1
|
Sharvit G, Schwartz D, Heering G, Shulman A, Avigdor A, Rahav G, Toren A, Nagler A, Canaani J. Evaluation of the clinical impact of bone marrow cultures in current medical practice. Sci Rep 2022; 12:9664. [PMID: 35690634 PMCID: PMC9188585 DOI: 10.1038/s41598-022-14059-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 05/31/2022] [Indexed: 11/15/2022] Open
Abstract
The clinical yield and benefit of performing bone marrow cultures for various clinical indications has been challenged and their clinical necessity remains debatable. We sought to assess the clinical yield and benefit of performing routine bone marrow cultures and determine whether various clinical, laboratory, and imaging parameters were predictive of a diagnostic bone marrow culture. This was a single center retrospective analysis of all patients who underwent a bone marrow study comprising bone marrow cultures from January 1, 2012, through March 1, 2018. Baseline clinical data were extracted from the institution's electronic medical records system. The analyzed cohort consisted of 139 patients with a median age of 46 years (range 4 months to 85 years). The most common indication for a bone marrow study was workup of a fever of unknown origin (105 patients, 76%) while investigation for infection in immunocompromised patients accounted for 22 cases (16%) and suspected tuberculosis was the reason for acquisition of bone marrow cultures in 6 patients (4%). Only 3 patients had positive bone marrow cultures, yielding in 2 patients a diagnosis of Mycobacterium avium and in one patient a microbiologically unclassifiable fungal infection. A univariate analysis revealed that mean age, hemoglobin level, platelet count, c-reactive protein levels, gender, indication for bone marrow study, yield of blood cultures, and contribution of imaging studies and bone marrow pathology results were not significantly different between patients with diagnostic and non-diagnostic bone marrow cultures. Mean white blood cell count was found to be significantly lower in patients with diagnostic bone marrow cultures (2.4 × 103/µL versus 8.7 × 103/µL; P = 0.038). We conclude that for most patients, performance of bone marrow cultures holds limited clinical value.
Collapse
Affiliation(s)
- Gal Sharvit
- Division of Hematology, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
| | - Daniel Schwartz
- MetroHealth Medical Center, Case Western Reserve University, 2500 Metrohealth Dr, Cleveland, OH, 44109, USA
| | - Gabriel Heering
- Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA
| | - Alexander Shulman
- The Infectious Diseases Unit, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
| | - Abraham Avigdor
- Division of Hematology, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
| | - Galia Rahav
- The Infectious Diseases Unit, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
| | - Amos Toren
- Pediatric Hemato-Oncology Division, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
| | - Arnon Nagler
- Division of Hematology, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
| | - Jonathan Canaani
- Division of Hematology, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel.
| |
Collapse
|
2
|
Abstract
For decades antimonials were the drugs of choice for the treatment of visceral
leishmaniasis (VL), but the recent emergence of resistance has made them redundant as
first-line therapy in the endemic VL region in the Indian subcontinent. The application of
other drugs has been limited due to adverse effects, perceived high cost, need for
parenteral administration and increasing rate of treatment failures. Liposomal
amphotericin B (AmB) and miltefosine (MIL) have been positioned as the effective
first-line treatments; however, the number of monotherapy MIL-failures has increased after
a decade of use. Since no validated molecular resistance markers are yet available,
monitoring and surveillance of changes in drug sensitivity and resistance still depends on
standard phenotypic in vitro promastigote or amastigote susceptibility
assays. Clinical isolates displaying defined MIL- or AmB-resistance are still fairly
scarce and fundamental and applied research on resistance mechanisms and dynamics remains
largely dependent on laboratory-generated drug resistant strains. This review addresses
the various challenges associated with drug susceptibility and -resistance monitoring in
VL, with particular emphasis on the choice of strains, susceptibility model selection and
standardization of procedures with specific read-out parameters and well-defined threshold
criteria. The latter are essential to support surveillance systems and safeguard the
limited number of currently available antileishmanial drugs.
Collapse
|
5
|
Alvar J, Cañavate C, Gutiérrez-Solar B, Jiménez M, Laguna F, López-Vélez R, Molina R, Moreno J. Leishmania and human immunodeficiency virus coinfection: the first 10 years. Clin Microbiol Rev 1997; 10:298-319. [PMID: 9105756 PMCID: PMC172921 DOI: 10.1128/cmr.10.2.298] [Citation(s) in RCA: 488] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Over 850 Leishmania-human immunodeficiency virus (HIV) coinfection cases have been recorded, the majority in Europe, where 7 to 17% of HIV-positive individuals with fever have amastigotes, suggesting that Leishmania-infected individuals without symptoms will express symptoms of leishmaniasis if they become immunosuppressed. However, there are indirect reasons and statistical data demonstrating that intravenous drug addiction plays a specific role in Leishmania infantum transmission: an anthroponotic cycle complementary to the zoonotic one has been suggested. Due to anergy in patients with coinfection, L. infantum dermotropic zymodemes are isolated from patient viscera and a higher L. infantum phenotypic variability is seen. Moreover, insect trypanosomatids that are currently considered nonpathogenic have been isolated from coinfected patients. HIV infection and Leishmania infection each induce important analogous immunological changes whose effects are multiplied if they occur concomitantly, such as a Th1-to-Th2 response switch; however, the consequences of the viral infection predominate. In fact, a large proportion of coinfected patients have no detectable anti-Leishmania antibodies. The microorganisms share target cells, and it has been demonstrated in vitro how L. infantum induces the expression of latent HIV-1. Bone marrow culture is the most useful diagnostic technique, but it is invasive. Blood smears and culture are good alternatives. PCR, xenodiagnosis, and circulating-antigen detection are available only in specialized laboratories. The relationship with low levels of CD4+ cells conditions the clinical presentation and evolution of disease. Most patients have visceral leishmaniasis, but asymptomatic, cutaneous, mucocutaneous, diffuse cutaneous, and post-kala-azar dermal leishmaniasis can be produced by L. infantum. The digestive and respiratory tracts are frequently parasitized. The course of coinfection is marked by a high relapse rate. There is a lack of randomized prospective treatment trials; therefore, coinfected patients are treated by conventional regimens. Prophylactic therapy is suggested to be helpful in preventing relapses.
Collapse
Affiliation(s)
- J Alvar
- Laboratorio de Referencia de Leishmaniasis, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | | | | | | | | | | | | | | |
Collapse
|