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Kosuta I, Premkumar M, Reddy KR. Review article: Evaluation and care of the critically ill patient with cirrhosis. Aliment Pharmacol Ther 2024; 59:1489-1509. [PMID: 38693712 DOI: 10.1111/apt.18016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/21/2024] [Accepted: 04/12/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients. AIM Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care. METHODS We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care. RESULTS Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource. CONCLUSIONS Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.
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Affiliation(s)
- Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Sehrawat SS, Premkumar M. Critical care management of acute liver failure. Indian J Gastroenterol 2024; 43:361-376. [PMID: 38578565 DOI: 10.1007/s12664-024-01556-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/12/2024] [Indexed: 04/06/2024]
Abstract
The management of acute liver failure (ALF) in modern hepatology intensive care units (ICU) has improved patient outcomes. Critical care management of hepatic encephalopathy, cerebral edema, fluid and electrolytes; prevention of infections and organ support are central to improved outcomes of ALF. In particular, the pathogenesis of encephalopathy is multifactorial, with ammonia, elevated intra-cranial pressure and systemic inflammation playing a central role. Although ALF remains associated with high mortality, the availability of supportive care, including organ failure support such as plasma exchange, timely mechanical ventilation or continuous renal replacement therapy, either conservatively manages patients with ALF or offers bridging therapy until liver transplantation. Thus, appropriate critical care management has improved the likelihood of patient recovery in ALF. ICU care interventions such as monitoring of cerebral edema, fluid status assessment and interventions for sepsis prevention, nutritional support and management of electrolytes can salvage a substantial proportion of patients. In this review, we discuss the key aspects of critical care management of ALF.
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Affiliation(s)
- Surender Singh Sehrawat
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India.
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3
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Calder AD, Perucca G, Johnson SM, Pandey AR, Moshal K, Kusters MA. Lung infections in immunocompromised children. Pediatr Radiol 2024; 54:530-547. [PMID: 37589764 DOI: 10.1007/s00247-023-05735-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/18/2023]
Abstract
Pulmonary infection is the leading cause of infectious morbidity and mortality in children with immune defects. We provide a comprehensive review of lung infections in immunocompromised children, with a focus on imaging findings and imaging-based management. We include an overview of the immune defences of the respiratory tract, the aetiologies of immune defects in children, the features of specific infections and important differential diagnoses and describe diagnostic strategies using imaging and non-imaging-based techniques.
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Affiliation(s)
- Alistair D Calder
- Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
| | - Giulia Perucca
- Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Sarah May Johnson
- Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ashwin R Pandey
- Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Karyn Moshal
- Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Maaike A Kusters
- Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Park SY, Ardura MI, Zhang SX. Diagnostic limitations and challenges in current clinical guidelines and potential application of metagenomic sequencing to manage pulmonary invasive fungal infections in patients with haematological malignancies. Clin Microbiol Infect 2024:S1198-743X(24)00115-0. [PMID: 38460819 DOI: 10.1016/j.cmi.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 02/24/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Pulmonary invasive fungal infections (pIFI) disproportionately affect patients with haematological malignancies (HM). Establishing a rapid and accurate diagnosis of pIFI is challenging. Multiple guidelines recommend diagnostic testing of invasive fungal infections but lack consensus and may contribute to inconsistent diagnostic approaches. OBJECTIVE To identify key diagnostic challenges and review metagenomic sequencing data. SOURCES PubMed, professional consortium, and scientific society websites search to identify relevant, published, evidence-based clinical guidelines within the past 5 years. PubMed searchs for papers describing clinically relevant novel diagnostic technologies. CONTENT Current guidelines for patients with HM and suspected pIFI recommend chest computed tomography imaging and specimen testing with microscopic examination (including calcofluor white stain, histopathology, cytopathology, etc.), Aspergillus galactomannan, β-D-glucan, PCR, and culture, each with certain limitations. Emerging real-world data support the adjunctive use of metagenomic sequencing-based tests for the timely diagnosis of pIFI. IMPLICATIONS High-quality evidence from robust clinical trials is needed to determine whether guidelines should be updated to include novel diagnostic technologies. Trials should ask whether the combination of powerful novel diagnostics, such as pathogen-agnostic metagenomic sequencing technologies in conjunction with conventional testing can optimize the diagnostic yield for all potential pIFI pathogens that impact the health of patients with HM.
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Affiliation(s)
| | - Monica I Ardura
- Section of Infectious Diseases & Host Defense Program, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sean X Zhang
- Medical Mycology Laboratory, Johns Hopkins Hospital, Baltimore, MD, USA; Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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5
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Kumar M, Hanisch BR. How I approach: the transplant recipient with fever and pulmonary infiltrates. Front Pediatr 2024; 12:1273590. [PMID: 38440184 PMCID: PMC10909924 DOI: 10.3389/fped.2024.1273590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 01/29/2024] [Indexed: 03/06/2024] Open
Abstract
Recipients of hematopoietic stem cell transplants and solid organ transplants frequently develop pulmonary infiltrates from both infectious and non-infectious etiologies. Differentiation and further characterization of microbiologic etiologies-viral, bacterial, and fungal-can be exceedingly challenging. Pediatric patients face unique challenges as confirmatory evaluations with bronchoscopy or lung biopsy may be limited. A generalizable approach to diagnosing and managing these conditions has not been well established. This paper aims to summarize our initial clinical approach while discussing the relative evidence informing our practices. A pediatric patient with characteristic infiltrates who has undergone HSCT is presented to facilitate the discussion. Generalizable approaches to similar patients are highlighted as appropriate while highlighting considerations based on clinical course and key risk factors.
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Affiliation(s)
- Madan Kumar
- Section of Pediatric Infectious Diseases, University of Chicago, Chicago, IL, United States
| | - Benjamin R. Hanisch
- Department of Pediatrics, School of Medicine and Health Sciences, Division of Infectious Diseases, Children’s National Hospital, The George Washington University, Washington, DC, United States
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Yeoh DK, McMullan BJ, Clark JE, Slavin MA, Haeusler GM, Blyth CC. The Challenge of Diagnosing Invasive Pulmonary Aspergillosis in Children: A Review of Existing and Emerging Tools. Mycopathologia 2023; 188:731-743. [PMID: 37040020 PMCID: PMC10564821 DOI: 10.1007/s11046-023-00714-4] [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: 01/09/2023] [Accepted: 02/07/2023] [Indexed: 04/12/2023]
Abstract
Invasive pulmonary aspergillosis remains a major cause of morbidity and mortality for immunocompromised children, particularly for patients with acute leukaemia and those undergoing haematopoietic stem cell transplantation. Timely diagnosis, using a combination of computed tomography (CT) imaging and microbiological testing, is key to improve prognosis, yet there are inherent challenges in this process. For CT imaging, changes in children are generally less specific than those reported in adults and recent data are limited. Respiratory sampling by either bronchoalveolar lavage or lung biopsy is recommended but is not always feasible in children, and serum biomarkers, including galactomannan, have important limitations. In this review we summarise the current paediatric data on available diagnostic tests for IPA and highlight key emerging diagnostic modalities with potential for future use.
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Affiliation(s)
- Daniel K Yeoh
- Department of Infectious Diseases, Perth Children's Hospital, 15 Hospital Avenue, Perth, WA, 6009, Australia.
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia.
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Murdoch Children's Research Institute, Parkville, VIC, Australia.
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.
| | - Brendan J McMullan
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia
- School of Women's and Children's Health, UNSW, Sydney, NSW, Australia
| | - Julia E Clark
- Infection Management Service, Queensland Children's Hospital, Brisbane, QLD, Australia
- School of Clinical Medicine, Children's Health Queensland Clinical Unit, The University of Queensland, Brisbane, QLD, Australia
| | - Monica A Slavin
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Gabrielle M Haeusler
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Royal Children's Hospital, Parkville, VIC, Australia
- The Paediatric Integrated Cancer Service, Melbourne, VIC, Australia
| | - Christopher C Blyth
- Department of Infectious Diseases, Perth Children's Hospital, 15 Hospital Avenue, Perth, WA, 6009, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Department of Microbiology, PathWest Laboratory Medicine WA, Nedlands, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
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Tomazin R, Simčič S, Stopinšek S, Kopitar AN, Kukec A, Matos T, Mulec J. Effects of Anthropogenic Disturbance and Seasonal Variation on Aerobiota in Highly Visited Show Caves in Slovenia. Microorganisms 2023; 11:2381. [PMID: 37894039 PMCID: PMC10608856 DOI: 10.3390/microorganisms11102381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/15/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023] Open
Abstract
Aerosols in caves are natural tracers and, together with climatic parameters, provide a detailed insight into atmospheric conditions, responses to climatic changes and anthropogenic influences in caves. Microbiological air monitoring in show caves is becoming increasingly useful to understand changes in cave ecosystems and to implement and review measures for sustainable cave use and tourism development. In 2017 and 2018, air along tourist trails in caves Postojnska jama and Škocjanske jame (Slovenia) was sampled before and after tourist visits. Samples were analysed using culture-dependent methods, flow cytometry, detection of β-D-glucan and lipopolysaccharide and compared with CO2 and temperature data to measure anthropogenic influences and seasonality on aerobiota. While the presence of tourists significantly increased concentrations of airborne microorganisms (p < 0.05), β-D-glucan and CO2 did not show such a trend and were more dependent on seasonal changes. Locally, concentrations of cultivable microorganisms above 1000 CFU/m3 were detected, which could have negative effects on the autochthonous microbiota and possibly on human health. A mixture of bacteria typically associated with humans was found in the air and identified with MALDI-TOF MS. Using MALDI-TOF MS, we achieved a 69.6% success rate in identification. Micrococcus luteus, Streptococcus mitis, Staphylococcus epidermidis and Moraxella spp. were recognized as good indicators of cave anthropisation.
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Affiliation(s)
- Rok Tomazin
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, SI-1000 Ljubljana, Slovenia; (R.T.); (S.S.); (A.N.K.); (T.M.)
| | - Saša Simčič
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, SI-1000 Ljubljana, Slovenia; (R.T.); (S.S.); (A.N.K.); (T.M.)
| | - Sanja Stopinšek
- Health Centre Hrastnik, Novi dom 11, SI-1430 Hrastnik, Slovenia;
| | - Andreja Nataša Kopitar
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, SI-1000 Ljubljana, Slovenia; (R.T.); (S.S.); (A.N.K.); (T.M.)
| | - Andreja Kukec
- Department of Public Health, Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, SI-1000 Ljubljana, Slovenia;
| | - Tadeja Matos
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, SI-1000 Ljubljana, Slovenia; (R.T.); (S.S.); (A.N.K.); (T.M.)
| | - Janez Mulec
- Karst Research Institute, Research Centre of the Slovenian Academy of Sciences and Arts, Titov trg 2, SI-6230 Postojna, Slovenia
- UNESCO Chair on Karst Education, University of Nova Gorica, SI-5271 Vipava, Slovenia
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M Abd El-Halim R, Hafez H, Albahet I, Sherif B. Respiratory co-infections in COVID-19-positive patients. Eur J Med Res 2023; 28:317. [PMID: 37660059 PMCID: PMC10474635 DOI: 10.1186/s40001-023-01305-1] [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: 09/09/2022] [Accepted: 08/19/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Opportunistic respiratory infections may complicate critically ill patients with COVID-19. Early detection of co-infections helps to administrate the appropriate antimicrobial agent, to guard against patient deterioration. This study aimed at estimating co-infections in COVID-19-positive patients. METHODS Eighty-nine COVID-19-positive patients confirmed by SARS-COV-2 PCR were tested for post-COVID-19 lower respiratory tract co-infections through bacterial culture, fungal culture and galactomannan (GM) testing. RESULTS Fourteen patients showed positive coinfection with Klebsiella, nine with Acinetobacter, six with Pseudomonas and three with E. coli. As for fungal infections, nine showed coinfection with Aspergillus, two with Zygomycetes and four with Candida. Galactomannan was positive among one patient with Aspergillus coinfection, one with Zygomycetes coinfection and three with Candida, 13 samples with negative fungal culture were positive for GM. Ten samples showed positive fungal growth, however, GM test was negative. CONCLUSION In our study, SARS-COV-2 respiratory coinfections were mainly implicated by bacterial pathogens; most commonly Klebsiella species (spp.), Aspergillus spp. were the most common cause of fungal coinfections, GM test showed low positive predictive value for fungal infection. Respiratory coinfections may complicate SARS-COV-2 probably due to the prolonged intensive care units (ICU) hospitalization, extensive empiric antimicrobial therapy, steroid therapy, mechanical ventilation during the COVID-19 outbreak. Antimicrobial stewardship programs are required so that antibiotics are prescribed judiciously according to the culture results.
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Affiliation(s)
- Rania M Abd El-Halim
- Clinical Pathology Department, Faculty of Medicine Ain Shams University, Cairo, 11566, Egypt
| | - Hala Hafez
- Clinical Pathology Department, Faculty of Medicine Ain Shams University, Cairo, 11566, Egypt
| | - Ibrahim Albahet
- Anaesthesia, Intensive Care and pain management department, Faculty of Medicine-Ain Shams University, Cairo, Egypt
| | - Basma Sherif
- Clinical Pathology Department, Faculty of Medicine Ain Shams University, Cairo, 11566, Egypt.
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Research Progress in Hemicellulose-Based Nanocomposite Film as Food Packaging. Polymers (Basel) 2023; 15:polym15040979. [PMID: 36850261 PMCID: PMC9964622 DOI: 10.3390/polym15040979] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
As the main component of agricultural and forestry biomass, hemicellulose has the advantages of having an abundant source, biodegradability, nontoxicity and good biocompatibility. Its application in food packaging has thus become the focus of efficient utilization of biomass resources. However, due to its special molecular structure and physical and chemical characteristics, the mechanical properties and barrier properties of hemicellulose films are not sufficient, and modification for performance enhancement is still a challenge. In the field of food packaging materials preparation, modification of hemicellulose through blending with nanofibers or nanoparticles, both inorganic and organic, has attracted research attention because this approach offers the advantages of efficient improvement in the expected properties and better cost efficiency. In this paper, the composition of hemicellulose, the classification of nanofillers and the research status of hemicellulose-based nanocomposite films are reviewed. The research progress in modification of hemicellulose by using layered silicate, inorganic nanoparticles and organic nanoparticles in food packaging is described. Challenges and outlook of research in hemicellulose-based nanocomposite film in food packaging is discussed.
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Serum Beta-D-Glucan in the Diagnosis of Invasive Fungal Disease in Neonates, Children and Adolescents: A Critical Analysis of Current Data. J Fungi (Basel) 2022; 8:jof8121262. [PMID: 36547595 PMCID: PMC9783846 DOI: 10.3390/jof8121262] [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: 11/15/2022] [Revised: 11/27/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022] Open
Abstract
β-D-glucan (BDG) is a cell wall component of many pathogenic fungi. The detection of BDG as an assay is clinically broadly used as a diagnostic tool. However, the current data on BDG in paediatrics are limited, prompting specific considerations about when BDG can be used in neonates and children. We aimed to analyse the available data for the use of serum BDG in neonates and immunocompromised children and adolescents; as well as to understand the extent and characteristics of the use of BDG in children in Europe.
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Al-Obaidi MM, Ayazi P, Shi A, Campanella M, Connick E, Zangeneh TT. The Utility of (1→3)-β-D-Glucan Testing in the Diagnosis of Coccidioidomycosis in Hospitalized Immunocompromised Patients. J Fungi (Basel) 2022; 8:jof8080768. [PMID: 35893136 PMCID: PMC9332557 DOI: 10.3390/jof8080768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 07/18/2022] [Accepted: 07/23/2022] [Indexed: 02/01/2023] Open
Abstract
Coccidioidomycosis is a fungal infection endemic to the Southwestern United States which is associated with high morbidity and mortality in immunocompromised hosts. Serology is the main diagnostic tool, although less sensitive among immunocompromised hosts. (1→3)-β-D-glucan (BDG) is a non-specific fungal diagnostic test that may identify suspected coccidioidomycosis and other invasive fungal infections. We retrospectively investigated the utility of BDG between 2017 and 2021 in immunocompromised hosts with positive Coccidioides spp. cultures at our institutions. During the study period, there were 368 patients with positive cultures for Coccidioides spp.; among those, 28 patients were immunocompromised hosts, had both Coccidioides serology and BDG results available, and met other inclusion and exclusion criteria. Half of the patients had positive Coccidioides serology, and 57% had a positive BDG ≥ 80 pg/mL. Twenty-three (82%) had at least one positive test during their hospitalization. Among immunocompromised hosts with suspicion for coccidioidomycosis, the combination of Coccidioides serology and BDG can be useful in the initial work up and the timely administration of appropriate antifungal therapy. However, both tests failed to diagnose many cases, underscoring the need for better diagnostic techniques for identifying coccidioidomycosis in this population.
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