of 18

Detection of Circulating Galactomannan in Penicillium marneffei. Infection and Cryptococcosis Among Patients Infected with Human ACCEPTED

0 views18 pages

Download

All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
JCM Accepts, published online ahead of print on June 00 J. Clin. Microbiol. doi:0./jcm Copyright 00, American Society for Microbiology and/or the Listed Authors/Institutions. All Rights Reserved.
JCM Accepts, published online ahead of print on June 00 J. Clin. Microbiol. doi:0./jcm Copyright 00, American Society for Microbiology and/or the Listed Authors/Institutions. All Rights Reserved. 0 0 Detection of Circulating Galactomannan in Penicillium marneffei Infection and Cryptococcosis Among Patients Infected with Human Immnunodeficiency Virus Yu-Tsung Huang,, Chien-Ching Hung, Chun-Hsing Liao,, Hsin-Yun Sun, Shan-Chwen Chang,, Yee-Chun Chen,* Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan; Department of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan *Corresponding author: Yee-Chun Chen, MD, PhD Department of Internal Medicine, National Taiwan University Hospital, No. Chung-Shan South Road, Taipei, Taiwan 00 Tel: -- Ext. 0 Fax: -- Running title: Detection of circulating galactomannan in penicilliosis and cryptococcosis Key words: Aspergillus galactomannan antigen, Penicillium marneffei, cryptococcosis, human immnunodeficiency virus Total word count: 00 Downloaded from on September 0, 0 by guest 0 0 ABSTRACT Galactomannan (GM) is a heteropolysaccharide in the cell wall of most Aspergillus and Penicillium species. Cross-reactivity of Cryptococcus neoformans galactoxylomannan in Aspergillus GM test was also reported. In this study, we tested serum samples obtained from HIV-infected patients for Aspergillus GM levels with the use of a commercial kit: with penicilliosis ( with fungemia alone, cavitary lung lesions alone, both fungemia and cavitary lung lesions, and disseminated disease), with cryptococcosis ( with fungemia alone, cavitary lung lesions, both, and meningitis alone), and without invasive fungal infection (control). None of them had aspergillosis or concurrent use of piperacillin-tazobactam or amoxicillin-clavulanate. The median time between diagnosis of fungal infection and collection of serum samples was 0 days for penicilliosis and. days for cryptococcosis. Of patients with penicilliosis, cryptococcosis, and controls,.%,.% and %, respectively, had GM optical density (O.D.) indices more than 0. (P=0.000). GM levels were higher in penicilliosis (median,.; range, 0. 0) than cryptococcosis (median, 0.; range, 0..) (p 0.00). Patients with fungemic penicilliosis had higher O.D. indices (median, 0.; range, 0.0 0) than patients with non-fungemic penicilliosis (median, 0.; range, 0..) and patients with cryptococcemia (median, 0.; range, 0..) (p 0.00). Of the patients with cavitary lung lesions, those with penicilliosis had higher antigen levels (median,.; range, 0. 0) than those with cryptococcosis (median, 0.; range, 0..) (p=0.0). This study showed that GM O.D. index was significantly elevated in HIV-patients with penicilliosis. The use of Aspergillus GM antigen assay may facilitate earlier diagnosis of P. marneffei infection in HIV-infected patients in endemic areas. Downloaded from on September 0, 0 by guest 0 0 INTRODUCTION Invasive fungal infections are common opportunistic infections associated with significant morbidity and mortality in patients with human immunodeficiency virus (HIV) infection, and the risk of invasive fungal infection varies with host immunity as well as environmental exposure (,,,,). Penicillium marneffei and Cryptococcus neoformans are important endemic fungi in Southeast Asia that cause systemic infections in HIV-infected patients, especially those who have low CD counts (, ). The clinical presentations of P. marneffei infection and cryptococcosis in HIV-infected patients may mimic those of tuberculosis, histoplasmosis, and others. Early diagnosis and timely initiation of appropriate therapy are complicated by nonspecific signs and symptoms and difficulties in obtaining tissues for histological recognition. Microbiologic isolation and species identification of the pathogens may be time-consuming (,, ). Non-invasive rapid microbiological diagnostic modalities for invasive fungal infections other than determinations of cryptococcal and histoplasma antigen are not available in most parts of the world (,, ). Although antigen detection to identify P. marneffei infection using monoclonal antibodies specific for P. marneffei has been reported (, ), these tests are not commercially available which hampers their usefulness. Galactomannan (GM) is a heteropolysaccharide composed of non-immunogenic mannan core and immunoreactive galactofuransyl side chains in the cell wall of most Aspergillus and Penicillium species (). Determination of Aspergillus GM was recently approved by US Food and Drug Administration (FDA) to facilitate early diagnosis of invasive aspergillosis. Studies have shown that monoclonal antibody against Aspergillus GM reacts with serum and tissue samples from P. marneffei-infected guinea pig as well Downloaded from on September 0, 0 by guest 0 0 as samples from an HIV-infected patient with penicilliosis (,0). Besides, yeast extracts and purified galactoxylomannan of C. neoformans gave positive reactions in Aspergillus GM test (). While clinical experience with Aspergillus GM test in invasive aspergillosis is accumulating (), data on penicilliosis and cryptococcosis remain limited. In this study, we aimed to compare the levels of Aspergillus GM antigen of P. marneffei infection and cryptococcosis in HIV-infected patients. MATERIALS AND METHODS Patients and serum samples Cases and controls were selected from HIV-infected patients who were hospitalized between January 000 and December 00 at the National Taiwan University Hospital, the largest referral hospital for HIV care in Taiwan. Medical records of HIV-infected patients diagnosed with penicilliosis and cryptococcosis in an ongoing prospective cohort study were reviewed using a standardized case record form (,). Diagnosis of infection due to P. marneffei or C. neoformans was made by identifying the fungus by microscopy and cultures of clinical specimens, including blood, bone marrow aspirate, cerebrospinal fluid (CSF), lung aspirate, lymph node biopsy, skin biopsy, and sputum. India ink smears and determinations of cryptococcal antigen of clinical specimens by the Latex-Crypto antigen detection system (Immuno mycologics, Inc., Norman, Okla) were also included for the diagnosis of cryptococcosis (, ). Stored serum samples from patients with penicilliosis and cryptococcosis were retrieved for analysis. The serum samples, obtained once the diagnosis of HIV infection and opportunistic infection was made, were stored at -0 before use. Serum samples from randomly selected HIV-infected patients without active opportunistic infections Downloaded from on September 0, 0 by guest 0 0 were obtained as controls. Patients who were receiving piperacillin-tazobactam or amoxicillin-clavulanate within days of serum collection were not included for serum GM detection because both antibiotics have been demonstrated to cause elevation of Aspergillus GM antigen levels (, ). Galactomannan antigen detection Aspergillus GM levels were determined using Platelia EIA (Bio-Rad, Marnes-la-Coquette, France) by following the instructions of the manufacturer. The test uses a rat anti-gm monoclonal antibody, EB-A, to recognize the galactofuranoside side chain of the GM molecule. Because there was no cut-off value of Aspergillus GM antigen in the diagnosis of P. marneffei and C. neoformans infection in the literature, we analyzed the results using three different optical density (O.D.) cut-off indices: 0.,.0 and.. For the diagnosis of aspergillosis, a cut-off index of 0. is accepted by FDA, while a cut-off index of 0. is commonly used in Europe. Besides,. was the initial proposed cut-off value. Statistical analysis All statistical analyses were performed using SPSS software version.0, 00 (SPSS Inc., Chicago, IL). Categorical variables were compared using χ or Fisher s exact test; whereas non-categorical variables were compared using Wilcoxon s rank-sum test. Because both invasive fungal infections are often associated with fungemia and cavitary lung lesions in HIV-infected patients (), subgroup analyses and comparisons of Aspergillus GM O.D. indices of the serum samples from the patients with penicilliosis and cryptococcosis were made for fungemia as well as cavitary lung lesions. RESULTS Downloaded from on September 0, 0 by guest 0 0 We selected serum samples obtained from HIV-infected patients, which included patients with penicilliosis, patients with cryptococcosis, and controls without invasive fungal infection. The clinical characteristics of patients are shown in Table. Among patients with penicilliosis, had fungemia alone, had cavitary lung lesions alone, had both, and had P. marneffei isolated from lymph node aspirate, sputum and skin biopsy. All of the four cases of cavitary lung lesions alone due to penicilliosis were diagnosed by positive cultures of computed tomography- or sonography-guided lung aspirates. Among patients with cryptococcosis, had fungemia alone, had cavitary lung lesions alone, had both, and had meningitis alone. Serum cryptococcal antigen titers ranged from : to :0 (median, :). None of patients had Aspergillus spp. isolated from clinical specimens during the two-month follow-up. The median time between diagnosis of invasive fungal infection and collection of serum samples was 0 days (range, - to days) for penicilliosis and. days (range, 0 to days) for cryptococcosis. Fourteen patients with penicilliosis had the serum samples collected before initiation of antifungal therapy. Of patients with cryptococcosis, had sera collected prior to initiation of antifungal therapy; within hours of initiation of antifungal therapy, and within days of therapy. The median O.D. index was significantly higher in patients with penicilliosis (.) than patients with cryptococcosis (0.) (p 0.00) and controls (0.) (p=0.00) (Table, Figure and Figure ). In patients with fungemia, 0 patients with penicilliosis also had a higher median O.D. index than patients with cryptococcosis (0. vs. 0., p 0.00) (Table and Figure). In non-fungemic patients, the median Downloaded from on September 0, 0 by guest 0 0 O.D. index of penicilliosis and cryptococcosis was not significantly different (0. vs. 0., p=0.). As for patients with cavitary lung lesions, the median O.D. index was higher in penicilliosis (median,.; range, 0.- 0) than in cryptococcosis (median, 0.; range, 0..) (p=0.0). Of patients with penicilliosis, cryptococcosis, and controls,.%,.% and %, respectively, had GM optical density (O.D.) indices more than 0. (P=0.000) (Table ). Of the four patients with penicilliosis who had O.D. indices less than 0. (.%), one had his serum sample obtained days before collection of first positive blood culture; two had non-fungemic penicilliosis with cavitary lung lesions, and one had P. marneffei isolated from lymph node aspirate, sputum and skin biopsy sample. Of the three patients with cryptococcosis who had O.D. indices greater than 0. (.%), one with an O.D. index of. presented with a cavitary lung lesion without fungemia; however, tissue biopsy was not performed. Of the other two patients who had no cavitary lung lesions, their O.D. index was 0. and., respectively. No microbiological evidence of aspergillosis or penicilliosis was documented during follow-up period. One of the control patients (.0%) had an elevated O.D. index of.0. After follow-up for months, he did not develop invasive fungal infections or lung lesions. DISCUSSION In this study, we found that patients with fungemia due to P. marneffei had the highest Aspergillus GM antigen levels, which were significantly higher than the levels in patients with penicilliosis but without fungemia, patients with cryptococcosis, and control patients. Downloaded from on September 0, 0 by guest 0 0 As invasive aspergillosis was very rare in our HIV cohort (), we did not compare the levels between HIV-infected patient with aspergillosis and those with penicilliosis. Compared with GM O.D indices in patients with invasive aspergillosis (,), this study showed relatively high GM antigen levels in patients with fungemic penicilliosis (median, 0.). This finding is in accordance with the fact that P. marneffei is more likely to be isolated from blood samples of HIV-infected patients than Aspergillus spp. (, ). The median GM O.D index was significantly lower in patients with cryptococcosis than that in patients with penicilliosis. However, three of patients (.%) with cryptococcosis had GM O.D indices more than 0.. First, concomitant penicilliosis can not be excluded. Alternatively, this may be caused by galactoxylomannan of C. neoformans that cross reacts with Aspergilllus GM antigen assay (). However, the cross-reactivity was not confirmed in a recent comprehensive study (). As determination of serum cryptococcal antigen using latex agglutination test is sensitive and specific in immunocompromised hosts, it will not hamper the usefulness of Aspergilllus GM antigen assay in the diagnosis of invasive fungal infection in HIV-infected patients. Pulmonary aspergillosis was reported to be a main cause of cavitary lung lesions in HIV-infected patients (), and the incidence of aspergillosis among HIV-infected patients was. cases per 000 person-years in a surveillance study between 0 and (). However, of, HIV-infected patients followed at this hospital, only three patients (0.%) had invasive aspergillosis diagnosed before introduction of highly active antiretroviral therapy (). This and our previous studies showed that a higher proportion of HIV-infected patients with penicilliosis or cryptococcosis had cavitary lung lesions (, ). As a result, penicilliosis should be included in the differential diagnosis of cavitary Downloaded from on September 0, 0 by guest 0 0 lung lesions in HIV-infected patients, and possibly in other immunocompromised patients, in endemic areas with GM antigenemia (). There are several limitations of this study. First, the sample size is small. More studies are needed to elucidate the role of this GM antigen assay in the diagnosis of penicilliosis in endemic areas. Second, diagnosis of non-fungemic penicilliosis may be limited by the relatively low serum levels of GM. Therefore, bronchoscopy or aspiration/biopsy guided by computed tomography or sonography should be considered in such patients. Third, the GM index was determined using stored serum samples and the influence of freezing and thawing on GM antigen assay is not clear. Fourth, only one serum sample of each patient was used for analysis. Previous report showed that the GM O.D. index in an HIV-infected patient with penicilliosis declined after treatment for two months (). The temporal trend of GM antigen levels following initiation of antifungal therapies and whether the antigen levels can be used to monitor the response to antifungal therapies remain to be investigated. In conclusion, our data suggest that O.D. index of Aspergillus GM antigen is significantly elevated in HIV-patients with penicilliosis when compared with HIV-infected patients with cryptococcosis or controls. The determination of Aspergillus GM antigen index may facilitate earlier diagnosis of P. marneffei infection in HIV-infected patients with compatible clinical presentations before results of microbiologic cultures are available. ACKNOWLEDGMENTS Downloaded from on September 0, 0 by guest 0 0 We would like to thank Miss Christina Tai for the technical assistance. This work was supported by a grant from the National Science Council, R.O.C. (NSC --B-00-00) REFERENCES. Boutboul, F., C. Alberti, T. Leblanc, A. Sulahian, E. Gluckman, F. Derouin, and P. Ribaud. 00. Invasive aspergillosis in allogeneic stem cell transplant recipients: increasing antigenemia is associated with progressive disease. Clin. Infect. Dis. :-.. Chaiyaroj, S. C., R. Chawengkirttikul, S. Sirisinha, P. Watkins, and Y. Srinoulprasert. 00. Antigen detection assay for identification of Penicillium marneffei infection. J. Clin. Microbiol. :-.. Chongtrakool, P., S. C. Chaiyaroj, V. Vithayasai, S. Trawatcharegon, R. Teanpaisan, S. Kalnawakul, and S. Sirisinha.. Immunoreactivity of a -kilodalton Penicillium marneffei antigen with human immunodeficiency virus-positive sera. J. Clin. Microbiol. :0-.. Dalle, F., P. E. Charles, K. Blanc, D. Caillot, P. Chavanet, F. Dromer, and A. Bonnin. 00. Cryptococcus neoformans Galactoxylomannan contains an epitope(s) that is cross-reactive with Aspergillus Galactomannan. J. Clin. Microbiol. :-. De Jesus, M., E. Hackett, M. Durkin, P. Connolly, A. Casadevall, R. Petraitiene, T. J. Walsh, and L. J. Wheat. 00. Galactoxylomannan does not Downloaded from on September 0, 0 by guest 0 0 0 exhibit cross-reactivity in the Platelia Aspergillus EIA. Clin. Vaccine. Immunol. in press (CVI00-0). Gallant, J. E., and A. H. Ko.. Cavitary pulmonary lesions in patients infected with human immunodeficiency virus. Clin. Infect. Dis. :-.. Hajjeh, R. A.. Disseminated histoplasmosis in persons infected with human immunodeficiency virus. Clin. Infect. Dis. (Suppl ):S0-0.. Holding, K. J., M. S. Dworkin, P. C. Wan, D. L. Hanson, R. M. Klevens, J. L. Jones, and P. S. Sullivan Aspergillosis among people infected with human immunodeficiency virus: incidence and survival. Adult and Adolescent Spectrum of HIV Disease Project. Clin. Infect. Dis. :-.. Kaufman, L., P. G. Standard, M. Jalbert, P. Kantipong, K. Limpakarnjanarat, and T. D. Mastro.. Diagnostic antigenemia tests for Penicilliosis marneffei. J. Clin. Microbiol. : Latge, J. P., H. Kobayashi, J. P. Debeaupuis, M. Diaquin, J. Sarfati, J. M. Wieruszeski, E. Parra, J. P. Bouchara, and B. Fournet.. Chemical and immunological characterization of the extracellular galactomannan of Aspergillus fumigatus. Infect. Immun. :-.. Mennink-Kersten, M. A., J. P. Donnelly, and P. E. Verweij. 00. Detection of circulating galactomannan for the diagnosis and management of invasive aspergillosis. Lancet Infect. Dis. :-.. Mennink-Kersten, M. A., A. Warris, and P. E. Verweij. 00.,-beta-D-glucan in patients receiving intravenous amoxicillin-clavulanic acid. N. Engl. J. Med. :-. Downloaded from on September 0, 0 by guest 0 0. Pfeiffer, C. D., J. P. Fine, and N. Safdar. 00. Diagnosis of invasive aspergillosis using a galactomannan assay: a meta-analysis. Clin. Infect. Dis. :-.. Rimek, D., T. Zimmermann, M. Hartmann, C. Prariyachatigul, and R. Kappe.. Disseminated Penicillium marneffei infection in an HIV-positive female from Thailand in Germany. Mycoses (Suppl ):-.. Stynen, D., J. Sarfati, A. Goris, M. C. Prevost, M. Lesourd, H. Kamphuis, V. Darras, and J. P. Latge.. Rat monoclonal antibodies against Aspergillus galactomannan. Infect. Immun. 0:-.. Sulahian, A., S. Touratier, and P. Ribaud. 00. False positive test for Aspergillus antigenemia related to concomitant administration of piperacillin and tazobactam. N. Engl. J. Med. :-.. Sun, H. Y., M. Y. Chen, C. F. Hsiao, S. M. Hsieh, C. C. Hung, and S. C. Chang. 00. Endemic fungal infections caused by Cryptococcus neoformans and Penicillium marneffei in patients infected with human immunodeficiency virus and treated with highly active anti-retroviral therapy. Clin. Microbiol. Infect. :-.. Sun, H. Y., M. Y. Chen, S. M. Hsieh, W. H. Sheng, S. Y. Chang, C. F. Hsiao, C. C. Hung, and S. C. Chang. 00. Changes in the clinical spectrum of opportunistic illnesses in persons with HIV infection in Taiwan in the era of highly active antiretroviral therapy. Jpn. J. Infect. Dis. :-. Downloaded from on September 0, 0 by guest 0. Supparatpinyo, K., C. Khamwan, V. Baosoung, K. E. Nelson, and T. Sirisanthana.. Disseminated Penicillium marneffei infection in southeast Asia. Lancet : Van Cutsem, J., L. Meulemans, F. Van Gerven, and D. Stynen. 0. Detection of circulating galactomannan by Pastorex Aspergillus in experimental invasive aspergillosis. Mycoses :-.. Vanittanakom, N., C. R. Cooper, Jr., M. C. Fi
Advertisement
MostRelated
View more
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks