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Current Algorithms in Fungal Diagnosis in the Immunocompromised Host

  • Thomas LehrnbecherEmail author
  • Karsten Becker
  • Andreas H. Groll
Protocol
Part of the Methods in Molecular Biology book series (MIMB, volume 1508)

Abstract

Invasive fungal diseases (IFDs) are a major cause of morbidity and mortality in immunocompromised patients such as patients with hematological malignancies or allogeneic hematopoietic stem cell transplant recipients. Whereas the definite diagnosis of IFD requires invasive diagnostic procedures, imaging and noninvasive diagnostic assays may help in decision making with regard to the institution and the choice of antifungal agents, the duration of therapy, surgical intervention, and monitoring of fungal manifestations.

Unfortunately, signs and symptoms of IFD are often nonspecific in the immunocompromised patient. Therefore, in immunocompromised patients with suspected IFD, all samples collected need to be cultured for fungi, and, in the case of specimens obtained by invasive diagnostic procedures, also microscopically examined. For high sensitivity of the cultural and microscopic approaches, specific media and stains, respectively, are crucial. Non-culture based method such as the detection of galactomannan or ß-d-glucan and molecular tools such as polymerase chain reaction may help in the early diagnosis of IFD. Imaging studies may be indicative for IFD, but invasive diagnostics such as bronchoalveolar lavage and/or biopsy should be pursued in order to identify the causative pathogen. This chapter summarizes the current knowledge on diagnosing IFD and proposes practical help in the use of diagnostic tools.

Key words

Invasive fungal disease Culture Galactomannan ß-d-glucan Polymerase chain reaction Computerized tomography Magnetic resonance imaging Brochoalveolar lavage Biopsy 

References

  1. 1.
    Upton A, Kirby KA, Carpenter P et al (2007) Invasive aspergillosis following hematopoietic cell transplantation: outcomes and prognostic factors associated with mortality. Clin Infect Dis 44:531–540CrossRefPubMedGoogle Scholar
  2. 2.
    Pagano L, Caira M, Nosari A et al (2007) Fungal infections in recipients of hematopoietic stem cell transplants: results of the SEIFEM B-2004 study—Sorveglianza Epidemiologica Infezioni Fungine Nelle Emopatie Maligne. Clin Infect Dis 45:1161–1170CrossRefPubMedGoogle Scholar
  3. 3.
    Denning DW, Kibbler CC, Barnes RA et al (2003) British Society for Medical Mycology proposed standards of care for patients with invasive fungal infections. Lancet Infect Dis 3:230–240CrossRefPubMedGoogle Scholar
  4. 4.
    Ruhnke M, Bohme A, Buchheidt D et al (2012) Diagnosis of invasive fungal infections in hematology and oncology—guidelines from the Infectious Diseases Working Party in Haematology and Oncology of the German Society for Haematology and Oncology (AGIHO). Ann Oncol 23:823–833CrossRefPubMedGoogle Scholar
  5. 5.
    Hayden RT, Isotalo PA, Parrett T et al (2003) In situ hybridization for the differentiation of Aspergillus, Fusarium, and Pseudallescheria species in tissue section. Diagn Mol Pathol 12:21–26Google Scholar
  6. 6.
    Rickerts V, McCormick Smith I, Mousset S et al (2013) Deciphering the aetiology of a mixed fungal infection by broad-range PCR with sequencing and fluorescence in situ hybridisation. Mycoses 56:681–686Google Scholar
  7. 7.
    Cuenca-Estrella M, Verweij PE, Arendrup MC et al (2012) ESCMID* guideline for the diagnosis and management of Candida diseases 2012: diagnostic procedures. Clin Microbiol Infect 18(Suppl 7):9–18Google Scholar
  8. 8.
    Meyer MH, Letscher-Bru V, Jaulhac B et al (2004) Comparison of Mycosis IC/F and plus Aerobic/F media for diagnosis of fungemia by the bactec 9240 system. J Clin Microbiol 42:773–777CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Idelevich EA, Grunewald CM, Wullenweber J et al (2014) Rapid identification and susceptibility testing of Candida spp. from positive blood cultures by combination of direct MALDI-TOF mass spectrometry and direct inoculation of Vitek 2. PLoS One 9:e114834Google Scholar
  10. 10.
    Gorton RL, Ramnarain P, Barker K et al (2014) Comparative analysis of Gram's stain, PNA-FISH and Sepsityper with MALDI-TOF MS for the identification of yeast direct from positive blood cultures. Mycoses 57:592–601CrossRefPubMedGoogle Scholar
  11. 11.
    Schmalreck AF, Lackner M, Becker K et al (2014) Phylogenetic relationships matter: antifungal susceptibility among clinically relevant yeasts. Antimicrob Agents Chemother 58:1575–1585CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    EUCAST (European Committee on Antimicrobial Susceptibility Testing) EECoAS Document E.DEF 7.2: Method for the determination of broth dilution of antifungal agents for fermentative yeasts, revised March, 2012. http://www.eucast.org/ast_of_fungi/methods_of_antifungal_susceptibility_testing/susceptibility_testing_of_yeasts/. Accessed 20 July 2015
  13. 13.
    EUCAST (European Committee on Antimicrrobial Susceptibility Testing) EECoAS Method for the determination of broth dilution minimum inhibitory concentrations of antifungal agents for conidia forming moulds; version 9.2 (Aug 25,2014). http://www.eucast.org/ast_of_fungi/methods_of_antifungal_susceptibility_testing/susceptibility_testing_of_moulds/. Accessed 20 July 2015
  14. 14.
    Maertens J, Theunissen K, Verhoef G et al (2005) Galactomannan and computed tomography-based preemptive antifungal therapy in neutropenic patients at high risk for invasive fungal infection: a prospective feasibility study. Clin Infect Dis 41:1242–1250CrossRefPubMedGoogle Scholar
  15. 15.
    Maertens J, Verhaegen J, Demuynck H et al (1999) Autopsy-controlled prospective evaluation of serial screening for circulating galactomannan by a sandwich enzyme-linked immunosorbent assay for hematological patients at risk for invasive Aspergillosis. J Clin Microbiol 37:3223–3228PubMedPubMedCentralGoogle Scholar
  16. 16.
    Maertens J, Theunissen K, Verbeken E et al (2004) Prospective clinical evaluation of lower cut-offs for galactomannan detection in adult neutropenic cancer patients and haematological stem cell transplant recipients. Br J Haematol 126:852–860CrossRefPubMedGoogle Scholar
  17. 17.
    Maertens J, Verhaegen J, Lagrou K et al (2001) Screening for circulating galactomannan as a noninvasive diagnostic tool for invasive aspergillosis in prolonged neutropenic patients and stem cell transplantation recipients: a prospective validation. Blood 97:1604–1610CrossRefPubMedGoogle Scholar
  18. 18.
    Sulahian A, Boutboul F, Ribaud P et al (2001) Value of antigen detection using an enzyme immunoassay in the diagnosis and prediction of invasive aspergillosis in two adult and pediatric hematology units during a 4-year prospective study. Cancer 91:311–318CrossRefPubMedGoogle Scholar
  19. 19.
    Lehrnbecher T, Phillips R, Alexander S et al (2012) Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation. J Clin Oncol 30:4427–4438CrossRefPubMedGoogle Scholar
  20. 20.
    Groll AH, Castagnola E, Cesaro S et al (2014) Fourth European Conference on Infections in Leukaemia (ECIL-4): guidelines for diagnosis, prevention, and treatment of invasive fungal diseases in paediatric patients with cancer or allogeneic haemopoietic stem-cell transplantation. Lancet Oncol 15:e327–e340CrossRefPubMedGoogle Scholar
  21. 21.
    Maschmeyer G, Carratala J, Buchheidt D et al (2015) Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients (allogeneic SCT excluded): updated guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Oncol 26:21–33CrossRefPubMedGoogle Scholar
  22. 22.
    Maertens J, Marchetti O, Herbrecht R et al (2010) European guidelines for antifungal management in leukemia and hematopoietic stem cell transplant recipients: summary of the ECIL 3-2009 update. Bone Marrow Transplant 46:709–718CrossRefPubMedGoogle Scholar
  23. 23.
    De Pauw B, Walsh TJ, Donnelly JP et al (2008) 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. Clin Infect Dis 46:1813–1821CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Marr KA, Balajee SA, McLaughlin L et al (2004) Detection of galactomannan antigenemia by enzyme immunoassay for the diagnosis of invasive aspergillosis: variables that affect performance. J Infect Dis 190:641–649CrossRefPubMedGoogle Scholar
  25. 25.
    Duarte RF, Sanchez-Ortega I, Cuesta I et al (2014) Serum galactomannan-based early detection of invasive aspergillosis in hematology patients receiving effective antimould prophylaxis. Clin Infect Dis 59:1696–1702Google Scholar
  26. 26.
    Lamoth F, Cruciani M, Mengoli C et al (2012) beta-Glucan antigenemia assay for the diagnosis of invasive fungal infections in patients with hematological malignancies: a systematic review and meta-analysis of cohort studies from the Third European Conference on Infections in Leukemia (ECIL-3). Clin Infect Dis 54:633–643CrossRefPubMedGoogle Scholar
  27. 27.
    Oz Y, Kiraz N (2011) Diagnostic methods for fungal infections in pediatric patients: microbiological, serological and molecular methods. Expert Rev Anti Infect Ther 9:289–298CrossRefPubMedGoogle Scholar
  28. 28.
    Koltze A, Rath P, Schoning S et al (2015) Beta-D-glucan screening for the detection of invasive fungal disease in children undergoing allogeneic hematopoietic stem cell transplantation. J Clin Microbiol 53:2605–2610CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Smith PB, Benjamin DK Jr, Alexander BD et al (2007) Quantification of 1,3-beta-D-glucan levels in children: preliminary data for diagnostic use of the beta-glucan assay in a pediatric setting. Clin Vaccine Immunol 14:924–925CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Mikulska M, Calandra T, Sanguinetti M et al (2010) The use of mannan antigen and anti-mannan antibodies in the diagnosis of invasive candidiasis: recommendations from the Third European Conference on Infections in Leukemia. Crit Care 14:R222CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    White PL, Wingard JR, Bretagne S, et al (2015) Aspergillus PCR: a systematic review of evidence for clinical use in comparison with antigen testing. Clin Infect Dis 53:2832–2837Google Scholar
  32. 32.
    White PL, Bretagne S, Klingspor L et al (2010) Aspergillus PCR: one step closer to standardization. J Clin Microbiol 48:1231–1240Google Scholar
  33. 33.
    Idelevich EA, Silling G, Niederbracht Y et al (2015) Impact of multiplex PCR on antimicrobial treatment in febrile neutropenia: a randomized controlled study. Med Microbiol Immunol 204(5):585–592CrossRefPubMedGoogle Scholar
  34. 34.
    White PL, Barnes RA, Springer J, et al (2015) The clinical performance of Aspergillus PCR when testing serum and plasma—a study by the European Aspergillus PCR Initiative. J Clin MicrobiolGoogle Scholar
  35. 35.
    Morrissey CO, Chen SC, Sorrell TC et al (2013) Galactomannan and PCR versus culture and histology for directing use of antifungal treatment for invasive aspergillosis in high-risk haematology patients: a randomised controlled trial. Lancet Infect Dis 13:519–528CrossRefPubMedGoogle Scholar
  36. 36.
    Heng SC, Chen SC, Morrissey CO et al (2014) Clinical utility of Aspergillus galactomannan and PCR in bronchoalveolar lavage fluid for the diagnosis of invasive pulmonary aspergillosis in patients with haematological malignancies. Diagn Microbiol Infect Dis 79:322–327Google Scholar
  37. 37.
    Hoenigl M, Prattes J, Spiess B et al (2014) Performance of galactomannan, beta-d-glucan, Aspergillus lateral-flow device, conventional culture, and PCR tests with bronchoalveolar lavage fluid for diagnosis of invasive pulmonary aspergillosis. J Clin Microbiol 52:2039–2045CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Lass-Florl C, Resch G, Nachbaur D et al (2007) The value of computed tomography-guided percutaneous lung biopsy for diagnosis of invasive fungal infection in immunocompromised patients. Clin Infect Dis 45:e101–e104CrossRefPubMedGoogle Scholar
  39. 39.
    Rickerts V, Mousset S, Lambrecht E et al (2007) Comparison of histopathological analysis, culture, and polymerase chain reaction assays to detect invasive mould infections from biopsy specimens. Clin Infect Dis 44:1078–1083Google Scholar
  40. 40.
    Reinwald M, Buchheidt D, Hummel M et al (2013) Diagnostic performance of an Aspergillus-specific nested PCR assay in cerebrospinal fluid samples of immunocompromised patients for detection of central nervous system aspergillosis. PLoS One 8:e56706Google Scholar
  41. 41.
    Heussel CP, Kauczor HU, Heussel GE et al (1999) Pneumonia in febrile neutropenic patients and in bone marrow and blood stem-cell transplant recipients: use of high-resolution computed tomography. J Clin Oncol 17:796–805PubMedGoogle Scholar
  42. 42.
    Caillot D, Casasnovas O, Bernard A et al (1997) Improved management of invasive pulmonary aspergillosis in neutropenic patients using early thoracic computed tomographic scan and surgery. J Clin Oncol 15:139–147PubMedGoogle Scholar
  43. 43.
    Cornillet A, Camus C, Nimubona S et al (2006) Comparison of epidemiological, clinical, and biological features of invasive aspergillosis in neutropenic and nonneutropenic patients: a 6-year survey. Clin Infect Dis 43:577–584CrossRefPubMedGoogle Scholar
  44. 44.
    Georgiadou SP, Sipsas NV, Marom EM et al (2011) The diagnostic value of halo and reversed halo signs for invasive mould infections in compromised hosts. Clin Infect Dis 52:1144–1155Google Scholar
  45. 45.
    Burgos A, Zaoutis TE, Dvorak CC et al (2008) Pediatric invasive aspergillosis: a multicenter retrospective analysis of 139 contemporary cases. Pediatrics 121:e1286–e1294CrossRefPubMedGoogle Scholar
  46. 46.
    Caillot D, Couaillier JF, Bernard A et al (2001) Increasing volume and changing characteristics of invasive pulmonary aspergillosis on sequential thoracic computed tomography scans in patients with neutropenia. J Clin Oncol 19:253–259PubMedGoogle Scholar
  47. 47.
    Brodoefel H, Vogel M, Hebart H et al (2006) Long-term CT follow-up in 40 non-HIV immunocompromised patients with invasive pulmonary aspergillosis: kinetics of CT morphology and correlation with clinical findings and outcome. AJR Am J Roentgenol 187:404–413CrossRefPubMedGoogle Scholar
  48. 48.
    Teyton P, Baillet G, Hindie E et al (2009) Hepatosplenic candidiasis imaged with F-18 FDG PET/CT. Clin Nucl Med 34:439–440CrossRefPubMedGoogle Scholar
  49. 49.
    Hassler A, Porto L, Lehrnbecher T (2015) Cerebral fungal infection in pediatric cancer patients. Curr Fungal Infect Rep 9:6–14CrossRefGoogle Scholar
  50. 50.
    Aribandi M, McCoy VA, Bazan C 3rd (2007) Imaging features of invasive and noninvasive fungal sinusitis: a review. Radiographics 27:1283–1296CrossRefPubMedGoogle Scholar
  51. 51.
    Azoulay E, Mokart D, Lambert J et al (2010) Diagnostic strategy for hematology and oncology patients with acute respiratory failure: randomized controlled trial. Am J Respir Crit Care Med 182:1038–1046CrossRefPubMedGoogle Scholar
  52. 52.
    Sampsonas F, Kontoyiannis DP, Dickey BF et al (2011) Performance of a standardized bronchoalveolar lavage protocol in a comprehensive cancer center: a prospective 2-year study. Cancer 117:3424–3433CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Chellapandian D, Lehrnbecher T, Phillips B et al (2015) Bronchoalveolar lavage and lung biopsy in patients with cancer and hematopoietic stem-cell transplantation recipients: a systematic review and meta-analysis. J Clin Oncol 33:501–509CrossRefPubMedGoogle Scholar
  54. 54.
    Manhire A, Charig M, Clelland C et al (2003) Guidelines for radiologically guided lung biopsy. Thorax 58:920–936CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Anttila VJ, Elonen E, Nordling S et al (1997) Hepatosplenic candidiasis in patients with acute leukemia: incidence and prognostic implications. Clin Infect Dis 24:375–380CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Thomas Lehrnbecher
    • 1
    Email author
  • Karsten Becker
    • 2
  • Andreas H. Groll
    • 3
  1. 1.Pediatric Hematology and Oncology, Hospital for Children and AdolescentsJohann Wolfgang Goethe-UniversityFrankfurtGermany
  2. 2.Institute of Medical MicrobiologyUniversity Hospital MünsterMünsterGermany
  3. 3.Department of Pediatric Hematology/Oncology, Infectious Disease Research Program, Center for Bone Marrow TransplantationUniversity Children’s Hospital MünsterMünsterGermany

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