Detection of circulating galactomannan by Pastorex Aspergillus in experimental invasive aspergillosis

The performance of Pastorex Aspergillus, a new latex agglutination test for the detection of circulating galactomannan in the serum of patients with invasive aspergillosis, was evaluated in a blind trial in standardized guinea-pig models of invasive aspergillosis and other invasive mycoses. In these animal models, the invasive nature of the fungal infection was confirmed by re-isolation of the etiologic agent from the organs of every animal. Ninety-two plasma samples from 42 animals with invasive aspergillosis were submitted to the test. In 41 of these animals, at least one plasma sample was positive with the latex test (sensitivity 97.6%), titers ranging from 1/1 to 1/512. In general, antigen titers increased as a function of time, reaching the highest values shortly before death. Guinea-pigs infected with Penicillium marneffei also yielded positive agglutination reactions but antigen titers were lower (maximal titer 1/8). Plasma samples from animals with invasive candidosis (23), disseminated trichophytosis (11) and cryptococcosis (23) were all negative with the latex test. In 80 guinea-pigs without fungal infection, 3 false positive results (titers 1/1) were observed, which means a specificity of 96.2% in this control group.     

Invasive Rhino-Orbital Aspergillosis

Invasive aspergillosis usually affects immune-compromised patients and is common in diabetics. Proptosis, visual loss and ophthalmoplegia due to intra-orbital extension are common presentations. Three out of five patients in our series were immune-compromised. All the patients had visual loss and three patients presented with unilateral blindness. Three patients were treated by surgical debridement followed by Amphotericin B therapy. Two patients who had intra-cranial extension of the disease died during the treatment. Only one patient had improvement in vision following the treatment. High index of suspicion in immune-compromised patients, early diagnosis and prompt aggressive treatment is required to achieve clinical cure.     

Invasive aspergillosis: results of an 8-year study

We analysed retrospectively 90 cases of invasive aspergillosis (IA) which occurred at the University Hospital and the Thoraxklinik gGmbH Heidelberg between 1991 and 1998. 71 cases were histologically proven, 19 were probable diseases. There were 49 male and 41 female patients, with a mean age of 51.5 years (range 16 days to 80 years). Underlying diseases were: hematological malignancies in 52% (n = 47; 24 with acute leukemia), solid organ transplantation (n = 11; 9 liver, 1 kidney, 1 heart), solid cancer (n = 10), others (n = 21), and in one case no underlying disease was diagnosed. Only 54 cases (60%) were correctly diagnosed as IA during lifetime of the patients. In 59 cases (65%) only the lung was affected, 25 patients suffered from disseminated IA, in 6 patients only extrapulmonary lesions were present. 11 patients underwent lung surgery, 63 patients received antimycotic drugs (44 amphotericin B, 15 fluconazole, 4 itraconazole), 21 were not treated antimycotically. 68 patients (71%) died, from these 30 (36%) due to IA during remission of the underlying disease. The laboratory methods showed the following sensitivities, respectively: microscopy by calcofluor white staining 17%, culture 69%, Aspergillus-PCR from respiratory tract samples and biopsies 95%, galactomannan antigen detection by latex agglutination 28%, by enzyme immunoassay 59%, Aspergillus antibody detection 23%.     

血清半乳甘露聚糖检测对血液病患者侵袭性曲霉菌感染早期诊断的价值

 目的　评价血清半乳甘露聚糖（GM）检测对血液病患者侵袭性曲霉菌（IA）感染早期诊断的价值。方法　前瞻性采用酶联免疫吸附试验（ELISA）每周2次测定患者的GM水平,并计算该诊断试验的各项评价指标。结果　共有来自92例患者的113例次感染进入研究,检测血清标本472份,以确诊IA感染和临床诊断IA感染为真阳性组,排除IA感染为真阴性组,0.7为阈值,连续2次GM结果阳性为真阳性,该诊断试验的敏感度为83.3 %,特异度为91.1 %,阳性预测值为78.9 %,阴性预测值为93.1 %。GM阳性结果较痰培养阳性时间提前4 d（1～7 d）,比影像学改变提早7 d（1～14 d）,较抗真菌治疗提前6 d（1～15 d）。结论　通过ELISA方法进行血清GM检测可以快速、灵敏的为早期诊断IA感染提供有力证据。     

Efficacy of Immunoprecipitation Methods for Rapid Serodiagnosis of Allergic Bronchopulmonary Aspergillosis: Die Aussagekraft von Immunpräzipitationstechniken für die Seroschnelldiagnose der allergisch-bronchopulmonalen Aspergillose

The relative efficacy of Ouchterlony's double diffusion (ODD), Wadsworth's gel diffusion (WGD) and counter-immunoelectrophoresis (CIE) is reported for serodiagnosis of allergic bronchopulmonary aspergillosis (ABPA). Of the 50 sera taken from patients with confirmed or suspected ABPA, serum precipitins were demonstrated against Aspergillus fumigatus by CIE, WGD and ODD in sera from 34, 31 and 25 patients, respectively. The results were negative by the three methods in sera taken from 10 healthy volunteers. It is concluded that CIE followed by WGD is more efficacious than ODD for serodiagnosis of ABPA.     

Potential of polymerase chain reaction and galactomannan for the diagnosis of invasive aspergillosis in patients with febrile neutropenia

The incidence of invasive aspergillosis (IA) has increased over the last years, especially in immuncompromised patients with high mortality rates. Because of difficulties about the diagnosis; serological methods [galactomannan (GM) antigen test] and polymerase chain reaction (PCR) developed in recent years. MycAssay Aspergillus PCR performance in the diagnosis of IA was evaluated and compared with the GM and in‐house PCR. This study was conducted with 358 serum samples obtained from 99 patient with febrile neutropenic episodes who were followed in haematology and bone marrow transplantation units. Patients were classified by the European Organization for the Research and Treatment of Cancer/Mycoses Study Group criteria, 18 of them is proven and probable IA. GM antigen test and two different real‐time PCR; one of them is fist commercial PCR for IA; Mycassay Aspergillus and the other one is in‐house real‐time PCR performed. Sensitivity values were Mycassay Aspergillus PCR, in‐house PCR, and GM 65.38%, 11.53% and 23.07%, respectively. The high sensitivity obtained from Mycassay Aspergillus PCR and sensitivity is increased by using a combination of diagnostic methods. GM antigen test and real‐time PCR could be beneficial for early diagnosis and treatment of IA. For routine usage of PCR as diagnostic assay more studies needed in future.     

Minireview: host defence in invasive aspergillosis

Aspergillus is a saprophytic fungus, which mainly becomes pathogenic in immunosuppressed hosts. A failure of host defences results in a diverse set of illnesses, ranging from chronic colonisation, aspergilloma, invasive disease and hypersensitivity. A key concept in immune responses to Aspergillus species is that host susceptibility determines the morphological form, antigenic structure and physical location of the fungus. Traditionally, innate immunity has been considered as a first line of defence and activates adaptive immune mechanisms by the provision of specific signals; innate and adaptive immune responses are intimately linked. The T‐helper cell (T_H1) response is associated with increased production of inflammatory cytokines IFN‐γ, IL‐2 and IL‐12 and stimulation of antifungal effector cells. Alternatively, T_H2‐type responses are associated with suppression of antifungal effector cell activity, decreased production of IFN‐γ and increased concentrations of IL‐4 and IL‐10, which promote humoral responses to Aspergillus. The host’s defensive capacity is defined by the sum of resistance and tolerance. Resistance displays the ability to limit fungal burden and elimination of the pathogen, and tolerance means the ability to limit host damage caused by immune response.     

Invasive pulmonary aspergillosis: A rare complication after microwave ablation

Three cases are reported of invasive pulmonary aspergillosis (IPA) occurring after microwave ablation (MWA) for lung tumours. This is a rare complication that has not previously been described in the literature. The diagnosis of IPA was based on the following factors: host factors, clinical manifestations and mycological findings. The first case was a 63-year-old man treated for primary lung squamous carcinoma. Significant tumour regression was achieved by 18 days after MWA, medical treatment with itraconazole for 6 weeks, and postural drainage. The second case, a 65-year-old man, was confirmed with primary lung squamous cell carcinoma. Voriconazole administration using intravenous infusion combined with intracavitary lavage was therapeutically effective after MWA at 1 year follow-up. The third case was a 61-year-old woman with primary lung adenocarcinoma. Delayed pneumothorax and bronchopleural fistula secondary to IPA persisted. The patient died from secondary multiple organ function failure. Despite its very low incidence, the significance of early diagnosis and early administration of antifungal therapy should be highlighted because of the relentless severity of IPA in patients undergoing MWA.     

Invasive Mold Infections in FLT3-Mutated Acute Myeloid Leukemia

BackgroundThe incidence and risk factors for invasive mold infections (IMI) in acute myeloid leukemia (AML) patients carrying FLT3 mutations have not been addressed.Patients and MethodsThis retrospective cohort included FLT3-mutated AML patients (2008-2018). Primary outcome was IMI incidence within 6 months after first induction or salvage therapy.ResultsWe included 108 patients receiving fluconazole or micafungin prophylaxis. IMI incidence after induction and salvage therapy was 4.8% and 14.8%, respectively, and did not differ between patients receiving 3+7 regimen or 3+7 plus midostaurin (4.3% vs 4.5%). In a bivariate analysis, age (odds ratio, 1.11; P = .027) and FLT3 ITD mutation (odds ratio, 0.05; P = .023) were independently associated with IMI after induction chemotherapy. Gilteritinib was more frequently prescribed in patients with relapsed/refractory disease who developed IMI (50% vs 27.3%, P = .563).ConclusionFLT3 ITD mutation may be a preventive factor for IMI. Neither midostaurin nor salvage gilteritinib significantly increased the risk of IMI in this population.     

Invasive Aspergillosis Demonstrating the Air Crescent Sign: Occurrence in a Previously Healthy Alcoholic

A case of invasive pulmonary aspergillosis in a previously healthy alcoholic patient is presented. The air crescent sign was extremely useful in directing the diagnostic work up and establishing the correct diagnosis. The air crescent is a result of vascular invasion by Aspergillus with subsequent infarction and necrosis. In an immuno-compromised or alcoholic patient, the air crescent sign should suggest the possibility of invasive aspergillosis.     

Efficacy of liposomal amphotericin B for prophylaxis of acute or reactivation models of invasive pulmonary aspergillosis

The efficacy of antifungal prophylaxis for prevention of invasive aspergillosis (IA) may depend on whether IA results from recent inhalation of spores or reactivation of latent colonisation. Compare the efficacy of liposomal amphotericin B (LAmB) for prophylaxis in acute and reactivation models of IA. In the acute model, mice immunosuppressed from day 0 were challenged at day 3 with an aerosol of Aspergillus fumigatus. LAmB (15 mg kg^?1) was administered at day 0 or at challenge. In the reactivation model, naïve mice exposed to A. fumigatus remained untreated until clearance of spores from the lungs, then immunosuppressed to induce reactivation. A single LAmB dose was administered at start of immunosuppression. In the acute model, a single administration of LAmB at start of immunosuppression was not effective, but an additional administration resulted in a significant decrease in lung fungal burden (P < 0.05 vs. controls). A significant prophylactic efficacy was observed when LAmB was administered once at challenge (P < 0.01). In the reactivation model, a single LAmB administration at start of immunosuppression significantly reduced both reactivation rate and fungal burden vs. controls (P < 0.01). Our results show that the conditions under which IA develop and timing of administration of LAmB were determinant variables for prophylactic efficacy.     

Zur Bedeutung von sekretorischen und stukturassoziierten Proteasen von Aspergillus fumigatus für die Pathogenese der invasiven Aspergillose

Zusammenfassung. Ein Charakteristikum der invasiven Aspergillose ist, daß Aspergillus fumigatus in der Lage ist, proteinreiche Gewebsschichten des Wirtes zu penetrieren. Verantwortlich hierfür könnten sekretorische Proteasen des Pilzes sein, die fibrilläre Proteine wie Kollagen oder Elastin aufweichen und so der Hyphe das Eindringen ermöglichen. Allerdings sprechen Infektionsversuche mit Gendeletions-Mutanten von allen bekannten sekretorischen Aspergillus-Proteasen gegen eine entscheidende Beteiligung dieser Enzyme an der Pathogenese der invasiven Aspergillose. Ebenso deuten mikroskopische Untersuchungen an Gefäßwand-pene-trierenden Aspergillen nicht auf eine stärkere Auflösung des Bindegewebes, so daß auch eine rein mechanische Verdrängung der Struktur-Proteine durch das Wachstum der Hyphe möglich wäre. Weiter vorstellbar ist auch eine streng lokalisierte Proteolyse an dén Wachstumszonen der Hyphen durch Zellwand-assoziierte Proteasen. Kandidaten für einen solchen Mechanismus sind Aspartat- und Serinproteasen, deren Aktivitäten in der Zellwandfraktion von A. fumigatus gefunden wurden. Summary. In the course of invasive aspergillosis, Aspergillus fumigatus is capable of penetrating any tissue of the host. Secretory proteinases of the fungus might facilitate the hyphae to grow through fibrillar proteins like elastin and collagen. However, using systemic infection models, no significantly reduced virulence could be shown with fungal mutants deficient for all known secretory proteinases. Thus, secretory proteinases might be of minor relevance for the pathogenesis of invasive aspergillosis. In addition, microscopic examination of aspergilli penetrating vessel walls did not reveal obvious lysis of wall proteins, thus emphasizing a mechanical disruption of fibrillar proteins by the growing hyphae. However, a strictly localized proteolysis at the tips of growing hyphae caused by wall associated proteinases might be involved. Candidates for such a mechanism art the activities of aspartic and serine proteinases which we have discovered in the cell wall fraction of A. fumigatus.     

Invasive aspergillosis in a paediatric haematology department: a 15-year review

Invasive aspergillosis (IA) is an increasingly common and often fatal fungal infection in children with haematological disorders. To describe the epidemiology, diagnosis, treatment and outcome of IA in children, retrospective review of the medical records of proven and probable IA between January 1986 and December 2000 was used. Twenty-four patients with IA were identified (10 proven and 14 probable) with a median age of 8.5 years. The incidence of IA was particularly high in acute myeloblastic leukaemia (5.35%) and leukaemia relapse (4%). Twenty-two patients presented with lung involvement. Broncho-alveolar lavage led to a diagnosis in 11 cases, but diagnosis was difficult and repeated invasive explorations were required. Antifungal therapy mainly consisted of amphotericin B. Eight patients underwent open-thorax surgery without any complication. Nine patients (37.5%) were cured of IA and three are still alive. The mortality was 87.5%. Three patients died of massive haemoptysis, including two before neutropenia recovery. Four patients presented with IA recurrence and three were cured again. Despite significant progress having been made in the treatment and diagnosis of IA, it is still a devastating complication in children with haematological disorders. New antifungal therapies and strategies are promising, but objective data are still lacking.     

Invasive Aspergillosis in Neutropenic Patients with Hematological Disorders

Between 1983-1988, 72 patients with acute leukemia and 4 with aplastic anemia were treated in the Hematology Unit of The Chaim Sheba Medical Center. Ten patients with acute leukemia developed invasive pulmonary aspergillosis and 2 with aplastic anemia developed invasive aspergillosis of the nose and paranasal sinuses. These infections were diagnosed during a period of profound neutropenia while these patients were receiving broad spectrum antibiotics. The diagnosis of pulmonary aspergillosis was based on positive sputum cultures in 4 cases and on the appearance of typical clinical and radiologic features in six. In 2 culture-positive and in one culture-negative patient, the diagnosis was confirmed at autopsy. Thus, the diagnosis was definitive in 5 patients and probable in the remaining five patients. The 5 patients who achieved remission responded to antifungal treatment and recovered, while of the 5 who eventually died from the fungal infection, 4 did not achieve remission, and one died while in complete remission. In the 2 patients with aplastic anemia, aspergillosis was detected in cultures from necrotic nasal tissue. Both patients remained neutropenic, failed to respond to antifungal treatment and died within a short time after diagnosis. From this experience it appears that invasive aspergillosis in neutropenic patients is potentially curable if treated early by amphotericin B, provided that the neutrophil count recovers.     

Hospital environment fungal contamination and aspergillosis risk in acute leukaemia patients in Sousse (Tunisia)

Hospital environment is considered the main source of invasive aspergillosis (IA) in leukemic patients. This study aimed to describe Aspergillus colonisation in leukemic patients and their hospital environment and to test whether Aspergillus environmental contamination was associated with IA. For a 2‐year period including 14‐month renovation work, 91 acute leukaemia inpatients at the hematology department of University hospital in Sousse (Tunisia) were prospectively included. The incidence of probable IA (EORTC/MSG criteria) was 9.9%. Fifty‐six Aspergillus were isolated from 53 (6.5%) of 811 sputa collected from 35 (38.5%) patients. Aspergillus spp. were isolated in 59.7% of 494 air samples and in 52.8% of 1579 surface samples taken in the patients' room. Aspergillus section Nigri (72.7%) was the most frequent. Aspergillus contamination peaked in autumn and winter on surface and in summer and autumn in air samples and was higher (P = 0.03) during the renovation work period. Multivariate analysis showed that for each Aspergillus section Nigri CFU airborne contamination IA risk increased by 1.05 (P = 0.04). In Tunisia, Aspergillus section Nigri and Flavi, but not Fumigati, are chiefly involved in IA. Our findings support swift implementation of airborne fungal contamination control measures in areas where immunocompromised patient are hospitalised.     

Outcome analysis of invasive aspergillosis in hematologic malignancy and hematopoietic stem cell transplant patients: the role of novel antimold azoles

Background.

Invasive aspergillosis (IA) continues to be a leading cause of morbidity and mortality in hematologic malignancy (HM) patients. We evaluated the prognostic factors for IA in HM patients.

Methods.

In this retrospective study, we included all HM patients diagnosed with proven or probable IA between June 1993 and June 2008.

Results.

A total of 449 HM patients were analyzed, the majority of which (75%) had underlying leukemia. Multivariate logistic regression analysis showed that neutropenia for more than two weeks during IA, steroid use, and intensive care admission were independently associated with failure to respond to antifungal therapy, as well as increased IA-attributable mortality (all p-values < .01). Antifungal therapy with an antimold azole-containing regimen (voriconazole or posaconazole) was also independently associated with improved response to treatment, as well as decreased IA-attributable mortality (all p-values < .0001). Survival analysis showed that primary or salvage therapy with a regimen that contained antimold azoles was significantly associated with improved survival (p < .001).

Conclusions.

In HM patients, persistent neutropenia and the need for intensive care are associated with failure to respond to antifungal therapy. Use of novel antimold azoles, either as primary or salvage therapy, improves the overall outcome and IA-attributable death of HM patients with IA.     

Chronic necrotizing pulmonary aspergillosis with concomitant aspergilluria

Summary. This paper reports a case of chronic necrotizing pulmonary aspergillosis in a patient without underlying disease. Aspergilluria was the starting point in the search for the origin of the pulmonary disease, later confirmed by an open lung biopsy.
Zusammenfassung. Es wird über einen Fall von chronischer nekrotisierender Lungenaspergillose bei einem Patienten ohne Prädisposition berichtet. Aspergillurie war der Ausgangspunkt bei der Suche nach der Ursache der Lungenkrankheit, die später durch eine offene Lungenbiopsie bestätigt wurde.     

Viability Damage on Aspergillus flavus Spores by an Antifungal Aerosol/Schädigung der Lebensfähigkeit von Aspergillus flavus-Sporen durch ein pilzhemmendes Aerosol

Summary: An Aspergillus flavus spore aerosol was submitted to 0,6 g/m³ driol-containing Fumispore®. Among preventive means for invasive pulmonary aspergillosis, Fumispore®, releasing an antifungal aerosol constituted by an active compound (parahydroxyphenylsalicylamide or driol) has been proposed. However, no study has been made concerning the effect of Fumispore® on fungus spores. The number of air viable spores exposed, or not, to Fumispore® in an experimental chamber was determined by a low velocity impactor sampler. A significant decrease in isolated viable spores was observed between the two groups (control and exposed-Fumispore® aerosols) during the experiments. These experimental results indicate that a chemical effect is associated with spore viability damage.
Zusammenfassung: Ein Aerosol von Aspergillus flavus-Sporen wurde dem Driol-enthaltenden Präparat Fumispore® in einer Konzentration von 0,6 g/m³ ausgesetzt. Fumispore®, das ein pilzhemmendes Aerosol mit der aktiven Verbindung Parahydroxyphenylsalicylamid (oder Driol) freisetzt, wurde als ein Präventivmittel gegen invasive pulmonale Aspergillosen empfohlen. Bisher liegen jedoch keine Studien über den Einfluß von Fumispore® auf Pilzsporen vor. In unseren Experimenten bestimmten wir die Anzal lebensfähiger Sporen unter experimentellen Bedingungen mit und ohne Fumispore®-Exposition. Beim Vergleich der beiden Gruppen ließ sich ein deutlicher Abfall der lebensfähigen Sporen besonders nach Fumispore®-Exposition feststellen. Diese experimentellen Ergebnisse zeigen an, daß die chemische Wirkung des Präparates mit einer Schädigung der Lebensfähigkeit der Sporen in Zusammenhang steht.