Stereoisomeric configuration of arabinitol in serum, urine, and tissues in invasive candidiasis

Invasive mycoses: diagnostic challenges

Despite the availability of newer antifungal drugs, outcomes for patients with invasive fungal infections (IFIs) continue to be poor, in large part due to delayed diagnosis and initiation of appropriate antifungal therapy. Standard histopathologic diagnostic techniques are often untenable in at-risk patients, and culture-based diagnostics typically are too insensitive or nonspecific, or provide results after too long a delay for optimal IFI management. Newer surrogate markers of IFIs with improved sensitivity and specificity are needed to enable earlier diagnosis and, ideally, to provide prognostic information and/or permit therapeutic monitoring. Surrogate assays should also be accessible and easy to implement in the hospital. Several nonculture-based assays of newer surrogates are making their way into the medical setting or are currently under investigation. These new or up-and-coming surrogates include antigens/antibodies (mannan and antimannan antibodies) or fungal metabolites (d-arabinitol) for detection of invasive candidiasis, the Aspergillus cell wall component galactomannan used to detect invasive aspergillosis, or the fungal cell wall component and panfungal marker β-glucan. In addition, progress continues with use of polymerase chain reaction- or other nucleic acid- or molecular-based assays for diagnosis of either specific or generic IFIs, although the various methods must be better standardized before any of these approaches can be more fully implemented into the medical setting. Investigators are also beginning to explore the possibility of combining newer surrogate markers with each other or with more standard diagnostic approaches to improve sensitivity, specificity, and capacity for earlier diagnosis, at a time when fungal burden is still relatively low and more responsive to antifungal therapy.

Detection of transaldolase deficiency by quantification of novel seven-carbon chain carbohydrate biomarkers in urine

Transaldolase deficiency, a recently discovered disorder of carbohydrate metabolism with multisystem involvement, has been diagnosed in 6 patients. Affected patients have abnormal concentrations of polyols in body fluids and in all patients we have previously found increased amounts of a seven-carbon chain carbohydrate which we suspected of being sedoheptulose. We report development of a liquid chromatography-tandem mass spectrometry method for quantitation of the seven-carbon carbohydrates sedoheptulose and mannoheptulose in urine. Additionally, other seven-carbon chain carbohydrates were characterized in urine, including sedoheptitol, perseitol and sedoheptulose 7-phosphate. Transaldolase-deficient patients had significantly increased urinary sedoheptulose and sedoheptulose 7-phosphate, associated with subtle elevations of mannoheptulose, sedoheptitol and perseitol. Our findings reveal novel urinary biomarkers for identification of transaldolase deficiency.

The MAP kinase Hog1p differentially regulates stress-induced production and accumulation of glycerol and d-arabitol in Candida albicans

Candida albicansproduces and accumulates large amounts of the polyolsd-arabitol and glycerol in culture, and/or in infected mammalian tissues. However, the effects of environmental stresses on production and accumulation of these polyols, and the means by which polyol production and accumulation are regulated have not been studied.C. albicansgrown in glucose at 30 °C (i) produced maximal amounts of glycerol within 6 h, (ii) produced maximal amounts ofd-arabitol and ribitol within 12 h, and (iii) released most of these polyols into the extracellular environment.C. albicansresponded to osmotic and citric acid stress by producing and accumulating more glycerol, and to temperature and oxidative stresses by producing mored-arabitol. The increase in intracellular glycerol was proportional to extracellular osmolarity, suggesting that glycerol functions as an osmolyte. The MAP kinase Hog1p is required for wild-type glycerol production in several fungal species subjected to osmotic stress, but it is not known if Hog1p plays a role in regulatingd-arabitol production. Therefore, twoC. albicans hog1null mutants were constructed and tested for the ability to produce glycerol andd-arabitol in response to environmental stresses. The ability to grow and produce glycerol when exposed to osmotic or citric acid stresses, and to produced-arabitol when exposed to oxidative stress, was partially dependent on Hog1p, but the ability to produced-arabitol when exposed to temperature stress was Hog1p independent. These results imply that multiple pathways regulate glycerol andd-arabitol synthesis inC. albicans.

Current status of nonculture methods for diagnosis of invasive fungal infections

The incidence of invasive fungal infections has increased dramatically in recent decades, especially among immunocompromised patients. However, the diagnosis of these infections in a timely fashion is often very difficult. Conventional microbiologic and histopathologic approaches generally are neither sensitive nor specific, and they often do not detect invasive fungal infection until late in the course of disease. Since early diagnosis may guide appropriate treatment and prevent mortality, there has been considerable interest in developing nonculture approaches to diagnosing fungal infections. These approaches include detection of specific host immune responses to fungal antigens, detection of specific macromolecular antigens using immunologic reagents, amplification and detection of specific fungal nucleic acid sequences, and detection and quantitation of specific fungal metabolite products. This work reviews the current status and recent developments as well as problems in the design of nonculture diagnostic methods for invasive fungal infections.

D-arabinitol--a marker for invasive candidiasis

The five-carbon sugar alcohol D-arabinitol (DA) is a metabolite of most pathogenic Candida species, in vitro as well as in vivo, and can be determined by gas chromatography or enzymatic analysis. Endogenous DA and L-arabinitol (LA) are present in human body fluids, and serum DA and LA increase in renal dysfunction. In prospective clinical studies, elevated DA/LA or DA/creatine ratios in serum or urine have been found in immunocompromised, usually neutropenic, patients with invasive candidiasis. In addition, positive DA results have been obtained several days to weeks before positive blood cultures, and the normalization of DA levels has been correlated with therapeutic response in both humans and animals. However, to date, only a few prospective studies have been conducted in which adequate analytical methods were used. Thus, further investigation of various patient groups is needed to establish the applicability of the 'arabinitol method' in the diagnostic battery for invasive Candida infections.

Diagnosis and therapeutic monitoring of invasive candidiasis by rapid enzymatic detection of serum D-arabinitol

BACKGROUND

Using a rapid automated enzymatic assay, we prospectively investigated serum D-arabinitol (DA), a biochemical marker of invasive candidiasis, in a large population of high-risk patients to determine its potential diagnostic, therapeutic, and prognostic significance in invasive candidiasis.

PATIENTS AND METHODS

A total of 3,223 serum samples were collected from 274 patients with cancer. Serum DA concentrations were determined in coded serum samples analyzed by rapid enzymatic assay. Creatinine also was analyzed in the same system to determine a serum DA and creatinine ratio (DA/Cr). The sensitivity, specificity, correlation with therapeutic response, and prognostic significance were analyzed for all patient study groups.

RESULTS

A DA/Cr of > or = 4.0 mumol/L per mg/dL was detected in 31 (74%) of all 42 cases of fungemia and 25 (83%) of the 30 cases of the subset of persistent fungemia. Elevated DA/Cr was detected in 4 (40%) of 10 patients with tissue-proven, deeply invasive candidiasis and negative blood cultures (eg, hepatosplenic candidiasis or localized abscess) and 7 (44%) of 16 cases of deep mucosal candidiasis (eg, esophageal candidiasis). Elevated serial DA/Cr levels also were detected in persistently febrile and granulocytopenic patients requiring empirical amphotericin B. Among 26 assessable cases of fungemia, abnormally elevated DA/Cr values were detected in 14 (54%) before, 10 (38%) after, and 2 (8%) simultaneously with the first microbiologic report of fungemia. The trends of serial DA/Cr values correlated with therapeutic response in 29 (85%) of 34 patients with assessable cases of fungemia, decreasing in 8 (89%) of 9 patients with clearance of fungemia and increasing in 21 (84%) of 25 patients with persistence of fungemia. Among the 34 assessable patients with fungemia, mortality was directly related to the trend of serial DA/Cr determinations over time: 71% among fungemic patients who had persistently elevated or increasing DA/Cr, and 18% among the fungemic patients who had resolving DA/Cr or never had elevated DA/Cr (P < 0.01).

CONCLUSIONS

Rapid enzymatic detection of DA in serially collected serum samples from high-risk cancer patients permitted detection of invasive candidiasis, early recognition of fungemia, and therapeutic monitoring in DA-positive cases. Serially collected serum DA determinations complement blood cultures for improving detection and monitoring therapeutic response in patients at risk for invasive candidiasis.

Isolation, characterization and expression of the gene that encodes D-arabinitol dehydrogenase in Candida tropicalis

The gene (ARD) that encodes NAD-dependent D-arabinitol dehydrogenase (ArDH) in the pathogenic fungus Candida tropicalis (Ct) was cloned by transforming Escherichia coli (Ec) BW31M (araCc) with a plasmid library of Ct genomic DNA and selecting for D-arabinitol-utilizing (D-arab+) clones. Plasmid DNA from a D-arab+ clone retransformed fresh Ec BW31M cells to D-arab+; these cells produced both ArDH catalytic activity and a 31-kDa protein recognized by antibodies to native Ct ArDH. The plasmid contained an 846-bp open reading frame (ORF) that encoded a deduced protein of 282 amino acids (aa) (30,748 Da). Four partial aa sequences from Ct ArDH were present in the deduced aa sequence, thus verifying that Ct ARD had been cloned. Ct ArDH was 95% identical to ArDH from Candida albicans (Ca), 85% identical to a xylitol dehydrogenase (XDH) from Pichia stipitis (Ps) and 20-25% identical to many other short-chain dehydrogenases. Ct ArDH, Ca ArDH and Ps XDH were typical short-chain dehydrogenases except that they lacked an N-terminal Gly that is conserved in other members of this family. Thus, these enzymes may represent a subclass of closely-related fungal pentitol dehydrogenases. Large amounts of recombinant ArDH (re-ArDH) were produced in Ec and purified by dye ligand affinity chromatography. The physical and catalytic properties of re-ArDH were similar to those of native Ct ArDH, and re-ArDH and native ArDH performed similarly in an automated enzymatic assay for D-arabinitol in human serum.

Gas chromatographic determination of D-arabinitol/L-arabinitol ratios in urine: a potential method for diagnosis of disseminated candidiasis

A gas chromatographic procedure was developed to determine the relative amounts of D- and L-arabinitol in urine. Samples were filtered, diluted, purified through extractions, evaporated, and treated with trifluoroacetic anhydride; the arabinitol derivatives thus obtained were separated on a chiral stationary phase and registered by using an electron-capture detector. Urine samples from a patient with disseminated candidiasis had higher D-arabinitol/L-arabinitol ratios (referred to as D/L-arabinitol ratios)--up to 19.0--than samples from 96 study individuals with no signs of deep Candida infections (range, 1.1 to 4.5). D/L-Arabinitol ratios in urine samples from hospitalized patients without Candida infections were slightly higher than those in samples from healthy individuals; ratios in urine from children were slightly higher than those in adult urine samples. The D/L-arabinitol ratios in several urine samples culture positive for Candida albicans, but from patients without symptoms of disseminated candidiasis, did not differ from those in the urine of healthy individuals. The described gas chromatographic method is straightforward and can be implemented clinically to determine urine D/L-arabinitol ratios as a means of diagnosing disseminated candidiasis.

Serum D-arabinitol measured by automated quantitative enzymatic assay for detection and therapeutic monitoring of experimental disseminated candidiasis: correlation with tissue concentrations of Candida albicans

In order to further understand serum D-arabinitol (DA) as a marker for the diagnosis of disseminated candidiasis and for monitoring response to antifungal therapy, we studied the serum levels of this Candida carbohydrate metabolite by rapid automated enzymatic assay in rabbits with experimental disseminated candidiasis. The enzymatic reaction steps were performed on a standard automated clinical chemistry analyser. As a correction for renal impairment, data were expressed as serum D-arabinitol/creatinine ratio (DA/Cr). Serum creatinine concentrations were determined from the same sample with the same instrument, thereby allowing rapid determination of the DA/Cr within one laboratory. The DA/Cr was determined in 321 samples from 132 rabbits. The mean serum DA/Cr in 31 normal non-infected rabbits was 1.51 +/- 0.2 microM mg-1 dl-1. Among 84 rabbits with disseminated candidiasis and pre-terminal samples, there was a direct correlation between DA/Cr and tissue concentration of Candida albicans (r = 0.80; P < 0.001). A threshold of elevated DA/Cr (> or = 3.0 microM mg-1 dl-1) was evident in rabbits with a tissue concentration of C. albicans > or = 3 x 10(4) colony forming units (CFU) g-1. Elevated DA/Cr was detected in 48 (89%) of 54 rabbits at a C. albicans tissue concentration of > or = 3 x 10(4) CFU g-1 vs. one (3%) of 30 rabbits with < 3 x 10(4) CFU g-1 (P < 0.0001). Among all 101 rabbits with disseminated candidiasis, an elevated DA/Cr was detected at any point during infection in 60 (92%) of 65 rabbits having a C. albicans tissue concentration > or = 3 x 10(4) CFU g-1 vs. 13 (36%) of 36 rabbits with < 3 x 10(4) CFU g-1 (P < 0.0001). The relationship between the tissue response to antifungal therapy and change in DA/Cr was then further analysed. Ten (91%) of 11 rabbits with a tissue-proven response to antifungal therapy (defined as > or = 10(2)-fold reduction of CFU g-1 in comparison to untreated controls) had a > 50% reduction in elevated DA/Cr levels. By comparison, 10 (83%) of 12 treated rabbits with no response to therapy had persistently elevated DA/Cr levels (P < 0.001). These findings provide an experimental basis for understanding the patterns of expression of serum DA in disseminated candidiasis and further indicate that serial DA/Cr measurements may be useful for diagnosis and therapeutic monitoring of disseminated candidiasis.

Diagnosis and monitoring of disseminated candidiasis based on serum/urine D/L-arabinitol ratios

Disseminated candidiasis, a devastating disease with high morbidity and mortality in immunosuppressed patients, is difficult to diagnose because of the protean nature of symptoms and the lack of rapid and reliable laboratory diagnostic procedures. The subject of this review is the status of gas chromatographic-mass spectrometric techniques for the determination of D-arabinitol, a unique metabolite of pathogenic Candida species, in serum and urine. The enantiomers are separated by chiral chromatography followed by specific and sensitive detection using chemical ionization and selected ion monitoring. Using D/L-arabinitol ratios, instead of individual concentrations, eliminates the need for knowing the volume of samples and for calibration curves. A new filter paper technique requires only an unmeasured drop of whole blood (venous or finger/heel puncture) or urine; paper spots are mailable. Parallel determinations of D/L-arabinitol ratios in serum and urine in normal subjects and cancer patients with both normal and increased D/L-arabinitol ratios revealed constant (1.2-1.3 range) ratios of serum D/L-arabinitol/urine D/L-arabinitol for all populations studied. Analyzing two body fluids taken at the same time increases reliability by reducing false positives.

An automated enzymatic method for measurement of D-arabinitol, a metabolite of pathogenic Candida species

An automated enzymatic method was developed for the measurement of D-arabinitol in human serum. The assay is based on a novel, highly specific D-arabinitol dehydrogenase from Candida tropicalis. This enzyme catalyzes the oxidation of D-arabinitol to D-ribulose and the concomitant reduction of NAD+ to NADH. The NADH produced is used in a second reaction to reduce p-iodonitrotetrazolium violet (INT) to INT-formazan, which is measured spectrophotometrically. The entire reaction sequence can be performed automatically on a COBAS MIRA-S clinical chemistry analyzer (Roche Diagnostic Systems, Inc., Montclair, N.J.). Replicate analyses of human sera supplemented with D-arabinitol over a concentration range of 0 to 40 microM demonstrated that the pentitol could be measured with an accuracy of +/- 7% and a precision (standard deviation) of +/- 0.4 microM. Serum D-arabinitol measurements correlated with those determined by gas chromatography (r = 0.94). The enzymatic method is unaffected by L-arabinitol, D-mannitol, or other polyols commonly found in human serum. Any of 17 therapeutic drugs potentially present in serum did not significantly influence assay performance. Data illustrating the application of the assay in patients for possible diagnosis of invasive candidiasis and the monitoring of therapeutic intervention are presented. The automated assay described here was developed to facilitate the investigation of D-arabinitol as a serum marker for invasive Candida infections.

Nonculture methods for diagnosis of disseminated candidiasis

Two of the nonculture approaches to the diagnosis of DC, enzymatic-fluorometric determination of serum D-arabinitol and detection of marker antigens in antigenemia (enolase and CWMP), have been commercialized and have shown promise in limited clinical trials. These approaches are not new but are the culmination of efforts made over 10 or more years. Clearly, further fine-tuning of both metabolite and antigen detection is needed to simplify the methods and to improve their sensitivity and specificity so that they will be valuable in guiding clinical treatment decisions. An alternative approach, detection of DC by DNA amplification methods such as PCR, is a special case of a compelling technology and one that is capable of standardization across microbial genera. The availability of simplified PCR diagnostic methods for DC remains a tantalizing prospect. Nevertheless, the development of methods to release DNA from very small numbers of Candida organisms in the blood in a form that is sufficiently free of inhibitors of PCR will require further intensive effort. The maturation of these converging laboratory approaches to nonculture diagnosis of DC leads to more optimism about the eventual use of these methods in clinical laboratories.

D-arabitol metabolism in Candida albicans: studies of the biosynthetic pathway and the gene that encodes NAD-dependent D-arabitol dehydrogenase

Candida albicans produces large amounts of the pentitol D-arabitol in culture and in infected mammalian hosts, but the functional and pathogenic significance of D-arabitol in C. albicans is not known. In this study, we sought to elucidate the pathway by which C. albicans synthesizes D-arabitol and to identify and characterize key enzymes in this pathway. C. albicans B311 produced D-[14C-1]arabitol from [14C-2]glucose; this finding implies on structural grounds that D-ribulose-5-PO4 from the pentose pathway is the major metabolic precursor of D-arabitol. NAD- or NADP-dependent pentitol dehydrogenases catalyze the final steps in D-arabitol biosynthesis in other fungi; therefore, lysates of C. albicans B311 were tested for enzymes of this class and were found to contain a previously unknown NAD-dependent D-arabitol dehydrogenase (ArDH). The ArDH structural gene was cloned by constructing a new D-arabitol utilization pathway in Escherichia coli. The C. albicans ArDH gene expressed in E. coli and Saccharomyces cerevisiae an enzyme that catalyzes the reaction D-arabitol + NAD <-->D-ribulose + NADH; this gene was present as a single copy per haploid genome, and its deduced peptide sequence was homologous with sequences of several members of the short-chain dehydrogenase family of enzymes. These results suggest that (i) C. albicans synthesizes D-arabitol by dephosphorylating and reducing the pentose pathway intermediate D-ribulose-5-PO4 and (ii) ArDH catalyzes the final step in this pathway.

Crossed immunoelectrophoresis of fungal antigens in tissues as a means of diagnosing systemic aspergillosis and zygomycosis in cattle

A novel method for diagnosing bovine aspergillosis and zygomycosis is described. Rabbit hyperimmune antisera raised against somatic antigens of Aspergillus fumigatus and Absidia corymbifera were used in crossed immunoelectrophoresis with supernatants from disintegrated tissues from acute necrohaemorrhagic mycotic lesions from cattle. The method specifically identified 4 of 5 lesions with aspergillosis and 2 of 5 lesions with zygomycosis. One lesion dually infected with aspergillosis and zygomycosis was negative. The method worked with unabsorbed sera, was specific, and required only standard electrophoretic equipment. It can therefore supplement chemical detection of fungi in tissues in the diagnosis of bovine aspergillosis and zygomycosis.

Diagnosis of disseminated candidiasis based on serum D/L-arabinitol ratios using negative chemical ionization mass spectrometry

The main objective was to appraise the diagnostic specificity of the serum D/L-arabinitol ratio technique in a patient population biased for renal dysfunction. The D/L ratio (mean +/- S.D.) in normal serum (n = 29) was 1.76 +/- 0.47 (range 0.77-2.75). D/L-Arabinitol greater than 3.18 (mean + 3 S.D.) are considered indicative of disseminated candidiasis. Of 49 patients without candidiasis, but 46% with serum creatinine greater than 1.5 mg/dl, diagnostic specificity was 88%. In confirmed candidiasis (n = 16) sensitivity was 94% (D/L range 3.2-50.1). Switching from positive to negative chemical ionization permits the use of as little as 5 microliters sample (20 microliters used routinely; D/L ratios constant in the 5-200 microliters range) permitting the extension of the technique to pediatric applications. Results can obtained in 2 h. Suggested areas of clinical application include aiding diagnosis, monitoring patients as risk so that treatment could be initiated while fungus load is still small, and following the course of antifungal chemotherapy.

Arabinitol enantiomers in cerebrospinal fluid

D-Arabinitol is a metabolite of Candida species, and its presence in serum above endogenous concentration may indicate disseminated candidiasis. The o-trifluoroacetylated derivatives of arabinitol enantiomers in cerebrospinal fluid (CSF) were separated using perpentylated cyclodextrin capillary columns and measured by selected ion monitoring using negative chemical ionization mass spectrometry. The presence of D-arabinitol was confirmed using highly specific D-arabinitol dehydrogenase. The mean D/L-arabinitol ratio, 16.7 +/- 4.8 (range: 8.6-22.8), in CSF of the "controls" is approximately 10-fold higher than the ratio previously found in normal serum and urine. At the same time, the mean L-arabinitol concentration, 0.13 +/- 0.05 (range: 0.09-0.2), is virtually identical to that in serum. Therefore, the high D/L-arabinitol ratio in CSF is attributed to D-arabinitol. Persistently high D/L ratios were found in a variety of diseases (without Candida infection). The finding of D-arabinitol in CSF suggests that serum D-arabinitol may originate from the brain or the spinal cord, rather than from resident Candida species in the gut, and that the accumulation of D-arabinitol in CSF may be caused by non-consumption or, conversely, the high concentration may be maintained in order to have it readily available for metabolism in the brain.

Production of the hexitol D-mannitol by Cryptococcus neoformans in vitro and in rabbits with experimental meningitis

We studied the ability of Cryptococcus neoformans to produce the hexitol D-mannitol in vitro and in rabbits with experimental meningitis. Twelve of twelve human isolates of C. neoformans produced D-mannitol in yeast nitrogen base plus 1% glucose and released D-mannitol into the medium. In a pilot study, pooled cerebrospinal fluid (CSF) from cortisone-treated rabbits given 3 x 10(7) C. neoformans H99 intracisternally contained more D-mannitol (identified by gas chromatography and enzymatically) than CSF from normal controls or cortisone-untreated rabbits with self-limited meningitis. In a second experiment, cortisone-treated rabbits given C. neoformans intracisternally had significantly higher CSF D-mannitol concentrations than controls given cortisone alone at 4, 6, and 8 days after infection. Moreover, log10 CSF D-mannitol correlated well with log10 CSF CFU (r = 0.81) and log10 CSF cryptococcal antigen titers (r = 0.78). Lastly, the initial volume of distribution and elimination half-life of D-mannitol given intracisternally to normal rabbits suggested that D-mannitol was distributed in total CSF and was removed by CSF bulk flow. Thus, C. neoformans produces D-mannitol in vitro and in vivo, and D-mannitol is a quantitative marker for experimental cryptococcal meningitis. D-Mannitol produced by C. neoformans may also contribute to brain edema and interfere with phagocyte killing by scavenging hydroxyl radicals.

Separation and quantification by gas chromatography-mass spectrometry of arabinitol enantiomers to aid the differential diagnosis of disseminated candidiasis

To differentiate increased arabinitol due to fungal (only D-arabinitol) and non-fungal origin, O-trifluoroacetyl derivatives of the enantiomers were separated using alpha-perpentylated cyclodextrin columns and measured by selected ion monitoring. Mean +/- S.D. D/L in normal serum: 1.40 +/- 0.42. D/L ratios greater than 2.24, defined as normal mean + 2S.D., were considered outside normal range. D/L was greater than 2.2 in 10 of 12 confirmed candidiasis cases with one false negative and one borderline. Renal dysfunction without candidiasis yielded normal D/L despite high arabinitol concentrations. D/L in normal urine was nearly identical to that in serum despite 60 times larger concentration. D/L ratios, determined by peak heights or areas, could be used without the need to determine concentrations.

Effects of gastrointestinal candidiasis, antibiotics, dietary arabinitol, and cortisone acetate on levels of the Candida metabolite D-arabinitol in rat serum and urine

We studied the effects of gastrointestinal (GI) colonization by Candida albicans, dietary arabinitol, intragastric antibiotics, and cortisone on levels of the Candida metabolite D-arabinitol in rat serum and urine. Rats given conventional laboratory chow, intragastric gentamicin and chloramphenicol, and 6.0 x 10(8) live C. albicans B311 blastoconidia by gavage had minimal invasive GI disease and no more DL-arabinitol in the urine than controls given killed C. albicans. However, colonized and uncolonized rats given intragastric antibiotics had transiently higher urine arabinitol levels than the corresponding controls given saline. Rats given conventional laboratory chow (which contained 50 micrograms of arabinitol per g) had higher serum and urine arabinitol levels than rats given no dietary arabinitol, but the differences were less than expected. Moreover, intragastric antibiotics did not cause increased arabinitol excretion in rats given no dietary arabinitol. Rats given intragastric antibiotics and live C. albicans but no dietary arabinitol had no more arabinitol in their serum or urine than controls given antibiotics and killed C. albicans or saline and live or killed C. albicans. Lastly, cortisone acetate (10 mg/kg of body weight per day intramuscularly for 10 days) did not cause increased serum or urine arabinitol levels. We conclude that neither GI colonization by C. albicans nor cortisone should interfere with the usefulness of arabinitol as a marker for invasive candidiasis; antibiotics appear to increase arabinitol excretion by suppressing GI bacteria capable of consuming dietary arabinitol.

Enantioselective measurement of the Candida metabolite D-arabinitol in human serum using multi-dimensional gas chromatography and a new chiral phase

A multi-dimensional gas chromatographic method was developed to measure the Candida metabolite D-arabinitol enantioselectively in human serum. The heptafluorobutyrate derivatives of D-arabinitol, L-arabinitol and ribitol (internal standard) were separated from other serum constituents with a 60 m X 0.32 mm fused-silica SPB-5 precolumn, and (after intermediate cold trapping) they were separated from each other with a 25 m x 0.25 mm fused-silica column coated with a new bonded chiral phase. Replicate analyses of spiked human sera showed that D-arabinitol could be quantified accurately and precisely. The D- and L-arabinitol concentrations in 24 normal adult sera were 0.20 +/- 0.053 and 0.11 +/- 0.040 mu/ml, respectively, and the D- and L-arabinitol/creatinine ratios were 0.023 +/- 0.011 and 0.012 +/- 0.0051, respectively (mean +/- S.D.). In a patient with Candida albicans fungemia, the D-arabinitol/creatinine ratios rose early during infection and fell with successful treatment, whereas L-arabinitol/creatinine ratios did not change significantly. This enantioselective analytical method is more practical than earlier ones; it should facilitate further investigation of D-arabinitol as a diagnostic marker for candidiasis.

Levels of the Candida metabolite D-arabinitol in sera of steroid-treated and untreated patients with sarcoidosis

We measured the Candida metabolite D-arabinitol and its enantiomer L-arabinitol in 42 serum samples from 33 patients with sarcoidosis and compared the results with those from 27 healthy adults and 4 patients with candidiasis. The D- and L-arabinitol concentrations and the D- and L-arabinitol/creatinine ratios did not differ significantly in the sarcoidosis patients and the controls; the D-arabinitol concentrations and the D-arabinitol/creatinine ratios were much higher in the patients with candidiasis. Among the patients with sarcoidosis, the D- and L-arabinitol levels in the steroid recipients did not differ significantly from those in patients not receiving steroids. Higher D-arabinitol/creatinine ratios were associated with roentgenographic evidence of pulmonary fibrosis and low forced vital capacities, but not with disease activity as determined by the proportion of lymphocytes to total nucleated cells in bronchoalveolar lavage fluid or the CD4/CD8 ratio in bronchoalveolar lymphocytes. We conclude that neither sarcoidosis nor corticosteroid treatment is associated with high levels of D-arabinitol in serum.

Mannan and D-arabinitol concentrations in serum from a patient with Candida albicans endocarditis

In an attempt to clarify the comparative values of serological and microbiological examinations for the early diagnosis of systemic candidiasis, antibodies against Candida albicans, serum mannan, and the D-arabinitol creatinine ratio were investigated in a patient with aortic valve endocarditis associated with carcinoma of the bile duct. Candida precipitins and the antibody titer against Candida cell wall mannan were examined by an immunodiffusion technique and hemagglutination test, respectively. Serum mannan was tested by enzyme-linked immunosorbent assay (ELISA) using the biotin-streptavidin procedure. The upper limit of negativity of the assay was determined by adding 0.06 to the absorbance of pooled serum from healthy laboratory workers. This value was about 0.8 ng/ml with ELISA. The D-arabinitol concentration in serum was examined by an enzymatic fluorometric method. Rising antibody titers against C. albicans, mannan antigenemia, and an elevated D-arabinitol creatinine ratio were first observed between the 11th and 12th hospital days. Blood cultures obtained on 8th, 9th, and 11th hospital days grew C. albicans after 3 to 4 days of incubation. Of 11 serum samples, 5 were positive for mannan, whereas D-arabinitol creatinine ratio was positive in 7 of 9 samples. Blood cultures was the earliest evidence of Candida infections in our cases. However, because of saprophytic nature of Candida species, tests for antibodies, antigenemia, and the D-arabinitol creatinine ratio in combination with blood cultures are necessary to confirm systemic candidiasis at an early stage of infection.

Enantioselective measurement of fungal D-arabinitol in the sera of normal adults and patients with candidiasis

A new method was used to measure D-arabinitol enantioselectively in the sera of 27 healthy adults and four patients with candidiasis. Arabinitol was measured by gas chromatography in serum that was treated with and without the Klebsiella pneumoniae enzyme D-arabinitol dehydrogenase, lactic dehydrogenase, NAD, and sodium pyruvate. Since enzyme treatment removed 98% of 0 to 20 micrograms of D-arabinitol per ml and none of 0 to 20 micrograms of L-arabinitol per ml from spiked sera, D-arabinitol could be determined from the difference in the treated and untreated samples. The concentrations of D- and L-arabinitol in serum from normal subjects were 0.22 +/- 0.052 and 0.16 +/- 0.055 micrograms/ml, respectively, and their D-arabinitol/creatinine and L-arabinitol/creatinine ratios were 0.024 +/- 0.0089 and 0.017 +/- 0.0053 (all means +/- standard deviations). The infected patients all had markedly elevated serum D-arabinitol levels, but their L-arabinitol levels were either normal or proportionately much lower. The excess arabinitol in the sera of individuals with candidiasis is D-arabinitol, and use of enantioselective analytical methods should result in improved ability to diagnose and estimate the severity of candidiasis.

Risk factors for candidemia in cancer patients: a case-control study

Risk factors for candidemia were analyzed in a case-control study of 30 cancer patients with candidemia and 58 controls. In a univariate analysis, previous surgery, neutropenia, central catheterization, chemotherapy, specific antibiotic treatments, and peripheral cultures positive for Candida spp. were associated with a significantly increased risk of candidemia. In a multivariate logistic model, the significant risk factors for candidemia were positive peripheral cultures for Candida spp. (P = 0.02), central catheterization (P = 0.03), and neutropenia (P = 0.05). These results should help to identify cancer patients with a high risk of candidemia, who should be given early systemic antifungal therapy.

Role of individual serum pentitol concentrations in the diagnosis of disseminated visceral candidiasis

A technique was developed for separating total serum pentitols into individual arabinitol, adonitol and xylitol and determining their relevance for the diagnosis of disseminated candidiasis. Pentitols were separated as trimethylsilyl derivatives on two 25 m long, bonded methyl silicone columns with a 0.32 mm i.d., and quantified by selected ion monitoring of their protonated molecular ions obtained in chemical ionization. The 173 samples studied were divided into culture-positive, culture-negative, and no-culture groups. Twelve percent of all samples were false positives by the total pentitols method due to increased adonitol and/or xylitol. The continued use of the total pentitols method is, nevertheless, recommended because of its convenience; however, samples with increased total pentitols (and normal creatinine) should be reanalyzed for individual pentitols. Increased arabinitol and normal creatinine are indicative of candidiasis even when blood cultures are negative.

Emphysematous pyelonephritis caused by Candida albicans

We report a case of emphysematous pyelonephritis that was proved by histological examination and culture to be caused by Candida albicans. The fungal infection caused ureteral obstruction. Nephrectomy alone resulted in complete recovery.