RESUMO
Aspergillus species can colonize and infect immunocompetent and immunocompromised hosts. Conventional fungal identification depends on microscopic analysis and microorganism medium growth. Other diagnostic methods, non-growth dependent, to invasive fungal infections, are the biomarkers that detect circulating polysaccharides, for example, 1-3-ß-d-Glucan and galactomannan. Both are polysaccharides present on the external layer of fungi cell wall and can be detected in clinical samples during the growth of the fungus in the patient. This study aimed to compare the galactomannan detection of Lateral Flow Assay and Enzyme Immunoassay methods in Bronchoalveolar Lavage Fluid. The galactomannan antigen in Bronchoalveolar Lavage Fluid was measured using Enzyme Immunoassay according to the manufacturer's instructions (PLATELIA ASPERGILLUS™ BioRad) and, using a Lateral Flow Assay according to the manufacturer's instructions (Galactomannan LFA IMMY©). The 71 samples were Bronchoalveolar Lavage Fluid of patients hospitalized at Unicamp Clinical Hospital between 2019 and 2021; of these samples 12/71 (16.9 %) resulted in positive Galactomannan-Lateral Flow Assay. In contrast, Galactomannan-Enzyme Immunoassay resulted as positive in 9/71 (12.6 %) samples, a difference that showed not significant statistically (p-value = 0.36) Comparing both assays' results identified 8 divergences between them, about 11 % of the total sample. The Sensitivity (73.3 %), Specificity (92.35 %), Positive Predictive Value (62.85 %) and Negative Predictive Value (95.15 %) of Lateral Flow Assay were calculated using the Galactomannan Enzyme Immunoassay as standard. The Lateral Flow Assay demonstrated good results when compared with the Enzyme Immunoassay.
Assuntos
Aspergillus , Líquido da Lavagem Broncoalveolar , Galactose , Técnicas Imunoenzimáticas , Mananas , Sensibilidade e Especificidade , Mananas/análise , Galactose/análogos & derivados , Humanos , Líquido da Lavagem Broncoalveolar/microbiologia , Líquido da Lavagem Broncoalveolar/química , Aspergillus/imunologia , Aspergillus/isolamento & purificação , Técnicas Imunoenzimáticas/métodos , Aspergilose/diagnóstico , Aspergilose/microbiologia , Biomarcadores/análise , Antígenos de Fungos/análise , Reprodutibilidade dos TestesRESUMO
INTRODUCCIÓN: Las opacidades pulmonares en receptores de trasplante de precursores hematopoyéticos (TPH) representan un desafío diagnóstico y son una causa de morbimortalidad. Existen grandes discrepancias con respecto a la sensibilidad diagnóstica del lavado broncoalveolar (LBA), sus complicaciones, y los factores asociados a la identificación microbiológica. OBJETIVO: Conocer la utilidad del estudio microbiológico del LBA en el diagnóstico, modificación de la conducta médica y estimar las complicaciones y mortalidad asociada al procedimiento, en receptores de TPH con opacidades pulmonares. PACIENTES Y MÉTODOS: Estudio de cohorte, retrospectivo, en adultos receptores de TPH a los que se les realizó una broncoscopía con LBA por presentar opacidades pulmonares, en el Hospital Italiano de Buenos Aires entre el 01/01/2011 y el 31/12/2020. RESULTADOS: De los 189 procedimientos analizados, en 79 se logró un hallazgo microbiológico (41,8%) y 122 permitieron modificar la conducta médica (64,6%). En 11 casos se observaron complicaciones graves dentro de las 12 horas (5,8%) de efectuado el LBA. La mortalidad intrahospitalaria fue de 16,8% (N = 21/125). El valor de neutrófilos en sangre previo al LBA (p = 0,037) y la presencia de nódulos pulmonares como lesión tomográfica predominante (p = 0,029) se asociaron independientemente al hallazgo microbiològico global. CONCLUSIONES: Nuestra investigación apoya la realización del LBA como herramienta diagnóstica en pacientes que reciben un TPH y presentan opacidades pulmonares.
BACKGROUND: Lung opacities are a cause of morbimortality in bone marrow transplant patients, and represent a diagnostic challenge. There are large discrepancies regarding the diagnostic sensitivity of bronchoalveolar lavage (BAL), its complications, and the factors associated with microbiological detection. AIM: To know the usefulness of the microbiological study of BAL in the diagnosis, in the modification in medical behavior and to estimate the complications and associated mortality of this diagnostic procedure in patients transplanted with hematopoietic progenitor cells with pulmonary opacities. METHODS: Retrospective cohort study in bone marrow transplant adult patients who underwent bronchoscopy with BAL due to lung opacities at Hospital Italiano de Buenos Aires between 01/01/2011 and 12/31/2020. RESULTS: Of the 189 BAL analyzed, 79 presented a microbiological detection (41.8%) and 122 allowed to modify the medical behavior (64.6%). Severe complications were observed within 12 hours after the procedure in11 cases (5.8%). In-hospital mortality was 16,8% (N = 21/125). The value of blood neutrophils prior to bronchoalveolar lavage (p = 0.037) and the presence of pulmonary nodules as the predominant tomographic lesion (p = 0.029) were independently associated with global microbiological detection. CONCLUSION: Our research supports the performance of BAL as a diagnostic tool in bone marrow transplant patients with lung opacities.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Broncoscopia/métodos , Líquido da Lavagem Broncoalveolar/microbiologia , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Lavagem Broncoalveolar/métodos , Neoplasias Hematológicas/terapia , Bactérias/isolamento & purificação , Vírus/isolamento & purificação , Análise Multivariada , Estudos de Coortes , Hospedeiro Imunocomprometido , Transplantados , Fungos/isolamento & purificação , Pulmão/microbiologiaRESUMO
INTRODUCCIÓN: Desde el inicio de la pandemia por COVID-19 se han registrado casos de infecciones de aspergilosis pulmonar asociada a esta infección, la cual tiene características diferentes a la aspergilosis pulmonar clásica y, por lo tanto, han significado un desafío diagnóstico. OBJETIVO: Validar una reacción de polimerasa en cadena (RPC) en tiempo real (sigla en inglés RT-PCR) comercial, como herramienta diagnóstica alternativa a la técnica de galactomanano (GM) en el diagnóstico de aspergilosis pulmonar asociada a COVID-19 (sigla en inglés CAPA). PACIENTES Y MÉTODO: Se analizaron resultados de RT-PCR de Aspergillus spp y GM en lavado bronco-alveolar (LBA) de 72 pacientes, hospitalizados por COVID-19 de Clínica Dávila entre los años 2020 y 2021. De estos pacientes, 33 presentaron CAPA. RESULTADOS: La RT-PCR de Aspergillus y GM presentaron una correlación positiva (r = 0,6351, valor p < 0,0001). La técnica de RT-PCR presentó una sensibilidad (S), especificidad (E), valor predictor positivo (VPP) y valor predictor negativo (VPN) de 100, 44, 66 y 100%, respectivamente, mientras que en GM fueron de 64, 89, 84 y 73%, respectivamente para LBA. Al utilizar ambas técnicas en combinación se obtuvo una S, E, VPP y VPN de 100, 82, 88 y 100%, respectivamente. CONCLUSIÓN: Este estudio concluyó que usar una técnica de RT-PCR de Aspergillus y GM en conjunto en LBA mejoraron los parámetros de desempeño de ambas técnicas usadas de manera individual para diagnosticar CAPA. Se requieren más estudios para evaluar el desempeño de técnicas combinadas en otros tipos de aspergilosis.
BACKGROUND: Since the beginning of the COVID-19 pandemic, there have been cases of pulmonary aspergillosis infections associated with this infection, which has different characteristics from classical pulmonary aspergillosis and therefore, have been diagnostic challenges. AIM: To validate a commercial real-time PCR (RT-PCR) method as an alternative diagnostic tool to the galactomannan (GM) technique in the diagnosis of COVID-19-associated pulmonary aspergillosis (CAPA). METHODS: Results of RT-PCR of Aspergillus spp and GM in broncho-alveolar lavage (BAL) of 72 patients hospitalized for COVID-19 at Clínica Dávila between 2020 and 2021 were analyzed. Of these patients, 33 presented CAPA. RESULTS: The RT-PCR for Aspergillus and GM showed a positive correlation (r = 0.6351, p-value < 0.0001). The RT-PCR for Aspergillus technique presented a sensitivity (S), specificity (S), positive predictive value (PPV) and negative predictive value (NPV) of 100, 44, 66 and 100% respectively, while the GM technique presented 64, 89, 84 and 73%, respectively for BAL. Using both techniques in combination a S, E, PPV and NPV of 100, 82, 88 and 100% were obtained respectively. CONCLUSION: This study concluded that using RT-PCR and GM techniques in combination in BAL improved the performance parameters of both techniques from those used individually to diagnose CAPA. Further studies are required to evaluate the performance of combined techniques in other aspergillosis focus.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Adulto Jovem , Aspergilose Pulmonar/diagnóstico , Reação em Cadeia da Polimerase em Tempo Real , COVID-19/complicações , Aspergillus/isolamento & purificação , Ensaio de Imunoadsorção Enzimática , Líquido da Lavagem Broncoalveolar/microbiologia , Chile , Valor Preditivo dos Testes , Sensibilidade e Especificidade , Aspergilose Pulmonar/complicações , Galactose/análogos & derivados , Mananas/análiseRESUMO
BACKGROUND: A clear cutoff value of galactomannan (GM) has not been established for chronic pulmonary aspergillosis (CPA) and is frequently extrapolated from invasive pulmonary aspergillosis. We performed a systematic review and meta-analysis to evaluate the diagnostic performance of serum and bronchoalveolar lavage (BAL) GM, and to propose a cutoff. METHODS: We extracted from the studies the cutoff of serum or/and BAL GM associated with true positives, false positives, true negatives, and false negatives. We performed a multi-cutoff model and a non-parametric random effect model. We estimated the optimal cutoff and the area under the curve (AUC) for GM in serum and BAL samples. RESULTS: Nine studies from 1999 to 2021 were included. Overall, the optimal cutoff of serum GM was 0.96 with a sensitivity of 0.29 (95%CI: 0.14-0.51); specificity of 0.88 (95%CI: 0.73-0.95); and AUC of 0.529 (with a CI: [0.415-0.682] [0.307-0.713]). The AUC for the non-parametric ROC model was 0.631. For BAL GM the cutoff was 0.67 with a sensitivity of 0.68 (95%CI: 0.51-0.82), specificity of 0.84 (95%CI: 0.70-0.92), and AUC of 0.814 (with a CI: [0.696-0.895] [0.733-0.881]). The AUC for the non-parametric model was 0.789. CONCLUSION: The diagnosis of CPA requires the assessment of a combination of mycological and serological factors, as no single serum and/or BAL GM antigen test is adequate. BAL GM performed better than serum, with better sensitivity and excellent accuracy.
Assuntos
Aspergilose Pulmonar , Humanos , Sensibilidade e Especificidade , Líquido da Lavagem Broncoalveolar/microbiologia , Aspergilose Pulmonar/diagnóstico , Lavagem Broncoalveolar , Mananas/análiseRESUMO
Mycoplasma (M.) hyopneumoniae interacts with the respiratory microbiota and facilitates colonization of other pathogens. The present study investigated the pulmonary and nasal microbiota of M. hyopneumoniae-infected and M. hyopneumoniae-free pigs. Sixty-six pigs from three commercial herds were selected at the end of the finishing phase: 44 originated from two M. hyopneumoniae-positive herds and 22 from a M. hyopneumoniae-negative farm. At the slaughterhouse, samples of nasal turbinate (NT) and bronchus-alveolar lavage fluid (BALF) were collected. DNA was extracted with a commercial kit and the infection status was confirmed by qPCR. All samples from the same herd were pooled, and next-generation sequencing based on the hypervariable region V3-V4 of the 16 s bacterial rDNA was performed. Data analysis included the taxonomic analysis, Alpha diversity indexes, and Principal coordinates analysis (Pcoa) using Jaccard, Bray-Curtis, Weighted Unifrac, and Unweighted Unifrac distances. All pigs from the infected herds tested PCR positive for M. hyopneumoniae, whereas all pigs from the negative farm were negative. There was a greater diversity of microorganisms in BALF when compared to NT samples in all the farms. BALF samples from infected animals showed higher abundance of M. hyopneumoniae than NT samples and a predominance of Pasteurella multocida among the main species identified, which was also abundant in the M. hyopneumoniae-free herd. PCoa diagrams indicated that for most of the samples, dissimilarity on bacterial composition was observed, regardless of infection status and sample type. Therefore, the lung microbiota was modulated by M. hyopneumoniae infection, which could play a role in the pathogenesis of M. hyopneumoniae-disease.
Assuntos
Microbiota , Mycoplasma hyopneumoniae , Pneumonia Suína Micoplasmática , Doenças dos Suínos , Animais , Líquido da Lavagem Broncoalveolar/microbiologia , Pulmão/patologia , Mycoplasma hyopneumoniae/genética , Pneumonia Suína Micoplasmática/microbiologia , Suínos , Doenças dos Suínos/microbiologiaRESUMO
BACKGROUND: Ecthyma gangrenosum (EG) is a cutaneous infectious disease characterized by eschar-like skin ulcers typically caused by Pseudomonas aeruginosa. Here, we report a case of relapsing EG in a patient who had returned from a trip to Colombia, thus establishing EG as an important differential diagnosis of tropical diseases, and demonstrating that even long-term antibiotic treatment can result in only partial remission of EG. CASE PRESENTATION: A 77-year-old man with underlying chronic lymphocytic leukemia (CLL) on ibrutinib treatment was admitted because of a superinfected mosquito bite on the left ear and multiple partially necrotic skin lesions disseminated all over the entire body five days after returning from a trip to Colombia. The initial clinical suspicion of a tropical disease (leishmaniosis, systemic mycosis, or others) could not be confirmed. During the diagnostic workup, microbiological cultures of the skin biopsies and bronchoalveolar lavage revealed Pseudomonas aeruginosa, leading to a diagnosis of EG. Initial antibiotic treatment resulted in partial remission. However, the patient had to be re-admitted due to a relapse 3-4 weeks after the first episode. Finally, the patient was successfully treated with a combined approach consisting of antibiotics, recurrent surgical incisions, and administration of immunoglobulins. CONCLUSIONS: In conclusion, EG should be considered as a differential diagnosis in immunosuppressed patients presenting with eschar-like skin ulcers. A combined treatment approach seems to be the best choice to achieve clinical cure and avoid relapse.
Assuntos
Ectima/diagnóstico , Úlcera Cutânea/diagnóstico , Adenina/análogos & derivados , Adenina/uso terapêutico , Administração Intravenosa , Idoso , Antibacterianos/uso terapêutico , Líquido da Lavagem Broncoalveolar/microbiologia , Colômbia , Diagnóstico Diferencial , Ectima/tratamento farmacológico , Ectima/microbiologia , Ectima/cirurgia , Humanos , Hospedeiro Imunocomprometido , Imunoglobulinas/uso terapêutico , Leucemia Linfocítica Crônica de Células B/tratamento farmacológico , Leucemia Linfocítica Crônica de Células B/patologia , Masculino , Piperidinas/uso terapêutico , Pseudomonas aeruginosa/isolamento & purificação , Úlcera Cutânea/microbiologia , Úlcera Cutânea/cirurgiaRESUMO
BACKGROUND: Patients with severe viral pneumonia are likely to receive high-dose immunomodulatory drugs to prevent clinical worsening. Aspergillus species have been described as frequent secondary pneumonia agents in severely ill influenza patients receiving steroids. COVID-19 patients admitted to Intensive Care Unit (ICU) are receiving steroids as part of their treatment and they share clinical characteristics with other patients with severe viral pneumonias. COVID-19 patients receiving steroids should be considered a putative risk group of invasive aspergillosis. CASE REPORT: We are reporting a SARS-CoV-2/Aspergillus section Fumigati coinfection in an elderly intubated patient with a history of pulmonary embolism treated with corticosteroids. The diagnosis was made following the ad hoc definitions described for patients admitted to ICU with severe influenza, including clinical criteria (fever for 3 days refractory to the appropriate antibiotic therapy, dyspnea, pleural friction rub, worsening of respiratory status despite antibiotic therapy and need of ventilator support), a radiological criterion (pulmonary infiltrate) and a mycological criterion (several positive galactomannan tests on serum with ratio ≥0.5). In addition, Aspergillus section Fumigati DNA was found in serum and blood samples. These tests were positive 4 weeks after the patient was admitted to the ICU. The patient received voriconazole and after two month in ICU his respiratory status improved; he was discharged after 6 weeks of antifungal treatment. CONCLUSIONS: Severely ill COVID-19 patients would be considered a new aspergillosis risk group. Galactomannan and Aspergillus DNA detection would be useful methods for Aspergillus infection diagnosis as they allow avoiding the biosafety issues related to these patients.
Assuntos
Aspergillus fumigatus/isolamento & purificação , Tratamento Farmacológico da COVID-19 , COVID-19/complicações , Coinfecção/diagnóstico , Imunocompetência , Imunossupressores/efeitos adversos , Aspergilose Pulmonar Invasiva/complicações , Metilprednisolona/efeitos adversos , SARS-CoV-2/isolamento & purificação , Acetaminofen/uso terapêutico , Idoso , Anti-Infecciosos/uso terapêutico , Líquido da Lavagem Broncoalveolar/microbiologia , COVID-19/diagnóstico , COVID-19/terapia , COVID-19/virologia , Teste de Ácido Nucleico para COVID-19 , Coinfecção/microbiologia , Coinfecção/terapia , Coinfecção/virologia , Terapia Combinada , Diagnóstico Diferencial , Quimioterapia Combinada , Enoxaparina/uso terapêutico , Galactose/análogos & derivados , Humanos , Hidroxicloroquina/uso terapêutico , Imunossupressores/uso terapêutico , Intubação Intratraqueal , Aspergilose Pulmonar Invasiva/diagnóstico , Aspergilose Pulmonar Invasiva/microbiologia , Aspergilose Pulmonar Invasiva/terapia , Masculino , Mananas/sangue , Metilprednisolona/uso terapêutico , Nasofaringe/virologia , Pneumonia por Mycoplasma/diagnóstico , Pseudomonas aeruginosa/isolamento & purificação , Reação em Cadeia da Polimerase em Tempo Real , Respiração Artificial , Staphylococcus aureus/isolamento & purificação , Traqueia/microbiologiaRESUMO
Infections caused by uncommon and resistant pathogens in unusual sites have been increasingly reported in medical literature. We describe four cases of rare cytological findings and clinical impact for patients. In the first case, Aspergillus sp and Pneumocystis jirovecii were observed in the bronchoalveolar lavage of a patient with severe systemic lupus. In the second and third cases, we describe the presence of Trichomonas sp and Strongyloides sp larvae in samples of pleural and peritoneal fluid, respectively. The fourth report is about a patient with a wrist subcutaneous nodule whose synovial aspiration and cytology revealed the presence of brown septate hyphae. The early identification of the infectious agent in the cytological examination was essential for the introduction and/or re-adaptation of therapy in the four cases described. Patients in this report were immunocompromised with severe comorbidities, conditions often associated with unfavorable clinical outcomes.
Assuntos
Doenças Transmissíveis/diagnóstico , Citodiagnóstico/métodos , Animais , Líquido Ascítico/parasitologia , Aspergillus/isolamento & purificação , Líquido da Lavagem Broncoalveolar/microbiologia , Evolução Fatal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Derrame Pleural/parasitologia , Pneumocystis carinii/isolamento & purificação , Strongyloides/isolamento & purificação , Estrongiloidíase/diagnóstico , Trichomonas/isolamento & purificação , Tricomoníase/diagnósticoRESUMO
RATIONALE: Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junctions that leads to fluctuating weakness and disabling fatigability. Due to difficulty in breathing caused by weakness of the respiratory muscles, patients with MG are more susceptible to pneumonia and other respiratory infections. As many patients with MG are given immunosuppressive therapy, this makes them more prone to infections. However, coinfection with 3 pathogens is very rare. PATIENT CONCERNS: Here, we report the case of a 41-year-old gentleman with MG who was receiving long-term steroid therapy. He presented with a cough with pale brown expectoration that occurred without obvious inducement, severe pain in the scapula, as well as swelling and weakness of both legs. Despite undergoing treatment, but his symptoms did not improve, prompting two additional hospital admissions over a period of several months. DIAGNOSIS: Bronchoscopy and bronchoalveolar lavage (BAL) were performed, revealing the presence of Pneumocystis jirovecii , Nocardia brasiliensis, and Mycobacterium tuberculosis (MTB). N brasiliensis was identified by positive modified acid-fast Kinyoun staining as well as a positive colony culture identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry from the BAL sample. MTB was confirmed using GeneXpert, and due to the limitations of the culture conditions, methenamine silver stain was used to confirm Pneumocystis jirovecii. Next-generation sequencing (NGS) assay of the BAL samples also confirmed these pathogens. INTERVENTIONS: The patient was transferred to a designated tuberculosis hospital and received anti-infective and anti-TB treatment. OUTCOMES: During treatment at the designated hospital, the patient developed gastrointestinal bleeding and impaired liver function. One month later, he developed multiple organ failure, consolidation of the left lower lung, and pan-drug resistant bacteremia. He refused further treatment and was discharged. CONCLUSION: In conclusion, physicians should be aware of the predisposition of MG patients to co-infections, especially patients with metabolic disorders, to avoid inadequate treatment and poor patient outcomes. Due to the limitations of culture conditions, NGS should be considered as a new technique for identifying pathogens.
Assuntos
Miastenia Gravis , Mycobacterium tuberculosis/isolamento & purificação , Nocardia/isolamento & purificação , Pneumocystis carinii/isolamento & purificação , Pneumonia Bacteriana/diagnóstico , Pneumonia por Pneumocystis/diagnóstico , Tuberculose Pulmonar/diagnóstico , Adulto , Líquido da Lavagem Broncoalveolar/microbiologia , Coinfecção , Diagnóstico Diferencial , Humanos , Masculino , Pneumonia Bacteriana/complicações , Pneumonia Bacteriana/microbiologia , Pneumonia por Pneumocystis/complicações , Pneumonia por Pneumocystis/microbiologia , Tuberculose Pulmonar/complicações , Tuberculose Pulmonar/microbiologiaRESUMO
BACKGROUND: Differentiation of bone marrow eosinophils (BM-EO) and its trafficking to peripheral blood and respiratory mucosa are a hallmark of inflammatory diseases. Staphylococcal enterotoxin B (SEB) has been shown to aggravate airways eosinophilic inflammation. This study aimed to investigate the effects of mouse airways SEB exposure on BM-EO population, as well as its adhesive properties and release of cytokines/chemokines that orchestrate BM-EO trafficking to lungs. METHODS: Male BALB/c mice were intranasally exposed to SEB (1 µg), and at 4, 16, 24 and 48 h thereafter, bone marrow (BM), circulating blood and bronchoalveolar lavage (BAL) fluid were collected. Levels of cytokines/chemokines and expressions of VLA-4 and CCR3 in BM were evaluated. Adhesion of BM to ICAM-1 and VCAM-1 were also evaluated. RESULTS: SEB exposure promoted a marked eosinophil influx to BAL at 16 and 24 h after exposure, which was accompanied by significant increases in counts of immature (16 h) and mature (4 to 48 h) forms of eosinophil in BM, along with blood eosinophilia (16 h). In BM, higher levels of eotaxin, IL-5, IL-4, IL-3 and IL-7 were detected at 16 to 48 h. SEB also significantly increased CCR3 expression and calcium levels in BM-EO, and enhanced the cell adhesion to ICAM-1 (24 h) and ICAM-1 (48 h). CONCLUSION: Airways SEB exposure increases the number of eosinophils in BM by mechanisms involving a network of cytokine and chemokine release, facilitating the BM-EO adhesion to ICAM-1 and VCAM-1 to gain access to the peripheral blood and lung tissues.