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Matsumoto K, Goto M, Kamikokura Y, Takasawa K, Kobayashi N, Aoyama T, Murakami T, Kamikokura M, Ikechi Y, Kawahata T, Tanaka K, Takatori S, Fujishiro D, Okamoto K, Makino Y, Nishikawa Y, Takasawa A. Molecular and ultrastructural morphological analyses of highly metamorphosed Aspergillus fumigatus on human formalin-fixed paraffin-embedded tissue. Med Mol Morphol 2024:10.1007/s00795-024-00402-2. [PMID: 39141108 DOI: 10.1007/s00795-024-00402-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 07/26/2024] [Indexed: 08/15/2024]
Abstract
Invasive fungal infections including invasive pulmonary aspergillosis (IPA) generally have a poor prognosis, because the fungi spread throughout various organs. Therefore, it is important to accurately identify the fungal species for treatment. In this article, we present the results of pathological and molecular morphological analyses that were performed to elucidate the cause of respiratory failure in a patient who died despite suspicion of IPA and treatment with micafungin (MCFG). Pathological analysis revealed the existence of cystic and linear fungi in lung tissue. The fungi were identified as Aspergillus fumigatus (A. fumigatus) by partial sequencing of genomic DNA. Correlative light microscopy and electron microscopy (CLEM) analysis confirmed that fungi observed with light microscopy can also be observed with scanning electron microscopy (SEM) using formalin-fixed paraffin-embedded tissue sections. SEM revealed an atypical ultrastructure of the fungi including inhomogeneous widths, rough surfaces, and numerous cyst-like structures of various sizes. The fungi showed several morphological changes of cultured A. fumigatus treated with MCFG that were previously reported. Our results indicate that integrated analysis of ultrastructural observation by SEM and DNA sequencing may be an effective tool for analyzing fungi that are difficult to identify by conventional pathological analysis.
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Affiliation(s)
- Kazuhiro Matsumoto
- Division of Tumor Pathology, Department of Pathology, Asahikawa Medical University School of Medicine, Higashi 2-1-1-1, Midorigaoka, Asahikawa, 078-8510, Japan
| | - Masanori Goto
- Division of Tumor Pathology, Department of Pathology, Asahikawa Medical University School of Medicine, Higashi 2-1-1-1, Midorigaoka, Asahikawa, 078-8510, Japan.
| | - Yuki Kamikokura
- Division of Tumor Pathology, Department of Pathology, Asahikawa Medical University School of Medicine, Higashi 2-1-1-1, Midorigaoka, Asahikawa, 078-8510, Japan
- Department of Diagnostic Pathology, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Kumi Takasawa
- Division of Tumor Pathology, Department of Pathology, Asahikawa Medical University School of Medicine, Higashi 2-1-1-1, Midorigaoka, Asahikawa, 078-8510, Japan
| | - Nobuyuki Kobayashi
- Medical Laboratory and Blood Center, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Tomoyuki Aoyama
- Department of Pathology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Taro Murakami
- Department of Pathology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masayo Kamikokura
- Division of Tumor Pathology, Department of Pathology, Asahikawa Medical University School of Medicine, Higashi 2-1-1-1, Midorigaoka, Asahikawa, 078-8510, Japan
| | - Yuta Ikechi
- Division of Endocrinology, Metabolism, and Rheumatology Department of Internal Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Tomoki Kawahata
- Division of Endocrinology, Metabolism, and Rheumatology Department of Internal Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Kitaru Tanaka
- Division of Endocrinology, Metabolism, and Rheumatology Department of Internal Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Sayaka Takatori
- Division of Endocrinology, Metabolism, and Rheumatology Department of Internal Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Daisuke Fujishiro
- Division of Endocrinology, Metabolism, and Rheumatology Department of Internal Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Kensaku Okamoto
- Division of Endocrinology, Metabolism, and Rheumatology Department of Internal Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Yuichi Makino
- Center for Integrated Medical Education and Regional Symbiosis, Asahikawa Medical University Hospital, Asahikawa, Japan
| | | | - Akira Takasawa
- Division of Tumor Pathology, Department of Pathology, Asahikawa Medical University School of Medicine, Higashi 2-1-1-1, Midorigaoka, Asahikawa, 078-8510, Japan.
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Suresh D, Rastogi P, Bal A, Lad D, Naseem S, Jain A, Khadwal AR, Malhotra P. Bridging the gap: understanding contemporary autopsies in acute leukemia by comparing ante-mortem and post-mortem profiles. Leuk Lymphoma 2024:1-16. [PMID: 38949830 DOI: 10.1080/10428194.2024.2372408] [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: 02/26/2024] [Accepted: 06/20/2024] [Indexed: 07/02/2024]
Abstract
This study investigates acute myeloid leukemia/lymphoblastic leukemia (AML/ALL) through a 14-year analysis (2009-2022) of 46 autopsied cases (age >12 years). B-ALL was the dominant subtype (34.8%). Liver and spleen were the common sites of active leukemia (63% cases). Symptoms like dyspnea and altered sensorium associated significantly with heart (p = .031) and brain leukostasis (p = .006). Measurable residual disease (MRD) negativity correlated with disease-free status outside the bone marrow, while MRD-positive cases displayed leukemic infiltrates. Infections were identified in 23 autopsied cases, notably linked to post-induction and post-transplant fatalities. Surprisingly, 18 of these 23 cases had unexpected infections mainly fungal (13 cases) with Aspergillus species as the most common. Diagnostic discrepancies were identified in 48% of cases. Malignant infiltration (46%) and infections (25%) were the leading causes of death. This research sheds light on leukemia in extra-medullary tissues, uncovers novel clinical-pathological associations, and highlights overlooked therapy side effects, offering insights for future case management.
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Affiliation(s)
- Deepthi Suresh
- Department of Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pulkit Rastogi
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepesh Lad
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shano Naseem
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arihant Jain
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alka Rani Khadwal
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Goldman BI, Bharadwaj R, Fuller M, Love T, Metlay L, Dignan C. Error codes at autopsy to study potential biases in diagnostic error. Diagnosis (Berl) 2023; 10:375-382. [PMID: 37791806 DOI: 10.1515/dx-2023-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 08/20/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVES Current autopsy practice guidelines do not provide a mechanism to identify potential causes of diagnostic error (DE). We used our autopsy data registry to ask if gender or race were related to the frequency of diagnostic error found at autopsy. METHODS Our autopsy reports include International Classification of Diseases (ICD) 9 or ICD 10 diagnostic codes for major diagnoses as well as codes that identify types of error. From 2012 to mid-2015 only 2 codes were used: UNDOC (major undocumented diagnoses) and UNCON (major unconfirmed diagnoses). Major diagnoses contributed to death or would have been treated if known. Since mid-2015, codes included specific diagnoses, i.e. undiagnosed or unconfirmed myocardial infarction, infection, pulmonary thromboembolism, malignancy, or other diagnosis as well as cause of death. Adult autopsy cases from 2012 to 2019 were assessed for DE associated with reported sex or race (nonwhite or white). 528 cases were evaluated between 2012 and 2015 and 699 between 2015 and 2019. RESULTS Major DEs were identified at autopsy in 65.9 % of cases from 2012 to 2015 and in 72.1 % from 2015 to 2019. From 2012 to 2015, female autopsy cases showed a greater frequency in 4 parameters of DE, i.e., in the total number of cases with any error (p=0.0001), in the number of cases with UNDOC errors (p=0.0038) or UNCON errors (p=0.0006), and in the relative proportions of total numbers of errors (p=0.0001). From 2015 to 2019 undocumented malignancy was greater among males (p=0.0065); no other sex-related error was identified. In the same period some DE parameters were greater among nonwhite than among white subjects, including unconfirmed cause of death (p=0.035), and proportion of total error diagnoses (p=0.0003), UNCON diagnoses (p=0.0093), and UNDOC diagnoses (p=0.035). CONCLUSIONS Coding for DE at autopsy can identify potential effects of biases on diagnostic error.
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Affiliation(s)
- Bruce I Goldman
- Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Rajnish Bharadwaj
- Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Michelle Fuller
- Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Tanzy Love
- Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, USA
| | - Leon Metlay
- Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Caroline Dignan
- Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
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Kubota Y, Takasawa A, Ono Y, Aoyama T, Takasawa K, Tada A, Magara K, Murakami T, Daimon F, Yamamoto S, Sato S, Hiratsuka Y, Kyuno D, Osanai M. Invasive pulmonary aspergillosis with candidiasis: usefulness of molecular and ultrastructural morphological analysis on FFPE tissue for invasive fungal infections. Med Mol Morphol 2023; 56:144-151. [PMID: 36806624 PMCID: PMC9940076 DOI: 10.1007/s00795-023-00349-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/06/2023] [Indexed: 02/23/2023]
Abstract
Invasive pulmonary aspergillosis (IPA) is one of the most frequent forms of invasive fungal infections (IFI); however, it is often difficult to identify the pathogenic fungal species and to select appropriate treatments for patients with IFI including IPA. Here, we describe the detailed pathophysiology of an autopsy case of severe respiratory failure due to IPA with candidiasis. The patient developed severe respiratory failure after influenza infection and died, and the autopsy revealed a mixed disease of IPA with candidiasis. In this study, in addition to the routine pathological examination, we further examined formalin-fixed paraffin-embedded (FFPE) tissues by scanning electron microscopy (SEM) and partial genomic DNA sequencing. Although optical microscopy alone was insufficient to identify the pathogenic organisms, SEM clearly depicted the characteristic morphology of Aspergillus sp. and Candida sp. as closely overlapping in a nested fashion, providing evidence of mixed infection of both fungal species in a focal site. The technique using FFPE tissue in combination with ultrastructural observation by SEM, elemental analysis by SEM-EDX, and DNA sequencing is promising for analyzing the pathophysiology of IFI.
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Affiliation(s)
- Yusaku Kubota
- Department of Pathology, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Akira Takasawa
- Department of Pathology, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556, Japan.
| | - Yusuke Ono
- Department of Pathology, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Tomoyuki Aoyama
- Department of Pathology, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Kumi Takasawa
- Department of Pathology, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Akinori Tada
- Department of Pathology, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Kazufumi Magara
- Department of Pathology, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Taro Murakami
- Department of Pathology, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Fuminori Daimon
- Department of Pathology, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Soh Yamamoto
- Department of Microbiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Shota Sato
- Emergency and Critical Care Center, Hakodate Municipal Hospital, Hakodate, Japan
| | - Yutaro Hiratsuka
- Department of Pathology, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556, Japan
- Department of Internal Medicine, Kin-ikyo Chuo Hospital, Sapporo, Japan
| | - Daisuke Kyuno
- Department of Pathology, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Makoto Osanai
- Department of Pathology, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556, Japan
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Anisimova AS, Poleeva MV, Aronova NV, Tsimbalistova MV, Pavlovich NV. Pecularities of Candida yeast identification by mass spectrometric analysis (MALDI-ToF MS). Klin Lab Diagn 2022; 67:244-249. [PMID: 35575399 DOI: 10.51620/0869-2084-2022-67-4-244-249] [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: 11/06/2022]
Abstract
To carry the comparative analysis of sample preparation methods for the most effective identification of Candida yeast by mass spectrometric analysis. 265 strains of yeast and yeast-like fungi isolated from the sputum of patients with pneumonia were investigated. The selected strains were identified by conventional methods (cultural, morphological, tinctorial, enzymatic properties) and MALDI-ToF MS using the Autoflex speed III Bruker Daltonics mass spectrometer (Germany) and Flex Control software. To evaluate the effectiveness of fungi species determinination, the comparative analysis of sample preparation was performed using 4 methods: direct application to the target, an extended direct application method, protein extraction using ethanol/formic acid or trifluoroacetic acid. The accelerated scheme of identification of fungi by the culture method does not provide clear and unambiguous results. When using mass spectrometric analysis, the reliability of the results depended on the sample preparation. A comparative study of the effectiveness of fungi species determination by various methods of the sample preparation of 50 clinical isolates was carried out. It was revealed that the extraction of cells using TFC acid does not lead to the appearance of the recordable protein spectra. The use of direct and extended direct application methods made it possible to establish the species only in 32-44% of the strains. The most effective method of sample preparation was the method using formic acid and ethanol, which allowed us to determine the species affiliation in 100% of the studied fungi (Score 2.0). Depending on the yeast species, a high statistical indicator (Score≥2.3) was registered for 42-100% of samples. The results of present study show that the use of MALDI-ToF MS is the most reliable and informative method of Candida spp.identification.
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Affiliation(s)
- A S Anisimova
- Federal State Health Institution «Rostov-on-Don Anti-Plague Institute» of the Federal Service for Supervision of Consumer Rights Protection and Human Welfare
| | - M V Poleeva
- Federal State Health Institution «Rostov-on-Don Anti-Plague Institute» of the Federal Service for Supervision of Consumer Rights Protection and Human Welfare
| | - N V Aronova
- Federal State Health Institution «Rostov-on-Don Anti-Plague Institute» of the Federal Service for Supervision of Consumer Rights Protection and Human Welfare
| | - M V Tsimbalistova
- Federal State Health Institution «Rostov-on-Don Anti-Plague Institute» of the Federal Service for Supervision of Consumer Rights Protection and Human Welfare
| | - N V Pavlovich
- Federal State Health Institution «Rostov-on-Don Anti-Plague Institute» of the Federal Service for Supervision of Consumer Rights Protection and Human Welfare
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Population Pharmacokinetic Analysis and Dosing Optimization of Prophylactic Fluconazole in Japanese Patients with Hematological Malignancy. J Fungi (Basel) 2021; 7:jof7110975. [PMID: 34829262 PMCID: PMC8618010 DOI: 10.3390/jof7110975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 11/24/2022] Open
Abstract
We conducted population pharmacokinetic (PPK) analysis and Monte Carlo simulations to determine the appropriate prophylactic dose of fluconazole to prevent invasive candidiasis in patients with hematological malignancies. Patients receiving chemotherapy or hematopoietic stem cell transplantation at Yokohama City University Hospital between November 2018 and March 2020 were included. Additionally, patients receiving oral fluconazole for prophylaxis were recruited. We set the free area under the curve/minimum inhibitory concentration (MIC) = 50 as the target and determined the largest MIC (breakpoint MIC) that could achieve more than 90% probability of target attainment. The blood fluconazole concentration of 54 patients (119 points) was used for PPK analysis. The optimal model was the one-compartment model with first-order administration and first-order elimination incorporating creatinine clearance (CLcr) as a covariate of clearance and body weight as a covariate of distribution volume. We conducted Monte Carlo simulation with fluconazole at 200 mg/day or 400 mg/day dosing schedules and patient body weight and CLcr ranging from 40 to 70 kg and 40–140 mL/min, respectively. The breakpoint MICs on the first dosing day and at steady state were 0.5–1.0 μg/mL and 1.0–2.0 μg/mL for 200 mg/day and 1.0–2.0 μg/mL and 2.0–4.0 μg/mL for 400 mg/day, respectively. The recommended dose was 400–700 mg/day for the loading dose and 200–400 mg/day for the maintenance dose. Our findings suggest that the optimal prophylactic dose of fluconazole in hematological malignancy patients depends on CLcr and body weight, and a sufficient loading and maintenance dose may be needed to completely prevent invasive candidiasis.
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