1
|
Lieu A, Lee TC, Lawandi A, Tellier R, Cheng MP, Dufresne PJ. Microbiological characterization of Pneumocystis jirovecii pneumonia using quantitative PCR from nasopharyngeal specimens: a retrospective study in a Canadian province from 2019 to 2023. J Clin Microbiol 2023; 61:e0091323. [PMID: 37877691 PMCID: PMC10662352 DOI: 10.1128/jcm.00913-23] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/14/2023] [Indexed: 10/26/2023] Open
Abstract
Bronchoalveolar lavage is usually employed for molecular diagnosis of Pneumocystis jirovecii but requires a specialized procedure. By contrast, nasopharyngeal (NP) specimens are easily obtained. In this retrospective study of 35 patients with paired NP and bronchoscopy specimens, NP specimens had a 100% negative percent agreement (95% CI 80.5-100) but only 72.2% positive percent agreement (95% CI 46.5-90.3).
Collapse
Affiliation(s)
- Anthony Lieu
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
- Division of Medical Microbiology, Department of Laboratory Medicine, McGill University Health Centre, Montréal, Canada
| | - Todd C. Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Alexander Lawandi
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
- Division of Medical Microbiology, Department of Laboratory Medicine, McGill University Health Centre, Montréal, Canada
| | - Raymond Tellier
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
- Division of Medical Microbiology, Department of Laboratory Medicine, McGill University Health Centre, Montréal, Canada
| | - Matthew P. Cheng
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
- Division of Medical Microbiology, Department of Laboratory Medicine, McGill University Health Centre, Montréal, Canada
| | - Philippe J. Dufresne
- Laboratoire de santé publique du Québec, Institut national de santé publique du Québec, Sainte-Anne-de-Bellevue, Québec, Canada
| |
Collapse
|
2
|
Hänsel L, Schumacher J, Denis B, Hamane S, Cornely OA, Koehler P. How to diagnose and treat a non-HIV patient with Pneumocystis jirovecii pneumonia (PCP)? Clin Microbiol Infect 2023:S1198-743X(23)00186-6. [PMID: 37086781 DOI: 10.1016/j.cmi.2023.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Pneumocystis jirovecii Pneumonia (PCP) incidence is increasing in non-HIV infected patients. In contrast to PCP in patients infected with HIV, diagnosis is often delayed, and illness is associated with an increased mortality. OBJECTIVE To provide a comprehensive review of clinical presentation, risk factors, diagnostic strategies, and treatment options of PCP in non-HIV-infected patients. SOURCES Web-based literature review on PCP for trials, meta-analyses and systematic reviews using PubMed. Restriction to English language was applied. CONTENT Common underlying conditions in non-HIV-infected patients with PCP are haematological malignancies, autoimmune and inflammatory diseases, solid organ or haematopoietic stem cell transplant and prior exposure to corticosteroids. New risk groups include patients receiving monoclonal antibodies and immunomodulating therapies. Non-HIV-infected patients with PCP present with rapid onset and progression of pneumonia, increased duration of hospitalization and a significantly higher mortality rate than patients infected with HIV. PCP is diagnosed by a combination of clinical symptoms, radiological and mycological features. Immunofluorescence microscopy from bronchoalveolar lavage (BAL) or PCR testing CT imaging and evaluation of the clinical presentation are required. The established treatment regime consists of trimethoprim and sulfamethoxazole. IMPLICATIONS While the number of patients immunosuppressed for other causes than HIV is increasing, a simultaneous rise in PCP incidence is observed. In the group of non-HIV-infected patients, a rapid onset of symptoms, a more complex course, and a higher mortality rate are recorded. Therefore, time to diagnosis must be as short as possible to initiate effective therapy promptly. This review aims to raise awareness of PCP in an increasingly affected at-risk group and provide clinicians with a practical guide for efficient diagnosis and targeted therapy. Furthermore, it intends to display current inadequacies in research on the topic of PCP.
Collapse
Affiliation(s)
- Luise Hänsel
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany
| | - Jana Schumacher
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany
| | - Blandine Denis
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France, Excellence Centre for Medical Mycology (ECMM), Paris, France
| | - Samia Hamane
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France, Excellence Centre for Medical Mycology (ECMM), Paris, France
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany
| | - Philipp Koehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany.
| |
Collapse
|
3
|
Veintimilla C, Álvarez-Uría A, Martín-Rabadán P, Valerio M, Machado M, Padilla B, Alonso R, Diez C, Muñoz P, Marín M. Pneumocystis jirovecii Pneumonia Diagnostic Approach: Real-Life Experience in a Tertiary Centre. J Fungi (Basel) 2023; 9:jof9040414. [PMID: 37108869 PMCID: PMC10142180 DOI: 10.3390/jof9040414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/14/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP) in immunocompromised patients entails high mortality and requires adequate laboratory diagnosis. We compared the performance of a real time-PCR assay against the immunofluorescence assay (IFA) in the routine of a large microbiology laboratory. Different respiratory samples from HIV and non-HIV-infected patients were included. The retrospective analysis used data from September 2015 to April 2018, which included all samples for which a P. jirovecii test was requested. A total of 299 respiratory samples were tested (bronchoalveolar lavage fluid (n = 181), tracheal aspirate (n = 53) and sputum (n = 65)). Forty-eight (16.1%) patients fulfilled the criteria for PJP. Five positive samples (10%) had only colonization. The PCR test was found to have a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 96%, 98%, 90% and 99%, compared to 27%, 100%, 100% and 87%, for the IFA, respectively. PJ-PCR sensitivity and specificity were >80% and >90% for all tested respiratory samples. Median cycle threshold values in definite PJP cases were 30 versus 37 in colonized cases (p < 0.05). Thus, the PCR assay is a robust and reliable test for the diagnosis PJP in all respiratory sample types. Ct values of ≥36 could help to exclude PJP diagnosis.
Collapse
|
4
|
Alsayed AR, Al-Dulaimi A, Alkhatib M, Al Maqbali M, Al-Najjar MAA, Al-Rshaidat MMD. A comprehensive clinical guide for Pneumocystis jirovecii pneumonia: a missing therapeutic target in HIV-uninfected patients. Expert Rev Respir Med 2022; 16:1167-1190. [PMID: 36440485 DOI: 10.1080/17476348.2022.2152332] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii is an opportunistic, human-specific fungus that causes Pneumocystis pneumonia (PCP). PCP symptoms are nonspecific. A patient with P. jirovecii and another lung infection faces a diagnostic challenge. It may be difficult to determine which of these agents is responsible for the clinical symptoms, preventing effective treatment. Diagnostic and treatment efforts have been made more difficult by the rising frequency with which coronavirus 2019 (COVID-19) and PCP co-occur. AREAS COVERED Herein, we provide a comprehensive review of clinical and pharmacological recommendations along with a literature review of PCP in immunocompromised patients focusing on HIV-uninfected patients. EXPERT OPINION PCP may be masked by identifying co-existing pathogens that are not necessarily responsible for the observed infection. Patients with severe form COVID-19 should be examined for underlying immunodeficiency, and co-infections must be considered as co-infection with P. jirovecii may worsen COVID-19's severity and fatality. PCP should be investigated in patients with PCP risk factors who come with pneumonia and suggestive radiographic symptoms but have not previously received PCP prophylaxis. PCP prophylaxis should be explored in individuals with various conditions that impair the immune system, depending on their PCP risk.
Collapse
Affiliation(s)
- Ahmad R Alsayed
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Abdullah Al-Dulaimi
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Mohammad Alkhatib
- Department of Experimental Medicine, University of Rome "Tor Vergata", Roma, Italy
| | - Mohammed Al Maqbali
- Department of Nursing Midwifery and Health, Northumbria University, Newcastle-Upon-Tyne, UK
| | - Mohammad A A Al-Najjar
- Department of Pharmaceutical Sciences and Pharmaceutics, Applied Science Private University, Amman, Kingdom of Jordan
| | - Mamoon M D Al-Rshaidat
- Laboratory for Molecular and Microbial Ecology (LaMME), Department of Biological Sciences, School of Sciences, The University of Jordan, Amman, Jordan
| |
Collapse
|
5
|
Salazar F, Bignell E, Brown GD, Cook PC, Warris A. Pathogenesis of Respiratory Viral and Fungal Coinfections. Clin Microbiol Rev 2022; 35:e0009421. [PMID: 34788127 PMCID: PMC8597983 DOI: 10.1128/cmr.00094-21] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Individuals suffering from severe viral respiratory tract infections have recently emerged as "at risk" groups for developing invasive fungal infections. Influenza virus is one of the most common causes of acute lower respiratory tract infections worldwide. Fungal infections complicating influenza pneumonia are associated with increased disease severity and mortality, with invasive pulmonary aspergillosis being the most common manifestation. Strikingly, similar observations have been made during the current coronavirus disease 2019 (COVID-19) pandemic. The copathogenesis of respiratory viral and fungal coinfections is complex and involves a dynamic interplay between the host immune defenses and the virulence of the microbes involved that often results in failure to return to homeostasis. In this review, we discuss the main mechanisms underlying susceptibility to invasive fungal disease following respiratory viral infections. A comprehensive understanding of these interactions will aid the development of therapeutic modalities against newly identified targets to prevent and treat these emerging coinfections.
Collapse
Affiliation(s)
- Fabián Salazar
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Elaine Bignell
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Gordon D. Brown
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Peter C. Cook
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Adilia Warris
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| |
Collapse
|
6
|
Aissaoui N, Hamane S, Gits-Muselli M, Petit A, Benderdouche M, Denis B, Alanio A, Dellière S, Bagot M, Bretagne S. Imported leishmaniasis in travelers: a 7-year retrospective from a Parisian hospital in France. BMC Infect Dis 2021; 21:953. [PMID: 34525963 PMCID: PMC8442464 DOI: 10.1186/s12879-021-06631-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/19/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Leishmaniases are regularly seen in non-endemic areas due to the increase of international travels. They include cutaneous leishmaniases (CL) and mucocutaneous (MC) caused by different Leishmania species, and visceral leishmaniases (VL) which present with non-specific symptoms. METHODS We reviewed all consecutive leishmaniasis cases seen between September 2012 and May 2020. The diagnostic strategy included microscopy after May-Grünwald-Giemsa staining, a diagnostic quantitative PCR (qPCR) assay, and species identification based on sequencing of the cytochrome b gene. RESULTS Eighty-nine patients had a definitive leishmaniasis diagnosis. Nine patients had VL with Leishmania infantum. Eighty patients had CL. Twelve patients acquired CL after trips in Latin America (7 Leishmania guyanensis, 2 Leishmania braziliensis, 2 Leishmania mexicana, and 1 Leishmania panamensis). Species could be identified in 63 of the 68 CLs mainly after travel in North Africa (59%) with Leishmania major (65%), Leishmania tropica/killicki (24%), and L. infantum (11%), or in West Sub-Saharan Africa (32%), all due to L. major. The median day between appearance of the lesions and diagnosis was 90 [range 60-127]. CONCLUSIONS Our diagnostic strategy allows both positive diagnoses and species identifications. Travelers in West Sub-Saharan Africa and North Africa should be better aware of the risk of contracting leishmananiasis.
Collapse
Affiliation(s)
- Nesrine Aissaoui
- Laboratoire de Parasitologie et de Mycologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), 1 Avenue Claude Vellefaux, 75475, Paris, France
| | - Samia Hamane
- Laboratoire de Parasitologie et de Mycologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), 1 Avenue Claude Vellefaux, 75475, Paris, France
| | - Maud Gits-Muselli
- Laboratoire de Parasitologie et de Mycologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), 1 Avenue Claude Vellefaux, 75475, Paris, France.,Université de Paris, Paris, France
| | - Antoine Petit
- Service de Dermatologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Mazouz Benderdouche
- Laboratoire de Parasitologie et de Mycologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), 1 Avenue Claude Vellefaux, 75475, Paris, France
| | - Blandine Denis
- Département de Maladies Infectieuses, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Alexandre Alanio
- Laboratoire de Parasitologie et de Mycologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), 1 Avenue Claude Vellefaux, 75475, Paris, France.,Université de Paris, Paris, France
| | - Sarah Dellière
- Laboratoire de Parasitologie et de Mycologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), 1 Avenue Claude Vellefaux, 75475, Paris, France.,Université de Paris, Paris, France
| | - Martine Bagot
- Service de Dermatologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,INSERM U976, Paris, France
| | - Stéphane Bretagne
- Laboratoire de Parasitologie et de Mycologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), 1 Avenue Claude Vellefaux, 75475, Paris, France. .,Université de Paris, Paris, France.
| |
Collapse
|
7
|
Szydłowicz M, Matos O. Pneumocystis pneumonia in the COVID-19 pandemic era: similarities and challenges. Trends Parasitol 2021; 37:859-862. [PMID: 34364804 PMCID: PMC8335554 DOI: 10.1016/j.pt.2021.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 12/16/2022]
Abstract
The clinical picture of the fungal disease, Pneumocystis pneumonia, resembles the course of coronavirus disease 2019 (COVID-19), presenting a diagnostic challenge in the pandemic era. We discuss the concern of Pneumocystis jirovecii and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) coinfection, their similarities, and the impact of immunosuppression, with a suggested diagnostic pathway for their suspected coinfection.
Collapse
Affiliation(s)
- Magdalena Szydłowicz
- Department of Biology and Medical Parasitology, Wroclaw Medical University, 50-345 Wroclaw, Poland.
| | - Olga Matos
- Unit of Medical Parasitology, Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, 1349-008 Lisboa, Portugal; Environmental Health Institute, Faculdade de Medicina da Universidade de Lisboa, 1649-028 Lisboa, Portugal
| |
Collapse
|
8
|
Características clínico-epidemiológicas de la neumonía por Pneumocystis jirovecii en un hospital de tercer nivel en España. An Pediatr (Barc) 2021. [DOI: 10.1016/j.anpedi.2020.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
9
|
Clinical-epidemiological characteristics of Pneumocystis jirovecii pneumonia in a tertiary hospital in Spain. An Pediatr (Barc) 2021; 95:4-10. [PMID: 34154986 DOI: 10.1016/j.anpede.2020.04.023] [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: 12/02/2019] [Accepted: 04/13/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION HIV infection was the main risk of suffering Pneumocystis jirovecii pneumonia (PJP). The clinical-epidemiological characteristics of PJP have currently changed, with there being few studies on this. METHODS A retrospective observational study was carried out on paediatric patients diagnosed with PJP over a 17 year period in a third level hospital in Spain. RESULTS A total of 23 patients were included, of whom 7/23 (47.8%) suffered a haematological disease, 5/23 (21.7%) a primary immunodeficiency, and 4/23 (17.4%) an HIV infection. Prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) was received by 11/23 (47.8%) patients. All were treated with TMP-SMX and 18/23 (78.3%) with systemic glucocorticoids. There were six (26.1%) deaths, of which one of them (16.7%) suffered an HIV infection. A higher mortality was seen in the non-HIV patients with greater leucocytosis, greater CO2 retention, and a higher heart rate at onset, differences not observed in HIV patients. No differences were found in mortality in relation to the predisposing factor, use of pTMP-SMX, or treatment with glucocorticoids. CONCLUSIONS Paediatric patients with haematological cancers are currently the main risk group of developing PJP in this age group. No differences were found in mortality between patients with or without HIV infection as predisposing factor. The mortality among non-HIV patients was higher in those that had greater leucocytosis, greater CO2 retention, and increased heart rate at onset. A better prognosis was not seen in patients that received prophylaxis with TMP-SMX prior to the development of the PJP, or in those that received glucocorticoids as part of the treatment.
Collapse
|
10
|
Gits-Muselli M, White PL, Mengoli C, Chen S, Crowley B, Dingemans G, Fréalle E, L Gorton R, Guiver M, Hagen F, Halliday C, Johnson G, Lagrou K, Lengerova M, Melchers WJG, Novak-Frazer L, Rautemaa-Richardson R, Scherer E, Steinmann J, Cruciani M, Barnes R, Donnelly JP, Loeffler J, Bretagne S, Alanio A. The Fungal PCR Initiative's evaluation of in-house and commercial Pneumocystis jirovecii qPCR assays: Toward a standard for a diagnostics assay. Med Mycol 2021; 58:779-788. [PMID: 31758173 DOI: 10.1093/mmy/myz115] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/22/2019] [Accepted: 10/31/2019] [Indexed: 01/04/2023] Open
Abstract
Quantitative real-time PCR (qPCR) is increasingly used to detect Pneumocystis jirovecii for the diagnosis of Pneumocystis pneumonia (PCP), but there are differences in the nucleic acids targeted, DNA only versus whole nucleic acid (WNA), and also the target genes for amplification. Through the Fungal PCR Initiative, a working group of the International Society for Human and Animal Mycology, a multicenter and monocenter evaluation of PCP qPCR assays was performed. For the multicenter study, 16 reference laboratories from eight different countries, performing 20 assays analyzed a panel consisting of two negative and three PCP positive samples. Aliquots were prepared by pooling residual material from 20 negative or positive- P. jirovecii bronchoalveolar lavage fluids (BALFs). The positive pool was diluted to obtain three concentrations (pure 1:1; 1:100; and 1:1000 to mimic high, medium, and low fungal loads, respectively). The monocenter study compared five in-house and five commercial qPCR assays testing 19 individual BALFs on the same amplification platform. Across both evaluations and for all fungal loads, targeting WNA and the mitochondrial small sub-unit (mtSSU) provided the earliest Cq values, compared to only targeting DNA and the mitochondrial large subunit, the major surface glycoprotein or the beta-tubulin genes. Thus, reverse transcriptase-qPCR targeting the mtSSU gene could serve as a basis for standardizing the P. jirovecii load, which is essential if qPCR is to be incorporated into clinical care pathways as the reference method, accepting that additional parameters such as amplification platforms still need evaluation.
Collapse
Affiliation(s)
- Maud Gits-Muselli
- Institut Pasteur, Molecular Mycology Unit, CNRS UMR2000, Paris, France.,Laboratoire de Parasitologie-Mycologie, Hôpital Saint-Louis, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Université de Paris, Paris, France
| | - P Lewis White
- Public Health Wales, Microbiology Cardiff, UHW, Heath Park, Cardiff, UK
| | | | - Sharon Chen
- Clinical Mycology reference Laboratory, Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, and the University of Sydney, Australia
| | - Brendan Crowley
- Department of Virology, St James's Hospital, Dublin, Ireland
| | | | - Emilie Fréalle
- CHU Lille, Laboratoire de Parasitologie-Mycologie, F-59000 Lille, France & Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, U1019-UMR8204-CIIL-Centre for Infection and Immunity of Lille, F-59000 Lille, France
| | - Rebecca L Gorton
- Regional UK Clinical Mycology Network (UK CMN) Laboratory, Dept. Infection Sciences, Health Services Laboratories (HSL) LLP, London, UK
| | - Malcom Guiver
- Public Health Laboratory, National Infection Service Public Health England, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ferry Hagen
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands.,Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands.,Laboratory of Medical Mycology, Jining No. 1 People's Hospital, Jining, China
| | - Catriona Halliday
- Clinical Mycology reference Laboratory, Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, and the University of Sydney, Australia
| | | | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, and Department of Laboratory Medicine and National Reference Centre for Mycosis, Excellence Centre for Medical Mycology (ECMM), University Hospitals Leuven, Leuven, Belgium
| | - Martina Lengerova
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | - Willem J G Melchers
- Radboud University Medical Centre, Department of Medical Microbiology, Nijmegen, The Netherlands
| | - Lily Novak-Frazer
- Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust; and Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Riina Rautemaa-Richardson
- Department of Infectious Diseases and the Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust; and Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Emeline Scherer
- Department of Parasitology-Mycology, University Hospital of Besançon, Besançon, France
| | - Joerg Steinmann
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany.,Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Mario Cruciani
- Infectious Diseases Unit, San Bonifacio Hospital, Verona, Italy
| | | | | | - Juergen Loeffler
- University Hospital Wuerzburg, Medical Hospital II, C11, Wuerzburg, Germany
| | - Stéphane Bretagne
- Institut Pasteur, Molecular Mycology Unit, CNRS UMR2000, Paris, France.,Laboratoire de Parasitologie-Mycologie, Hôpital Saint-Louis, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Université de Paris, Paris, France
| | - Alexandre Alanio
- Institut Pasteur, Molecular Mycology Unit, CNRS UMR2000, Paris, France.,Laboratoire de Parasitologie-Mycologie, Hôpital Saint-Louis, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Université de Paris, Paris, France
| |
Collapse
|
11
|
Wilmes D, Coche E, Rodriguez-Villalobos H, Kanaan N. Fungal pneumonia in kidney transplant recipients. Respir Med 2021; 185:106492. [PMID: 34139578 DOI: 10.1016/j.rmed.2021.106492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
Fungal pneumonia is a dreaded complication encountered after kidney transplantation, complicated by increased mortality and often associated with graft failure. Diagnosis can be challenging because the clinical presentation is non-specific and diagnostic tools have limited sensitivity and specificity in kidney transplant recipients and must be interpreted in the context of the clinical setting. Management is difficult due to the increased risk of dissemination and severity, multiple comorbidities, drug interactions and reduced immunosuppression which should be applied as an important adjunct to therapy. This review will focus on the main causes of fungal pneumonia in kidney transplant recipients including Pneumocystis, Aspergillus, Cryptococcus, mucormycetes and Histoplasma. Epidemiology, clinical presentation, laboratory and radiographic features, specific characteristics will be discussed with an update on diagnostic procedures and treatment.
Collapse
Affiliation(s)
- D Wilmes
- Division of Internal Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - E Coche
- Division of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - H Rodriguez-Villalobos
- Division of Microbiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - N Kanaan
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
| |
Collapse
|
12
|
Georges O, Risso K, Lemiale V, Schlemmer F. [The place of bronchoalveolar lavage in the diagnosis of pneumonia in the immunocompromised patient]. Rev Mal Respir 2020; 37:652-661. [PMID: 32888730 DOI: 10.1016/j.rmr.2020.06.016] [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: 02/16/2020] [Accepted: 06/05/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Bronchoalveolar lavage (BAL) was previously considered as the standard diagnostic procedure to investigate pneumonia occurring in immunocompromised patients, and it is probably still widely used. However, the development of new microbiological diagnostic tools, applicable to samples obtained non-invasively, leads to questioning of the predominant place of BAL in this situation. BACKGROUND The available studies agree on the acceptable tolerance of BAL performed in immunocompromised patients. Although imperfect, the diagnostic yield of BAL in immunocompromised patients is well established, but it may vary between studies depending on the underlying disease. However, it must also be compared to the yield of non-invasive microbiological tools, now widely available and effective. The position of BAL remains important both for the diagnosis of fungal infections (invasive aspergillosis, pneumocystis pneumonia) and non-infectious lung diseases both of which occur frequently in immunocompromised patients. CONCLUSION The place of BAL in the diagnostic work-up of pneumonia occurring in immunocompromised patients must be considered in the framework of a structured consideration, taking into account the diagnostic performance of non invasive microbiological tests and the broad spectrum of lung diseases occurring in this context.
Collapse
Affiliation(s)
- O Georges
- Service de Pneumologie et Réanimation Respiratoire, CHU de Amiens - Picardie, 80000 Amiens, France
| | - K Risso
- Service de Maladies Infectieuses et Tropicales, hôpital l'Archet, centre hospitalier universitaire de Nice, 06200 Nice, France
| | - V Lemiale
- Service de Réanimation Médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), hôpital Saint-Louis, université Paris-Diderot, 75010 Paris, France
| | - F Schlemmer
- Unité de Pneumologie, Assistance Publique - Hôpitaux de Paris (AP-HP), hôpitaux universitaires Henri-Mondor, DHU A-TVB, université Paris-Est-Créteil, 94010 Créteil, France; Inserm U955-Institut Mondor de Recherche Biomédicale, université Paris-Est-Créteil, 94010 Créteil, France.
| |
Collapse
|
13
|
Molecular Diagnosis of Pneumocystis jirovecii Pneumonia by Use of Oral Wash Samples in Immunocompromised Patients: Usefulness and Importance of the DNA Target. J Clin Microbiol 2019; 57:JCM.01287-19. [PMID: 31578265 DOI: 10.1128/jcm.01287-19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 09/26/2019] [Indexed: 12/23/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an important cause of pneumonia in the HIV-negative immunocompromised population, for whom the fungal load is low, the differential diagnosis is difficult, and a bronchoalveolar lavage (BAL) sample is often not readily available. Molecular techniques have improved the microbiological diagnosis in this scenario. The usefulness of two real-time PCR techniques targeting nuclear single-copy and mitochondrial multicopy genes, respectively, applied to oral wash specimens (OW) for PJP diagnosis was assessed, and its accuracy was compared to a BAL fluid-based diagnosis. Immunocompromised patients having PJP in the differential diagnosis of an acute respiratory episode, and from whom OW and BAL or lung biopsy specimens were obtained ≤48 h apart, were retrospectively included. PCRs targeting the dihydropteroate synthase gene (DHPS) and the mitochondrial small-subunit (mtSSU) rRNA gene were performed in paired OW-BAL specimens. Thirty-six patients were included (88.6% HIV negative). Fifteen patients (41.7%) were classified as PJP, and a further 8 were considered P. jirovecii colonized. Quantification of DHPS and mtSSU in BAL fluid showed an accuracy of 96.9% and 93.0%, respectively, for PJP diagnosis, whereas a qualitative approach performed better when applied to OW (accuracy, 91.7%) irrespective of the PCR target studied (kappa = 1). Qualitative molecular diagnosis applied to OW showed an excellent performance for PJP diagnosis regardless of the target studied, being easier to interpret than the quantitative approach needed for BAL fluid.
Collapse
|
14
|
Desoubeaux G, Chesnay A, Mercier V, Bras-Cachinho J, Moshiri P, Eymieux S, De Kyvon MA, Lemaignen A, Goudeau A, Bailly É. Combination of β-(1, 3)-D-glucan testing in serum and qPCR in nasopharyngeal aspirate for facilitated diagnosis of Pneumocystis jirovecii pneumonia. Mycoses 2019; 62:1015-1022. [PMID: 31494981 DOI: 10.1111/myc.12997] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/25/2019] [Accepted: 08/30/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Currently, the biological diagnosis of Pneumocystis jirovecii pneumonia (PjP infection) usually relies on microbiological investigations in bronchial-alveolar lavage fluid (BALF) by conventional staining methods and/or molecular biology. However, bronchial-alveolar lavage is sometimes complicated to manage, especially in weakened patients. Therefore, alternative clinical samples-easier to collect-are warranted in such specific contexts. OBJECTIVE Over a four-year period, diagnostic performance of an original method based on combination of quantitative real-time polymerase chain reaction (qPCR) in nasopharyngeal aspirate (NPA) with measurement of β-(1, 3)-D-glucan antigen (BDG) in serum was prospectively assessed in a single centre. PATIENTS/METHODS Results were compared with those obtained in BALF through direct staining methods and qPCR. True positives were defined by an independent committee based on clinical, radiological and biological data. Overall, 48 individuals with a definitive diagnosis of PjP infection were included, and 48 controls were selected upon matching for age, sex and underlying disease(s). RESULTS qPCR results were strongly correlated between BALF and NPA (P < .0001). Altogether, greater diagnostic performance was achieved when establishing the positive cut-off of BDG antigen at 143 pg/mL. In such conditions, sensitivity of the testing based on either positive BDG measurement or positive qPCR in NPA was then calculated at 93.75%, 95% CI [82.37%-98.40%], and specificity at 97.87%, 95% CI [87.66%-100.00%]. CONCLUSIONS Further validation through multicentre studies is now required, especially for establishing clear cut-offs. However, one could already state that combination of qPCR in the NPA with BDG measurement in serum may be a valuable substitute for BALF examination.
Collapse
Affiliation(s)
- Guillaume Desoubeaux
- Parasitologie, Mycologie, Médecine Tropicale, CHU de Tours, Tours, France.,CEPR - INSERM U1100/Équipe 3, Faculté de Médecine, Université de Tours, Tours, France
| | - Adélaïde Chesnay
- Parasitologie, Mycologie, Médecine Tropicale, CHU de Tours, Tours, France.,CEPR - INSERM U1100/Équipe 3, Faculté de Médecine, Université de Tours, Tours, France
| | - Victor Mercier
- Parasitologie, Mycologie, Médecine Tropicale, CHU de Tours, Tours, France
| | - José Bras-Cachinho
- Parasitologie, Mycologie, Médecine Tropicale, CHU de Tours, Tours, France
| | - Parastou Moshiri
- Parasitologie, Mycologie, Médecine Tropicale, CHU de Tours, Tours, France
| | - Sébastien Eymieux
- Parasitologie, Mycologie, Médecine Tropicale, CHU de Tours, Tours, France
| | | | - Adrien Lemaignen
- Médecine interne & Maladies Infectieuses, CHU de Tours, Tours, France
| | | | - Éric Bailly
- Parasitologie, Mycologie, Médecine Tropicale, CHU de Tours, Tours, France
| |
Collapse
|
15
|
Vindrios W, Argy N, Le Gal S, Lescure FX, Massias L, Le MP, Wolff M, Yazdanpanah Y, Nevez G, Houze S, Dorent R, Lucet JC. Outbreak of Pneumocystis jirovecii Infection Among Heart Transplant Recipients: Molecular Investigation and Management of an Interhuman Transmission. Clin Infect Dis 2017; 65:1120-1126. [DOI: 10.1093/cid/cix495] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/24/2017] [Indexed: 11/14/2022] Open
|
16
|
Abstract
Pneumocystis jirovecii is an unusual ascomycetous fungus that can be detected in the lungs of healthy individuals. Transmission from human to human is one of its main characteristics in comparison with other fungi responsible for invasive infections.
P. jirovecii is transmitted through the air between healthy individuals, who are considered to be the natural reservoir, at least transiently. In immunocompromised patients,
P. jirovecii multiplies, leading to subacute infections and acute life-threatening pneumonia, called Pneumocystis pneumonia [PCP]. PCP is caused by genotypically distinct mixtures of organisms in more than 90% of cases, reinforcing the hypothesis that there is constant inhalation of
P. jirovecii from different contacts over time, although reactivation of latent organisms from previous exposures may be possible. Detection of
P. jirovecii DNA without any symptoms or related radiological signs has been called “colonization”. This situation could be considered as the result of recent exposure to
P. jirovecii that could evolve towards PCP, raising the issue of cotrimoxazole prophylaxis for at-risk quantitative polymerase chain reaction (qPCR)-positive immunocompromised patients. The more accurate way to diagnose PCP is the use of real-time quantitative PCR, which prevents amplicon contamination and allows determination of the fungal load that is mandatory to interpret the qPCR results and manage the patient appropriately. The detection of
P. jirovecii in respiratory samples of immunocompromised patients should be considered for potential risk of developing PCP. Many challenges still need to be addressed, including a better description of transmission, characterization of organisms present at low level, and prevention of environmental exposure during immunodepression.
Collapse
Affiliation(s)
- Alexandre Alanio
- Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal Hospitals, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris-Diderot, Sorbonne Paris Cité University, Paris, France.,Molecular Mycology Unit, CNRS, Institut Pasteur, URA 3012, Paris, France
| | - Stéphane Bretagne
- Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal Hospitals, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris-Diderot, Sorbonne Paris Cité University, Paris, France.,Molecular Mycology Unit, CNRS, Institut Pasteur, URA 3012, Paris, France
| |
Collapse
|
17
|
Robin C, Alanio A, Gits-Muselli M, la Martire G, Schlemmer F, Botterel F, Angebault C, Leclerc M, Beckerich F, Redjoul R, Pautas C, Toma A, Maury S, Bretagne S, Cordonnier C. Molecular Demonstration of a Pneumocystis Outbreak in Stem Cell Transplant Patients: Evidence for Transmission in the Daycare Center. Front Microbiol 2017; 8:700. [PMID: 28484441 PMCID: PMC5401873 DOI: 10.3389/fmicb.2017.00700] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 04/05/2017] [Indexed: 12/24/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PCP) is a life-threatening infection in hematology. Although occasionally reported, the role of interhuman transmission of P. jirovecii in PCP, compared to that of reactivation, remains an unresolved question; the recommendation to isolate PCP patients in the hematology ward are not well evidence-based. Following an unexpected increase in the number of febrile pneumonia patients with P. jirovecii DNA detected in respiratory samples in our hematology ward, we explored 12 consecutive patients from November 2015 to May 2016. Genotyping of P jirovecii was performed using microsatellite markers. The frequency of simultaneous occupancy of these 12 patients in the same unit on the same day from 4 months prior to the first diagnosis was recorded. In three patients, the P. jirovecii genotype could not be determined because DNA was insufficient. One rare single genotype (Gt2) was found in four of the other nine, all allogeneic stem cell transplant recipients. The transmission map showed that these 4 patients had multiple opportunities to meet on the same day (median, 6.5; range, 4-10) at the daycare center. It was much less among the eight non-Gt2 patients (median, 1; range, 0-9; P = 0.048). This study, based on modern molecular technics, strongly suggests that interhuman transmission of P. jirovecii between allogeneic stem cell transplant recipients is possible. P. jirovecii DNA detected in respiratory specimens supports that isolation and respiratory precautions be recommended in such cases in the hematology ward.
Collapse
Affiliation(s)
- Christine Robin
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Teaching HospitalCréteil, France
- Paris-Est Créteil UniversityCréteil, France
| | - Alexandre Alanio
- Parasitology-Mycology Laboratory, Assistance Publique-Hôpitaux de Paris, Lariboisière Saint-Louis Fernand Widal HospitalParis, France
- Paris-Diderot, Sorbonne Paris Cité UniversityParis, France
- Molecular Mycology Unit, National Reference Center of Invasive Mycosis and Antifungals, Centre National de la Recherche Scientifique, Institut Pasteur, URA3012Paris, France
| | - Maud Gits-Muselli
- Parasitology-Mycology Laboratory, Assistance Publique-Hôpitaux de Paris, Lariboisière Saint-Louis Fernand Widal HospitalParis, France
- Paris-Diderot, Sorbonne Paris Cité UniversityParis, France
| | - Giulia la Martire
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Teaching HospitalCréteil, France
| | - Frédéric Schlemmer
- Paris-Est Créteil UniversityCréteil, France
- Unit of Pneumology, Intensive Care Department, Assistance Publique-Hôpitaux de Paris, Henri Mondor Teaching Hospital, DHU A-TVBCréteil, France
| | - Françoise Botterel
- Paris-Est Créteil UniversityCréteil, France
- Parasitology-Mycology Laboratory, Assistance Publique-Hôpitaux de Paris, Henri Mondor Teaching HospitalCréteil, France
| | - Cécile Angebault
- Paris-Est Créteil UniversityCréteil, France
- Parasitology-Mycology Laboratory, Assistance Publique-Hôpitaux de Paris, Henri Mondor Teaching HospitalCréteil, France
| | - Mathieu Leclerc
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Teaching HospitalCréteil, France
- Paris-Est Créteil UniversityCréteil, France
| | - Florence Beckerich
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Teaching HospitalCréteil, France
- Paris-Est Créteil UniversityCréteil, France
| | - Rabah Redjoul
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Teaching HospitalCréteil, France
- Paris-Est Créteil UniversityCréteil, France
| | - Cécile Pautas
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Teaching HospitalCréteil, France
| | - Andrea Toma
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Teaching HospitalCréteil, France
| | - Sébastien Maury
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Teaching HospitalCréteil, France
- Paris-Est Créteil UniversityCréteil, France
| | - Stéphane Bretagne
- Parasitology-Mycology Laboratory, Assistance Publique-Hôpitaux de Paris, Lariboisière Saint-Louis Fernand Widal HospitalParis, France
- Paris-Diderot, Sorbonne Paris Cité UniversityParis, France
- Molecular Mycology Unit, National Reference Center of Invasive Mycosis and Antifungals, Centre National de la Recherche Scientifique, Institut Pasteur, URA3012Paris, France
| | - Catherine Cordonnier
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Teaching HospitalCréteil, France
- Paris-Est Créteil UniversityCréteil, France
| |
Collapse
|
18
|
Hviid CJ, Lund M, Sørensen A, Ellermann- Eriksen S, Jespersen B, Dam MY, Dahlerup JF, Benfield T, Jespersen S, Østergaard LJ, Laursen AL. Detection of Pneumocystis jirovecii in oral wash from immunosuppressed patients as a diagnostic tool. PLoS One 2017; 12:e0174012. [PMID: 28358900 PMCID: PMC5373571 DOI: 10.1371/journal.pone.0174012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 03/01/2017] [Indexed: 11/29/2022] Open
Abstract
Background Diagnosis of Pneumocystis jirovecii (PJ) pneumonia ordinarily requires invasive procedures that could be avoided by PCR methodologies, if these could be designed with adequate cut-off values for confounding background carriage. Methods We designed a novel quantitative real-time PCR assay to detect the mitochondrial large subunit rRNA gene of PJ in oral washes. To benchmark levels of PJ carriage versus infection, we tested asymptomatic immunosuppressed patients including Danish (n = 88) and West African HIV-infected (n = 142) patients, renal transplant recipients (n = 51), rheumatologic patients (n = 102), patients with inflammatory bowel diseases (n = 98), and healthy blood donors (controls, n = 50). The fungal burden in patients with PJ pneumonia (PCP, n = 7) was also investigated. Results Danish HIV-infected patients (with viremia/low CD4) and recent transplant recipients were at most risk of being carriers (prevalence of 23% and 16.7% respectively), whereas PJ was rarely detected among rheumatologic patients, patients with inflammatory bowel diseases, and untreated West African HIV patients. PJ was not detected among healthy controls. The fungal burden in patients with PCP fell rapidly on treatment. Conclusions The quantitative PCR method described could conceivably discriminate between carriage and disease, given suitable threshold values for the former, and predict treatment efficacy by measures of the fungal burden in daily oral washes.
Collapse
Affiliation(s)
- Cecilie Juul Hviid
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne Lund
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Allan Sørensen
- The Bissau HIV Cohort Study Group, Bandim Health Project, Bissau, Guinea Bissau
| | | | - Bente Jespersen
- Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Yde Dam
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Frederik Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus Aarhus University Hospital, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Hvidovre Hospital, Hvidovre, Denmark
| | - Sanne Jespersen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- The Bissau HIV Cohort Study Group, Bandim Health Project, Bissau, Guinea Bissau
| | - Lars Jørgen Østergaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- * E-mail: (ALL); (LJØ)
| | - Alex Lund Laursen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- The Bissau HIV Cohort Study Group, Bandim Health Project, Bissau, Guinea Bissau
- * E-mail: (ALL); (LJØ)
| | | |
Collapse
|
19
|
White PL, Backx M, Barnes RA. Diagnosis and management of Pneumocystis jirovecii infection. Expert Rev Anti Infect Ther 2017; 15:435-447. [PMID: 28287010 DOI: 10.1080/14787210.2017.1305887] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii is a ubiquitous fungus, which causes pneumonia in humans. Diagnosis was hampered by the inability to culture the organism, and based on microscopic examination of respiratory samples or clinical presentation. New assays can assist in the diagnosis and even aid with the emergence of resistant infections. Areas covered: This manuscript will provide background information on Pneumocystis pneumonia (PcP). Diagnosis, from radiological to non-microbiological (e.g. Lactate dehydrogenase) and microbiological investigations (Microscopy, PCR, β-D-Glucan) will be discussed. Recommendations on prophylactic and therapeutic management will be covered. Expert commentary: PcP diagnosis using microscopy is far from optimal and false negatives will occur. With an incidence of 1% or less, the pre-test probability of not having PcP is 99% and testing is suited to excluding disease. Microscopy provides a high degree of diagnostic confidence but it is not infallible, and its lower sensitivity limits its application. Newer diagnostics (PCR, β-D-Glucan) can aid management and improve performance when testing less invasive specimens, such as upper respiratory samples or blood, alleviating clinical pressure. Combination testing may allow PcP to be both diagnosed and excluded, and molecular testing can assist in the detection of emerging resistant PcP.
Collapse
Affiliation(s)
- P Lewis White
- a Public Health Wales Microbiology Cardiff, UHW , Cardiff , UK
| | - Matthijs Backx
- a Public Health Wales Microbiology Cardiff, UHW , Cardiff , UK
| | - Rosemary A Barnes
- a Public Health Wales Microbiology Cardiff, UHW , Cardiff , UK.,b Infection, Immunity and Biochemistry , Cardiff University, School of Medicine, UHW , Cardiff , UK
| |
Collapse
|
20
|
Alanio A, Hauser PM, Lagrou K, Melchers WJG, Helweg-Larsen J, Matos O, Cesaro S, Maschmeyer G, Einsele H, Donnelly JP, Cordonnier C, Maertens J, Bretagne S. ECIL guidelines for the diagnosis of Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients. J Antimicrob Chemother 2016; 71:2386-96. [PMID: 27550991 DOI: 10.1093/jac/dkw156] [Citation(s) in RCA: 165] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The Fifth European Conference on Infections in Leukaemia (ECIL-5) convened a meeting to establish evidence-based recommendations for using tests to diagnose Pneumocystis jirovecii pneumonia (PCP) in adult patients with haematological malignancies. Immunofluorescence assays are recommended as the most sensitive microscopic method (recommendation A-II: ). Real-time PCR is recommended for the routine diagnosis of PCP ( A-II: ). Bronchoalveolar lavage (BAL) fluid is recommended as the best specimen as it yields good negative predictive value ( A-II: ). Non-invasive specimens can be suitable alternatives ( B-II: ), acknowledging that PCP cannot be ruled out in case of a negative PCR result ( A-II: ). Detecting β-d-glucan in serum can contribute to the diagnosis but not the follow-up of PCP ( A-II: ). A negative serum β-d-glucan result can exclude PCP in a patient at risk ( A-II: ), whereas a positive test result may indicate other fungal infections. Genotyping using multilocus sequence markers can be used to investigate suspected outbreaks ( A-II: ). The routine detection of dihydropteroate synthase mutations in cases of treatment failure is not recommended ( B-II: ) since these mutations do not affect response to high-dose co-trimoxazole. The clinical utility of these diagnostic tests for the early management of PCP should be further assessed in prospective, randomized interventional studies.
Collapse
Affiliation(s)
- Alexandre Alanio
- Parasitology-Mycology Laboratory, Groupe Hospitalier Lariboisière Saint-Louis Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Diderot, Sorbonne Paris Cité, and Institut Pasteur, Unité de Mycologie Moléculaire, CNRS URA3012, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | - Philippe M Hauser
- Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Katrien Lagrou
- Department of Microbiology and Immunology, Catholic University Leuven, Leuven, Belgium and National Reference Center for Mycosis, Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jannik Helweg-Larsen
- Department of Infectious Diseases, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
| | - Olga Matos
- Medical Parasitology Unit, Group of Opportunistic Protozoa/HIV and Other Protozoa, Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Portugal Universidade Nova de Lisboa, Lisboa, Portugal
| | - Simone Cesaro
- Hematology Department, Oncoematologia Pediatrica, Policlinico G. B. Rossi, Verona, Italy
| | - Georg Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Ernst-von-Bergmann Klinikum, Potsdam, Germany
| | - Hermann Einsele
- Medizinische Klinik und Poliklinik II, Julius Maximilians Universitaet, Würzburg, Germany
| | - J Peter Donnelly
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catherine Cordonnier
- Hematology Department, Henri Mondor Hospital, APHP and Université Paris-Est-Créteil, Créteil, France
| | - Johan Maertens
- Hematology Department, University Hospital Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Stéphane Bretagne
- Parasitology-Mycology Laboratory, Groupe Hospitalier Lariboisière Saint-Louis Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Diderot, Sorbonne Paris Cité, and Institut Pasteur, Unité de Mycologie Moléculaire, CNRS URA3012, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | | |
Collapse
|