Comprehensive evaluation of bronchoalveolar lavage from patients with severe COVID-19 and correlation with clinical outcomes

Ian Gelarden, Jessica Nguyen, Juehua Gao, Qing Chen, Luisa Morales-Nebreda, Richard Wunderink, Lin Li, Joan S. Chmiel, Mary Ann Hrisinko, Laura Marszalek, Sumaiya Momnani, Pinal Patel, Ricardo Sumugod, Qi Chao, Lawrence J. Jennings, Teresa R. Zembower, Peng Ji, Yi Hua Chen*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

20 Scopus citations


Information on bronchoalveolar lavage (BAL) in patients with COVID-19 is limited, and clinical correlation has not been reported. This study investigated the key features of BAL fluids from COVID-19 patients and assessed their clinical significance. A total of 320 BAL samples from 83 COVID-19 patients and 70 non-COVID-19 patients (27 patients with other respiratory viral infections) were evaluated, including cell count/differential, morphology, flow cytometric immunophenotyping, and immunohistochemistry. The findings were correlated with clinical outcomes. Compared to non-COVID-19 patients, BAL from COVID-19 patients was characterized by significant lymphocytosis (p < 0.001), in contrast to peripheral blood lymphopenia commonly observed in COVID-19 patients and the presence of atypical lymphocytes with plasmacytoid/plasmablastic features (p < 0.001). Flow cytometry and immunohistochemistry demonstrated that BAL lymphocytes, including plasmacytoid and plasmablastic cells, were composed predominantly of T cells with a mixture of CD4+ and CD8+ cells. Both populations had increased expression of T-cell activation markers, suggesting important roles of helper and cytotoxic T-cells in the immune response to SARS-CoV-2 infection in the lung. More importantly, BAL lymphocytosis was significantly associated with longer hospital stay (p < 0.05) and longer requirement for mechanical ventilation (p < 0.05), whereas the median atypical (activated) lymphocyte count was associated with shorter hospital stay (p < 0.05), shorter time on mechanical ventilation (p < 0.05) and improved survival. Our results indicate that BAL cellular analysis and morphologic findings provide additional important information for diagnostic and prognostic work-up, and potential new therapeutic strategies for patients with severe COVID-19.

Original languageEnglish (US)
Pages (from-to)92-103
Number of pages12
JournalHuman pathology
StatePublished - Jul 2021


  • Atypical lymphocyte
  • Bronchoalveolar lavage
  • COVID-19
  • Clinical outcome
  • SARS-CoV-2

ASJC Scopus subject areas

  • Pathology and Forensic Medicine


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