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Villareal K, Price A, Pasqualotto AC, Bahr NC. The Current and Future States of Diagnostic Tests for Histoplasmosis with a Focus on People with HIV and Disseminated Histoplasmosis. J Fungi (Basel) 2023; 9:793. [PMID: 37623564 PMCID: PMC10456117 DOI: 10.3390/jof9080793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/26/2023] Open
Abstract
Histoplasmosis is caused by Histoplasma capsulatum and, although endemic in large parts of the world, is often underrecognized in many locations. In addition to underrecognition, inadequate availability of diagnostic tests is a major contributor to poor outcomes in disseminated disease in people with HIV. For those with advanced HIV and disseminated disease, antibody testing is less useful. Culture and histopathology can be useful in this situation, but each has limitations, including variable sensitivity by site and, in the case of culture, the need for a biosafety level three laboratory and a long period of growth. Antigen testing has proven useful for disseminated histoplasmosis due to the excellent sensitivity of urine. Yet, turnaround is slower than ideal due to use in a limited number of centers. The development of lateral flow assays has the potential to make for true rapid point-of-care assays for histoplasmosis, but in order to meet that promise, the tests must be widely available and affordable.
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Affiliation(s)
- Kenneth Villareal
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS 66160, USA; (K.V.); (A.P.)
| | - Austin Price
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS 66160, USA; (K.V.); (A.P.)
| | - Alessandro C. Pasqualotto
- Department of Clinical Medicine and Post-Graduation Program in Pathology, Universidade Federal de Ciências da Saúde, Porto Alegre 90050-170, Brazil;
| | - Nathan C. Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS 66160, USA; (K.V.); (A.P.)
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Cáceres DH, Gómez BL, Tobón ÁM, Restrepo Á, Chiller T, Lindsley MD, Meis JF, Verweij PE. Tackling Histoplasmosis Infection in People Living with HIV from Latin America: From Diagnostic Strategy to Public Health Solutions. J Fungi (Basel) 2023; 9:jof9050558. [PMID: 37233269 DOI: 10.3390/jof9050558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/27/2023] Open
Abstract
Histoplasmosis, caused by the thermally dimorphic fungus Histoplasma spp., is a disease with a broad clinical spectrum, presenting from asymptomatic/flu-like symptoms to progressive disseminated disease in people with immunosuppression. In recent years, the concept of histoplasmosis as a disease restricted to the American continent has changed, as now histoplasmosis is reported in many regions around the world. In Latin America, histoplasmosis represents a threat, especially in people with advanced HIV disease (AHD). Diagnosis of histoplasmosis in people living with HIV (PLHIV) is challenging due to the low index of suspicion of the disease, non-specificity of signs and symptoms, and limited access to specific laboratory testing, while the diagnostic delay is significantly associated with mortality. In the last decade, novel diagnostic tests have been developed for the rapid detection of histoplasmosis, such as commercial kits for antigen detection. Furthermore, advocacy groups were created that presented histoplasmosis as a public health problem, with emphasis on patients at risk of progressive disseminated disease. This review aims to discuss the impact of histoplasmosis associated with AHD in Latin America and the strategies employed to tackle histoplasmosis, from the implementation of laboratory testing to disease advocacy and public health interventions.
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Affiliation(s)
- Diego H Cáceres
- Center of Expertise in Mycology Radboudumc/Canisius Wilhelmina Hospital, 6532 SZ Nijmegen, The Netherlands
- Studies in Translational Microbiology and Emerging Diseases (MICROS) Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogota 111221, Colombia
- IMMY, Norman, OK 73069, USA
| | - Beatriz L Gómez
- Studies in Translational Microbiology and Emerging Diseases (MICROS) Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogota 111221, Colombia
| | - Ángela M Tobón
- Instituto Colombiano de Medicina Tropical, Universidad CES, Medellín 055450, Colombia
| | - Ángela Restrepo
- COLCIENCIAS Emeritus Researcher, Ministerio de Ciencias, Tecnología e Innovación, Bogota 111321, Colombia
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA
| | - Mark D Lindsley
- Mycotic Diseases Branch, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA
| | - Jacques F Meis
- Center of Expertise in Mycology Radboudumc/Canisius Wilhelmina Hospital, 6532 SZ Nijmegen, The Netherlands
- Department I of Internal Medicine, Excellence Center for Medical Mycology, University Hospital Cologne, 50931 Cologne, Germany
| | - Paul E Verweij
- Center of Expertise in Mycology Radboudumc/Canisius Wilhelmina Hospital, 6532 SZ Nijmegen, The Netherlands
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Cáceres DH, Gómez BL, Tobón ÁM, Minderman M, Bridges N, Chiller T, Lindsley MD. Validation and Concordance Analysis of a New Lateral Flow Assay for Detection of Histoplasma Antigen in Urine. J Fungi (Basel) 2021; 7:799. [PMID: 34682221 DOI: 10.3390/jof7100799] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 12/13/2022] Open
Abstract
Histoplasmosis is a major cause of mortality in people living with HIV (PLHIV). Rapid methods to diagnose Histoplasma capsulatum disease could dramatically decrease the time to initiate treatment, resulting in reduced mortality. The aim of this study was to validate a MiraVista® Diagnostics (MVD) Histoplasma urine antigen lateral flow assay (MVD LFA) for the detection of H. capsulatum antigen (Ag) in urine and compare this LFA against the MVista® Histoplasma Ag quantitative enzyme immunoassays (MVD EIA). We assessed the MVD LFA using a standardized reference panel of urine specimens from Colombia. We tested 100 urine specimens, 26 from PLHIV diagnosed with histoplasmosis, 42 from PLHIV with other infectious diseases, and 32 from non-HIV infected persons without histoplasmosis. Sensitivity and specificity of the MVD LFA was 96%, compared with 96% sensitivity and 77% specificity of the MVD EIA. Concordance analysis between MVD LFA and the MVD EIA displayed an 84% agreement, and a Kappa of 0.656. The MVD LFA evaluated in this study has several advantages, including a turnaround time for results of approximately 40 min, no need for complex laboratory infrastructure or highly trained laboratory personnel, use of urine specimens, and ease of performing.
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Falci DR, Dalla Lana DF, Pasqualotto AC. The era of histoplasmosis in Brazilian endemic mycoses. Lancet Reg Health Am 2021; 3:100037. [PMID: 36777401 PMCID: PMC9903817 DOI: 10.1016/j.lana.2021.100037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/28/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Diego R. Falci
- Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil,Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Alessandro C. Pasqualotto
- Universidade Federal de Ciencias da Saude de Porto Alegre, Porto Alegre, Brazil,Santa Casa de Misericordia de Porto Alegre, Porto Alegre, Brazil,Corresponding author: Prof. Alessandro C. Pasqualotto. Molecular Biology Laboratory, Santa Casa de Misericórdia de Porto Alegre. Av. Independência 155, Hospital Dom Vicente Scherer, Heliponto. Porto Alegre, RS, Brazil. 90035075.
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Rakislova N, Hurtado JC, Palhares AEM, Ferreira L, Freire M, Lacerda M, Monteiro W, Navarro M, Casas I, Teixeira MDM, Castillo P, Rodrigo-Calvo MT, Marimon L, Guerrero J, Varo R, Delgado V, Quintó L, Marco F, Letang E, Vila J, Bassat Q, Menéndez C, Ordi J, Martínez MJ. High prevalence and mortality due to Histoplasma capsulatum in the Brazilian Amazon: An autopsy study. PLoS Negl Trop Dis 2021; 15:e0009286. [PMID: 33819269 PMCID: PMC8049479 DOI: 10.1371/journal.pntd.0009286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/15/2021] [Accepted: 03/02/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Histoplasmosis is acquired by inhalation of spores of the dimorphic fungus Histoplasma spp. Although this pathogen is distributed worldwide, it is more prevalent in the Americas. However, the real burden of histoplasmosis remains undefined in many endemic regions. METHODOLOGY We conducted a series of 61 autopsies to individuals who died in a hospital in the Brazilian Amazon focused on infectious diseases. We performed a detailed histological and microbiological evaluation with genetic characterization of Histoplasma strains with the aim to evaluate the contribution of histoplasmosis to morbidity and mortality. Additionally, we assessed the clinicopathological correlation. PRINCIPAL FINDINGS Evidence of Histoplasma infection was detected in 21 patients (34%). Eight cases were disseminated infections, all of them occurred in HIV-positive patients. Six cases were localized histoplasmosis, limited to the lungs. In seven patients Histoplasma DNA was detected by PCR in patients with no histological lesions. Histoplasma infection was detected in 38% of HIV-positive patients and was a major contributor to death in 22% of them. Lungs, liver and spleen were affected in all cases of disseminated histoplasmosis. Phylogenetic analysis of the strains suggested a high diversity of Histoplasma species circulating in the Brazilian Amazon. Histoplasmosis was clinically missed in 75% of the disseminated infections. CONCLUSIONS The high incidence of histoplasmosis, the low index of clinical suspicion, and the severity of the disseminated disease highlight the need of proactively implementing sensitive routine screening methods for this pathogen in endemic areas. Antifungal prophylaxis against Histoplasma should be encouraged in the severely immunocompromised HIV patients in these areas. In conclusion, substantial mortality is associated with disseminated histoplasmosis among HIV-positive patients in the Brazilian Amazon.
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Affiliation(s)
- Natalia Rakislova
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Department of Pathology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Juan Carlos Hurtado
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | | | - Luiz Ferreira
- Fundação de Medicina Tropical Doutor Heitor Viera Dourado, Manaus, Brazil
| | - Monique Freire
- Universidade do Estado do Amazonas, Manaus, Brazil
- Fundação de Medicina Tropical Doutor Heitor Viera Dourado, Manaus, Brazil
- Fundação Centro de Controle de Oncologia do Amazonas, Manaus, Brazil
| | - Marcus Lacerda
- Fundação de Medicina Tropical Doutor Heitor Viera Dourado, Manaus, Brazil
- Instituto de Pesquisas Leônidas & Maria Deane, Fiocruz, Manaus, Brazil
| | - Wuelton Monteiro
- Universidade do Estado do Amazonas, Manaus, Brazil
- Fundação de Medicina Tropical Doutor Heitor Viera Dourado, Manaus, Brazil
| | - Mireia Navarro
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Isaac Casas
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Marcus de Melo Teixeira
- The Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
- Núcleo de Medicina Tropical, Faculdade de Medicina, Universidade de Brasília, Brasilia, Brazil
| | - Paola Castillo
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Department of Pathology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | | | - Lorena Marimon
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Department of Pathology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - José Guerrero
- Department of Pathology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Rosauro Varo
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Vima Delgado
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Llorenç Quintó
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Francesc Marco
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Emilio Letang
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Jordi Vila
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Quique Bassat
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- ICREA, Catalan Institution for Research and Advanced Studies, Barcelona, Spain
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Clara Menéndez
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Jaume Ordi
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Department of Pathology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Miguel J. Martínez
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
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Toscanini MA, Nusblat AD, Cuestas ML. Diagnosis of histoplasmosis: current status and perspectives. Appl Microbiol Biotechnol 2021; 105:1837-1859. [PMID: 33587157 DOI: 10.1007/s00253-021-11170-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/29/2021] [Accepted: 02/03/2021] [Indexed: 11/29/2022]
Abstract
Histoplasmosis is a worldwide-distributed systemic mycosis caused by the dimorphic fungus Histoplasma capsulatum. Its clinical manifestations range from subclinical or mild respiratory illness to progressive disseminated histoplasmosis (PDH), a life-threatening disease, whose accurate diagnosis is still challenging and limited in many countries, where this disease is highly endemic. In this regard, Histoplasma antigen testing is now included in the WHO Essential Diagnostics List. The final diagnosis of histoplasmosis is established by culture and/or visualization of the yeast cells by cytology or histopathology using specific stains. However, both procedures have limited sensitivity to detect the disease and cultures are time-consuming. Antibody detection assays are effective for the subacute and chronic clinical forms of histoplasmosis. However, their sensitivity is low in the immunocompromised host. Several molecular "in-house" tests were also developed and showed promising results, but none of these tests are commercially available and their standardization and validation are still pending. Antigen detection assays have high sensitivity in PDH cases and are of great value for the follow-up of patients with histoplasmosis; however, cross-reactivity with other related fungi are common. In addition, this assay is expensive and only performed in few laboratories. Novel protein antigen candidates have been recently identified and produced by DNA-recombinant techniques in order to obtain standardized and specific reagents for the diagnosis of histoplasmosis, as opposed to the unspecific antigens or crude extracts currently used. This review describes the currently available assays, highlighting their strengths and limitations and reports the latest approaches to achieve reliable and rapid diagnostic tests for histoplasmosis. KEY POINTS: • PDH causes thousands of deaths per year globally. • Rapid accurate diagnosis of PDH is unfeasible in many regions. • Fast, accurate, and low-cost diagnostic alternatives are currently under development.
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Affiliation(s)
- María Agustina Toscanini
- Facultad de Farmacia y Bioquímica, CONICET, Instituto de Nanobiotecnología (NANOBIOTEC), Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Alejandro David Nusblat
- Facultad de Farmacia y Bioquímica, CONICET, Instituto de Nanobiotecnología (NANOBIOTEC), Universidad de Buenos Aires, Buenos Aires, Argentina
| | - María Luján Cuestas
- CONICET, Instituto de Investigaciones en Microbiología y Parasitología Médica (IMPaM), Universidad de Buenos Aires, Buenos Aires, Argentina.
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Caceres DH, Fernandez NB, Lockhart SR. Innovative Approaches for Histoplasma Detection. Curr Fungal Infect Rep 2020; 14:310-6. [DOI: 10.1007/s12281-020-00393-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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8
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Melo ASDA, Santos DWDCL, Lima SL, Rodrigues AM, Camargo ZP, Finkelman M, Colombo AL. Evaluation of (1 → 3)‐β‐D‐glucan assay for diagnosing paracoccidioidomycosis. Mycoses 2019; 63:38-42. [DOI: 10.1111/myc.13007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 02/01/2023]
Affiliation(s)
- Analy Salles de Azevedo Melo
- Laboratório Especial de Micologia Departamento de Medicina Universidade Federal de São Paulo (UNIFESP) São Paulo Brasil
| | | | - Soraia Lopes Lima
- Laboratório Especial de Micologia Departamento de Medicina Universidade Federal de São Paulo (UNIFESP) São Paulo Brasil
| | - Anderson Messias Rodrigues
- Laboratório de Patógenos Fúngicos Emergentes Departamento de Microbiologia, Imunologia e Parasitologia Universidade Federal de São Paulo (UNIFESP) São Paulo Brazil
| | - Zoilo Pires Camargo
- Laboratório de Micologia Médica Departamento de Microbiologia, Imunologia e Parasitologia Universidade Federal de São Paulo (UNIFESP) São Paulo Brazil
| | - Malcolm Finkelman
- Associates of Cape Cod Clinical Development Department Research Laboratory Falmouth MA USA
| | - Arnaldo Lopes Colombo
- Laboratório Especial de Micologia Departamento de Medicina Universidade Federal de São Paulo (UNIFESP) São Paulo Brasil
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Caceres DH, Knuth M, Derado G, Lindsley MD. Diagnosis of Progressive Disseminated Histoplasmosis in Advanced HIV: A Meta-Analysis of Assay Analytical Performance. J Fungi (Basel) 2019; 5:E76. [PMID: 31426618 DOI: 10.3390/jof5030076] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 12/30/2022] Open
Abstract
Histoplasmosis is an important cause of mortality in people with advanced HIV, especially in countries with limited access to diagnostic assays. Histoplasmosis can be diagnosed using culture, histopathology, and antibody, antigen, and molecular assays. Several factors may affect the analytical performance of these laboratory assays, including sample type, clinical stage of the disease, and previous use of antifungal treatment, among others. Here we describe the results of a systematic literature review, followed by a meta-analysis of the analytical performances of the diagnostic laboratory assays employed. Our initial search identified 1631 references, of which 1559 references were excluded after title and abstract screening, leaving 72 references identified as studies relevant to the validation of histoplasmosis diagnostic assays. After evaluating the full text, 30 studies were selected for final review, including one paper not identified in the initial search. The meta-analysis for assay analytical performance shows the following results for the overall sensitivity (Sen) and specificity (Spe) of the various methods evaluated: Culture, Sen 77% (no data for specificity calculation); antibody detection assays, Sen 58%/Spe 100%; antigen detection assays, Sen 95%/Spe 97%; and DNA detection assays (molecular), Sen 95%/Spe 99%. Of the 30 studies reviewed, nearly half (n = 13) evaluated Histoplasma antigen assays, which were determined to be the most accurate methodology for diagnosis of progressive disseminated histoplasmosis in advanced HIV (inverse of the negative likelihood ratio was 13.2). Molecular assays appear promising for accurate diagnosis of histoplasmosis, but consensus on exact techniques is needed. Cultures showed variable sensitivity related to sample type and laboratory handling. Finally, antibody assays presented high specificity but low sensitivity. This poor sensitivity is most likely due the highly immunosuppressed state of this patient population. Diagnostic assays are crucial for accurate diagnosis of progressive disseminated histoplasmosis (PDH) with advanced HIV disease.
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Torres-González P, Niembro-Ortega MD, Martínez-Gamboa A, Ahumada-Topete VH, Andrade-Villanueva J, Araujo-Meléndez J, Chaparro-Sánchez A, Crabtree-Ramírez B, Cruz-Martínez S, Gamboa-Domínguez A, Flores-Barrientos OI, Gaytán-Martínez JE, González-Hernández LA, Hernández-León C, Lozano-Fernandez VH, Manríquez-Reyes M, Magaña-Aquino M, Martínez-Ayala P, Ramírez-Hinojosa JP, Rangel-Cordero A, Rivera-Martínez NE, Reyes-Gutiérrez E, Reyes-Terán G, Rodríguez-Zulueta P, Ruíz-Quiñones J, Santiago-Cruz J, Velázquez-Zavala NG, Sifuentes-Osornio J, Ponce de León A. Diagnostic accuracy cohort study and clinical value of the Histoplasma urine antigen (ALPHA Histoplasma EIA) for disseminated histoplasmosis among HIV infected patients: A multicenter study. PLoS Negl Trop Dis 2018; 12:e0006872. [PMID: 30395572 PMCID: PMC6237426 DOI: 10.1371/journal.pntd.0006872] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 11/15/2018] [Accepted: 09/25/2018] [Indexed: 11/23/2022] Open
Abstract
Background The Histoplasma urine antigen (HUAg) is the preferred method to diagnose progressive disseminated histoplasmosis (PDH) in HIV patients. In 2007, IMMY ALPHA Histoplasma EIA was approved for clinical for on-site use, and therefore useful for regions outside the United States. However, ALPHA-HUAg is considered inferior to the MVista-HUAg which is only available on referral. We aim to evaluate the diagnostic accuracy of ALPHA-HUAg. Methodology/Principal findings We conducted a multicenter, prospective, diagnostic test study in two secondary and eight tertiary-care facilities in Mexico. We included HIV patient with PDH suspicion and evaluated ALPHA-HUAg diagnostic accuracy using as reference standard the Histoplasma capsulatum growth on blood, bone marrow, and tissue cultures or compatible histopathologic exam (PDH–proven). We evaluated the results of 288 patients, 29.5% (85/288; 95% confidence interval [CI], 24.3–35.1) had PDH. The sensitivity of ALPHA-HUAg was 67.1% (95% CI, 56–76.8%) and the specificity was 97.5% (95% CI, 94.3%-99.1%). The positive likelihood ratio was 27.2 (95% CI; 11.6–74.4). In 10.5% of the PDH–proven patients, a co-existing opportunistic infection was diagnosed, mostly disseminated Mycobacterium avium complex infection. Conclusions/Significance We observed a high specificity but low sensitivity of IMMY-HUAg. The test may be useful to start early antifungals, but a culture-based approach is necessary since co-infections are frequent and a negative IMMY-HUAg result does not rule out PDH. Histoplasmosis is an endemic mycosis in many regions of Latin America. In the HIV population it manifests as progressive disseminated histoplasmosis (PDH), an entity hard to diagnose since the causative fungi—Histoplasma capsulatum—is slow growing and requires advance biosafety for its handling. As an alternative, the diagnosis can be made by detecting the histoplasma urinary antigen, but only one kit is commercially available outside the US. We evaluated this kit (IMMY ALPHA Histoplasma EIA) among HIV patients with suspected and found a high specificity but low sensitivity (i.e., a positive histoplasma urine antigen is almost unequivocal, but a negative result does not rule out the PDH). However, we believe the test is useful since the positive likelihood rates show that a patient with PDH is 27 times more likely to have an IMMY-HUAg positive result; this may allow early targeted treatment.
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Affiliation(s)
- Pedro Torres-González
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - María Dolores Niembro-Ortega
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Areli Martínez-Gamboa
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Víctor Hugo Ahumada-Topete
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan, Mexico City, Mexico
| | | | - Javier Araujo-Meléndez
- Department of Internal Medicine, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, San Luis Potosí, Mexico
| | - Alberto Chaparro-Sánchez
- Adult Infectious Diseases Department, Hospital de Infectología del Centro Médico Nacional “La Raza”, Instituto Mexicano del Seguro Social, Atzcapotzalco, Mexico City, Mexico
| | - Brenda Crabtree-Ramírez
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Sofia Cruz-Martínez
- Department of Infectious Diseases, Hospital Regional de Alta Especialidad de Oaxaca, HRAEO, San Bartolo Coyotepec, Oaxaca, Mexico
| | - Armando Gamboa-Domínguez
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Tlalpan, Mexico City, Mexico
| | - Oscar I. Flores-Barrientos
- Intensive Care Unit, Department of Internal Medicine, Hospital “Dr. Juan Graham Casasus”, Villahermosa, Tabasco, Mexico
| | - Jesús Enrique Gaytán-Martínez
- Adult Infectious Diseases Department, Hospital de Infectología del Centro Médico Nacional “La Raza”, Instituto Mexicano del Seguro Social, Atzcapotzalco, Mexico City, Mexico
| | | | - Christian Hernández-León
- Area of Infectious Diseases, Department of Internal Medicine, Hospital General de Puebla “Dr. Eduardo Vazquez Navarro”, Puebla, Puebla, Mexico
| | - Víctor Hugo Lozano-Fernandez
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan, Mexico City, Mexico
| | - Marisol Manríquez-Reyes
- Department of Internal Medicine, Hospital de Alta Especialidad de Veracruz, Veracruz, Veracruz, Mexico
| | - Martin Magaña-Aquino
- Department of Internal Medicine, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, San Luis Potosí, Mexico
| | - Pedro Martínez-Ayala
- HIV Unit, Hospital Civil de Guadalajara “Fray Antonio Alcalde”, Guadalajara, Jalisco, Mexico
| | | | - Andrea Rangel-Cordero
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Norma Erendira Rivera-Martínez
- Department of Infectious Diseases, Hospital Regional de Alta Especialidad de Oaxaca, HRAEO, San Bartolo Coyotepec, Oaxaca, Mexico
| | - Edgardo Reyes-Gutiérrez
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Tlalpan, Mexico City, Mexico
| | - Gustavo Reyes-Terán
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan, Mexico City, Mexico
| | | | - Jesús Ruíz-Quiñones
- Intensive Care Unit, Department of Internal Medicine, Hospital “Dr. Juan Graham Casasus”, Villahermosa, Tabasco, Mexico
| | - Janeth Santiago-Cruz
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Nancy Guadalupe Velázquez-Zavala
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - José Sifuentes-Osornio
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Alfredo Ponce de León
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
- * E-mail:
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11
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Ramos IC, Soares YC, Damasceno LS, Libório MP, Farias LABG, Heukelbach J, Alencar CHMD, Leitão TDMJS. Predictive factors for disseminated histoplasmosis in AIDS patients with fever admitted to a reference hospital in Brazil. Rev Soc Bras Med Trop 2018; 51:479-484. [PMID: 30133631 DOI: 10.1590/0037-8682-0425-2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 07/03/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION In many settings, the lack of sensitive biomarkers of disseminated histoplasmosis (DH) leads to a clinical reliance on older diagnostic methods and delayed treatment initiation. The early recognition of DH is critical for survival, especially in patients with human immunodeficiency virus (HIV). This study aimed to identify clinical and laboratory findings associated with the definitive diagnosis of DH in low-income HIV patients in endemic areas. METHODS Febrile AIDS patients with suspected DH who were admitted to a reference hospital in northeastern Brazil from January 2006 to January 2007 were evaluated for clinical and laboratory findings associated with DH diagnosis. RESULTS One hundred seventeen patients with fever were included, and 48 (41%) cases of DH were determined by Histoplasma capsulatum identification. A higher fever (≥38.5ºC), maculopapular/papular rash, splenomegaly, hepatomegaly, wheezing, hemoglobin ≤9.5g/dL, platelets ≤80,000/µL, CD4 count ≤75/µL, aspartate aminotransferase (AST) level ≥2.5 times the upper limit of normal (ULN), lactate dehydrogenase (LDH) ≥5times the ULN; and international normalized ratio (INR) >2 times the ULN were significantly associated with DH. A multivariable analysis identified hepatomegaly [adjusted (a) prevalence ratio (PR)= 1.96; 95% confidence interval (CI): 1.21-3.16), CD4 count ≤75/µL (aPR = 2.02; 95% CI: 1.06-3.83), LDH ≥5 times the ULN (aPR = 2.23; 95% CI: 1.44-3.48), and maculopapular/papular rash (aPR = 1.70; 95% CI: 1.02-2.83) were independent risk factors for DH. CONCLUSIONS These easily assessed parameters can facilitate clinical decision-making for febrile AIDS patients with suspected DH in low socioeconomic and Histoplasma-endemic regions.
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Affiliation(s)
- Isadora Cavalcanti Ramos
- Departamento de Saúde Comunitária, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - Yuri Coelho Soares
- Departamento de Saúde Comunitária, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | | | - Mariana Pitombeira Libório
- Hospital São José de Doenças Infecciosas, Fortaleza, CE, Brasil.,Departamento de Saúde Comunitária, Universidade de Fortaleza, Fortaleza, CE, Brasil
| | | | - Jorg Heukelbach
- Departamento de Saúde Comunitária, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | | | - Terezinha do Menino Jesus Silva Leitão
- Departamento de Saúde Comunitária, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil.,Hospital São José de Doenças Infecciosas, Fortaleza, CE, Brasil
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