAL in graphical form. Table 3 shows
yield of sputum compared with the BAL for diagnosis
Processing: in Microbiology Department, sputum and of fungal infections. It showed sensitivity of 85.93%,
BAL samples were divided into two parts: specificity of 85.29%, positive predictive value of
91.66%, negative predictive value of 76.31%, and
Part 1 was used for direct examination by wet mounts. accuracy of 85.71%.
Slide and tube KOH mounts are prepared to establish
the diagnosis.
Discussion
Part 2 was digested for homogenization, concentration Fungi are present in respiratory passages silently (so
by centrifugation and decontamination of the most of called commensals) but may be true pathogens that can
 Screening for pulmonary mycosis: sputum versus BAL Gupta et al.
Figure 1
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Graphs showing the prevalence of fungi in sputum and BAL. BAL, bronchoalveolar lavage.
Table 3 Yield of sputum compared with the bronchoalveolar
lavage for diagnosis of fungal infections
Sputum Positive BAL Negative BAL Total
Positive 55 5 60
Negative 9 29 38
Total 64 34 98
BAL, bronchoalveolar lavage. Sensitivity=85.93%;
specificity=85.29%; positive predictive value=91.66; negative
predictive value=76.31; accuracy=85.71.
manifest as various syndromes [6]. Fungal diseases
affect more than one billion people and kill more
than 1.5 million. In lung, one or more opportunistic
or endemic fungi can cause infection known as fungal
pneumonia. Fungal pneumonia occurs owing to
reactivation of latent infection or owing to inhalation
of conidia or spores. Immunocompromised patients are
at more risk for hematogenous dissemination [7]. Many
immunosuppressed conditions like AIDS, organ
transplantation, corticosteroid therapies, and cancer
251
predispose to serious fungal infections. If diagnosed
early and antifungal treatment started promptly,
mortality owing to fungal infection can be reduced
[1]. However, it is very difficult to diagnose fungal
pneumonia and usually presumptive diagnosis is made
on the basis of clinical and radiological factors [8].
Every patient with persisting respiratory symptoms
should be screened for pulmonary mycosis. Prevalence of
pulmonary fungal infections is less than viral or bacterial
infections; it may be because of difficulties in diagnosis.
Mycosis virulence varies from causing no symptoms to
death. Prevalence of pulmonary fungal infections is
increasing because of increase in the number of
immunocompromised susceptible people, increased
awareness about such infections, and improvement in
laboratory diagnostic methods [2]. Incidence of
opportunistic fungal pathogens is affected by various
factors. Overall, there is increase in the number of
susceptible hosts.
 252 The Egyptian Journal of Chest Diseases and Tuberculosis, Vol. 70 No. 2, April-June 2021
In immunocompromised patients, widespread use of
prophylactic therapy such as antibiotics like
fluoroquinolones and antifungal like fluconazole has
enhanced the risk of colonization with resistant fungal
species and leading to increase in invasive fungal
infection [9]. There is increase in susceptibility for
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invasive Aspergillus pneumonia in solid organ
transplant recipients, severely malnourished or
burned patients, prolonged stays in the ICU (>21
days), postcardiac surgical patients, those receiving
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systemic corticosteroids for more than 7 days, near-
drowning victims, patients with renal failure requiring
renal replacement therapy, and patients with diabetes
mellitus [10]. So, we must be vigilant and aware about
the invasive pulmonary fungal infections and should
expand the diagnostic consideration even in moderately
immune-suppressed individuals. There is increase in
the incidence of non-albicans Candida and other
mycelial fungal infections in immune-compromised
population. The primary cause of infection, in
significant corticosteroid users (>20 mg equivalent
per day of prednisone), especially during absolute
neutropenia (<500 neutrophils/μl over ≥14 days), is
Aspergillus. However, Candida, Fusarium, and
Scedosporium species are also of concern [11].
Diabetic patients with poorly controlled blood sugar
level require special attention, as there occurs reduction
in neutrophil function despite adequate number,
predisposing these individuals toward invasive
Aspergillus pneumonitis, although on rare occasion,
and also toward invasive Mucormycosis sinusitis.
To diagnose pulmonary fungal infection is challenging.
However, diagnostic methods like induced sputum and
BAL using bronchoscopy have significantly improved our
ability to diagnose these infections. Because of lack of
consideration of these entities as differential, often there
occursdelayinthediagnosisofpulmonaryfungalinfection.
Most rapid mean to confirm diagnosis is direct
microscopy of respiratory secretions, tissue sample,
and BAL. Examination is performed after KOH
digestion or with the aid of silver stain, traditional
Wright–Giemsa stain, or calcofluor, depending upon
the suspected organisms. Gold standard to diagnose
fungal infections is culture of respiratory secretions or
blood or tissue samples. Culture for fungal organisms
requires several days to a couple of weeks to yield and
identify an organism. The diagnostic benefits vary
widely according to fungal species and the disease
state of fungal infection [5].
Detecting fungus is not a routine investigation in
pulmonary medicine. Generally, we restrict our
sphere of investigations to pyogenic lung
infection, pulmonary tuberculosis, and malignancy.
We fail to investigate so many patients with
infiltration, and many times, we start treatment
empirically. They just roam about and suffer
owing to their illness.
In the present study, the maximum number of patients
belonged to middle age group, that is, 31 patients in the
age group of 51–60 years, followed by 19 in 31–40 and
61–70 years age group, respectively. Only four patients
were found in the younger age group. Mean age of the
patients was 50.16±15.27 years, with a range of 15–80
years. This shows that old age people are more prone to
superadded fungal infection as their immune status is
compromised and have various comorbid conditions.In
our study, the number of male patients was 79 (80.62%)
and 19 (19.38%) female. Endemic fungal disease
affects males (75–95%) more often than females.
The reason for male predominance is estrogen-
mediated inhibition of mycelium-to-yeast
transformation in females. Against cryptococcal
infection also, estrogen seems to have protective
effect, and Cryptococcosis has a male-to-female ratio
of 2–3 : 1 [12]. Other reason is owing the fact that
males are more exposed to the external environment
than females.
All the patients (98) were initially considered
according to their speculated/previous diagnosis.
Majority of patients were previously treated for
pulmonary tuberculosis, that is, 46 (46.93%)
patients. The number of patients with lung
carcinoma was 20 (20.40%); patients of COPD are
10 (10.20%). Patients with bronchial asthma were
nine (9.18%), four (4.08%) patients had
bronchiectasis, three (3.06%) patients had
pneumonia, and two (2.04%) patients had
bronchitis and pleural effusion. Only one patient
each of allergic bronchitis and aspergilloma was
found. This shows that old cases of pulmonary
tuberculosis have cavitary lesion which provides
space to grow and flourish. Patients with lung
carcinoma also have coexisting fungal infection
which deteriorates the symptoms.
Of 98 patients, 60 were detected with fungal
infection via sputum, whereas 64 of 98 patients
were detected positive for fungal infection via
BAL. Yield of sputum compared with the BAL
for diagnosis of fungal infection showed sensitivity
of 85.93%, specificity of 85.29%, positive predictive
value of 91.66%, negative predictive value of 76.31%,
and accuracy of 85.71%.
 Screening for pulmonary mycosis: sputum versus BAL Gupta et al.
Conclusion
Results were slightly better with BAL, but the
difference was not much significant. Induced sputum
offers advantage of being noninvasive.
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Financial support and sponsorship
Nil.
Conflicts of interest
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There are no conflicts of interest.
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