title: Combining standard clinical methods with PCR showed improved diagnosis of invasive pulmonary aspergillosis in patients with hematological malignancies and prolonged neutropenia.
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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Faculty of Medicine, Department of Human Genetics, University of Debrecen, Nagyerdei krt. 98, H-4032, Debrecen, Hungary. paholcsek.melinda@med.unideb.hu.
authors.forename: Melinda
authors.initials: M
authors.lastname: Paholcsek
authors.affiliation: Faculty of Medicine, Department of Human Genetics, University of Debrecen, Nagyerdei krt. 98, H-4032, Debrecen, Hungary. fidler.gabor@med.unideb.hu.
authors.forename: Gabor
authors.initials: G
authors.lastname: Fidler
authors.affiliation: Faculty of Medicine, Department of Medical Microbiology, University of Debrecen, Debrecen, Hungary. konya@med.unideb.hu.
authors.forename: Jozsef
authors.initials: J
authors.lastname: Konya
authors.affiliation: Faculty of Medicine, Institute of Internal Medicine, University of Debrecen, Debrecen, Hungary. lrejto@med.unideb.hu.
authors.forename: Laszlo
authors.initials: L
authors.lastname: Rejto
authors.affiliation: Faculty of Medicine, Institute of Pathology, University of Debrecen, Debrecen, Hungary. gabor.mehes@med.unideb.hu.
authors.forename: Gabor
authors.initials: G
authors.lastname: Mehes
authors.affiliation: Faculty of Medicine, Department of Medical Microbiology, University of Debrecen, Debrecen, Hungary. evelin.mb@gmail.com.
authors.forename: Evelin
authors.initials: E
authors.lastname: Bukta
authors.affiliation: Department for Internal Medicine II, University of Wuerzburg Medical Centre, Wuerzburg, Germany. loeffler_j@medizin.uni-wuerzburg.de.
authors.forename: Juergen
authors.initials: J
authors.lastname: Loeffler
authors.affiliation: Faculty of Medicine, Department of Human Genetics, University of Debrecen, Nagyerdei krt. 98, H-4032, Debrecen, Hungary. sbiro@med.unideb.hu.
authors.forename: Sandor
authors.initials: S
authors.lastname: Biro
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000935:Antifungal Agents / Q000627:therapeutic use; D000946:Antigens, Fungal / Q000276:immunology; D001232:Aspergillus fumigatus / Q000235:genetics* / Q000276:immunology; D016022:Case-Control Studies; D004271:DNA, Fungal / Q000235:genetics*; D005260:Female; D005690:Galactose / Q000031:analogs & derivatives; D019337:Hematologic Neoplasms / Q000150:complications / Q000276:immunology*; D006801:Humans; D007118:Immunoassay / Q000379:methods; D055744:Invasive Pulmonary Aspergillosis / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy / Q000276:immunology; D008168:Lung / Q000000981:diagnostic imaging; D008297:Male; D008351:Mannans / Q000276:immunology; D008875:Middle Aged; D009503:Neutropenia / Q000150:complications / Q000276:immunology*; D010865:Pilot Projects; D016133:Polymerase Chain Reaction / Q000379:methods; D011446:Prospective Studies; D014057:Tomography, X-Ray Computed / Q000379:methods; D055815:Young Adult
chemical_list: D000935:Antifungal Agents; D000946:Antigens, Fungal; D004271:DNA, Fungal; D008351:Mannans; C012990:galactomannan; D005690:Galactose