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Lehman A, Ellis J, Nalintya E, Bahr NC, Loyse A, Rajasingham R. Advanced HIV disease: A review of diagnostic and prophylactic strategies. HIV Med 2023; 24:859-876. [PMID: 37041113 PMCID: PMC10642371 DOI: 10.1111/hiv.13487] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/13/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Despite expanded access to antiretroviral therapy (ART) and the rollout of the World Health Organization's (WHO) 'test-and-treat' strategy, the proportion of people with HIV (PWH) presenting with advanced HIV disease (AHD) remains unchanged at approximately 30%. Fifty percent of persons with AHD report prior engagement to care. ART failure and insufficient retention in HIV care are major causes of AHD. People living with AHD are at high risk for opportunistic infections and death. In 2017, the WHO published guidelines for the management of AHD that included a comprehensive package of care for screening and prophylaxis of major opportunistic infections (OIs). In the interim, ART regimens have evolved: integrase inhibitors are first-line therapy globally, and the diagnostic landscape is evolving. The objective of this review is to highlight novel point-of-care (POC) diagnostics and treatment strategies that can facilitate OI screening and prophylaxis for persons with AHD. METHODS We reviewed the WHO guidelines for recommendations for persons with AHD. We summarized the scientific literature on current and emerging diagnostics, along with emerging treatment strategies for persons with AHD. We also highlight the key research and implementation gaps together with potential solutions. RESULTS While POC CD4 testing is being rolled out in order to identify persons with AHD, this alone is insufficient; implementation of the Visitect CD4 platform has been challenging given operational and test interpretation issues. Numerous non-sputum POC TB diagnostics are being evaluated, many with limited sensitivity. Though imperfect, these tests are designed to provide rapid results (within hours) and are relatively affordable for resource-poor settings. While novel POC diagnostics are being developed for cryptococcal infection, histoplasmosis and talaromycosis, implementation science studies are urgently needed to understand the clinical benefit of these tests in the routine care. CONCLUSIONS Despite progress with HIV treatment and prevention, a persistent 20%-30% of PWH present to care with AHD. Unfortunately, these persons with AHD continue to carry the burden of HIV-related morbidity and mortality. Investment in the development of additional POC or near-bedside CD4 platforms is urgently needed. Implementation of POC diagnostics theoretically could improve HIV retention in care and thereby reduce mortality by overcoming delays in laboratory testing and providing patients and healthcare workers with timely same-day results. However, in real-world scenarios, people with AHD have multiple comorbidities and imperfect follow-up. Pragmatic clinical trials are needed to understand whether these POC diagnostics can facilitate timely diagnosis and treatment, thereby improving clinical outcomes such as HIV retention in care.
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Affiliation(s)
- Alice Lehman
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jayne Ellis
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Nathan C. Bahr
- Division of Infectious Diseases, University of Kansas, Kansas City, Kansas, USA
| | - Angela Loyse
- Division of Infection and Immunity Research Institute, St George’s University of London, London, UK
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Zhao Y, Ye L, Zhao F, Zhang L, Lu Z, Chu T, Wang S, Liu Z, Sun Y, Chen M, Liao G, Ding C, Xu Y, Liao W, Wang L. Cryptococcus neoformans, a global threat to human health. Infect Dis Poverty 2023; 12:20. [PMID: 36932414 PMCID: PMC10020775 DOI: 10.1186/s40249-023-01073-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Emerging fungal pathogens pose important threats to global public health. The World Health Organization has responded to the rising threat of traditionally neglected fungal infections by developing a Fungal Priority Pathogens List (FPPL). Taking the highest-ranked fungal pathogen in the FPPL, Cryptococcus neoformans, as a paradigm, we review progress made over the past two decades on its global burden, its clinical manifestation and management of cryptococcal infection, and its antifungal resistance. The purpose of this review is to drive research efforts to improve future diagnoses, therapies, and interventions associated with fungal infections. METHODS We first reviewed trends in the global burden of HIV-associated cryptococcal infection, mainly based on a series of systematic studies. We next conducted scoping reviews in accordance with the guidelines described in the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews using PubMed and ScienceDirect with the keyword Cryptococcus neoformans to identify case reports of cryptococcal infections published since 2000. We then reviewed recent updates on the diagnosis and antifungal treatment of cryptococcal infections. Finally, we summarized knowledge regarding the resistance and tolerance of C. neoformans to approved antifungal drugs. RESULTS There has been a general reduction in the estimated global burden of HIV-associated cryptococcal meningitis since 2009, probably due to improvements in highly active antiretroviral therapies. However, cryptococcal meningitis still accounts for 19% of AIDS-related deaths annually. The incidences of CM in Europe and North America and the Latin America region have increased by approximately two-fold since 2009, while other regions showed either reduced or stable numbers of cases. Unfortunately, diagnostic and treatment options for cryptococcal infections are limited, and emerging antifungal resistance exacerbates the public health burden. CONCLUSION The rising threat of C. neoformans is compounded by accumulating evidence for its ability to infect immunocompetent individuals and the emergence of antifungal-resistant variants. Emphasis should be placed on further understanding the mechanisms of pathogenicity and of antifungal resistance and tolerance. The development of novel management strategies through the identification of new drug targets and the discovery and optimization of new and existing diagnostics and therapeutics are key to reducing the health burden.
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Affiliation(s)
- Youbao Zhao
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China.
| | - Leixin Ye
- State Key Laboratory of Mycology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, 100039, China
| | - Fujie Zhao
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China
| | - Lanyue Zhang
- State Key Laboratory of Mycology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, 100039, China
| | - Zhenguo Lu
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China
| | - Tianxin Chu
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China
| | - Siyu Wang
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China
| | - Zhanxiang Liu
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China
| | - Yukai Sun
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China
| | - Min Chen
- Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, Changzheng Hospital, Shanghai, 200003, China
| | - Guojian Liao
- The Medical Research Institute, College of Pharmaceutical Sciences, Southwest University, Chongqing, 400715, China
| | - Chen Ding
- College of Life and Health Sciences, Northeastern University, Shenyang, 110819, Liaoning, China
| | - Yingchun Xu
- Department of Laboratory Medicine, and Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Wanqing Liao
- Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, Changzheng Hospital, Shanghai, 200003, China
| | - Linqi Wang
- State Key Laboratory of Mycology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, 100101, China.
- University of Chinese Academy of Sciences, Beijing, 100039, China.
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Oboho IK, Paulin H, Corcoran C, Hamilton M, Jordan A, Kirking HL, Agyemang E, Podewils LJ, Pretorius C, Greene G, Chiller T, Desai M, Bhatkoti R, Shiraishi RW, Shah NS. Modelling the impact of CD4 testing on mortality from TB and cryptococcal meningitis among patients with advanced HIV disease in nine countries. J Int AIDS Soc 2023; 26:e26070. [PMID: 36880429 PMCID: PMC9989935 DOI: 10.1002/jia2.26070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 02/10/2023] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Despite antiretroviral therapy (ART) scale-up among people living with HIV (PLHIV), those with advanced HIV disease (AHD) (defined in adults as CD4 count <200 cells/mm3 or clinical stage 3 or 4), remain at high risk of death from opportunistic infections. The shift from routine baseline CD4 testing towards viral load testing in conjunction with "Test and Treat" has limited AHD identification. METHODS We used official estimates and existing epidemiological data to project deaths from tuberculosis (TB) and cryptococcal meningitis (CM) among PLHIV-initiating ART with CD4 <200 cells/mm3 , in the absence of select World Health Organization recommended diagnostic or therapeutic protocols for patients with AHD. We modelled the reduction in deaths, based on the performance of screening/diagnostic testing and the coverage and efficacy of treatment/preventive therapies for TB and CM. We compared projected TB and CM deaths in the first year of ART from 2019 to 2024, with and without CD4 testing. The analysis was performed for nine countries: South Africa, Kenya, Lesotho, Mozambique, Nigeria, Uganda, Zambia, Zimbabwe and the Democratic Republic of Congo. RESULTS The effect of CD4 testing comes through increased identification of AHD and consequent eligibility for protocols for AHD prevention, diagnosis and management; algorithms for CD4 testing avert between 31% and 38% of deaths from TB and CM in the first year of ART. The number of CD4 tests required per death averted varies widely by country from approximately 101 for South Africa to 917 for Kenya. CONCLUSIONS This analysis supports retaining baseline CD4 testing to avert deaths from TB and CM, the two most deadly opportunistic infections among patients with AHD. However, national programmes will need to weigh the cost of increasing CD4 access against other HIV-related priorities and allocate resources accordingly.
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Affiliation(s)
- Ikwo Kitefre Oboho
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Heather Paulin
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Carl Corcoran
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | | | - Alex Jordan
- Division of FoodborneWaterborne and Environmental DiseasesCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Hannah L. Kirking
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Elfriede Agyemang
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Laura Jean Podewils
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
- Denver Health and Hospital AuthorityDenverColoradoUSA
| | | | - Greg Greene
- Division of FoodborneWaterborne and Environmental DiseasesCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Tom Chiller
- Division of FoodborneWaterborne and Environmental DiseasesCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Mitesh Desai
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
- U.S. Office of Global AIDS Coordinator and Health DiplomacyWashingtonDCUSA
| | - Roma Bhatkoti
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Ray W. Shiraishi
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - N. Sarita Shah
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGeorgiaUSA
- Emory Rollins School of Public HealthAtlantaGeorgiaUSA
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Misra A, Yetmar ZA, Milone AA, Ruefthaler LA, Wengenack NL, Vergidis P, Theel ES. The Brief Case: the Cryptic Cryptococcus. J Clin Microbiol 2023; 61:e0054822. [PMID: 36840562 PMCID: PMC9945492 DOI: 10.1128/jcm.00548-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Affiliation(s)
- Anisha Misra
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachary A. Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amber A. Milone
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lydia A. Ruefthaler
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nancy L. Wengenack
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paschalis Vergidis
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Elitza S. Theel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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5
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Wake RM, Molloy SF, Jarvis JN, Harrison TS, Govender NP. Cryptococcal Antigenemia in Advanced Human Immunodeficiency Virus Disease: Pathophysiology, Epidemiology, and Clinical Implications. Clin Infect Dis 2023; 76:764-770. [PMID: 35986670 PMCID: PMC9938740 DOI: 10.1093/cid/ciac675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 11/14/2022] Open
Abstract
Cryptococcal antigen (CrAg) is detectable in blood prior to the onset of symptomatic cryptococcal meningitis (CM), a leading cause of death among people with advanced human immunodeficiency virus (HIV) disease globally. Highly sensitive assays can detect CrAg in blood, and screening people with HIV with low CD4 counts, followed by preemptive antifungal treatment, is recommended and widely implemented as part of a global strategy to prevent CM and end cryptococcal-related deaths. Cryptococcal antigenemia encompasses a spectrum of conditions from preclinical asymptomatic infection (cerebrospinal fluid [CSF] CrAg-negative) through subclinical (CSF CrAg-positive without overt meningism) to clinical symptomatic cryptococcal disease, usually manifesting as CM. In this review, we summarize current understanding of the pathophysiology, risk factors for, and clinical implications of cryptococcal antigenemia within this spectrum. We also provide an update on global prevalence, recommended screening and treatment strategies, and future considerations for improving outcomes among patients with cryptococcal antigenemia.
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Affiliation(s)
- Rachel M Wake
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Síle F Molloy
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Thomas S Harrison
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Nelesh P Govender
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
- Division of the National Health Laboratory Service, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, Johannesburg, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
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6
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Chisale MRO, Jordan A, Kamudumuli PS, Mvula B, Odo M, Maida A, Kandulu J, Chilima B, Sinyiza FW, Katundu P, Lee HY, Mtegha R, Wu TSJ, Bitirinyo J, Nyirenda R, Kalua T, Greene G, Chiller T. Six months survival and risk factors for attrition for patients detected with cryptococcal antigenemia through screening in Malawi. PLoS One 2023; 18:e0284367. [PMID: 37141243 PMCID: PMC10159159 DOI: 10.1371/journal.pone.0284367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 03/29/2023] [Indexed: 05/05/2023] Open
Abstract
MAIN OBJECTIVE A cohort of adult Malawian people living with HIV (PLHIV) testing positive for cryptococcal antigenemia was observed and followed to determine the outcomes and risk factors for attrition. METHODS CONCEPT Eligible PLHIV were enrolled at 5 health facilities in Malawi, representing different levels of health care. ART naïve patients, ART defaulters returning to care, and patients with suspected or confirmed ART treatment failure with CD4 <200 cells/μL or clinical stage 3 or 4 were enrolled and received CrAg tests on whole blood specimens from August 2018 to August 2019. Hospitalized PLHIV were enrolled and tested for CrAg from January 2019 to August 2019, regardless of CD4 or clinical stage. Patients with cryptococcal antigenemia were managed per Malawian clinical guidelines and were followed up for six months. Survival and risk factors for attrition at six months were assessed. RESULTS A total of 2146 patients were screened and 112 (5.2%) had cryptococcal antigenemia. Prevalence ranged from 3.8% (Mzuzu Central Hospital) to 25.8% (Jenda Rural Hospital). Of the 112 patients with antigenemia, 33 (29.5%) were diagnosed with concurrent CM at the time of enrollment. Six-month crude survival of all patients with antigenemia (regardless of CM status) ranged from 52.3% (assuming lost-to-follow-up (LTFU) patients died) to 64.9% (if LTFU survived). Patients who were diagnosed with concurrent CM by CSF test had poor survival (27.3-39.4%). Patients with antigenemia who were not diagnosed with concurrent CM had 71.4% (if LTFU died)- 89.8% (if LTFU survived) survival at six months. In adjusted analyses, patients with cryptococcal antigenemia detected after admission to inpatient care (aHR: 2.56, 1.07-6.15) and patients with concurrent CM at the time of positive antigenemia result (aHR: 2.48, 1.04-5.92) had significantly higher hazard of attrition at six months. CONCLUSIONS Overall, our findings indicate a need for routine access to CrAg screening and pre-emptive fluconazole treatment as a way to detect cryptococcal antigenemia and prevent CM in outpatient and inpatient settings. Rapid access to diagnosis and treatment for cryptococcal meningitis (CM) with gold-standard antifungals is needed to improve survival of patients with advanced HIV in Malawi.
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Affiliation(s)
- Master R O Chisale
- Ministry of Health, Malawi, Mzuzu Central Hospital, Luwinga, Mzuzu, Malawi
- College of Medicine, University of Malawi, Zomba, Malawi
- Faculty of Science Technology and Innovations, Biological Sciences Department, Mzuzu University, Mzuzu, Malawi
| | - Alex Jordan
- Centres for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, United States of America
| | - Pocha S Kamudumuli
- University of Maryland Global Initiative Corporation (UMGIC), Lilongwe, Malawi
| | - Bernard Mvula
- Ministry of Health, National HIV Unit laboratory, Lilongwe, Malawi
| | - Michael Odo
- Ministry of Health, Department of HIV and AIDS (DHA), Lilongwe, Malawi
| | - Alice Maida
- Centres for Disease Control and Prevention-Malawi, Malawi
| | - James Kandulu
- Capitol Hill (Headquarters), Ministry of Health, Ministry of Health, Lilongwe, Malawi
| | - Ben Chilima
- Public Health Institute of Malawi (PHIM), Ministry of Health, Lilongwe, Malawi
| | - Frank W Sinyiza
- Ministry of Health, Malawi, Mzuzu Central Hospital, Luwinga, Mzuzu, Malawi
| | - Pauline Katundu
- Public Health Institute of Malawi (PHIM), Ministry of Health, Lilongwe, Malawi
| | - Hsin-Yi Lee
- College of Medicine, University of Malawi, Zomba, Malawi
| | - Rebecca Mtegha
- College of Medicine, University of Malawi, Zomba, Malawi
| | - Tsung-Shu Joseph Wu
- College of Medicine, University of Malawi, Zomba, Malawi
- Luke International, Mzuzu, Malawi
| | - Joseph Bitirinyo
- Public Health Institute of Malawi (PHIM), Ministry of Health, Lilongwe, Malawi
| | - Rose Nyirenda
- Ministry of Health, Department of HIV and AIDS (DHA), Lilongwe, Malawi
| | - Thoko Kalua
- University of Maryland Global Initiative Corporation (UMGIC), Lilongwe, Malawi
| | - Greg Greene
- Centres for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, United States of America
| | - Tom Chiller
- Centres for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, United States of America
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Prevalence and Associated Factors of Cryptococcal Antigenemia in HIV-Infected Patients with CD4 < 200 Cells/µL in São Paulo, Brazil: A Bayesian Analysis. J Fungi (Basel) 2022; 8:jof8121284. [PMID: 36547617 PMCID: PMC9786117 DOI: 10.3390/jof8121284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Cryptococcosis is a severe life-threatening disease and a major cause of mortality in people with advanced AIDS and CD4 ≤ 100 cells/µL. Considering the knowledge gap regarding the benefits of routine application of antigenemia tests in HIV-infected patients with 100−200 CD4 cells/µL for the prevention of cryptococcal meningitis (CM), we aimed to evaluate the prevalence of positive antigenemia through lateral flow assay (LFA) and associated factors in HIV-infected patients with CD4 < 200 cells/µL. Our findings of 3.49% of positive LFA (LFA+) patients with CD4 < 100 cells/µL and 2.24% with CD4 between 100−200 cells/µL have been included in a Bayesian analysis with 12 other studies containing similar samples worldwide. This analysis showed a proportion of 3.6% LFA+ patients (95% credible interval-Ci [2.5−5.7%]) with CD4 < 100 cells/µL and 1.1% (95%Ci [0.5−4.3%]) with CD4 between 100−200 cells/µL, without statistical difference between these groups. The difference between mortality rates in LFA+ and negative LFA groups was e = 0.05013. Cryptococcoma and CM were observed in the LFA+ group with 100−200 and <100 CD4 cells/µL, respectively. Considering the benefits of antifungal therapy for LFA+ patients, our data reinforced the recommendation to apply LFA as a routine test in patients with 100−200 CD4 cells/µL aiming to expand cost-effectiveness studies in this group.
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8
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Epidemiology and Mortality of Cryptococcal Disease in Guatemala: Two-Year Results of a Cryptococcal Antigen Screening Program. Microorganisms 2022; 10:microorganisms10071388. [PMID: 35889106 PMCID: PMC9323764 DOI: 10.3390/microorganisms10071388] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 12/10/2022] Open
Abstract
Cryptococcal disease is an important opportunistic infection among people living with HIV. The cryptococcal antigen (CrAg) can be detected before the clinical onset of meningitis and its screening is recommended. Here, we evaluated CrAg frequency, and describe the epidemiological characteristics and mortality at 180 days in a cohort of HIV patients from Guatemala. A total of 3457 patients were screened with a CrAg lateral flow assay in serum between January 2017 and December 2018. CrAg positivity was 11.5% in patients with ≤100 CD4/mm3, 8.7% in patients with <200 CD4/mm3, and 6.3% in patients with <350 CD4/mm3. In Latin America, we estimated 9.2% CrAg positivity (IC95% 7.9−10.7%) in patients with ≤100 CD4/mm3. Among patients newly diagnosed with HIV, we estimated 4416 incident cases per year in Latin America in those with <200 CD4/mm3 and 5289 in those with <350 CD4/mm3. In addition, we calculated the burden in people not on ARV or without viral suppression and found 28,672 cases. CrAg screening should be considered in patients who have a CD4 cell count < 350 cells/mm3. Cryptococcal meningitis was associated with 30.8% mortality in Guatemala. Global access to diagnosis as well as to liposomal amphotericin B and flucytosine is a priority.
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9
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Liu Y, Kang M, Wu SY, Wu LJ, He L, Xiao YL, Zhang WL, Liao QF, Deng J, Chen ZX, Ma Y. Evaluation of a Cryptococcus Capsular Polysaccharide Detection FungiXpert LFA (Lateral Flow Assay) for the Rapid Diagnosis of Cryptococcosis. Med Mycol 2022; 60:6562084. [PMID: 35362524 DOI: 10.1093/mmy/myac020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/22/2022] [Indexed: 02/05/2023] Open
Abstract
Cryptococcus is an opportunistic pathogenic fungus and is the major cause of fungal meningitis. The cryptococcal antigen (CrAg) lateral flow assay (LFA) is an immunochromatographic test system that has simplified diagnosis as a point-of-care test. In this study, we evaluated the diagnostic performance of Cryptococcal capsular polysaccharide detection FungiXpert (Genobio Pharmaceutical, Tianjin, China) using serum and cerebrospinal fluid (CSF) samples for the diagnosis of cryptococcosis and investigated the cross-reaction of the assays to pathogenic fungi and bacterium by comparing it to the U.S. Food and Drug Administration (US FDA)-approved IMMY CrAg LFA. Eighty CSF and 119 serum/plasma samples from 158 patients were retrospectively collected to test for qualitative or semi-quantitative detection of CrAg. Cross-reaction of the assays was tested using 28 fungi and 1 bacterium. Compared to IMMY CrAg LFA, the FungiXpert LFA demonstrated 99.1% sensitivity and 98.9% specificity in the qualitative test. In the 96 semi-quantitative CrAg assay results, 39 (40.6%) test titers of FungiXpert LFA were 1-2 dilutions higher than those of IMMY CrAg LFA. The Intraclass Correlation Coefficient of the Semi-quantitative results of CrAg titer tests via the two assays was 0.976. Similar to IMMY CrAg LFA, FungiXpert LFA showed cross-reactivity with Trichosporon asahii. Compared with the IMMY CrAg LFA, the FungiXpert LFA showed an equal, yet, excellent performance. However, it is important to note that these two assays have potential cross-reactivity to T. asahii when diagnosing patients. FungiXpert LFA is a rapid screening method for the effective and practical diagnosis and treatment of cryptococcosis.
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Affiliation(s)
- Ya Liu
- Division of Clinical Microbiology, Department of Laboratory Medicine, West China Hospital Sichuan University, Chengdu, China
| | - Mei Kang
- Division of Clinical Microbiology, Department of Laboratory Medicine, West China Hospital Sichuan University, Chengdu, China
| | - Si-Ying Wu
- Division of Clinical Microbiology, Department of Laboratory Medicine, West China Hospital Sichuan University, Chengdu, China
| | - Li-Juan Wu
- Department of Laboratory Medicine, Guigang City People's Hospital, Guigang, China
| | - Lan He
- Department of Laboratory Medicine, The Sixth People's Hospital of Chengdu, Chengdu, China
| | - Yu-Ling Xiao
- Division of Clinical Microbiology, Department of Laboratory Medicine, West China Hospital Sichuan University, Chengdu, China
| | - Wei-Li Zhang
- Division of Clinical Microbiology, Department of Laboratory Medicine, West China Hospital Sichuan University, Chengdu, China
| | - Quan-Feng Liao
- Division of Clinical Microbiology, Department of Laboratory Medicine, West China Hospital Sichuan University, Chengdu, China
| | - Jin Deng
- Division of Clinical Microbiology, Department of Laboratory Medicine, West China Hospital Sichuan University, Chengdu, China
| | - Zhi-Xing Chen
- Division of Clinical Microbiology, Department of Laboratory Medicine, West China Hospital Sichuan University, Chengdu, China
| | - Ying Ma
- Division of Clinical Microbiology, Department of Laboratory Medicine, West China Hospital Sichuan University, Chengdu, China
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McEwan SA, Sykes JE. Nasopharyngeal cryptococcosis in a cat: interlaboratory variation in cryptococcal antigen assay test results. JFMS Open Rep 2022; 8:20551169221074624. [PMID: 35359825 PMCID: PMC8961386 DOI: 10.1177/20551169221074624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Case summary An indoor-only 6-year-old spayed female domestic cat was evaluated for a
history of stertorous respiration. Skull radiographs revealed increased soft
tissue density within the caudal aspect of the left nasal cavity. CT and
rhinoscopy revealed a mass lesion in the choana, plus a smaller lesion,
nearly completely occluding flow through the nasal passages. Rhinoscopy was
used to collect a biopsy specimen from a fleshy, tan–yellow mass visualized
in the caudal nasopharynx. Histopathology was diagnostic for
Cryptococcus species infection and systemic antifungal
therapy with fluconazole was initiated. Following a series of discordant
results, serum samples were submitted to a veterinary diagnostic laboratory
that utilized a cryptococcal antigen latex agglutination system with
pretreatment of serum with pronase. Twenty-three months after the initial
diagnosis, the cat’s serum cryptococcal antigen titer declined to 1:5 and
the cat has responded well to continuing treatment. Relevance and novel information This case illustrates challenges associated with discordant test results for
cryptococcal antigen among laboratories. Discordancies may be due to
differences in assay design, or the underlying disease state itself, or
whether serum is pre-treated with pronase; with some tests relying on the
training and experience of the operator if the cryptococcal antigen
detection test requires a subjective interpretation. It also resolves some
confusion in the literature related to the assay types available and
terminology used to describe them, and emphasizes the importance of
considering cryptococcosis as an important differential for cats with upper
respiratory signs, without nasal discharge, even if the cat is kept
exclusively indoors.
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Affiliation(s)
- Stephanie A McEwan
- Departments of Medicine and Surgery, Biological Science and Psychological Science, University of California, Irvine, CA, USA
| | - Jane E Sykes
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California-Davis, Davis, CA, USA
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11
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Stott KE, Loyse A, Jarvis JN, Alufandika M, Harrison TS, Mwandumba HC, Day JN, Lalloo DG, Bicanic T, Perfect JR, Hope W. Cryptococcal meningoencephalitis: time for action. THE LANCET. INFECTIOUS DISEASES 2021; 21:e259-e271. [PMID: 33872594 DOI: 10.1016/s1473-3099(20)30771-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
Cryptococcal meningoencephalitis was first described over a century ago. This fungal infection is preventable and treatable yet continues to be associated with excessive morbidity and mortality. The largest burden of disease resides in people living with HIV in low-income and middle-income countries. In this group, mortality with the best antifungal induction regimen (7 days of amphotericin B deoxycholate [1·0 mg/kg per day] and flucytosine [100·0 mg/kg per day]) in a clinical trial setting was 24% at 10 weeks. The world is now at an inflection point in terms of recognition, research, and action to address the burden of morbidity and mortality from cryptococcal meningoencephalitis. However, the scope of interventional programmes needs to increase, with particular attention to implementation science that is specific to individual countries. This Review summarises causes of excessive mortality, interventions with proven survival benefit, and gaps in knowledge and practice that contribute to the ongoing high death toll from cryptococcal meningoencephalitis. TRANSLATIONS: For the Vietnamese and Chichewa translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Katharine Elizabeth Stott
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool Health Partners, Liverpool, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Angela Loyse
- Institute of Infection and Immunity, St George's University and Hospital, London, UK
| | - Joe N Jarvis
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Melanie Alufandika
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK
| | | | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University and Hospital, London, UK
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, USA
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool Health Partners, Liverpool, UK
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12
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Osaigbovo II, Bongomin F. Point of care tests for invasive fungal infections: a blueprint for increasing availability in Africa. Ther Adv Infect Dis 2021; 8:20499361211034266. [PMID: 34422265 PMCID: PMC8371725 DOI: 10.1177/20499361211034266] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/05/2021] [Indexed: 01/17/2023] Open
Abstract
Invasive fungal infections (IFIs) such as cryptococcosis, disseminated histoplasmosis, and chronic pulmonary aspergillosis are significant causes of morbidity and mortality in Africa. Lack of laboratory infrastructure and laboratory personnel trained in diagnostic mycology hamper prompt detection and management of IFIs on the continent. Point-of-care tests (POCT) obviate the need for complex infrastructure, skilled technicians, and stable electricity and have had major impacts on the diagnosis of bacterial, viral, and parasitic infections in low- and middle-income countries. Over the last 10 years, POCTs for IFIs have become increasingly available and they have the potential to revolutionize the management of these infections if scaled up in Africa. At the beginning of 2021, the World Health Organization (WHO) Essential Diagnostic List (EDL) included a cryptococcal antigen test for the diagnosis of cryptococcosis, Histoplasma antigen test for the diagnosis of disseminated histoplasmosis, and Aspergillus-specific test for the diagnosis of chronic pulmonary aspergillosis. All of these are available in formats that may be used as POCTs and it is hoped that this will improve the diagnosis of these life-threatening IFIs, especially in low- and middle-income countries. This perspective review discusses commercially available POCTs and outlines strategies of a blueprint to achieve their roll-out in Africa. The strategies include raising awareness, conducting research that uncovers the exact burden of IFIs, increasing advocacy, integrating diagnosis of IFIs into existing public health programs, adoption of the WHO EDL at country levels, and improving logistics and supply chains.
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Affiliation(s)
- Iriagbonse Iyabo Osaigbovo
- Department of Medical Microbiology, School of Medicine, College of Medical Sciences, University of Benin, Benin City, Nigeria, Department of Medical Microbiology, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
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13
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Tadeo KK, Nimwesiga A, Kwizera R, Apeduno L, Martyn E, Okirwoth M, Nalintya E, Rajasingham R, Williams DA, Rhein J, Meya DB, Kafufu B, Boulware DR, Skipper CP. Evaluation of the Diagnostic Performance of a Semiquantitative Cryptococcal Antigen Point-of-Care Assay among HIV-Infected Persons with Cryptococcal Meningitis. J Clin Microbiol 2021; 59:e0086021. [PMID: 34076472 PMCID: PMC8373252 DOI: 10.1128/jcm.00860-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/26/2021] [Indexed: 12/24/2022] Open
Abstract
A newly developed cryptococcal antigen (CrAg) semiquantitative (SQ) lateral flow assay (LFA) provides a semiquantitative result in a rapid one-step test instead of performing serial dilutions to determine CrAg titer. We prospectively compared the diagnostic performance of the CrAgSQ assay (IMMY) with the CrAg LFA (IMMY) on cerebrospinal fluid (CSF) samples collected from persons with HIV-associated meningitis. The CrAgSQ grades (1+ to 5+) were compared with CrAg LFA titers and quantitative CSF fungal cultures. Among 87 participants screened for HIV-associated meningitis, 60 had cryptococcal meningitis (59 CrAg positive [CrAg+] by LFA and 1 false negative due to prozone with CrAg LFA titer of 1:1,310,000 and culture positivity), and 27 had no cryptococcal meningitis by CrAg LFA or culture. The CrAgSQ on CSF had 100% (60/60) sensitivity and 100% specificity (27/27). CSF CrAg titers ranged from 1:5 to 1:42 million. CrAgSQ grades of 1+, 2+, 3+, 4+, and 5+ corresponded to median CrAg LFA titers of 1:<10, 1:60, 1:7,680, 1:81,920, and 1:1,474,000, respectively. CSF CrAgSQ grades 3+ or higher were always CSF culture positive. Mortality at 14 days for those with low CrAgSQ grade (1+ to 3+) was 5% (1/22) versus 21% (8/38) with high CrAgSQ grades (4+ to 5+) (P = 0.084). The CrAgSQ demonstrates excellent diagnostic performance, maintaining both the sensitivity and specificity of the CrAg LFA, and counters false-negative prozone effects. The CrAgSQ assay reading is more complex but does provide useful clinical information about disease burden and probability of culture positivity in a single rapid diagnostic test.
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Affiliation(s)
- Kiiza Kandole Tadeo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Audrey Nimwesiga
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Richard Kwizera
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lucy Apeduno
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emily Martyn
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Michael Okirwoth
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elizabeth Nalintya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Darlisha A. Williams
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joshua Rhein
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B. Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Bosco Kafufu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David R. Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Caleb P. Skipper
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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14
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Blasich NP, Wake RM, Rukasha I, Prince Y, Govender NP. Association of semi-quantitative cryptococcal antigen results in plasma with subclinical cryptococcal meningitis and mortality among patients with advanced HIV disease. Med Mycol 2021; 59:1041-1047. [PMID: 34169984 DOI: 10.1093/mmy/myab038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 01/02/2023] Open
Abstract
Blood cryptococcal antigen (CrAg) titres > 160 are associated with concurrent subclinical cryptococcal meningitis (CM). When lumbar puncture (LP) is not immediately available in a CrAg screening programme, semi-quantitative CrAg assays may provide risk stratification for CM. Two semi-quantitative assays (SQ [Immuno-Mycologics, Norman, OK, USA] and CryptoPS [Biosynex, Strasbourg, France]) were evaluated against a qualitative lateral flow assay (LFA) using 194 plasma samples from a cohort of HIV-seropositive individuals with CD4 counts < 100 cells/µL. We compared SQ and CryptoPS results to titres for LFA-positive samples. Among patients with LP, we examined the association between semi-quantitative CrAg results and CM. We used a Cox proportional hazards model to determine the association between SQ score and mortality. Of 194 participants, 60 (31%) had positive LFA results, of whom 41 (68%) had a titre of ≤ 160 and 19 (32%) a titre > 160. Fifty individuals with antigenaemia had an LP; a clinically-useful SQ score that identified all ten cases of subclinical CM was ≥ 3 (100% sensitivity, 55% specificity). Patients with an SQ score of 3 or 4 also had a 2.2-fold increased adjusted hazards of 6-month mortality (95% CI, 0.79-6.34; p = 0.13) versus those with score of < 3. Nine of ten patients with subclinical CM had a strong-positive CryptoPS result versus 10/40 without subclinical CM (p<0.001). Semi-quantitative assays offered a sensitive though not specific means of gauging the risk of concurrent CM in this patient population. LAY ABSTRACT We evaluated two single-step laboratory tests that can quantify the amount of cryptococcal antigen in plasma of patients with advanced HIV disease and could thus gauge the risk of concurrent cryptococcal meningitis and subsequent mortality. These tests are not a substitute for a lumbar puncture.
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Affiliation(s)
- Nozuko P Blasich
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,Department of Biomedical Sciences, Faculty of Health and Wellness, Cape Peninsula University of Technology, Cape Town, South Africa
| | - Rachel M Wake
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,Institute of Infection & Immunity, St George's, University of London, United Kingdom
| | - Ivy Rukasha
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Yvonne Prince
- Department of Biomedical Sciences, Faculty of Health and Wellness, Cape Peninsula University of Technology, Cape Town, South Africa
| | - Nelesh P Govender
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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15
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Wang C, Liu M, Wang Z, Li S, Deng Y, He N. Point-of-care diagnostics for infectious diseases: From methods to devices. NANO TODAY 2021; 37:101092. [PMID: 33584847 PMCID: PMC7864790 DOI: 10.1016/j.nantod.2021.101092] [Citation(s) in RCA: 195] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 05/04/2023]
Abstract
The current widespread of COVID-19 all over the world, which is caused by SARS-CoV-2 virus, has again emphasized the importance of development of point-of-care (POC) diagnostics for timely prevention and control of the pandemic. Compared with labor- and time-consuming traditional diagnostic methods, POC diagnostics exhibit several advantages such as faster diagnostic speed, better sensitivity and specificity, lower cost, higher efficiency and ability of on-site detection. To achieve POC diagnostics, developing POC detection methods and correlated POC devices is the key and should be given top priority. The fast development of microfluidics, micro electro-mechanical systems (MEMS) technology, nanotechnology and materials science, have benefited the production of a series of portable, miniaturized, low cost and highly integrated POC devices for POC diagnostics of various infectious diseases. In this review, various POC detection methods for the diagnosis of infectious diseases, including electrochemical biosensors, fluorescence biosensors, surface-enhanced Raman scattering (SERS)-based biosensors, colorimetric biosensors, chemiluminiscence biosensors, surface plasmon resonance (SPR)-based biosensors, and magnetic biosensors, were first summarized. Then, recent progresses in the development of POC devices including lab-on-a-chip (LOC) devices, lab-on-a-disc (LOAD) devices, microfluidic paper-based analytical devices (μPADs), lateral flow devices, miniaturized PCR devices, and isothermal nucleic acid amplification (INAA) devices, were systematically discussed. Finally, the challenges and future perspectives for the design and development of POC detection methods and correlated devices were presented. The ultimate goal of this review is to provide new insights and directions for the future development of POC diagnostics for the management of infectious diseases and contribute to the prevention and control of infectious pandemics like COVID-19.
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Affiliation(s)
- Chao Wang
- State Key Laboratory of Bioelectronics, School of Biological Science and Medical Engineering, Southeast University, Nanjing 210096, PR China
- Department of Biomedical Engineering, School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing 211166, Jiangsu, PR China
| | - Mei Liu
- State Key Laboratory of Bioelectronics, School of Biological Science and Medical Engineering, Southeast University, Nanjing 210096, PR China
- School of Chemistry and Chemical Engineering, Southeast University, Nanjing 211189, PR China
| | - Zhifei Wang
- School of Chemistry and Chemical Engineering, Southeast University, Nanjing 211189, PR China
| | - Song Li
- Hunan Key Laboratory of Biomedical Nanomaterials and Devices, Hunan University of Technology, Zhuzhou 412007, PR China
| | - Yan Deng
- Hunan Key Laboratory of Biomedical Nanomaterials and Devices, Hunan University of Technology, Zhuzhou 412007, PR China
| | - Nongyue He
- State Key Laboratory of Bioelectronics, School of Biological Science and Medical Engineering, Southeast University, Nanjing 210096, PR China
- Hunan Key Laboratory of Biomedical Nanomaterials and Devices, Hunan University of Technology, Zhuzhou 412007, PR China
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16
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Lass-Flörl C, Samardzic E, Knoll M. Serology anno 2021-fungal infections: from invasive to chronic. Clin Microbiol Infect 2021; 27:1230-1241. [PMID: 33601011 DOI: 10.1016/j.cmi.2021.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/26/2021] [Accepted: 02/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Diagnosing invasive or chronic fungal infections is a challenge, particularly in the immunocompromised host. Microscopy and culture remain the reference standard, but are insensitive. The use of non-culture-based techniques is recommended in conjunction with conventional methods to improve the diagnostic yield. OBJECTIVES The aim was to provide an updated 2021 inventory of fungal antigen and serology tests for diagnosing invasive and chronic fungal infections, the key focus was set on Aspergillus, Candida and Cryptococcus species. SOURCES Pubmed search for publications with the key words fungal antigen tests, laboratory-based diagnosis of invasive pulmonary aspergillosis, chronic pulmonary aspergillosis, invasive candidiasis, invasive fungal infections and cryptococcal infections published from 2017 to 2020. CONTENT Antigen assays such as the galactomannan (GM) and β-d-glucan detection systems are frequently used, but these tests vary in sensitivity and specificity, depending on the patient population involved, specimens inspected, cut-offs defined, test strategy applied and inclusion or exclusion of possible fungal case definitions. Multiple different detection systems are available, with recently introduced new point-of-care tests such as the lateral flow device and the lateral flow assay. Despite a wide heterogeneity in populations evaluated, studies indicate a better diagnostic performance of bronchoalveolar lavage GM in comparison with serum GM, and a suboptimal specificity of GM bronchoalveolar lavages (cut-off ≥1) and serum β-d-glucan in non-neutropenic individuals. Point-of-care cryptococcal antigen tests show excellent performance. IMPLICATIONS There are fungal antigen detection tests available with excellent to reasonable clinical performance to diagnose invasive fungal infections. Only a few assays are useful to monitor therapeutic response. There are multiple marketed IgG antibody tests to detect Aspergillus fumigatus antibodies, the titres vary widely and the performance differs significantly. In general, diagnostic tests are vulnerable to being affected by the host, the microbe and laboratory setting.
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Affiliation(s)
- Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Austria.
| | - Eldina Samardzic
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Austria
| | - Miriam Knoll
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Austria
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17
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Diagnostic Accuracy of the Biosynex CryptoPS Cryptococcal Antigen Semiquantitative Lateral Flow Assay in Patients with Advanced HIV Disease. J Clin Microbiol 2020; 59:JCM.02307-20. [PMID: 33087436 PMCID: PMC7771453 DOI: 10.1128/jcm.02307-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/14/2020] [Indexed: 01/20/2023] Open
Abstract
High cryptococcal antigen (CrAg) titers in blood are associated with subclinical meningitis and mortality in CrAg-positive individuals with advanced HIV disease (AHD). We evaluated a novel semiquantitative lateral flow assay (LFA), CryptoPS, that may be able to identify individuals with high CrAg titers in a cohort of AHD patients undergoing CrAg screening. In a prospective cohort of patients with AHD (CD4 cell count, ≤200/μl) receiving CD4 count testing, whole blood was tested for CrAg by CryptoPS and the IMMY LFA; the two assays were conducted by two different operators, each blind to the results of the other assay. High cryptococcal antigen (CrAg) titers in blood are associated with subclinical meningitis and mortality in CrAg-positive individuals with advanced HIV disease (AHD). We evaluated a novel semiquantitative lateral flow assay (LFA), CryptoPS, that may be able to identify individuals with high CrAg titers in a cohort of AHD patients undergoing CrAg screening. In a prospective cohort of patients with AHD (CD4 cell count, ≤200/μl) receiving CD4 count testing, whole blood was tested for CrAg by CryptoPS and the IMMY LFA; the two assays were conducted by two different operators, each blind to the results of the other assay. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CryptoPS were assessed against the IMMY LFA as a reference. CryptoPS low-titer (T1 band) and high-titer (T2 band) results were compared with IMMY LFA titers obtained through serial dilution. A total of 916 specimens were tested. The sensitivity of the CryptoPS assay was 61.0% (25/41) (95% confidence interval [95% CI], 44.5 to 75.8%), its specificity was 96.6% (845/875) (95% CI, 95.1 to 97.7%), its PPV was 45.5% (95% CI, 32.0 to 59.4%), and its NPV was 98.1% (95% CI, 97.0 to 98.9%). All (16/16) CryptoPS false-negative results were obtained for samples with IMMY titers of ≤1:160. Of 29 patients (30 specimens) who tested positive by CryptoPS but negative by the IMMY LFA, none developed cryptococcal meningitis over 3 months of follow-up without fluconazole. Median CrAg titers were 1:20 (interquartile range [IQR], 0 to 1:160) in CryptoPS T1-positive samples and 1:2,560 (IQR, 1:1,280 to 1:10,240) in T2-positive samples. We conclude that the diagnostic accuracy of the CryptoPS assay was suboptimal in the context of CrAg screening, with poor sensitivity at low CrAg titers. However, the CryptoPS assay reliably detected individuals with high titers, which are associated with poor outcomes.
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