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Clinical Diagnostics - Reference Information

reference lists

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  29. Metan, G., Agkus, C., Buldu, H., Koç, A.N. (2010). The interaction between piperacillin/tazobactam and assays for Aspergillus galactomannan and 1,3-beta-D-glucan in patients without risk factors for invasive fungal infections Infection. 38:217-21.

  30. Mikulska, M., Furfaro, E., Del Bono, V., Gualandi, F., Van Lint, M.T., Miletich, F., Bacigalupo, A., and Viscoli, C. (2011) Persistence of positive (1,3)-beta-glucan test after clearance of candidemia in HSCT recipients. Clin. Vacc. Immunol. 18: 518-519.

  31. Mohr, J.F., Sims, C., Paetznick, V., Rodriguez, J., Finkelman, M.A., Rex, J.H., and Ostrosky-Zeichner, L. (2010). A Prospective survey of (1→3)-ß-D-glucan and its relationship to Invasive candidiasis in the surgical ICU setting. J Clin Microbiol. 49: 58-61.

  32. Mularoni, A., Furfaro, E., Faraci, M., Franceschi, A., Mezzano, P., Bandettini, R., Viscoli, C., and Castagnola, E. (2010) High Levels of beta-D-glucan in immunocompromised children with proven invasive fungal disease. Clin Vaccine Immunol. 17:882-3.

  33. Obayashi, T., Negishi, K., Suzuki, T., and Funata, N. (2008) Reappraisal of the serum (1→3)-beta-D-glucan assay for the diagnosis of invasive fungal infections - a study based on autopsy cases from 6 years. Clin. Infect. Dis. 46: 1864-1870.

  34. Odabasi, Z., Mattiuzzi, G., Estey, E., Kantarjian,H., Saeki, F., Ridge, R., Ketchum, P., Finkelman, M., Rex, J. and Ostrosky-Zeichner, L. (2004) Beta-D-glucan as a diagnostic adjunct for invasive fungal infections: Validation, cutoff development, and performance in patients with Acute Myelogenous Leukemia and Myelodysplastic Syndrome. Clinical Infectious Diseases. 39:199-205.

  35. Odabasi, Z., Paetznick, V.L., Rodriguez, J.R., Chen, E., McGinnis, M.R., and Ostrosky-Zeichner, L. (2006) Differences in beta-glucan levels in culture supernatants of a variety of fungi. Med Mycol. 44:267-72.

  36. Ostrosky-Zeichner, L., Alexander, B.D., Kett, D.H., Vazquez, J., Pappas, P.G., Saeki, F., Ketchum, P.A., Wingard, J., Schiff, R., Tamura, H., Finkelman, M.A., and Rex, J.H. (2005) Multicenter clinical evaluation of the (1→3)-ß-D-glucan assay as an aid to diagnosis of fungal infections in humans. Clin. Inf. Dis. 41: 299-305.

  37. Ostrosky-Zeichner, L., Paetznick, V.L., Rodriguez, J., Chen, E., and Sheehan, D.J. (2009) Activity of anidulafungin in a murine model of Candida krusei infection: evaluation of mortality and disease burden by quantitative tissue cultures and measurement of serum (1→3)-ß-D-glucan levels. Antimicrob. Agents Chemother. 53: 1639-1641.

  38. Pazos, C., Ponton, J., and Del Palacio, A. (2005) Contribution of (1→3)-ß-D-glucan chromogenic assay to diagnosis and therapeutic monitoring of invasive aspergillosis in neutropenic adult patients: A comparison with serial screening for circulating galactomannan. Journal of Clinical Microbiology 43(1): 299-305.

  39. Pazos, C., Moragues, M-D., Quindos, G., and del Palacio, A. (2006) Diagnostic potential of (1→3)-ß-D-glucan and anti-Candida albicans germ tube antibodies for the diagnosis and therapeutic monitoring of invasive candidiasis in neutropenic adult patients. Re. Iberoam Micol. 23: 209-215

  40. Persat, F., Ranque, S., Derouin, F., Michel-Nguyen, A., Picot, S., and Sulahian, A. (2008) Contribution of the (1→3)-ß-D-glucan Assay for the Diagnosis of Invasive Fungal Infections. J. Clin. Micro. 36: 1009-1013.

  41. Petraitiene, R., Petraitis, V., Hope, W.W., Mickiene, D., Kelaher, A.M., Murray, H.A., Mya-San, C., Hughes, J.E., Cotton, M.P., Bacher, J., and Walsh, T.J. (2008) CSF and Plasma (1→3)-ß-D-glucan as surrogate markers for detection and therapeutic response of experimental hematogenous candida meningoencephalitis. Antimicrobial Agents and Chemotherapy Antimicrob. Agents. Chemo. 52: 4121-4129.

  42. Pickering, J.W., Sant, H.W., Bowles, C.A., Roberts, W.L., and Woods, GL. (2005) Evaluation of a (1→3)-beta-D-glucan assay for diagnosis of invasive fungal infections. J. Clin. Microbiol. 43:5957-62.

  43. Ponton, J. (2009) Usefulness of biological markers in the diagnosis of invasive candidiasis. Rev. Iberoam. Micol. 26:8-14.

  44. Sax, P.E. and Piscuilli, M.L. (2008), Use of a Serum ß-D-Glucan Assay for Diagnosis of HIV-Related Pneumocystis jiroveci Pneumonia in Patients with Negative Microscopic Examination Results. CID 2008:46.

  45. Smith, P.B., Benjamin, D.K., Alexander, B.D., Johnson, M.D., Finkelman, M.A., and Steinbach, W.J. (2007) (1→3)-ß-D-glucan levels in pediatric patients: Preliminary data for the use of the beta-glucan test in children. Clin. Vaccine Immunol. 14: 924-925.

  46. Racil, Z., Kocmanova, I., Lengerova, M., Weinbergerova, B., Buresova, L., Toskova, M., Winterova, J., Timilsina, S., Rodriguez, I., Mayer, J. (2010) Difficulties in using 1,3-beta-D glucan as the screening test for the early diagnosis of invasive fungal diseases in patients with hematological malignancies - high frequency of false positive results and their analysis. J Med Microbiol. 2010 May 20. [Epub ahead of print].

  47. Thornton, C.R. (2008) Development of an immunochromatographic lateral-flow device for rapid serodiagnosis of invasive aspergillosis. Clin Vaccine Immunol. 2008 15:1095-105.

  48. Wiederhold, N.P., Najvar, L.K., Vallor, A.C., Kirkpatrick, W.R., Bocanegra, R., Molian, D., Olivo, M., Graybill, J.R., and Patterson, T.F. (2008) Assessment of (1→3)-ß-D-glucan concentration as a measure of disease burden in a murine model of invasive pulmonary aspergillosis Antimicrob. Agents and Chemotherapy. Antimicrob. Agents Chemother. 52; 1176-1178.

reference abstracts

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1. Diagnosis of fungal infection: new technologies for the mycology laboratory.

Alexander BD.

transplant Infectious Diseases Services, Clinical Mycology Laboratory, Duke University Medical Center, Durham, NC 27710, USA. alexa011@mc.duke.edu

Abstract: The dramatic increase in nosocomial invasive mycoses over the past two decades has led to increased interest in the area of antifungal development. Unfortunately, the infusion of new diagnostic technology into the clinical mycology laboratory has lagged behind. Although newer, automated, continuous-monitoring blood culture systems are as sensitive as the older, manual "gold standard" system, the recovery of fungi from blood, as well as other clinical specimens, remains an insensitive marker for invasive fungal infection. Antigen assays for the rapid diagnosis of invasive fungal infections are in development, and galactomannan and glucan are two such promising antigens. Glucan may be present in the blood of patients with infection secondary to a wide variety of fungal pathogens, including Candida, Aspergillus, Fusarium, Saccharomyces, trichosporon and Acremonium species. Early data suggest galactomannan may be present in the blood in detectable levels very early in the course of invasive aspergillosis. The galactomannan assay currently undergoing evaluations may actually be positive prior to the clinical suspicion for infection and may be useful in monitoring therapeutic response as well; however, the etiology of false-positive results following cytotoxic chemotherapy still has to be elucidated. PCR assays are also being developed in the research laboratory, however, the PCR assays will require a significant amount of adaptation and validation before they are ready for clinical care. Well-planned studies to evaluate the performance characteristics as well as appropriate clinical and cost-effective application of these new tests are needed.

2. Plasma (1→3)-ß-D-glucan and fungal antigenemia in patients with candidemia, aspergillosis, and cryptococcosis.

T Miyazaki, S Kohno, K Mitsutake, S Maesaki, K Tanaka, N Ishikawa, and K Hara

Second Department of Internal Medicine, Nagasaki University School of Medicine, Japan.

(1→3)-ß-D-Glucan is one of the major structural components of fungi, and it seems that it can be detected by the fractionated (1→3)-ß-D-glucan-sensitive component from a Limulus lysate, factor G. We evaluated the concentration of (1→3)-ß-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)-ß-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)-ß-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)-ß-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)-ß-D-glucan levels are elevated in patients with candidiasis and aspergillosis but not in those with cryptococcosis.

3. Impact of diagnostic markers on early antifungal therapy.

Jones BL,McLintock LA.

Department of Medical Microbiology, North Glasgow Hospitals University NHS trust, Royal Infirmary, University of Glasgow, Glasgow, UK. b.l.jones@clinmed.gla.ac.uk

Purpose of Review The early treatment of invasive fungal infection is critical but is hampered by the non-specific nature of clinical and radiological signs and the insensitivity of current laboratory diagnostic methods. If mortality due to invasive fungal infection is to be reduced, new, preemptive therapeutic strategies, targeting those patients at highest risk, are required and these will depend on the development of rapid, sensitive diagnostic methods. Such methods have become available in the form of high-resolution computed tomography scanning and serological and molecular techniques and in this review the authors describe recent studies assessing the utility of these methods and consider their role in management strategies.

Recent Findings: Sensitive assays for the detection of fungal DNA and antigens such as galactomannan and glucan have been prospectively evaluated in the clinical setting and enable identification of patients at an earlier stage of infection. However, the sensitivity and specificity of the assays vary considerably in different studies, depending on several factors including patient selection and clinical application of the test, and issues regarding the release and circulation of galactomannan and fungal DNA remain to be clarified.

Summary: Rapid serological and molecular diagnostic methods facilitate the early diagnosis of invasive fungal infection and would appear to be most useful when used prospectively to screen high-risk patients. However, in order to determine the optimal approach to treatment it is essential that these tests are incorporated into management strategies and their impact on incidence of invasive fungal infection and clinical outcome evaluated in further clinical trials.

4. Beta-D-glucan as a diagnostic adjunct for invasive fungal infections: validation, cutoff development, and performance in patients with acute myelogenous leukemia and myelodysplastic syndrome.

Odabasi Z, Mattiuzzi G, Estey E, Kantarjian H, Saeki F, Ridge RJ, Ketchum PA, Finkelman MA, Rex JH, Ostrosky-Zeichner L.

Laboratory of Medical Mycology, University of Texas-Houston Medical School, Houston, TX, USA.

The Glucatell (1→3)-ß-D-glucan (BG) detection assay (Associates of Cape Cod) was studied as a diagnostic adjunct for invasive fungal infections (IFIs). On the basis of findings from a preliminary study of 30 candidemic subjects and 30 healthy adults, a serum BG level of >or=60 pg/mL was chosen as the cutoff. Testing was performed with serial serum samples obtained from 283 subjects with acute myeloid leukemia or myelodysplastic syndrome who were receiving antifungal prophylaxis. At least 1 serum sample was positive for BG at a median of 10 days before the clinical diagnosis in 100% of subjects with a proven or probable IFI. IFIs included candidiasis, fusariosis, trichosporonosis, and aspergillosis. Absence of a positive BG finding had a 100% negative predictive value, and the specificity of the test was 90% for a single positive test result and >or=96% for >or=2 sequential positive results. The Glucatell serum BG detection assay is highly sensitive and specific as a diagnostic adjunct for IFI.

5. Plasma (1→3)-ß-D-glucan measurement in diagnosis of invasive deep mycosis and fungal febrile episodes.

Obayashi, T., Yoshida, M., Mori, T., Goto, H. Yasuoka, A., Iwasaki, H., Teshima, H., Kohno, S., Horichi, A., Ito, A., Yamaguchi, H., Shimada, K., and Kawai, T. (1995)


(1→3)-ß-D-glucan is a characteristic fungal cell-wall constituent. To assess the clinical usefulness of this glucan in screening for invasive fungal infection or fungal febrile episodes, we measured the plasma concentration at the time of routine blood culture in 202 febrile episodes by means of factor G , a horseshoe-crab coagulation enzyme that is extremely sensitive to this polysaccharide.

With a plasma cut-off value of 20 pg/mL, 37 of 41 episodes of definite fungal infections (confirmed at necropsy or by microbiology) had positive results (sensitivity 90%). All of 59 episodes of non-fungal infections, tumour fever, or collagen diseases had concentrations below the cut-off value (specificity 100%). Of 102 episodes of fever of unknown origin, 26 had plasma glucan concentrations of more than 20 pg/mL. With those 102 cases taken as non-fungal infections, the positive predictive value of the test was estimated as 59% (37/63), the negative predictive value as 97% (135/139), and the efficiency as 85% 9172/202). The positive predictive value should improve if there were a sensitive gold standard that could discriminate fungal from non-fungal infections. Causative fungi included candida, aspergillus, cryptococcus, and trichosporon.

Determination of plasma (1→3)-ß-D-glucan with factor G is a highly sensitive and specific test for invasive deep mycosis and fungal febrile episodes, and will substantially benefit immunocompromised patients.

6. (1→3)-ß-D-glucan in patients with pulmonary aspergilloma.

Yuasa K., and Goto H. (1997)

Division of Hematology, Department of Medicine and Department of Clinical Pathology, Jichi Medical School, Minamikawachi-machi, Tochigi-ken, Japan, 329-04

Abstract: To elucidate the role of (1→3)-ß-D-glucan in pulmonary aspergilloma, serum concentrations of (1→3)-ß-D-glucan were measured repeatedly for as long as 10 months in eight patients. In four patients with inactive disease, concentrations of (1→3)-ß-D-glucan were in the normal range.The concentrations of (1→3)-ß-D-glucan increased in two patients, although the disease was inactive. This increase might show the earliest stage of the invasive process of the disease. In two other patients with active disease, (1→3)-ß-D-glucan increased. Other parameters, such as galactomannan, immunodiffusion and a radio-allergosorbent test, as well as inflammatory markers such as C-reactive protein and the leukocyte count, did not show any consistent tendency in regard to the activity of the disease. Thus, a (1→3)-ß-D-glucan assay may add valuable data for evaluating the disease activity and understanding the disease process of pulmonary aspergilloma.

7. Detection of plasma (1→3)-beta-D-glucan in patients with Fusarium, trichosporon, Saccharomyces and Acremonium fungaemias.

Yoshida M, Obayashi T, Iwama A, Ito M, Tsunoda S, Suzuki T, Muroi K, Ohta M, Sakamoto S, Miura Y. (1997)

Department of Medicine, Jichi Medical School, Tochigi-ken, Japan.

Abstract: (1→3)-ß-D-glucan, a characteristic fungal molecule, is known to increase in blood in invasive candidiasis, aspergillosis and cryptococcosis. This report shows that the plasma glucan concentration was also elevated in four patients infected with Fusarium, trichosporon beigelii, Saccharomyces cerevisiae and Acremonium. In three of the patients, the elevation preceded positive blood cultures by 5-17 days, and in one of them it even preceded the onset of fever by 6 days. In a fourth patient, the glucan level decreased with clinical improvement. Plasma (1→3)-ß-D-glucan determination appears to be useful also for diagnosis and follow-up of these unusual deep mycoses.

8. Contribution of (1→3)-beta-D-glucan chromogenic assay to diagnosis and therapeutic monitoring of invasive aspergillosis in neutropenic adult patients: A comparison with serial screening for circulating galactomannan.

Pazos C, Ponton J, Del Palacio A.

Unidad de Micologia, Departamento de Microbiologia, Hospital Universitario 12 de Octubre, Avenida de Cordoba s/n, 28041 Madrid, Spain. pazos.c@terra.es

Abstract: Two noninvasive diagnostic tests, (1→3)-ß-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.

resource links

Dr. Fungus www.doctorfungus.org
The Aspergillus Website     www.aspergillus.man.ac.uk
NIH - Medline Plus http://www.nlm.nih.gov/medlineplus/
PubMed http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

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