Golde Score in Bronchoscopy
What is the Golde Score?
The Golde score is a semi-quantitative grading system that assesses hemosiderin content in alveolar macrophages obtained from bronchoalveolar lavage (BAL) fluid to diagnose and quantify alveolar hemorrhage. 1, 2
The score evaluates individual alveolar macrophages after Prussian blue (Perls') staining, which highlights iron-containing hemosiderin granules as blue deposits within the cytoplasm. 1, 2
How the Golde Score is Calculated
Grading Individual Macrophages
Each alveolar macrophage is assigned a grade from 0 to 4 based on the amount of hemosiderin present: 2
- Grade 0: No hemosiderin granules visible
- Grade 1: Rare, faint blue granules
- Grade 2: Moderate number of blue granules
- Grade 3: Numerous blue granules throughout cytoplasm
- Grade 4: Macrophage packed with blue granules, obscuring the nucleus
Calculating the Total Hemosiderin Score (THS)
Count at least 100–200 consecutive alveolar macrophages on Prussian blue–stained cytocentrifuge slides 3, 4
Assign each cell a grade (0–4) 2
Calculate the score using this formula: 3, 2
Golde Score = Σ (number of cells in each grade × grade value)
For example: (20 cells × 0) + (30 cells × 1) + (25 cells × 2) + (15 cells × 3) + (10 cells × 4) = 0 + 30 + 50 + 45 + 40 = 165
Diagnostic Thresholds for Clinically Significant Alveolar Hemorrhage
Golde Score Threshold
A Golde score ≥75 indicates clinically significant alveolar hemorrhage, with a sensitivity of 94% and specificity of 88%. 3
This threshold demonstrates very good agreement beyond chance (Cohen's kappa = 74%) for detecting alveolar hemorrhage. 3
Alternative Simplified Method
An alternative, easier method counts the percentage of hemosiderin-laden macrophages (siderophages): ≥20% siderophages among total alveolar macrophages indicates clinically significant alveolar hemorrhage. 4
This percentage-based method correlates well with the Golde score and has been validated in immunocompromised patients. 4
Clinical Context and Interpretation
When to Suspect Alveolar Hemorrhage
Grossly bloody BAL fluid that returns with increasing intensity in sequential aliquots indicates acute diffuse alveolar hemorrhage. 5
However, alveolar hemorrhage is often occult—the classic triad of hemoptysis, anemia, and radiological infiltrates is frequently absent. 1, 6
Associated Risk Factors
Alveolar hemorrhage detected by elevated Golde scores is significantly associated with: 4
- Thrombocytopenia (<50,000/mm³)
- Other coagulation abnormalities
- Renal failure (creatinine ≥2.5 mg/dL)
- History of heavy smoking
- Cardiac transplant recipients (75% prevalence)
Diagnostic Utility in Specific Conditions
In pulmonary veno-occlusive disease (PVOD), the percentage of hemosiderin-laden macrophages is significantly higher (54±37%) compared to idiopathic pulmonary arterial hypertension (3±6%), and the Golde score is markedly elevated (109±97 versus 4±10). 5
Combined evidence of pulmonary arterial hypertension, elevated hemosiderin-laden macrophages in BAL, and interstitial infiltrates on imaging is highly suggestive of PVOD. 5
Critical Pitfalls to Avoid
Do not dismiss the possibility of alveolar hemorrhage based solely on the absence of hemoptysis or grossly bloody BAL returns—occult hemorrhage is common and requires Prussian blue staining for detection. 1, 6
Recognize that some degree of hemosiderin in alveolar macrophages can be present in normal individuals or those without active hemorrhage—the threshold of ≥75 (Golde score) or ≥20% siderophages distinguishes clinically significant hemorrhage. 3, 4
Alveolar hemorrhage is rarely the sole cause of lung injury in immunocompromised patients—it is usually associated with other causes of pneumonia (infection, drug toxicity, vasculitis) and should prompt investigation for underlying etiologies. 4, 6
In patients with suspected PVOD, perform BAL before initiating vasodilator therapy—the presence of elevated hemosiderin scores helps identify patients at high risk for pulmonary edema with prostanoid treatment. 5