Birgitta Versluijs

118 Discussion FIGURE 2. Cumulative incidence of allo-LSs in patients with po- sitive BAL fluid RV results according to the presence of grade II to IV aGVHD in another organ. possibly because of earlier initiation of increased immunosuppression. Allo-LSs were treated with high-dose steroids but remained a life-threatening complication; patients with allo-LSs had significantly higher TRM associated with a trend toward lower overall survival. This high TRM warrants novel or additional treatment in prospective trials; etanercept is one of the agents suggested by others, although conflicting data exist. 12,13 Identification of high-risk patients, preventive strategies, and awareness and early detec- tion of allo-LSs could lead to improved survival chances. A limitation of our sampling method might be the possible contamination of the bron- choscope on its route through the upper airway, influencing the RV DNA/RNA positivity of the BAL samples. However, in all patients BAL was done through a tracheal tube some time after intubation, reducing the risk of direct contamination. Moreover, we have not found any differ-ence in Ct values between NPAs and BAL fluid, and therefore conta- mination seems unlikely (because one would expect a much higher Ct value and lower viral load when contaminated). If some positive BAL samples were contaminated, the suggested association between BAL fluid RVand allo-LSs would be even stronger. An im- portant note is that during the study period, as it became clear there was an association between RV positivity in NPAs and allo-LSs, 6 we started taking preventive measures in Days after HCT No aGvHD 31% (±6) aGvHD 7% (±7) p=0.09 7 0 50 100 150 200 250 1,0 0,8 0,6 0,4 0,2 0,0