title: Diagnosis of invasive fungal infections in haematological patients by combined use of galactomannan, 1,3-β-D-glucan, Aspergillus PCR, multifungal DNA-microarray, and Aspergillus azole resistance PCRs in blood and bronchoalveolar lavage samples: results of a prospective multicentre study.
abstract: High mortality rates of invasive fungal disease (IFD), especially invasive aspergillosis (IA), in immunocompromised haematological patients and current diagnostic limitations require improvement of detection of fungal pathogens by defining the optimal use of biomarkers and clinical samples. Concurrent bronchoalveolar lavage (BAL) and peripheral blood samples of 99 haematological patients with suspected IFD were investigated within a multicentre prospective study. Diagnostic performance of a galactomannan (GM) enzyme immune assay (EIA), a 1,3-β-D-glucan assay (BDG), an Aspergillus PCR, and a multifungal DNA-microarray (Chip) alone or in combination were calculated. IFD were classified as proven (n=3), probable (n=34), possible (n=33), and no IFD (n=29) according to EORTC/MSG criteria. GM, PCR, and Chip showed superior diagnostic performance in BAL than in blood, whereas specificity of BDG in BAL was poor (48% (14/29)). The combination of GM (BAL) with BDG (blood) showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and DOR (diagnostic odds ratio) of 92% (34/37), 93% (27/29), 94%, 90%, and 153.0, respectively. Combining GM (BAL) with PCR (BAL) showed convincing diagnostic potential for diagnosing IA with sensitivity, specificity, PPV, NPV, and DOR of 85% (17/20), 97% (28/29), 94%, 90%, and 158.7. Addition of the DNA-microarray resulted in further detection of two mucormycetes infections. In 1 out of 15 Aspergillus DNA-positive samples a triazole resistance-mediating Cyp51A mutation was found. Combination of biomarkers is superior to their sole use in diagnosing IFD, particularly IA. Integrating blood and BAL samples into a diagnostic algorithm is an advantageous approach.
authors.affiliation: Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany. Electronic address: tobias.boch@medma.uni-heidelberg.de.
authors.forename: T
authors.initials: T
authors.lastname: Boch
authors.affiliation: Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: B
authors.initials: B
authors.lastname: Spiess
authors.affiliation: Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany; Clinical Trials Centre Cologne, ZKS Cologne, BMBF 01KN1106, Cologne, Germany; Centre for Integrated Oncology CIO Cologne-Bonn, Cologne, Germany; Cologne Excellence Cluster on Cellular Stress Response in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.
authors.forename: O A
authors.initials: OA
authors.lastname: Cornely
authors.affiliation: Department I of Internal Medicine, University Hospital of Cologne, German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany.
authors.forename: J J
authors.initials: JJ
authors.lastname: Vehreschild
authors.affiliation: Institute of Medical Microbiology, University Hospital Essen, Germany.
authors.forename: P M
authors.initials: PM
authors.lastname: Rath
authors.affiliation: Institute of Medical Microbiology, University Hospital Essen, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Steinmann
authors.affiliation: Department II of Internal Medicine, University Hospital Würzburg, Germany.
authors.forename: W J
authors.initials: WJ
authors.lastname: Heinz
authors.affiliation: Department of Hematology Oncology, University Hospital Regensburg, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Hahn
authors.affiliation: Department of Hematology Oncology, University Hospital Erlangen, Germany.
authors.forename: S W
authors.initials: SW
authors.lastname: Krause
authors.affiliation: Department I of Internal Medicine, Klinikum Frankfurt/Oder, Germany.
authors.forename: M G
authors.initials: MG
authors.lastname: Kiehl
authors.affiliation: Department V of Internal Medicine, University Hospital Heidelberg, Germany.
authors.forename: G
authors.initials: G
authors.lastname: Egerer
authors.affiliation: Department of Bone Marrow Transplantation, University Hospital Essen, Germany.
authors.forename: T
authors.initials: T
authors.lastname: Liebregts
authors.affiliation: Department of Bone Marrow Transplantation, University Hospital Essen, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Koldehoff
authors.affiliation: Department I of Internal Medicine, Prosper-Hospital Recklinghausen, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Klein
authors.affiliation: Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: F
authors.initials: F
authors.lastname: Nolte
authors.affiliation: Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: M C
authors.initials: MC
authors.lastname: Mueller
authors.affiliation: Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: N
authors.initials: N
authors.lastname: Merker
authors.affiliation: Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Will
authors.affiliation: Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Mossner
authors.affiliation: Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: H
authors.initials: H
authors.lastname: Popp
authors.affiliation: Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: W-K
authors.initials: WK
authors.lastname: Hofmann
authors.affiliation: Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Reinwald
authors.affiliation: Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: D
authors.initials: D
authors.lastname: Buchheidt
mesh_terms: D001228:Aspergillosis / Q000097:blood / Q000175:diagnosis*; D001230:Aspergillus / Q000187:drug effects / Q000235:genetics; D001393:Azoles / Q000494:pharmacology; D001992:Bronchoalveolar Lavage Fluid / Q000382:microbiology*; D005690:Galactose / Q000031:analogs & derivatives; D006801:Humans; D000072742:Invasive Fungal Infections / Q000097:blood / Q000175:diagnosis*; D008351:Mannans / Q000032:analysis; D008828:Microbiological Techniques / Q000379:methods*; D025202:Molecular Diagnostic Techniques / Q000379:methods*; D060885:Multiplex Polymerase Chain Reaction / Q000379:methods; D020411:Oligonucleotide Array Sequence Analysis / Q000379:methods; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D047071:beta-Glucans / Q000032:analysis
chemical_list: D001393:Azoles; D008351:Mannans; D047071:beta-Glucans; C012990:galactomannan; C033363:beta-1,3-glucan; D005690:Galactose
keywords: AspergillusPCR; Fungal diagnostics; Galactomannan; Invasive fungal disease; Multifungal DNA-microarray; β-D-glucan