epiglucan and galactomannan

Invasive fungal infections (IFI) cause considerable morbidity and mortality in pediatric patients. Serum biomarkers such as 1,3-beta-D glucan (BDG) and galactomannan (GM) have been evaluated for the IFI diagnosis. However, most evidence regarding their utility is derived from studies in adult oncology patients. This systematic review aimed to compare the diagnostic accuracy of BDG and GM individually or in combination for diagnosing IFI in pediatric patients. PubMed, CINAHL, Embase, and Cochrane Library were searched until March 2019 for diagnostic studies evaluating both serum GM and BDG for diagnosing pediatric IFI. The pooled diagnostic odds ratio (DOR), specificity and sensitivity were computed. Receiver operating characteristics (ROC) curve and area under the curve (AUC) were used for summarizing overall assay performance. Six studies were included in the meta-analysis. The summary estimates of sensitivity, specificity, pooled DOR, AUC of the GM assay for proven or probable IFI were 0.74, 0.76, 13.25, and 0.845. The summary estimates of sensitivity, specificity, pooled DOR, AUC of the BDG assay were 0.70, 0.69, 4.3, and 0.722. The combined predictive ability of both tests was reported in two studies (sensitivity: 0.67, specificity: 0.877). Four studies were performed in hematology-oncology patients, while two were retrospective studies from pediatric intensive care units (ICUs). In the subgroup of hematology-oncology patients, DOR of BDG remained similar at 4.25 but increased to 40.28 for GM. We conclude that GM and BDG have a modest performance for identifying IFI in pediatric patients. GM has a better accuracy over BDG. Combining both improves the specificity at the cost of sensitivity.

Topics: beta-Glucans; Child; Clinical Laboratory Techniques; Galactose; Humans; Invasive Fungal Infections; Invasive Pulmonary Aspergillosis; Mannans; Pediatrics; Reproducibility of Results; Retrospective Studies; ROC Curve; Sensitivity and Specificity

Galactomannan (GM), 1,3-β-D-glucan (BDG) and aspergillus-lateral flow device (LFD) are recognized as diagnostic tools for invasive aspergillosis (IA). The combined performance of these assays, however, is inconsistent in various studies. We undertook a meta-analysis of 13 studies involving 1513 patients to evaluate the utility of GM in combination with BDG or LFD for diagnosing IA. The pooled SEN, SPE, PLR, NLR and diagnostic odds ratio (DOR) were calculated and constructed to summarize the overall combined performance. Combining both positive results of GM and BDG assays leaded to the pooled SEN 0.49 (95%CI 0.27-0.72), SPE 0.98 (95%CI 0.94-1.00), PLR 31.68 (95%CI 5.36-187.37), NLR 0.52 (95%CI 0.32-0.84) and DOR 61.23 (95%CI 6.96-538.90). Comparing with GM and BDG assays, both positive results of GM and LFD leaded to high SEN, similar SPE, low PLR and NLR. At least one positive result of GM or LFD conferred great SEN 0.93 and low NLR 0.08. Both positive results of GM and BDG or LFD assay were in favor of confirming the existence of IA. And both negative results of GM and LFD were beneficial to rule out IA. Further studies with sufficient sample size should focus on the diagnostic performance and cost-effectiveness of these combined tests in clinical setting.

Topics: Antigens, Fungal; Aspergillus; beta-Glucans; Diagnostic Tests, Routine; Galactose; Humans; Immunoassay; Invasive Pulmonary Aspergillosis; Mannans; Microbiological Techniques; Odds Ratio; Sensitivity and Specificity

The fungus Aspergillus fumigatus is the main pathogenic agent responsible for invasive pulmonary aspergillosis. Immunocompromised patients are more likely to develop this pathology due to a decrease in the immune system's defense capacity. Despite of the low occurrence of invasive pulmonary aspergillosis, this pathology presents high rates of mortality, mostly due to late and unspecific diagnosis. Currently, the diagnostic methods used to detect this fungal infection are conventional mycological examination (direct microscopic examination, histological examination, and culture), imaging, non-culture-based tests for the detection of galactomannan, β(1,3)-glucan and an extracellular glycoprotein, and molecular tests based on PCR. However, most of these methods do not detect the species A. fumigatus; they only allow the identification of genus Aspergillus. The development of more specific detection methods is of extreme importance. Fluorescent in situ hybridization-based molecular methods can be a good alternative to achieve this purpose. In this review, it is intended to point out that most of the methods used for the diagnosis of invasive pulmonary aspergillosis do not allow to detect the fungus at the species level and that fluorescence in situ hybridization-based molecular method will be a promising approach in the A. fumigatus detection.

Topics: Aspergillus fumigatus; beta-Glucans; Galactose; Glycoproteins; Humans; Invasive Pulmonary Aspergillosis; Mannans

Invasive mould infections (IMIs), such as invasive aspergillosis or mucormycosis, are a major cause of death in patients with haematological cancer and in patients receiving long-term immunosuppressive therapy. Early diagnosis and prompt initiation of antifungal therapy are crucial steps in the management of patients with IMI. The diagnosis of IMI remains a major challenge, with an increased spectrum of fungal pathogens and a diversity of clinical and radiological presentations within the expanding spectrum of immunocompromised hosts. Diagnosis is difficult to establish and is expressed on a scale of probability (proven, probable and possible). Imaging (CT scan), microbiological tools (direct examination, culture, PCR, fungal biomarkers) and histopathology are the pillars of the diagnostic work-up of IMI. None of the currently available diagnostic tests provides sufficient sensitivity and specificity alone, so the optimal approach relies on a combination of multiple diagnostic strategies, including imaging, fungal biomarkers (galactomannan and 1,3-β-d-glucan) and molecular tools. In recent years, the development of PCR for filamentous fungi (primarily Aspergillus or Mucorales) and the progress made in the standardization of fungal PCR technology, may lead to future advances in the field. The appropriate diagnostic approach for IMI should be individualized to each centre, taking into account the local epidemiology of IMI and the availability of diagnostic tests.

Topics: Aspergillosis; Aspergillus fumigatus; beta-Glucans; Early Diagnosis; Galactose; Hematologic Neoplasms; Humans; Immunocompromised Host; Immunosuppression Therapy; Invasive Fungal Infections; Magnetic Resonance Imaging; Mannans; Mucor; Mucormycosis; Organ Transplantation; Polymerase Chain Reaction; Positron Emission Tomography Computed Tomography; Tomography, X-Ray Computed

Infections caused by filamentous fungi represent a major burden in the ICU. Invasive aspergillosis is emerging in non-neutropenic individuals with predisposing conditions, e.g. corticosteroid treatment, chronic obstructive pulmonary disease, liver cirrhosis, solid organ cancer, HIV infection and transplantation. Diagnosis is challenging because the signs and symptoms are non-specific, and initiation of additional diagnostic examinations is often delayed because clinical suspicion is low. Isolation of an Aspergillus species from the respiratory tract in critically ill patients, and tests such as serum galactomannan, bronchoalveolar lavage 1-3-β-d-glucan and specific PCR should be interpreted with caution. ICU patients should start adequate antifungal therapy upon suspicion of invasive aspergillosis, without awaiting definitive proof. Voriconazole, and now isavuconazole, are the drugs of choice. Mucormycosis is a rare, but increasingly prevalent disease that occurs mainly in patients with uncontrolled diabetes mellitus, immunocompromised individuals or previously healthy patients with open wounds contaminated with Mucorales. A high proportion of cases are diagnosed in the ICU. Rapidly progressing necrotizing lesions in the rhino-sinusal area, the lungs or skin and soft tissues are the characteristic presentation. Confirmation of diagnosis is based on demonstration of tissue invasion by non-septate hyphae, and by new promising molecular techniques. Control of underlying predisposing conditions, rapid surgical resection and administration of liposomal amphotericin B are the main therapeutic actions, but new agents such as isavuconazole are a promising alternative. Patients with mucormycosis receive a substantial part of their care in ICUs and, despite advances in diagnosis and treatment, mortality remains very high.

Topics: Antifungal Agents; Aspergillosis; Aspergillus; beta-Glucans; Critical Illness; Galactose; Humans; Immunocompromised Host; Intensive Care Units; Invasive Fungal Infections; Lung Diseases, Fungal; Mannans; Mucor; Mucormycosis; Nitriles; Opportunistic Infections; Pyridines; Respiratory System; Triazoles; Voriconazole

Invasive fungal diseases are important clinical problems that are often complicated by severe illness and therefore the inability to use invasive measures to definitively diagnose the disease. Tests for a range of fungal biomarkers that do not require an invasive sample-collection procedure have been incorporated into adult clinical practice, but pediatric data and pediatric-specific recommendations for some of these diagnostic tools are lacking. In this review, we summarize the published literature and contemporary strategies for using the biomarkers galactomannan, (1→3)-β-d-glucan, Candida mannan antigen and anti-mannan antibody, and fungal polymerase chain reaction for diagnosing invasive fungal disease in children. Data on biomarker use in neonates and children with cancer, history of hematopoietic stem cell transplant, or primary immunodeficiency are included. Fungal biomarker tests performed on blood, other body fluids, or tissue specimens represent promising adjuncts to the diagnostic armamentarium in populations with a high prevalence of invasive fungal disease, but substantial gaps exist in the correct use and interpretation of these diagnostic tools in pediatric patients.

Topics: Antibodies, Fungal; Antigens, Fungal; Aspergillosis; Aspergillus; beta-Glucans; Biomarkers; Candida; Candidiasis; Child; DNA, Fungal; Galactose; Humans; Immunoassay; Invasive Fungal Infections; Mannans; Polymerase Chain Reaction

Invasive aspergillosis (IA) is an important cause of morbidity and mortality in children and adults with haematologic malignancies or undergoing allogeneic haematopoietic stem cell transplantation, and early diagnosis and adequate antifungal treatment improve outcome. However, important differences exist between children and adults regarding epidemiology, underlying disease, and comorbidities, and the value of diagnostic tools to detect IA may also differ between these patient populations. Imaging studies are important to detect IA early, but typical findings of IA in chest computed tomography of adults are not detected in the majority of children. Whereas the value of the serum marker galactomannan seems to be comparable in children and adults, data on the performance of beta-d-glucan in children are too limited for firm conclusions. PCR-based assays are a promising diagnostic approach to rapidly and reliably detect and identify Aspergillus species in various clinical samples. However, as the majority of data on PCR-based approaches has been obtained in adult patients, the value of this method in paediatric patients has not been defined to date. The present review focuses on studies of PCR-based methods to diagnose IA in immunocompromised paediatric patients.

Topics: Adolescent; Adult; Aspergillus; beta-Glucans; Biomarkers; Bronchoalveolar Lavage Fluid; Child; Child, Preschool; DNA, Fungal; Female; Galactose; Humans; Immunocompromised Host; Infant; Invasive Pulmonary Aspergillosis; Mannans; Polymerase Chain Reaction; Predictive Value of Tests; Proteoglycans; Young Adult

We systematically reviewed and analyzed the available data for galactomannan (GM), β-D-glucan (BG), and polymerase chain reaction (PCR)-based assays to detect invasive fungal disease (IFD) in patients with pediatric cancer or undergoing hematopoietic stem cell transplantation when used as screening tools during immunosuppression or as diagnostic tests in patients presenting with symptoms such as fever during neutropenia (FN). Of 1532 studies screened, 25 studies reported on GM (n = 19), BG (n = 3), and PCR (n = 11). All fungal biomarkers demonstrated highly variable sensitivity, specificity, and positive predictive values, and these were generally poor in both clinical settings. GM negative predictive values were high, ranging from 85% to 100% for screening and 70% to 100% in the diagnostic setting, but failure to identify non-Aspergillus molds limits its usefulness. Future work could focus on the usefulness of combinations of fungal biomarkers in pediatric cancer and HSCT.

Topics: Adolescent; Adult; beta-Glucans; Child; Child, Preschool; Galactose; Hematopoietic Stem Cell Transplantation; Humans; Infant; Infant, Newborn; Invasive Fungal Infections; Mannans; Neoplasms; Polymerase Chain Reaction; Young Adult

The optimal management of invasive fungal infections (IFIs) in children requires prompt and precise diagnosis that enables timely implementation of appropriate antifungal therapy and decreased use of unnecessary toxic antifungals. Areas covered: Traditional approaches such as culture, microscopy and histopathology remain the gold standard but are often not sufficiently sensitive and specific. These limitations have led to the development of alternative non-invasive diagnostic methods that in most cases detect fungal components, such as antigens or nucleic acids. To date, galactomannan and 1,3 β-D-glucan assays are the most efficient non-culture methods for diagnosis and monitoring of antifungal therapy. New technologies from nano-sciences are applied, like T2Candida assay. However, these are not standardized or validated in children. Herein, we focus on IFI diagnosis emphasizing current perspectives, interpretation difficulties, and need for further evaluation in pediatrics. Expert commentary: The new diagnostic tools may enhance diagnostic capacity in combination with traditional methods.

Topics: Antibodies, Fungal; Antifungal Agents; Antigens, Fungal; beta-Glucans; Child; Colony Count, Microbial; Drug Monitoring; Galactose; Humans; Invasive Fungal Infections; Mannans

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.

Topics: Antigens, Fungal; beta-Glucans; Candidiasis, Invasive; Galactose; Humans; Invasive Pulmonary Aspergillosis; Mannans; Microbiological Techniques; Polymerase Chain Reaction

Invasive aspergillosis is an infection with high morbidity and mortality that affects mostly immunocompromised individuals. Early identification and targeted treatment of the infection is essential to improve survival of affected patients. The purpose of our review is to highlight the most recent developments in diagnosis and screening for invasive aspergillosis (IA) along with the challenges associated with the development and validation of novel diagnostic approaches.. Ovid MEDLINE and The Cochrane library were searched for studies that evaluated serologic, molecular and novel methodologies for the diagnosis of IA.. Traditional diagnostic approaches, such as histopathology and culture, are still considered the gold standard but lack sufficient sensitivity. Newer serologic techniques, such as galactomannan (GM) and beta-glucan, have already been incorporated into clinical guidelines, but recent evidence suggests that their performance might be limited in certain clinical settings. Molecular methods, such as the Aspergillus spp. polymerase chain reaction (PCR), have not yet found their place in clinical practice mainly due to lack of standardization. Novel methodologies, such as volatile organic compound detection and lateral flow devices, have recently been developed and promise noninvasive and rapid diagnosis of aspergillosis, while diagnostic algorithms that incorporate both GM and PCR have proven to be effective in early randomized trials as screening methods and can reduce the use of antifungal agents.. Diagnosis of IA remains challenging. Novel methodologies and the standardization of GM and PCR might provide more reliable diagnostic tools in the future.

Topics: Aspergillosis; beta-Glucans; Early Diagnosis; Galactose; Humans; Mannans; Real-Time Polymerase Chain Reaction; Volatile Organic Compounds

Topics: beta-Glucans; Biomarkers; DNA, Fungal; Fungemia; Galactose; Humans; Immunocompromised Host; Mannans; Neoplasms; Sepsis

Aspergillus polymerase chain reaction (PCR) was excluded from the European Organisation for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) definitions of invasive fungal disease because of limited standardization and validation. The definitions are being revised.. A systematic literature review was performed to identify analytical and clinical information available on inclusion of galactomannan enzyme immunoassay (GM-EIA) (2002) and β-d-glucan (2008), providing a minimal threshold when considering PCR. Categorical parameters and statistical performance were compared.. When incorporated, GM-EIA and β-d-glucan sensitivities and specificities for diagnosing invasive aspergillosis were 81.6% and 91.6%, and 76.9% and 89.4%, respectively. Aspergillus PCR has similar sensitivity and specificity (76.8%-88.0% and 75.0%-94.5%, respectively) and comparable utility. Methodological recommendations and commercial PCR assays assist standardization. Although all tests have limitations, currently, PCR is the only test with independent quality control.. We propose that there is sufficient evidence that is at least equivalent to that used to include GM-EIA and β-d-glucan testing, and that PCR is now mature enough for inclusion in the EORTC/MSG definitions.

Topics: Antigens, Fungal; Aspergillosis; Aspergillus; beta-Glucans; Galactose; Humans; Immunoenzyme Techniques; Mannans; Polymerase Chain Reaction; Quality Control; Sensitivity and Specificity

An established diagnosis of invasive aspergillus is seldom achieved premortem. Conventional laboratory diagnostic methods such as culture and microscopy, although very useful when positive, are insensitive and time-consuming, resulting in late diagnosis and treatment and contributing to high mortality rates. As a result, routine antifungal prophylaxis and early empirical treatment have been recommended. The use of sensitive and rapid non-culture-based diagnostic assays for the detection of Aspergillus antigens (using commercially available tests to detect galactomannan and 1, 3 β-D-glucan) or detection of genomic DNA sequences may allow a shift in emphasis from empirical to preemptive therapy, especially when substantiated by suggestive radiological findings. These new tools may be used to confirm a presumed diagnosis of invasive aspergillosis, or, when used to screen high-risk patients, may identify an infection at an early stage of disease. Their excellent negative predictive value should convince clinicians to withhold antifungal therapy in patients with no other signs of fungal disease. On the other hand, consecutive positive results should at least trigger a complete diagnostic workup. This article will review the diagnostic utility as well as the pitfalls of using these non-culture-based tools for diagnosing invasive aspergillosis.

Topics: Antifungal Agents; Aspergillosis; Aspergillus; beta-Glucans; Bronchoalveolar Lavage Fluid; Galactose; Humans; Mannans; Proteoglycans; Triazoles; Voriconazole

Invasive pulmonary aspergillosis is an opportunistic mycosis, difficult to diagnose, due to the environmental fungi of the genus Aspergillus. The diagnostic tools, even if more are available, are still limited in number and effectiveness. The current recommendations issued by the EORTC/MSG (European Organization of Research and Treatment of Cancer/Mycoses Study Group) and the ECIL (European Conference for Infection in Leukemia) suggest collecting epidemiological, radio-clinical, and biological data to support the diagnosis of aspergillosis with a strong presumption. Thus, medical imaging and serum galactomannan antigen currently constitute the basis of the screening approach, although they both have some limitations in specificity. (1→3)-β-D-glucans are pan-fungal serum markers with a very good negative predictive value. Real-time PCR lacks standardization, and fungal culture from respiratory specimens is sometimes not sensitive enough. Histology allows proving the diagnosis of aspergillosis, but biopsy is not always possible in immunodepressed patients. We present the various arguments for the diagnosis of invasive aspergillosis, with a particular emphasis on recent exploration techniques.

Topics: Antibodies, Fungal; Antigens, Fungal; Aspergillus; beta-Glucans; Biomarkers; Biopsy; Diagnostic Imaging; DNA, Fungal; Early Diagnosis; Europe; Galactose; Humans; Immunocompromised Host; Invasive Pulmonary Aspergillosis; Mannans; Practice Guidelines as Topic; Predictive Value of Tests; Real-Time Polymerase Chain Reaction; Sensitivity and Specificity; Tomography, X-Ray Computed

Topics: Antigens, Fungal; beta-Glucans; Candidiasis, Invasive; Galactose; Humans; Mannans; Mycoses; Proteoglycans; Pulmonary Aspergillosis; Serologic Tests

The biomarkers galactomannan and 1,3-β-d-glucan have been well studied over the past years and are gaining a role in the diagnosis of invasive fungal infections. Although not as well studied until recently, molecular methods for the diagnosis of invasive fungal infection are also being evaluated. Outcomes data for molecular testing are expanding, but have not yet provided enough evidence for inclusion of molecular diagnostics in formal clinical guidelines. Lack of standardization and validation of the various molecular assays and platforms has hindered their widespread acceptance in the evaluation of invasive fungal infections, although the future is promising.

Topics: Aspergillosis; beta-Glucans; Biomarkers; Bronchoalveolar Lavage Fluid; Candidiasis; False Positive Reactions; Galactose; Humans; Mannans; Pathology, Molecular; Polymerase Chain Reaction; Predictive Value of Tests; Sugar Alcohols

Topics: Antigens, Fungal; Aspergillosis; Aspergillus fumigatus; beta-Glucans; Biomarkers; Diagnosis, Differential; Early Diagnosis; Galactose; Humans; Immunocompromised Host; Mannans; Molecular Diagnostic Techniques; Proteoglycans; Reagent Kits, Diagnostic; Tomography, X-Ray Computed

As culture-based methods for the diagnosis of invasive fungal diseases (IFD) in leukemia and hematopoietic SCT patients have limited performance, non-culture methods are increasingly being used. The third European Conference on Infections in Leukemia (ECIL-3) meeting aimed at establishing evidence-based recommendations for the use of biological tests in adult patients, based on the grading system of the Infectious Diseases Society of America. The following biomarkers were investigated as screening tests: galactomannan (GM) for invasive aspergillosis (IA); β-glucan (BG) for invasive candidiasis (IC) and IA; Cryptococcus Ag for cryptococcosis; mannan (Mn) Ag/anti-mannan (A-Mn) Ab for IC, and PCR for IA. Testing for GM, Cryptococcus Ag and BG are included in the revised EORTC/MSG (European Organization for Research and Treatment of Cancer/Mycoses Study Group) consensus definitions for IFD. Strong evidence supports the use of GM in serum (A II), and Cryptococcus Ag in serum and cerebrospinal fluid (CSF) (A II). Evidence is moderate for BG detection in serum (B II), and the combined Mn/A-Mn testing in serum for hepatosplenic candidiasis (B III) and candidemia (C II). No recommendations were formulated for the use of PCR owing to a lack of standardization and clinical validation. Clinical utility of these markers for the early management of IFD should be further assessed in prospective randomized interventional studies.

Topics: Antigens, Fungal; beta-Glucans; Biomarkers; Congresses as Topic; European Union; Galactose; Hematopoietic Stem Cell Transplantation; Leukemia; Mannans; Mycoses; Transplantation, Homologous

Topics: Antigens, Fungal; Aspergillosis; Aspergillus; beta-Glucans; Breath Tests; DNA, Fungal; Early Diagnosis; Galactose; Hematopoietic Stem Cell Transplantation; Humans; Immunocompromised Host; Leukemia; Lung; Mannans; Neutropenia; Organ Transplantation; Transplantation Immunology

Invasive fungal infections (IFIs) are difficult to diagnose, especially early in the course of infection when antifungal therapy is most effective. There are two commercially available biomarker assays useful for detection of the IFIs most commonly seen in patients with hematologic malignancies, the galactomannan and beta glucan assays. The former is specific for aspergillosis, the latter positive for not only Aspergillus and Candida species, but several other clinically relevant fungal pathogens as well. Both have good assay performance characteristics, provide rapid test results, are widely available, can be assayed non-invasively, and are positive early in the course of infection, often before onset of signs and symptoms of infection. Adoption of these assays into clinical practice has led to reduced need to perform invasive procedures to obtain deep tissue to establish the diagnosis of invasive fungal infections. Improved survival rates from aspergillosis are, in part, due to earlier detection of infection and earlier therapy.

Topics: Acute Disease; Aspergillosis; Aspergillus; beta-Glucans; Biomarkers; Candida; Candidiasis; Galactose; Hematopoietic Stem Cell Transplantation; Humans; Leukemia; Mannans; Transplantation, Homologous

Invasive fungal infections are associated with high morbidity and mortality in critically ill patients due, in part, to diagnostic difficulties in the early stages. Nonculture-based techniques such as (1,3)-β-d-glucan, galactomannan, mannan and antimannan antibodies, Candida albicans germ tube-specific antibodies or fungal DNA are required for earlier diagnosis, prognostic information and monitoring outcome. A decision-tree algorithm based on the combination of nonculture-based techniques is suggested to optimize the diagnosis and evolution of critically ill patients at risk of invasive mycoses. The use of (1,3)-β-d-glucan and blood cultures twice a week is proposed; if positive, treatment initiation is recommended alongside the performance of the nonculture-based microbiological tool depending on suspected mycoses and the availability of techniques.

Topics: Antibodies, Fungal; Aspergillus; beta-Glucans; Candida; Decision Trees; DNA, Fungal; Galactose; Humans; Mannans; Mycoses; Proteoglycans; Serologic Tests

Although invasive fungal infections (IFIs) are relatively rare, they are important causes of morbidity and mortality in immunocompromised pediatric patients. Early and precise diagnosis of IFI is important to allow antifungal treatment to be started in time and to reduce the unnecessary use of toxic antifungal agents. Although traditional approaches such as direct microscopic examination, histopathological evaluation and cultivation are still gold standard, the diagnosis of IFI is generally difficult because of inadequate sensitivity and specificity with these tests. Commercial systems detecting the Aspergillus cell wall antigen galactomannan and 1,3-β-D-glucan are seen as the most convenient nonculture methods for the diagnosis of the IFI and monitoring of antifungal treatment. Several molecular methods have been described for the diagnosis of opportunistic mycoses. However, they have not been standardized and have only been used in experimental studies.

Topics: Aspergillosis; Aspergillus; beta-Glucans; Candida; Candidiasis, Invasive; Child; Culture Techniques; Diagnostic Techniques and Procedures; Early Diagnosis; Galactose; Humans; Mannans; Sensitivity and Specificity

The (1→3)-β-D-Glucan (BG) assay has been approved for diagnosing invasive fungal disease (IFD). However, the test performance has been variable. We conducted a meta-analysis to determine the overall accuracy of BG assay for diagnosing IFD.. The sensitivity, specificity, and positive and negative likelihood ratios (PLR and NLR, respectively) of BG for diagnosing IFD were pooled using a bivariate meta-analysis. We also performed subgroup analyses.. Twelve reports, including 15 studies, were included for the analysis (proven and probable IFD vs possible or no IFD). The sensitivity, specificity, PLR and NLR were 0.76 (95% CI, 0.67-0.83), 0.85 (95% CI, 0.73-0.92), 5.05 (95% CI, 2.71-9.43), and 0.28 (95% CI, 0.20-0.39), respectively. Subgroup analyses showed that the BG assay had higher specificities for patients with hematological disorders and a positive BG result with two consecutive samples. The combination of galactomannan and BG increased the specificity value to 0.98 (95% CI, 0.95-0.99) for diagnosing invasive aspergillosis.. Serum BG determination is clinically useful for diagnosing IFD in at-risk patients, especially for hematology patients. The combination of galactomannan and BG was sufficient for diagnosing invasive aspergillosis. Since the BG assay is not absolutely sensitive and specific for IFD, the BG results should be interpreted in parallel with clinical findings.

Topics: Aspergillosis; beta-Glucans; Biomarkers; Candidiasis, Invasive; Galactose; Humans; Likelihood Functions; Linear Models; Mannans; Mycoses; Proteoglycans; ROC Curve; Sensitivity and Specificity

Fungal infections are of great relevance in surgical intensive care and Candida species represent the predominant part of fungal pathogens. Invasive aspergillosis is also relevant especially in patients with chronic pulmonary diseases. It is crucial for therapy success to begin adequate antifungal treatment at an early stage of the disease. Risk stratification of individual patient symptoms is essential for therapy timing. In case of suspected or proven candida infection, fluconazole is the agent of choice when the patient is clinically stable and no azoles have been administrated in advance and the local epidemiology makes azol resistance unlikely. For clinically instable patients with organ dysfunction the echinocandins serve as primary therapy because of their broad spectrum and reasonable safety profile. Due to a relevant proportion of azole resistant Candida species, susceptibility testing should be done routinely. Depending on the species detected de-escalating to an azole is feasible if organ dysfunctions have resolved. An invasive aspergillosis is primarily treated with voriconazole.

Topics: Adjuvants, Immunologic; Antifungal Agents; Azoles; beta-Glucans; Candidiasis; Critical Care; Cryptococcosis; Echinocandins; Galactose; Humans; Mannans; Mucus; Mycoses; Polyenes; Reverse Transcriptase Polymerase Chain Reaction; Risk Assessment; Tomography, X-Ray Computed

Topics: Antifungal Agents; Aspergillosis; beta-Glucans; Biomarkers; Candidiasis; Galactose; Hematologic Diseases; Humans; Immunocompromised Host; Lung Diseases, Fungal; Mannans; Molecular Diagnostic Techniques; Mycoses

In the last few years, major advances in the treatment of transplant recipients, with hemato-oncological diseases or admitted to the intensive care unit, has been accompanied by an increase in classical fungal infections and by the emergence of uncommon fungal infections. Despite the development of new diagnostic techniques such as galactomannan detection and the availability of new antifungal agents, these opportunistic infections continue to pose a diagnostic challenge, prolong length of hospital stay, and increase costs. In addition, mortality from these infections is high. The present chapter provides a brief review of the epidemiology of these infections, diagnostic advances, and the new antifungal agents that have been developed in the last few years.

Topics: Anidulafungin; Antifungal Agents; Aspergillosis; beta-Glucans; Candidiasis; Clinical Trials as Topic; Critical Care; Diabetes Complications; Disease Susceptibility; Echinocandins; Fungemia; Galactose; Hematologic Diseases; Humans; Immunocompromised Host; Mannans; Meta-Analysis as Topic; Mycoses; Neoplasms; Opportunistic Infections

In high-risk patient cohorts, such as patients after solid-organ or allogeneic stem-cell transplantation, or patients with acute leukaemia, early diagnosis of invasive fungal infections (IFIs) is essential, as delayed or missing diagnosis of IFI results in increasing rates of mortality. However, diagnosis of most IFIs, especially of invasive aspergillosis, is difficult because classic tests have low sensitivity and specificity, and radiology often provides non-specific and transient results. The limited sensitivity and specificity of conventional assays for the detection of IFI and the growing number of immunocompromised patients who are at risk for opportunistic fungal infections have led to the development of new assays. These methods include antigen detection systems, such as ELISAs, and different molecular methods (PCR assays). Serological tests, such as the detection of the carbohydrate galactomannan, are standardised and commercially available. However, they still need to be evaluated in large patient cohorts, especially children. The benefit of antibody detection remains unclear if patients are under immune suppression or are heavily colonised but not infected. A range of different PCR assays (conventional, nested, real-time) have been developed, targeting different gene regions (cytochrome P450, heat-shock proteins, 18S, 5.8S, 28S, internal transcribed spacer), including a variety of amplicon detection methods, such as gel electrophoresis, hybridisation with specific probes, ELISA and restriction fragment length polymorphism. These molecular assays provide high potential in terms of sensitivity and specificity, but vary widely in their feasibility and up to now have not been standardised. Taken together, new non-culture-based diagnostic assays are appropriate as simple and rapid screening tests with high sensitivities and quick turnaround times. Thus, they might help to reduce empirical antifungal therapy and might be valuable tools to allow early initiation and monitoring of pre-emptive antifungal therapy. In this review, we assess the performance of a variety of non-culture-based tests for the detection of IFI in high-risk haematological patients, with emphasis on the impact of the assays on different management strategies.

Topics: Aspergillosis; Aspergillus; beta-Glucans; DNA, Fungal; Enzyme-Linked Immunosorbent Assay; Galactose; Humans; Immunocompromised Host; Mannans; Polymerase Chain Reaction; Sensitivity and Specificity; Tomography, X-Ray Computed

A reliable diagnosis of invasive aspergillosis in patients with haematological malignancies is seldom achieved antemortem. Conventional laboratory diagnostic methods are insensitive and time-consuming, resulting in late diagnosis and treatment and contributing to unacceptably high mortality. As a result, routine antifungal prophylaxis and early empirical treatment have been recommended. However, overtreatment associated with these strategies results in increased toxicity and cost. The use of sensitive and rapid non-culture-based diagnostic assays, such as detection of Aspergillus antigens (galactomannan, beta-D-glucan) or detection of genomic DNA sequences may allow a shift in emphasis from empirical to pre-emptive therapy, especially when substantiated by suggestive radiological findings. These new tools may be used to confirm a presumed diagnosis of invasive aspergillosis, or, when used to screen high-risk patients, may identify an infection at the early stage of disease. The excellent negative predictive value of these assays should convince clinicians to withhold antifungal therapy in persistently febrile neutropenic patients with no other signs of fungal infection. On the other hand, consecutive positive results in a high-risk population should at least trigger a complete diagnostic work-up. This review will focus on the diagnostic utility as well as on the pitfalls of serial screening for the presence of circulating fungal antigens in haematology patients.

Topics: Antigens, Fungal; Aspergillosis; Aspergillus; beta-Glucans; Galactose; Hematologic Neoplasms; Humans; Immunoassay; Mannans; Proteoglycans; Serologic Tests

During recent years, a rising incidence of invasive pulmonary aspergillosis (IPA) in non-neutropenic critically ill patients has been reported. Critically ill patients are prone to develop disturbances in immunoregulation during their stay in the ICU, which render them more vulnerable for fungal infections. Risk factors such as chronic obstructive pulmonary disease (COPD), prolonged use of steroids, advanced liver disease, chronic renal replacement therapy, near-drowning and diabetes mellitus have been described. Diagnosis of IPA may be difficult and obtaining histo- or cytopathological demonstration of the fungus in order to meet the gold standard for IPA is not always feasible in these patients. Laboratory markers used as a non-invasive diagnostic tool, such as the galactomannan antigen test (GM), 1,3-beta-glucan, and Aspergillus PCR, show varying results. Antifungal therapy might be considered in patients with persistent pulmonary infection who exhibit risk factors together with positive cultures or sequentially positive GM and Aspergillus PCR in serum, in whom voriconazole is the drug of choice. The benefit of combination antifungal therapy lacks sufficient evidence so far, but this treatment might be considered in patients with breakthrough infections or refractory disease.

Topics: Antifungal Agents; Antigens, Fungal; Aspergillosis; Aspergillus; beta-Glucans; Critical Illness; DNA, Fungal; Drug Therapy, Combination; Galactose; Humans; Intensive Care Units; Lung Diseases, Fungal; Mannans; Opportunistic Infections; Polymerase Chain Reaction; Risk Factors

Early diagnosis of fungal infections and the implementation of appropriate treatment represent major issues for clinicians, nowadays. Histopathological demonstration of microorganisms in tissue specimens or growth of fungal agents in culture media is still considered the "gold standard", but obtaining such specimens may be difficult. Several groups have investigated serological assays for cell wall elements unique to fungal organisms in serum or other body fluids to improve diagnostics in patients with haematological malignancies or undergoing haematopoietic stem-cell transplantation. In this review we have concentrated on the currently available assays allowing for detection of highly immunogenic components of fungal cell wall: galactomannan, mannan, and also (1-->3)-beta-D-glucan. Rapid serological tests appear to be useful for screening high-risk haematological patients, since they allow for the early diagnosis of invasive fungal infections, including infections with the most common pathogens such as Aspergillus and Candida. Based on current literature, factors increasing the probability of obtaining false-positive or false-negative results detected by each test were also analysed and tabulated.

Topics: Antigens, Fungal; beta-Glucans; Body Fluids; Galactose; Humans; Mannans; Mycoses; Proteoglycans; Serologic Tests

The usefulness of surrogate markers in the diagnosis of invasive fungal infections caused by Aspergillus and other emerging mycelial fungi is based on the ability of surrogate markers to detect the infection caused by different species of mycelial fungi. Conventional microbiological methods for diagnosis of fungal disease are slow and insensitive. Antigen based assays or measurement of (1-3)-beta-D-glucan in blood have been developed and validated in clinical laboratories. We review these diagnostic contemporary tools, their clinical application and impact.

Topics: Antibodies, Fungal; Antigens, Fungal; Aspergillosis; beta-Glucans; Biomarkers; Clinical Trials as Topic; Communicable Diseases, Emerging; DNA, Fungal; Early Diagnosis; Fungemia; Galactose; Humans; Immunologic Techniques; Mannans; Predictive Value of Tests; Proteoglycans; Risk Factors; Zygomycosis

Early treatment of invasive mold infections improves the outcome. Therapy is often delayed, however, because available diagnostic tools such as culture, microscopy and conventional radiology lack sensitivity; consequently, empirical initiation of antifungal therapy has been advocated, particularly for patients with prolonged unexplained neutropenic fever.. Much recent progress has been made in the development and evaluation of nonculture-based assays, including the detection of the fungal antigens galactomannan and beta-D-glucan and the detection of fungal DNA by polymerase chain reaction techniques. These new tools should aid the rapid, early diagnosis of invasive fungal disease, especially when used as screening tools in conjunction with sensitive imaging techniques.. The review will consider these recent developments with the purpose of introducing the concept of preemptive antifungal therapy.

Topics: Antifungal Agents; Antigens, Fungal; beta-Glucans; Diagnostic Imaging; DNA, Fungal; Galactose; Humans; Mannans; Mycoses; Proteoglycans

Invasive aspergillosis (IA) is a serious cause of morbidity and mortality among immunocompromised patients. Prompt and non-invasive methods for diagnosing IA are needed to improve the management of this life-threatening infection in patients with hematological disorders. In summary, this retrospective review of studies performed on the two assays finds that both assays have high sensitivity and specificity but are more useful when used together as a diagnostic strategy for patients with invasive aspergillosis.

Topics: Aspergillosis; beta-Glucans; Clinical Trials as Topic; Diagnostic Tests, Routine; Galactose; Humans; Lung Diseases, Fungal; Mannans; Multicenter Studies as Topic; Predictive Value of Tests; Proteoglycans; Reproducibility of Results

Topics: Antibodies, Fungal; Antigens, Fungal; Aspergillosis; Aspergillosis, Allergic Bronchopulmonary; Aspergillus; beta-Glucans; Biomarkers; Colorimetry; DNA, Fungal; Enzyme-Linked Immunosorbent Assay; Galactose; Humans; Latex Fixation Tests; Lung Diseases, Fungal; Mannans; Nephelometry and Turbidimetry; Polymerase Chain Reaction; Proteoglycans

Invasive deep mycoses following bone marrow and solid-organ transplantation remain a major cause of morbidity and mortality. Species of Candida and Aspergillus account for more than 80% of these mycoses. Because these infections are often difficult to diagnose and treat successfully, antifungal prophylaxis is recommended in high-risk patients. Fluconazole is useful in patients who are at risk of invasive candidiasis, including bone marrow transplants, liver and pancreatic transplants. Although invasive aspergillosis is frequent in patients with bone marrow, lung and heart transplantation, no established methods have been available for its prophylaxis. Recently, efforts to improve the efficiency of diagnostic tests have been directed toward the detection of fungal components or metabolites. The requirements for clinical use (monitoring) are as follows: capability of early diagnosis, quantitative measurement, and easy sampling and simple assay procedure. The detection of plasma (1-3)-beta-D-glucan (BDG), a characteristic cell wall component of almost all fungi, is widely used in Japan. Twenty-seven episodes of fungemia were observed in our hematology ward and all were positive with BDG. Positive results were observed before the documentation of fungemia in 14 patients (51.9%). Although the positive rate of BDG also was 100% in 17 patients with invasive aspergillosis, it rose slightly at an early stage of the disease in 13 patients (76.5%). The determination of plasma BDG appears useful in the monitoring of deep fungal infection, but its usefulness for early diagnosis remains to be determined. The utility of detection of Aspergillus galactomannan by ELISA and fungal DNA by polymerase chain reaction are also discussed.

Topics: Animals; Antifungal Agents; Antigens, Fungal; beta-Glucans; Biomarkers; Galactose; Glucans; Humans; Mannans; Monitoring, Physiologic; Mycoses; Organ Transplantation; Polymerase Chain Reaction; Postoperative Complications

Coil overlap occurs when random coil polysaccharides such as cereal beta-glucan or galactomannan in solution are abundant enough and large enough to entangle with one another to form networks. It was recently shown that this concept applied to

Topics: Adult; beta-Glucans; Blood Glucose; Bread; Cross-Over Studies; Cyamopsis; Dietary Fiber; Digestion; Edible Grain; Flour; Galactose; Humans; Insulin; Mannans; Overweight; Postprandial Period; Starch; Triticum

Patients receiving chemotherapy for acute myeloid leukemia (AML) are at high risk for invasive fungal disease (IFD). Diagnosis of IFD is challenging, leading to interest in fungal biomarkers. The objective was to define the utility of surveillance testing with Platelia Aspergillus galactomannan (GM) enzyme immunoassay (EIA) and Fungitell β-d-glucan (BDG) assay in children with AML receiving antifungal prophylaxis.. Twice-weekly surveillance blood testing with GM EIA and BDG assay was performed during periods of neutropenia in the context of a randomized trial of children, adolescents, and young adults with AML allocated to fluconazole or caspofungin prophylaxis. Proven or probable IFD was adjudicated using blinded central reviewers. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for Platelia and Fungitell assays alone and in combination for the outcomes of proven and probable invasive aspergillosis (IA) or invasive candidiasis (IC).. Among 471 patients enrolled, 425 participants (209 fluconazole and 216 caspofungin) contributed ≥1 blood specimen. In total, 6103 specimens were evaluated, with a median of 15 specimens per patient (range 1-43). The NPV was >99% for GM EIA and BDG assay alone and in combination. However, there were no true positive results, resulting in sensitivity and PPV for each assay of 0%.. The GM EIA and the BDG assay alone or in combination were not successful at detecting IA or IC during periods of neutropenia in children, adolescents, and young adults with AML receiving antifungal prophylaxis. Utilization of these assays for surveillance in this clinical setting should be discouraged.

Topics: Adolescent; beta-Glucans; Child; Galactose; Glucans; Humans; Invasive Fungal Infections; Leukemia, Myeloid, Acute; Mannans; Sensitivity and Specificity; Young Adult

The utility of Aspergillus galactomannan (GM) and β-D-glucan (BG) in liver transplant recipients remains uncertain.. As part of a randomized, double-blind trial of antifungal prophylaxis in liver transplant recipients at risk for invasive fungal infections (IFIs), GM and BG were assessed in 199 patients at baseline (enrollment) and weekly thereafter for the duration of study drug. Receiver operating characteristic (ROC) analysis was used to evaluate the accuracy of these for the diagnosis of IFIs.. Overall, 46.4% of the patients at baseline had positive GM (index ≥ 0.5) and 89.6% had BG of 80 pg/mL or greater with BG level of 500 pg/mL or greater in 31.8%. Patients with invasive aspergillosis (IA) (3/3) had positive GM at baseline as did 45.5% of those without IA (P = 0.098); the area under the ROC curve for the diagnosis of IA was 0.77 (fair test, ie, good sensitivity but poor specificity). Using BG cutoff of 80 pg/mL or higher, 100% (12/12) of the patients with IFI had positive baseline BG and as did 88.9% (160/180) of those without IFI (P = 0.618); the area under the ROC curve for predicting IFIs was 0.56 (poor test). In multivariate analyses, GM positivity was associated with study site (P = 0.041), and BG positivity with renal replacement therapy (P = 0.05) and study site (P = 0.01). The GM and BG levels declined over time; positivity at subsequent time points was lower in comparison with baseline (P < 0.001).. The GM and BG tests had significant center variability and limited accuracy for the diagnosis of IFIs in high-risk liver transplant recipients.

Topics: Adult; Aged; Antifungal Agents; Aspergillosis; beta-Glucans; Double-Blind Method; Female; Follow-Up Studies; Galactose; Humans; Liver Transplantation; Male; Mannans; Middle Aged; Postoperative Complications; Prospective Studies; Proteoglycans; Risk Factors; ROC Curve; Young Adult

Invasive pulmonary aspergillosis has been increasingly reported in nonneutropenic patients, including those with underlying respiratory diseases.. We compared the diagnostic performances of galactomannan, 1,3-β-D-glucan, and Aspergillus-specific lateral-flow device tests with that of conventional culture by using bronchoalveolar lavage fluid samples from patients with underlying respiratory diseases.. We analyzed 268 bronchoalveolar lavage samples from 221 patients with underlying respiratory diseases (and without hematologic malignancy or previous solid organ transplantation) that were collected for routine microbiological workup between February 2012 and May 2014 at the University Hospital of Graz, Austria. Invasive pulmonary aspergillosis was defined according to European Organization of Research and Treatment of Cancer/Mycoses Study Group criteria modified for patients with respiratory diseases.. Thirty-one patients (14%) had probable or proven, 25 possible, and the remaining 165 patients no invasive pulmonary aspergillosis. Probable/proven aspergillosis was associated with a significantly higher (P = 0.034) 30-day mortality rate of 32%. Sensitivities, specificities, and diagnostic odd ratios differed markedly between galactomannan (cut-off 0.5: optical density index, 0.97, 0.81, 124.4; cut-off 1.0: 0.97, 0.93, 422.1; cut-off 3.0: 0.61, 0.99, 109.8), β-D-glucan (cut-off 80 pg/ml: 0.90, 0.42, 6.57; cut-off 200 pg/ml: 0.70, 0.61, 3.7), lateral-flow device tests (0.77, 0.92, 41.8), and mycological culture (0.29, 0.97, 14).. Probable or proven invasive pulmonary aspergillosis was diagnosed in 14% of our study population and associated with significantly higher 30-day mortality rates. Although the performance of β-D-glucan was limited by low specificity and that of mycological culture by low sensitivity, the Aspergillus lateral-flow device seems to be a promising alternative to galactomannan testing, which remains the diagnostic gold standard for aspergillosis. Clinical trial registered with www.clinicaltrials.gov (NCT 02058316).

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Antibodies, Monoclonal; Antigens, Fungal; Aspergillus; beta-Glucans; Bronchoalveolar Lavage Fluid; Cell Culture Techniques; Female; Galactose; Humans; Invasive Pulmonary Aspergillosis; Male; Mannans; Middle Aged; Point-of-Care Systems; Prospective Studies; Proteoglycans; Respiratory Tract Diseases; Retrospective Studies; Sensitivity and Specificity; Young Adult

Galactomannan (GM) and (1, 3)-β-D-glucan (BG) are considered useful seromarkers for the diagnosis of invasive pulmonary aspergillosis (IPA) in patients with neutropenia. However, there is still limited data on these seromarkers for testing non-neutropenic patients who are at the risk of IPA. The aim of this study was to evaluate the value of these two serum antigen assays for the early diagnosis of IPA in patients without neutropenia.. Between January 2011 and December 2012, 97 patients with suspected IPA admitted to the department of respiratory diseases and the respiratory intensive care unit were prospectively monitored. Serum GM and BG assays were performed before the patients received antifungal therapy.. Patients were classified as proven IPA (n=11), probable IPA (n=16), possible IPA (n=4), or non-IPA (n=66). The most common underlying disease of patients with IPA was chronic obstructive pulmonary disease (18.5%), and 22.2% patients with IPA had no known diseases. The sensitivities, specificities, and positive and negative predictive values of the GM and BG assays and at least one positive on both assays were 40.7%/89.4%/61.1%/78.7%, 48.1%/78.8%/48.1%/78.8%, and 70.4%/75.8%/54.3%/86.2%, respectively.. Compared with the testing of neutropenic patients, the serum GM or BG assay alone was less useful for the diagnosis of IPA in non-neutropenic patients. However, at least one positive result of the two serum assays appeared to be useful in the diagnosis of IPA in non-neutropenic patients.

Topics: Adult; Aged; Aged, 80 and over; beta-Glucans; Biomarkers; China; Early Diagnosis; Female; Galactose; Humans; Intensive Care Units; Invasive Pulmonary Aspergillosis; Male; Mannans; Middle Aged; Neutropenia; Proteoglycans; Sensitivity and Specificity; Young Adult

This study was conducted as a prospective, multicenter trial to evaluate the efficacy and safety of micafungin as an empirical therapy for suspected invasive fungal infections (IFIs), including febrile neutropenia (FN), and to evaluate the usefulness of β-D: -glucan (BG) and Aspergillus galactomannan (GM) antigen in patients with hematologic diseases. A total of 121 patients were enrolled and assessed for safety, and 119 were examined for clinical efficacy. The main underlying diseases were acute myeloid leukemia (38.0%), acute lymphoblastic leukemia (18.2%), and malignant lymphoma (18.2%). The median initial daily dose and duration of micafungin treatment were 150 mg/day and 13 days, respectively. The overall response rate for suspected IFIs (n = 119), based on four composite endpoints, including baseline IFI, breakthrough IFIs (proven and probable), survival, and premature discontinuation, was 79.0%. In addition, the response rate for FN (n = 81), based on these four endpoints as well as defervescence during neutropenia, was 39.5%. Breakthrough IFIs (proven, probable, and possible) occurred in five patients during micafungin treatment. All of these patients were positive for either BG or GM before the breakthrough IFIs. The incidence of adverse events (AEs) associated with micafungin was 10.7% and most were mild. The majority of AEs were liver dysfunction. These results indicate the effectiveness and safety of micafungin as an empirical therapy for suspected IFIs, including FN, and the usefulness of monitoring both BG and GM to detect breakthrough IFIs.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Antifungal Agents; Antigens, Bacterial; Aspergillosis; beta-Glucans; Candidiasis, Invasive; Chemical and Drug Induced Liver Injury; Early Diagnosis; Echinocandins; Female; Galactose; Hematologic Neoplasms; Humans; Leukemia, Myeloid, Acute; Lipopeptides; Lymphoma; Male; Mannans; Micafungin; Middle Aged; Mycoses; Precursor Cell Lymphoblastic Leukemia-Lymphoma; Young Adult

The clinical utility of Pastorex Aspergillus, a commercially available circulating aspergillus galactomannan antigen detection kit was evaluated. In animal models of pulmonary aspergillosis, it was extremely sensitive for detection of not only A. fumigatus antigen but also antigens of A. flavus and A. niger both in serum and urine. In a preliminary study in autopsied or clinically proven cases with aspergillus infections a high positive rate of antigen detection was obtained when it was applied prospectively. A total of 1,373 clinical samples obtained from patients with suspected aspergillus infection were examined. Among 67 patients giving antigen-positive results in their clinical samples including serum, urine, sputum and others, 17 patients proved to have aspergillus infection by histological or cultural studies. Sixteen patients were judged to be suspicious of aspergillus infection. Measurement of serum (1 --> 3) beta-D glucan by G-test in these cases was well correlated to the results of the antigen detection test. However, the serum showed often antigen-negative even when it was examined at the peak of illness. The rapid clearance of the antigen from circulation was considered to be one of the reasons for this phenomenon. In these cases, antigen detection in samples other than serum, such as urine, sputum, and pleural fluid was also useful. In conclusion, when using Pastorex Aspergillus to obtain the early diagnosis of aspergillus infection frequent examination in different types of samples is recommended.

Topics: Animals; Antigens, Fungal; Aspergillosis; Aspergillus; beta-Glucans; Galactose; Glucans; Humans; Lung Diseases, Fungal; Mannans; Rats; Reagent Kits, Diagnostic; Serologic Tests

(1-->3)-beta-D-Glucan is one of the major structural components of fungi, and it seems that it can be detected by the fractionated (1-->3)-beta-D-glucan-sensitive component from a Limulus lysate, factor G. We evaluated the concentration of (1-->3)-beta-D-glucan by using factor G and other fungal antigens in 24 patients with clinical evidence of mycosis and 36 healthy subjects. The mean concentration of (1-->3)-beta-D-glucan in the plasma of the healthy subjects was found to be 2.7 +/- 1.9 pg/ml (range, < 6.9 pg/ml), and it was found to be substantially higher in all 11 patients with candidemia (mean, 2,207.4 pg/ml; range, 325.4 to 8,449.0 pg/ml). Eight of those 11 patients with candidemia (73%) were positive for the Cand-Tec heat-labile candida antigen and only 3 patients (27%) were positive for mannan antigen. Three patients with invasive pulmonary aspergillosis were positive for galactomannan and had, in addition, high concentrations of (1-->3)-beta-D-glucan (mean, 323.3 pg/ml; range, 27.0 to 894.0 pg/ml). All 10 patients with cryptococcosis (including 2 patients with probable cryptococcosis) were positive for cryptococcal antigen by the Eiken latex test; however, (1-->3)-beta-D-glucan levels were not elevated in these patients (mean, 7.0 pg/ml; range, < 16.5 pg/ml). Our results indicated that (1-->3)-beta-D-glucan levels are elevated in patients with candidiasis and aspergillosis but not in those with cryptococcosis.

Topics: Adult; Antigens, Fungal; Aspergillosis; beta-Glucans; Candidiasis; Cryptococcosis; Female; Fungemia; Galactose; Glucans; Humans; Limulus Test; Male; Mannans; Middle Aged; Serologic Tests

To evaluate vitreous Galactomannan(GM) and 1,3 β-D-Glucan (BDG) levels in the diagnosis of fungal endophthalmitis, with emphasis on culture-negative cases.. Vitreous from 31 clinically suspected fungal endophthalmitis patients and 11 controls were evaluated for GM and BDG using ELISA Kits. The Receiver Operating Characteristic (ROC) curves and diagnostic significance was calculated.. The median vitreous GM in culture-positive (60.83pg/ml) and culture-negative (59.9pg/ml) samples were higher than the (51.2pg/ml) control group. The median vitreous BDG in culture-positive (1.47pg/ml) and culture-negative (1.52pg/ml) samples were also similar, and higher than the control group (1.18pg/ml). ROC analysis showed that at a cut-off of 51.35pg/ml, the sensitivity and specificity for GM were 0.88 and 0.73.Similarly, for BDG at a cut-off of 1.18pg/ml, the sensitivity and specificity were 0.94 and 0.82 respectively.. Vitreous GM and BDG above the indicated threshold level could suggest a fungal infection, even when cultures are negative.

Topics: beta-Glucans; Endophthalmitis; Eye Infections, Fungal; Glucans; Humans; Mannans; Sensitivity and Specificity

Since February 2021 active screening of COVID-19-associated pulmonary aspergillosis (CAPA) has been implemented in our institution.. To evaluate CAPA incidence in our centre and evaluate performance of our screening protocol.. We screened once per week, collecting endotracheal aspirates for fungal culture and galactomannan (GM) and serum for 1,3-ß-D-glucan (BG). In case of positivity (GM more than 4.5, platelia assay, and/or BG >7 pg/ml, wako and/or positive fungal culture), second-level investigations were performed to pursue CAPA diagnosis according to ECMM/ISHAM criteria: bronchoalveolar lavage (BAL) fungal culture and GM, chest computed tomography (CT), serum GM.. A total of 102 patients were screened (median age 64 years, range 39-79; 28 (27.4%) females). Twenty-two patients were diagnosed with CAPA (21%). 12 patients were positive for serum BG, 17 patients were positive for endotracheal aspirates GM and 27 patients were positive for endotracheal aspirates fungal culture. Thirty-two BALs were performed, and 26 patients underwent CT chest. Following the second level investigations 61% of the patients with positive screening tests were diagnosed with CAPA. Serum BG above 20 pg/ml or positive serum GM were always associated with typical CT chest signs of aspergillosis. Compared with 1 single positive test, having 2 positive screening test was significantly more associated with CAPA diagnosis (p = .0004).. Active CAPA screening with serum 1,3-ß-D-glucan and endotracheal aspirates galactomannan and fungal cultures and consequent second level investigations led to high number of CAPA diagnosis. Combining more positive fungal biomarkers was more predictive of CAPA diagnosis.

Topics: Adult; Aged; beta-Glucans; Bronchoalveolar Lavage Fluid; COVID-19; Female; Humans; Invasive Pulmonary Aspergillosis; Male; Mannans; Middle Aged; Pulmonary Aspergillosis; Sensitivity and Specificity

Opportunistic fungal infections are an important cause of morbidity and mortality in immunocompromised patients. Invasive aspergillosis (IA) has an important place among these infections with ~ 250.000 cases annually. Reducing the mortality rate due to invasive aspergillosis is possible with early diagnosis and treatment of the disease. Because of the low sensitivity in microscopic examination, the time consuming of culture growth, and the difficulties in distinguishing colonization/infection, serological methods are frequently used in the diagnosis of invasive aspergillosis. The aim of this study was to determine the diagnostic performance of galactomannan and beta glucan tests for the diagnosis of invasive pulmonary aspergillosis (IPA). Sixty patients, followed up with the suspicion of invasive pulmonary aspergillosis in Gazi University Hospital were included in the study. The clinical classification of the patients was made according to the revised European Organization for Research and Treatment of Cancer and the Mycoses Study Group (EORTC/MSG) criteria. A total of 10 patients were classified as probable invasive aspergillosis and 20 patients were classified as possible invasive fungal disease. Demographic data of the patients and various risk factors were recorded. One hundred and thirty serum and nine bronchoalveolar lavage (BAL) fluid samples were studied with Plateliaᵀᴹ Aspergillus Ag (Bio-Rad, France), Dynamiker Aspergillus Galactomannan and Dynamiker Fungus (1-3)-beta-D-Glucan (Dynamiker, China) kits. Sensitivity and specificity values were calculated according to U.S. Food and Drug Administration (FDA) approved Plateliaᵀᴹ Aspergillus Ag test. According to this study, the most important risk factors in the development of IPA were the use of steroids and immunomodulatory drugs. The sensitivity of the galactomannan test in the probable group was 77.8%, the specificity was 96.7%, the sensitivity of the beta glucan test was 61.1%, and the specificity was 92.6%. When these two tests were evaluated together, it was observed that the sensitivity in the probable group increased to 83.3% and the specificity decreased to 89.3%. The combined use of galactomannan and beta glucan tests increases the diagnostic sensitivity. Although the presence of prolonged neutropenia is an important risk factor for IA, the use of steroids and immunomodulatory drugs should be kept in mind in non-neutropenic patients.

Topics: Aspergillosis; beta-Glucans; Bronchoalveolar Lavage Fluid; Humans; Immunomodulating Agents; Invasive Pulmonary Aspergillosis; Mannans; Sensitivity and Specificity

Both 1,3-beta-D-glucan (BDG) and galactomannan (GM) are polysaccharide components of the fungal cell wall. Although elevated levels of serum BDG and Aspergillus GM suggest invasive fungal infection or Pneumocystis pneumonia and aspergillosis, respectively, it is also necessary to consider the possibility of false-positives. We herein report a 68-year-old man with marked elevation in serum BDG and GM levels accompanied by Mendelson's syndrome after rice aspiration. With the improvement of Mendelson's syndrome, his serum BDG and GM levels decreased. The false-positive serum BDG and GM findings may have been due to his aspiration of food containing them. It is important to take a detailed history of aspiration in addition to making a conventional differential diagnosis in patients with pneumonia with elevated serum BDG and GM levels.

Topics: Aged; Aspergillus; beta-Glucans; Galactose; Glucans; Humans; Male; Mannans; Oryza; Pneumonia, Aspiration; Pneumonia, Pneumocystis; Sensitivity and Specificity

The incidence of Aspergillus and Candida CNS infection, which are characterised by high mortality rates, is underestimated. This underdiagnosis presumably results from the limitations of available diagnostic tools and the need for invasive sampling. Little is known about the role of serologic biomarkers in the setting of CNS aspergillosis and candidiasis.. Serum and cerebrospinal fluid (CSF; 10) samples of 19 patients, whose CNS specimens yielded growth of Aspergillus or Candida, were analysed for different biomarkers for fungal infection, that is galactomannan (GM), galactomannoprotein (GP), mannan, anti-mannan-antibodies and β-1,3-D-glucan (BDG). Serum and CSF specimens of time-matched patients (two each for every case of fungal CNS infection) were included as controls.. Galactomannan, GP and BDG seropositivity was found in one, two and three of five cases of CNS aspergillosis. BDG and mannan/anti-mannan-antibody sensitivity in proven CNS candidiasis was 40% and 20%, respectively. Applying the serum cut-off, sensitivity in CSF testing was 100% for GM and BDG and 50% for mannans. While serum specificity for all assays ranged from 89 to 97%, specificity for CSF BDG was only 70%. No false-positive GM results from CSF were obtained.. Sensitivity for diagnosing CNS aspergillosis and CNS candidiasis from serum is mediocre for all serological biomarkers. GM testing in CSF proved excellent performance. With a sensitivity of 100% but a specificity of only 70%, CSF BDG might be most useful when used in patients with a high pre-test probability.

Topics: Aspergillosis; Aspergillus; beta-Glucans; Biomarkers; Candida; Candidiasis; Central Nervous System; Galactose; Humans; Mannans; Sensitivity and Specificity

Vast efforts have been devoted to the development of antifungal drugs targeting the cell wall, but the supramolecular architecture of this carbohydrate-rich composite remains insufficiently understood. Here we compare the cell wall structure of a fungal pathogen Aspergillus fumigatus and four mutants depleted of major structural polysaccharides. High-resolution solid-state NMR spectroscopy of intact cells reveals a rigid core formed by chitin, β-1,3-glucan, and α-1,3-glucan, with galactosaminogalactan and galactomannan present in the mobile phase. Gene deletion reshuffles the composition and spatial organization of polysaccharides, with significant changes in their dynamics and water accessibility. The distribution of α-1,3-glucan in chemically isolated and dynamically distinct domains supports its functional diversity. Identification of valines in the alkali-insoluble carbohydrate core suggests a putative function in stabilizing macromolecular complexes. We propose a revised model of cell wall architecture which will improve our understanding of the structural response of fungal pathogens to stresses.

Topics: Alkalies; Antifungal Agents; Aspergillus fumigatus; beta-Glucans; Cell Wall; Chitin; Fungal Proteins; Fungi; Galactose; Gene Deletion; Genomics; Glucans; Magnetic Resonance Spectroscopy; Mannans; Mutation; Polysaccharides

Coronavirus disease 2019 or COVID-19 is a new infectious disease responsible for potentially severe respiratory impairment associated with initial immunosuppression. Similarly to influenza, several authors have described a higher risk of fungal infection after COVID-19, in particular for invasive pulmonary aspergillosis. The main objective here is to define the prevalence of invasive pulmonary aspergillosis (IPA) in a cohort of COVID-19 patients with moderate to severe acute respiratory disease syndrome (ARDS).. We conducted a large monocentric retrospective study investigating all the ventilated COVID-19 patients with ARDS hospitalized at Valenciennes' general hospital, France, between March 15, 2020 and April 30, 2020. In the center a systematic IPA screening strategy was carried out for all ARDS patients, with weekly tests of serum galactomannan and beta-D-glucan. Bronchoalveolar lavage with culture and chest CT scan were performed when the serum assays were positives.. A total of 54 patients were studied. Their median age was 65 years, and 37 of the patients (71%) were male. Two patients had chronic immunosuppression and among all the patients, only 2 non-immunocompromised presented a putative IPA during their stay.. The prevalence of IPA in this cohort of COVID-19 patients (3.7%) is not higher than what is described in the other ARDS populations in the literature. These results are however different from the previous publications on COVID-19 patients and must therefore be confirmed by larger and multicentric studies.

Topics: Adult; Aged; Aged, 80 and over; beta-Glucans; Biomarkers; Comorbidity; COVID-19; Critical Illness; Female; France; Galactose; Hospitals, General; Humans; Immunocompromised Host; Intensive Care Units; Invasive Pulmonary Aspergillosis; Male; Mannans; Middle Aged; Opportunistic Infections; Respiration, Artificial; Respiratory Distress Syndrome; Retrospective Studies; Risk Factors

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.

Topics: Adult; Aspergillosis; beta-Glucans; Child; Galactose; Glucans; Humans; Immunocompromised Host; Mannans; Sensitivity and Specificity

Heterologous endo-xanthanase (EX) from the thermophilic planktomycete Thermogutta terrifontis strain was obtained using Penicillium verruculosum 537 (ΔniaD) expression system with the cellobiohydrolase 1 gene promoter. Homogeneous EX with a molecular weight of 23.7 kDa (pI 6.5) was isolated using liquid chromatography methods. This xanthan degrading enzyme also possesses the enzymatic activity towards CM-cellulose, β-glucan, curdlan, lichenan, laminarin, galactomannan, xyloglucan but not towards p-nitrophenyl derivatives of β-D-glucose, mannose and cellobiose. The temperature and pH optima of EX were 55°C and 4.0, respectively; the enzyme exhibited 90% of its maximum activity in the temperature range 50-60°C and pH 3-5.

Topics: Bacterial Proteins; beta-Glucans; Cellulose; Cloning, Molecular; Galactose; Glucans; Glycoside Hydrolases; Hot Temperature; Hydrogen-Ion Concentration; Mannans; Planctomycetales; Planctomycetes; Substrate Specificity; Talaromyces; Xylans

The prevalence of fungal infection (FI) in developing countries is high, but the diagnosis of FI is still challenging to determine, so it is needed evaluation of biomarkers other than microbiological culture, because the culture has low sensitivity, high cost, not available in every laboratory and needs a long time. The detection of human galactomannan Aspergillus antigen (GAL) and 1,3-beta-D-glucan (BDG) on the fungal cell wall could be the promising biomarkers for fungal infection. Neutropenia, lymphopenia and CD4T cells in the immunocompromised patients are essential factors, but these cell associations with BDG and GAL levels have not been evaluated yet. The study aimed to evaluate GAL and BDG for detecting fungal infection and their association with total leucocyte count, neutrophil, monocyte, lymphocyte and CD4T cells.. A cross-sectional study was conducted among 86 patient with suspected FI. Fungal infection established using EORTC/MSG criteria. Serology test performed using ELISA. Leucocyte cells were measured using a haematology autoanalyser, and CD4T cells were analysed using BD FACSPresto. Statistical analysis obtained using Spearman's correlation coefficient, ROC curve analysis and 2 × 2 contingency table.. Serum Galactomannan and BDG had a significant correlation with CD4T cells and total lymphocyte count (p < 0.05). The cut-off OD GAL >0.3 had sensitivity 54.6%, specificity 87.5% and AUC 0.71; meanwhile, the BDG cut-off >115.78 pg/ mL had sensitivity 71.2%, specificity 52.4% and AUC 0.63 for detecting fungal infection.. The immunocompromised patients can undergo GAL for determining the diagnose of FI. The lower the CD4T cells and total lymphocyte count, the higher the GAL and BDG serum levels.

Topics: Adolescent; Adult; Aged; Antigens, Fungal; Aspergillus; beta-Glucans; Cross-Sectional Studies; Female; Follow-Up Studies; Galactose; Humans; Immunocompromised Host; Male; Mannans; Middle Aged; Mycoses; Prognosis; Young Adult

To assess the utility of galactomannan and beta-D-glucan assays in the diagnosis of invasive aspergillosis in clinically suspected cases, and to compare their diagnostic potential to determine whether a combination of the two may result in an early and specific diagnosis.. The descriptive cross-sectional case-control study was conducted at the Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from April 1, 2017, to March 31, 2018, and comprised serum samples from clinically suspected invasive aspergillosis patients and healthy controls. The sera were tested for galactomannan and beta-D-glucan detection. Proven, probable and possible categories of invasive aspergillosis according to European Organisation for Research and Treatment of Cancer / Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group criteria. Galactomannan antigen was detected using a one-stage immunoenzymatic sandwich microplate assay. Beta-D-Glucan antigen was detected using a protease zymogen-based colorimetric assay. Sensitivity and positive / negative likelihood ratio of both the cases and the controls were calculated and compared.. Of the 178 subjects, 119(67%) were cases and 59(33%) were controls. Beta-D-glucan assay was more sensitive than galactomannan assay (91.6% versus 80.67%) whereas galactomannan assay was more specific than beta-D-glucan assay (86.44% versus 76.27%) in the diagnosis of invasive aspergillosis. The sensitivities of both assays decreased with decreasing probability of invasive aspergillosis, i.e., maximum sensitivities of both beta-D-glucan and galactomannan assays were for proven cases (100% versus 87.5%), followed by probable cases (89.29% versus 85.71%), and possible cases (91.57% versus 78.31%).. Both beta-D-glucan and galactomannan assays seemed to play an encouraging role in the diagnosis of invasive aspergillosis in high-risk clinically suspected cases, with the former assay being more sensitive and the latter assay being more specific.

Topics: Antigens, Fungal; Aspergillosis; Aspergillus; beta-Glucans; Early Diagnosis; Galactose; Humans; Immunoenzyme Techniques; Invasive Fungal Infections; Mannans; Sensitivity and Specificity

Topics: beta-Glucans; Bronchoalveolar Lavage Fluid; Europe; Galactose; Humans; Influenza, Human; Intensive Care Units; Mannans; Proteoglycans; Pulmonary Aspergillosis; Surveys and Questionnaires

Water binding capacity and viscosity of soluble dietary fibers are known to be essential drivers of their nutritional benefits. Phenolic compounds, often found in the presence of dietary fibers, are also known to bind non-covalently with soluble dietary fibers. In this study, we characterized the impact of gallic acid (1-30 mM) on the physical properties of four soluble dietary fibers in solution (0.75% w/w oat β-glucans with medium and high molecular weights, 0.75% w/w guar galactomannan and 0.5% w/w xanthan mannoglucuronoglucan). Isothermal titration calorimetry and particle size analysis showed that gallic acid and soluble dietary fibers formed poorly dissociable non-covalent complexes, leading to colloidal aggregation of the fibers. Upon complexation, the physical properties of the fibers changed dramatically with up to a 65% increase in water mobility (reflecting a dramatic decrease in water binding capacity), up to a 41% increase in pseudo-plastic behavior leading to near-Newtonian behavior, and up to a 95% decrease in viscosity. This suggests that combinations of free phenolic compounds and soluble dietary fibers may be detrimental to the physical and potentially the nutritional properties of the fibers.

Topics: Avena; beta-Glucans; Colloids; Dietary Fiber; Drug Interactions; Galactans; Galactose; Gallic Acid; Humans; Mannans; Molecular Weight; Phenols; Plant Gums; Polysaccharides, Bacterial; Solubility; Viscosity; Water

Even though both cellular and humoral immunities contribute to host defense, the role played by humoral immunity against the airborne opportunistic fungal pathogen

Topics: Aspergillosis; Aspergillus fumigatus; beta-Glucans; Bronchoalveolar Lavage Fluid; Cell Wall; Complement Activation; Complement C3; Cytokines; Fungal Polysaccharides; Galactose; Host Microbial Interactions; Humans; Immunity, Cellular; Immunity, Humoral; Integrin alphaXbeta2; Macrophage-1 Antigen; Macrophages; Mannans; Opsonin Proteins; Phagocytosis; Primary Cell Culture; Protein Binding; Reactive Oxygen Species; Serum; Spores, Fungal

Topics: Adult; Aged; Aged, 80 and over; Antigens, Fungal; Aspergillus fumigatus; beta-Glucans; Bronchoalveolar Lavage Fluid; COVID-19; Critical Illness; Female; Galactose; Humans; Invasive Pulmonary Aspergillosis; Male; Mannans; Middle Aged; Proteoglycans; Real-Time Polymerase Chain Reaction; SARS-CoV-2; United Kingdom

Aspergillus terreus, a fungus commonly used in pharmaceutical industry to produce lovastatin and other secondary metabolites, has been reported to have beneficial biological properties. In this study the exopolysaccharides (AT-EPS) produced by A. terreus were evaluated as potential modulators of certain functions of macrophages. The production parameters for EPS obtained from the liquid culture broth of the studied fungus were optimized using response surface methodology (RSM) and indicated good correlation between the experimental and predicted values. The optimum conditions for AT-EPS extraction included fermentation at 28 °C, pH 8.79, under 98 rpm of agitation, using 2.39% glucose (carbon source) and 0.957% ammonium nitrate (nitrogen source). Under these optimized conditions, AT-EPS production was 1.34 g/L medium. The chemical analyses showed that AT-EPS was composed by mannose (Man; 40.5 mol%), galactose (Gal; 35.2 mol%), and glucose (Glc; 24.3 mol%), and the spectroscopic (FTIR; NMR) and methylation analyses indicated the presence of galactomannans, β-1,3-glucans, and glycogen-like glucans. AT-EPS was tested on murine macrophages to verify its immunoactivity and the treated cells were able to produce nitric oxide, superoxide anion, TNF-α and interleukin 6 similarly to the positive control cells. Furthermore, the macrophages treated with AT-EPS showed activated-like morphological alterations.

Topics: Animals; Aspergillus; beta-Glucans; Carbon; Culture Media; Fermentation; Galactose; Gas Chromatography-Mass Spectrometry; Glucose; Glycogen; Hydrogen-Ion Concentration; Interleukin-1; Macrophages; Macrophages, Peritoneal; Magnetic Resonance Spectroscopy; Male; Mannans; Methylation; Mice; Nitric Oxide; Polysaccharides; Spectroscopy, Fourier Transform Infrared; Superoxides; Temperature; Tumor Necrosis Factor-alpha

To study the prevalence, risk factors, role of serum biomarkers for diagnosis and impact of invasive fungal infections (IFIs) in patients with acute-on-chronic liver failure (ACLF).. An analysis of IFI in patients with ACLF (EASL criteria) was conducted retrospectively. The diagnosis of IFI in clinically suspected patients was based on EORTC/MSG criteria. The demographical, clinical, laboratory details and outcomes were analysed.. Out of 264 patients with ACLF, 54 (20.4%) patients with suspicion of IFI were evaluated and IFI was diagnosed in 39 (14.7%). Invasive candidiasis was documented in 25 (64.1%) and invasive aspergillosis in 14 (35.8%). The most common source of infection was respiratory (n = 13) followed by renal (n = 7) and spontaneous fungal peritonitis (n = 6). On univariate analysis, diabetes mellitus, hemodialysis, prior antibiotic use, cerebral and respiratory organ failures, Chronic Liver Failure Consortium (CLIF-OF and CLIF-C ACLF) scores were predictors for development of IFI (P < 0.05). On multivariate analysis, hemodialysis and prior antibiotics use predicted the development of IFI (P < 0.05). Non-survivors were more likely to have IFI (P = 0.029), high CLIF-OF and CLIF-C ACLF scores (P < 0.001; for both) and higher 1,3-β D Glucan (BDG) levels (P = 0.009). The sensitivity, specificity, and AUROC of BDG (80 pg/mL) and Galactomannan index (GMI [0.5]) for diagnosing IFI were 97.4%, 60%, 0.770% and 43.6%, 100%, 0.745 respectively.. Invasive fungal infections constitutes an important cause of mortality in ACLF patients. BDG and GMI can be useful markers to guide antifungal therapy in patients at high risk for IFI.

Topics: Acute-On-Chronic Liver Failure; Adult; Aged; Antifungal Agents; beta-Glucans; Biomarkers; Female; Galactose; Humans; India; Invasive Fungal Infections; Male; Mannans; Middle Aged; Predictive Value of Tests; Prevalence; Prognosis; Proteoglycans; Retrospective Studies; Risk Assessment; Risk Factors

Immunofluorescence microscopy is a powerful technique to detect surface antigens and study their distribution. Analysis of fungi is often hampered by their weak adherence to glass. We therefore established a novel immunofluorescence staining method to overcome this problem.. Fungal material from colonies is bound to adhesive tape and stained with antibodies.. The obtained samples had very good optical quality, showing low unspecific background staining and allowing analysis by confocal laser scanning microscopy. We have exemplified applying the new method to study the distribution of galactomannan on conidiophores of Aspergillus fumigatus and of β-glucans on Malassezia pachydermatis.. Tape mount immunostaining facilitates analysis of fungal surface molecules and provides a base for expeditious diagnostic procedures.

Topics: Adhesives; Aspergillus fumigatus; beta-Glucans; Fluorescent Antibody Technique; Galactose; Humans; Malassezia; Mannans; Staining and Labeling

The fungal cell wall is a complex and dynamic entity essential for the development of fungi. It is composed mainly of polysaccharides that are synthetized by protein complexes. At the cell wall level, enzyme activities are involved in postsynthesis polysaccharide modifications such as cleavage, elongation, branching, and cross-linking. Glycosylphosphatidylinositol (GPI)-anchored proteins have been shown to participate in cell wall biosynthesis and specifically in polysaccharide remodeling. Among these proteins, the DFG family plays an essential role in controlling polar growth in yeast. In the filamentous fungus and opportunistic human pathogen

Topics: Aspergillus fumigatus; beta-Glucans; Cell Wall; Chitin; Fungal Proteins; Galactose; Gene Deletion; Glycosylphosphatidylinositols; Mannans; Proteoglycans; Virulence

Detection of serum galactomannan (GM) and (1,3)-β-d-glucan (BG) is considered useful for non-culture diagnosis of invasive pulmonary aspergillosis (IPA) in neutropenic patients. Only few studies evaluated these seromarkers in non-neutropenic patients suspected of having IPA. The aim of this study was to evaluate both tests together with the Aspergillus fumigatus-specific serum IgG and IgA (IgAG) test for serological IPA diagnosis in non-neutropenic patients. Sera from 87 patients suspected of having IPA were retrospectively analysed. Patients were categorised into groups of proven IPA (n = 10), putative IPA (n = 31) and non-IPA colonisation (n = 46). When the GM, BG and IgAG assays were used for patients included in the study, the sensitivity/specificity/positive predictive value (PPV)/negative predictive value (NPV) were 48.8%/91.3%/83.3%/66.7%, 82.9%/73.9%/73.9%/82.9% and 75.6%/95.7%/93.9%/81.5%, respectively. Thus, the highest specificity and PPV were confirmed for the IgAG assay. Improvements in the sensitivity and NPV were achieved by "at least one positive" analysis with the GM and BG assays, with the sensitivity/specificity/PPV/NPV values being 85.0%/69.6%/71.4%/84.2%. Nevertheless, the highest sensitivity and NPV were achieved by the "at least one positive" analysis combining the GM, BG and IgAG tests (97.6% and 96.8%, respectively). The involvement of the IgAG assay could improve IPA diagnosis in non-neutropenic patients by increasing the sensitivity and NPV when combined with the GM or BG assays. Furthermore, improvement was achieved by combining the GM, BG and IgAG assays using the "at least one positive test" strategy, especially if doubt exists.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Antibodies, Fungal; Aspergillus fumigatus; beta-Glucans; Female; Galactose; Humans; Immunoglobulin A; Immunoglobulin G; Invasive Pulmonary Aspergillosis; Male; Mannans; Middle Aged; Predictive Value of Tests; Proteoglycans; Retrospective Studies; Sensitivity and Specificity; Serum; Young Adult

We prospectively evaluated a combination of fungal biomarkers in adult haematology patients with focus on their clinical utility at different time points during the course of infection. In total, 135 patients were monitored once to twice weekly for serum (1-3)-ß-d-glucan (BG), galactomannan (GM), bis-methyl-gliotoxin and urinary d-arabinitol/l-arabinitol ratio. In all, 13 cases with proven or probable invasive fungal disease (IFD) were identified. The sensitivity of BG and GM at the time of diagnosis (TOD) was low, but within 2 weeks from the TOD the sensitivity of BG was 92%. BG >800 pg/mL was highly specific for IFD. At a pre-test probability of 12%, both BG and GM had negative predictive values (NPV) >0.9 but low positive predictive values (PPV). In a subgroup analysis of patients with clinically suspected IFD (pre-test probability of 35%), the NPV was lower, but the PPV for BG was 0.86 at cut-off 160 pg/mL. Among IFD patients, 91% had patterns of consecutively positive and increasing BG levels. Bis-methyl-gliotoxin was undetectable in 15 patients with proven, probable and possible IA. To conclude, BG was the superior fungal marker for IFD diagnosis. Quantification above the limit of detection and graphical evaluation of the pattern of dynamics are warranted in the interpretation of BG results.

Topics: Adolescent; Adult; Aged; beta-Glucans; Biomarkers; Diagnostic Tests, Routine; Female; Galactose; Gliotoxin; Hematologic Diseases; Humans; Invasive Fungal Infections; Male; Mannans; Middle Aged; Prospective Studies; Proteoglycans; Sensitivity and Specificity; Serum; Sugar Alcohols; Urinalysis; Young Adult

Aspergillus fumigatus is frequently encountered in sputum samples of patients with cystic fibrosis (CF), which traditionally has been interpreted as saprophytic airway colonization. However, this mere bystander role has been challenged by recent data. There is now evidence that Aspergillus fumigatus accelerates the decline of pulmonary function. (1→3)-β-D-glucan (BDG) and galactomannan (GM) are highly sensitive fungal biomarkers that are used to diagnose invasive fungal disease. However, their diagnostic value in CF patients is largely unknown.. We conducted a retrospective cohort study on 104 CF patients to determine whether serum BDG and GM levels correlate with parameters such as Aspergillus-positive sputum cultures and lung function.. Aspergillus fumigatus was persistently detected in 22 of the 104 CF patients (21%). Mean serum BDG and GM levels in the Aspergillus-positive patients were significantly higher than in those without persistent Aspergillus detection (89 versus 40 pg/ml [p = 0.022] and 0.30 versus 0.15 ODI [p = 0.013], respectively). 27 and 7 patients had elevated BDG (≥ 60 pg/ml) or GM levels (> 0.5 ODI), respectivly. BDG and GM levels showed a significant correlation (p = 0.004). Patients with increased serum concentrations of BDG were more frequently Aspergillus-positive (40.7 versus 14.3%, p = 0.004) and had a significantly lower forced expiratory volume in one second (FEV1) than patients with a normal BDG (61.6 versus 77.1%, p = 0.007). In the multivariate analysis, BDG but not GM or the growth of A. fumigatus, proved to be an independent predictor for the FEV1.. CF patients with persistent Aspergillus detection have elevated BDG and GM levels which ranged between healthy and invasively infected patients. Serum BDG may be superior to GM and fungal culture in predicting an impaired lung function in CF patients.

Topics: Adolescent; Adult; Aspergillus fumigatus; beta-Glucans; Case-Control Studies; Child; Child, Preschool; Cohort Studies; Culture Techniques; Cystic Fibrosis; Female; Forced Expiratory Volume; Galactose; Humans; Male; Mannans; Middle Aged; Multivariate Analysis; Proteoglycans; Pulmonary Aspergillosis; Retrospective Studies; Sputum; Young Adult

Invasive pulmonary aspergillosis (IPA) is an emerging and life-threatening infectious disease in patients admitted to the intensive care unit (ICU). Most diagnostic studies are conducted in hematological patients and results cannot readily be transferred to ICU patients lacking classical host factors. In a multicenter, prospective clinical trial including 44 ICU patients, hematological (n = 14) and non-hematological patients (n = 30), concurrent serum and bronchoalveolar lavage (BAL) samples were analyzed by conventional culture, galactomannan (GM), 1-3-beta-D-glucan (BDG) as well as an Aspergillus specific nested polymerase chain reaction (PCR). Nine patients (20%) had putative IPA according to AspICU classification. GM and PCR showed superior performance in BAL with sensitivity/specificity of 56%/94% and 44%/94% compared to 33%/97% and 11%/94% in serum. Despite better sensitivity of 89%, BDG showed poor specificity of only 31% (BAL) and 26% (serum). Combination of GM and PCR (BAL) with BDG (serum) resulted in 100% sensitivity, but also reduced specificity to 23%. Whereas mean GM levels were significantly higher in hematological patients BDG and PCR did not differ between hematological and non-hematological patients. Under present clinical conditions test combinations integrating both BAL and blood samples are advantageous. BDG might best serve as possible indicator for ruling out IPA.. ClinicalTrials.gov Identifier: NCT01695499. First posted: September 28, 2012, last update posted: May 8, 2017.

Topics: Adult; Aged; Aged, 80 and over; Aspergillus; beta-Glucans; Bronchoalveolar Lavage Fluid; Critical Illness; Diagnostic Tests, Routine; Galactose; Humans; Invasive Pulmonary Aspergillosis; Male; Mannans; Middle Aged; Pilot Projects; Polymerase Chain Reaction; Prospective Studies; Young Adult

We evaluated the usefulness of an

Topics: Aged; Aged, 80 and over; Aspergillus; beta-Glucans; Bronchoalveolar Lavage Fluid; Diagnostic Tests, Routine; Female; Galactose; Humans; Immunoassay; Male; Mannans; Middle Aged; Polymerase Chain Reaction; Predictive Value of Tests; Proteoglycans; Pulmonary Aspergillosis; Sensitivity and Specificity

Aspergillus is a medically important fungal genus that causes a life-threatening infection known as aspergillosis in immunocompromised patients. β-1,3-Glucan is detected in the plasma of patients with aspergillosis and appears to be useful for the diagnosis of aspergillosis. In this study, we cultured Aspergillus spp. in a chemically defined liquid medium and prepared an Aspergillus water-soluble fraction (ASWS) from the culture supernatants. ASWS was found to be primarily composed of polysaccharides and proteins. Nuclear magnetic resonance analysis suggested that ASWS is a complex carbohydrate, consisting of α-1,3-glucan, β-1,3-glucan, galactomannan, and protein. The ASWS from Aspergillus fumigatus showed limulus factor G activity, whereas zymolyase-treated ASWS did not. ASWS was eliminated from the blood more rapidly than Aspergillus solubilized cell wall β-glucan. We analyzed the reactivity of human immunoglobulin towards ASWS by an enzyme-linked immunosorbent assay. Anti-ASWS antibodies were detected in human sera, with titers differing among individuals. This study demonstrated that the ASWS corresponds to the limulus factor G-activating substance found in the blood of patients with aspergillosis.

Topics: Animals; Antibodies, Fungal; Aspergillosis; Aspergillus fumigatus; beta-Glucans; Biomarkers; Fungal Proteins; Galactose; Glucans; Humans; Immunoglobulins; Male; Mannans; Mice, Inbred DBA; Solubility; Water

The relationship among (1,3)-β-D-glucans (BG), galactomannan (GM), and the risk of developing invasive fungal infections (IFI) has been observed in adult ICU and in children with hematological malignancies. Only scant data evaluated the value of BG/GM assays for diagnosis of IFI in patients with nonhematological diseases in pediatric intensive care unit (PICU). In this study, we assessed the diagnostic value of these markers for IFI in PICU. The records of 230 patients were retrospectively evaluated. Out of 117 patients (7 proven, 23 probable, and 87 cases without evidence of IFI) performed GM and BG assays. The results showed many factors were associated with false-positive test results. Patients who aged over 3 years had higher levels of GM and BG than younger infants. The levels of BG were higher in subjects with dairy, human blood products, antibiotics, and corticosteroids therapy than in cases without these treatments. Unlike BG assay, GM assay was less susceptible to above-mentioned factors expect blood products. The levels of BG and GM in IFI cases were dramatically higher than in controls. The diagnostic performance of these assays showed that GM assay had better results when compared with BG assay. On the whole, negative predictive value in both GM and BG assays was dramatically higher than other diagnostic parameters. In conclusion, BG assay was highly susceptible to many factors, and GM assay could be useful for diagnosis of IFI for its high sensitivity, but the over benefit of this assay limited in its inadequate specificity. The comparative advantage of BG and BG assays lied in excluding IFI in non-hematological PICU patients.

Topics: Antigens, Fungal; beta-Glucans; Diagnostic Tests, Routine; Female; Galactose; Humans; Infant; Intensive Care Units, Pediatric; Invasive Fungal Infections; Male; Mannans; Predictive Value of Tests; Proteoglycans; Retrospective Studies; Sensitivity and Specificity

Limited specific data and investigations are available for the diagnosis of Invasive Fungal Infection (IFI) in paediatrics cancer patients. Three non-invasive tests; Platelia Aspergillus EIA for galactomannan (GM), β-D-glucan (BDG) assay and pan-fungal real-time PCR for fungal DNA in blood were evaluated. One hundred twenty-five paediatrics cancer patients at the high risk of IFI were enrolled. Single blood and serum samples were evaluated by all the three methods. Patients were classified into 10 proven, 52 probable and 63 no IFI cases in accordance with EORTC MSG 2008 revised guidelines. The sensitivity, specificity, PPV and NPV of all the three tests in proven, probable and no IFIs cases were analysed singly and in combination. The sensitivity, specificity, PPV and NPV of GM, BDG and pan-fungal real-time PCR were: 87%, 61%, 81%, 69.5% for GM, 88%, 59.5%, 81%, 71.4% for BDG and 89%, 69.2%, 85%, 67.5% for PCR (95% CI). Among different combinations, best combination was found to be GM and PCR with sensitivity, specificity, PPV and NPV of 98.2%, 89.3%, 97.1% and 90% respectively. Single samples must be evaluated by combination of tests.

Topics: Adolescent; Antigens, Fungal; beta-Glucans; Child; Child, Preschool; DNA, Fungal; Fungi; Galactose; Humans; Immunoassay; Infant; Invasive Fungal Infections; Male; Mannans; Neoplasms; Patients; Real-Time Polymerase Chain Reaction; Sensitivity and Specificity

The value of (1 → 3)-beta-D-glucans (BG) and galactomannan (GM) assays on diagnostic invasive fungal infections (IFIs) has been observed in adult ICU and in children with hematological malignancies. Only scant data evaluated non-hematological in pediatric intensive care unit (PICU). Here, we retrospectively analyzed the role of bacterial infection to the reactivity of BG and GM assays in PICU. The results showed that the overall prevalence of bacteremia was 13.8% (65/470). The most common underlying disease was pneumonia (81.8%), followed by congenital heart disease (43.2%). The median levels of GM and range for each group [A: without bacterial infection nor IFIs (n = 151); B, patients with bacterial infection (n = 36); C, patients with bacterial infection and IFIs (n = 8)] were, respectively: 0.14 (0.01-1.34), 0.21 (0.06-1.34), 0.14 (0.02-0.99). No significant difference was found among three groups (P = 0.66). The median levels of BG and range for each group (A, B, C) were, respectively: 50.00 pg/mL (16.20-548.20 pg/mL), 50.00 pg/mL (16.10-597.60 pg/mL), 268.7 pg/mL (50.9-4224.00 pg/mL). Patients with bacteremia and IFIs showed significantly higher BG levels than these who with or without bacteremia (P = 0.003), but there was no significant difference between control subjects and patients with bacteremia group. We also observed the GM and BG levels in Gram-negative and Gram-positive groups. No significant difference was found between two groups. In conclusions, the results showed that bacteremia was unlikely cause of false-positive results of the BG and GM assays in PICU.

Topics: Bacteremia; beta-Glucans; Child; Child, Preschool; Female; Galactose; Humans; Infant; Intensive Care Units, Pediatric; Invasive Fungal Infections; Male; Mannans; Retrospective Studies

Topics: Antigens, Fungal; beta-Glucans; False Positive Reactions; Food; Galactose; Glucans; Glucocorticoids; Graft vs Host Disease; Hematopoietic Stem Cell Transplantation; Humans; Invasive Fungal Infections; Kelp; Male; Mannans; Methylprednisolone; Middle Aged; Proteoglycans; Sezary Syndrome; Tomography, X-Ray Computed; Transplantation Conditioning

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.

Topics: Aged; Amphotericin B; Antifungal Agents; Aspergillosis; Aspergillus fumigatus; beta-Glucans; Clarithromycin; Coinfection; Critical Illness; Extracorporeal Membrane Oxygenation; Galactose; Hematopoietic Stem Cell Transplantation; Humans; Immunocompromised Host; Linezolid; Male; Mannans; Meropenem; Pneumonia; Pseudallescheria; Severe Acute Respiratory Syndrome; Thienamycins; Transplant Recipients; Voriconazole

We investigated the clinical performance of (1 → 3)-β-D-glucan (BG), as an early marker of invasive fungal infections (IFI), in different clinical settings.. BG serum levels were assessed by Fungitell (Associates of Cape Cod, Inc), in parallel with galactomannan (GM) when requested by clinicians. By a prospective monocentric study, 270 episodes at risk or with suspect of IFI were enrolled, namely 58 proven-probable invasive aspergillosis (IA), 27 proven invasive candidiasis (IC), 11 possible IC, 16 P.jirovecii pneumonia (PJP), 4 episodes of other IFI and 154 non-IFI controls.. We found that (a) the BG overall sensitivity, specificity, positive predictive value and negative predictive value (NPV) were 87.9, 80.5, 76.7 and 89.9 %, respectively; (b) the highest sensitivity was found in the IC groups, followed by PJP, IA and other IFI groups; (c) an association was observed between BG kinetics and patients outcome; (d) in the IA episodes, the combination of BG or GM vs GM alone increased sensitivity from 60.0 to 83.3 % in the haematological patients; (e) false-positive BG results were related to Gram-negative infections or infusion of polyclonal IgM-enriched immunoglobulins, where high levels of BG were indeed detected.. Besides strengthening its overall good clinical performance, we provide evidence that serum BG correlates with clinical outcome and that, once used in combination with GM, BG allows to enhance IFI diagnosis rate. The high sensitivity and NPV, observed in the Intensive Care Unit setting, open to BG validation as a marker for assessment of antifungal treatment.

Topics: Adult; Aged; Aged, 80 and over; Antigens, Fungal; beta-Glucans; Female; Fungemia; Galactose; Humans; Male; Mannans; Middle Aged; Predictive Value of Tests; Prospective Studies; Proteoglycans; Sensitivity and Specificity; Serum; Young Adult

The EuropeanAspergillusPCR Initiative (EAPCRI) has provided recommendations for the PCR testing of whole blood (WB) and serum/plasma. It is important to test these recommended protocols on nonsimulated "in vivo" specimens before full clinical evaluation. The testing of an animal model of invasive aspergillosis (IA) overcomes the low incidence of disease and provides experimental design and control that is not possible in the clinical setting. Inadequate performance of the recommended protocols at this stage would require reassessment of methods before clinical trials are performed and utility assessed. The manuscript describes the performance of EAPCRI protocols in an animal model of invasive aspergillosis. Blood samples taken from a guinea pig model of IA were used for WB and serum PCR. Galactomannan and β-d-glucan detection were evaluated, with particular focus on the timing of positivity and on the interpretation of combination testing. The overall sensitivities for WB PCR, serum PCR, galactomannan, and β-d-glucan were 73%, 65%, 68%, and 46%, respectively. The corresponding specificities were 92%, 79%, 80%, and 100%, respectively. PCR provided the earliest indicator of IA, and increasing galactomannan and β-d-glucan values were indicators of disease progression. The combination of WB PCR with galactomannan and β-d-glucan proved optimal (area under the curve [AUC], 0.95), and IA was confidently diagnosed or excluded. The EAPRCI-recommended PCR protocols provide performance comparable to commercial antigen tests, and clinical trials are warranted. By combining multiple tests, IA can be excluded or confirmed, highlighting the need for a combined diagnostic strategy. However, this approach must be balanced against the practicality and cost of using multiple tests.

Topics: Animals; beta-Glucans; Blood; Diagnostic Tests, Routine; Disease Models, Animal; Galactose; Guinea Pigs; Invasive Pulmonary Aspergillosis; Male; Mannans; Molecular Diagnostic Techniques; Polymerase Chain Reaction; Proteoglycans; Sensitivity and Specificity; Time Factors

Invasive pulmonary aspergillosis (IPA) is an important cause of morbidity/mortality in critically ill patients with hematological malignancies. New diagnosis strategies include the noninvasive biomarkers 1,3-beta-D-glucan (BDG) and serum galactomannan (GM).. For early detection of IPA, we compared BDG Fungitell assay with GM Platelia assay.. Twenty-two out of 30 patients (74 %) had elevated BDG levels (mean 306 pg/ml) beyond the cutoff of 80 pg/ml. GM levels were elevated in only 3 patients (10 %) over the ODI cutoff of >0.5. Following the BDG/GM and microbiological findings, 10 (34 %) cases were classified as probable IPA and 12 (40 %) as possible IPA. Eight (26 %) were classified as no IPA. An overall sensitivity of 90 % (95 % CI 86-96 %) and specificity of 85 % (95 % CI 79-86 %) was found for the BDG Fungitell assay in IPA. In contrast, an overall sensitivity of 30 % (95 % CI 26-38 %) and specificity of 98 % (95 % CI 94-100 %) was found for the GM Platelia assay. A false-negative rate of 70 % for probable IPA and 85 % for probable/possible IPA was detected for GM. The false-negative rate for BDG was 0 % in cases of probable IPA and 45 % in cases of possible cases.. BDG is a sensitive marker for patients' surveillance at risk of IPA. In patients with hematological malignancies and septic shock, early diagnosis of IPA might be significantly improved by BDG compared to GM, also considering that BDG has the advantage of detecting fungal diseases other than IPA.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Animals; beta-Glucans; Critical Illness; Diagnostic Tests, Routine; Early Diagnosis; Female; Galactose; Hematologic Neoplasms; Humans; Invasive Pulmonary Aspergillosis; Male; Mannans; Middle Aged; Proteoglycans; Sensitivity and Specificity; Serum; Shock, Septic; Young Adult

Naturally occurring galactomannans were sulfated to give sulfated galactomannans with degrees of substitution of 0.7-1.4 per sugar unit and molecular weights of M¯n=0.6×10(4)-2.4×10(4). Sulfated galactomannans were found to have specific biological activities in vitro such as anticoagulant, anti-HIV and anti-Dengue virus activities. The biological activities were compared with those of standard dextran and curdlan sulfates, which are polysaccharides with potent antiviral activity and low cytotoxicity. It was found that sulfated galactomannans had moderate to high anticoagulant activity, 13.4-36.6unit/mg, compared to that of dextran and curdlan sulfates, 22.7 and 10.0unit/mg, and high anti-HIV and anti-Dengue virus activities, 0.04-0.8μg/mL and 0.2-1.1μg/mL, compared to those curdlan sulfates, 0.1μg/mL, respectively. The cytotoxicity on MT-4 and LCC-MK2 cells was low. Surface plasmon resonance (SPR) of sulfated galactomannans revealed strong interaction with poly-l-lysine as a model compound of virus proteins, and suggested that the specific biological activities might originate in the electrostatic interaction of negatively charged sulfate groups of sulfated galactomannans and positively charged amino groups of surface proteins of viruses. These results suggest that sulfated galactomannans effectively prevented the infection of cells by viruses and the degree of substitution and molecular weights played important roles in the biological activities.

Topics: Anticoagulants; Antiviral Agents; beta-Glucans; Dengue; Dengue Virus; Galactose; HIV; HIV Infections; Humans; Mannans; Polylysine; Sulfates

A critical challenge for the successful application of antifungal therapies for invasive aspergillosis (IA) is a lack of reliable biomarkers to assess early treatment response. Patients with proven or probable IA were prospectively enrolled, and serial blood samples were collected at 8 specified time points during 12-week antifungal therapy. Total nucleic acid was extracted from 2.5 ml blood and tested for Aspergillus-specific RNA by a pan-Aspergillus real-time nucleic acid sequence-based amplification (NASBA) assay. Serum 1, 3-β-D-glucan (BG) and galactomannan (GM) were measured in parallel. Clinical outcome was evaluated at 6 and 12 weeks. Overall, 48/328 (14.6%) blood samples from 29/46 (63%) patients had positive NASBA detection at baseline and/or some point during the study. Positive NASBA results during the first 4 and 6 weeks of treatment are significantly associated with the 12-week outcome. Blood RNA load change during weeks 4-6 may be informative to predict outcome at 12 weeks. While independent of serum GM, the kinetic change of circulating Aspergillus RNA appears to be well correlated with that of BG on some patient individuals. Monitoring blood Aspergillus RNA during the first 4-6 weeks of antifungal treatment may help assess therapeutic response. Combination of circulating Aspergillus RNA and BG may be a useful adjunct to assess response.

Topics: Antifungal Agents; Aspergillus; beta-Glucans; Biomarkers; Drug Monitoring; Galactose; Humans; Invasive Pulmonary Aspergillosis; Mannans; Nucleic Acid Amplification Techniques; Prognosis; Prospective Studies; Proteoglycans; RNA, Fungal; Time Factors; Treatment Outcome

High mortality rates of invasive fungal disease (IFD), especially invasive aspergillosis (IA), in immunocompromised haematological patients and current diagnostic limitations require improvement of detection of fungal pathogens by defining the optimal use of biomarkers and clinical samples. Concurrent bronchoalveolar lavage (BAL) and peripheral blood samples of 99 haematological patients with suspected IFD were investigated within a multicentre prospective study. Diagnostic performance of a galactomannan (GM) enzyme immune assay (EIA), a 1,3-β-D-glucan assay (BDG), an Aspergillus PCR, and a multifungal DNA-microarray (Chip) alone or in combination were calculated. IFD were classified as proven (n=3), probable (n=34), possible (n=33), and no IFD (n=29) according to EORTC/MSG criteria. GM, PCR, and Chip showed superior diagnostic performance in BAL than in blood, whereas specificity of BDG in BAL was poor (48% (14/29)). The combination of GM (BAL) with BDG (blood) showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and DOR (diagnostic odds ratio) of 92% (34/37), 93% (27/29), 94%, 90%, and 153.0, respectively. Combining GM (BAL) with PCR (BAL) showed convincing diagnostic potential for diagnosing IA with sensitivity, specificity, PPV, NPV, and DOR of 85% (17/20), 97% (28/29), 94%, 90%, and 158.7. Addition of the DNA-microarray resulted in further detection of two mucormycetes infections. In 1 out of 15 Aspergillus DNA-positive samples a triazole resistance-mediating Cyp51A mutation was found. Combination of biomarkers is superior to their sole use in diagnosing IFD, particularly IA. Integrating blood and BAL samples into a diagnostic algorithm is an advantageous approach.

Topics: Aspergillosis; Aspergillus; Azoles; beta-Glucans; Bronchoalveolar Lavage Fluid; Galactose; Humans; Invasive Fungal Infections; Mannans; Microbiological Techniques; Molecular Diagnostic Techniques; Multiplex Polymerase Chain Reaction; Oligonucleotide Array Sequence Analysis; Prospective Studies; Sensitivity and Specificity

Invasive pulmonary aspergillosis (IPA) is an important cause of morbidity/mortality in immunocompromised critically ill patients. New diagnostic strategies for early detection of IPA include the noninvasive biomarkers 1,3-β-d-glucan (BDG), serum, and bronchoalveolar (BAL) fluid galactomannan (GM). The aim of this study was to compare these markers for early detection of IPA in immunosuppressed critically ill patients.. Between December 2014 and December 2015, 49 immunosuppressed patients with respiratory failure were treated at our intensive care unit (ICU). We compared the BDG Fungitell assay with GM Platelia assay in serum and BAL for early detection of IPA. All tests were performed initially after admission at the ICU.. In our study with 49 patients, 13 (26%) had probable IPA. These patients had a higher Acute Physiology And Chronic Health Evaluation II score (28 vs 23, P<.001), Sequential Organ Failure Assessment score (16 vs 14, P<.001), more neutropenia (77% vs 30%, P<.001), worse Horowitz Index (99 vs 73 P<.020), a longer ICU stay (26 vs 17 days, P<.044), and a higher mortality rate (77% vs 58%, P<.001) as compared with patients without probable IPA. The used biomarker BDG presented in patients with probable IPA showed significantly higher levels as compared with patients without probable IPA (375 [103-1000 pg/mL; P<.001] vs 64 [30-105 pg/mL; P < .001]). Comparison of BDG with GM showed that positive serum GM could be detected in only 4 (30%), whereas positive BAL GM could be detected in 12 (92%; mean optical density index, 3.7) of 13 probable IPA cases. These results can be expressed as an overall sensitivity of 88% and a specificity of 82% for probable IPA using the BDG Fungitell assay, a sensitivity of 35% and a specificity of 70% using the serum GM Platelia assay, and a sensitivity of 70% and a specificity of 94% using the BAL GM Platelia assay. The negative predictive values of the used tests were 94% for the BDG Fungitell assay, 94% for the serum GM Platelia assay, and 90% for the BAL GM Platelia assay.. 1,3-β-d-Glucan may be a useful marker for patients under surveillance at risk for IPA. In critically ill patients with immunosuppression, early diagnosis of IPA may be improved by BDG as compared with serum GM. However, diagnostic performance and accuracy increase when BDG is run in parallel with GM from BAL; moreover, the association of the 2 parameters has also the advantage of detecting early and reliable IPA.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Antineoplastic Agents; APACHE; Aspergillus; Autoimmune Diseases; beta-Glucans; Biomarkers; Bronchoalveolar Lavage Fluid; Critical Illness; Early Diagnosis; Female; Galactose; Graft Rejection; Humans; Immunocompromised Host; Immunosuppressive Agents; Intensive Care Units; Invasive Pulmonary Aspergillosis; Length of Stay; Male; Mannans; Middle Aged; Mortality; Neoplasms; Neutropenia; Organ Dysfunction Scores; Organ Transplantation; Respiration, Artificial; Respiratory Insufficiency; Retrospective Studies; Sensitivity and Specificity; Young Adult

Topics: Aspergillus; beta-Glucans; Critical Illness; Galactose; Glucans; Humans; Mannans

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.

Topics: Aspergillus; beta-Glucans; Biomarkers; Bronchoalveolar Lavage Fluid; DNA, Fungal; Galactose; Humans; Immunologic Deficiency Syndromes; Invasive Pulmonary Aspergillosis; Mannans; Polymerase Chain Reaction

Echinocandins inhibit β-1,3-glucan synthesis and are one of the few antimycotic drug classes effective against Aspergillus spp. In this study, we characterized the β-1,3-glucan synthase Fks1 of Aspergillus fumigatus, the putative target of echinocandins. Data obtained with a conditional mutant suggest that fks1 is not essential. In agreement, we successfully constructed a viable Δfks1 deletion mutant. Lack of Fks1 results in characteristic growth phenotypes similar to wild type treated with echinocandins and an increased susceptibility to calcofluor white and sodium dodecyl sulfate. In agreement with Fks1 being the only β-1,3-glucan synthase in A. fumigatus, the cell wall is devoid of β-1,3-glucan. This is accompanied by a compensatory increase of chitin and galactosaminogalactan and a significant decrease in cell wall galactomannan due to a massively enhanced galactomannan shedding. Our data furthermore suggest that inhibition of hyphal septation can overcome the limitations of echinocandin therapy. Compounds inhibiting septum formation boosted the antifungal activity of caspofungin. Thus, development of clinically applicable inhibitors of septum formation is a promising strategy to improve existing antifungal therapy.

Topics: Antifungal Agents; Aspergillosis; Aspergillus fumigatus; Benzenesulfonates; beta-Glucans; Caspofungin; Cell Wall; Chitin; Echinocandins; Galactose; Glucosyltransferases; Hyphae; Lipopeptides; Mannans; Mutation; Phenotype; Polysaccharides

Fungal peritonitis is an uncommon but serious complication of peritoneal dialysis (PD) due to the fact that routine culture to recovered the etiologic agents are time consuming and KOH staining has very low sensitivity. Peritoneal (1→3)-β-D-glucan (BG) or galactomannan (GM), both fungal cell wall components, are candidate biomarkers of fungal peritonitis. Hence, a comparative cross-sectional analysis of peritoneal dialysis fluid (PDF) BG (Fungitell, Cape Cod, MA, USA) and GM (Platelia Aspergillus Ag kits, Bio-rad, France) from all PD patients with and without fungal peritonitis (13 cases, identified by culture), over a 1 year period, was performed. PDF of the fungal peritonitis group showed very high BG (494 ± 19 pg/ml) and high GM (3.41 ± 1.24) similar results were noted in specimens from cases of peritonitis with other causes, especially gram negative bacterial peritonitis. A BG cut-off value at 240 pg/ml and GM at 0.5 showed sensitivity/ specificity at 100%/ 83% and 77%/ 58%, respectively. A concomitantly positive GM reduced the false positive rate of BG from nonfungal peritonitis. In conclusion, BG and GM in peritoneal fluid with provisional cut-off values were applicable as surrogate biomarkers for the diagnosis of fungal peritonitis in PD patients.

Topics: Adult; Aged; Aged, 80 and over; beta-Glucans; Biomarkers; Cross-Sectional Studies; Dialysis Solutions; Female; Galactose; Humans; Male; Mannans; Middle Aged; Mycoses; Peritoneal Dialysis; Peritonitis; Pilot Projects; Proteoglycans; Sensitivity and Specificity

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.

Topics: Adult; Aged; Antifungal Agents; Aspergillus; beta-Glucans; Biomarkers; Female; Galactose; Humans; Invasive Pulmonary Aspergillosis; Male; Mannans; Middle Aged; Prognosis; Prospective Studies; Survival Analysis; Treatment Outcome

Galactomannan and (1→3)-β-D-glucan are useful biomarkers of invasive pulmonary aspergillosis (IPA). However, the effects of immunosuppression on levels of galactomannan or (1→3)-β-D-glucan in IPA are not well understood or quantified. We therefore studied the simultaneous levels of galactomannan and (1→3)-β-D-glucan in two rabbit models of experimental IPA: (1) AraC-induced neutropenia in untreated (UC-AraC) and liposomal amphotericin B-treated (LAMB-AraC) rabbits; and (2) nonneutropenic cyclosporine-methylprednisolone immunosuppression in untreated (UC-CsA+M) and LAMB-treated (LAMB-CsA+M) rabbits. Simultaneous levels of galactomannan and (1→3)-β-D-glucan were determined in bronchoalveolar lavage (BAL) fluid and serial serum specimens and correlated with pulmonary host response. Serum galactomannan index (GMI) and (1→3)-β-D-glucan concentration-time-curves were higher in UC-AraC vs. UC-CsA+M (Mann-Whitney U-test, P < .05). Serum galactomannan and (1→3)-β-D-glucan in treatment groups demonstrated therapeutic responses with similarly lower levels in comparison to UC (P < .01) in both models. Host differences did not affect BAL fluid GMI or (1→3)-β-D-glucan but did affect galactomannan and (1→3)-β-D-glucan levels in serum. The higher serum GMI and (1→3)-β-D-glucan concentration-time-curves in UC-AraC correlated with extensive pulmonary infiltration by angioinvasive hyphae and minimal inflammation, while the lower concentration-time-curves in UC-CsA+M were associated with shorter and fewer hyphae in lung tissue and an intensive neutrophil response to Aspergillus hyphae. Thus, serum levels of galactomannan and (1→3)-β-D-glucan in IPA depended upon immunosuppression, which also affected severity of infection and hyphal morphology, while BAL fluid galactomannan and (1→3)-β-D-glucan were sensitive biomarkers not affected by host response.

Topics: Animals; Antifungal Agents; beta-Glucans; Bronchoalveolar Lavage Fluid; Disease Models, Animal; Female; Galactose; Host-Pathogen Interactions; Invasive Pulmonary Aspergillosis; Lung; Mannans; Proteoglycans; Rabbits

Candida lusitaniae is usually susceptible to echinocandins. Beta-1,3-glucan synthase encoded by FKS genes is the target of echinocandins. A few missense mutations in the C. lusitaniae FKS1 hot spot 1 (HS1) have been reported. We report here the rapid emergence of antifungal resistance in C. lusitaniae isolated during therapy with amphotericin B (AMB), caspofungin (CAS), and azoles for treatment of persistent candidemia in an immunocompromised child with severe enterocolitis and visceral adenoviral disease. As documented from restriction fragment length polymorphism (RFLP) and random amplified polymorphic DNA (RAPD) analysis, the five C. lusitaniae isolates examined were related to each other. From antifungal susceptibility and molecular analyses, 5 different profiles (P) were obtained. These profiles included the following: profile 1 (P1) (CAS MIC [μg/ml], 0.5; fluconazole [FLC] MIC, 0.25), determined while the patient was being treated with liposomal AMB for 3 months; P2 (FLC MIC [μg/ml], 0.25; CAS MIC, 4), while the patient was being treated with CAS for 2 weeks; P3 (CAS MIC [μg/ml], 0.5; FLC MIC, 32), while the patient was being treated with azoles and CAS initially followed by azoles alone for a week; P4 (CAS MIC [μg/ml], 8; FLC MIC, 8), while the patient was being treated with both drugs for 3 weeks; and P5 (AMB MIC [μg/ml], 0.125; CAS MIC, 8), while the patient was being treated with AMB and FLC for 2 weeks. CAS resistance was associated with resistance not only to micafungin and anidulafungin but also to AMB. Analysis of CAS resistance revealed 3 novel FKS1 mutations in CAS-resistant isolates (S638Y in P2; S631Y in P4; S638P in P5). While S638Y and -P are within HS1, S631Y is in close proximity to this domain but was confirmed to confer candin resistance using a site-directed mutagenesis approach. FLC resistance could be linked with overexpression of major facilitator gene 7 (MFS7) in C. lusitaniae P2 and P4 and was associated with resistance to 5-flurocytosine. This clinical report describes resistance of C. lusitaniae to all common antifungals. While candins or azole resistance followed monotherapy, multidrug antifungal resistance emerged during combined therapy.

Topics: Amino Acid Sequence; Antifungal Agents; beta-Glucans; Candida; Candidiasis; DNA, Fungal; Drug Monitoring; Drug Resistance, Multiple, Fungal; Female; Galactose; Humans; Immunocompromised Host; Infant; Leukemia, Myeloid, Acute; Mannans; Microbial Sensitivity Tests; Molecular Sequence Data; Mutation; Polymorphism, Restriction Fragment Length

To evaluate the clinical value of serum 1,3-beta-D-glucan (BG) and galactomannan (GM) detection for early diagnosis of invasive aspergillosis (IA) in patients after renal transplantation.. Blood samples collected from 69 renal transplant recipients were divided into diagnosis group, clinical diagnosis group, suspected diagnosis group, and non-infected group for detection of serum BG and GM.. The mean serum levels of BG in the diagnosis group, clinical diagnosis group, and suspected diagnosis group were significantly higher than that in non-infected group (P<0.05). The sensitivity, specificity, and positive and negative predictive values of BG was 69.49%, 70%, 93.18% and 35.71% for IA diagnosis, respectively. The serum levels of GM in the 3 diagnosis groups were also significantly higher than that in the non-infected group (P<0.05) with the sensitivity, specificity, and positive and negative predictive values of 84.75%, 90%, 96.15% and 52.63% for IA diagnosis, respectively.. Increased serum BG and GM levels can serve as the evidence for early diagnosis of IA with a high diagnostic sensitivity and specificity in renal transplant recipients.

Topics: Aspergillosis; beta-Glucans; Early Diagnosis; Galactose; Humans; Kidney Transplantation; Mannans; Sensitivity and Specificity

This study was undertaken to examine the performance of the Fungitell β-glucan (BG) assay, to compare it with that of the galactomannan (GM) test for the diagnosis of invasive aspergillosis (IA) in patients with hematological malignancies, and to examine the rates of false-positive BG and GM test results due to β-lactam antibiotics among sera of patients with Gram-positive or Gram-negative bacteremia and selected sera with false-positive results from the GM test. Serum samples from 105 patients with proven (n = 14) or probable (n = 91) IA, 97 hematology patients at risk for invasive fungal infections, 50 healthy blood donors, and 60 patients with bacteremia were used to study the sensitivities and specificities of the assays. The GM test was more specific than the BG assay (97% versus 82%, respectively; P = 0.0001) and the BG assay was more sensitive than the GM test (81% versus 49%, respectively; P < 0.0001) for IA diagnosis. The study of 49 separate batches of β-lactam antibiotics showed high and very similar rates of false-positive results for the GM and BG assays (29 and 33%, respectively; P = 0.82) but with an almost complete lack of concordance between the 2 assays. For patients with bacteremia, the rate of false-positive results was much higher with the BG test than with the GM test (37% versus 2%, respectively; P < 0.0001), with no significant difference between Gram-positive and Gram-negative bacteremia. In conclusion, the BG test may be useful for the diagnosis of IA because of its high sensitivity in comparison with the GM test, but the overall benefit of this assay remains limited because of its inadequate specificity and its cost.

Topics: Anti-Bacterial Agents; Antigens, Fungal; beta-Glucans; beta-Lactams; False Positive Reactions; Galactose; Hematologic Neoplasms; Humans; Invasive Pulmonary Aspergillosis; Mannans; Proteoglycans; Sensitivity and Specificity; Serum

To investigate the utility of beta-D-glucan (BDG) testing in bronchoalveolar lavage (BAL) fluid for the diagnosis of invasive fungal infection (IFI), as compared to BAL galactomannan (GM).. We retrospectively reviewed medical records of 132 consecutive patients at the National Institutes of Health (NIH) in whom BAL BDG testing was performed for diagnosis of pneumonia. Using the European Organization for Research and Treatment of Cancer/Mycoses Study Group guidelines, we determined which patients had proven or probable IFI, and assessed the diagnostic performance of BAL BDG testing, relative to BAL GM. We also determined the reproducibility of the BDG assay in BAL via repeat testing of patient samples.. Ten patients had Pneumocystis pneumonia, and 34 patients had proven/probable IFI, including 14 with invasive aspergillosis (IA). BAL BDG was 100% sensitive for Pneumocystis. Although BAL BDG had similar sensitivity to BAL GM for the diagnosis of IA and IFI, it exhibited inferior specificity. Repeat testing demonstrated poor reproducibility of the BDG assay in BAL but not in serum.. BDG testing exhibits poor specificity and reproducibility in BAL. Identification of the BAL-specific factors that may interfere with the performance of the assay could improve the clinical usefulness of BAL BDG testing.

Topics: beta-Glucans; Bronchoalveolar Lavage Fluid; Female; Fusariosis; Galactose; Humans; Invasive Pulmonary Aspergillosis; Lung Diseases, Fungal; Male; Mannans; Mucormycosis; Paecilomyces; Pneumonia, Pneumocystis; Reproducibility of Results; Retrospective Studies; Scopulariopsis; Sensitivity and Specificity

Aspergillus fumigatus, a thermotolerant fungus, is the main causative agent of invasive pulmonary aspergillosis (IPA) in immunocompromised patients that is associated with high mortality rates. Early diagnosis of IPA is crucial for mortality reduction and improved prognosis. An experimental inhalational model of IPA was developed in rats and the efficacy of three biomarkers, namely β-D-glucan (BDG), a panfungal marker, galactomannan (GM), a genus-specific marker, and A. fumigatus DNA, a species-specific marker was evaluated in serum and bronchoalveolar lavage (BAL) specimens at different time points postinfection for early diagnosis of IPA. BDG and GM were detected by using commercial Fungitell and Platelia Aspergillus EIA kits, respectively. A. fumigatus DNA was detected by developing a sensitive, single-step PCR assay. IPA was successfully developed in immunosuppressed rats and all animals until 5 days post-infection were positive for A. fumigatus by culture and KOH-calcofluor microscopy also showed A. fumigatus in 19 of 24 (79%) lung tissue samples. Fourteen of 30 (47%) and 27 of 30 (90%) serum and BAL specimens, respectively, were positive for all three biomarkers with 100% specificity (none of sera or BAL specimens of 12 control rats was positive for biomarkers). Our data show that BAL is a superior specimen than serum and combined detection of BDG, GM and A. fumigatus DNA provide a sensitive diagnosis of IPA in an experimental animal model. Moreover, combined detection of GM and DNA in BAL and detection of either GM or DNA in serum was also positive in 27 of 30 (90%) animals. For economic reasons and considering that the positive predictive value of BDG is low, the detection of GM and/or DNA in serum and BAL samples has the potential to serve as an integral component of the diagnostic-driven strategy in high-risk patients suspected for IPA.

Topics: Animals; Aspergillus fumigatus; beta-Glucans; Biological Assay; Biomarkers; Bronchoalveolar Lavage; Disease Models, Animal; Female; Galactose; Immunocompromised Host; Inhalation; Invasive Pulmonary Aspergillosis; Lung; Mannans; Polymerase Chain Reaction; Rats; Rats, Wistar

The performance of serum biomarkers for the early detection of invasive aspergillosis expectedly depends on the timing of test results relative to the empirical administration of antifungal therapy during neutropenia, although a dynamic evaluation framework is lacking.. We developed a multi-state model describing simultaneously the likelihood of empirical antifungal therapy and the risk of invasive aspergillosis during neutropenia. We evaluated whether the first positive test result with a biomarker is an independent predictor of invasive aspergillosis when both diagnostic information used to treat and risk factors of developing invasive aspergillosis are taken into account over time. We applied the multi-state model to a homogeneous cohort of 185 high-risk patients with acute myeloid leukemia. Patients were prospectively screened for galactomannan antigenemia twice a week for immediate treatment decision; 2,214 serum samples were collected on the same days and blindly assessed for (1->3)- β-D-glucan antigenemia and a quantitative PCR assay targeting a mitochondrial locus.. The usual evaluation framework of biomarker performance was unable to distinguish clinical benefits of β-glucan or PCR assays. The multi-state model evidenced that the risk of invasive aspergillosis is a complex time function of neutropenia duration and risk management. The quantitative PCR assay accelerated the early detection of invasive aspergillosis (P = .010), independently of other diagnostic information used to treat, while β-glucan assay did not (P = .53).. The performance of serum biomarkers for the early detection of invasive aspergillosis is better apprehended by the evaluation of time-varying predictors in a multi-state model. Our results provide strong rationale for prospective studies testing a preemptive antifungal therapy, guided by clinical, radiological, and bi-weekly blood screening with galactomannan antigenemia and a standardized quantitative PCR assay.

Topics: Adult; Aged; Antifungal Agents; Antigens, Fungal; Antineoplastic Agents; beta-Glucans; Biomarkers; Chemotherapy-Induced Febrile Neutropenia; DNA, Fungal; Early Diagnosis; Female; Fungal Polysaccharides; Galactose; Genes, Fungal; Humans; Invasive Pulmonary Aspergillosis; Leukemia, Myeloid, Acute; Male; Mannans; Markov Chains; Middle Aged; Models, Biological; Prospective Studies; Randomized Controlled Trials as Topic; Real-Time Polymerase Chain Reaction

Invasive fungal infections (IFIs) frequently occur and are associated with high morbidity and mortality in patients with hematologic malignancies (HMs) and hematopoietic stem cell transplant (HSCT) recipients. Early diagnosis of IFI in these patients facilitates prompt institution of therapy and leads to improved clinical outcomes. This article reviews widely used methodologies for diagnosing IFIs in patients with HM and HSCT recipients. Advantages and limitations of radiologic studies; microbiologic and histopathologic techniques; fungal biomarker assays, including those for galactomannan antigen and β-(1-3)-D-glucan; and molecular assays that are available to establish an early diagnosis of clinically relevant invasive fungal infections are discussed. Recommendations are provided regarding effective use of these methodologies in clinical practice.

Topics: beta-Glucans; Biomarkers; Diagnostic Imaging; Galactose; Hematologic Neoplasms; Hematopoietic Stem Cell Transplantation; Humans; Mannans; Mycological Typing Techniques; Mycoses; Proteoglycans

Invasive pulmonary aspergillosis is a rare and fatal complication in patients with cystic fibrosis (CF) who lack concomitant risk factors. The few documented cases in children have all resulted in deaths during hospitalisation. We present the case of a 12-year-old boy with CF who was admitted for an exacerbation which was unresponsive to antibiotic therapy. The findings on imaging raised concerns about a possible fungal infection. As a result, voriconazole therapy was started prior to his respiratory deterioration. He was later found to be β-D glucan and Aspergillus Ag galactomannan positive confirming the suspicion for invasive pulmonary aspergillosis. Three months after diagnosis, he was discharged home under stable condition. Voriconazole was continued beyond discharge and resulted in improvement of respiratory symptoms. This underscores the importance of early treatment of pulmonary aspergillosis in patients with CF. Unfortunately, the patient died 6 months after diagnosis from a CF exacerbation.

Topics: Antifungal Agents; beta-Glucans; Biomarkers; Bronchoalveolar Lavage; Child; Cystic Fibrosis; Early Diagnosis; Fatal Outcome; Galactose; Humans; Immunocompromised Host; Invasive Pulmonary Aspergillosis; Male; Mannans; Pyrimidines; Triazoles; Voriconazole

Fungal wound infection is a leading cause of burn wound infections, and diagnosis is often delayed as it conventionally requires culture and histopathology. Fungal screening assays have sped diagnosis of invasive fungal infections in other populations. Few studies have evaluated the performance of fungal screening assays outside of the hematologic malignancy and hematopoietic stem cell transplant populations.. We performed a three year retrospective analysis of all fungal screening assays in burn patients in the ICU between 2008 and 2011. The primary goal was to evaluate the correlation between the two available fungal screening assays, (1→3)-β-d-glucan (BG) and galactomannan (GM) assay, and fungal wound colonization (FWC) and infection (FWI). We also evaluated previously hypothesized causes of false positives and their associations with false positives in the burn population.. We identified 53 patients [median 29% total body surface area burned (TBSA), IQR 17-51] with BG or GM serological tests available, of which 15 had a FWI or FWC. FWC/FWI was associated with higher TBSA (p=0.02). BG and GM correlated with TBSA (BG 0.57, p<0.01; GM 0.35, p=0.02), but neither assay was associated with FWI/FWC or species of fungus involved when FWI/FWC was diagnosed.. Positive BG and GM fungal screening assays are not associated with FWI/FWC, or with species of fungus when FWC/FWI is present. BG false positives are common and associated with higher TBSA burns.

Topics: Adult; Antigens, Fungal; beta-Glucans; Biomarkers; Burns; Female; Galactose; Humans; Male; Mannans; Middle Aged; Mycoses; Retrospective Studies; Wound Infection

Diagnosis of invasive fungal disease (IFD) in patients under intensive care is challenging. Circulating biomarkers, (1,3)-β-D-glucan (BG) and galactomannan (GM), were prospectively assessed in 98 critically ill patients at risk of IFD. There were 11 cases of invasive aspergillosis (IA; 4 proven and 7 probable), 9 cases of proven invasive candidiasis (IC), 1 case of mixed proven IC and probable IA, 1 case of proven zygomycosis, and 1 case of mixed mycelial proven IFD. In all IA cases there was no significant difference when the area under the receiver operating characteristic curve (AUC) of GM (0.873 [95%CI, 0.75-0.99]) and BG (0.856 [95% CI, 0.71-0.99]) were compared (p = 0.871). The AUC for BG in IC and for the rest of the IFD cases was 0.605 (95% CI, 0.39-0.82) and 0.768 (95% CI, 0.63-0.90) respectively. Positive BG (40%) predated blood culture (n = 3) and abdominal pus (n = 1) a mean of 3.25 days before Candida was grown. In patients with IFD caused by molds, BG appeared a mean of 5.65 days before culture results. For the diagnosis of patients at risk of IC, BG has shown a high NPV (94.5%), with positive results also predating blood cultures in 30% of patients. In conclusion, early BG results permit a timely initiation of antifungal therapy in patients at risk of IFD.

Topics: Adult; Aged; Aged, 80 and over; beta-Glucans; Critical Illness; Female; Galactose; Humans; Male; Mannans; Middle Aged; Mycoses; Prospective Studies; Proteoglycans; ROC Curve; Sepsis

We assessed the performance of galactomannan and (1→3)-β-d-glucan in 29 serum samples from patients with multiple myeloma and Waldenstrom's macroglobulinemia without invasive fungal disease to address issues of false positivity and uninterpretable results previously reported among patients with these conditions. Galactomannan and (1→3)-β-d-glucan assays were not falsely elevated in any patient. (1→3)-β-d-glucan assay results were uninterpretable in 24% of patients. Patients with IgG levels of >2,000 mg/dl had higher odds of uninterpretable (1→3)-β-d-glucan results.

Topics: Adult; Aged; Aged, 80 and over; beta-Glucans; Diagnostic Errors; Female; Galactose; Humans; Male; Mannans; Middle Aged; Multiple Myeloma; Mycoses; Proteoglycans; Serum; Waldenstrom Macroglobulinemia

We developed and assessed the diagnostic value of a novel quantitative nested real-time (QNRT) PCR assay targeting the internal transcribed spacer region of ribosomal DNA (rDNA) in a guinea pig model of invasive pulmonary aspergillosis. Groups of 5 immunosuppressed animals that were infected using an aerosol chamber with Aspergillus fumigatus conidia were humanely terminated 1 h postinoculation and at days 3, 5, 7, and 11 postchallenge, and lung tissue, bronchoalveolar lavage (BAL) fluid, whole blood, and serum samples were collected. The QNRT PCR results obtained with the serum and BAL fluid were compared to those achieved with galactomannan and (1→3)-β-d-glucan assays. High fungal burden levels were detected by QNRT PCR in both lung tissue and BAL fluid in all infected animals at each time point, and the sensitivity of each assay in BAL fluid was 100% by day 3 and remained so through the remainder of the study. The sensitivity of detection of fungi in whole blood and serum samples was significantly lower, and some samples remained negative by all three assays despite the advanced stage of the infection. From these data, we can conclude that this novel QNRT PCR method was highly sensitive for the detection of A. fumigatus from different types of samples in this model. In addition, BAL fluid samples appeared to be the most suitable for the early diagnosis of invasive pulmonary aspergillosis. When testing serum, the use of a combination of available assays may increase the possibility of early detection of this opportunistic mycosis.

Topics: Animals; Aspergillus fumigatus; beta-Glucans; Bronchoalveolar Lavage Fluid; Colony Count, Microbial; Disease Models, Animal; DNA, Fungal; DNA, Ribosomal Spacer; Galactose; Guinea Pigs; Invasive Pulmonary Aspergillosis; Lung; Male; Mannans; Mycology; Polymerase Chain Reaction; Proteoglycans; Real-Time Polymerase Chain Reaction; Sensitivity and Specificity

Galactomannan (GM) is used to diagnose aspergillosis. We present a case of a hematopoietic stem cell transplantation recipient with fusariosis who received early antifungal treatment based on GM positivity. Additionally, 3 Fusarium isolates tested positive for GM. Fusarium is another mold containing GM. GM might be useful for diagnosing fusariosis in high-risk patients.

Topics: Antifungal Agents; beta-Glucans; Early Diagnosis; Fatal Outcome; Female; Fusariosis; Fusarium; Galactose; Hematopoietic Stem Cell Transplantation; Humans; Mannans; Middle Aged

The aim of this multicenter prospective study was to evaluate the incidence of invasive fungal infections (IFIs) in adult and pediatric patients with hematologic malignancies, involving nine nosocomial facilities in Southern Italy over a period of 18 months. Furthermore, results of an environmental microbial surveillance routinely carried out in some of the enrolled hospitals are reported. A total of 589 onco-hematological patients were enrolled and 27 IFIs were documented. The main infections were caused by yeasts, more than filamentous fungi (overall incidence of 2.7% and 1.9%, respectively). The yeasts were mainly represented by Candida spp. (87.5%), all isolated by blood cultures; C. parapsilosis was the most common species. Among mould infections, the most frequent site was the lung, with regard to aspergillosis (81.8%). In six of the 10 patients with suspected aspergillosis, the diagnosis was made by the detection of galactomannan and (1,3)-β-d-glucan antigens. The microbiological surveillance carried out on 156 air, 312 water and 312 surface samples revealed low environmental contamination: Alternaria alternata was the only fungus isolated from two surface samples. Our data, especially the low occurrence of filamentous fungi, suggest a particular local epidemiology. Further studies are needed to confirm this microbiological trend in onco-hematological patients in Southern Italy, the results of which might be helpful to improve the management of these patients.

Topics: Adolescent; Adult; Aged; Alternaria; Antineoplastic Agents; beta-Glucans; Bone Marrow Transplantation; Candida; Child; Child, Preschool; Female; Galactose; Hematologic Neoplasms; Humans; Incidence; Male; Mannans; Middle Aged; Mycoses; Prospective Studies; Proteoglycans; Young Adult

Limited specific data and investigations are available for invasive aspergillosis (IA) in pediatric patients. We evaluated the diagnostic potential of three noninvasive tests including the Platelia Aspergillus EIA kit for using galactomannan antigen, (1,3)-β-D-glucan Detection Reagent Kit, and nested-PCR for Aspergillus DNA in sera. We evaluated the diagnostic potential of three noninvasive tests including EIA for galactomannan antigen  (Platelia Aspergillus), nested  PCR assay for Aspergillus DNA and test for (1→3)-β-D-glucan (Glucatell assay Kit).. All pediatric patients treated at the hematology/oncology unit who were at increased risk of developing invasive aspergillosis were enrolled. Clinical samples were examined for Aspergillus infections by mycological methods. Serial blood samples were collected twice weekly and evaluated by noninvasive tests.. We analyzed 230 consecutive blood samples from 62 pediatric patients. The incidence rate of invasive aspergillosis in the patients was found to be 27.4%, and the etiologic agents were Aspergillus flavus, Aspergillus fumigatus, and Aspergillus spp.  The sensitivity, specificity, positive and negative predictive values, and likelihood ratios for positive and negative results of galactomannan in patients with proven and probable IA were 90%, 92%, 81.8%, 96%, 11.25, and 0.1; for beta-D-glucan they were 50%, 46%, 26%, 70.6%, 0.9, 0.9; and for nested-PCR they were 80%, 96.2%, 88.9%, 92.6%, 21, and 0.2, respectively.. The conventional methods are not able to detect IA, due to the lack of valid and proper sampling. Galactomannan and nested-PCR tests in serum, with enough accuracy and reliability, can serve as noninvasive methods for the detection of IA in pediatric patients. However, the beta-D-glucan test cannot serve as an efficient diagnostic tool in those with hematologic disorders. 

Topics: Adolescent; Aspergillus; beta-Glucans; Child; Child, Preschool; Clinical Laboratory Techniques; Female; Galactose; Humans; Immunoenzyme Techniques; Infant; Invasive Pulmonary Aspergillosis; Male; Mannans; Polymerase Chain Reaction; Proteoglycans; Reagent Kits, Diagnostic

Sera samples from commercial broiler chickens and turkeys diagnosed with respiratory and disseminated aspergillosis were tested for the presence of antigen and antibody to Aspergillus. Antigen detection consisted of testing for two cell-wall components, beta-glucan and galactomannan, which have been used extensively in human medicine. There were significantly higher levels of galactomannan in all broiler chicken submissions (100%) and antibody to Aspergillus in 6 out of 9 submissions (66.6%) vs. control birds. Beta-glucan analyses did not show any differences among levels in the broiler chicken groups. There were significantly higher levels of galactomannan antigen in 4 out of 7 submissions (57.1%) of aspergillosis in commercial turkeys, while only 2 out of 7 submissions (28.5%) had higher levels of antibody to Aspergillus vs. the control group. This study shows that diagnosis of respiratory and disseminated aspergillosis may be performed by detection of galactomannan antigenemia and antibodies in broiler chickens and to an extent in turkeys.

Topics: Animals; Antibodies, Fungal; Antigens, Fungal; Aspergillosis; Aspergillus; beta-Glucans; California; Chickens; Enzyme-Linked Immunosorbent Assay; Galactose; Mannans; Poultry Diseases; Serologic Tests; Species Specificity; Turkeys

Opportunistic fungal infections are life threatening especially for immunosuppressed patients. Early and accurate diagnosis is very important for the prompt initiation of treatment and to reduce unnecessary use of antifungal drugs. In recent years, efforts providing more rapid and more sensitive diagnosis of invasive fungal infections have been increasing. These methods include detection of fungal antigens, specific antibodies, fungal metabolites and DNA in the clinical samples. In this case, we report a seven year-old male patient with cystic fibrosis and diffuse large B-cell lymphoma, who presented with fever, vomiting and chronic cough. Diffuse parenchymal infiltrations and alveolar opacities in the inferior lobe of right lung and focal patchy alveolar infiltrates in different segments in both lungs were seen in thoracal CT scanning. Bronchoalveolar lavage (BAL) sample obtained by bronchoscopy was sent to the mycology laboratory and hypha elements that were compatible with Aspergillus were seen in direct examination. Aspergillus fumigatus was isolated from the culture of BAL sample. Real-time polymerase chain reaction (Rt-PCR), galactomannan (GM = 1.08 ng/ml) and 1,3-ß-D-Glucan (BG > 523 pg/ml) tests in BAL sample yielded positive results, however simultaneously performed PCR, GM (0.13 ng/ml) and BG (< 7 pg/ml) tests in serum sample were found to be negative. Treatment with voriconazole was started and continued for 45 days. The patient was discharged after improvement of his general state. It was concluded that PCR, GM and BG tests performed both in sera and BAL samples might aid to the early diagnosis and treatment of patients with invasive fungal infections in immunosuppressed patients. These data should be supported with further larger scale studies.

Topics: Antifungal Agents; beta-Glucans; Bronchoalveolar Lavage Fluid; Bronchoscopy; Child; Cystic Fibrosis; Galactose; Humans; Immunocompromised Host; Invasive Pulmonary Aspergillosis; Lymphoma, Large B-Cell, Diffuse; Male; Mannans; Pyrimidines; Real-Time Polymerase Chain Reaction; Tomography, X-Ray Computed; Triazoles; Voriconazole

Diagnosis of fungal pneumonia (FP) in critically ill patients is challenging. Circulating biomarkers for the diagnosis of FP have limitations and the combination of different assays in serum samples and directly from the target organ may further improve the diagnosis of FP. We prospectively assessed the diagnostic utility of paired galactomannan (GM) in bronchoalveolar lavage fluid (BAL) and serum GM and (1→3)-β-D-glucan (BG) assays in critically ill patients at risk of FP. Patients with FP were classified according to European Organisation for Research and Treatment of Cancer-Mycoses Study Group criteria, with modifications. Out of 847 admissions, 51 patients were eligible. There were nine invasive aspergillosis (IA) cases (four proven, five probable), three proven Pneumocysitis jirovecii pneumonia (PJP) cases and one mixed FP case (probable IA and proven PJP). The diagnostic accuracy as given by the area under the receiver operating characteristic curve in IA cases (proven and probable) for GM in BAL was 0.98 (95% CI, 0.94-1.00), whilst for GM and BG in serum it was 0.85 (95% CI, 0.74-0.96) and 0.815 (95% CI, 0.66-0.96), respectively. For IA cases (proven and probable) AUC for GM in BAL was significantly higher than GM and BG in serum (p 0.025 and p 0.032, respectively). In one of four proven and one of six probable IA cases, GM in serum remained negative, whereas GM in BAL was positive. In patients with IA, GM (90%) and BG (80%) appeared a mean of 4.3 days (range, 1-10 days) before Aspergillus was cultured. GM detection in BAL appears to improve the diagnosis of IA in critical patients.

Topics: Adult; Aged; beta-Glucans; Bronchoalveolar Lavage Fluid; Critical Care; Critical Illness; Female; Galactose; Humans; Invasive Pulmonary Aspergillosis; Male; Mannans; Middle Aged; Prospective Studies; Proteoglycans; ROC Curve; Serum

To evaluate the diagnostic value of serum galactomannan antigen (GM) and (1→3)-β-D-glucan antigen (BG) assay in invasive fungal infections (IFI) in the patients with hematologic malignancies and the role in monitoring therapeutic response.. Fifty one patients with hematological malignancies met the criteria for inclusion: (1) body temperature above 38°C for 48 hours, (2) failure to respond to broad-spectrum antibiotic treatment, or (3) temperature rose again after the responded drop. Blood samples were collected twice at the first week, then once a week in at least four weeks. The double antibody sandwich enzyme-linked immunosorbent assay (ELISA) and colorimetric assay were used for detecting GM and BG. The positive GM test is defined as two consecutive tests at different time GM value > 0.5 or > 0.8 and the positive G test is defined as BG value > 80 pg/ml. The patients were assigned into four groups as proven, probable, possible, and non-fungal infection respectively, and 21 normal volunteers were as controls.. Two hundred and forty serum samples were collected from 51 patients including 2 of proven IFI, 26 probable IFI, 17 possible IFI and 6 non-fungal infection. The true-positive group including the proven and probable groups, and true negative group was the non-fungal infection group. GM tests were positive in 21 of 28 cases in true positive group, and only one of 6 cases in non-fungal infection. The sensitivity, specificity, positive predictive value and negative predictive value were 75%, 83.3%, 95.5% and 41.7%, respectively. G tests were positive in all 28 cases of the true positive group, and 4 in 6 non-fungal infection cases. The sensitivity, specificity, positive predictive value and negative predictive value were 100%, 33.3%, 87.5% and 100%, respectively. G test is more sensitive than GM test (P = 0.015), but there was no significant difference in specificity of the two tests (P = 0.242). In 19 of 21 patients with GM test positive, anti-fungal treatment was effective, and GM value gradually decreased to negative, two invalid patients were persistent with GM test positive. After two weeks treatment, the average GM value was significantly lower in the effective group than in the ineffective group (P < 0.05). BG values in the responded patients showed a gradual decline similar to that of GM values, but not to negative. The changes of BG value in ineffective group varied with a trend upward. The changes in BG value had no relation with treatment effectiveness.. Serum GM and BG antigens detection provides strong evidence for early diagnosis of IFI. Combination of GM and G tests can improve the diagnostic specificity and reduce the false positive GM test seems superior to G test for monitoring GM and BG values during treatment.

Topics: Adult; Aged; Aged, 80 and over; Antigens, Fungal; beta-Glucans; Female; Galactose; Hematologic Neoplasms; Humans; Male; Mannans; Middle Aged; Mycoses; Young Adult

β-D-(1,3)-glucan (BG) is a component of the cell walls of many fungal organisms. Our aims were to investigate the feasibility of the BG assay and its contribution to early diagnosis of different types of invasive fungal infections (IFI) commonly diagnosed in a tertiary care centre. The BG serum levels of 28 patients diagnosed with six IFI [13 probable invasive aspergillosis (IA), 2 proven IA, 2 zygomycosis, 3 fusariosis, 3 cryptococcosis, 3 candidaemia and 2 pneumocystosis] were retrospectively evaluated. The kinetic variations in BG serum levels from the 15 patients diagnosed with IA were compared with those of the galactomannan antigen (GM). In 5/15 cases of IA, BG was positive earlier than GM (time lapse from 4 to 30 days), in 8/15 cases, BG was positive at the same time as GM and, in 2/15 cases, BG was positive after GM. For the five other fungal diseases, BG was highly positive at the period of diagnosis except for the two cases of zygomycosis and one of the three cases of fusariosis. This study, which reflects the common activity of a tertiary care centre, confirms that BG detection could be of interest for IFI screening in patients with haematological malignancies.

Topics: Aspergillosis; beta-Glucans; France; Galactose; Hematologic Neoplasms; Humans; Immunocompromised Host; Mannans; Mycoses; Predictive Value of Tests; Proteoglycans; Retrospective Studies; Time Factors

A 66-year-old male with ischaemic cardiomyopathy and chronic lymphocytic leukemia developed signs of severe systemic inflammatory response syndrome. Serial blood cultures were negative and a SeptiFast test detected the presence of Aspergillus fumigatus DNA. Afterwards, detection of galactomannan and 1,3-β-D-glucan showed a positive result. Autopsy revealed the presence of branched fungal structures suggestive of Aspergillus.

Topics: Aged; Aspergillosis; Aspergillus fumigatus; Autopsy; beta-Glucans; Cardiomyopathies; DNA, Fungal; Endocarditis; Fatal Outcome; Galactose; Histocytochemistry; Humans; Leukemia, Lymphocytic, Chronic, B-Cell; Male; Mannans; Microscopy; Proteoglycans

The aim of this study was to investigate the interaction between intravenous piperacillin/tazobactam treatment and Aspergillus galactomannan antigen (GM) and 1,3-beta-D: -glucan (BDG) test results in patients without known risk factors for invasive fungal infections (IFI).. Patients without known risk factors for IFI and who were to receive piperacillin/tazobactam monotherapy were considered eligible for the study. Serum samples were obtained both before and after antibiotic infusion on the first, third, seventh and tenth days of a piperacillin/tazobactam treatment course and 4 days after the last dose. GM was determined by Platelia Aspergillus ELISA (Bio-Rad Laboratories) and BDG was assayed using the Fungitell kit (Associates of Cape Cod, East Falmouth, MA) according to manufacturers' specifications.. A total of 135 serum samples were collected from 15 patients. When a cut-off level of >or=0.7 was used for GM positivity, there were no false positive results. When a cut-off level of >or=0.5 was used, six serum samples were positive. There were no statistically significant differences between the median GM indices or median BDG levels of the various sampling times. However, 24 of 135 serum samples were positive for BDG for a threshold of 80 pg/mL. After ruling out fungal infections and all known potential causes of false BDG positivity, environmental contamination remained a possible cause of BDG reactivity.. No significant interaction was observed between piperacillin/tazobactam administration and Aspergillus GM and BDG assays. Positive results for these tests should be evaluated cautiously in patients at high risk for IFI receiving piperacillin/tazobactam.

Topics: Adult; Aged; Anti-Bacterial Agents; Antigens, Fungal; Aspergillosis; Aspergillus; beta-Glucans; False Positive Reactions; Female; Galactose; Humans; Infusions, Intravenous; Male; Mannans; Microbiological Techniques; Middle Aged; Mycology; Penicillanic Acid; Piperacillin; Piperacillin, Tazobactam Drug Combination; Risk Factors

To evaluate the performance of the galactomannan enzyme immunoassay (GM test) and (1,3)beta-D-glucan assay (G test) for the diagnosis of invasive fungal infection (IFI).. A retrospective study was performed in 115 hospitalized patients at Peking University First Hospital who were at risk of IFI. Patients were diagnosed as IFI according to revised definitions of invasive fungal disease from 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) Consensus Group. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated at different cutoff values for two assays respectively. Two tests were combined to evaluate the changes of sensitivity, specificity, PPV and NPV.. The best sensitivity (54.5%, 63.6%) and specificity (77.9%, 69.2%) were obtained with the cutoff values of 0.5 and 20 x 10(3) pg/L in GM test and G test respectively. The PPV were 20.7% and 17.9%, and the NPV were 94.2% and 94.7% respectively. The sensitivity increased to 90.9% and the specificity was 52.9% after a combined utility of two tests.. The GM test and G tests are both useful in diagnosis of IFI with the cutoff values of 0.5 and 20 x 10(3) pg/L. A better sensitivity is acquired if there is a combined utility of two tests.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; beta-Glucans; Child; Female; Galactose; Humans; Immunoenzyme Techniques; Male; Mannans; Middle Aged; Mycoses; Plasma; Predictive Value of Tests; Retrospective Studies; Sensitivity and Specificity; Serum; Young Adult

Acute invasive pulmonary aspergillosis is a rapidly progressive and frequently lethal infection. Relatively little is known about early events in the pathogenesis and relationship between the cell wall biomarkers galactomannan and (1→3)-β-d-glucan. The consequences of delayed antifungal therapy are also poorly defined. A persistently neutropenic rabbit model of invasive pulmonary aspergillosis was used to describe the histopathology of early invasive pulmonary aspergillosis and the kinetics of galactomannan and (1→3)-β-d-glucan. The time course of both molecules was mathematically modeled by using a population methodology, and Monte Carlo simulations were performed. The effect of progressive delay in the administration of amphotericin B deoxycholate 1 mg/kg at 24, 48, 72, and 96 h postinoculation on fungal burden, lung weight, pulmonary infarct score, and survival was determined. Histopathology showed phagocytosis of conidia by pulmonary alveolar macrophages at 4 h postinoculation. At 12 to 24 h, there was a progressive focal inflammatory response with conidial germination and hyphal extension. Subsequently, hyphae invaded into the contiguous lung. Galactomannan and (1→3)-β-d-glucan had similar trajectories, and both exhibited considerable interindividual variability, which was reflected in Monte Carlo simulations. Concentrations of both molecules began to rise <24 h postinoculation before pulmonary hemorrhagic infarction was present. Delays of 72 and 96 h in the administration of amphotericin B resulted in fungal burdens and lung weights that were indistinguishable from those of controls, respectively. Galactomannan and (1→3)-β-d-glucan have similar kinetics and are comparable biomarkers of early invasive pulmonary aspergillosis. Antifungal treatment at ≥48 h postinoculation is associated with suboptimal therapeutic outcomes.

Topics: Amphotericin B; Animals; Antifungal Agents; Aspergillus fumigatus; beta-Glucans; Deoxycholic Acid; Drug Combinations; Galactose; Invasive Pulmonary Aspergillosis; Mannans; Proteoglycans; Rabbits

A case of invasive pulmonary aspergillosis caused by Aspergillus terreus is described. The diagnosis was based on demonstration of branched septate hyphae in a sputum specimen and isolation of the fungus in culture. The diagnosis was further supported by detection of A. terreus-specific DNA, galactomannan (GM) and (1→3)-β-D-glucan (BDG) in consecutive serum specimens. The patient was treated for about 10 weeks with voriconazole. The decreasing levels of GM and BDG in serum samples were accompanied by symptomatic and radiological improvement. The report highlights the value of surrogate markers in the diagnosis and for monitoring the course of invasive aspergillosis during therapy.

Topics: Antifungal Agents; beta-Glucans; Child; Galactose; Humans; Lung Diseases, Fungal; Male; Mannans; Precursor Cell Lymphoblastic Leukemia-Lymphoma; Proteoglycans; Pulmonary Aspergillosis; Pyrimidines; Triazoles; Voriconazole

Topics: Antigens, Fungal; Aspergillosis; Aspergillus; beta-Glucans; Biomarkers; Colorimetry; DNA, Fungal; Enzyme-Linked Immunosorbent Assay; Galactose; Humans; Mannans; Nephelometry and Turbidimetry; Polymerase Chain Reaction; Proteoglycans

The incidence of aspergillosis which has high mortality rates, has increased gradually. Since invasive aspergillosis (IA) is one of the leading causes of death in immunocompromized and neutropenic patients, early and accurate diagnosis of IA is of crucial importance. The aims of this study were to compare the results of culture, real-time polymerase chain reaction (RtPCR), galactomannan (GM) antigen and glucan (GC) antigen detection tests and to evaluate their performances in view of rapid and accurate diagnosis of IA in neutropenic rat model. Female Wistar albino rats were included in the study with the consent of Animal Searching Ethical Committee and classified into three groups as healthy controls (n= 6), neutropenic controls (n= 10) and pulmonary aspergillosis (n= 35) groups. Rats were immunosuppressed with 5-flourourasil and then Aspergillus fumigatus conidia were inoculated intranasally. On the seventh day of the infection, blood, bronchoalveolar lavage (BAL) and lung tissue samples were collected from the animals, and control and aspergillosis groups were compared in terms of infection markers. All of the tests (culture, RtPCR, GM and BG tests) were found to be negative in controls. At the end of the study 22 rats in aspergillosis group survived. Lung tissue samples from those 22 animals were all positive for the presence of hypha on pathological preparations, while 20 (91%) yielded Aspergillus colonies on the cultures. Aspergillus DNA was detected in 7 of the 12 BAL samples (58.3%), 7 of 19 blood samples (36.8%) and 4 of 22 lung tissue samples (18%) using RtPCR method. GM antigen was detected in 7 of 20 serum samples (35%) with a commercial kit (Platelia® Aspergillus ELISA, BioRad, France). Quantitative detection of betalucan levels were investigated by using a commercial kit (Fungitell™, Cape Cod, USA) in serum and BAL samples and positive results were obtained in 11 of 22 serum (50%) and 9 of 17 BAL (52.9%) samples. In this study it was demonstrated that PCR performed in BAL samples is the most sensitive method compared to the others, for the diagnosis of IA in the rat model. The sensitivity rates were as follows when culture method accepted as the gold standard: 58.3% for BAL-PCR, 41.2% for blood-PCR, 20% for tissue-PCR, 38.9% for serum GM, 55% for serum GC and 52.9% for BAL-GC. It was also concluded that detection of GC activity in serum was more sensitive than GM detection in serum (sensitivity of GM was %38.9, sensitivity of GC was %55, whi

Topics: Animals; Antigens, Fungal; Aspergillus fumigatus; beta-Glucans; Bronchoalveolar Lavage Fluid; Disease Models, Animal; DNA, Fungal; Enzyme-Linked Immunosorbent Assay; Female; Fluorouracil; Galactose; Immunosuppression Therapy; Immunosuppressive Agents; Invasive Pulmonary Aspergillosis; Lung; Mannans; Neutropenia; Rats; Rats, Wistar; Real-Time Polymerase Chain Reaction; Sensitivity and Specificity

To evaluate the value of plasma 1, 3-β-D-glucan (G), serum mannan, galactomannan (GM) and cryptococcus capsular antigen assays for diagnosis of invasive fungal infections (IFI) in non-neutropenic adult patients.. This was a prospective case control study. Plasma and serum samples from 25 patients with IFI (candidiasis, aspergillosis, cryptococcosis, zygomycosis, pneumocystis carinii pneumonia), 27 patients with bacterial infections, and 25 healthy adults were collected from February 2007 to February 2009 in Beijing Hospital. The serum antigenic assays were performed and their sensitivity and specificity were analyzed. Optimal cut-off level of G test and mannan was established with receiver operating characteristic curve (ROC).. The concentration of G test in plasma of patients with IFI [89.4 (25.8, 336.9) ng/L] was significantly higher than that of patients with bacterial infection [8.1 (5.0, 34.9) ng/L, U = 120.5, P < 0.001] and healthy adults [3.8 (3.8, 26.0) ng/L, U = 76.5, P < 0.001]. The area under curve (AUC) was 0.858, and the optimal cut-off value was 71.7 ng/L. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 65.0% (13/20), 92.3% (48/52), 76.5% (13/17) and 87.2% (48/55) respectively. The concentration of mannan in serum from patients with candidiasis [1.13 (0.44, 1.22) µg/L] was significantly higher than that from patients with non-candidiasis IFI [0.21 (0.14, 0.27) µg/L, U = 19, P < 0.05], bacterial infection [0.26 (0.22, 0.32) µg/L, U = 36.5, P < 0.001] and healthy adults [0.25 (0.22, 0.30) µg/L, U = 29.5, P < 0.001]. The AUC was 0.894, and the optimal cut-off value was 0.41 µg/L. The sensitivity, specificity, PPV and NPV were 83.3% (10/12), 90.4% (47/52), 66.7% (10/15) and 96.0% (47/49) respectively. The sensitivity, specificity, PPV and NPV of GM antigen to diagnose aspergillosis were 25.0% (1/4), 96.1% (50/52), 33.3% (1/3) and 92.6% (50/54) respectively. The sensitivity, specificity, PPV and NPV of cryptococcus capsular antigen to diagnose cryptococcosis were all 100%.. 1,3-β-D-glucan, mannan and cryptococcus capsular antigen were useful for diagnosis of IFI in non-neutropenic adult patients. GM antigen did not show a good sensitivity for diagnosis of aspergillosis in non-neutropenic adult patients.

Topics: Adult; Aged; Aged, 80 and over; Antigens, Fungal; Bacterial Infections; beta-Glucans; Case-Control Studies; Female; Galactose; Humans; Male; Mannans; Middle Aged; Mycoses; Predictive Value of Tests; Prospective Studies; Proteoglycans; Sensitivity and Specificity

Previous studies have reported that galactomannan (GM) enzyme immunoassay and 1,3 beta-glucan (BG) assay may be useful diagnostic tools, but their sensitivities are variable. We compared the performances of both tests. Between October 2002 and May 2005, 82 patients were prospectively monitored for 12 weeks. A total of 414 samples were tested by GM assay and 409 samples were tested by BG assay for the following four groups of patients: those with invasive aspergillosis (IA), those with other mold infections (Fusarium, scedosporium, zygomycosis, etc.), those with candidemia, and control patients. Blood samples were obtained twice on week 1 and once every other week for a total of 12 weeks. Patients in the invasive fungal infection groups had comparable risk factors. The sensitivity of the GM test was significantly higher for patients with IA due to non-fumigatus Aspergillus species than for patients with IA due to Aspergillus fumigatus (49% versus 13%; P < 0.0001) or with other mold infections (49% versus 6%; P < 0.0001). However, the sensitivity range (47% to 64%) and specificity (88%) of the BG assay were comparable among all patients tested, regardless of the infecting pathogen. The performance of GM-based diagnosis appears to be better for detecting non-fumigatus Aspergillus species. The diagnostic marker BG was shown to have a higher sensitivity than that of GM in detecting IA and other mold infections in hematologic malignancy patients.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; beta-Glucans; Child; Female; Galactose; Hematologic Neoplasms; Humans; Immunoenzyme Techniques; Male; Mannans; Middle Aged; Mycoses; Proteoglycans; Sensitivity and Specificity

In order to establish the reliable cut-off value of galactomannan (GM) antigen as well as that for beta-D-glucan for CNPA diagnosis, we conducted the following study. From 2001 to 2008, in a total of 1511 patients we measured GM and anti-aspergillus antibody simultaneously. These patients had chronic pulmonary disease including old tuberculosis, nontuberculous mycobacteriosis, COPD, and had bullous lung, interstitial lung disease or were suspected to have suspected to have interstitial lung disease. We designated cases as probable CNPA when the sample represented a positive anti-aspergillus antibody. We then analyzed the sensitivity and specificity according to various GM antigen values. When using the GM antigen cut-off value at 0.5, the sensitivity and specificity for CNPA were 63.4% and 68.6% respectively. Using 1.0 for cut-off value resulted in the better specificity for CNPA diagnosis. Similar analysis was performed on beta-D-glucan for CNPA diagnosis. When using D-glucan cut-off value as 20 pg/ml, the sensitivity and specificity for CNPA. These results indicate that the cut-off value of serological examination for infectious disease should be considered by the type of disease.

Topics: Antigens, Bacterial; beta-Glucans; Chronic Disease; Galactose; Humans; Mannans; Necrosis; Proteoglycans; Pulmonary Aspergillosis; Sensitivity and Specificity

1,3-beta-D glucan (BG) -- the antigen of fungal cell wall can be detected by a commercially available test for early detection of invasive fungal infections (IFI). The main advantage of this test is its broad coverage of fungal species. The aim of our study was to evaluate usefulness of BG detection for screening of IFI and for confirmation of galactomannan (GM) positive blood samples. Combination of the results of both tests could lead to correct and early diagnosis of invasive aspergillosis (IA).. Between January 2005 and July 2007 blood samples were collected in patients from intermediate to high risk of IFI. Moreover, between February and October 2007 all patients that had consecutive positive results of GM had their positive symplex tested also for BG.. In BG screening study, 1154 of blood samples from 104 treatment cycles were tested for BG. The incidence of IFI was 17.3 % (n = 18) and probable or proven IFI was detected in 9 cases (8.6%). The highest sensitivity, specificity, PPV and NPV (88.9 %, 40.7 %, 13.6 % and 97.2 %) were obtained when as criteria for positivity cut off 80 pg/ml and one positive result were used. When consecutive positivity of the test was applied as criterium, cut off 60 pg/ml was found more useful (sensitivity 66.7 %, specificity 47.7 %, PPV 11.8 % and NPV 93.2 %). Low PPV, caused by frequent false positive results, was identified as main limitation of this assay. 65 treatment cycles were positive if 1 sample above 80 pg/ml was used as a cut of for positivity. If consecutive positivity with cut off 60 pg/ml was used, 58 treatment cycles were positive. But in 51 (78.4 %) and 45 (77.5 %) cases, respectively, the positivity was not associated with IFI (false positivity). We did not find any correlation between positive BG assay result and frequency of empirical antifungal treatment, mucositis, yeast colonization, administration of selected antibiotics or infusion solutions or bacteriaemia. In our confirmation study, 40 GM positive episodes in 39 patients were identified. In 31 (78 %) GM positivity was false and was not associated with clinical signs and symptoms of IA. Sensitivity of GM detection in IA was 100 % but PPV only 18 %. Confirmation of consecutive GM positive samples (using cut off index positivity 0,5) by consecutive positivity of BG (with cut off 60 pg/ml) was found very useful for diagnosis of IA -- most of GM false positive results were eliminated and PPV increased to 88 %.. Our analysis focused on routine use of BG test for panfungal screening of IFI in patients with hematological malignancy and confirmed limited usefulness of this test in such setting. Low sensitivity together with low PPV are major limits of this test. On the other hand, BG testing seems to be a promising tool for confirmation of consecutive GM positive result in serum in patients with IA. Positivity of both tests could increase their PPV of tests and eliminate false positive results.

Topics: Antigens, Fungal; beta-Glucans; Female; Galactose; Hematologic Neoplasms; Humans; Male; Mannans; Mycoses; Opportunistic Infections; Predictive Value of Tests; Proteoglycans; Sensitivity and Specificity

Invasive aspergillosis is a major cause of morbidity and mortality in immunocompromised patients receiving intensive care. The double-sandwich ELISA for galactomannan is reported to have a high sensitivity (96.5%) for the detection of invasive aspergillosis when a cut-off value of 0.8 ng/ml is used. However, we have experienced a case of lethal disseminated aspergillosis in a patient that presented with a negative galactomannan (GM) test and persistent elevation of beta-D glucan (BG) levels. A 63-year-old female was admitted to our Intensive Care Unit (ICU) in acute respiratory failure and elevated BG. She had been receiving medication for Good-pasture syndrome based on anti-glomerular basement membrane antibodies and myeloperoxidase-antineutrophil cytoplasmic antibodies for 9 months and was receiving long-term prednisolone therapy (20 mg/day). On admission, her trachea was immediately intubated, and a PCR analysis of the bronchoalveolar lavage sample revealed Pneumocystis jiroveci. Trimethoprimsulfamethoxazole therapy was started for Pneumocystis pneumonia. The levels of BG remained elevated (> 100 pg/ml) during the treatment period despite the clinical resolution of Pneumocystis pneumonia, raising concerns of another complicated invasive fungal disease; consequently, fosfluconazole was administered empirically. The serum BG levels, however, did not decrease. Blood cultures did not detect a fungal infection. Serum GM levels measured by a double-sandwich ELISA on the 6th, 11th, and 24th days in the ICU were negative (< 0.2 ng/ml). The patient ultimately died of multiple organ failure on the 45th ICU day. Postmortem examination revealed a disseminated fungal infection with aggressive vascular invasion of the lungs, heart, and brain. In situ hybridization with a 568-bp probe of the alkaline proteinase sequence of Aspergillus fumigatus showed specific positive staining within the fungus present in the infected lung tissue, revealing that this patient may have had a systemic infection by A. fumigatus or A. flavus. This is a case of serum GM-negative disseminated aspergillosis pathologically proven by autopsy. Persistent elevated BG levels (> 100 pg/ml) refractory to trimethoprim-sulfamethoxazole and fosfluconazole may suggest possible Aspergillus infection and should prompt the initiation of empiric anti-aspergillosis therapies in patients at risk for fungal infection.

Topics: Antifungal Agents; Aspergillosis; Aspergillus; beta-Glucans; Brain; Fatal Outcome; Female; Galactose; Heart; Humans; Immunosuppressive Agents; Intensive Care Units; Lung; Mannans; Middle Aged; Pneumocystis carinii; Pneumonia, Pneumocystis; Prednisolone; Trimethoprim, Sulfamethoxazole Drug Combination

We compared a lateral flow device to galactomannan and (1-->3)-beta-D-glucan assays to detect invasive aspergillosis in an established guinea pig model of pulmonary disease. The lateral flow device became positive earlier (day 3) than the (1-->3)-beta-D-glucan and galactomannan assays (day 5), with all samples positive by each assay on day 7.

Topics: Animals; Antigens, Fungal; Aspergillus; beta-Glucans; Biomarkers; Chromatography, Liquid; Galactose; Guinea Pigs; Immunoassay; Invasive Pulmonary Aspergillosis; Male; Mannans; Point-of-Care Systems; Proteoglycans; Sensitivity and Specificity

Persistent or recurrent fevers of unknown origin (PFUO) in neutropenic patients on broad-spectrum antibiotics have traditionally been treated with empirical antifungal therapy (EAFT). The lack of survival benefit seen with the use of amphotericin B deoxycholate (AmB-D) as EAFT has been attributed to its toxicities. More recently, newer, less toxic and more expensive antifungal agents such as the lipid formulations of AmB, the newer azoles (fluconazole, itraconazole and voriconazole) and caspofungin have been analysed in a number of EAFT trials. Compared with AmB-D the newer agents have superior safety but are of equivalent efficacy. This lack of survival advantage is related to the fact that the trigger for commencement of EAFT is late and non-specific. Thus, alternative approaches are required. New sensitive serological and molecular tests for the detection of Aspergillus antigens and genomic DNA have been developed and evaluated in accuracy studies. These tests have been incorporated into management strategies (i.e. pre-emptive strategies) to direct antifungal therapy. The pre-emptive approach has been shown to be safe and feasible but its impact on clinically important patient outcomes such as survival is less clear. Other advances include the introduction of effective, non-toxic mould-active antifungal prophylaxis and patient risk-group stratification. In this paper we provide new evidence-based algorithms for the diagnosis and treatment of PFUO in adult patients undergoing stem cell transplantation and chemotherapy for haematological malignancy which incorporate these newer diagnostic tests and are directed by the risk category of the patient and type of antifungal prophylaxis the patient is receiving.

Topics: Adult; Algorithms; Antifungal Agents; Antigens, Fungal; Aspergillus; beta-Glucans; Evidence-Based Medicine; Fever of Unknown Origin; Galactose; Humans; Leukemia; Mannans; Polymerase Chain Reaction; Recurrence; Stem Cell Transplantation; Tomography, X-Ray Computed

Topics: Acyltransferases; alpha-Amylases; beta-Glucans; Coffea; Galactose; Humulus; Mannans; Oryza; Triticum

The aim of this study was to detect Aspergillus fumigatus-specific DNA by nested PCR (nPCR) in serum and bronchoalveolar lavage (BAL) specimens of experimentally infected rats and compare the results with (1-3)-beta-D-glucan (BDG) and galactomannan (GM) detection. Sixty Wistar rats, immunosuppressed with an intraperitoneal injection of cyclophosphamide (70 mg kg(-1)) were infected with 1 x 10(6)A. fumigatus conidia. The rats were killed on days 1, 3, 5, 7 and 9 postinfection in groups of six each and their BAL, blood and lungs were cultured. The A. fumigatus-specific DNA, BDG and GM in serum and BAL were detected by nPCR, Fungitell kit and Aspergillus Platelia kit respectively. Base line values were obtained by using sera from six healthy rats. Except the lungs, blood and BAL specimens of all the infected rats were negative for A. fumigatus culture. The BDG, GM and nPCR positivity in serum specimens was 80%, 77% and 63% respectively. The sensitivity of GM and nPCR tests in BAL specimens was 77% and 70% respectively. The data suggest that BDG and GM appear early in the course of infection, and have similar kinetics (r = 0.483, P = 0.007). Hence, their combined detection could be useful in the early diagnosis of invasive aspergillosis.

Topics: Animals; Aspergillosis; Aspergillus fumigatus; beta-Glucans; Bronchoalveolar Lavage Fluid; DNA, Fungal; Female; Galactose; Humans; Lung; Lung Diseases, Fungal; Mannans; Polymerase Chain Reaction; Rats; Rats, Wistar; Sensitivity and Specificity; Specific Pathogen-Free Organisms

A case of cerebral aspergillosis was diagnosed by the detection of Aspergillus flavus-specific DNA in brain biopsy and serum specimens. The diagnosis was also supported by detection of elevated levels of galactomannan and (1-->3)-beta-d-glucan in serum specimens. Despite the presence of dichotomously branched septate hyphae in brain biopsy, the culture remained negative. The inability to isolate the organism in culture suggested that combined therapy of AmBisome and caspofungin was fungicidal for the fungus in the brain abscess.

Topics: Amphotericin B; Antifungal Agents; Aspergillosis; Aspergillus flavus; beta-Glucans; Brain; Brain Diseases; Caspofungin; Diagnosis, Differential; DNA, Fungal; Echinocandins; Electrophoresis, Agar Gel; Galactose; Humans; Lipopeptides; Male; Mannans; Middle Aged; Peptides, Cyclic; Polymerase Chain Reaction

Invasive fungal infection (IFI) is a leading cause of infection-related mortality among patients with cancer and prolonged neutropenia and among allogeneic hematopoietic stem cell transplant recipients with graft-versus-host disease. Invasive candidiasis was the principal IFI in the period predating fluconazole prophylaxis, whereas today, invasive aspergillosis and other mold infections cause the majority of deaths from fungal infection in this patient population. The changing epidemiology of IFI, in addition to advances made in antifungal therapeutics and early diagnosis of IFI, warrant a reevaluation of earlier strategies aimed at prevention and early treatment of IFI that were developed several years ago. Here, we propose that persistent neutropenic fever is nonspecific for an IFI and should not be used as the sole criterion for empirical modification in the antifungal regimen in a patient receiving mold-active prophylaxis. We explore the potential benefits and gaps in knowledge associated with employing chest CT scans and laboratory markers as diagnostic adjuncts for IFI. Finally, we discuss the implications of newer antifungal agents and diagnostic adjuncts in the design of future clinical trials to evaluate prophylaxis and early prevention strategies.

Topics: Antifungal Agents; beta-Glucans; Biomarkers; Evaluation Studies as Topic; Fever; Fungi; Galactose; Hematopoietic Stem Cell Transplantation; Humans; Mannans; Mycoses; Neoplasms; Neutropenia; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Tomography, X-Ray Computed; Yeasts

Topics: Adult; Antifungal Agents; Antigens, Fungal; Aspergillosis; beta-Glucans; Caspofungin; Echinocandins; Fungal Proteins; Galactose; Humans; Lipopeptides; Mannans; Peptides, Cyclic

The aim of this study was to evaluate the diagnostic value of Aspergillus terreus-specific DNA, (1-3)-beta-d-glucan (BDG), and galactomannan (GM) in immunosuppressed mice infected intravenously with A. terreus conidia and sacrificed in groups of 12 each on days 1, 3, 5, 7, and 9. A. terreus-specific DNA, BDG, and GM in serum and bronchoalveolar lavage (BAL) were detected by nested polymerase chain reaction (nPCR), Fungitell kit (Associates of Cape Cod, E. Falmouth, MA), and Aspergillus Platelia kit (Bio-Rad, Marnes-laCoquette, France), respectively. Cultures of lung homogenate of all the animals yielded A. terreus. The BDG positivity, GM positivity, and nPCR positivity in serum specimens were 43%, 78%, and 73%, respectively. Combined detection enhanced the positivity to 95% for A. terreus DNA and GM, 83% for GM and BDG, and 95% for DNA, GM, and BDG. In BAL, the GM positivity and nPCR positivity were 80% and 81%, respectively, whereas combined detection increased the positivity to 98%. Detection of GM and DNA offers a sensitive and specific diagnostic option for invasive aspergillosis.

Topics: Animals; Aspergillosis; Aspergillus; beta-Glucans; Bronchoalveolar Lavage Fluid; DNA, Fungal; Female; Galactose; Humans; Mannans; Mice; Mice, Inbred BALB C; Polymerase Chain Reaction; Reagent Kits, Diagnostic; Sensitivity and Specificity; Specific Pathogen-Free Organisms

Topics: Aspergillosis; Aspergillus; beta-Glucans; Blood; Enzyme-Linked Immunosorbent Assay; Galactose; Humans; Mannans; Mycology; Polymerase Chain Reaction; Sensitivity and Specificity; Tomography, X-Ray Computed

Two noninvasive diagnostic tests, (1-->3)-beta-D-glucan (BG) (Glucatell) and galactomannan (GM) (Platelia Aspergillus), were used retrospectively in a twice-weekly screening for the diagnosis of invasive aspergillosis (IA) in 40 treatment episodes (one hospital visit per patient) in 40 neutropenic adult patients at high risk for IA. Five proven IA cases, three probable IA cases, and three possible IA cases were diagnosed. Diagnostic levels of both BG and GM were detected in 100% of patients with proven IA cases and in 66% of patients with probable IA cases. The kinetics of both markers in patients with IA were similar. The sensitivity, specificity, and positive and negative predictive values for GM and BG were identical, namely, 87.5, 89.6, 70, and 96.3%, respectively. False-positive reactions occurred at a rate of 10.3% in both tests, but the patients showing false-positive results were different in each test. Both tests anticipated the clinical diagnosis, computed tomography abnormalities, and the initiation of antifungal therapy in most patients, but BG tended to become positive earlier than GM. A combination of the two tests improved the specificity (to 100%) and positive predictive value (to 100%) of each individual test without affecting the sensitivity and negative predictive values. In conclusion, BG and GM detection are useful tests for the diagnosis of IA in high-risk hematological patients, but a combination of the two tests was very useful to identify false-positive reactions by each test.

Topics: Adolescent; Adult; Aged; Antifungal Agents; Aspergillosis; Aspergillus; beta-Glucans; Chromogenic Compounds; Female; Galactose; Humans; Male; Mannans; Middle Aged; Neutropenia; Predictive Value of Tests; Sensitivity and Specificity

The establishment of an optimal noninvasive method for diagnosing invasive aspergillosis (IA) is needed to improve the management of this life-threatening infection in patients with hematological disorders, and a number of noninvasive tests for IA that target different fungal components, including galactomannan, (1-->3)-beta-d-glucan (BDG), and Aspergillus DNA, have been developed. In this study, we prospectively evaluated the diagnostic potential of three noninvasive tests for IA that were used in a weekly screening strategy: the double-sandwich enzyme-linked immunosorbent assay (ELISA) for galactomannan (Platelia Aspergillus), a real-time PCR assay for Aspergillus DNA (GeniQ-Asper), and an assay for BDG (beta-glucan Wako). We analyzed 149 consecutive treatment episodes in 96 patients with hematological disorders who were at high risk for IA and diagnosed 9 proven IA cases, 2 probable IA cases, and 13 possible invasive fugal infections. In a receiver-operating characteristic (ROC) analysis, the area under the ROC curve was greatest for ELISA, using two consecutive positive results (0.97; P = 0.036 for ELISA versus PCR, P = 0.055 for ELISA versus BDG). Based on the ROC curve, the cutoff for the ELISA could be reduced to an optical density index (O.D.I.) of 0.6. With the use of this cutoff for ELISA and cutoffs for PCR and BDG that give a comparable level of specificity, the sensitivity/specificity/positive predictive value/negative predictive value of the ELISA and the PCR and BDG tests were 1.00/0.93/0.55/1.00, 0.55/0.93/0.40/0.96, and 0.55/0.93/0.40/0.96, respectively. In conclusion, among these weekly screening tests for IA, the double-sandwich ELISA test was the most sensitive at predicting the diagnosis of IA in high-risk patients with hematological disorders, using a reduced cutoff of 0.6 O.D.I.

Topics: Adolescent; Adult; Aged; Aspergillosis; beta-Glucans; Enzyme-Linked Immunosorbent Assay; Female; Galactose; Glucans; Hematologic Diseases; Humans; Male; Mannans; Middle Aged; Polymerase Chain Reaction; Prospective Studies; ROC Curve; Sensitivity and Specificity

We analyzed the performance of (1, 3)-Beta-D-glucan (measurement by the alkaline-kinetic chromogenic Limulus method (FUNGITEC G test-MK, Fungitec) and the kinetic turbidimetric Limulus method [Beta-Glucan test WAKO, Wako]) and we carried out Aspergillus galactomannan antigen detection (enzyme-linked immunosorbent assay, ELISA test) for the early diagnosis of invasive aspergillosis in patients with hematological diseases at the time of febrile episodes of unknown origin that did not respond to antibacterial therapy for more than 3 days. During a one-year period (April 2002 to March 2003), a total of 69 febrile episodes in 58 patients were studied; 8 cases of invasive aspergillosis were diagnosed according to the definition of the European Organization for Research and Treatment of Cancer/Mycosis Study Group, and 61 cases were found to be non-mycotic diseases. Based on the analysis of 69 results with confirmed disease status, the overall performance of the Fungitec, the Wako, and the ELISA test were as follows: sensitivity was 0.88, 0.63, and 0.50, respectively, whereas the specificity was 0.85, 0.98, and 1.0, respectively. Moreover, there was a strong relationship between the log-transformed values of the (1, 3)-Beta-D-glucan levels measured by the two methods (r = 0.92 [95%CI, 0.89-0.94] ; p<0.001). For the statistical analysis of these serological tests a receiver operating characteristic curve (ROC) was used, as well as the resulting area under the ROC curve (ROC AUC). The ROC AUC and the cut-off values that gave the highest accuracy were as follows: 0.92, 24.9 pg/ml for the Fungitec, 0.84, 7.3 pg/ml for the Wako, and 0.89, 0.9 COI for the ELISA test, respectively. In conclusion, these results indicate that both of the two (1, 3)-Beta-D-glucan measurement approaches served equally well as surveillance tools for determining the extent of invasive aspergillosis; in addition, the log-transformed value of these tests can be used for comparison. Moreover, the ELISA test was found to have clinical utility, both as a surveillance and as a diagnostic tool when invasive aspergillosis was suspected. It should be noted that the galactomannan assay had sensitivity-related limitations; lowering the cut-off value is expected to increase the diagnostic value for use in cases of invasive aspergillosis.

Topics: Adult; Aged; Aged, 80 and over; Antigens, Fungal; Aspergillosis; beta-Glucans; Female; Galactose; Glucans; Hematologic Neoplasms; Humans; Limulus Test; Lung Diseases, Fungal; Male; Mannans; Middle Aged; Sensitivity and Specificity

We compared PCR, galactomannan detection assay using a latex agglutination test and (1-->3)-beta-D-glucan detection assay in detecting infection in rats experimentally infected with Aspergillus fumigatus. On day 2 after inoculation, (1-->3)-beta-D-glucan and nested PCR were positive for 80%, while galactomannan detection assay was positive for 60%. In addition, the positive result of nested PCR (87.5%) was higher than those of galactomannan detection assay (75%) and (1-->3)-beta-D-glucan (71.4%) on day 3 after inoculation. The sensitivity of nested PCR was superior to those of galactomannan detection assay and (1-->3)-beta-D-glucan detection assay. The three diagnostic tests were compared with histopathological findings, and the sensitivity of three diagnostic tests was correlated with histopathological changes. In addition, the elevated levels of (1-->3)-beta-D-glucan paralleled the development and progression of pulmonary aspergillosis. Our results indicate that a combination of two or three of these tests seems to provide a rapid diagnosis of invasive aspergillosis and assist in the evaluation of the development and severity of invasive aspergillosis.

Topics: Animals; Aspergillosis; Aspergillus fumigatus; beta-Glucans; Galactose; Glucans; Latex Fixation Tests; Lung Diseases, Fungal; Male; Mannans; Polymerase Chain Reaction; Rats; Rats, Sprague-Dawley

The G test containing factor G, fractioned from the Limulus lysate, was used to detect (1-3)-beta-D-glucan in a rat model of aspergillosis. Aspergillus fumigatus strain MF-13, 1 x 10(4) conidia, were inoculated transtracheally into rats treated with cortisone acetate (100 mg/kg) and fed a low-protein (8%) diet. Increased serum (1-3)-beta-D-glucan was found on the sixth day after inoculation in concentrations of 370 +/- 178 pg/ml (mean +/- SD) in untreated controls, and 154 +/- 43 pg/ml in rats treated with 0.5 mg/kg of amphotericin B. On day 11 (1-3)-beta-D-glucan concentrations were 2,590 +/- 2,940 pg/ml and 448 +/- 442 pg/ml, respectively. The elevation in levels of (1-3)-beta-D-glucan increased in correlation with the elevation of galactomannan antigen titers; (1-3)-beta-D-glucan is thus measurable during experimental aspergillosis in rats.

Topics: Amphotericin B; Animals; Aspergillosis; Aspergillus fumigatus; beta-Glucans; Disease Models, Animal; Galactose; Glucans; Horseshoe Crabs; Lung; Male; Mannans; Rats; Rats, Sprague-Dawley

(1-3)-beta-D-Glucan (beta-glucan) is a major structural component of fungi. The G test is a direct method to detect beta-glucan using fractionated (1-3)-beta-D-glucan-sensitive component, factor G, eluted from the limulus lysate. Previously, we reported that the G test is a more sensitive method than the mannan detection assay for the serological diagnosis of Candida infection. In this study, we discuss beta-glucanemia in patients with pulmonary aspergillosis and cryptococcosis. The concentration of beta-glucan was less than 10 pg/ml in 9 of 10 cases of pulmonary cryptococcosis, except for one case receiving hemodialysis (16.5 pg/ml). beta-Glucan increased in 3 cases of invasive pulmonary aspergillosis (27-937 pg/ml). Galactomannan antigen was positive in all of those cases. In 8 cases of aspergilloma, which showed fungus ball on roentgenogram, the mean concentration of beta-glucan was 67.1 +/- 92.7 pg/ml. Two of 8 cases were positive for galactomannan antigen. One of three cases of PAIC (productive aspergilloma on the inner wall of a cavity) and one case of chronic necrotizing pulmonary aspergillosis showed slightly increased levels of beta-glucan and positive results of galactomannan antigen test.

Topics: Adult; Aged; Antigens, Fungal; Aspergillosis; beta-Glucans; Child; Cryptococcosis; Female; Galactose; Glucans; Humans; Lung Diseases, Fungal; Male; Mannans; Middle Aged