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Rocha MF, Bain HDC, Stone N, Meya D, Darie L, Toma AK, Lunn MPT, Mehta AR, Coughlan C. Reframing the clinical phenotype and management of cryptococcal meningitis. Pract Neurol 2024:pn-2024-004133. [PMID: 38997136 DOI: 10.1136/pn-2024-004133] [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: 05/27/2024] [Indexed: 07/14/2024]
Abstract
Cryptococcal meningitis is an important global health problem, resulting from infection with the yeast Cryptococcus, especially Cryptococcus neoformans and Cryptococcus gattii, which cause a spectrum of disease ranging from pulmonary and skin lesions to life-threatening central nervous system involvement. The diagnosis and management of cryptococcal meningitis have substantially changed in recent years. Cryptococcal meningitis often occurs in people living with advanced HIV infection, though in high-income countries with robust HIV detection and treatment programmes, it increasingly occurs in other groups, notably solid-organ transplant recipients, other immunosuppressed patients and even immunocompetent hosts. This review outlines the clinical presentation, management and prognosis of cryptococcal meningitis, including its salient differences in people living with HIV compared with HIV-negative patients. We discuss the importance of managing raised intracranial pressure and highlight the advantages of improved multidisciplinary team working involving neurologists, infectious disease specialists and neurosurgeons.
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Affiliation(s)
- Maria Francisca Rocha
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hamish D C Bain
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Neil Stone
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Lucia Darie
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ahmed K Toma
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael P T Lunn
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Arpan R Mehta
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
- MRC Protein Phosphorylation & Ubiquitylation Unit, School of Life Sciences, University of Dundee, Dundee, UK
| | - Charles Coughlan
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
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2
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Mullis CE, Heldman M, Bahr NC, Minamoto GY, Puius YA, Malinis M. Persistent fever after coronavirus disease 2019 in liver/kidney transplant recipient. Transpl Infect Dis 2024; 26:e14271. [PMID: 38605533 PMCID: PMC11187683 DOI: 10.1111/tid.14271] [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: 02/26/2024] [Accepted: 03/09/2024] [Indexed: 04/13/2024]
Abstract
In this case, a 64-year-old male with a history of simultaneous orthotopic liver transplant and cadaveric renal transplant presented five years prior presented with persistent fevers two days after a positive SARS-CoV-2 nasal PCR. A CT scan of the chest on hospital day nine revealed innumerable 1-2 mm nodules in a miliary pattern throughout the lung. (1,3)-β-D-glucan on hospital day 11 was 133 pg/mL. In this article, the approach, diagnostic and management strategies for patients with persistent fevers after diagnosis of COVID-19 in a transplant recipient are discussed.
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Affiliation(s)
- Caroline E. Mullis
- Department of Medicine, Division of Infectious Diseases, Montefiore Medical Center, Bronx, NY
| | - Madeleine Heldman
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC
| | - Nathan C. Bahr
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Grace Y. Minamoto
- Department of Medicine, Division of Infectious Diseases, Montefiore Medical Center, Bronx, NY
| | - Yoram A. Puius
- Department of Medicine, Division of Infectious Diseases, Montefiore Medical Center, Bronx, NY
| | - Maricar Malinis
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine , New Haven, CT
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3
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Walsh TJ, Zhang SX. Emerging Roles of (1→3)-β-D-Glucan in Cerebrospinal Fluid for Detection and Therapeutic Monitoring of Invasive Fungal Diseases of the Central Nervous System. Clin Infect Dis 2024; 78:11-14. [PMID: 37650506 DOI: 10.1093/cid/ciad520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/25/2023] [Indexed: 09/01/2023] Open
Affiliation(s)
- Thomas J Walsh
- Center for Innovative Therapeutics and Diagnostics, Richmond, Virginia, USA
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sean X Zhang
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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4
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McHale TC, Boulware DR, Kasibante J, Ssebambulidde K, Skipper CP, Abassi M. Diagnosis and management of cryptococcal meningitis in HIV-infected adults. Clin Microbiol Rev 2023; 36:e0015622. [PMID: 38014977 PMCID: PMC10870732 DOI: 10.1128/cmr.00156-22] [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] [Indexed: 11/29/2023] Open
Abstract
Cryptococcal meningitis is a leading cause of morbidity and mortality globally, especially in people with advanced HIV disease. Cryptococcal meningitis is responsible for nearly 20% of all deaths related to advanced HIV disease, with the burden of disease predominantly experienced by people in resource-limited countries. Major advancements in diagnostics have introduced low-cost, easy-to-use antigen tests with remarkably high sensitivity and specificity. These tests have led to improved diagnostic accuracy and are essential for screening campaigns to reduce the burden of cryptococcosis. In the last 5 years, several high-quality, multisite clinical trials have led to innovations in therapeutics that have allowed for simplified regimens, which are better tolerated and result in less intensive monitoring and management of medication adverse effects. One trial found that a shorter, 7-day course of deoxycholate amphotericin B is as effective as the longer 14-day course and that flucytosine is an essential partner drug for reducing mortality in the acute phase of disease. Single-dose liposomal amphotericin B has also been found to be as effective as a 7-day course of deoxycholate amphotericin B. These findings have allowed for simpler and safer treatment regimens that also reduce the burden on the healthcare system. This review provides a detailed discussion of the latest evidence guiding the clinical management and special circumstances that make cryptococcal meningitis uniquely difficult to treat.
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Affiliation(s)
- Thomas C. McHale
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R. Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Caleb P. Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Thompson GR, Boulware DR, Bahr NC, Clancy CJ, Harrison TS, Kauffman CA, Le T, Miceli MH, Mylonakis E, Nguyen MH, Ostrosky-Zeichner L, Patterson TF, Perfect JR, Spec A, Kontoyiannis DP, Pappas PG. Noninvasive Testing and Surrogate Markers in Invasive Fungal Diseases. Open Forum Infect Dis 2022; 9:ofac112. [PMID: 35611348 PMCID: PMC9124589 DOI: 10.1093/ofid/ofac112] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/02/2022] [Indexed: 02/04/2023] Open
Abstract
Invasive fungal infections continue to increase as at-risk populations expand. The high associated morbidity and mortality with fungal diseases mandate the continued investigation of novel antifungal agents and diagnostic strategies that include surrogate biomarkers. Biologic markers of disease are useful prognostic indicators during clinical care, and their use in place of traditional survival end points may allow for more rapid conduct of clinical trials requiring fewer participants, decreased trial expense, and limited need for long-term follow-up. A number of fungal biomarkers have been developed and extensively evaluated in prospective clinical trials and small series. We examine the evidence for these surrogate biomarkers in this review and provide recommendations for clinicians and regulatory authorities.
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Affiliation(s)
- George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California-Davis Medical Center, Sacramento California, USA
- Department of Medical Microbiology and Immunology, University of California-Davis, Davis, California, USA
| | - David R Boulware
- Division of Infectious Diseases, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Thomas S Harrison
- Centre for Global Health, Institute of Infection and Immunity, St George’s University of London, London, United Kingdom
- Clinical Academic Group in Infection, St George’s Hospital NHS Trust, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Carol A Kauffman
- VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, USA
| | - Thuy Le
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Eleftherios Mylonakis
- Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - M Hong Nguyen
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Thomas F Patterson
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center, San Antonio, Texas, USA
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Infectious Diseases, Department of Molecular Genetics and Microbiology, Duke University, Durham, North Carolina, USA
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Dimitrios P Kontoyiannis
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Peter G Pappas
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Mikulska M, Balletto E, Castagnola E, Mularoni A. Beta-D-Glucan in Patients with Haematological Malignancies. J Fungi (Basel) 2021; 7:jof7121046. [PMID: 34947028 PMCID: PMC8706797 DOI: 10.3390/jof7121046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
(1-3)-beta-D-glucan (BDG) is an almost panfungal marker (absent in zygomycetes and most cryptococci), which can be successfully used in screening and diagnostic testing in patients with haematological malignancies if its advantages and limitations are known. The aim of this review is to report the data, particularly from the last 5 years, on the use of BDG in haematological population. Published data report mainly on the performance of the Fungitell™ assay, although several others are currently available, and they vary in method and cut-off of positivity. The sensitivity of BDG for invasive fungal disease (IFD) in haematology patients seems lower than in other populations, possibly because of the type of IFD (lower sensitivity was found in case of aspergillosis compared to candidiasis and pneumocystosis) or the use of prophylaxis. The specificity of the test can be improved by using two consecutive positive assays and avoiding testing in the case of the concomitant presence of factors associated with false positive results. BDG should be used in combination with clinical assessment and other diagnostic tests, both radiological and mycological, to provide maximum information. Good performance of BDG in cerebrospinal fluid (CSF) has been reported. BDG is a useful diagnostic method in haematology patients, particularly for pneumocystosis or initial diagnosis of invasive fungal infections.
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Affiliation(s)
- Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genoa, 16132 Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy;
- Correspondence: ; Tel.: +39-010-555-4649
| | - Elisa Balletto
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy;
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, Istituto Giannina Gaslini, 16147 Genova, Italy;
| | - Alessandra Mularoni
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), 90127 Palermo, Italy;
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Xu L, Zhao H, Zhou M, Lang G, Lou H. Single and Repeated Episodes of Candida Species Isolated From Cerebrospinal Fluid for Diagnosing Probable Candida meningitis. Front Microbiol 2021; 12:742931. [PMID: 34721340 PMCID: PMC8554295 DOI: 10.3389/fmicb.2021.742931] [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: 07/17/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The clinical relevance of single or repeated episodes of Candida spp. in cerebrospinal fluid (CSF) in adult patients is debatable. Methods: Forty-two patients with positive Candida episodes in CSF were enrolled in this retrospective study. Results: A total of 42.9% (18/42) were determined to have probable Candida meningitis (PCM). Neurosurgery [odds ratio (OR) (95% confidence interval), OR: 14.4 (1.6–126.1), P = 0.004], lumbar drainage [OR: 5.8 (1.5–23.3), P = 0.009], VP shunt [(OR: 5.6 (1.2–25.8), P = 0.020)], external ventricular drainage [OR: 4.7 (1.3–17.7), P = 0.018], CRP ≥ 10.0 mg/L [OR: 4.9 (1.3–18.1), P = 0.034], and postsurgical broad-spectrum antibiotics [OR: 9.5 (1.8–50.5), P = 0.004] were risk factors associated with PCM. A single CSF Candida episode for the diagnosis of PCM had 7.7% (0.4–37.9%) sensitivity and 20.7% (8.7–40.3%) specificity, whereas repeated episodes of Candida had 66.7% (41.2–85.6%) sensitivity and 95.8% (76.9–99.8%) specificity. No significant difference was found in radiological imaging or CSF profiles between PCM and non-PCM patients. A total of 37.5% (9/24) of patients without PCM received empirical antifungal treatment, and 88.9% (16/18) of patients with PCM received preemptive antifungal treatment. PCM patients had hospitalized mortality rates of 50.0% (9/18). The odds ratio of mortality was 23.0 (2.5–208.6) for PCM patients compared with non-PCM patients (P = 0.001). Conclusion: Both single and repeated positive CSF samples have low validity for the diagnosis of PCM, suggesting that novel strategies for diagnosis algorithms of PCM are urgently needed. Empirical antifungal treatment should be started immediately for suspicious patients with risk factors.
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Affiliation(s)
- Lijun Xu
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Handan Zhao
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Minghan Zhou
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Guanjing Lang
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Haiyan Lou
- Department of Radiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Challenges with Utilizing the 1,3-Beta-d-Glucan and Galactomannan Assays To Diagnose Invasive Mold Infections in Immunocompromised Children. J Clin Microbiol 2021; 59:e0327620. [PMID: 33883182 DOI: 10.1128/jcm.03276-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Establishing the diagnosis of invasive mold infections (IMI) in immunocompromised children is challenging due to nonspecific clinical presentations and the limited sensitivity of traditional culture-based methods. Rapid non-culture-based diagnostics such as the 1,3-beta-d-glucan and galactomannan assays have emerged as promising adjuncts to conventional diagnostic tests in adults. Available data suggest that 1,3-beta-d-glucan has limited accuracy in the pediatric population and is not recommended to be used for the diagnosis of IMI in children. On the other hand, the diagnostic performance of the serum and bronchoalveolar lavage galactomannan in immunocompromised children is comparable to results observed in adults and can be used as a screening tool in children at high risk of developing invasive aspergillosis (IA) who are not receiving mold-active antifungal prophylaxis and as a diagnostic tool in symptomatic children suspected of having IA. Herein, we summarize the available evidence for the use of these rapid non-culture-based diagnostics in immunocompromised children. We also summarize potential causes of false positivity for the 1,3-beta-d-glucan and galactomannan assays.
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Alanio A, Gits-Muselli M, Guigue N, Denis B, Bergeron A, Touratier S, Hamane S, Bretagne S. Prospective comparison of (1,3)-beta-D-glucan detection using colorimetric and turbidimetric assays for diagnosing invasive fungal disease. Med Mycol 2021; 59:882-889. [PMID: 33877326 DOI: 10.1093/mmy/myab016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 12/30/2022] Open
Abstract
Serum (1→3)-β-D-glucan (BDG), an pan fungal antigen, is detected in some invasive fungal diseases (IFDs). We compared two commercial kits, the Fungitell assay (FA) (colorimetric) and the Wako assay (WA) (turbidimetric) over a 4-month period to prospectively test 171 patients who mainly had hematological conditions (62%) and experienced episodes (n = 175) of suspected invasive fungal infection. Twenty-three episodes due to BDG-producing fungi were diagnosed (pneumocystosis, n = 12; invasive aspergillosis, n = 5; candidemia, n = 3; invasive fusariosis, n = 2; hepato-splenic candidiasis, n = 1).Both assays provided similar areas under the curves (AUC = 0.9). Using the optimized positivity thresholds (≥120 pg/ml for FA and ≥ 4 pg/ml for WA), the sensitivity and specificity were 81.8% (CI95: 61.5-92.7), 94.8% (90.1-97.3) for FA and 81.8% (61.5-92.7), 95.4% (90.9-97.8) for WA. Negative predictive value was 97.3% (93.3-99.0) for both tests. If the manufacturer's positivity threshold (≥11 pg/ml) was applied, the WA sensitivity decreased to 50%. Among 71 patients with bacterial infections, 21.1% were FA-positive and 5.6% were WA-positive (p < 10-2).The WA performed similarly as compared to the FA with an optimized cutoff value. The WA is a single sample test that is clinically relevant when a prompt therapeutic decision is required. LAY SUMMARY Serum (1→3)-β-D-glucan testing is dominated by two kits including Fungitell colorimetric assay (FA) and the Wako turbidimetric assay (WA). We compared them prospectively and observed that they both perform similarly when selecting their optimal threshold (≥120 pg/ml for FA and ≥ 4 pg/ml for WA).
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Affiliation(s)
- Alexandre Alanio
- Laboratoire de Parasitologie-Mycologie, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France.,Université de Paris, 75006 Paris, France.,Institut Pasteur, Unité de Mycologie Moléculaire, CNRS UMR2000, 75724 Paris, France
| | - Maud Gits-Muselli
- Laboratoire de Parasitologie-Mycologie, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France.,Université de Paris, 75006 Paris, France
| | - Nicolas Guigue
- Laboratoire de Parasitologie-Mycologie, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France
| | - Blandine Denis
- Service de maladies infectieuses et tropicales, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France
| | - Anne Bergeron
- Service de Pneumologie, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France
| | - Sophie Touratier
- Pharmacie centrale, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France
| | - Samia Hamane
- Laboratoire de Parasitologie-Mycologie, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France
| | - Stéphane Bretagne
- Laboratoire de Parasitologie-Mycologie, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France.,Université de Paris, 75006 Paris, France.,Institut Pasteur, Unité de Mycologie Moléculaire, CNRS UMR2000, 75724 Paris, France
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Efficacy and Pharmacokinetics of Fosmanogepix (APX001) in the Treatment of Candida Endophthalmitis and Hematogenous Meningoencephalitis in Nonneutropenic Rabbits. Antimicrob Agents Chemother 2021; 65:AAC.01795-20. [PMID: 33361304 DOI: 10.1128/aac.01795-20] [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: 10/09/2020] [Accepted: 12/12/2020] [Indexed: 12/22/2022] Open
Abstract
Candida endophthalmitis is a serious sight-threatening complication of candidemia that may occur before or during antifungal therapy. Hematogenous Candida meningoencephalitis (HCME) is also a serious manifestation of disseminated candidiasis in premature infants, immunosuppressed children, and immunocompromised adults. We evaluated the antifungal efficacy and pharmacokinetics of the prodrug fosmanogepix (APX001) in a rabbit model of endophthalmitis/HCME. Manogepix (APX001A), the active moiety of prodrug fosmanogepix, inhibits the fungal enzyme Gwt1 and is highly active in vitro and in vivo against Candida spp., Aspergillus spp., and other fungal pathogens. Plasma pharmacokinetics of manogepix after oral administration of fosmanogepix on day 6 at 25, 50, and 100 mg/kg resulted in maximum concentration of drug in plasma (C max) of 3.96 ± 0.41, 4.14 ± 1.1, and 11.5 ± 1.1 μg/ml, respectively, and area under the concentration-time curve from 0 to 12 h (AUC0-12) of 15.8 ± 3.1, 30.8 ± 5.0, 95.9 ± 14 μg·h/ml, respectively. Manogepix penetrated the aqueous humor, vitreous, and choroid with liquid-to-plasma ratios ranging from 0.19 to 0.52, 0.09 to 0.12, and 0.02 to 0.04, respectively. These concentrations correlated with a significant decrease in Candida albicans burden in vitreous (>101 to 103 log CFU/g) and choroid (>101 to 103 log CFU/g) (P ≤ 0.05 and P ≤ 0.001, respectively). The aqueous humor had no detectable C. albicans in treatment and control groups. The tissue/plasma concentration ratios of manogepix in meninges, cerebrum, cerebellum, and spinal cord were approximately 1:1, which correlated with a >102 to 104 decline of C. albicans in tissue versus control (P ≤ 0.05). Serum and cerebrospinal fluid (CSF) (1→3)-β-d-glucan levels demonstrated significant declines in response to fosmanogepix treatment. These findings provide an experimental foundation for fosmanogepix in treatment of Candida endophthalmitis and HCME and derisk the clinical trials of candidemia and invasive candidiasis.
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12
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Yoon HA, Riska PF, Jain R, Morales C, Pirofski LA. Unexpected case of cryptococcal meningoencephalitis in a patient with long-standing well-controlled HIV infection. Med Mycol Case Rep 2021; 32:14-16. [PMID: 33552883 PMCID: PMC7851412 DOI: 10.1016/j.mmcr.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 11/30/2022] Open
Abstract
Cryptococcal meningoencephalitis (CM) classically occurs in individuals with advanced HIV infection, solid organ transplants, or other immunocompromising conditions. We report a case of fatal CM in a 78-year-old woman with well-controlled HIV infection who had delayed diagnosis, persistently elevated intracranial pressure and pleocytosis of the cerebrospinal fluid. Initial suspicion for CM was low due to her relatively high CD4+ T cell counts, which likely contributed to greater inflammation.
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Affiliation(s)
- Hyun Ah Yoon
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Paul F Riska
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Ruchika Jain
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Cariane Morales
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Liise-Anne Pirofski
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
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13
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White SK, Schmidt RL, Walker BS, Hanson KE. (1→3)-β-D-glucan testing for the detection of invasive fungal infections in immunocompromised or critically ill people. Cochrane Database Syst Rev 2020; 7:CD009833. [PMID: 32693433 PMCID: PMC7387835 DOI: 10.1002/14651858.cd009833.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Invasive fungal infections (IFIs) are life-threatening opportunistic infections that occur in immunocompromised or critically ill people. Early detection and treatment of IFIs is essential to reduce morbidity and mortality in these populations. (1→3)-β-D-glucan (BDG) is a component of the fungal cell wall that can be detected in the serum of infected individuals. The serum BDG test is a way to quickly detect these infections and initiate treatment before they become life-threatening. Five different versions of the BDG test are commercially available: Fungitell, Glucatell, Wako, Fungitec-G, and Dynamiker Fungus. OBJECTIVES To compare the diagnostic accuracy of commercially available tests for serum BDG to detect selected invasive fungal infections (IFIs) among immunocompromised or critically ill people. SEARCH METHODS We searched MEDLINE (via Ovid) and Embase (via Ovid) up to 26 June 2019. We used SCOPUS to perform a forward and backward citation search of relevant articles. We placed no restriction on language or study design. SELECTION CRITERIA We included all references published on or after 1995, which is when the first commercial BDG assays became available. We considered published, peer-reviewed studies on the diagnostic test accuracy of BDG for diagnosis of fungal infections in immunocompromised people or people in intensive care that used the European Organization for Research and Treatment of Cancer (EORTC) criteria or equivalent as a reference standard. We considered all study designs (case-control, prospective consecutive cohort, and retrospective cohort studies). We excluded case studies and studies with fewer than ten participants. We also excluded animal and laboratory studies. We excluded meeting abstracts because they provided insufficient information. DATA COLLECTION AND ANALYSIS We followed the standard procedures outlined in the Cochrane Handbook for Diagnostic Test Accuracy Reviews. Two review authors independently screened studies, extracted data, and performed a quality assessment for each study. For each study, we created a 2 × 2 matrix and calculated sensitivity and specificity, as well as a 95% confidence interval (CI). We evaluated the quality of included studies using the Quality Assessment of Studies of Diagnostic Accuracy-Revised (QUADAS-2). We were unable to perform a meta-analysis due to considerable variation between studies, with the exception of Candida, so we have provided descriptive statistics such as receiver operating characteristics (ROCs) and forest plots by test brand to show variation in study results. MAIN RESULTS We included in the review 49 studies with a total of 6244 participants. About half of these studies (24/49; 49%) were conducted with people who had cancer or hematologic malignancies. Most studies (36/49; 73%) focused on the Fungitell BDG test. This was followed by Glucatell (5 studies; 10%), Wako (3 studies; 6%), Fungitec-G (3 studies; 6%), and Dynamiker (2 studies; 4%). About three-quarters of studies (79%) utilized either a prospective or a retrospective consecutive study design; the remainder used a case-control design. Based on the manufacturer's recommended cut-off levels for the Fungitell test, sensitivity ranged from 27% to 100%, and specificity from 0% to 100%. For the Glucatell assay, sensitivity ranged from 50% to 92%, and specificity ranged from 41% to 94%. Limited studies have used the Dynamiker, Wako, and Fungitec-G assays, but individual sensitivities and specificities ranged from 50% to 88%, and from 60% to 100%, respectively. Results show considerable differences between studies, even by manufacturer, which prevented a formal meta-analysis. Most studies (32/49; 65%) had no reported high risk of bias in any of the QUADAS-2 domains. The QUADAS-2 domains that had higher risk of bias included participant selection and flow and timing. AUTHORS' CONCLUSIONS We noted considerable heterogeneity between studies, and these differences precluded a formal meta-analysis. Because of wide variation in the results, it is not possible to estimate the diagnostic accuracy of the BDG test in specific settings. Future studies estimating the accuracy of BDG tests should be linked to the way the test is used in clinical practice and should clearly describe the sampling protocol and the relationship of time of testing to time of diagnosis.
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Affiliation(s)
- Sandra K White
- Department of Pathology, University of Utah, School of Medicine, Salt Lake City, Utah, USA
| | - Robert L Schmidt
- Department of Pathology, University of Utah, School of Medicine, Salt Lake City, Utah, USA
| | | | - Kimberly E Hanson
- Director, Transplant Infectious Diseases and Immunocompromised Host Service, Section Head, Clinical Microbiology, Director, Medical Microbiology Fellowship Program, University of Utah and ARUP Laboratories, Salt Lake City, Utah, USA
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Ahamefula Osibe D, Lei S, Wang B, Jin C, Fang W. Cell wall polysaccharides from pathogenic fungi for diagnosis of fungal infectious disease. Mycoses 2020; 63:644-652. [PMID: 32401381 DOI: 10.1111/myc.13101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/12/2020] [Accepted: 05/04/2020] [Indexed: 12/12/2022]
Abstract
Invasive fungal diseases are associated with significant morbidity and mortality, particularly in immunocompromised individuals. Early and accurate diagnosis is crucial for effective treatment. Despite traditional methods such as microbiological culture, histopathology, radiology and direct microscopy are available, antigen/antibody-based diagnostics are emerging for diagnosis of invasive fungal infections (IFI). Fungal cell wall is a unique structure composed of polysaccharides that are well correlated with fungal burden during fungal infections. Based on this feature, cell wall polysaccharides have been explored as antigens in IFIs diagnostics such as the galactomannan assay, mannan test, β-glucan assay and cryptococcal CrAg test. Herein, we provide an overview on the cell wall polysaccharides from three opportunistic pathogens: Aspergillus fumigatus, Candida albicans and Cryptococcus neoformans, and their applications for IFIs diagnosis. The clinical outcome of newly developed cell wall polysaccharides-based diagnostics is also discussed.
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Affiliation(s)
- Dandy Ahamefula Osibe
- State Key Laboratory of Non-Food Biomass and Enzyme Technology, National Engineering Research Center for Non-Food Biorefinery, Guangxi Academy of Sciences, Nanning, China.,College of Life Science and Technology, Guangxi University, Nanning, China.,Department of Plant Science & Biotechnology, University of Nigeria, Nsukka, Nigeria
| | - Shuhan Lei
- State Key Laboratory of Non-Food Biomass and Enzyme Technology, National Engineering Research Center for Non-Food Biorefinery, Guangxi Academy of Sciences, Nanning, China.,College of Life Science and Technology, Guangxi University, Nanning, China
| | - Bin Wang
- State Key Laboratory of Non-Food Biomass and Enzyme Technology, National Engineering Research Center for Non-Food Biorefinery, Guangxi Academy of Sciences, Nanning, China
| | - Cheng Jin
- State Key Laboratory of Non-Food Biomass and Enzyme Technology, National Engineering Research Center for Non-Food Biorefinery, Guangxi Academy of Sciences, Nanning, China.,College of Life Science and Technology, Guangxi University, Nanning, China
| | - Wenxia Fang
- State Key Laboratory of Non-Food Biomass and Enzyme Technology, National Engineering Research Center for Non-Food Biorefinery, Guangxi Academy of Sciences, Nanning, China
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15
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Abstract
Infectious meningitis can be caused by viral, bacterial or fungal pathogens. Despite widely available treatments, many types of infectious meningitis are still associated with significant morbidity and mortality. Delay in diagnosis contributes to poor outcomes. Cerebrospinal fluid cultures have been used traditionally but are time intensive and sensitivity is decreased by empiric treatment prior to culture. More rapid techniques such as the cryptococcal lateral flow assay (IMMY), GeneXpert MTB/Rif Ultra (Cepheid) and FilmArray multiplex-PCR (Biofire) are three examples that have drastically changed meningitis diagnostics. This review will discuss a holistic approach to diagnosing bacterial, mycobacterial, viral and fungal meningitis.
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Affiliation(s)
- Victoria Poplin
- Department of Medicine, University of Kansas, Kansas City, KS 66160, USA
| | - David R Boulware
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66160, USA
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16
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Efficacy of Cerebrospinal Fluid Beta-d-Glucan Diagnostic Testing for Fungal Meningitis: a Systematic Review. J Clin Microbiol 2020; 58:JCM.02094-19. [PMID: 31996446 DOI: 10.1128/jcm.02094-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 01/25/2020] [Indexed: 12/15/2022] Open
Abstract
Several case reports and cohort studies have examined the use of (1,3)-beta-d-glucan measurement with cerebrospinal fluid to diagnose fungal meningitis. This systematic review aims to characterize the evidence regarding cerebrospinal fluid (1,3)-beta-d-glucan measurement to detect fungal meningitis. We searched PubMed for (1,3)-beta-d-glucan and each of several distinct fungi, cerebrospinal fluid, and meningitis. Summary data including diagnostic performance (where applicable) were recorded. A total of 939 records were examined via a PubMed search. One hundred eighteen records remained after duplicates were removed, and 104 records were excluded, as they did not examine cerebrospinal fluid, included animals, or focused on nonfungal infections. Fourteen studies were included in this systematic review. A variety of fungi, including species of Candida, Aspergillus, Exserohilum, Cryptococcus, Histoplasma, and Coccidioides, were studied, although most were case reports. Diagnostic accuracy was examined in 5 studies. Cerebrospinal fluid (CSF) (1,3)-beta-d-glucan measurement showed >95% sensitivity in the corticosteroid injection-related outbreak of Exserohilum rostratum One study in Histoplasma meningitis found 53% (53/87) sensitivity and 87% (133/153) specificity, while another study of Cryptococcus meningitis found 89% (69/78) sensitivity and 85% (33/39) specificity. CSF (1,3)-beta-d-glucan testing may be useful, primarily as a nonspecific marker of fungal meningitis. Although the FDA black box warning states that Cryptococcus spp. do not make (1,3)-beta-d-glucan, the current evidence shows that (1,3)-beta-d-glucan is detectable in cryptococcal meningitis. Organism-specific testing should be used in conjunction with (1,3)-beta-d-glucan measurement.
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17
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Abstract
PURPOSE OF REVIEW Defective cell-mediated immunity is a major risk factor for cryptococcosis, a fatal disease if untreated. Cryptococcal meningitis (CM), the main presentation of disseminated disease, occurs through hematogenous spread to the brain from primary pulmonary foci, facilitated by yeast virulence factors. We revisit remarkable recent improvements in the prevention, diagnosis and management of CM. RECENT FINDINGS Cryptococcal antigen (CrAg), main capsular polysaccharide of Cryptococcus spp. is detectable in blood and cerebrospinal fluid of infected patients with point of care lateral flow assays. Recent World Health Organization guidelines recommend 7-day amphotericin B plus flucytosine, then 7-day high dose (1200 mg/day) fluconazole for induction treatment of HIV-associated CM. Management of raised intracranial pressure, a consequence of CM, should rely mainly on daily therapeutic lumbar punctures until normalisation. In HIV-associated CM, following introduction of antifungal therapy, (re)initiation of antiretroviral therapy should be delayed by 4-6 weeks to prevent immune reconstitution inflammatory syndrome, common in CM. CM is a fatal disease whose diagnosis has recently been simplified. Treatment should always include antifungal combination therapy and management of raised intracranial pressure. Screening for immune deficiency should be mandatory in all patients with cryptococcosis.
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18
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Skipper C, Abassi M, Boulware DR. Diagnosis and Management of Central Nervous System Cryptococcal Infections in HIV-Infected Adults. J Fungi (Basel) 2019; 5:jof5030065. [PMID: 31330959 PMCID: PMC6787675 DOI: 10.3390/jof5030065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 11/24/2022] Open
Abstract
Cryptococcal meningitis persists as a significant source of morbidity and mortality in persons with HIV/AIDS, particularly in sub-Saharan Africa. Despite increasing access to antiretrovirals, persons presenting with advanced HIV disease remains common, and Cryptococcus remains the most frequent etiology of adult meningitis. We performed a literature review and herein present the most up-to-date information on the diagnosis and management of cryptococcosis. Recent advances have dramatically improved the accessibility of timely and affordable diagnostics. The optimal initial antifungal management has been newly updated after the completion of a landmark clinical trial. Beyond antifungals, the control of intracranial pressure and mitigation of toxicities remain hallmarks of effective treatment. Cryptococcal meningitis continues to present challenging complications and continued research is needed.
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Affiliation(s)
- Caleb Skipper
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
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19
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Trevijano-Contador N, Pirofski L. Antibody immunity and natural resistance to cryptococcosis. CURRENT TROPICAL MEDICINE REPORTS 2019; 6:50-54. [PMID: 31134140 DOI: 10.1007/s40475-019-00174-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The encapsulated fungus Cryptococcus neoformans (Cn) causes cryptococcal meningitis (CM). There are ~180,000 deaths per year worldwide attributed to CM, which is the most common cause of meningitis in adults with HIV in sub-Saharan Africa. HIV infection with advanced immunodeficiency is the most important predisposing risk factor for CM, highlighting the critical role that T cell mediated immunity plays in disease prevention. Numerous studies in the past decade demonstrate that antibody immunity also plays a role in resistance to CM, although its role has taken more time to establish. In mice, B cells reduce early dissemination from lungs to brain, and naïve mouse IgM can enhance fungal containment in the lungs. In concert with these findings, human studies show that patients with CM have lower IgM memory B cell levels and/or different serological profiles than controls. In this article, we review recent data on the role that B cells and/or antibody-based immunity play in host defense against Cn and natural resistance to CM.
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Affiliation(s)
- N Trevijano-Contador
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA
| | - L Pirofski
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA.,Department of Microbiology & Immunology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA.poly
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20
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Dellière S, Guery R, Candon S, Rammaert B, Aguilar C, Lanternier F, Chatenoud L, Lortholary O. Understanding Pathogenesis and Care Challenges of Immune Reconstitution Inflammatory Syndrome in Fungal Infections. J Fungi (Basel) 2018; 4:E139. [PMID: 30562960 PMCID: PMC6308948 DOI: 10.3390/jof4040139] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/14/2018] [Accepted: 12/15/2018] [Indexed: 12/16/2022] Open
Abstract
Immune deficiency of diverse etiology, including human immunodeficiency virus (HIV), antineoplastic agents, immunosuppressive agents used in solid organ recipients, immunomodulatory therapy, and other biologics, all promote invasive fungal infections. Subsequent voluntary or unintended immune recovery may induce an exaggerated inflammatory response defining immune reconstitution inflammatory syndrome (IRIS), which causes significant mortality and morbidity. Fungal-associated IRIS raises several diagnostic and management issues. Mostly studied with Cryptococcus, it has also been described with other major fungi implicated in human invasive fungal infections, such as Pneumocystis, Aspergillus, Candida, and Histoplasma. Furthermore, the understanding of IRIS pathogenesis remains in its infancy. This review summarizes current knowledge regarding the clinical characteristics of IRIS depending on fungal species and existing strategies to predict, prevent, and treat IRIS in this patient population, and tries to propose a common immunological background to fungal IRIS.
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Affiliation(s)
- Sarah Dellière
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
| | - Romain Guery
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
| | - Sophie Candon
- Medical School, Paris-Descartes University, INSERM U1151-CNRS UMR 8253APHP, Necker-Enfants Malades Hospital, APHP, Clinical Immunology, 75015 Paris, France.
| | - Blandine Rammaert
- Medical School, Poitiers University, Poitiers, France; Poitiers University Hospital, Infectious Disease Unit, Poitiers, France; INSERM U1070, 86022 Poitiers, France.
| | - Claire Aguilar
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
| | - Fanny Lanternier
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
- Pasteur Institute, Molecular Mycology Unit, National Reference Center for Invasive Fungal Disease and Antifungals, CNRS UMR 2000, 75015 Paris, France.
| | - Lucienne Chatenoud
- Medical School, Paris-Descartes University, INSERM U1151-CNRS UMR 8253APHP, Necker-Enfants Malades Hospital, APHP, Clinical Immunology, 75015 Paris, France.
| | - Olivier Lortholary
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
- Pasteur Institute, Molecular Mycology Unit, National Reference Center for Invasive Fungal Disease and Antifungals, CNRS UMR 2000, 75015 Paris, France.
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21
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Use of Cerebrospinal Fluid (1,3)-β-d-Glucan to Monitor Treatment Response in Candida albicans Meningitis in an HIV-infected Patient. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2018. [DOI: 10.1097/ipc.0000000000000624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Detection of (1,3)-β-d-Glucan in Cerebrospinal Fluid in Histoplasma Meningitis. J Clin Microbiol 2018; 56:JCM.00663-18. [PMID: 30021828 DOI: 10.1128/jcm.00663-18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/05/2018] [Indexed: 11/20/2022] Open
Abstract
The diagnosis of central nervous system (CNS) histoplasmosis is often difficult. Although cerebrospinal fluid (CSF) (1,3)-β-d-glucan (BDG) is available as a biological marker for the diagnosis of fungal meningitis, there are limited data on its use for the diagnosis of Histoplasma meningitis. We evaluated CSF BDG detection, using the Fungitell assay, in patients with CNS histoplasmosis and controls. A total of 47 cases and 153 controls were identified. The control group included 13 patients with a CNS fungal infection other than histoplasmosis. Forty-nine percent of patients with CNS histoplasmosis and 43.8% of controls were immunocompromised. The median CSF BDG level was 85 pg/ml for cases, compared to <31 pg/ml for all controls (P < 0.05) and 82 pg/ml for controls with other causes of fungal meningitis (P = 0.27). The sensitivity for detection of BDG in CSF was 53.2%, whereas the specificity was 86.9% versus all controls and 46% versus other CNS fungal infections. CSF BDG levels of ≥80 pg/ml are neither sensitive nor specific to support a diagnosis of Histoplasma meningitis.
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23
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Farhour Z, Mehraj V, Chen J, Ramendra R, Lu H, Routy JP. Use of (1→3)-β-d-glucan for diagnosis and management of invasive mycoses in HIV-infected patients. Mycoses 2018; 61:718-722. [PMID: 29855088 PMCID: PMC6175469 DOI: 10.1111/myc.12797] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/24/2018] [Accepted: 05/25/2018] [Indexed: 01/10/2023]
Abstract
People living with HIV (PLHIV) are highly vulnerable to invasive fungal infections (IFIs) due to their immune dysfunction. Diagnosis and treatment of IFIs remain challenging due to the requirement of deep tissue sampling to visualise and culture fungi before initiating treatment. Such techniques are less practical in resource‐limited settings due to their cost and requirement of relatively invasive procedures. Hence, identification of surrogate markers for the early diagnosis and therapeutic monitoring of IFIs is required. Recent studies have shown that (1→3)‐β‐d‐glucan (BDG), a major fungal cell wall antigen, represents a promising soluble marker for the presumptive diagnosis and therapeutic monitoring of IFIs in HIV‐infected patients. Herein, we review findings on the merits of BDG assays in the diagnosis of IFIs and monitoring of antifungal therapies for PLHIV. Conversely to other types of immunocompromised patients, HIV infection is associated with gut damage and subsequent bacterial and fungal translocation leading to elevated BDG plasma levels.
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Affiliation(s)
- Zahra Farhour
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada.,Research Institute, McGill University Health Centre, Montreal, QC, Canada
| | - Vikram Mehraj
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada.,Research Institute, McGill University Health Centre, Montreal, QC, Canada.,CR-CHUM, Université de Montréal, Montreal, QC, Canada
| | - Jun Chen
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada.,Research Institute, McGill University Health Centre, Montreal, QC, Canada.,Department of Infectious Diseases, Shanghai Public Health Clinical Center, Shanghai, China
| | - Rayoun Ramendra
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada.,Research Institute, McGill University Health Centre, Montreal, QC, Canada
| | - Hongzhou Lu
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Shanghai, China
| | - Jean-Pierre Routy
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada.,Research Institute, McGill University Health Centre, Montreal, QC, Canada.,Division of Hematology, McGill University Health Centre, Montreal, QC, Canada
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24
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Maldonado S, Fitzgerald-Bocarsly P. Antifungal Activity of Plasmacytoid Dendritic Cells and the Impact of Chronic HIV Infection. Front Immunol 2017; 8:1705. [PMID: 29255464 PMCID: PMC5723005 DOI: 10.3389/fimmu.2017.01705] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 11/20/2017] [Indexed: 01/10/2023] Open
Abstract
Due to the effectiveness of combined antiretroviral therapy, people living with HIV can control viral replication and live longer lifespans than ever. However, HIV-positive individuals still face challenges to their health and well-being, including dysregulation of the immune system resulting from years of chronic immune activation, as well as opportunistic infections from pathogenic fungi. This review focuses on one of the key players in HIV immunology, the plasmacytoid dendritic cell (pDC), which links the innate and adaptive immune response and is notable for being the body’s most potent producer of type-I interferons (IFNs). During chronic HIV infection, the pDC compartment is greatly dysregulated, experiencing a substantial depletion in number and compromise in function. This immune dysregulation may leave patients further susceptible to opportunistic infections. This is especially important when considering a new role for pDCs currently emerging in the literature: in addition to their role in antiviral immunity, recent studies suggest that pDCs also play an important role in antifungal immunity. Supporting this new role, pDCs express C-type lectin receptors including dectin-1, dectin-2, dectin-3, and mannose receptor, and toll-like receptors-4 and -9 that are involved in recognition, signaling, and response to a wide variety of fungal pathogens, including Aspergillus fumigatus, Cryptococcus neoformans, Candida albicans, and Pneumocystis jirovecii. Accordingly, pDCs have been demonstrated to recognize and respond to certain pathogenic fungi, measured via activation, cytokine production, and fungistatic activity in vitro, while in vivo mouse models indicated a strikingly vital role for pDCs in survival against pulmonary Aspergillus challenge. Here, we discuss the role of the pDC compartment and the dysregulation it undergoes during chronic HIV infection, as well as what is known so far about the role and mechanisms of pDC antifungal activity.
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Affiliation(s)
- Samuel Maldonado
- Rutgers School of Graduate Studies, Newark, NJ, United States.,Department of Pathology and Laboratory Medicine, New Jersey Medical School, Newark, NJ, United States
| | - Patricia Fitzgerald-Bocarsly
- Rutgers School of Graduate Studies, Newark, NJ, United States.,Department of Pathology and Laboratory Medicine, New Jersey Medical School, Newark, NJ, United States
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25
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Giacobbe DR, Del Bono V, Viscoli C, Mikulska M. Use of 1,3-β-D-glucan in invasive fungal diseases in hematology patients. Expert Rev Anti Infect Ther 2017; 15:1101-1112. [PMID: 29125373 DOI: 10.1080/14787210.2017.1401467] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Invasive fungal diseases (IFD) remain a leading cause of morbidity and mortality in hematology patients. Within a diagnostic-driven approach, the use of the serum (1,3)-ß-D-glucan (BDG) test represents a valid tool for the early diagnosis and treatment of IFD. Areas covered: The available literature on the use of BDG in hematology patients was systematically retrieved. Then, it was reviewed and discussed, to identify key issues pertaining to a clinically-oriented narrative presentation of the topic. Expert commentary: The use of BDG in hematology patients at risk for invasive aspergillosis (IA) is secondary to the use of galactomannan. However, since BDG is not specific for IA, it offers an advantage of diagnosing also other IFD, such as candidiasis and pneumocystosis. The limitations of BDG include high costs and lower sensitivity in hematology patients compared to other cohorts. The risk of false positive results is possibly lower in real life than in theory, since glucan-free equipment is available and modern dialysis membranes and blood products usually do not release BDG. Thus, in experienced hands and selected clinical situations, BDG is a useful diagnostic tool, particularly due to short turnover time to results and versatility in diagnosing different IFD.
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Affiliation(s)
- Daniele Roberto Giacobbe
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
| | - Valerio Del Bono
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
| | - Claudio Viscoli
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
| | - Malgorzata Mikulska
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
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26
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Abstract
This chapter provides an overview of infectious syndromes, pathogens, and diagnostic testing modalities for central nervous system infections in the immunocompromised host.
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McCarthy MW, Petraitiene R, Walsh TJ. Translational Development and Application of (1→3)-β-d-Glucan for Diagnosis and Therapeutic Monitoring of Invasive Mycoses. Int J Mol Sci 2017; 18:ijms18061124. [PMID: 28538702 PMCID: PMC5485948 DOI: 10.3390/ijms18061124] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 05/09/2017] [Accepted: 05/16/2017] [Indexed: 12/24/2022] Open
Abstract
Early diagnosis and prompt initiation of appropriate antimicrobial therapy are crucial steps in the management of patients with invasive fungal infections. However, the diagnosis of invasive mycoses remains a major challenge in clinical practice, because presenting symptoms may be subtle and non-invasive diagnostic assays often lack sensitivity and specificity. Diagnosis is often expressed on a scale of probability (proven, probable and possible) based on a constellation of imaging findings, microbiological tools and histopathology, as there is no stand-alone assay for diagnosis. Recent data suggest that the carbohydrate biomarker (1→3)-β-d-glucan may be useful in both the diagnosis and therapeutic monitoring of invasive fungal infections due to some yeasts, molds, and dimorphic fungi. In this paper, we review recent advances in the use of (1→3)-β-d-glucan to monitor clinical response to antifungal therapy and explore how this assay may be used in the future.
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Affiliation(s)
- Matthew W McCarthy
- Division of General Internal Medicine, Weill Cornell Medicine of Cornell University, New York, NY 10065, USA.
| | - Ruta Petraitiene
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, NY 10065, USA.
| | - Thomas J Walsh
- Departments of Pediatrics, and Microbiology & Immunology, Weill Cornell Medicine, New York, NY 10065, USA.
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Repeated therapeutic lumbar punctures in cryptococcal meningitis – necessity and/or opportunity? Curr Opin Infect Dis 2016; 29:539-545. [DOI: 10.1097/qco.0000000000000315] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Cerebrospinal Fluid (1,3)-Beta-d-Glucan Testing Is Useful in Diagnosis of Coccidioidal Meningitis. J Clin Microbiol 2016; 54:2707-2710. [PMID: 27558179 DOI: 10.1128/jcm.01224-16] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 08/16/2016] [Indexed: 11/20/2022] Open
Abstract
Diagnosing coccidioidal meningitis (CM) can be problematic owing to its infrequency and/or a delay in the positivity of a cerebrospinal fluid (CSF) culture or CSF antibody, particularly if the primary coccidioidal infection is unrecognized. We tested 37 CSF specimens, 26 from patients with confirmed CM and 11 from patients with suspected microbial meningitis without fungal diagnosis, for (1,3)-beta-glucan (BG). BG in CM CSF specimens ranged from 18 to 3,300 pg/ml and in controls ranged from <3.9 to 103 pg/ml. Diagnostic performance was determined using a 31-pg/ml cutoff (the bottom of the serum range according to the directions for the commercial kit, although further serial dilutions of the standard indicated linearity to 3.9). Sensitivity was 96%, specificity was 82%, positive and negative predictive values were 93% and 90%, and the area under the receiver operating characteristic curve was 0.937. Fifteen of 15 samples of >103 pg/ml were CM. The one false-negative specimen was from a patient with a pseudosyrinx, without inflammatory evidence of meningitis activity. Serial samples from some patients were positive at ≤8 years, indicating no loss of positivity with chronicity. Samples stored frozen since 2000 included those with 2 of the 3 highest values, indicating that fresh samples not required. A previous study indicated serum sensitivities of 53% in acute, 50% in resolved, and 83% in disseminated and meningeal coccidioidomycosis. Three studies of other fungal meningitides ranged from 86 to 1,524 pg/ml CSF, with 37 controls of <4 to 115 pg/ml CSF. CSF BG analysis had good diagnostic performance in CM. CSF BG testing can be useful in CM, and a commercial kit is available. It will be of interest to correlate this with course, treatment, outcome, inflammation, and antigen. The only mycoses with common central nervous system (CNS) involvement are cryptococcal and coccidioidal, so CSF BG screening can be useful in meningitis diagnosis.
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Angebault C, Lanternier F, Dalle F, Schrimpf C, Roupie AL, Dupuis A, Agathine A, Scemla A, Paubelle E, Caillot D, Neven B, Frange P, Suarez F, d'Enfert C, Lortholary O, Bougnoux ME. Prospective Evaluation of Serum β-Glucan Testing in Patients With Probable or Proven Fungal Diseases. Open Forum Infect Dis 2016; 3:ofw128. [PMID: 27419189 PMCID: PMC4942764 DOI: 10.1093/ofid/ofw128] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 06/14/2016] [Indexed: 11/22/2022] Open
Abstract
We evaluated the positivity of (1-3)-β-D-glucan, a serum marker of invasive fungal diseases (IFD), at diagnosis and during treatment. (1-3)-β-D-Glucan may not be an early marker but could prove useful for diagnosis of chronic IFD. Background. Early diagnosis and treatment are crucial in invasive fungal diseases (IFD). Serum (1-3)-β-d-glucan (BG) is believed to be an early IFD marker, but its diagnostic performance has been ambiguous, with insufficient data regarding sensitivity at the time of IFD diagnosis (TOD) and according to outcome. Whether its clinical utility is equivalent for all types of IFD remains unknown. Methods. We included 143 patients with proven or probable IFD (49 invasive candidiasis, 45 invasive aspergillosis [IA], and 49 rare IFD) and analyzed serum BG (Fungitell) at TOD and during treatment. Results. (1-3)-β-d-glucan was undetectable at TOD in 36% and 48% of patients with candidemia and IA, respectively; there was no correlation between negative BG results at TOD and patients' characteristics, localization of infection, or prior antifungal use. Nevertheless, patients with candidemia due to Candida albicans were more likely to test positive for BG at TOD (odds ratio = 25.4, P = .01) than patients infected with other Candida species. In 70% of the patients with a follow-up, BG negativation occurred in >1 month for candidemia and >3 months for IA. A slower BG decrease in patients with candidemia was associated with deep-seated localizations (P = .04). Thirty-nine percent of patients with rare IFD had undetectable BG at TOD; nonetheless, all patients with chronic subcutaneous IFD tested positive at TOD. Conclusions. Undetectable serum BG does not rule out an early IFD, when the clinical suspicion is high. After IFD diagnostic, kinetics of serum BG are difficult to relate to clinical outcome.
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Affiliation(s)
- Cécile Angebault
- Unitéde Parasitologie-Mycologie, Service de Microbiologie Clinique; Université Paris Descartes, Sorbonne Paris-Cité
| | - Fanny Lanternier
- Centre d'Infectiologie Necker Pasteur; Université Paris Descartes, Sorbonne Paris-Cité,; Unité de Mycologie Médicale, Centre National de Référence Mycoses Invasives et Antifongiques, Institut Pasteur, Paris
| | | | | | | | - Aurélie Dupuis
- Unité de Parasitologie-Mycologie, Service de Microbiologie Clinique
| | - Aurélie Agathine
- Unité de Parasitologie-Mycologie, Service de Microbiologie Clinique
| | - Anne Scemla
- Service de Néphrologie et Transplantation Adulte; Université Paris Descartes, Sorbonne Paris-Cité,; Réseau Thématique de Recherche et de SoinsCentaure, Labex Transplantex, Paris
| | - Etienne Paubelle
- Service d'Hématologie Adulte; Université Paris Descartes, Sorbonne Paris-Cité
| | - Denis Caillot
- Service d'Hématologie Clinique , Centre Hospitalier Universitaire Dijon Bourgogne
| | - Bénédicte Neven
- Unité d'Immunologie, Hématologie et Rhumatologie Pédiatriques
| | - Pierre Frange
- Unité d'Immunologie, Hématologie et Rhumatologie Pédiatriques; Unité d'Hygiène, Service de Microbiologie Clinique, Hôpital Necker-Enfants malades, Assistance Publique des Hôpitaux de Paris
| | - Felipe Suarez
- Service d'Hématologie Adulte; Université Paris Descartes, Sorbonne Paris-Cité
| | - Christophe d'Enfert
- Unité Biologie et Pathogénicité Fongiques, Département de Mycologie, Institut Pasteur, Paris; Institut National de la Recherche Agronomique, Unité Sous Contrat 2019, Paris, France
| | - Olivier Lortholary
- Centre d'Infectiologie Necker Pasteur; Université Paris Descartes, Sorbonne Paris-Cité,; Unité de Mycologie Médicale, Centre National de Référence Mycoses Invasives et Antifongiques, Institut Pasteur, Paris
| | - Marie-Elisabeth Bougnoux
- Unitéde Parasitologie-Mycologie, Service de Microbiologie Clinique; Université Paris Descartes, Sorbonne Paris-Cité,; Unité Biologie et Pathogénicité Fongiques, Département de Mycologie, Institut Pasteur, Paris; Institut National de la Recherche Agronomique, Unité Sous Contrat 2019, Paris, France
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Hoenigl M, de Oliveira MF, Pérez-Santiago J, Zhang Y, Woods SP, Finkelman M, Gianella S. Correlation of (1→3)-β-D-glucan with other inflammation markers in chronically HIV infected persons on suppressive antiretroviral therapy. GMS INFECTIOUS DISEASES 2015; 3. [PMID: 27917362 PMCID: PMC5132183 DOI: 10.3205/id000018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We evaluated associations between levels of BDG and other biomarkers of inflammation in blood from 41 virologically suppressed persons with chronic HIV-infection. We found a significant correlation between BDG and neopterin levels (r=0.68), and trends to significance for correlations with other inflammation markers (tumor-necrosis-factor-α: r=0.30; interleukin-8: r=0.30; interleukin-6: r=0.28). In conclusion, BDG levels correlated with inflammation markers in a cohort of virologically suppressed individuals with chronic HIV infection. Future studies are needed to evaluate whether BDG may be a marker for morbidity in chronic HIV infection.
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Affiliation(s)
- Martin Hoenigl
- Division of Infectious Diseases, University of California San Diego, San Diego, California, USA; Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria; Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Josué Pérez-Santiago
- Division of Infectious Diseases, University of California San Diego, San Diego, California, USA
| | - Yonglong Zhang
- Research Laboratory, Associates of Cape Cod, Inc., Falmouth, Massachusetts, USA
| | | | - Malcolm Finkelman
- Research Laboratory, Associates of Cape Cod, Inc., Falmouth, Massachusetts, USA
| | - Sara Gianella
- Division of Infectious Diseases, University of California San Diego, San Diego, California, USA
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1,3-β-D-glucan in cryptococcal meningitis. THE LANCET. INFECTIOUS DISEASES 2015; 15:1136-1137. [DOI: 10.1016/s1473-3099(15)00306-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 08/26/2015] [Indexed: 11/23/2022]
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Liew YX, Teo J, Too IAL, Ngan CCL, Tan AL, Chlebicki MP, Kwa ALH, Lee W. Candida Surveillance in Surgical Intensive Care Unit (SICU) in a Tertiary Institution. BMC Infect Dis 2015; 15:256. [PMID: 26137997 PMCID: PMC4490638 DOI: 10.1186/s12879-015-0997-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 06/23/2015] [Indexed: 11/24/2022] Open
Abstract
Background Colonization of patients occurs before development into invasive candidiasis. There is a need to determine the incidences of Candida colonization and infection in SICU patients, and evaluate the usefulness of beta-D-glucan (BDG) assay in diagnosing invasive candidiasis when patients are colonized. Methods Clinical data and fungal surveillance cultures in 28 patients were recorded from November 2010, and January to February 2011. Susceptibilities of Candida isolates to fluconazole, voriconazole, amphotericin B, micafungin, caspofungin and anidulafungin were tested via Etest. The utilities of BDG, Candida score and colonization index for candidiasis diagnosis were compared via ROC. Results 30 BDG assays were performed in 28 patients. Four assay cases had concurrent colonization and infection; 23 had concurrent colonization and no infection; three had no concurrent colonization and infection. Of 136 surveillance swabs, 52 (38.24 %) were positive for Candida spp, with C. albicans being the commonest. Azole resistance was detected in C. albicans (7 %). C. glabrata and C. tropicalis were, respectively, 100 and 7 % SDD to fluconazole. All 3 tests showed high sensitivity of 75–100 % but poor specificity ranging 15.38–38.46 %. BDG performed the best (AUC of 0.89). Conclusions Despite that positive BDG is common in surgical patients with Candida spp colonization, BDG performed the best when compared to CI and CS.
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Affiliation(s)
- Yi Xin Liew
- Department of Pharmacy, Singapore General Hospital, Block 8 Level 2, Outram Road, Singapore, 169608, Singapore.
| | - Jocelyn Teo
- Department of Pharmacy, Singapore General Hospital, Block 8 Level 2, Outram Road, Singapore, 169608, Singapore.
| | - Irene Ai-Ling Too
- Division of Nursing, Department of SICU, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
| | - Cecilia Cheng-Lai Ngan
- Department of Pathology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
| | - Ai Ling Tan
- Department of Pathology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
| | - Maciej Piotr Chlebicki
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
| | - Andrea Lay-Hoon Kwa
- Department of Pharmacy, Singapore General Hospital, Block 8 Level 2, Outram Road, Singapore, 169608, Singapore. .,Emerging Infectious Diseases, Duke-National University of Singapore Graduate Medical School, 8 College Rd, Singapore, 169857, Singapore. .,Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, Singapore, 117543, Singapore.
| | - Winnie Lee
- Department of Pharmacy, Singapore General Hospital, Block 8 Level 2, Outram Road, Singapore, 169608, Singapore.
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Abassi M, Boulware DR, Rhein J. Cryptococcal Meningitis: Diagnosis and Management Update. CURRENT TROPICAL MEDICINE REPORTS 2015; 2:90-99. [PMID: 26279970 PMCID: PMC4535722 DOI: 10.1007/s40475-015-0046-y] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Recent advances in the diagnosis and management of cryptococcal meningitis are promising and have been improving long-term survival. Point of care testing has made diagnosing cryptococcal meningitis rapid, practical, and affordable. Targeted screening and treatment programs for cryptococcal antigenemia are a cost effective method for reducing early mortality on antiretroviral therapy (ART). Optimal initial management with amphotericin and flucytosine improves survival against alternative therapies, although amphotericin is difficult to administer and flucytosine is not available in middle or low income countries, where cryptococcal meningitis is most prevalent. Controlling increased intracranial pressure with serial therapeutic lumbar punctures has a proven survival benefit. Delaying ART initiation for 4 weeks after the diagnosis of cryptococcal meningitis is associated with improved survival. Fortunately, new approaches have been leading the way toward improving care for cryptococcal meningitis patients. New trials utilizing different combinations of antifungal therapy are reviewed, and we summarize the efficacy of different regimens.
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Affiliation(s)
- Mahsa Abassi
- University of Minnesota, Minneapolis, MN, USA
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | - Joshua Rhein
- University of Minnesota, Minneapolis, MN, USA
- Infectious Disease Institute, Makerere University, Kampala, Uganda
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