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Schmidt C. Fungal diseases are spreading undetected. Nature 2024:10.1038/d41586-024-00751-z. [PMID: 38485825 DOI: 10.1038/d41586-024-00751-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
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Nkinsi NT, Galagan SR, Benzekri NA, Govere S, Drain PK. Food Insecurity at HIV Diagnosis Associated with Subsequent Viremia Amongst Adults Living with HIV in an Urban Township of South Africa. AIDS Behav 2023; 27:3687-3694. [PMID: 37249804 DOI: 10.1007/s10461-023-04085-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 05/31/2023]
Abstract
We assessed the temporal impact of food insecurity on 12-month antiretroviral (ART) adherence, retention in care, hospitalization, and HIV viremia (> 1000 copies/mL) in ART naïve adults presenting for HIV testing in Umlazi, South Africa. At the time of HIV testing and prior to ART initiation, we determined each participants' food security status using the validated Household Food Insecurity Access Scale (HFIAS). Following HIV testing and ART initiation, we then assessed the above outcomes of each study participant at 3-month intervals for a total of 12 months. Among 2,383 participants with HIV in this study, 253 (10.6%) experienced food insecurity. We found that food insecurity is associated with 20% higher adjusted prevalence odd ratios (aPOR) of having HIV viremia (> 1000 copies/mL) at 12 months following initial diagnosis (aPOR 1.2, 95% CI 1.1-1.4). We found no significant differences in ART adherence, retention in care, and hospitalization occurrences between the food secure and food insecure cohorts.
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Affiliation(s)
- Naomi T Nkinsi
- School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.
- Department of Global Health, University of Washington, Seattle, USA.
| | - Sean R Galagan
- Department of Global Health, University of Washington, Seattle, USA
| | | | | | - Paul K Drain
- School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
- Department of Global Health, University of Washington, Seattle, USA
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Baker J, Denning DW. The SSS revolution in fungal diagnostics: speed, simplicity and sensitivity. Br Med Bull 2023; 147:62-78. [PMID: 37328942 PMCID: PMC10502448 DOI: 10.1093/bmb/ldad011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 04/24/2023] [Accepted: 05/29/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Fungal disease has historically presented a diagnostic challenge due to its often non-specific clinical presentations, relative infrequency and reliance on insensitive and time-intensive fungal culture. SOURCES OF DATA We present the recent developments in fungal diagnostics in the fields of serological and molecular diagnosis for the most clinically relevant pathogens; developments that have the potential to revolutionize fungal diagnosis through improvements in speed, simplicity and sensitivity. We have drawn on a body of evidence including recent studies and reviews demonstrating the effectiveness of antigen and antibody detection and polymerase chain reaction (PCR) in patients with and without concurrent human immunodeficiency virus infection. AREAS OF AGREEMENT This includes recently developed fungal lateral flow assays, which have a low cost and operator skill requirement that give them great applicability to low-resource settings. Antigen detection for Cryptococcus, Histoplasma and Aspergillus spp. are much more sensitive than culture. PCR for Candida spp., Aspergillus spp., Mucorales and Pneumocystis jirovecii is more sensitive than culture and usually faster. AREAS OF CONTROVERSY Effort must be made to utilize recent developments in fungal diagnostics in clinical settings outside of specialist centres and integrate their use into standard medical practice. Given the clinical similarities of the conditions and frequent co-infection, further study is required into the use of serological and molecular fungal tests, particularly in patients being treated for tuberculosis. GROWING POINTS Further study is needed to clarify the utility of these tests in low-resource settings confounded by a high prevalence of tuberculosis. AREAS TIMELY FOR DEVELOPING RESEARCH The diagnostic utility of these tests may require revision of laboratory work flows, care pathways and clinical and lab coordination, especially for any facility caring for the immunosuppressed, critically ill or those with chronic chest conditions, in whom fungal disease is common and underappreciated.
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Affiliation(s)
- Jacob Baker
- Department of Medicine, Shrewsbury and Telford Hospitals Trust, Mytton Oak Rd, Shrewsbury SY3 8XQ, UK
| | - David W Denning
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Global Action For Fungal Infections (GAFFI), Rue Le Corbusier 1208 Geneva, Switzerland
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Dlamini K, Moetlhoa B, Turner A, Maluleke K, Mashamba-Thompson T. Mapping evidence on cryptococcal antigen infection among HIV-infected persons in sub-Saharan Africa- A scoping review protocol. PLoS One 2023; 18:e0281849. [PMID: 37294775 PMCID: PMC10256208 DOI: 10.1371/journal.pone.0281849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/30/2023] [Indexed: 06/11/2023] Open
Abstract
INTRODUCTION Infections of the central nervous system are a considerable basis of mortality in people living with HIV, with progression to cryptococcal meningitis documented at around 15% of HIV-associated mortality globally, with nearly three-quarters occurring in the sub-Saharan Africa. Discoveries from previous studies prelude to the mortality of cryptococcal antigen positive, which persisted to be elevated than in cryptococcal antigen negative persons. One feasible interpretation of this could be due to undiagnosed cryptococcus. Laboratory investigations identify cryptococcal disease prior to cryptococcal meningitis progression. Point-of-care testing has high sensitivity and specificity as seen with the cryptococcal antigen lateral flow assay screening to expedite treatment. The aim of the study is to map and translate evidence on cryptococcal antigen infection among HIV-infected persons in sub-Saharan Africa. METHODOLOGY The proposed scoping review will be conducted using guidelines proposed by Arksey and O'Malley methodological framework and Levac et al. advanced method. It will be guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews. A comprehensive literature search of studies published from the first relevant publication to 2022 will be conducted on multiple electronic databases. Additional sources (grey literature) will also be searched. The search strategy will be generated and implemented by the principal investigator with assistance from a subject specialist, and an information specialist. Two reviewers will screen eligible studies. The screening will be guided by an inclusion and exclusion criteria. The mixed methods appraisal tool version 2018 will be used to appraise the quality of the empirical studies. DISCUSSION The proposed scoping review will map and translate evidence on cryptococcal antigen infection among HIV-infected persons in sub-Saharan Africa. Synthesising and sharing recent evidence in this area has potential to help guide future research and interventions aimed at improving the management of cryptococcal antigen infection among HIV-infected persons in sub-Saharan Africa and other high HIV- burdened settings.
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Affiliation(s)
- Khululiwe Dlamini
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Boitumelo Moetlhoa
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Astrid Turner
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Kuhlula Maluleke
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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Diagnostic Accuracy of Point of Care Cryptococcal Antigen Lateral Flow Assay in Fingerprick Whole Blood and Urine Samples for the Detection of Asymptomatic Cryptococcal Disease in Patients with Advanced HIV Disease. Microbiol Spectr 2022; 10:e0107522. [PMID: 35924841 PMCID: PMC9430595 DOI: 10.1128/spectrum.01075-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cryptococcal disease (CD) is a leading cause of mortality among individuals with advanced HIV disease (AHD). Screening with serum cryptococcal antigen (sCrAg) lateral flow assay (LFA) enables early detection of subclinical disease but requires venipuncture and laboratory processing. Clinic-based point of care (POC) CrAg screening tests using urine or fingerprick whole blood could facilitate early diagnosis of CD. We evaluated the diagnostic performance of POC clinic-based fingerprick whole blood and urine CrAg compared to the gold standard laboratory sCrAg LFA in screening for CD among asymptomatic individuals with CD4 counts of <200 cells/μL in Harare, Zimbabwe. sCrAg positive participants who consented to a lumbar puncture also had cerebrospinal fluid (CSF) CrAg testing and titers for CSF-positive specimens. A total of 1,333 individuals were screened, and over half (56.6%) were males. The median (interquartile range) CD4 count was 27.5 (11–46) cells/μL. We found a sensitivity of 63.8% (95% CI: 54.8–72.1) and specificity of 84.0% (95% CI: 81.7–86.0) for urine CrAg, and a sensitivity of 48.0% (95% CI: 39.1–57.1) and specificity of 99.5% (95% CI: 98.9–99.8) was found for fingerprick whole blood. The sensitivity of both POC CrAg tests increased in individuals with sCrAg titers of ≥1:160, CD4 count of <50 cells/μL and disseminated central nervous system (CNS) disease. Clinic-based POC urine and fingerprick whole blood CrAg testing performed better in screening for CD among AHD patients with CNS disease. More sensitive assays to identify AHD patients with asymptomatic CD are needed. IMPORTANCE Cryptococcal disease (CD) remains a leading cause of morbidity and mortality among individuals with advanced HIV disease (AHD). Identifying point of care (POC) approaches to screening for CD in asymptomatic individuals is important to guide therapeutic management. We evaluated the use of POC fingerprick whole blood and urine testing for cryptococcal disease in patients with AHD as compared with laboratory-based serum antigen testing. POC fingerprick whole blood and urine testing had low sensitivity and specificity in asymptomatic individuals with AHD. Most analysis has focused on evaluating test performance in symptomatic individuals. Here we show that POC testing with whole blood and urine samples should not be used to screen for asymptomatic CD in AHD.
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Ding M, Smith KD, Wiesner DL, Nielsen JN, Jackson KM, Nielsen K. Use of Clinical Isolates to Establish Criteria for a Mouse Model of Latent Cryptococcus neoformans Infection. Front Cell Infect Microbiol 2022; 11:804059. [PMID: 35186781 PMCID: PMC8847453 DOI: 10.3389/fcimb.2021.804059] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/10/2021] [Indexed: 12/15/2022] Open
Abstract
The mechanisms of latency in the context of C. neoformans infection remain poorly understood. Two reasons for this gap in knowledge are: 1) the lack of standardized criteria for defining latent cryptococcosis in animal models and 2) limited genetic and immunological tools available for studying host parameters against C. neoformans in non-murine models of persistent infection. In this study, we defined criteria required for latency in C. neoformans infection models and used these criteria to develop a murine model of persistent C. neoformans infection using clinical isolates. We analyzed infections with two clinical C. neoformans strains, UgCl223 and UgCl552, isolated from advanced HIV patients with cryptococcal meningitis. Our data show that the majority of C57BL/6 mice infected with the clinical C. neoformans isolates had persistent, stable infections with low fungal burden, survived beyond 90 days-post infection, exhibited weight gain, had no clinical signs of disease, and had yeast cells contained within pulmonary granulomas with no generalized alveolar inflammation. Infected mice exhibited stable relative frequencies of pulmonary immune cells during the course of the infection. Upon CD4+ T-cell depletion, the CD4DTR mice had significantly increased lung and brain fungal burden that resulted in lethal infection, indicating that CD4+ T-cells are important for control of the pulmonary infection and to prevent dissemination. Cells expressing the Tbet transcription factor were the predominant activated CD4 T-cell subset in the lungs during the latent infection. These Tbet-expressing T-cells had decreased IFNγ production, which may have implications in the capacity of the cells to orchestrate the pulmonary immune response. Altogether, these results indicate that clinical C. neoformans isolates can establish a persistent controlled infection that meets most criteria for latency; highlighting the utility of this new mouse model system for studies of host immune responses that control C. neoformans infections.
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Affiliation(s)
- Minna Ding
- Department of Microbiology and Immunology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Kyle D. Smith
- Department of Microbiology and Immunology, University of Minnesota Medical School, Minneapolis, MN, United States
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Darin L. Wiesner
- Department of Microbiology and Immunology, University of Minnesota Medical School, Minneapolis, MN, United States
- Department of Medicine, Center for Immunity and Inflammation, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Judith N. Nielsen
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Katrina M. Jackson
- Department of Microbiology and Immunology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Kirsten Nielsen
- Department of Microbiology and Immunology, University of Minnesota Medical School, Minneapolis, MN, United States
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Kendall EA, Hussain H, Kunkel A, Kubiak RW, Trajman A, Menzies R, Drain PK. Isoniazid or rifampicin preventive therapy with and without screening for subclinical TB: a modeling analysis. BMC Med 2021; 19:315. [PMID: 34903214 PMCID: PMC8670249 DOI: 10.1186/s12916-021-02189-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Short-course, rifamycin-based regimens could facilitate scale-up of tuberculosis preventive therapy (TPT), but it is unclear how stringently tuberculosis (TB) disease should be ruled out before TPT use. METHODS We developed a state-transition model of a TPT intervention among two TPT-eligible cohorts: adults newly diagnosed with HIV in South Africa (PWH) and TB household contacts in Pakistan (HHCs). We modeled two TPT regimens-4 months of rifampicin [4R] or 6 months of isoniazid [6H]-comparing each to a reference of no intervention. Before initiating TPT, TB disease was excluded either through symptom-only screening or with additional radiographic screening that could detect subclinical TB but might limit access to the TPT intervention. TPT's potential curative effects on both latent and subclinical TB were modeled, as were both acquisitions of resistance and prevention of drug-resistant disease. Although all eligible individuals received the screening and/or TPT interventions, the modeled TB outcomes comprised only those with latent or subclinical TB that would have progressed to symptomatic disease if untreated. RESULTS When prescribed after only symptom-based TB screening (such that individuals with subclinical TB were included among TPT recipients), 4R averted 45 active (i.e., symptomatic) TB cases (95% uncertainty range 24-79 cases or 40-89% of progressions to active TB) per 1000 PWH [17 (9-29, 43-94%) per 1000 HHCs]; 6H averted 37 (19-66, 52-73%) active TB cases among PWH [13 (7-23, 53-75%) among HHCs]. With this symptom-only screening, for each net rifampicin resistance case added by 4R, 12 (3-102) active TB cases were averted among PWH (37 [9-580] among HHCs); isoniazid-resistant TB was also reduced. Similarly, 6H after symptom-only screening increased isoniazid resistance while reducing overall and rifampicin-resistant active TB. Screening for subclinical TB before TPT eliminated this net increase in resistance to the TPT drug; however, if the screening requirement reduced TPT access by more than 10% (the estimated threshold for 4R among HHCs) to 30% (for 6H among PWH), it was likely to reduce the intervention's overall TB prevention impact. CONCLUSIONS All modeled TPT strategies prevent TB relative to no intervention, and differences between TPT regimens or between screening approaches are small relative to uncertainty in the outcomes of any given strategy. If most TPT-eligible individuals can be screened for subclinical TB, then pairing such screening with rifamycin-based TPT maximizes active TB prevention and does not increase rifampicin resistance. Where subclinical TB cannot be routinely excluded without substantially reducing TPT access, the choice of TPT regimen requires weighing 4R's efficacy advantages (as well as its greater safety and shorter duration that we did not directly model) against the consequences of rifampicin resistance in a small fraction of recipients.
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Affiliation(s)
- Emily A Kendall
- Division of Infectious Diseases and Center for Tuberculosis Research, Johns Hopkins University School of Medicine, 1550 Orleans Street, Baltimore, Maryland, 21287, USA.
| | - Hamidah Hussain
- Interactive Research and Development (IRD) Global, 583 Orchard Road #06-01 Forum, Singapore, Singapore
| | - Amber Kunkel
- Emerging Diseases Epidemiology Unit, Institut Pasteur, 25-28 Rue du Dr Roux, 75015, Paris, France
| | - Rachel W Kubiak
- Department of Epidemiology, University of Washington, 3980 15th Ave NE, Seattle, Washington, 98195, USA
| | - Anete Trajman
- Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, R. São Francisco Xavier, Rio de Janeiro, 20550-900, Brazil
| | - Richard Menzies
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & McGill International TB Centre, 3650 St-Urbain Street, Montreal, Quebec, H2X 2P, Canada
| | - Paul K Drain
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Box 359927, 325 Ninth Ave, Seattle, Washington, 98104, USA
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Drain PK, Galagan SR, Govere S, Krows M, Thulare H, Wallis CL, Gosnell BI, Moosa MY, Celum C, Bassett IV. Laboratory Reflex and Clinic-Based Point-of-Care Cryptococcal Antigen Screening for Preventing Meningitis and Mortality Among People Living With HIV. J Acquir Immune Defic Syndr 2021; 87:1205-1213. [PMID: 33990495 PMCID: PMC8263484 DOI: 10.1097/qai.0000000000002717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/08/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Cryptococcosis remains a leading cause of meningitis and mortality among people living with HIV (PLHIV) worldwide. We sought to evaluate laboratory-based cryptococcal antigen (CrAg) reflex testing and a clinic-based point-of-care (POC) CrAg screening intervention for preventing meningitis and mortality among PLHIV in South Africa. METHODS We conducted a prospective pre-post intervention study of adults presenting for HIV testing in Umlazi township, South Africa, over a 6-year period (2013-2019). Participants were enrolled during 3 phases of CrAg testing: CrAg testing ordered by a clinician (clinician-directed testing, 2013-2015); routine laboratory-based CrAg reflex testing for blood samples with CD4 ≤100 cells/mm3 (laboratory reflex testing, 2015-2017); and a clinic-based intervention with POC CD4 testing and POC CrAg testing for PLHIV with CD4 ≤200 cells/mm3 with continued standard-of-care routine laboratory reflex testing among those with CD4 ≤100 cells/mm3 (clinic-based testing, 2017-2019). The laboratory and clinical teams performed serum CrAg by enzyme immunoassay and lateral flow assay (Immy Diagnostics, Norman, OK). We followed up participants for up to 14 months to compare associations between baseline CrAg positivity, antiretroviral therapy and fluconazole treatment initiation, and outcomes of cryptococcal meningitis, hospitalization, and mortality. RESULTS Three thousand one hundred five (39.4%) of 7877 people screened were HIV-positive, of whom 908 had CD4 ≤200 cells/mm3 and were included in the analyses. Laboratory reflex and clinic-based testing increased CrAg screening (P < 0.001) and diagnosis of CrAg-positive PLHIV (P = 0.011). When compared with clinician-directed testing, clinic-based CrAg testing showed an increase in the number of PLHIV diagnosed with cryptococcal meningitis (4.5% vs. 1.5%; P = 0.059), initiation of fluconazole preemptive therapy (7.2% vs. 2.5%; P = 0.010), and initiation of antiretroviral therapy (96.8% vs. 91.3%; P = 0.012). Comparing clinic-based testing with laboratory reflex testing, there was no significant difference in the cumulative incidence of cryptococcal meningitis (4.5% vs. 4.1%; P = 0.836) or mortality (8.1% vs. 9.9%; P = 0.557). CONCLUSIONS Laboratory reflex and clinic-based CrAg testing facilitated the diagnosis of HIV-associated cryptococcosis and fluconazole initiation but did not reduce cryptococcal meningitis or mortality. In this nonrandomized cohort, clinical outcomes were similar between laboratory reflex testing and clinic-based POC CrAg testing.
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Affiliation(s)
- Paul K. Drain
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Sean R. Galagan
- Department of Global Health, University of Washington, Seattle, USA
| | | | - Meighan Krows
- Department of Global Health, University of Washington, Seattle, USA
| | | | | | - Bernadett I. Gosnell
- Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
| | - Mahomed-Yunus Moosa
- Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Ingrid V. Bassett
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Scharf S, Bartels A, Kondakci M, Haas R, Pfeffer K, Henrich B. fuPCR as diagnostic method for the detection of rare fungal pathogens, such as Trichosporon, Cryptococcus and Fusarium. Med Mycol 2021; 59:1101-1113. [PMID: 34379780 DOI: 10.1093/mmy/myab045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/21/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022] Open
Abstract
Fungal respiratory tract colonisation is a common finding in patients with hematologic neoplasms due to immunosuppression inherent in the diseases and exacerbated by therapy. This greatly increases the risk of fungal infections of the lungs, which is associated with significant mortality. Therefore, reliable diagnostic methods with rapidly available results are needed to administer adequate antifungal therapy.We have established an improved method for fungal DNA extraction and amplification that allows simultaneous detection of fungal families based on a set of multiplexed real time PCR reactions (fuPCR). We analysed respiratory rinses and blood of 94 patients with haematological systemic diseases by fuPCR and compared it with the results of culture and serological diagnostic methods. 40 healthy subjects served as controls.Regarding Candida species, the highest prevalence resulted from microbiological culture of respiratory rinses and from detection of antibodies in blood serum in patients (61% and 47%, respectively) and in the control group (29% and 51%, respectively). Detection of other pathogenic yeasts, such as Cryptococcus and Trichosporon, and moulds, such as Fusarium, was only possible in patients by fuPCR from both respiratory rinses and whole blood and serum. These fungal species were found statistically significantly more frequent in respiratory rinses collected from patients after myeloablative therapy for stem cell transplantation compared to samples collected before treatment (p<<0.05i>).The results show that fuPCR is a valuable complement to culturing and its inclusion in routine mycological diagnostics might be helpful for early detection of pathophysiologically relevant respiratory colonisation for patients with hematologic neoplasms. LAY ABSTRACT We validated a set of PCR reactions (fuPCR) for use in routine diagnostic. In contrast to culture and serological methods, only by fuPCR pathogenic yeasts (Cryptococcus and Trichosporon) and moulds (Aspergillus and Fusarium) were detected in respiratory rinses and blood of haematological patients.
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Affiliation(s)
- Sebastian Scharf
- Institute of Medical Microbiology and Hospital Hygiene, Heinrich-Heine University of Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Anna Bartels
- Department of Haematology, Oncology and Clinical Immunology, Heinrich-Heine University of Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Mustafa Kondakci
- Department of Haematology, Oncology and Clinical Immunology, Heinrich-Heine University of Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Rainer Haas
- Department of Haematology, Oncology and Clinical Immunology, Heinrich-Heine University of Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Klaus Pfeffer
- Institute of Medical Microbiology and Hospital Hygiene, Heinrich-Heine University of Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Birgit Henrich
- Institute of Medical Microbiology and Hospital Hygiene, Heinrich-Heine University of Duesseldorf, Medical Faculty, Duesseldorf, Germany
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Bremer M, Kadernani YE, Wasserman S, Wilkinson RJ, Davis AG. Strategies for the diagnosis and management of meningitis in HIV-infected adults in resource limited settings. Expert Opin Pharmacother 2021; 22:2053-2070. [PMID: 34154509 DOI: 10.1080/14656566.2021.1940954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The incidence of human immunodeficiency virus-1 (HIV-1) associated meningitis has been declining in the post-combination antiretroviral treatment (ART) era, although survival rates remain low for the common causes like tuberculosis and cryptococcal disease. Diagnosis and treatment of meningitis in HIV-1 is complicated by atypical clinical presentations, limited accuracy of diagnostic tests, access to diagnostic tests, and therapeutic agents in low- and middle-income countries (LMIC) and immune reconstitution inflammatory syndrome (IRIS). AREAS COVERED We provide an overview of the common etiologies of meningitis in HIV-1-infected adults, suggest a diagnostic approach based on readily available tests, and review specific chemotherapeutic agents, host-directed therapies, supportive care, timing of ART initiation, and considerations in the management of IRIS with a focus on resource-limited settings. They identify key knowledge gaps and suggest areas for future research. EXPERT OPINION Evidence-based management of HIV-1-associated meningitis is sparse for common etiologies. More readily available and sensitive diagnostic tests as well as standardized investigation strategies are required in LMIC. There is a lack of availability of recommended drugs in areas of high HIV-1 prevalence and a limited pipeline of novel chemotherapeutic agents. Host-directed therapies have been inadequately studied.
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Affiliation(s)
- Marise Bremer
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory
| | - Yakub E Kadernani
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory
| | - Sean Wasserman
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory.,Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Republic of South Africa
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory.,Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Republic of South Africa.,Department of Infectious Diseases, Imperial College London, London, UK.,Francis Crick Institute, London, UK.,Faculty of Life Sciences, University College London, London, UK
| | - Angharad G Davis
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory.,Francis Crick Institute, London, UK.,Faculty of Life Sciences, University College London, London, UK
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Evaluation of the Dynamiker Cryptococcal Antigen Lateral Flow Assay for the Diagnosis of HIV-Associated Cryptococcosis. J Clin Microbiol 2021; 59:JCM.02421-20. [PMID: 33268538 DOI: 10.1128/jcm.02421-20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/21/2020] [Indexed: 12/12/2022] Open
Abstract
Cryptococcal meningitis is a leading cause of meningitis in sub-Saharan Africa. Given the need for rapid point-of-care testing, we evaluated the diagnostic performance of the Dynamiker cryptococcal antigen (CrAg) lateral flow assay (LFA). We assessed the diagnostic performance of the Dynamiker CrAg LFA compared to the IMMY CrAg LFA as the reference standard. We tested 150 serum, 115 plasma, and 100 cerebrospinal fluid (CSF) samples from HIV patients with symptomatic meningitis and 113 serum samples from patients with suspected asymptomatic cryptococcal antigenemia. Compared to the IMMY CrAg LFA, sensitivity of Dynamiker CrAg LFA was 98% in serum, 100% in plasma, 100% in CSF from symptomatic patients and 96% in serum from asymptomatic patients. Specificity was 66% in serum, 61% in plasma, and 91% in CSF from symptomatic patients, and 86% in serum from asymptomatic patients. The positive predictive value was 85% in serum, 82% in plasma, and 96% in CSF from symptomatic patients, and 69% in serum from asymptomatic patients. The negative predictive value was 94% in serum, 100% in plasma, and 100% in CSF from symptomatic patients, and 99% in serum from asymptomatic patients. The interassay reproducibility was 100% across the four sample types with no observed discordant results when Dynamiker CrAg LFA was tested in duplicate. However, a high number of false positives were observed on serum of symptomatic patients (11%), serum of asymptomatic patients (11%) and plasma of symptomatic patients (14%). The Dynamiker CrAg LFA had excellent sensitivity but poor specificity, particularly when tested on serum and plasma.
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Kainz DM, Breiner BJ, Früh SM, Hutzenlaub T, Zengerle R, Paust N. Eliminating viscosity bias in lateral flow tests. MICROSYSTEMS & NANOENGINEERING 2021; 7:72. [PMID: 34567784 PMCID: PMC8433459 DOI: 10.1038/s41378-021-00296-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/17/2021] [Accepted: 06/28/2021] [Indexed: 05/15/2023]
Abstract
Despite the widespread application of point-of-care lateral flow tests, the viscosity dependence of these assay results remains a significant challenge. Here, we employ centrifugal microfluidic flow control through the nitrocellulose membrane of the strip to eliminate the viscosity bias. The key feature is the balancing of the sample flow into the cassette of the lateral flow test with the air flow out of the cassette. A viscosity-independent flow rate of 3.01 ± 0.18 µl/min (±6%) is demonstrated for samples with viscosities ranging from 1.1 mPas to 24 mPas, a factor greater than 20. In a model human IgG lateral flow assay, signal-intensity shifts caused by varying the sample viscosity from 1.1 mPas to 2.3 mPas could be reduced by more than 84%.
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Affiliation(s)
- Daniel M. Kainz
- Laboratory for MEMS Applications, IMTEK - Department of Microsystems Engineering, University of Freiburg, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
| | | | - Susanna M. Früh
- Laboratory for MEMS Applications, IMTEK - Department of Microsystems Engineering, University of Freiburg, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
| | - Tobias Hutzenlaub
- Laboratory for MEMS Applications, IMTEK - Department of Microsystems Engineering, University of Freiburg, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
| | - Roland Zengerle
- Laboratory for MEMS Applications, IMTEK - Department of Microsystems Engineering, University of Freiburg, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
| | - Nils Paust
- Laboratory for MEMS Applications, IMTEK - Department of Microsystems Engineering, University of Freiburg, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
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13
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Flower B, Brown JC, Simmons B, Moshe M, Frise R, Penn R, Kugathasan R, Petersen C, Daunt A, Ashby D, Riley S, Atchison CJ, Taylor GP, Satkunarajah S, Naar L, Klaber R, Badhan A, Rosadas C, Khan M, Fernandez N, Sureda-Vives M, Cheeseman HM, O'Hara J, Fontana G, Pallett SJC, Rayment M, Jones R, Moore LSP, McClure MO, Cherepanov P, Tedder R, Ashrafian H, Shattock R, Ward H, Darzi A, Elliot P, Barclay WS, Cooke GS. Clinical and laboratory evaluation of SARS-CoV-2 lateral flow assays for use in a national COVID-19 seroprevalence survey. Thorax 2020; 75:1082-1088. [PMID: 32796119 PMCID: PMC7430184 DOI: 10.1136/thoraxjnl-2020-215732] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/22/2020] [Accepted: 07/25/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Accurate antibody tests are essential to monitor the SARS-CoV-2 pandemic. Lateral flow immunoassays (LFIAs) can deliver testing at scale. However, reported performance varies, and sensitivity analyses have generally been conducted on serum from hospitalised patients. For use in community testing, evaluation of finger-prick self-tests, in non-hospitalised individuals, is required. METHODS Sensitivity analysis was conducted on 276 non-hospitalised participants. All had tested positive for SARS-CoV-2 by reverse transcription PCR and were ≥21 days from symptom onset. In phase I, we evaluated five LFIAs in clinic (with finger prick) and laboratory (with blood and sera) in comparison to (1) PCR-confirmed infection and (2) presence of SARS-CoV-2 antibodies on two 'in-house' ELISAs. Specificity analysis was performed on 500 prepandemic sera. In phase II, six additional LFIAs were assessed with serum. FINDINGS 95% (95% CI 92.2% to 97.3%) of the infected cohort had detectable antibodies on at least one ELISA. LFIA sensitivity was variable, but significantly inferior to ELISA in 8 out of 11 assessed. Of LFIAs assessed in both clinic and laboratory, finger-prick self-test sensitivity varied from 21% to 92% versus PCR-confirmed cases and from 22% to 96% versus composite ELISA positives. Concordance between finger-prick and serum testing was at best moderate (kappa 0.56) and, at worst, slight (kappa 0.13). All LFIAs had high specificity (97.2%-99.8%). INTERPRETATION LFIA sensitivity and sample concordance is variable, highlighting the importance of evaluations in setting of intended use. This rigorous approach to LFIA evaluation identified a test with high specificity (98.6% (95%CI 97.1% to 99.4%)), moderate sensitivity (84.4% with finger prick (95% CI 70.5% to 93.5%)) and moderate concordance, suitable for seroprevalence surveys.
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Affiliation(s)
- Barnaby Flower
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
- NIHR BRC, Imperial College NHS Trust, London, UK
| | - Jonathan C Brown
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Bryony Simmons
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Maya Moshe
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Rebecca Frise
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Rebecca Penn
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Ruthiran Kugathasan
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | | | - Anna Daunt
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Deborah Ashby
- Department of Epidemiology and Public Health, Imperial College London, London, UK
| | - Steven Riley
- Department of Epidemiology and Public Health, Imperial College London, London, UK
| | - Christina Joanne Atchison
- NIHR BRC, Imperial College NHS Trust, London, UK
- Department of Epidemiology and Public Health, Imperial College London, London, UK
| | - Graham P Taylor
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Sutha Satkunarajah
- Institute of Global Health Innovation, Imperial College London, London, UK
| | - Lenny Naar
- Institute of Global Health Innovation, Imperial College London, London, UK
| | | | - Anjna Badhan
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Carolina Rosadas
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Maryam Khan
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Natalia Fernandez
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Macià Sureda-Vives
- Synthetic Biology Group, MRC London Institute of Medical Sciences, Imperial College London, London, UK
| | - Hannah M Cheeseman
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Jessica O'Hara
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Gianluca Fontana
- Institute of Global Health Innovation, Imperial College London, London, UK
| | - Scott J C Pallett
- Centre for Defence Pathology, British Army, Birmingham, UK
- Chelsea and Westminster Healthcare NHS Trust, London, UK
| | | | - Rachael Jones
- Chelsea and Westminster Healthcare NHS Trust, London, UK
| | - Luke S P Moore
- Chelsea and Westminster Healthcare NHS Trust, London, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Myra O McClure
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Peter Cherepanov
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Richard Tedder
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Hutan Ashrafian
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Robin Shattock
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Helen Ward
- NIHR BRC, Imperial College NHS Trust, London, UK
- Department of Epidemiology and Public Health, Imperial College London, London, UK
| | - Ara Darzi
- NIHR BRC, Imperial College NHS Trust, London, UK
- Institute of Global Health Innovation, Imperial College London, London, UK
| | - Paul Elliot
- NIHR BRC, Imperial College NHS Trust, London, UK
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
| | - Wendy S Barclay
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Graham S Cooke
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
- NIHR BRC, Imperial College NHS Trust, London, UK
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Xie LM, Lin GL, Dong HN, Liao YX, Liu YL, Qin JF, Guo XG. Evaluation of lateral flow immunochromatographic assay for diagnostic accuracy of cryptococcosis. BMC Infect Dis 2020; 20:650. [PMID: 32887568 PMCID: PMC7472705 DOI: 10.1186/s12879-020-05368-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 08/25/2020] [Indexed: 11/20/2022] Open
Abstract
Background Cryptococcus is a conditional pathogenic fungus causing cryptococcosis, which is one of the most serious fungal diseases faced by humans. Lateral flow immunochromatographic assay (LFA) is successfully applied to the rapid detection of cryptococcal antigens. Methods Studies were retrieved systematically from the Embase, PubMed, Web of Science, and Cochrane Library before July 2019. The quality of the studies was assessed by Review Manager 5.0 based on the Quality Assessment of Diagnostic Accuracy Study guidelines. The extracted data from the included studies were analyzed by Meta-DiSc 1.4. Stata 12.0 software was used to detect the publication bias. Results A total of 15 articles with 31 fourfold tables were adopted by inclusion and exclusion criteria. The merged sensitivity and specificity in serum were 0.98 and 0.98, respectively, and those in the cerebrospinal fluid were 0.99 and 0.99, respectively. Conclusions Compared to the urine and other samples, LFA in serum and cerebrospinal fluid is favorable evidence for the diagnosis of cryptococcosis with high specificity and sensitivity.
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Affiliation(s)
- Li-Min Xie
- Department of Clinical Medicine, The Third Clinical School of Guangzhou Medical University, Guangzhou, 511436, China.,Department of Clinical Laboratory Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Geng-Ling Lin
- Department of Clinical Medicine, The Third Clinical School of Guangzhou Medical University, Guangzhou, 511436, China.,Department of Clinical Laboratory Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Hao-Neng Dong
- Department of Clinical Medicine, The Third Clinical School of Guangzhou Medical University, Guangzhou, 511436, China.,Department of Clinical Laboratory Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Ying-Xia Liao
- Department of Clinical Medicine, The Third Clinical School of Guangzhou Medical University, Guangzhou, 511436, China.,Department of Clinical Laboratory Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Ye-Ling Liu
- Department of Clinical Medicine, The Third Clinical School of Guangzhou Medical University, Guangzhou, 511436, China.,Department of Clinical Laboratory Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Jian-Feng Qin
- Department of Clinical Pharmacy, The Pharmic School of Guangzhou Medical University, Guangzhou, 511436, China
| | - Xu-Guang Guo
- Department of Clinical Medicine, The Third Clinical School of Guangzhou Medical University, Guangzhou, 511436, China. .,Department of Clinical Laboratory Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China. .,Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China. .,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China.
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15
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Greene G, Lawrence DS, Jordan A, Chiller T, Jarvis JN. Cryptococcal meningitis: a review of cryptococcal antigen screening programs in Africa. Expert Rev Anti Infect Ther 2020; 19:233-244. [PMID: 32567406 DOI: 10.1080/14787210.2020.1785871] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Cryptococcal meningitis remains a significant contributor to AIDS-related mortality despite widened access to antiretroviral therapy. Cryptococcal antigen (CrAg) can be detected in the blood prior to development of meningitis. Development of highly sensitive and specific rapid diagnostic CrAg tests has helped facilitate the adoption of CrAg screening programs in 19 African countries. AREAS COVERED The biological rationale for CrAg screening and the programmatic strategies for its implementation are reviewed. We describe the approach to the investigation of patients with cryptococcal antigenemia and the importance of lumbar puncture to identify individuals who may have cryptococcal meningitis in the absence of symptoms. The limitations of current treatment recommendations and the potential role of newly defined combination antifungal therapies are discussed. A literature review was conducted using a broad database search for cryptococcal antigen screening and related terms in published journal articles dating up to December 2019. Conference abstracts, publicly available guidelines, and project descriptions were also incorporated. EXPERT OPINION As we learn more about the risks of cryptococcal antigenemia, it has become clear that the current management paradigm is inadequate. More intensive investigation and management are required to prevent the development of cryptococcal meningitis and reduce mortality associated with cryptococcal antigenemia.
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Affiliation(s)
- Greg Greene
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, a Division of the NHLS , Johannesburg, South Africa.,Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine , London, UK
| | - David S Lawrence
- Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine , London, UK.,Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana
| | - Alex Jordan
- Mycotic Diseases Branch, Centers for Disease Control and Prevention , Atlanta, USA
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention , Atlanta, USA
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine , London, UK.,Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana
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16
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Wykowski J, Galagan SR, Govere S, Wallis CL, Moosa MY, Celum C, Drain PK. Cryptococcal antigenemia is associated with meningitis or death in HIV-infected adults with CD4 100-200 cells/mm 3. BMC Infect Dis 2020; 20:61. [PMID: 31959112 PMCID: PMC6971851 DOI: 10.1186/s12879-020-4798-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/15/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Cryptococcal antigen (CrAg) screening with fluconazole prophylaxis has been shown to prevent cryptococcal meningitis and mortality for people living with HIV (PLWH) with CD4 < 100 cells/mm3. While cryptococcal meningitis occurs in individuals with CD4 100-200 cells/mm3, there is limited evidence that CrAg screening predicts cryptococcal meningitis or mortality among this group with moderate immunosuppression. Current IDSA and WHO clinical guidelines recommend restricting CrAg screening to PLWH with CD4 < 100 cells/mm3. METHODS We conducted a prospective cohort study of PLWH 18+ years who had not initiated ART in South Africa. We followed participants for 14 months to determine onset of cryptococcal meningitis or all-cause mortality. At study completion, we retrospectively tested stored serum samples for CrAg using an enzyme immunoassay (EIA). We calculated CD4-stratified incidence rates of outcomes and used Cox proportional hazards to measure associations between CrAg positivity and outcomes. RESULTS We enrolled 2383 PLWH, and 1309 participants had serum samples tested by CrAg EIA. The median CD4 was 317 cells/mm3 (interquartile range: 173-491 cells/mm3). By CD4 count at baseline, there were 209 individuals with a CD4 count of 100-200 cells/mm3 and available CrAg test results. Of these, four (1.9%) tested positive. Two of four (IR: 58.8 per 100 person-years) CrAg+ participants and 11 of 205 (IR: 5.6 per 100 person-years) CrAg- participants developed cryptococcal meningitis or died for an overall rate of death or cryptococcal meningitis that was 10.0-times higher for those who were CrAg+ (95% confidence interval: 2.2-45.3). Among those with CD4 < 100 cell/mm3 and CrAg EIA test results (N = 179), ten (5.6%) participants tested CrAg+. Among this group, seven of ten (IR: 137.6 per 100 person-years) CrAg+ participants and 26 of 169 (IR: 17.8 per 100 person-years) CrAg- participants developed cryptococcal meningitis or died, for a rate of death or cryptococcal meningitis that was 6.3-times higher for those who were CrAg+ (95% confidence interval: 2.7-14.6). CONCLUSIONS Although few PLWH with moderate immunosuppression screened CrAg positive, a positive CrAg test was predictive of increased risk of cryptococcal meningitis or death. Similar to those with a CD4 < 100 cell/mm3, systematic CrAg screening may reduce morbidity and mortality in PLWH with CD4 100-200 cells/mm3.
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Affiliation(s)
- James Wykowski
- Department of Medicine, University of Washington, Seattle, USA.
| | | | | | | | - Mahomed-Yunus Moosa
- Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
| | - Connie Celum
- Department of Medicine, University of Washington, Seattle, USA.,Global Health, University of Washington, Seattle, USA
| | - Paul K Drain
- Department of Medicine, University of Washington, Seattle, USA.,Global Health, University of Washington, Seattle, USA.,Epidemiology, University of Washington, Seattle, USA
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Thornton CR. Detection of the 'Big Five' mold killers of humans: Aspergillus, Fusarium, Lomentospora, Scedosporium and Mucormycetes. ADVANCES IN APPLIED MICROBIOLOGY 2019; 110:1-61. [PMID: 32386603 DOI: 10.1016/bs.aambs.2019.10.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Fungi are an important but frequently overlooked cause of morbidity and mortality in humans. Life-threatening fungal infections mainly occur in immunocompromised patients, and are typically caused by environmental opportunists that take advantage of a weakened immune system. The filamentous fungus Aspergillus fumigatus is the most important and well-documented mold pathogen of humans, causing a number of complex respiratory diseases, including invasive pulmonary aspergillosis, an often fatal disease in patients with acute leukemia or in immunosuppressed bone marrow or solid organ transplant recipients. However, non-Aspergillus molds are increasingly reported as agents of disseminated diseases, with Fusarium, Scedosporium, Lomentospora and mucormycete species now firmly established as pathogens of immunosuppressed and immunocompetent individuals. Despite well-documented risk factors for invasive fungal diseases, and increased awareness of the risk factors for life-threatening infections, the number of deaths attributable to molds is likely to be severely underestimated driven, to a large extent, by the lack of readily accessible, cheap, and accurate tests that allow detection and differentiation of infecting species. Early diagnosis is critical to patient survival but, unlike Aspergillus diseases, where a number of CE-marked or FDA-approved biomarker tests are now available for clinical diagnosis, similar tests for fusariosis, scedosporiosis and mucormycosis remain experimental, with detection reliant on insensitive and slow culture of pathogens from invasive bronchoalveolar lavage fluid, tissue biopsy, or from blood. This review examines the ecology, epidemiology, and contemporary methods of detection of these mold pathogens, and the obstacles to diagnostic test development and translation of novel biomarkers to the clinical setting.
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