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Moreno A, Mah J, Budvytiene I, Ho DY, Schwenk HT, Banaei N. Dynamics and prognostic value of plasma cell-free DNA PCR in patients with invasive aspergillosis and mucormycosis. J Clin Microbiol 2024; 62:e0039424. [PMID: 38602412 PMCID: PMC11237630 DOI: 10.1128/jcm.00394-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024] Open
Abstract
Aspergillus species and Mucorales agents are the primary etiologies of invasive fungal disease (IFD). Biomarkers that predict outcomes are needed to improve care. Patients diagnosed with invasive aspergillosis and mucormycosis using plasma cell-free DNA (cfDNA) PCR were retested weekly for 4 weeks. The primary outcome included all-cause mortality at 6 weeks and 6 months based on baseline cycle threshold (CT) values and results of follow-up cfDNA PCR testing. Forty-five patients with Aspergillus and 30 with invasive Mucorales infection were retested weekly for a total of 197 tests. Using the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium (EORTC/MSG) criteria, 30.7% (23/75), 25.3% (19/75), and 38.7% (29/75) had proven, probable, and possible IFD, respectively. In addition, 97.3% (73/75) were immunocompromised. Baseline CT increased significantly starting at week 1 for Mucorales and week 2 for Aspergillus. Aspergillosis and mucormycosis patients with higher baseline CT (CT >40 and >35, respectively) had a nonsignificantly higher survival rate at 6 weeks, compared with patients with lower baseline CT. Mucormycosis patients with higher baseline CT had a significantly higher survival rate at 6 months. Mucormycosis, but not aspergillosis patients, with repeat positive cfDNA PCR results had a nonsignificantly lower survival rate at 6 weeks and 6 months compared with patients who reverted to negative. Aspergillosis patients with baseline serum Aspergillus galactomannan index <0.5 and <1.0 had significantly higher survival rates at 6 weeks when compared with those with index ≥0.5 and ≥1.0, respectively. Baseline plasma cfDNA PCR CT can potentially be used to prognosticate survival in patients with invasive Aspergillus and Mucorales infections. IMPORTANCE We show that Aspergillus and Mucorales plasma cell-free DNA PCR can be used not only to noninvasively diagnose patients with invasive fungal disease but also to correlate the baseline cycle threshold with survival outcomes, thus potentially allowing the identification of patients at risk for poor outcomes, who may benefit from more targeted therapies.
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Affiliation(s)
- Angel Moreno
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Jordan Mah
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Indre Budvytiene
- Clinical Microbiology Laboratory, Stanford Health Care, Palo Alto, California, USA
| | - Dora Y. Ho
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Hayden T. Schwenk
- Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Niaz Banaei
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
- Clinical Microbiology Laboratory, Stanford Health Care, Palo Alto, California, USA
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California, USA
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2
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Friedman DZP, Theel ES, Walker RC, Vikram HR, Razonable RR, Vergidis P. Serial Bronchoalveolar Lavage Fluid Aspergillus Galactomannan and Treatment Response in Invasive Pulmonary Aspergillosis. Open Forum Infect Dis 2024; 11:ofae114. [PMID: 38560609 PMCID: PMC10977621 DOI: 10.1093/ofid/ofae114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
We studied patients diagnosed with aspergillosis based on positive bronchoalveolar lavage (BAL) Aspergillus galactomannan (GM) who had follow-up BAL sampling within 180 days. GM trend and clinical outcome were concordant in only 60% (30/50). While useful for the initial diagnosis, BAL GM trending does not always correlate with treatment response.
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Affiliation(s)
- Daniel Z P Friedman
- Section of Infectious Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Section of Infectious Diseases and Public Health, University of Chicago, Chicago, Illinois, USA
| | - Elitza S Theel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Randall C Walker
- Section of Infectious Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Raymund R Razonable
- Section of Infectious Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Paschalis Vergidis
- Section of Infectious Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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3
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Heylen J, Vanbiervliet Y, Maertens J, Rijnders B, Wauters J. Acute Invasive Pulmonary Aspergillosis: Clinical Presentation and Treatment. Semin Respir Crit Care Med 2024; 45:69-87. [PMID: 38211628 DOI: 10.1055/s-0043-1777769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Among all clinical manifestations of pulmonary aspergillosis, invasive pulmonary aspergillosis (IPA) is the most acute presentation. IPA is caused by Aspergillus hyphae invading the pulmonary tissue, causing either tracheobronchitis and/or bronchopneumonia. The degree of fungal invasion into the respiratory tissue can be seen as a spectrum, going from colonization to deep tissue penetration with angio-invasion, and largely depends on the host's immune status. Patients with prolonged, severe neutropenia and patients with graft-versus-host disease are at particularly high risk. However, IPA also occurs in other groups of immunocompromised and nonimmunocompromised patients, like solid organ transplant recipients or critically ill patients with severe viral disease. While a diagnosis of proven IPA is challenging and often warranted by safety and feasibility, physicians must rely on a combination of clinical, radiological, and mycological features to assess the likelihood for the presence of IPA. Triazoles are the first-choice regimen, and the choice of the drug should be made on an individual basis. Adjunctive therapy such as immunomodulatory treatment should also be taken into account. Despite an improving and evolving diagnostic and therapeutic armamentarium, the burden and mortality of IPA still remains high. This review aims to give a comprehensive and didactic overview of the current knowledge and best practices regarding the epidemiology, clinical presentation, diagnosis, and treatment of acute IPA.
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Affiliation(s)
- Jannes Heylen
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Yuri Vanbiervliet
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Joost Wauters
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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4
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Long-Term Kinetics of Serum Galactomannan during Treatment of Complicated Invasive Pulmonary Aspergillosis. J Fungi (Basel) 2023; 9:jof9020157. [PMID: 36836274 PMCID: PMC9965572 DOI: 10.3390/jof9020157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 01/26/2023] Open
Abstract
Several studies have evaluated the serum galactomannan (GM) antigen assay in pediatric patients, and there is convincing evidence for its usefulness as a diagnostic tool for invasive Aspergillus infections in patients with acute leukemias or post allogeneic hematopoietic cell transplantation (HCT). Less is known about the utility of the assay in monitoring responses to treatment in patients with established invasive aspergillosis (IA). Here, we present the long-term kinetics of serum galactomannan in two severely immunocompromised adolescents with invasive pulmonary aspergillosis (IPA) who were cured after complicated clinical courses. We also review the utility of the GM antigen assay in serum as a prognostic tool around the time of diagnosis of IA and as a biomarker to monitor disease activity in patients with established IA and assess responses to systemic antifungal therapy.
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5
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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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Little JS, Shapiro RM, Aleissa MM, Kim A, Chang JBP, Kubiak DW, Zhou G, Antin JH, Koreth J, Nikiforow S, Cutler CS, Romee R, Issa NC, Ho VT, Gooptu M, Soiffer RJ, Baden LR. Invasive Yeast Infection After Haploidentical Donor Hematopoietic Cell Transplantation Associated with Cytokine Release Syndrome. Transplant Cell Ther 2022; 28:508.e1-508.e8. [PMID: 35526780 PMCID: PMC9357112 DOI: 10.1016/j.jtct.2022.04.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Use of haploidentical donor hematopoietic cell transplantation (haploHCT) has expanded but recent reports raise concern for increased rates of infectious complications. The incidence and risk factors for invasive fungal disease (IFD) after haploHCT have not been well elucidated. OBJECTIVE The objective of this study is to evaluate the incidence and risk factors for IFD after haploHCT. The identification of key risk factors will permit targeted prevention measures and may explain elevated risk for other infectious complications after haploHCT. STUDY DESIGN We performed a single-center retrospective study of all adults undergoing haploHCT between May 2011 and May 2021 (n=205). The 30-day and one-year cumulative incidence of proven or probable IFD and one-year non-relapse mortality (NRM) were assessed. Secondary analysis evaluated risk factors for invasive yeast infection (IYI) using univariate and multivariable Cox regression models. RESULTS Twenty-nine patients (14%) developed IFD following haploHCT. Nineteen (9.3%) developed IYI in the first year, 13 of which occurred early with a 30-day cumulative incidence of 6.3% (95% CI 2.9 - 9.6%) and increased NRM in patients with IYI (53.9% versus 10.9%). The majority of yeast isolates (17/20; 85%) were fluconazole susceptible. The incidence of IYI in the first 30 days after haploHCT was 10% among the 110 (54%) patients who developed cytokine release syndrome (CRS) and 21% among the 29 (14%) who received tocilizumab. On multivariable analysis, AML (HR 6.24; 1.66 - 23.37; p=0.007) and CRS (HR 4.65; 1.00 - 21.58; p=0.049) were associated with an increased risk of early IYI after haploHCT. CONCLUSION CRS after haploHCT is common and is associated with increased risk of early IYI. The identification of CRS as a risk factor for IYI raises questions about its potential association with other infections after haploHCT. Recognition of key risk factors for infection may permit individualized strategies for prevention and intervention and minimize potential side effects.
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Affiliation(s)
- Jessica S Little
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA; Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA.
| | - Roman M Shapiro
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA; Department of Pharmacy, Brigham and Women's Hospital, Boston, USA
| | - Muneerah M Aleissa
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Austin Kim
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA
| | - Jun Bai Park Chang
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA
| | - David W Kubiak
- Harvard Medical School, Boston, USA; Department of Pharmacy, Brigham and Women's Hospital, Boston, USA
| | - Guohai Zhou
- Harvard Medical School, Boston, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Boston, USA
| | - Joseph H Antin
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - John Koreth
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Sarah Nikiforow
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Corey S Cutler
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Rizwan Romee
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Nicolas C Issa
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA; Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Vincent T Ho
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Mahasweta Gooptu
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Robert J Soiffer
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Lindsey R Baden
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA; Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Boston, USA.
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7
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Douglas AP, Smibert OC, Bajel A, Halliday CL, Lavee O, McMullan B, Yong MK, Hal SJ, Chen SC. Consensus guidelines for the diagnosis and management of invasive aspergillosis, 2021. Intern Med J 2021; 51 Suppl 7:143-176. [DOI: 10.1111/imj.15591] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Abby P. Douglas
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Infectious Diseases Austin Health Melbourne Victoria Australia
| | - Olivia. C. Smibert
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Infectious Diseases Austin Health Melbourne Victoria Australia
| | - Ashish Bajel
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- Department of Clinical Haematology Peter MacCallum Cancer Centre and The Royal Melbourne Hospital Melbourne Victoria Australia
| | - Catriona L. Halliday
- Centre for Infectious Diseases and Microbiology Laboratory Services Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital Sydney New South Wales Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity The University of Sydney Sydney New South Wales Australia
| | - Orly Lavee
- Department of Haematology St Vincent's Hospital Sydney New South Wales Australia
| | - Brendan McMullan
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Immunology and Infectious Diseases Sydney Children's Hospital Sydney New South Wales Australia
- School of Women's and Children's Health University of New South Wales Sydney New South Wales Australia
| | - Michelle K. Yong
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Victorian Infectious Diseases Service Royal Melbourne Hospital Melbourne Victoria Australia
| | - Sebastiaan J. Hal
- Sydney Medical School University of Sydney Sydney New South Wales Australia
- Department of Microbiology and Infectious Diseases Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Sharon C.‐A. Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital Sydney New South Wales Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity The University of Sydney Sydney New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
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8
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Affiliation(s)
- George R Thompson
- From the Department of Medicine, Division of Infectious Diseases, and the Department of Medical Microbiology and Immunology, University of California, Davis, Sacramento (G.R.T.); and the Department of Medicine, Division of Infectious Disease and International Medicine, Program in Adult Transplant Infectious Disease, University of Minnesota, Minneapolis (J.-A.H.Y.)
| | - Jo-Anne H Young
- From the Department of Medicine, Division of Infectious Diseases, and the Department of Medical Microbiology and Immunology, University of California, Davis, Sacramento (G.R.T.); and the Department of Medicine, Division of Infectious Disease and International Medicine, Program in Adult Transplant Infectious Disease, University of Minnesota, Minneapolis (J.-A.H.Y.)
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9
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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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10
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Cadena J, Thompson GR, Patterson TF. Aspergillosis: Epidemiology, Diagnosis, and Treatment. Infect Dis Clin North Am 2021; 35:415-434. [PMID: 34016284 DOI: 10.1016/j.idc.2021.03.008] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The spectrum of disease produced by Aspergillus species ranges from allergic syndromes to chronic pulmonary conditions and invasive infections. Invasive aspergillosis is a major cause of morbidity and mortality in immunocompromised patients. Risk factors continue to evolve and include newer biological agents that target the immune system and postinfluenza infection; and it has been observed following COVID-19 infection. Diagnosis remains a challenge but non-culture-based methods are available. Antifungal resistance has emerged. Voriconazole remains the treatment of choice but isavuconazole and posaconazole have similar efficacy with less toxicity. Combination therapy is used with extensive infection and in severe immunosuppression.
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Affiliation(s)
- Jose Cadena
- Department of Medicine, Division of Infectious Diseases, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive - MSC 7881, San Antonio, TX 78229-3900, USA
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California - Davis Health; Department of Medical Microbiology and Immunology, University of California - Davis Health.
| | - Thomas F Patterson
- Department of Medicine, Division of Infectious Diseases, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive - MSC 7881, San Antonio, TX 78229-3900, USA
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11
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Neofytos D, Garcia-Vidal C, Lamoth F, Lichtenstern C, Perrella A, Vehreschild JJ. Invasive aspergillosis in solid organ transplant patients: diagnosis, prophylaxis, treatment, and assessment of response. BMC Infect Dis 2021; 21:296. [PMID: 33761875 PMCID: PMC7989085 DOI: 10.1186/s12879-021-05958-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/04/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Invasive aspergillosis (IA) is a rare complication in solid organ transplant (SOT) recipients. Although IA has significant implications on graft and patient survival, data on diagnosis and management of this infection in SOT recipients are still limited. METHODS Discussion of current practices and limitations in the diagnosis, prophylaxis, and treatment of IA and proposal of means of assessing treatment response in SOT recipients. RESULTS Liver, lung, heart or kidney transplant recipients have common as well as different risk factors to the development of IA, thus each category needs a separate evaluation. Diagnosis of IA in SOT recipients requires a high degree of awareness, because established diagnostic tools may not provide the same sensitivity and specificity observed in the neutropenic population. IA treatment relies primarily on mold-active triazoles, but potential interactions with immunosuppressants and other concomitant therapies need special attention. CONCLUSIONS Criteria to assess response have not been sufficiently evaluated in the SOT population and CT lesion dynamics, and serologic markers may be influenced by the underlying disease and type and severity of immunosuppression. There is a need for well-orchestrated efforts to study IA diagnosis and management in SOT recipients and to develop comprehensive guidelines for this population.
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Affiliation(s)
- Dionysios Neofytos
- Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland.
| | - Carolina Garcia-Vidal
- Servicio de Enfermedades Infecciosas, Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, FungiCLINIC Research group (AGAUR), Barcelona, Spain
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, 1011, Lausanne, Switzerland
- Department of Laboratories, Institute of Microbiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Christoph Lichtenstern
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, Heidelberg, Germany
| | - Alessandro Perrella
- VII Department of Infectious Disease and Immunology, Hospital D. Cotugno, Naples, Italy
- CLSE-Liver Transplant Unit, Hospital A. Cardarelli, Naples, Italy
| | - Jörg Janne Vehreschild
- Medical Department II, Hematology and Oncology, University Hospital of Frankfurt, Frankfurt, Germany
- Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany
- German Centre for Infection Research, partner site Bonn-Cologne, University of Cologne, Cologne, Germany
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12
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Liu L, Gu Y, Wang Y, Shen K, Su X. The Clinical Characteristics of Patients With Nonneutropenic Invasive Pulmonary Aspergillosis. Front Med (Lausanne) 2021; 8:631461. [PMID: 33659265 PMCID: PMC7917130 DOI: 10.3389/fmed.2021.631461] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/04/2021] [Indexed: 12/04/2022] Open
Abstract
Objective: The goal of this study was to reveal the clinical manifestations of nonneutropenic invasive pulmonary aspergillosis (IPA), which are different from those of neutropenic patients. Methods: The clinical data of patients with nonneutropenic IPA were collected at the Department of Respiratory and Critical Care Medicine, Jinling Hospital, from February 2009 to November 2019. We analyzed the general conditions, clinical manifestations, imaging findings, and laboratory tests of these IPA patients. Results: A total of 116 patients with nonneutropenic IPA (31 proven and 85 probable) were included. They had an average age of 59.8 years. The most common underlying disease was chronic obstructive pulmonary disease (COPD, n = 33). The common clinical symptoms included cough (93.1%, n = 108), expectoration (59.5%, n = 69), fever (57.8%, n = 67), hemoptysis (30.2%, n = 35), and dyspnea (40.5%, n = 47). The common CT imaging manifestations included consolidation (47.4%, n = 55), cavities (47.4%, n = 55), air crescent sign (14.7%, n = 17), and nodules (8.6%, n = 10). Multiple lesions (74.1%, n = 86) were more common than single lesions (17.2%, n = 20) and diffuse lesions (8.6%, n = 10). The positive rate of laboratory tests was 88.2% (30/34) for BALF galactomannan (GM), 55.4% (56/101) for serum GM, 45.3% (48/106) for 1,3-β-D-glucan (BDG), 43.3% (46/106) for sputum culture, and 36.4% (20/55) for BALF culture. Patients who had high serum GM level [GM optical density index (ODI) >1] were more likely to have severe respiratory symptoms and higher serum ferritin. Further investigation showed that there was a positive correlation between serum GM level and serum ferritin level. Conclusion: The clinical symptoms and radiological manifestations of nonneutropenic IPA are diverse and often lead to delayed diagnosis. It is important to become more vigilant of aspergillosis in nonneutropenic patients in order to achieve early diagnosis and treatment and to reduce mortality.
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Affiliation(s)
- Lulu Liu
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yu Gu
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Yu Wang
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Kunlu Shen
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Southern Medical University, Guangzhou, China
| | - Xin Su
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China.,Department of Respiratory and Critical Care Medicine, Jinling Hospital, Southern Medical University, Guangzhou, China
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13
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Pang L, Zhao X, Dickens BL, Lim JT, Cook AR, Netea MG, Donnelly JP, Herbrecht R, Johnson EM, Maertens JA, Kullberg BJ, Troke PF, Marr KA, Chai LYA. Using routine blood parameters to anticipate clinical outcomes in invasive aspergillosis. Clin Microbiol Infect 2019; 26:781.e1-781.e8. [PMID: 31669427 DOI: 10.1016/j.cmi.2019.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 10/03/2019] [Accepted: 10/15/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE In invasive aspergillosis (IA), monitoring response to antifungal treatment is challenging. We aimed to explore if routine blood parameters help to anticipate outcomes following IA. METHODS Post hoc secondary analysis of two multicenter randomized trials was performed. The Global Comparative Aspergillosis Study (GCA, n = 123) and the Combination Antifungal Study (CAS, n = 251) constituted the discovery and validation cohorts respectively. The outcome measures were response to treatment and survival to 12 weeks. Interval platelet, galactomannan index (GMI) and C-reactive protein (CRP) levels prior and during antifungal treatment were analysed using logistic regression, Kaplan-Meier survival and receiver operating characteristic (ROC) analyses. RESULTS The 12-week survival was 70.7% and 63.7% for the GCA and CAS cohorts respectively. In the GCA cohort, every 10 × 109/L platelet count increase at week 2 and 4 improved 12-week survival odds by 6-18% (odds ratio (OR) 1.06-1.18, 95% confidence interval (CI) 1.02-1.33). Survival odds also improved 13% with every 10 mg/dL CRP drop at week 1 and 2 (OR 0.87, 95% CI 0.78-0.97). In the CAS cohort, week 2 platelet count was also associated with 12-week survival with 10% improved odds for every 10 × 109/L platelet increase (OR, 1.10, 95% CI 1.04-1.15). A GMI drop of 0.1 unit was additionally found to increase the odds of treatment response by 3% at the baseline of week 0 (OR 0.97, 95% CI 0.95-0.99). Week 2 platelet and CRP levels performed better than GMI on ROC analyses for survival (area under ROC curve 0.76, 0.87 and 0.67 respectively). A baseline platelet count higher than 30 × 109/L clearly identified patients with >75% survival probability. CONCLUSIONS Higher serial platelets were associated with overall survival while GMI trends were linked to IA treatment response. Routine and simple laboratory indices may aid follow-up of response in IA patients.
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Affiliation(s)
- L Pang
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - X Zhao
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - B L Dickens
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - J T Lim
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - A R Cook
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - M G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J P Donnelly
- Department of Hematology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - R Herbrecht
- Department of Oncology and Hematology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - E M Johnson
- Mycology Reference Laboratory, Public Health England National Infection Services, Bristol, UK
| | - J A Maertens
- University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - B J Kullberg
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - K A Marr
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - L Y A Chai
- Division of Infectious Diseases, University Medicine Cluster, National University Health System, Singapore and Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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14
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de Heer K, Gerritsen MG, Visser CE, Leeflang MMG. Galactomannan detection in broncho-alveolar lavage fluid for invasive aspergillosis in immunocompromised patients. Cochrane Database Syst Rev 2019; 5:CD012399. [PMID: 31107543 PMCID: PMC6526785 DOI: 10.1002/14651858.cd012399.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Invasive aspergillosis (IA) is a life-threatening opportunistic mycosis that occurs in some people with a compromised immune system. The serum galactomannan enzyme-linked immunosorbent assay (ELISA) rapidly gained widespread acceptance as part of the diagnostic work-up of a patient suspected of IA. Due to its non-invasive nature, it can be used as a routine screening test. The ELISA can also be performed on bronchoalveolar lavage (BAL), allowing sampling of the immediate vicinity of the infection. The invasive nature of acquiring BAL, however, changes the role of the galactomannan test significantly, for example by precluding its use as a routine screening test. OBJECTIVES To assess the diagnostic accuracy of galactomannan detection in BAL for the diagnosis of IA in people who are immunocompromised, at different cut-off values for test positivity, in accordance with the Cochrane Diagnostic Test Accuracy Handbook. SEARCH METHODS We searched three bibliographic databases including MEDLINE on 9 September 2016 for aspergillosis and galactomannan as text words and subject headings where appropriate. We checked reference lists of included studies for additional studies. SELECTION CRITERIA We included cohort studies that examined the accuracy of BAL galactomannan for the diagnosis of IA in immunocompromised patients if they used the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) classification as reference standard. DATA COLLECTION AND ANALYSIS Two review authors assessed study quality and extracted data. Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used for quality assessment. MAIN RESULTS We included 17 studies in our review. All studies except one had a high risk of bias in two or more domains. The diagnostic performance of an optical density index (ODI) of 0.5 as cut-off value was reported in 12 studies (with 1123 patients). The estimated sensitivity was 0.88 (95% confidence interval (CI) 0.75 to 1.00) and specificity 0.81 (95% CI 0.71 to 0.91). The performance of an ODI of 1.0 as cut-off value could be determined in 11 studies (with 648 patients). The sensitivity was 0.78 (95% CI 0.61 to 0.95) and specificity 0.93 (95% CI 0.87 to 0.98). At a cut-off ODI of 1.5 or higher, the heterogeneity in specificity decreased significantly and was invariably >90%. AUTHORS' CONCLUSIONS The optimal cut-off value depends on the local incidence and clinical pathway. At a prevalence of 12% a hypothetical population of 1000 patients will consist of 120 patients with IA. At a cut-off value of 0.5 14 patients with IA will be missed and there will be 167 patients incorrectly diagnosed with IA. If we use the test at a cut-off value of 1.0, we will miss 26 patients with IA. And there will be 62 patients incorrectly diagnosed with invasive aspergillosis. The populations and results were very heterogeneous. Therefore, interpretation and extrapolation of these results has to be performed with caution. A test result of 1.5 ODI or higher appears a strong indicator of IA.
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Affiliation(s)
- Koen de Heer
- FlevoziekenhuisDepartment of Internal MedicineAlmereNetherlands
- Academic Medical CenterDepartment of HematologyAmsterdamNetherlands
| | | | - Caroline E Visser
- Academic Medical CentreDepartment of Medical MicrobiologyAmsterdamNetherlands
| | - Mariska MG Leeflang
- Amsterdam University Medical Centers, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsP.O. Box 22700AmsterdamNetherlands1100 DE
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15
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Heinz WJ, Vehreschild JJ, Buchheidt D. Diagnostic work up to assess early response indicators in invasive pulmonary aspergillosis in adult patients with haematologic malignancies. Mycoses 2019; 62:486-493. [PMID: 30329192 DOI: 10.1111/myc.12860] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/03/2018] [Accepted: 10/07/2018] [Indexed: 12/20/2022]
Abstract
In immunocompromised patients with acute leukaemia as well as in allogeneic hematopoietic stem cell transplant patients, pulmonary lesions are commonly seen. Existing guidelines provide useful algorithms for diagnostic procedures and treatment options, but they do not give recommendations on how to evaluate early success or failure and if or when it is best to change therapy. Here, we review the diagnostic techniques currently used in association with clinical findings and propose an approach using a combination of computer tomography, clinical and all available biomarkers and inflammation parameters, especially those positive at baseline, to assess early response in invasive pulmonary aspergillosis. Computed tomography scans should be carried out at regular intervals during early and long-term follow-up. Imaging on day seven, or even earlier in clinically unstable patients, combined with an additional testing of biomarkers and inflammatory markers in between, is needed for a reliable assessment at day 14. If no improvement is seen after 2 weeks of therapy or the clinical condition is deteriorating, a change of antifungal therapy should be considered. Alleged breakthrough infections or treatment failure should undergo early diagnostic workup, including tissue biopsies when possible, to retrieve fungal cultures for resistance testing.
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Affiliation(s)
- Werner J Heinz
- Klinikum Weiden, Weiden, Würzburg university medical center, Würzburg, Germany
| | - Jörg J Vehreschild
- Department for Internal Medicine, German Centre for Infection Research, University Hospital of Cologne, Partner Site Bonn-Cologne, University of Cologne, Köln, Germany
| | - Dieter Buchheidt
- Department of Internal Medicine-Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
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16
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Impacts and Challenges of Advanced Diagnostic Assays for Transplant Infectious Diseases. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7121269 DOI: 10.1007/978-1-4939-9034-4_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The advanced technologies described in this chapter should allow for full inventories to be made of bacterial genes, their time- and place-dependent expression, and the resulting proteins as well as their outcome metabolites. The evolution of these molecular technologies will continue, not only in the microbial pathogens but also in the context of host-pathogen interactions targeting human genomics and transcriptomics. Their performance characteristics and limitations must be clearly understood by both laboratory personnel and clinicians to ensure proper utilization and interpretation.
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17
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Yu LS, Rodriguez-Manzano J, Malpartida-Cardenas K, Sewell T, Bader O, Armstrong-James D, Fisher MC, Georgiou P. Rapid and Sensitive Detection of Azole-Resistant Aspergillus fumigatus by Tandem Repeat Loop-Mediated Isothermal Amplification. J Mol Diagn 2018; 21:286-295. [PMID: 30529128 DOI: 10.1016/j.jmoldx.2018.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/07/2018] [Accepted: 10/16/2018] [Indexed: 12/11/2022] Open
Abstract
Invasive fungal infections caused by multiazole-resistant Aspergillus fumigatus are associated with increasing rates of mortality in susceptible patients. Current methods of diagnosing infections caused by multiazole-resistant A. fumigatus are, however, not well suited for use in clinical point-of-care testing or in the field. Loop-mediated isothermal amplification (LAMP) is a widely used method of nucleic acid amplification with rapid and easy-to-use features, making it suitable for use in different resource settings. Here, we developed a LAMP assay to detect a 34 bp tandem repeat, named TR34-LAMP. TR34 is a high-prevalence allele that, in conjunction with the L98H single-nucleotide polymorphism, is associated with the occurrence of multiazole resistance in A. fumigatus in the environment and in patients. This process was validated with both synthetic double-stranded DNA and genomic DNA prepared from azole-resistant isolates of A. fumigatus. Use of our assay resulted in rapid and specific identification of the TR34 allele with high sensitivity, detecting down to 10 genomic copies per reaction within 25 minutes. Fluorescent and colorimetric detections were used for the analysis of 11 clinical isolates as cross validation. These results show that the TR34-LAMP assay has the potential to accelerate the screening of clinical and environmental A. fumigatus to provide a rapid and accurate diagnosis of azole resistance, which current methods struggle to achieve.
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Affiliation(s)
- Ling-Shan Yu
- Centre for Bio-Inspired Technology, Institute of Biomedical Engineering, Department of Electrical and Electronic Engineering.
| | - Jesus Rodriguez-Manzano
- Centre for Bio-Inspired Technology, Institute of Biomedical Engineering, Department of Electrical and Electronic Engineering.
| | - Kenny Malpartida-Cardenas
- Centre for Bio-Inspired Technology, Institute of Biomedical Engineering, Department of Electrical and Electronic Engineering
| | - Thomas Sewell
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Oliver Bader
- Institute for Medical Microbiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Matthew C Fisher
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Pantelis Georgiou
- Centre for Bio-Inspired Technology, Institute of Biomedical Engineering, Department of Electrical and Electronic Engineering
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18
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Melancon CC, Lindsey J, Russell GB, Clinger JD. The role of galactomannan Aspergillus
antigen in diagnosing acute invasive fungal sinusitis. Int Forum Allergy Rhinol 2018; 9:60-66. [DOI: 10.1002/alr.22225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 08/29/2018] [Accepted: 09/10/2018] [Indexed: 11/11/2022]
Affiliation(s)
- C. Claire Melancon
- Department of Otolaryngology; Wake Forest Baptist Medical Center; Winston Salem NC
| | - Jennifer Lindsey
- Department of Otolaryngology; Wake Forest Baptist Medical Center; Winston Salem NC
| | - Gregory B. Russell
- Department of Biostatistical Sciences, Division of Public Health Sciences; Wake Forest Baptist Medical Center; Winston Salem NC
| | - John D. Clinger
- Department of Otolaryngology; Wake Forest Baptist Medical Center; Winston Salem NC
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19
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Blau IW, Heinz WJ, Schwartz S, Lipp HP, Schafhausen P, Maschmeyer G. [Pulmonary infiltrates in haematological patients]. MMW Fortschr Med 2018; 160:12-17. [PMID: 29974434 DOI: 10.1007/s15006-018-0727-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 01/30/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Pulmonary complications are frequent in haematologic patients. METHOD This review article summarizes the outcome of a discussion that took place during an expert meeting on the subject of pulmonary infiltrates. RESULTS AND CONCLUSIONS The most common causes of pulmonary infiltrates in haematologic patients are bacterial infections. Viral infections are subject to relevant seasonal variations, but they may also cause an important proportion of pulmonary infiltrates. Microbiological examination of respiratory tract material (if possible, bronchoalveolar lavage, BAL) is the most important diagnostic procedure. Particularly in the case of prolonged (> 7 days) neutropenia, the likelihood of infiltrates being caused by fungal infections increases. For a differential diagnosis, however, also non-infectious causes, e.g. drug-induced infiltrates, have to be taken into consideration. The diagnostic workup, however, should not delay a timely start of an adequate antimicrobial therapy.
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Affiliation(s)
- Igor-Wolfgang Blau
- Medizinische Klinik für Hämatologie, Onkologie und Tumorimmunologie, Leitender Oberarzt Knochenmarktransplantation, Campus Virchow Klinikum der Charité - Universitätsmedizin Berlin, Berlin, Deutschland.
- Klinik für Hämatologie, Onkologie und Tumorimmunologie, Campus Virchow Klinikum der Charité - Universitätsmedizin Berlin, Augustenburgerplatz 1, D-13353, Berlin, Deutschland.
| | - Werner J Heinz
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Stefan Schwartz
- Medizinische Klinik für Hämatologie, Onkologie und Tumorimmunologie, Campus Benjamin Franklin der Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | | | - Philippe Schafhausen
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, UKE Hamburg, Hamburg, Deutschland
| | - Georg Maschmeyer
- Klinik für Hämatologie, Onkologie und Palliativmedizin, Klinikum Ernst von Bergmann gemeinnützige GmbH, Potsdam, Deutschland
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20
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Mercier T, Guldentops E, Lagrou K, Maertens J. Galactomannan, a Surrogate Marker for Outcome in Invasive Aspergillosis: Finally Coming of Age. Front Microbiol 2018; 9:661. [PMID: 29670608 PMCID: PMC5893815 DOI: 10.3389/fmicb.2018.00661] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/21/2018] [Indexed: 01/13/2023] Open
Abstract
Detection of galactomannan has become widely available for diagnosing invasive aspergillosis. The test characteristics, using the Platelia™ enzyme-immunoassay, have been well described. This assay could potentially also be useful for the early evaluation of the efficacy of antifungal therapy and for predicting the outcome in terms of response and survival. In this systematic review, we assessed the available evidence for the use of serum galactomannan at baseline as a prognostic marker, and the predictive value of serum galactomannan kinetics after initiation of antifungal therapy. Overall, serum galactomannan at baseline and galactomannan kinetics appear to be good predictors of therapy response and survival. However, breakpoints for predicting therapy failure and validation in different patient populations are still lacking.
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Affiliation(s)
- Toine Mercier
- Laboratory of Clinical Bacteriology and Mycology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Ellen Guldentops
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Katrien Lagrou
- Laboratory of Clinical Bacteriology and Mycology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Johan Maertens
- Laboratory of Clinical Bacteriology and Mycology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Department of Hematology, University Hospitals Leuven, Leuven, Belgium
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21
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Kaya S, Gençalioğlu E, Sönmez M, Köksal I. The importance of risk factors for the prediction of patients with invasive pulmonary aspergillosis. ACTA ACUST UNITED AC 2018; 63:764-770. [PMID: 29239468 DOI: 10.1590/1806-9282.63.09.764] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 03/01/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Invasive pulmonary aspergillosis (IPA) is a major challenge in the management of immunocompromised patients. Despite all the advances in diagnosis, it remains a problem. The purpose of our study was to investigate the risk factors associated with IPA seen in patients with hematological malignancies. METHOD A total of 152 febrile neutropenia (FEN) patients with hematological malignancies aged over 18 years and receiving high-dose chemotherapy or stem cell transplant between January 1, 2010, and December 31, 2012 were included in the study. Sixty-five (65) cases with IPA according to the European Organization for the Research and Treatment of Cancer and Infectious Diseases Mycoses Study Group criteria were enrolled as the case group, while 87 patients without IPA development during concomitant monitoring were enrolled as the control group. Incidence of IPA was 21.4% (3/14) in patients receiving bone marrow transplant (allogeneic 2, autologous 1) and those cases were also added into the case group. The two groups were compared in terms of demographic, clinical and laboratory findings and risk factors associated with IPA investigated retrospectively. RESULTS Presence of relapse of primary disease, neutropenia for more than 3 weeks, presence of bacterial infection, and non-administration of antifungal prophylaxis were identified as risk factors associated with IPA. CONCLUSION It may be possible to reduce the incidence of the disease by eliminating preventable risk factors. Predicting those risks would, per se, enable early diagnosis and treatment and, thus, the mortality rate of these patients would unquestionably decline.
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Affiliation(s)
- Selçuk Kaya
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Eda Gençalioğlu
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Mehmet Sönmez
- Department of Hematology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Iftihar Köksal
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
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22
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Patel MH, Vanikar AV, Patel HV, Patel RD. Atypical Presentation of Isolated Cerebral Aspergillosis in a Renal Allograft Recipient. J Clin Diagn Res 2017; 11:DD01-DD02. [PMID: 28892898 DOI: 10.7860/jcdr/2017/27919.10288] [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: 02/27/2017] [Accepted: 05/13/2017] [Indexed: 11/24/2022]
Abstract
The immunosuppressive state in organ transplantation leads to infectious complications responsible for high mortality rate. Fungal infections account for 5% of all infections in Renal Transplantation (RT) recipients. Aspergillus species are filamentous fungi frequently causing fungal infections in RT recipients. Lungs and paranasal sinuses are the usual portal of entry from where it disseminates to other organs. Here, we are reporting a case of 14-year-old boy with RT from mother's kidney, who had atypical presentation of isolated cerebral aspergillosis at 19 months post-transplant without identified portal of entry. Early diagnosis and prompt treatment saved the patient and the graft.
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Affiliation(s)
- Minaxi H Patel
- Assistant Professor, Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre (IKDRC) - Dr. H.L. Trivedi, Ahmedabad, Gujarat, India
| | - Aruna V Vanikar
- Professor and Head, Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre (IKDRC) - Dr. H.L. Trivedi, Ahmedabad, Gujarat, India
| | - Himanshu V Patel
- Professor, Department of Nephrology and Transplantation Medicine, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre (IKDRC) - Dr. H.L. Trivedi, Ahmedabad, Gujarat, India
| | - Rashmi D Patel
- Professor, Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases & Research Centre (IKDRC) - Dr. H.L. Trivedi, Ahmedabad, Gujarat, India
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23
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Progressive Dispersion of Azole Resistance in Aspergillus fumigatus: Fatal Invasive Aspergillosis in a Patient with Acute Myeloid Leukemia Infected with an A. fumigatus Strain with a cyp51A TR 46 Y121F M172I T289A Allele. Antimicrob Agents Chemother 2017; 61:61/8/e00270-17. [PMID: 28743702 DOI: 10.1128/aac.00270-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Patients with hematologic malignancies as well as allogeneic hematopoietic stem cell transplantation (HSCT) patients are at high risk for invasive aspergillosis. Here, we report a culture- and autopsy-proven fatal invasive aspergillosis in an allogeneic HSTC patient which he developed despite posaconazole prophylaxis. The agent was determined to be an azole-resistant Aspergillus fumigatus strain bearing the cyp51A mutation combination TR46 Y121F M172I T289A. At increasing frequency, the azole resistance of A. fumigatus is being reported globally, limiting treatment options and complicating regimens.
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24
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Maertens JA, Blennow O, Duarte RF, Muñoz P. The current management landscape: aspergillosis. J Antimicrob Chemother 2017; 71:ii23-ii29. [PMID: 27880666 DOI: 10.1093/jac/dkw393] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Diagnosing invasive aspergillosis (IA) has long been challenging due to the inability to culture the causal Aspergillus agent from blood or other body fluids. This shortcoming has fuelled an interest in non-culture-based diagnostic techniques such as the detection of galactomannan (GM) in blood and bronchoalveolar lavage fluid, the detection of 1,3-β-d-glucan (BDG) in blood and the detection of Aspergillus DNA by PCR-based techniques. Past decades have witnessed important improvements in our understanding of the strengths and limitations of antigen assays and in the standardization of PCR-based DNA techniques. These assays are now being incorporated into care pathways and diagnostic algorithms; they help us to steward and monitor antifungal therapies and to predict treatment outcomes.
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Affiliation(s)
- Johan A Maertens
- University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Ola Blennow
- Unit of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, and Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Rafael F Duarte
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Disease Division, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Hospital Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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25
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Kovanda LL, Desai AV, Hope WW. Prognostic value of galactomannan: current evidence for monitoring response to antifungal therapy in patients with invasive aspergillosis. J Pharmacokinet Pharmacodyn 2017; 44:143-151. [PMID: 28181136 DOI: 10.1007/s10928-017-9509-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 02/03/2017] [Indexed: 12/28/2022]
Abstract
Galactomannan (GM) is a polysaccharide present in the cell wall of Aspergillus spp. that is released during growth of the organism. It has been successfully used to aide in the diagnosis of invasive aspergillosis allowing for earlier recognition of disease compared to conventional methods. Since its implementation in the clinic as a diagnostic tool, GM has been used in experimental models to measure therapeutic response. Several clinical studies describe the prognostic value of GM. Herein, we review the evidence supporting the utilization of GM antigen as a biomarker to measure response to systemic antifungal therapy.
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Affiliation(s)
- Laura L Kovanda
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA. .,Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.
| | - Amit V Desai
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - William W Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Vehreschild JJ, Heussel CP, Groll AH, Vehreschild MJGT, Silling G, Würthwein G, Brecht M, Cornely OA. Serial assessment of pulmonary lesion volume by computed tomography allows survival prediction in invasive pulmonary aspergillosis. Eur Radiol 2017; 27:3275-3282. [PMID: 28083695 DOI: 10.1007/s00330-016-4717-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 12/01/2016] [Accepted: 12/16/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Serial chest CT is the standard of care to establish treatment success in invasive pulmonary aspergillosis (IPA). Data are lacking how response should be defined. METHODS Digital CT images from a clinical trial on treatment of IPA were re-evaluated and compared with available biomarkers. Total volume of pneumonia was added up after manual measurement of each lesion, followed by statistical analysis. RESULTS One-hundred and ninety CT scans and 309 follow-up datasets from 40 patients were available for analysis. Thirty-one were neutropenic. Baseline galactomannan (OR 4.06, 95%CI: 1.08-15.31) and lesion volume (OR 3.14, 95%CI: 0.73-13.52) were predictive of death. Lesion volume at d7 and trend between d7 and d14 were strong predictors of death (OR 20.01, 95%CI: 1.42-282.00 and OR 15.97, 95%CI: 1.62-157.32) and treatment being rated as unsuccessful (OR 4.75, 95%CI: 0.94-24.05 and OR 40.69, 95%CI: 2.55-649.03), which was confirmed by a Cox proportional hazards model using time-dependent covariates. CONCLUSION Any increase in CT lesion volume between day 7 and day 14 was a sensitive marker of a lethal outcome (>50%), supporting a CT rescan each one and 2 weeks after initial detection of IPA. The predictive value exceeded all other biomarkers. Further CT follow-up after response at day 14 was of low additional value. KEY POINTS • CT evaluation offers good prediction of outcome for invasive pulmonary aspergillosis. • Predictive capability exceeds galactomannan, blood counts, and lesion count. • Any progression between day 7 and day 14 constitutes a high-risk scenario.
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Affiliation(s)
- J J Vehreschild
- Department I of Internal Medicine, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
- German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany.
| | - C P Heussel
- Diagnostic and Interventional Radiology with Nuclear Medicine, Chest Clinic at University Hospital Heidelberg, Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - A H Groll
- Infectious Disease Research Program, Department of Paediatric Haematology/Oncology, University Children's Hospital, Muenster, Germany
| | - M J G T Vehreschild
- Department I of Internal Medicine, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - G Silling
- Department of Medicine A, Haematology/Oncology, University of Muenster, Muenster, Germany
| | - G Würthwein
- Centre for Clinical Trials, ZKS Muenster (BMBF 01KN1105), University Hospital Muenster, Muenster, Germany
| | - M Brecht
- Diagnostic and Interventional Radiology with Nuclear Medicine, Chest Clinic at University Hospital Heidelberg, Heidelberg, Germany
| | - O A Cornely
- Department I of Internal Medicine, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Clinical Trials Center Cologne, ZKS Koeln (BMBF 01KN1106), University of Cologne, Cologne, Germany
- Center for Integrated Oncology CIO KölnBonn, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
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27
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Avcu G, Karapinar DY, Akinci AB, Sivis ZO, Sahin A, Bal ZS, Polat SH, Metin DY, Vardar F, Aydinok Y. Utility of the serum galactomannan assay for the diagnosis of invasive aspergillosis in children with acute lymphoblastic leukemia. Int J Infect Dis 2017; 54:8-12. [DOI: 10.1016/j.ijid.2016.10.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/11/2016] [Accepted: 10/25/2016] [Indexed: 01/29/2023] Open
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Cadena J, Thompson GR, Patterson TF. Invasive Aspergillosis: Current Strategies for Diagnosis and Management. Infect Dis Clin North Am 2016; 30:125-42. [PMID: 26897064 DOI: 10.1016/j.idc.2015.10.015] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Aspergillosis remains a significant cause of morbidity and mortality in the immunocompromised population. The spectrum of disease is broad, ranging from severe and rapidly fatal infection to noninvasive disease. The diversity of patients and risk factors complicates diagnostic and therapeutic decision-making. Invasive procedures are often precluded by host status; noninvasive diagnostic tests vary in their sensitivity and specificity. Advancements in understanding the pathophysiology of invasive aspergillosis and host genetics in differential risk have also occurred. Future work may assist in therapeutic decision-making and patient prognosis. Voriconazole remains the preferred agent for treatment. Additional alternatives have emerged.
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Affiliation(s)
- Jose Cadena
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center and South Texas Veterans Health Care System, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA
| | - George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California - Davis, 1 Shields Avenue, Tupper Hall, Room 3146, Davis, CA, USA
| | - Thomas F Patterson
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center and South Texas Veterans Health Care System, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA.
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29
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de Heer K, Gerritsen MG, Visser CE, Leeflang MMG. Galactomannan detection in broncho-alveolar lavage fluid for invasive aspergillosis in immunocompromised patients. Hippokratia 2016. [DOI: 10.1002/14651858.cd012399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Koen de Heer
- Flevoziekenhuis; Department of Internal Medicine; Almere Netherlands
- Academic Medical Center; Department of Hematology; Amsterdam Netherlands
| | - Marije G Gerritsen
- Academic Medical Center; Department of Hematology; Amsterdam Netherlands
| | - Caroline E Visser
- Academic Medical Centre; Department of Medical Microbiology; Amsterdam Netherlands
| | - Mariska MG Leeflang
- Academic Medical Center, University of Amsterdam; Department of Clinical Epidemiology, Biostatistics and Bioinformatics; P.O. Box 22700 Amsterdam Netherlands 1100 DE
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30
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Galactomannan and 1,3-β-d-Glucan Testing for the Diagnosis of Invasive Aspergillosis. J Fungi (Basel) 2016; 2:jof2030022. [PMID: 29376937 PMCID: PMC5753135 DOI: 10.3390/jof2030022] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 06/21/2016] [Accepted: 06/28/2016] [Indexed: 11/16/2022] Open
Abstract
Invasive aspergillosis (IA) is a severe complication among hematopoietic stem cell transplant recipients or patients with hematological malignancies and neutropenia following anti-cancer therapy. Moreover, IA is increasingly observed in other populations, such as solid-organ transplant recipients, patients with solid tumors or auto-immune diseases, and among intensive care unit patients. Frequent delay in diagnosis is associated with high mortality rates. Cultures from clinical specimens remain sterile in many cases and the diagnosis of IA often only relies on non-specific radiological signs in the presence of host risk factors. Tests for detection of galactomannan- (GM) and 1,3-β-d-glucan (BDG) are useful adjunctive tools for the early diagnosis of IA and may have a role in monitoring response to therapy. However, the sensitivity and specificity of these fungal biomarkers are not optimal and variations between patient populations are observed. This review discusses the role and interpretation of GM and BDG testing for the diagnosis of IA in different clinical samples (serum, bronchoalveolar lavage fluid, cerebrospinal fluid) and different groups of patients (onco-hematological patients, solid-organ transplant recipients, other patients at risk of IA).
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31
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Patterson TF, Thompson GR, Denning DW, Fishman JA, Hadley S, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Nguyen MH, Segal BH, Steinbach WJ, Stevens DA, Walsh TJ, Wingard JR, Young JAH, Bennett JE. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 63:e1-e60. [PMID: 27365388 DOI: 10.1093/cid/ciw326] [Citation(s) in RCA: 1611] [Impact Index Per Article: 201.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 12/12/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
- Thomas F Patterson
- University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System
| | | | - David W Denning
- National Aspergillosis Centre, University Hospital of South Manchester, University of Manchester, United Kingdom
| | - Jay A Fishman
- Massachusetts General Hospital and Harvard Medical School
| | | | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Vicki A Morrison
- Hennepin County Medical Center and University of Minnesota, Minneapolis
| | | | - Brahm H Segal
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, and Roswell Park Cancer Institute, New York
| | | | | | - Thomas J Walsh
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | | | | | - John E Bennett
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
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32
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Imbert S, Gauthier L, Joly I, Brossas JY, Uzunov M, Touafek F, Brun S, Mazier D, Datry A, Gay F, Fekkar A. Aspergillus PCR in serum for the diagnosis, follow-up and prognosis of invasive aspergillosis in neutropenic and nonneutropenic patients. Clin Microbiol Infect 2016; 22:562.e1-8. [PMID: 26899830 PMCID: PMC7129605 DOI: 10.1016/j.cmi.2016.01.027] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 01/24/2016] [Accepted: 01/29/2016] [Indexed: 12/12/2022]
Abstract
We evaluated the usefulness of a serum Aspergillus PCR assay for the diagnosis and prognosis of invasive aspergillosis in a study involving 941 patients for a total of 5146 serum samples. Fifty-one patients had proven/probable aspergillosis. We compared galactomannan (GM), PCR and mycologic analysis of pulmonary samples in both neutropenic and nonneutropenic patients. PCR performed in serum yielded 66.7% sensitivity, 98.7% specificity, 75.6% positive predictive value and 98.0% negative predictive value, while the GM index yielded 78.4% sensitivity, 87.5% specificity, 27% positive predictive value and 98.6% negative predictive value. The inclusion of PCR in the European Organization for Research and Treatment of Cancer (EORTC) and the Mycosis Study Group (MSG) mycologic criteria permitted the reclassification of nine other cases from possible to probable aspergillosis and increased the sensitivity to 71.7%. Combining the GM index with serum PCR increased the detection rate of invasive aspergillosis with 88.2% sensitivity. PCR was systematically negative in 16 patients with noninvasive forms of aspergillosis (namely aspergilloma and chronic aspergillosis). Remaining PCR positive after a period of 14 to 20 days of treatment was related to poor outcome at 30 and 90 days. Our results also indicate that, unlike the determination of the GM index, the initial fungus load as determined by PCR was highly predictive of 90-day mortality, with the rate of the latter being 15.8% for patients with <150 copies/mL vs. 73.2% for patients at or above that cutoff (p <0.0001). Therefore, PCR appears to be a powerful and interesting tool for the identification of patients with invasive aspergillosis who might benefit from more intense care.
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Affiliation(s)
- S Imbert
- Service de Parasitologie Mycologie, France
| | - L Gauthier
- Service de Parasitologie Mycologie, France
| | - I Joly
- Service de Parasitologie Mycologie, France
| | - J-Y Brossas
- Centre d'Immunologie et des Maladies Infectieuses, CIMI-Paris, France
| | - M Uzunov
- Service d'Hématologie, AP-HP, Groupe hospitalier Pitié-Salpêtrière, France
| | - F Touafek
- Service de Parasitologie Mycologie, France
| | - S Brun
- Service de Parasitologie Mycologie, France
| | - D Mazier
- Service de Parasitologie Mycologie, France; Centre d'Immunologie et des Maladies Infectieuses, CIMI-Paris, France; Sorbonne Universités, UPMC Univ Paris 06, Paris, France
| | - A Datry
- Service de Parasitologie Mycologie, France
| | - F Gay
- Service de Parasitologie Mycologie, France; Sorbonne Universités, UPMC Univ Paris 06, Paris, France
| | - A Fekkar
- Service de Parasitologie Mycologie, France; Centre d'Immunologie et des Maladies Infectieuses, CIMI-Paris, France; Sorbonne Universités, UPMC Univ Paris 06, Paris, France.
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33
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Ljungman P, Snydman D, Boeckh M. Pneumonia After Hematopoietic Stem Cell Transplantation. TRANSPLANT INFECTIONS 2016. [PMCID: PMC7153442 DOI: 10.1007/978-3-319-28797-3_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pneumonia is the main cause of morbidity and mortality after hematopoietic stem cell transplantation. Two thirds of pneumonias observed after both autologous and allogeneic stem cell transplantations are of infectious origin, and coinfections are frequent. One third is due to noninfectious process, such as alveolar hemorrhage, alveolar proteinosis, or alloimmune pulmonary complications such as bronchiolitis obliterans or idiopathic interstitial pneumonitis. Most of these noninfectious complications may require treatment with corticosteroids which may be deleterious in infection. On the other hand, these complications either mimic or may be complicated with infections. Therefore, a precise diagnosis of pneumonia is of crucial importance to decide of the optimal treatment. CT scan is the best procedure for imaging of the lung. Although several indirect biomarkers, such as serum or plasma galactomannan or (1-3) β(beta)-G-glucan, can help in the etiological diagnosis, only direct invasive investigations provide the best chance to identify the cause(s) of pneumonia. Bronchoalveolar lavage (BAL) under fiberoptic bronchoscopy is the procedure of choice to identify the cause of pulmonary infection. It is safe and reproducible, and its diagnostic yield is around 50 % if the BAL fluid is processed at the laboratory according to a prespecified protocol established between the transplanter, the infectious diseases’ specialist, the pneumologist, and the laboratory, allowing the identification of the most likely hypotheses. Transbronchial biopsy does not provide significant additional information to BAL in most cases and more often complicates with bleeding and pneumothorax. In case of a noncontributory BAL, the decision to proceed to a second BAL, a transthoracic biopsy, or a surgical biopsy should be cautiously weighted in a multidisciplinary approach in regard to the benefits and risks of invasive procedures versus empirical treatment.
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Affiliation(s)
- Per Ljungman
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - David Snydman
- Tufts University School of Medicine Tufts Medical Center, Boston, Massachusetts USA
| | - Michael Boeckh
- University of Washington Fred Hutchinson Cancer Research Center, Seattle, Washington USA
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34
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Boch T, Buchheidt D, Spiess B, Miethke T, Hofmann WK, Reinwald M. Direct comparison of galactomannan performance in concurrent serum and bronchoalveolar lavage samples in immunocompromised patients at risk for invasive pulmonary aspergillosis. Mycoses 2015; 59:80-5. [PMID: 26627577 DOI: 10.1111/myc.12434] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 10/21/2015] [Accepted: 10/21/2015] [Indexed: 02/02/2023]
Abstract
Invasive pulmonary aspergillosis (IPA) is a life-threatening infection mainly affecting immunocompromised patients. Early diagnosis is critical, but the diagnostic gold standard (histopathology and culture) is time consuming and cannot offer early confirmation of IPA. Fungal biomarkers like galactomannan (GM) are a promising extension to the diagnostic repertoire. However, it still remains under discussion if biomarker analysis from the site of the infection is superior to testing blood samples. We retrospectively evaluated the diagnostic performance of concurrent serum GM and bronchoalveolar lavage (BAL) GM (obtained within 24 h) of immunocompromised patients at high risk of IPA. Twenty-six proven/probable patients and eight patients with no IPA according to the EORTC/MSG 2008 criteria were included in this study. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic odds ratio were for BAL GM: 85%, 88%, 96%, 64% and 38.5, and for serum GM: 23%, 88%, 88%, 26% and 2.1 respectively. BAL GM proved to be significantly more sensitive for the detection of IPA compared to same-day serum GM in patients at high risk of IPA (P < 0.0001). Our data show that BAL GM testing is significantly superior to serum GM implying that diagnostic efforts should focus on specimens from the site of infection.
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Affiliation(s)
- Tobias Boch
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Birgit Spiess
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Thomas Miethke
- Institute of Medical Microbiology and Hygiene, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Wolf-Karsten Hofmann
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Mark Reinwald
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
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Arıkan Akdağlı S, Azap A, Başaran Demirkazık F, Ener B, Aşcıoğlu Hayran S, Özdemir Kumbasar Ö, Metan G, Odabaşı Z, Uzun Ö, Akan H. Diagnosis of Invasive Fungal Diseases in Hematological Malignancies: A Critical Review of Evidence and Turkish Expert Opinion (TEO-2). Turk J Haematol 2015; 31:342-56. [PMID: 25541650 PMCID: PMC4454048 DOI: 10.4274/tjh.2014.0218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
One of the most problematic issues in hematological malignancies is the diagnosis of invasive fungal diseases. Especially, the difficulty of mycological diagnosis and the necessity of immediate intervention in molds have led to the adoption of “surrogate markers” that do not verify but rather strongly suggest fungal infection. The markers commonly used are galactomannan (GM), beta-glucan, and imaging methods. Although there are numerous studies on these diagnostic approaches, none of these markers serve as a support for the clinician, as is the case in human immunodeficiency virus (HIV) or cytomegalovirus (CMV) infections. This paper has been prepared to explain the diagnostic tests. As molecular tests have not been standardized and are not used routinely in the clinics, they will not be mentioned here.
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36
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Lahmer T, Messer M, Ehmer U, Eser S, Beitz A, Fekecs L, Schmid RM, Huber W. Pseudallescheria boydii with Aspergillus fumigatus and Aspergillus terreus in a Critically Ill Hematopoietic Stem Cell Recipient with ARDS. Mycopathologia 2015; 181:267-71. [PMID: 26455910 PMCID: PMC7101908 DOI: 10.1007/s11046-015-9952-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 09/25/2015] [Indexed: 11/29/2022]
Abstract
Pseudallescheria boydii is a fungal organism known to affect immunocompromised patients. This organism is known to cause, in severe cases, invasive infection of various organs such as the central nervous, cardiovascular, and respiratory systems. We report an unusual case of pulmonary P. boydii pneumonia in an immunocompromised critically ill patient with a co-infection of Aspergillus fumigatus and Aspergillus terreus with ARDS. This case highlights the importance of a high index of suspicion for superimposed fungal infections in patients who are critically ill and immunocompromised. Uncommon fungal pathogens should be considered in the differential diagnosis of respiratory failure, especially if diagnostic markers such as galactomannan (from BAL and serum) or 1,3-beta-d-glucan are elevated. Further diagnostic interventions are warranted when insufficient clinical improvement is observed to prevent treatment failure and adverse outcomes.
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Affiliation(s)
- Tobias Lahmer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Marlena Messer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Ursula Ehmer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stefan Eser
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Analena Beitz
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Lisa Fekecs
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Roland M Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Wolfgang Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
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37
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Han SB, Kim SK, Lee JW, Yoon JS, Chung NG, Cho B, Jeong DC, Kang JH, Kim HK, Lee DG, Lee HS, Im SA. Serum galactomannan index for early prediction of mortality in immunocompromised children with invasive pulmonary aspergillosis. BMC Infect Dis 2015; 15:271. [PMID: 26168914 PMCID: PMC4501281 DOI: 10.1186/s12879-015-1014-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 07/06/2015] [Indexed: 11/24/2022] Open
Abstract
Background Invasive pulmonary aspergillosis (IPA) is the most common invasive fungal disease in immunocompromised patients, and it has a 30 % mortality rate despite appropriate antifungal therapy. This retrospective study was performed to determine risk factors for mortality in immunocompromised children with IPA. Methods Medical records of 45 probable/proven IPA cases diagnosed in children with hematologic/oncologic diseases were reviewed. Selected cases were divided into the survival (n = 30) and fatality (n = 15) groups based on survival at 12 weeks after antifungal therapy. Clinical characteristics and serum galactomannan indices (GMIs) were compared between the two groups. Results Significantly more children in the fatality group were male (p = 0.044), not in complete remission of the underlying malignancies (p = 0.016), and had received re-induction/salvage or palliative chemotherapy (p = 0.035) than those in the survival group. However, none of these factors was significantly associated with mortality in a multivariate analysis. Serum GMIs were higher in the fatality group than in the survival group during the entire period of antifungal therapy, and serum GMI at 1 week after antifungal therapy was most significantly associated with mortality. A serum GMI > 1.50 at 1 week after antifungal therapy exhibited a sensitivity and specificity of 61.5 % and 89.3 %, respectively, in predicting mortality within 12 weeks after antifungal therapy. Conclusions Higher serum GMI in the early phase of antifungal therapy was associated with mortality in immunocompromised children with IPA. These children should receive more intensive care for IPA than others.
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Affiliation(s)
- Seung Beom Han
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. .,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Seong Koo Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. .,The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Jae Wook Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. .,The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Jong-Seo Yoon
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. .,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Nack-Gyun Chung
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. .,The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Bin Cho
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. .,The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. .,Department of Pediatrics, Seoul St. Mary's Hospital, 222, Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea.
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Jin Han Kang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. .,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Hack-Ki Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. .,The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Dong-Gun Lee
- The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. .,The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. .,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Hyun Sil Lee
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Soo Ah Im
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Neofytos D, Railkar R, Mullane KM, Fredricks DN, Granwehr B, Marr KA, Almyroudis NG, Kontoyiannis DP, Maertens J, Fox R, Douglas C, Iannone R, Kauh E, Shire N. Correlation between Circulating Fungal Biomarkers and Clinical Outcome in Invasive Aspergillosis. PLoS One 2015; 10:e0129022. [PMID: 26107507 PMCID: PMC4480423 DOI: 10.1371/journal.pone.0129022] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 05/04/2015] [Indexed: 12/02/2022] Open
Abstract
Objective means are needed to predict and assess clinical response in patients treated for invasive aspergillosis (IA). We examined whether early changes in serum galactomannan (GM) and/or β-D-glucan (BDG) can predict clinical outcomes. Patients with proven or probable IA were prospectively enrolled, and serial GM and BDG levels and GM optical density indices (GMI) were calculated twice weekly for 6 weeks following initiation of standard-of-care antifungal therapy. Changes in these biomarkers during the first 2 and 6 weeks of treatment were analyzed for associations with clinical response and survival at weeks 6 and 12. Among 47 patients with IA, 53.2% (25/47) and 65.9% (27/41) had clinical response by weeks 6 and 12, respectively. Changes in biomarkers during the first 2 weeks were associated with clinical response at 6 weeks (GMI, P = 0.03) and 12 weeks (GM+BDG composite, P = 0.05; GM, P = 0.04; GMI, P = 0.02). Changes in biomarkers during the first 6 weeks were also associated with clinical response at 6 weeks (GM, P = 0.05; GMI, P = 0.03) and 12 weeks (BDG+GM, P = 0.02; GM, P = 0.02; GMI, P = 0.01). Overall survival rates at 6 weeks and 12 weeks were 87.2% (41/47) and 79.1% (34/43), respectively. Decreasing biomarkers in the first 2 weeks were associated with survival at 6 weeks (BDG+GM, P = 0.03; BDG, P = 0.01; GM, P = 0.03) and at 12 weeks (BDG+GM, P = 0.01; BDG, P = 0.03; GM, P = 0.01; GMI, P = 0.007). Similar correlations occurred for biomarkers measured over 6 weeks. Patients with negative baseline GMI and/or persistently negative GMI during the first 2 weeks were more likely to have CR and survival. These results suggest that changes of biomarkers may be informative to predict and/or assess response to therapy and survival in patients treated for IA.
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Affiliation(s)
- Dionysios Neofytos
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States of America
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, United States of America
| | - Radha Railkar
- Clinical Research, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Kathleen M. Mullane
- Department of Medicine, University of Chicago, Chicago, IL, United States of America
| | - David N. Fredricks
- Division of Allergy and Infectious Diseases, Fred Hutchinson Center, Seattle, WA, United States of America
| | - Bruno Granwehr
- Division of Infectious Diseases, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States of America
| | - Kieren A. Marr
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Nikolaos G. Almyroudis
- Roswell Park Cancer Institute, State University of New York, Buffalo, NY, United States of America
| | - Dimitrios P. Kontoyiannis
- Division of Infectious Diseases, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States of America
| | - Johan Maertens
- Department of Haematology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Rebecca Fox
- Clinical Research, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Cameron Douglas
- Clinical Research, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Robert Iannone
- Clinical Research, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Eunkyung Kauh
- Clinical Research, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Norah Shire
- Clinical Research, Merck & Co., Inc., Kenilworth, NJ, United States of America
- * E-mail:
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Ambasta A, Carson J, Church DL. The use of biomarkers and molecular methods for the earlier diagnosis of invasive aspergillosis in immunocompromised patients. Med Mycol 2015; 53:531-57. [DOI: 10.1093/mmy/myv026] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 04/08/2015] [Indexed: 12/15/2022] Open
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40
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False-positive Aspergillus galactomannan and its kinetics in allogeneic hematopoietic stem cell transplantation. J Infect 2015; 70:520-40. [DOI: 10.1016/j.jinf.2015.02.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/18/2015] [Accepted: 02/19/2015] [Indexed: 11/23/2022]
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41
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Amsden JR. Fungal Biomarkers, Antifungal Susceptibility Testing, and Therapeutic Drug Monitoring—Practical Applications for the Clinician in a Tertiary Care Center. CURRENT FUNGAL INFECTION REPORTS 2015. [DOI: 10.1007/s12281-015-0223-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
PURPOSE OF REVIEW Novel treatment modalities for previously fatal diseases, including newer chemotherapeutic and biologic agents and the expansion of the indications for solid organ and stem cell transplantation, have resulted in prolonged patient survival and a significant increase in the population of immunocompromised hosts (ICHs). RECENT FINDINGS This review discusses the increasing spectrum of opportunistic infections in the ICH, the general approach for early diagnosis and treatment of pulmonary infections in this population, and the current and novel diagnostic modalities available to establish a rapid and specific microbiologic diagnosis, focusing on recent controversies and advances. SUMMARY Early diagnosis and prompt initiation of effective therapy for infection help reduce morbidity in ICHs. Advances in diagnostic assays using nonculture-based methods, such as nucleic acid amplification, may allow for earlier targeted therapy. Invasive procedures including bronchoscopy and biopsy remain essential and should be vigorously pursued in ICHs given the broad differential diagnosis of possible pulmonary pathogens in this population, and the need to establish a specific diagnosis to allow accurate targeted therapy.
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43
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Hoyo I, Sanclemente G, de la Bellacasa JP, Cofán F, Ricart M, Cardona M, Colmenero J, Fernández J, Escorsell A, Navasa M, Moreno A, Cervera C. Epidemiology, clinical characteristics, and outcome of invasive aspergillosis in renal transplant patients. Transpl Infect Dis 2014; 16:951-957. [DOI: 10.1111/tid.12301] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- I. Hoyo
- Department of Infectious Diseases; Hospital Clinic of Barcelona - Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona; Barcelona Spain
| | - G. Sanclemente
- Department of Infectious Diseases; Hospital Clinic of Barcelona - Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona; Barcelona Spain
| | - J. Puig de la Bellacasa
- Microbiology, “Centre Diagnòstic Biomèdic” (CDB); Centre for International Health Research (CRESIB); Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - F. Cofán
- Renal Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - M.J. Ricart
- Renal Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - M. Cardona
- Heart Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - J. Colmenero
- Liver Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - J. Fernández
- Liver Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - A. Escorsell
- Liver Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - M. Navasa
- Liver Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - A. Moreno
- Department of Infectious Diseases; Hospital Clinic of Barcelona - Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona; Barcelona Spain
| | - C. Cervera
- Department of Infectious Diseases; Hospital Clinic of Barcelona - Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona; Barcelona Spain
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44
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Mikulska M, Furfaro E, Viscoli C. Non-cultural methods for the diagnosis of invasive fungal disease. Expert Rev Anti Infect Ther 2014; 13:103-17. [PMID: 25385534 DOI: 10.1586/14787210.2015.979788] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Invasive fungal diseases carry a high mortality risk which can be reduced by early treatment. Diagnosing invasive fungal diseases is challenging, because invasive methods for obtaining histological samples are frequently not feasible in thrombocytopenic immunocompromised patients, while fungal cultures have low sensitivity and a long turn-around time. Non-cultural methods are fundamental for a rapid diagnosis of invasive fungal diseases and they include assays based on the detection of fungal antigens (galactomannan, Aspergillus-lateral flow device, [1,3]-β-D-glucan, mannan), antibodies, such as anti-mannan, and molecular tests. With the exception of some molecular methods for rare fungi, the non-cultural assays are usually applied to the diagnosis of invasive aspergillosis, invasive candidiasis and pneumocystosis. The performance of a single test or a combination of tests will be discussed, with particular focus on choosing the most appropriate marker(s) for every specific patient population. Reasons for potential false-positive or false-negative results will be discussed.
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Affiliation(s)
- Małgorzata Mikulska
- Division of Infectious Diseases, IRCCS San Martino University Hospital - IST, L.go R. Benzi, 10 - 16132, Genoa, Italy
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45
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Lamoth F, Alexander BD. Nonmolecular methods for the diagnosis of respiratory fungal infections. Clin Lab Med 2014; 34:315-36. [PMID: 24856530 DOI: 10.1016/j.cll.2014.02.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diagnosis of invasive fungal pneumonias by conventional culture methods is difficult to assess and often delayed. Nonmolecular fungal markers have emerged as an important adjunctive tool to support their diagnosis in combination with other clinical, radiologic, and microbiological criteria of invasive fungal diseases. Concerns about the sensitivity and specificity of some tests in different patient populations should lead to warnings about their widespread use. None can identify the emerging and particularly deadly fungal pathogens responsible for mucormycosis. The role of nonmolecular fungal markers should be better defined in combination with other microbiological and radiologic tools in preemptive antifungal strategies.
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Affiliation(s)
- Frédéric Lamoth
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Box 102359, Durham, NC 27710, USA; Clinical Microbiology Laboratory, Department of Pathology, Duke University Medical Center, 108 Carl building, Durham, NC 27710, USA; Infectious Diseases Service and Institute of Microbiology, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - Barbara D Alexander
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Box 102359, Durham, NC 27710, USA; Clinical Microbiology Laboratory, Department of Pathology, Duke University Medical Center, 108 Carl building, Durham, NC 27710, USA.
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46
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Nucci M, Carlesse F, Cappellano P, Varon AG, Seber A, Garnica M, Nouér SA, Colombo AL. Earlier diagnosis of invasive fusariosis with Aspergillus serum galactomannan testing. PLoS One 2014; 9:e87784. [PMID: 24489964 PMCID: PMC3905034 DOI: 10.1371/journal.pone.0087784] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 12/30/2013] [Indexed: 11/21/2022] Open
Abstract
Cross-reactivity of Fusarium species with serum galactomannan antigen (GMI) test has been observed. We sought to evaluate if GMI could help to early diagnose invasive fusariosis and to monitor treatment response. We reviewed the records of all patients with invasive fusariosis between 2008 and 2012 in three Brazilian hospitals. We selected patients who had at least 1 GMI test within 2 days before or after the date of the first clinical manifestation of fusariosis, and analyzed the temporal relationship between the first positive GMI test and the date of the diagnosis of invasive fusariosis, and the kinetics of GMI in relation to patients' response to treatment. We also selected 18 controls to determine the sensitivity and specificity of the test. Among 18 patients, 15 (83%) had at least one positive GMI (median 4, range 1–15). The sensitivity and specificity of was 83% and 67%, respectively. GMI was positive before the diagnosis of invasive fusariosis in 11 of the 15 cases (73%), at a median of 10 days (range 3–39), and after the diagnosis in 4 cases. GMI became negative in 8 of the 15 patients; 3 of these 8 patients (37.5%) were alive 90 days after the diagnosis of fusariosis compared with 2 of 7 (29%) who did not normalize GMI (p = 1.0). GMI is frequently positive in invasive fusariosis, and becomes positive before diagnosis in most patients. These findings may have important implications for the choice of antifungal therapy in settings with high prevalence of invasive fusariosis.
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Affiliation(s)
- Marcio Nucci
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- * E-mail:
| | - Fabianne Carlesse
- Institute of Pediatric Oncology (GRAACC), Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Paola Cappellano
- University Hospital, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Andrea G. Varon
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Adriana Seber
- Institute of Pediatric Oncology (GRAACC), Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marcia Garnica
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Simone A. Nouér
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Arnaldo L. Colombo
- University Hospital, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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Ng TY, Kang ML, Tan BH, Ngan CCL. Case report: Enteral nutritional supplement as a likely cause of false-positive galactomannan testing. Med Mycol Case Rep 2013; 3:11-3. [PMID: 24567893 PMCID: PMC3930958 DOI: 10.1016/j.mmcr.2013.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 11/17/2013] [Indexed: 11/29/2022] Open
Abstract
The detection of galactomannan (GM) in the serum of in immunocompromised patients is widely used for the early diagnosis of invasive aspergillosis. We report a case of a false-positive GM test presumably caused by the enteral nutritional supplement given to a non-neutropenic patient with intestinal graft-versus-host disease after a hematopoietic stem cell transplant. Clinicians should be alert to the possibility of false-positive GM results in patients on nutritional supplements.
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Affiliation(s)
- Tong-Yong Ng
- Department of Pathology, Singapore General Hospital, Singapore
| | - Mei-Ling Kang
- Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - Ban-Hock Tan
- Department of Infectious Diseases, Singapore General Hospital, Singapore
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48
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Tutar N, Metan G, Koç AN, Yilmaz I, Bozkurt I, Simsek ZO, Buyukoglan H, Kanbay A, Oymak FS, Gulmez I, Demir R. Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease. Multidiscip Respir Med 2013; 8:59. [PMID: 24135224 PMCID: PMC3765339 DOI: 10.1186/2049-6958-8-59] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 07/24/2013] [Indexed: 11/10/2022] Open
Abstract
Background Invasive pulmonary aspergillosis (IPA) is an infection often occurring in neutropenic patients and has high mortality rates. In recent years, it has been reported that the incidence of IPA has also increased in patients with chronic obstructive pulmonary disease (COPD). The purpose of this study is to investigate the clinical and demographic characteristics and treatment responses of IPA in patients with COPD. Methods Seventy-one patients with a positive culture of Aspergillus from lower respiratory tract samples were examined retrospectively. Eleven (15.4%) of these patients, affected with grade 3 or 4 COPD, had IPA. Results Aspergillus hyphae were detected in lung biopsy in three (27.3%) out of 11 patients and defined as proven IPA; a pathological sample was not taken in the other eight (72.7%) patients, and these were defined as probable IPA. Aspergillus isolates were identified as six cases of Aspergillusfumigatus and three of Aspergillusniger in nine patients, while two isolates were not identified at species level. While five patients required intensive care unit admission, four of them received mechanical ventilation. The most common finding on chest X-ray and computed tomography (CT) (respectively 63.6%, 72.7%) was infiltration. Amphotericin B was the initial drug of choice in all patients and five patients were discharged with oral voriconazole after amphotericin B therapy. Six patients (54.5%) died before treatment was completed. Conclusions IPA should be taken into account in the differential diagnosis particularly in patients with severe and very severe COPD presenting with dyspnea exacerbation, poor clinical status, and a new pulmonary infiltrate under treatment with broad-spectrum antibiotics and steroids.
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Affiliation(s)
- Nuri Tutar
- Department of Pulmonary Medicine, Erciyes University Faculty of Medicine, Kayseri 38039, Turkey
| | - Gokhan Metan
- Department of Infectious Diseases and Clinical Microbiology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | | | - Insu Yilmaz
- Department of Pulmonary Medicine, Erciyes University Faculty of Medicine, Kayseri 38039, Turkey
| | - Ilkay Bozkurt
- Department of Infectious Diseases and Clinical Microbiology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Zuhal Ozer Simsek
- Department of Pulmonary Medicine, Erciyes University Faculty of Medicine, Kayseri 38039, Turkey
| | - Hakan Buyukoglan
- Department of Pulmonary Medicine, Erciyes University Faculty of Medicine, Kayseri 38039, Turkey
| | - Asiye Kanbay
- Department of Pulmonary Medicine, Erciyes University Faculty of Medicine, Kayseri 38039, Turkey
| | - Fatma Sema Oymak
- Department of Pulmonary Medicine, Erciyes University Faculty of Medicine, Kayseri 38039, Turkey
| | - Inci Gulmez
- Department of Pulmonary Medicine, Erciyes University Faculty of Medicine, Kayseri 38039, Turkey
| | - Ramazan Demir
- Department of Pulmonary Medicine, Erciyes University Faculty of Medicine, Kayseri 38039, Turkey
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49
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Fisher CE, Stevens AM, Leisenring W, Pergam SA, Boeckh M, Hohl TM. The serum galactomannan index predicts mortality in hematopoietic stem cell transplant recipients with invasive aspergillosis. Clin Infect Dis 2013; 57:1001-4. [PMID: 23759343 DOI: 10.1093/cid/cit393] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We examined the relationship between serum and bronchoalveolar lavage (BAL) galactomannan index (GMI) values and mortality in allogeneic hematopoietic cell transplant recipients with invasive pulmonary aspergillosis. Using a clinical sign and symptom-initiated approach, we found that the serum but not the BAL GMI level correlated with 42- and 180-day patient mortality.
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Affiliation(s)
- Cynthia E Fisher
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center
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50
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Riwes MM, Wingard JR. Diagnostic methods for invasive fungal diseases in patients with hematologic malignancies. Expert Rev Hematol 2013; 5:661-9. [PMID: 23216596 DOI: 10.1586/ehm.12.53] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Invasive fungal disease is associated with increased morbidity and mortality in hematologic malignancy patients and hematopoietic stem cell transplant recipients. Timely recognition and treatment of invasive fungal diseases in these patients are essential and decrease mortality. However, conventional definitive diagnostic methods are difficult and time consuming. While conventional microbiological and histopathological methods are still needed for a definitive diagnosis of invasive fungal disease, new noninvasive diagnostic methods including serologic and molecular biomarkers are now available. These new diagnostic methods facilitate an early diagnosis of invasive fungal disease and allow for utilization of a pre-emptive treatment approach, which may ultimately lead to improved treatment outcomes and reduced toxicity.
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Affiliation(s)
- Mary Mansour Riwes
- University of Florida, College of Medicine, Division of Hematology/Oncology 1600 W Archer Road, Gainesville, FL 32610-0278, USA
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