Limits...
Combining standard clinical methods with PCR showed improved diagnosis of invasive pulmonary aspergillosis in patients with hematological malignancies and prolonged neutropenia.

Paholcsek M, Fidler G, Konya J, Rejto L, Mehes G, Bukta E, Loeffler J, Biro S - BMC Infect. Dis. (2015)

Bottom Line: Sera were successively screened for galactomannan antigen and for Aspergillus fumigatus specific nucleic acid targets.Although bronchoalveolar lavage proved negative in 93 % of controls it did not detect IPA in 86 % of the cases.The data from this pilot-study demonstrate that the consideration of standard clinical methods combined with biomarker testing improves the capacity to make early and more accurate diagnostic decisions.

View Article: PubMed Central - PubMed

Affiliation: Faculty of Medicine, Department of Human Genetics, University of Debrecen, Nagyerdei krt. 98, H-4032, Debrecen, Hungary. paholcsek.melinda@med.unideb.hu.

ABSTRACT

Background: We assessed the diagnostic value of standard clinical methods and combined biomarker testing (galactomannan assay and polymerase chain reaction screening) in a prospective case-control study to detect invasive pulmonary aspergillosis in patients with hematological malignancies and prolonged neutropenia.

Methods: In this observational study 162 biomarker analyses were performed on samples from 27 febrile neutropenic episodes. Sera were successively screened for galactomannan antigen and for Aspergillus fumigatus specific nucleic acid targets. Furthermore thoracic computed tomography scanning was performed along with bronchoscopy with lavage when clinically indicated. Patients were retrospectively stratified to define a case-group with "proven" or "probable" invasive pulmonary aspergillosis (25.93 %) and a control-group of patients with no evidence for of invasive pulmonary aspergillosis (74.07 %). In 44.44 % of episodes fever ceased in response to antibiotic treatment (group II). Empirical antifungal therapy was administered for episodes with persistent or relapsing fever (group I). 48.15 % of patients died during the study period. Postmortem histology was pursued in 53.85 % of fatalities.

Results: Concordant negative galactomannan and computed tomography supported by a polymerase chain reaction assay were shown to have the highest discriminatory power to exclude invasive pulmonary aspergillosis. Bronchoalveolar lavage was performed in 6 cases of invasive pulmonary aspergillosis and in 15 controls. Although bronchoalveolar lavage proved negative in 93 % of controls it did not detect IPA in 86 % of the cases. Remarkably post mortem histology convincingly supported the presence of Aspergillus hyphae in lung tissue from a single case which had consecutive positive polymerase chain reaction assay results but was misdiagnosed by both computed tomography and consistently negative galactomannan assay results. For the galactomannan enzyme-immunoassay the diagnostic odds ratio was 15.33 and for the polymerase chain reaction assay it was 28.67. According to Cohen's kappa our in-house polymerase chain reaction method showed a fair agreement with the galactomannan immunoassay. Combined analysis of the results from the Aspergillus galactomannan enzyme immunoassay together with those generated by our polymerase chain reaction assay led to no misdiagnoses in the control group.

Conclusion: The data from this pilot-study demonstrate that the consideration of standard clinical methods combined with biomarker testing improves the capacity to make early and more accurate diagnostic decisions.

Show MeSH

Related in: MedlinePlus

Venn-diagrams with section-analysis comparing the outcomes of Platelia Aspergillus GM-EIA and facC-PCR. TP true-positive, FN false-negative, TN true-negative, FP false-positive. Cases (proven and probable IA) with positive GM-EIA and PCR results were regarded as true positive (TP) while those with negative outcomes were considered to be false negative (FN). Controls (unclassified patients with no EORTC/MSG evidence of IA) with negative GM-EIA and PCR results were coded to true negative (TN) and those with positive outcomes false positive (FP). a 27 of 32 (84 %) and 9 of 24 (38 %) serum samples from cases (proven/probable) proved to be true positive (TP) when testing with facC-PCR and GM-EIA respectively. GM-EIA failed to detect 15 of 24 and facC-PCR 5 of 32 samples. Section analysis: 8 of 24 specimens from cases (33 %) proved to be true positive (TP) with both assays and 3 of 24 (8 %) found to be negative (FN) by both of them. There was only one specimen (4 %) of 24 that was missed by facC-PCR but not by GM-EIA. 50 % of specimens (12 of 24) however were detected only by PCR but not with GM-EIA. b 51 of 53 (96 %) and 44 of 53 (83 %) serum specimens from controls (unclassified patients with no evidence of IA) proved to be negative (TN) thus 2 of 53 (3,8 %) and 9 of 53 (17 %) were undetected. There were 9 of 53 (17 %) specimens that proved to be false-positive with PCR but real-negative with GM and only 2 of 53 (4 %) that proved to be false-positive with GM-EIA but true-negative with facC-PCR. Section analysis: 83 % of specimens (44 of 53) remained consistently negative with both of the assays but there were none that proved to be false-positive when testing with both methods
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
getmorefigures.php?uid=PMC4487853&req=5

Fig4: Venn-diagrams with section-analysis comparing the outcomes of Platelia Aspergillus GM-EIA and facC-PCR. TP true-positive, FN false-negative, TN true-negative, FP false-positive. Cases (proven and probable IA) with positive GM-EIA and PCR results were regarded as true positive (TP) while those with negative outcomes were considered to be false negative (FN). Controls (unclassified patients with no EORTC/MSG evidence of IA) with negative GM-EIA and PCR results were coded to true negative (TN) and those with positive outcomes false positive (FP). a 27 of 32 (84 %) and 9 of 24 (38 %) serum samples from cases (proven/probable) proved to be true positive (TP) when testing with facC-PCR and GM-EIA respectively. GM-EIA failed to detect 15 of 24 and facC-PCR 5 of 32 samples. Section analysis: 8 of 24 specimens from cases (33 %) proved to be true positive (TP) with both assays and 3 of 24 (8 %) found to be negative (FN) by both of them. There was only one specimen (4 %) of 24 that was missed by facC-PCR but not by GM-EIA. 50 % of specimens (12 of 24) however were detected only by PCR but not with GM-EIA. b 51 of 53 (96 %) and 44 of 53 (83 %) serum specimens from controls (unclassified patients with no evidence of IA) proved to be negative (TN) thus 2 of 53 (3,8 %) and 9 of 53 (17 %) were undetected. There were 9 of 53 (17 %) specimens that proved to be false-positive with PCR but real-negative with GM and only 2 of 53 (4 %) that proved to be false-positive with GM-EIA but true-negative with facC-PCR. Section analysis: 83 % of specimens (44 of 53) remained consistently negative with both of the assays but there were none that proved to be false-positive when testing with both methods

Mentions: Testing control serum specimens with GM-EIA and facC-PCR yielded a high specificity (96 %) (Fig. 4b). Only two control specimens from episodes with no EORTC/MSG evidence of IPA were false-positive when testing with GM-EIA. GM-EIA failed to detect the presence of Aspergillus GM antigen in 63 % of the cases and sensitivity proved to be only 38 % (Fig. 4a). In the case population facC-PCR was able to detect the presence of Aspergillus fumigatus specific nucleic acid target molecules in 84 % of cases by considering a single positive run from triplicate reactions as significant. Conversely facC-PCR failed to detect 16 % of the samples from cases (Fig. 4a). With regard to specificity, 83 % of control specimens were negative when tested with facC-PCR ensuring a relatively high false-positivity rate of 17 % for PCR (Fig. 4b). Comparison analysis was done by examining the different sections of Venn-diagrams shown in Fig. 4. Only paired results were considered and those that were superior in numbers (in the cases of patient ID 4 and ID 10 for the benefit of facC-PCR) were excluded from the section analysis. In doing so we can see that 50 % of specimens from cases were detected only by facC-PCR but not with GM-EIA thus 8 % of specimens from cases were missed with either of the two methods. It is noteworthy that in 83 % of all cases when testing control specimens (from episodes with no EORTC/MSG evidence of IPA) both assays remained consistently negative furthermore there were no false-positive cases when testing with both methods.Fig. 4


Combining standard clinical methods with PCR showed improved diagnosis of invasive pulmonary aspergillosis in patients with hematological malignancies and prolonged neutropenia.

Paholcsek M, Fidler G, Konya J, Rejto L, Mehes G, Bukta E, Loeffler J, Biro S - BMC Infect. Dis. (2015)

Venn-diagrams with section-analysis comparing the outcomes of Platelia Aspergillus GM-EIA and facC-PCR. TP true-positive, FN false-negative, TN true-negative, FP false-positive. Cases (proven and probable IA) with positive GM-EIA and PCR results were regarded as true positive (TP) while those with negative outcomes were considered to be false negative (FN). Controls (unclassified patients with no EORTC/MSG evidence of IA) with negative GM-EIA and PCR results were coded to true negative (TN) and those with positive outcomes false positive (FP). a 27 of 32 (84 %) and 9 of 24 (38 %) serum samples from cases (proven/probable) proved to be true positive (TP) when testing with facC-PCR and GM-EIA respectively. GM-EIA failed to detect 15 of 24 and facC-PCR 5 of 32 samples. Section analysis: 8 of 24 specimens from cases (33 %) proved to be true positive (TP) with both assays and 3 of 24 (8 %) found to be negative (FN) by both of them. There was only one specimen (4 %) of 24 that was missed by facC-PCR but not by GM-EIA. 50 % of specimens (12 of 24) however were detected only by PCR but not with GM-EIA. b 51 of 53 (96 %) and 44 of 53 (83 %) serum specimens from controls (unclassified patients with no evidence of IA) proved to be negative (TN) thus 2 of 53 (3,8 %) and 9 of 53 (17 %) were undetected. There were 9 of 53 (17 %) specimens that proved to be false-positive with PCR but real-negative with GM and only 2 of 53 (4 %) that proved to be false-positive with GM-EIA but true-negative with facC-PCR. Section analysis: 83 % of specimens (44 of 53) remained consistently negative with both of the assays but there were none that proved to be false-positive when testing with both methods
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4487853&req=5

Fig4: Venn-diagrams with section-analysis comparing the outcomes of Platelia Aspergillus GM-EIA and facC-PCR. TP true-positive, FN false-negative, TN true-negative, FP false-positive. Cases (proven and probable IA) with positive GM-EIA and PCR results were regarded as true positive (TP) while those with negative outcomes were considered to be false negative (FN). Controls (unclassified patients with no EORTC/MSG evidence of IA) with negative GM-EIA and PCR results were coded to true negative (TN) and those with positive outcomes false positive (FP). a 27 of 32 (84 %) and 9 of 24 (38 %) serum samples from cases (proven/probable) proved to be true positive (TP) when testing with facC-PCR and GM-EIA respectively. GM-EIA failed to detect 15 of 24 and facC-PCR 5 of 32 samples. Section analysis: 8 of 24 specimens from cases (33 %) proved to be true positive (TP) with both assays and 3 of 24 (8 %) found to be negative (FN) by both of them. There was only one specimen (4 %) of 24 that was missed by facC-PCR but not by GM-EIA. 50 % of specimens (12 of 24) however were detected only by PCR but not with GM-EIA. b 51 of 53 (96 %) and 44 of 53 (83 %) serum specimens from controls (unclassified patients with no evidence of IA) proved to be negative (TN) thus 2 of 53 (3,8 %) and 9 of 53 (17 %) were undetected. There were 9 of 53 (17 %) specimens that proved to be false-positive with PCR but real-negative with GM and only 2 of 53 (4 %) that proved to be false-positive with GM-EIA but true-negative with facC-PCR. Section analysis: 83 % of specimens (44 of 53) remained consistently negative with both of the assays but there were none that proved to be false-positive when testing with both methods
Mentions: Testing control serum specimens with GM-EIA and facC-PCR yielded a high specificity (96 %) (Fig. 4b). Only two control specimens from episodes with no EORTC/MSG evidence of IPA were false-positive when testing with GM-EIA. GM-EIA failed to detect the presence of Aspergillus GM antigen in 63 % of the cases and sensitivity proved to be only 38 % (Fig. 4a). In the case population facC-PCR was able to detect the presence of Aspergillus fumigatus specific nucleic acid target molecules in 84 % of cases by considering a single positive run from triplicate reactions as significant. Conversely facC-PCR failed to detect 16 % of the samples from cases (Fig. 4a). With regard to specificity, 83 % of control specimens were negative when tested with facC-PCR ensuring a relatively high false-positivity rate of 17 % for PCR (Fig. 4b). Comparison analysis was done by examining the different sections of Venn-diagrams shown in Fig. 4. Only paired results were considered and those that were superior in numbers (in the cases of patient ID 4 and ID 10 for the benefit of facC-PCR) were excluded from the section analysis. In doing so we can see that 50 % of specimens from cases were detected only by facC-PCR but not with GM-EIA thus 8 % of specimens from cases were missed with either of the two methods. It is noteworthy that in 83 % of all cases when testing control specimens (from episodes with no EORTC/MSG evidence of IPA) both assays remained consistently negative furthermore there were no false-positive cases when testing with both methods.Fig. 4

Bottom Line: Sera were successively screened for galactomannan antigen and for Aspergillus fumigatus specific nucleic acid targets.Although bronchoalveolar lavage proved negative in 93 % of controls it did not detect IPA in 86 % of the cases.The data from this pilot-study demonstrate that the consideration of standard clinical methods combined with biomarker testing improves the capacity to make early and more accurate diagnostic decisions.

View Article: PubMed Central - PubMed

Affiliation: Faculty of Medicine, Department of Human Genetics, University of Debrecen, Nagyerdei krt. 98, H-4032, Debrecen, Hungary. paholcsek.melinda@med.unideb.hu.

ABSTRACT

Background: We assessed the diagnostic value of standard clinical methods and combined biomarker testing (galactomannan assay and polymerase chain reaction screening) in a prospective case-control study to detect invasive pulmonary aspergillosis in patients with hematological malignancies and prolonged neutropenia.

Methods: In this observational study 162 biomarker analyses were performed on samples from 27 febrile neutropenic episodes. Sera were successively screened for galactomannan antigen and for Aspergillus fumigatus specific nucleic acid targets. Furthermore thoracic computed tomography scanning was performed along with bronchoscopy with lavage when clinically indicated. Patients were retrospectively stratified to define a case-group with "proven" or "probable" invasive pulmonary aspergillosis (25.93 %) and a control-group of patients with no evidence for of invasive pulmonary aspergillosis (74.07 %). In 44.44 % of episodes fever ceased in response to antibiotic treatment (group II). Empirical antifungal therapy was administered for episodes with persistent or relapsing fever (group I). 48.15 % of patients died during the study period. Postmortem histology was pursued in 53.85 % of fatalities.

Results: Concordant negative galactomannan and computed tomography supported by a polymerase chain reaction assay were shown to have the highest discriminatory power to exclude invasive pulmonary aspergillosis. Bronchoalveolar lavage was performed in 6 cases of invasive pulmonary aspergillosis and in 15 controls. Although bronchoalveolar lavage proved negative in 93 % of controls it did not detect IPA in 86 % of the cases. Remarkably post mortem histology convincingly supported the presence of Aspergillus hyphae in lung tissue from a single case which had consecutive positive polymerase chain reaction assay results but was misdiagnosed by both computed tomography and consistently negative galactomannan assay results. For the galactomannan enzyme-immunoassay the diagnostic odds ratio was 15.33 and for the polymerase chain reaction assay it was 28.67. According to Cohen's kappa our in-house polymerase chain reaction method showed a fair agreement with the galactomannan immunoassay. Combined analysis of the results from the Aspergillus galactomannan enzyme immunoassay together with those generated by our polymerase chain reaction assay led to no misdiagnoses in the control group.

Conclusion: The data from this pilot-study demonstrate that the consideration of standard clinical methods combined with biomarker testing improves the capacity to make early and more accurate diagnostic decisions.

Show MeSH
Related in: MedlinePlus