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Mercier T, Castagnola E, Marr KA, Wheat LJ, Verweij PE, Maertens JA. Defining Galactomannan Positivity in the Updated EORTC/MSGERC Consensus Definitions of Invasive Fungal Diseases. Clin Infect Dis 2021; 72:S89-S94. [PMID: 33709125 DOI: 10.1093/cid/ciaa1786] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The consensus definitions of invasive fungal diseases from the EORTC/MSGERC were recently revised and updated. They now include consensus cutoff values for the galactomannan test that support the diagnosis of probable invasive aspergillosis. In this supplement article, we provide a rationale for these proposed thresholds based on the test's characteristics and performance in different patient populations and in different specimen types.
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Affiliation(s)
- Toine Mercier
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Elio Castagnola
- Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Kieren A Marr
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johan A Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Hematology, University Hospitals Leuven, Leuven, Belgium
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Ma Q, Huang H, Sun L, Zhou T, Zhu J, Cheng X, Duan L, Li Z, Cui L, Ba Y. Gene-environment interaction: Does fluoride influence the reproductive hormones in male farmers modified by ERα gene polymorphisms? Chemosphere 2017; 188:525-531. [PMID: 28910727 DOI: 10.1016/j.chemosphere.2017.08.166] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/25/2017] [Accepted: 08/30/2017] [Indexed: 06/07/2023]
Abstract
The occurrence of endemic fluorosis is derived from high fluoride levels in drinking water and industrial fumes or dust. Reproductive disruption is also a major harm caused by fluoride exposure besides dental and skeletal lesions. However, few studies focus on the mechanism of fluoride exposure on male reproductive function, especially the possible interaction of fluoride exposure and gene polymorphism on male reproductive hormones. Therefore, we conducted a cross-sectional study in rural areas of Henan province in China to explore the interaction between the estrogen receptor alpha (ERα) gene and fluoride exposure on reproductive hormone levels in male farmers living in the endemic fluorosis villages. The results showed that fluoride exposure significantly increased the serum level of estradiol in the hypothalamic-pituitary-testicular (HPT) axis in male farmers. Moreover, the observations indicated that fluoride exposure and genetic markers had an interaction on serum concentration of follicle-stimulating hormone and estradiol, and the interaction among different loci of the ERα gene could impact the serum testosterone level. Findings in the present work suggest that chronic fluoride exposure in drinking water could modulate the levels of reproductive hormones in males living in endemic fluorosis areas, and the interaction between fluoride exposure and ERα polymorphisms might affect the serum levels of hormones in the HPT axis in male farmers.
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Affiliation(s)
- Qiang Ma
- Department of Environmental Health, Zhengzhou University, Zhengzhou, Henan, 450001, China
| | - Hui Huang
- Department of Environmental Health, Zhengzhou University, Zhengzhou, Henan, 450001, China
| | - Long Sun
- Kaifeng Disease Control and Prevention Center, Kaifeng, Henan, 475004, China
| | - Tong Zhou
- Shandong Disease Control and Prevention Center, Jinan, Shandong, 250014, China
| | - Jingyuan Zhu
- Department of Environmental Health, Zhengzhou University, Zhengzhou, Henan, 450001, China
| | - Xuemin Cheng
- Department of Environmental Health, Zhengzhou University, Zhengzhou, Henan, 450001, China
| | - Lijv Duan
- Department of Environmental Health, Zhengzhou University, Zhengzhou, Henan, 450001, China
| | - Zhiyuan Li
- Department of Environmental Health, Zhengzhou University, Zhengzhou, Henan, 450001, China
| | - Liuxin Cui
- Department of Environmental Health, Zhengzhou University, Zhengzhou, Henan, 450001, China
| | - Yue Ba
- Department of Environmental Health, Zhengzhou University, Zhengzhou, Henan, 450001, China.
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White PL, Wingard JR, Bretagne S, Löffler J, Patterson TF, Slavin MA, Barnes RA, Pappas PG, Donnelly JP. Aspergillus Polymerase Chain Reaction: Systematic Review of Evidence for Clinical Use in Comparison With Antigen Testing. Clin Infect Dis 2015; 61:1293-303. [PMID: 26113653 PMCID: PMC4583581 DOI: 10.1093/cid/civ507] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/13/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Aspergillus polymerase chain reaction (PCR) was excluded from the European Organisation for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) definitions of invasive fungal disease because of limited standardization and validation. The definitions are being revised. METHODS A systematic literature review was performed to identify analytical and clinical information available on inclusion of galactomannan enzyme immunoassay (GM-EIA) (2002) and β-d-glucan (2008), providing a minimal threshold when considering PCR. Categorical parameters and statistical performance were compared. RESULTS When incorporated, GM-EIA and β-d-glucan sensitivities and specificities for diagnosing invasive aspergillosis were 81.6% and 91.6%, and 76.9% and 89.4%, respectively. Aspergillus PCR has similar sensitivity and specificity (76.8%-88.0% and 75.0%-94.5%, respectively) and comparable utility. Methodological recommendations and commercial PCR assays assist standardization. Although all tests have limitations, currently, PCR is the only test with independent quality control. CONCLUSIONS We propose that there is sufficient evidence that is at least equivalent to that used to include GM-EIA and β-d-glucan testing, and that PCR is now mature enough for inclusion in the EORTC/MSG definitions.
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Affiliation(s)
- P Lewis White
- Public Health Wales, Microbiology Cardiff, United Kingdom
| | | | | | | | - Thomas F Patterson
- University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio
| | - Monica A Slavin
- Peter MacCallum Cancer Centre, University of Melbourne, Australia
| | - Rosemary A Barnes
- Infection, Immunity and Biochemistry, Cardiff University, United Kingdom
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Kimpton G, Lewis White P, Barnes RA. The effect of sample storage on the performance and reproducibility of the galactomannan EIA test. Med Mycol 2014; 52:618-26. [DOI: 10.1093/mmy/myu014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Whilst diseases such as diabetes and cardiovascular disorders are increasing in the developed world, the main threat to global health remains viral-based infectious disease. Such diseases are notably prevalent in developing countries, where they represent a major cause of mortality; however, their detection and prevention is typically hampered by poor infrastructure and a lack of resources to support the sophisticated diagnostic tools commonly found in modern laboratories. Microfluidic-based diagnostics has the potential to close the gap between developed and developing world medical needs due to the robustness and reduced operating costs such technology offers. The most recent developments in microfluidic diagnostics for viral infections have explored the separation and enumeration of immune cells, the capture and identification of viral particles, and antiviral drug evaluation within microchannels and chambers. Advances in solid-phase separation, isothermal amplification, real-time detection of nucleotide products, and improved efficiency of detection systems in microfluidic platforms have also opened up opportunities for diagnostic innovation. This chapter reviews the potential capability microfluidic technology can offer in addressing the practical challenges of providing diagnostic technology for developing countries, illustrated by research on key viral diseases.
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Tanriover MD, Ascioglu S, Altun B, Uzun O. Galactomannan on the stage: prospective evaluation of the applicability in routine practice and surveillance. Mycoses 2010; 53:16-25. [PMID: 20091935 DOI: 10.1111/j.1439-0507.2008.01652.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Invasive aspergillosis (IA) presents a diagnostic and therapeutic dilemma for the physicians who take care of the patients with severe underlying diseases and immunosuppression. This study aimed to evaluate the usefulness of serum galactomannan (GM) measurements in the routine practice and surveillance of IA along with possible caveats in diagnosis and treatment. Adult patients with high-risk haematological malignancies admitted to the Internal Medicine wards during the 2-year study period were followed up by daily visits for vital signs, existing or newly developing signs and symptoms, clinical and laboratory findings. Blood samples were analysed for GM levels by the ELISA method at the end of the study period. Data of 58 hospitalisation episodes in 45 patients were analysed. Proven IA was diagnosed in one patient, probable IA was diagnosed in four patients. The sensitivity was 60% and the specificity was 21% when the index cut-off for positivity was accepted as 0.5. The yield of GM testing may be influenced by many variables and each centre should evaluate the usefulness of this test in its own conditions.
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Affiliation(s)
- Mine Durusu Tanriover
- Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
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Lau A, Chen S, Sleiman S, Sorrell T. Current status and future perspectives on molecular and serological methods in diagnostic mycology. Future Microbiol 2009; 4:1185-222. [DOI: 10.2217/fmb.09.70] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Invasive fungal infections are an important cause of infectious morbidity. Nonculture-based methods are increasingly used for rapid, accurate diagnosis to improve patient outcomes. New and existing DNA amplification platforms have high sensitivity and specificity for direct detection and identification of fungi in clinical specimens. Since laboratories are increasingly reliant on DNA sequencing for fungal identification, measures to improve sequence interpretation should support validation of reference isolates and quality control in public gene repositories. Novel technologies (e.g., isothermal and PNA FISH methods), platforms enabling high-throughput analyses (e.g., DNA microarrays and Luminex® xMAP™) and/or commercial PCR assays warrant further evaluation for routine diagnostic use. Notwithstanding the advantages of molecular tests, serological assays remain clinically useful for patient management. The serum Aspergillus galactomannan test has been incorporated into diagnostic algorithms of invasive aspergillosis. Both the galactomannan and the serum β-D-glucan test have value for diagnosing infection and monitoring therapeutic response.
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Affiliation(s)
- Anna Lau
- Centre for Infectious Diseases & Microbiology, University of Sydney, Sydney, Australia
| | - Sharon Chen
- Centre for Infectious Diseases & Microbiology, University of Sydney, Sydney, Australia and Centre for Infectious Diseases & Microbiology Laboratory Services, Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Sue Sleiman
- Centre for Infectious Diseases & Microbiology Laboratory Services, Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Tania Sorrell
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Darcy and Hawkesbury Roads, Westmead, NSW 2145, Australia
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9
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Walsh TJ, Anaissie EJ, Denning DW, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Segal BH, Steinbach WJ, Stevens DA, van Burik JA, Wingard JR, Patterson TF. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis 2008; 46:327-60. [PMID: 18177225 DOI: 10.1086/525258] [Citation(s) in RCA: 1832] [Impact Index Per Article: 114.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Thomas J Walsh
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, Maryland, USA
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Walsh T, Anaissie E, Denning D, Herbrecht R, Kontoyiannis D, Marr K, Morrison V, Segal B, Steinbach W, Stevens D, van Burik J, Wingard J, Patterson Y. Tratamiento de la Aspergilosis: Guías para la práctica clínica de la Sociedad de Enfermedades Infecciosas de los Estados Unidos de América (IDSA). Clin Infect Dis 2008. [DOI: 10.1086/590225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Kedzierska A, Kochan P, Pietrzyk A, Kedzierska J. Current status of fungal cell wall components in the immunodiagnostics of invasive fungal infections in humans: galactomannan, mannan and (1-->3)-beta-D-glucan antigens. Eur J Clin Microbiol Infect Dis 2007; 26:755-66. [PMID: 17671803 DOI: 10.1007/s10096-007-0373-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Early diagnosis of fungal infections and the implementation of appropriate treatment represent major issues for clinicians, nowadays. Histopathological demonstration of microorganisms in tissue specimens or growth of fungal agents in culture media is still considered the "gold standard", but obtaining such specimens may be difficult. Several groups have investigated serological assays for cell wall elements unique to fungal organisms in serum or other body fluids to improve diagnostics in patients with haematological malignancies or undergoing haematopoietic stem-cell transplantation. In this review we have concentrated on the currently available assays allowing for detection of highly immunogenic components of fungal cell wall: galactomannan, mannan, and also (1-->3)-beta-D-glucan. Rapid serological tests appear to be useful for screening high-risk haematological patients, since they allow for the early diagnosis of invasive fungal infections, including infections with the most common pathogens such as Aspergillus and Candida. Based on current literature, factors increasing the probability of obtaining false-positive or false-negative results detected by each test were also analysed and tabulated.
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Affiliation(s)
- A Kedzierska
- Department of Clinical Microbiology, Chair of Clinical Immunology and Transplantology, Polish-American Institute of Paediatrics, Jagiellonian University Medical College, 265 Wielicka Street, 30-663, Cracow, Poland
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WINN RICHARDM, WARRIS ADILIA, GAUSTAD PETER, ABRAHAMSEN TOREG. The effect of antifungal agents and human monocytes onin vitrogalactomannan release byAspergillusspp. in liquid culture medium. APMIS 2007; 115:1364-9. [DOI: 10.1111/j.1600-0463.2007.00719.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Maertens J, Theunissen K, Lodewyck T, Lagrou K, Van Eldere J. Advances in the serological diagnosis of invasive Aspergillus infections in patients with haematological disorders. Mycoses 2007; 50 Suppl 1:2-17. [PMID: 17394605 DOI: 10.1111/j.1439-0507.2007.01375.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A reliable diagnosis of invasive aspergillosis in patients with haematological malignancies is seldom achieved antemortem. Conventional laboratory diagnostic methods are insensitive and time-consuming, resulting in late diagnosis and treatment and contributing to unacceptably high mortality. As a result, routine antifungal prophylaxis and early empirical treatment have been recommended. However, overtreatment associated with these strategies results in increased toxicity and cost. The use of sensitive and rapid non-culture-based diagnostic assays, such as detection of Aspergillus antigens (galactomannan, beta-D-glucan) or detection of genomic DNA sequences may allow a shift in emphasis from empirical to pre-emptive therapy, especially when substantiated by suggestive radiological findings. These new tools may be used to confirm a presumed diagnosis of invasive aspergillosis, or, when used to screen high-risk patients, may identify an infection at the early stage of disease. The excellent negative predictive value of these assays should convince clinicians to withhold antifungal therapy in persistently febrile neutropenic patients with no other signs of fungal infection. On the other hand, consecutive positive results in a high-risk population should at least trigger a complete diagnostic work-up. This review will focus on the diagnostic utility as well as on the pitfalls of serial screening for the presence of circulating fungal antigens in haematology patients.
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Affiliation(s)
- Johan Maertens
- Department of Haematology, Universitaire Ziekenhuizen Leuven, Catholic University, Leuven, Belgium.
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Maertens JA, Klont R, Masson C, Theunissen K, Meersseman W, Lagrou K, Heinen C, Crépin B, Van Eldere J, Tabouret M, Donnelly JP, Verweij PE. Optimization of the cutoff value for the Aspergillus double-sandwich enzyme immunoassay. Clin Infect Dis 2007; 44:1329-36. [PMID: 17443470 DOI: 10.1086/514349] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Accepted: 02/01/2007] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Many health care centers worldwide use the Platelia Aspergillus enzyme immunoassay (PA-EIA; Bio-Rad Laboratories) for diagnosis of invasive aspergillosis (IA). A cutoff optical density (OD) index of 1.5 was originally recommended by the manufacturer, but in practice, most institutions use lower cutoff values. Moreover, a cutoff OD index of 0.5 was recently approved in the United States. In the present study, we set out to optimize the cutoff level by performing a retrospective analysis of PA-EIA values for samples that had been obtained prospectively from adult patients at risk for IA at 2 European health care centers. METHODS In total, 239 treatment episodes were included of which there were 19 episodes of proven IA and 19 episodes of probable IA. Per-episode and per-test analyses and receiver operating characteristic curves were used to determine the optimal cutoff value. RESULTS In the per-episode analysis, lowering the cutoff OD index for positivity from 1.5 to 0.5 increased the overall sensitivity by 21% (from 76.3% to 97.4%) but decreased the overall specificity by 7% (from 97.5% to 90.5%). Requiring 2 consecutive samples with an OD index > or = 0.5 resulted in the highest test accuracy, with an improved positive predictive value. At a cutoff OD index of 0.5, the antigen test result was positive during the week before conventional diagnosis in 65% of cases and during the week of diagnosis in 79.5% of cases. CONCLUSIONS A cutoff OD index of 0.5--identical to the approved cutoff in the United States--improves the overall performance of the PA-EIA for adult hematology patients.
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Affiliation(s)
- Johan A Maertens
- Department of Hematology, Universitaire Ziekenhuizen, Catholic University Leuven, Leuven, Belgium.
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Maertens J, Theunissen K, Deeren D, Meersseman W, Van Eldere J. Defining a case of invasive aspergillosis by serum galactomannan. Med Mycol 2006; 44:S173-S178. [DOI: 10.1080/13693780600835732] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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16
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Bart-Delabesse E, Basile M, Al Jijakli A, Souville D, Gay F, Philippe B, Bossi P, Danis M, Vernant JP, Datry A. Detection of Aspergillus galactomannan antigenemia to determine biological and clinical implications of beta-lactam treatments. J Clin Microbiol 2005; 43:5214-20. [PMID: 16207986 PMCID: PMC1248458 DOI: 10.1128/jcm.43.10.5214-5220.2005] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Detection of Aspergillus galactomannan (GM) in serum with the Platelia Aspergillus enzyme immunoassay (EIA) is useful for diagnosing invasive aspergillosis. From May 2003 to November 2004, 65 patients who did not develop aspergillosis had at least two positive sera while receiving a beta-lactam treatment (GM index [GMI], >or=0.5). Of the 69 treatment episodes scored, 41 consisted of a beta-lactam other than piperacillin-tazobactam (n=29), namely, amoxicillin-clavulanate (n=25), amoxicillin (n=10), ampicillin (n=3), or phenoxymethylpenicillin (n=2). In all cases, antigenemia became negative 24 h to 120 h upon stopping the antibiotic. Monitoring of 35 patients, including 26 with hematological malignancies, revealed three antigenemia kinetic patterns: each was observed with any drug regimen and consisted of a persistent GMI of >2.0 (65.7%), >0.5, and <or=1.5 (25.7%) or a variable GMI (14.3%) from the onset of antibiotic therapy. All available drug batches given to 26 patients cross-reacted with the EIA. Galactomannan titration in batches failed to predict the GM titers in the five patients studied at cumulative doses of ampicillin or amoxicillin-clavulanate, regardless of the time lapse between serum sampling and infusion period. Our results show that beta-lactams other than piperacillin-tazobactam may lead to false presumption of aspergillosis. The resulting kinetic patterns of GM antigenemia are variable, and sampling serum prior to the next beta-lactam dose may not decrease GMI below the threshold. Consequently, testing of suspected antibiotic batches remains the only indicator of possible false EIA positivity.
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Affiliation(s)
- Emmanuelle Bart-Delabesse
- Laboratoire de Parasitologie et Mycologie, Groupe Hospitalo-Universitaire Pitié-Salpêtrière, Paris, France.
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Upton A, Gugel A, Leisenring W, Limaye A, Alexander B, Hayden R, Marr KA. Reproducibility of low galactomannan enzyme immunoassay index values tested in multiple laboratories. J Clin Microbiol 2005; 43:4796-800. [PMID: 16145143 PMCID: PMC1234072 DOI: 10.1128/jcm.43.9.4796-4800.2005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Platelia galactomannan enzyme immunoassay is a commercially available nonculture method for diagnosing invasive aspergillosis. Recently, steps have been taken to improve sensitivity; specifically, a low (0.5 to 0.7) galactomannan index (GMI) value to determine positivity has been validated by multiple groups. We evaluated the intra-assay and interassay reproducibility at low index levels using three different kit lots on three different days in three different microbiology laboratories. Clinical and spiked sera were blinded and sent with galactomannan enzyme immunoassay (EIA) kits to the participating laboratories. We also prospectively collected data on all galactomannan EIAs performed between 1 September 2003 and 21 July 2004 at the University of Washington Medical Center microbiology laboratory to assess reproducibility of clinical samples analyzed in "real time." From the multilaboratory study, a total of 836 results were available for evaluation. Reproducibility was excellent between laboratories and on different days. Significant variability was seen between runs/lots, which may in part be associated with different threshold control values in different kits. Among the 1,410 clinical samples that were prospectively analyzed, 168 (90%) were confirmed to be positive on repeat testing (GMI, > or =0.5). Among the 19 (10.2%) initially positive samples not confirmed on repeat testing, the majority had a GMI at the threshold of the assay (between 0.5 and 0.7). Our findings suggest that the Platelia galactomannan immunoassay has good reproducibility. However, changes in GMI levels when different kit lots are used, and single samples with low-positive (GMI of 0.5 to 0.7) indices, should be interpreted with caution.
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Affiliation(s)
- Arlo Upton
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
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Pereira CN, Del Nero G, Lacaz CS, Machado CM. The contribution of galactomannan detection in the diagnosis of invasive aspergillosis in bone marrow transplant recipients. Mycopathologia 2005; 159:487-93. [PMID: 15983733 DOI: 10.1007/s11046-005-4996-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2004] [Accepted: 04/01/2005] [Indexed: 11/24/2022]
Abstract
Until recently, accurate microbiological diagnosis of invasive aspergillosis (IA) was seldom established in HSCT recipients. Blood samples are rarely positive for Aspergillus species, the reliability of the cultures depends of the specimen (if taken from a normally sterile site or not) and biopsy samples require invasive procedures, rarely recommended in patients with severe thrombocytopenia. Implementing the international consensus defining the microbiological criteria for the diagnosis of Aspergillus infection, we retrospectively evaluated the role of serum galactomannan (GM) detection by EIA to diagnose IA among HSCT patients with proven invasive fungal infection (IFI) and the impact of serum storage in GM concentrations. The EIA assay allowed categorizing as "probable" 5 of the 10 cases of "possible" aspergillosis (50%). Considering a lower cut-off level for the reaction (1.0), 80% of the cases could be categorized as "probable" aspergillosis. Positive or undetermined results were detected one to 4 months before the diagnosis of IA in eight of the 11 patients (72.7%) with proven IFI. Retesting the stored samples after a second storage for four years, we could observe lower reactivity in 20% of the samples. The detection of galactomannan by the EIA test represents a major advance in the diagnosis of IA in HSCT recipients at high risk of IA. A better understanding of the kinetics of the GM in different clinical situations is necessary to maximize the benefit of the test in Aspergillus surveillance.
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Affiliation(s)
- C N Pereira
- Mycology Laboratory, University of São Paulo Institute of Tropical Medicine, São Paulo, Brazil
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Walsh TJ, Shoham S, Petraitiene R, Sein T, Schaufele R, Kelaher A, Murray H, Mya-San C, Bacher J, Petraitis V. Detection of galactomannan antigenemia in patients receiving piperacillin-tazobactam and correlations between in vitro, in vivo, and clinical properties of the drug-antigen interaction. J Clin Microbiol 2004; 42:4744-8. [PMID: 15472335 PMCID: PMC522332 DOI: 10.1128/jcm.42.10.4744-4748.2004] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Recent case reports describe patients receiving piperacillin-tazobactam who were found to have circulating galactomannan detected by the double sandwich enzyme-linked immunosorbent assay (ELISA) system, leading to the false presumption of invasive aspergillosis. Since this property of piperacillin-tazobactam and galactomannan ELISA is not well understood, we investigated the in vitro, in vivo, and clinical properties of this interaction. Among the 12 reconstituted antibiotics representing four classes of antibacterial compounds that are commonly used in immunocompromised patients, piperacillin-tazobactam expressed a distinctively high level of galactomannan antigen in vitro (P = 0.001). After intravenous infusion of piperacillin-tazobactam into rabbits, the serum galactomannan index (GMI) in vivo changed significantly (P = 0.0007) from a preinfusion mean baseline value of 0.27 to a mean GMI of 0.83 by 30 min to slowly decline to a mean GMI of 0.44 24 h later. Repeated administration of piperacillin-tazobactam over 7 days resulted in accumulation of circulating galactomannan to a mean peak GMI of 1.31 and a nadir of 0.53. Further studies revealed that the antigen reached a steady state by the third day of administration of piperacillin-tazobactam. Twenty-six hospitalized patients with no evidence of invasive aspergillosis who were receiving antibiotics and ten healthy blood bank donors were studied for expression of circulating galactomannan. Patients (n = 13) receiving piperacillin-tazobactam had significantly greater mean serum GMI values (0.74 +/- 0.14) compared to patients (n = 13) receiving other antibiotics (0.14 +/- 0.08) and compared to healthy blood bank donors (0.14 +/- 0.06) (P < 0.001). Five (38.5%) of thirteen patients receiving piperacillin-tazobactam had serum GMI values > 0.5 compared to none of thirteen subjects receiving other antibiotics (P = 0.039) and to none of ten healthy blood bank donors (P = 0.046). These data demonstrate that among antibiotics that are commonly used in immunocompromised patients, only piperacillin-tazobactam contains significant amounts of galactomannan antigen in vitro, that in animals receiving piperacillin-tazobactam circulating galactomannan antigen accumulates in vivo to significantly increased and sustained levels, and that some but not all patients receiving this antibiotic will demonstrate circulating galactomannan above the threshold considered positive for invasive aspergillosis by the recently licensed double sandwich ELISA.
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Affiliation(s)
- Thomas J Walsh
- Immunocompromised Host Section, Pediatric Oncology Branch, National Cancer Institute, Bethesda, Maryland 20892, USA.
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Maertens J, Theunissen K, Verbeken E, Lagrou K, Verhaegen J, Boogaerts M, Eldere JV. Prospective clinical evaluation of lower cut-offs for galactomannan detection in adult neutropenic cancer patients and haematological stem cell transplant recipients. Br J Haematol 2004; 126:852-60. [PMID: 15352990 DOI: 10.1111/j.1365-2141.2004.05140.x] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The recent advent of an improved commercial serum enzyme-linked immunosorbent assay (ELISA) for the detection of circulating galactomannan (GM), a major constituent of Aspergillus cell walls, has contributed to the diagnosis of invasive aspergillosis (IA) in many haematology and transplant centres. However, the optimal threshold for positivity remains a matter of debate. We prospectively evaluated the impact of lowering the cut-off in 124 neutropenic episodes with a high pretest probability for IA. Two new cut-off points, lower than previously accepted, are proposed: (a) a 'static' cut-off at 0.8 and (b) a 'dynamic' cut-off at 0.5. A single assay with an optical density (OD) index > or = 0.8 warrants the initiation of anti-Aspergillus therapy. A further lowering of the 'static' threshold seems not clinically feasible given the drop in positive predictive value (PPV). However, the demonstration of at least two sequential sera with an OD > or = 0.5 ('dynamic' threshold) increased the specificity and the PPV to 98.6% and the efficiency to 98%. Applying both cut-offs to a subgroup of 21 'possible' fungal infections further identified and upgraded six cases of IA. However, the clinical benefit of lower cut-offs (particularly for earlier diagnosis) depends upon the kinetics of antigenaemia and the intensity of serum sampling.
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Affiliation(s)
- Johan Maertens
- Department of Haematology, University Hospital Gasthuisberg, Leuven, Belgium.
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21
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Zaspel U, Denning DW, Lemke AJ, Greene R, Schürmann D, Maschmeyer G, Ruhnke M, Herbrecht R, Ribaud P, Lortholary O, Zonderland H, Rabe KF, Röttgen R, Bittner R, Neumann K, Oestmann JW. Diagnosis of IPA in HIV: the role of the chest X-ray and radiologist. Eur Radiol 2004; 14:2030-7. [PMID: 15309496 DOI: 10.1007/s00330-004-2447-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2004] [Revised: 07/07/2004] [Accepted: 07/12/2004] [Indexed: 10/26/2022]
Abstract
The role of clinical information and chest film for the discrimination between invasive pulmonary aspergillosis (IPA) and its differential diagnoses in human immunodeficiency virus (HIV) infection was studied. The diagnostic performance of clinical information and chest film alone and in combination was studied for eight internists and eight radiologists with regular exposure to IPA patients. The multicenter case sample consisted of 25 patients with proven IPA and 25 with other pulmonary diseases typical for HIV. The cases were presented on a CD-ROM. Receiver operating characteristics (ROC) methodology was employed. With clinical information alone, internists achieved the highest diagnostic performance (area under curve/AUC=0.84). Viewing the chest films did not contribute to their performance (AUC=0.80, P=0.26). The radiologist's performance on the basis of viewing the chest film (AUC=0.75) increased significantly ( P=0.012) when clinical information (AUC=0.83) was supplied. IPA cases with characteristic radiological appearance were correctly identified in 90% with chest film. For radiologists with regular exposure to HIV patients, chest films hold relevant information and contribute to the determination in cases with characteristic radiological appearance. Overall and especially in cases with less characteristic radiological appearance, they have significant profit from full access to the clinical data. For internists with regular exposure to HIV patients, chest films do not provide information essential for the verification or differentiation of potential IPA.
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Affiliation(s)
- Uta Zaspel
- Institut für Radiologie, Charité-Universitätsmedizin Berlin, Campus Mitte, Schuhmannstr. 20/21, 10117 Berlin, Germany.
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22
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Singh N, Obman A, Husain S, Aspinall S, Mietzner S, Stout JE. Reactivity of platelia Aspergillus galactomannan antigen with piperacillin-tazobactam: clinical implications based on achievable concentrations in serum. Antimicrob Agents Chemother 2004; 48:1989-92. [PMID: 15155189 PMCID: PMC415629 DOI: 10.1128/aac.48.6.1989-1992.2004] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2003] [Revised: 01/20/2004] [Accepted: 02/10/2004] [Indexed: 11/20/2022] Open
Abstract
The possible reactivities of commonly used antibiotics of fungal, nonfungal, and nonmicrobial or synthetic sources with the Platelia Aspergillus galactomannan assay were assessed. For drugs that tested positive, the minimal concentration of the antibiotic in serum that yielded a positive test (index, >0.5) was determined. At undiluted concentrations, piperacillin and multiple lots of piperacillin-tazobactam tested positive, whereas amoxicillin, ampicillin-sulbactam, nafcillin, cefazolin, ceftazidime, erythromycin, gentamicin, and levofloxacin tested negative. All three lots of piperacillin-tazobactam and all bags within each lot tested positive, with a mean index value of 5.168. At achievable concentrations in serum, however, only one of three lots of piperacillin-tazobactam yielded a positive test. Concentrations of 75, 150, and 300 microg/ml of serum tested positive with the Platelia Aspergillus enzyme immunoassay, whereas lower concentrations, mimicking the trough levels, tested negative. Thus, while achievable serum piperacillin-tazobactam concentrations may potentially result in a positive test for galactomannan, the timing of the collection of serum samples from patients may influence the test results, with reactivity being less likely in samples collected at trough levels or prior to the administration of a dose of the antibiotic.
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Affiliation(s)
- Nina Singh
- Veterans Affairs Medical Center, Infectious Disease Section, University Dr. C, Pittsburgh, PA 15240, USA. nis5+@pitt.edu
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23
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O'Sullivan CE, Kasai M, Francesconi A, Petraitis V, Petraitiene R, Kelaher AM, Sarafandi AA, Walsh TJ. Development and validation of a quantitative real-time PCR assay using fluorescence resonance energy transfer technology for detection of Aspergillus fumigatus in experimental invasive pulmonary aspergillosis. J Clin Microbiol 2004; 41:5676-82. [PMID: 14662960 PMCID: PMC308994 DOI: 10.1128/jcm.41.12.5676-5682.2003] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Invasive pulmonary aspergillosis (IPA) is a frequently fatal infection in immunocompromised patients that is difficult to diagnose. Present methods for detection of Aspergillus spp. in bronchoalveolar lavage (BAL) fluid and in tissue vary in sensitivity and specificity. We therefore developed an A. fumigatus-specific quantitative real-time PCR-based assay utilizing fluorescent resonance energy transfer (FRET) technology. We compared the assay to quantitative culture of BAL fluid and lung tissue in a rabbit model of experimental IPA. Using an enzymatic and high-speed mechanical cell wall disruption protocol, DNA was extracted from samples of BAL fluid and lung tissues from noninfected and A. fumigatus-infected rabbits. A unique primer set amplified internal transcribed spacer regions (ITS) 1 and 2 of the rRNA operon. Amplicon was detected using FRET probes targeting a unique region of ITS1. Quantitation of A. fumigatus DNA was achieved by use of external standards. The presence of PCR inhibitors was determined by use of a unique control plasmid. The analytical sensitivity of the assay was </=10 copies of target DNA. No cross-reactivity occurred with other medically important filamentous fungi. The assay results correlated with pulmonary fungal burden as determined by quantitative culture (r = 0.72, Spearman rank correlation; P </= 0.0001). The mean number of genome equivalents detected in untreated animals was 3.86 log(10) (range, 0.86 to 6.39 log(10)) in tissue. There was a 3.53-log(10) mean reduction of A. fumigatus genome equivalents in animals treated with amphotericin B (AMB) (95% confidence interval, 3.38 to 3.69 log(10); P </= 0.0001), which correlated with the reduction of residual fungal burden in lung tissue measured in terms of log(10) CFU/gram. The enhanced quantitative sensitivity of the real-time PCR assay was evidenced by detection of A. fumigatus genome in infarcted culture-negative lobes, by a greater number of mean genome equivalents compared to the number of CFU per gram in tissue and BAL fluid, and by superior detection of therapeutic response to AMB in BAL fluid compared to culture. This real-time PCR assay using FRET technology is highly sensitive and specific in detecting A. fumigatus DNA from BAL fluid and lung tissue in experimental IPA.
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Affiliation(s)
- Cathal E O'Sullivan
- Immunocompromised Host Section, Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
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24
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Viscoli C, Machetti M, Cappellano P, Bucci B, Bruzzi P, Van Lint MT, Bacigalupo A. False-positive galactomannan platelia Aspergillus test results for patients receiving piperacillin-tazobactam. Clin Infect Dis 2004; 38:913-6. [PMID: 14999640 DOI: 10.1086/382224] [Citation(s) in RCA: 181] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2003] [Accepted: 12/15/2003] [Indexed: 11/03/2022] Open
Abstract
At the bone marrow transplantation center of the San Martino Hospital (Genoa), we observed an increase in the rate of patients with positive Platelia Aspergillus (PA; Bio-Rad) test results, from 10% (38 of 386 patients) in the period from January 1999 through January 2003 to 36% (21 of 59 patients) in the period from February 2003 through May 2003. Positivity was significantly (P<.001) associated with the administration of piperacillin-tazobactam (PT) (17 [74%] of 23 patients who received PT had positive results vs. 4 [11%] of 36 who did not receive PT). Multivariate analysis found administration of PT ( chi 2=34.7; P<.001) and underlying disease ( chi 2=21.14; P<.001) to be associated with PA positivity. Of 15 PT batches tested, 12 had positive PA test results.
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Affiliation(s)
- Claudio Viscoli
- Infectious Disease Unit, National Institute for Cancer Research and University of Genoa, Genoa, Italy.
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25
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Garcia ME, Duran C, Cruzado M, Andrino M, Blanco JL. Evaluation of molecular and immunological techniques for the diagnosis of mammary aspergillosis in ewes. Vet Microbiol 2004; 98:17-21. [PMID: 14738777 DOI: 10.1016/j.vetmic.2003.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Three techniques for the diagnosis of mammary aspergillosis in ewes were compared: indirect ELISA to detect the level of anti-Aspergillus IgG in serum, determination of galactomannan (Platelia procedure), and detection of DNA of Aspergillus in serum by a nested PCR. Twenty sera from proven cases of aspergillosis in ewes were positive using ELISA (100%), 80% were positive using PCR, but only 55% were positive using Platelia. All 20 control sera were negative using ELISA and PCR, whereas using Platelia methodology one was positive and the other doubtful. The detection of antibody by ELISA in sera is therefore a reliable criterion for the diagnosis of mammary aspergillosis in ewes. Platelia showed the same deficiencies reported in humans, with the appearance of false positives and negatives. The use of PCR was promising and might have valuable application in human medicine.
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Affiliation(s)
- Marta E Garcia
- Departamento Sanidad Animal, Facultad de Veterinaria, Universidad Complutense, 28040 Madrid, Spain
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26
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Einsele H, Bertz H, Beyer J, Kiehl MG, Runde V, Kolb HJ, Holler E, Beck R, Schwerdfeger R, Schumacher U, Hebart H, Martin H, Kienast J, Ullmann AJ, Maschmeyer G, Krüger W, Niederwieser D, Link H, Schmidt CA, Oettle H, Klingebiel T. Infectious complications after allogeneic stem cell transplantation: epidemiology and interventional therapy strategies--guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Hematol 2003; 82 Suppl 2:S175-85. [PMID: 13680165 PMCID: PMC7103165 DOI: 10.1007/s00277-003-0772-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The risk of infection after allogeneic stem cell transplantation is determined by the underlying disease, the intensity of previous treatments and complications that may have occurred during that time, but above all, the risk of infection is determined by the selected transplantation modality (e.g. HLA-match between the stem cell donor and recipient, T cell depletion of the graft, and others). In comparison with patients treated with high-dose chemotherapy and autologous stem cell transplantation, patients undergoing allogeneic stem cell transplantation are at a much higher risk of infection even after hematopoietic reconstitution, due to the delayed recovery of T and B cell functions. The rate at which immune function recovers after hematopoietic reconstitution greatly influences the incidence and type of post-transplant infectious complications. Infection-associated mortality, for example, is significantly higher following engraftment than during the short neutropenic period that immediately follows transplantation.
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Affiliation(s)
- Hermann Einsele
- Dept. of Hematology, Oncology, Medical Clinic II, University of Tübingen, Otfried-Müller-Strasse 10, 72076, Tübingen, Germany.
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27
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Becker MJ, Lugtenburg EJ, Cornelissen JJ, Van Der Schee C, Hoogsteden HC, De Marie S. Galactomannan detection in computerized tomography-based broncho-alveolar lavage fluid and serum in haematological patients at risk for invasive pulmonary aspergillosis. Br J Haematol 2003; 121:448-57. [PMID: 12716367 DOI: 10.1046/j.1365-2141.2003.04308.x] [Citation(s) in RCA: 161] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We determined the value of galactomannan (GM) detection in computerized tomography (CT)-based broncho-alveolar lavage (BAL) fluid and serum for the diagnosis of invasive pulmonary aspergillosis (IPA) in haemato-oncological patients with neutropenia. CT of the thorax and BAL were performed systematically at predefined clinical indications. GM was determined by sandwich enzyme-linked immunosorbent assay; the clinicians were unaware of the results. Of 160 patients, 17 patients (10.6%) presented with proven, probable or suspected IPA. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of GM detection in CT-based BAL fluid were all 100%. For GM detection in serially sampled serum, the sensitivity was 47%, the specificity 93%, the PPV 73% and the NPV 82%. A non-blinded follow-up study was performed to validate these results. In this study, 22 of 198 patients (11.1%) presented with IPA, and the sensitivity, specificity, PPV and NPV of GM detection in CT-based BAL fluid were 85%, 100%, 100% and 88% respectively. None of BAL fluids obtained after antifungal treatment of 3 d or more were positive. These results indicate that, when CT is used systematically and at an early stage, GM detection in CT-based BAL fluid has a high PPV for diagnosing IPA early in untreated patients.
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Affiliation(s)
- Martin J Becker
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Centre Rotterdam, the Netherlands
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28
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Pinel C, Fricker-Hidalgo H, Lebeau B, Garban F, Hamidfar R, Ambroise-Thomas P, Grillot R. Detection of circulating Aspergillus fumigatus galactomannan: value and limits of the Platelia test for diagnosing invasive aspergillosis. J Clin Microbiol 2003; 41:2184-6. [PMID: 12734275 PMCID: PMC154675 DOI: 10.1128/jcm.41.5.2184-2186.2003] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The effectiveness of galactomannan detection with the Platelia test was evaluated in a prospective study of 3,327 sera from 807 patients. The specificity was 99.6% (748 of 751 cases). For the groups of patients with proven and probable invasive aspergillosis, the sensitivity was 50.0% (17 of 34 cases). The disappointing sensitivity associated with the presence of rare false-positive cases underlines the limits of this test.
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Affiliation(s)
- Claudine Pinel
- Service de Parasitologie-Mycologie, Centre Hospitalier Universitaire, 38043 Grenoble, France.
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29
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Bennett JE, Kauffman C, Walsh T, de Pauw B, Dismukes W, Galgiani J, Glauser M, Herbrecht R, Lee J, Pappas P, Powers J, Rex J, Verweij P, Viscoli C. Forum report: issues in the evaluation of diagnostic tests, use of historical controls, and merits of the current multicenter collaborative groups. Clin Infect Dis 2003; 36:S123-7. [PMID: 12679896 DOI: 10.1086/367840] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This forum report contains conclusions about 3 different issues relevant to conducting clinical trials in deep mycoses. (1) Trials of diagnostic tests for deep mycoses must define the population appropriate for testing and the clinical question being asked. The unanswered question for the serum Aspergillus galactomannan assay is whether knowledge of results can change use of empirical therapy to treat febrile patients at high risk of invasive aspergillosis. (2) Use of historical controls is suboptimal but offers a pragmatic solution for studying rare mycoses; use of contemporaneous controls, matched for critical variables and evaluated by a blinded data review committee using detailed criteria, appears optimal. (3) Established groups of independent investigators, such as the European Organization for Research on Treatment of Cancer's Invasive Fungal Infections Group and National Institute of Allergy and Infectious Diseases's Bacteriology and Mycology Study Group, provide a pool of experienced investigators, defined operating rules, impartiality, and specialized expertise. Considering the enormous investment required for adequately powered efficacy trials of antifungal agents and the importance of these trials to guide clinical practice, use of collaborative groups outweighs the extra administrative time that is sometimes required.
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Affiliation(s)
- John E Bennett
- Clinical Mycology Section, Laboratory of Clinical Investigation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA.
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30
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Vilchez RA, Kwak EJ, Kusne S. Advances in diagnosis and management of invasive fungal infections in organ transplant recipients: . Curr Opin Organ Transplant 2002; 7:320-4. [DOI: 10.1097/00075200-200212000-00004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Chen SCA, Halliday CL, Meyer W. A review of nucleic acid-based diagnostic tests for systemic mycoses with an emphasis on polymerase chain reaction-based assays. Med Mycol 2002; 40:333-57. [PMID: 12230214 DOI: 10.1080/mmy.40.4.333.357] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Nucleic acid-based assays have good potential to complement and enhance the sensitivity and rapidity of conventional methods used in diagnostic mycology. The majority of molecular tests are polymerase chain reaction (PCR)-based assays focusing mainly on the detection of Candida and Aspergillus spp. from clinical samples. DNA extraction and purification procedures should be standardized and can be facilitated by using commercial extraction kits. In general, protocols that target multi-copy genes provide the greatest sensitivity. Objective endpoint assessments of PCR tests using enzyme-linked immunosorbent assays (ELISA) or commercial quantitative systems are capable of rapidly detecting and identifying Candida and Aspergillus spp. Sequencing of PCR products can be used to confirm the identity of amplicons. In cases of suspected invasive aspergillosis, PCR should be performed on both blood and bronchoalveolar lavage fluid to maximize test sensitivity and the positive predictive value. At least two blood specimens should be tested if PCR is undertaken on blood samples alone. In situ hybridization techniques have been used with success to identify fungi in tissue specimens. The wide application of PCR-based assays relies on the introduction of standardized protocols following their evaluation in multicentre, prospective studies.
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Affiliation(s)
- Sharon C A Chen
- Centre for Infectious Diseases and Microbiology, University of Sydney, Westmead Hospital, New South Wales, Australia.
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32
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Centeno-Lima S, de Lacerda JM, do Carmo JA, Abecasis M, Casimiro C, Exposto F. Follow-up of anti-Aspergillus IgG and IgA antibodies in bone marrow transplanted patients with invasive aspergillosis. J Clin Lab Anal 2002; 16:156-62. [PMID: 11968054 PMCID: PMC6807700 DOI: 10.1002/jcla.10035] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A total of 89 patients at risk for, or with invasive aspergillosis (IA) were recruited from bone marrow transplantation (BMT) units in two Lisbon hospitals, and followed for 2(1/2) years to monitor their immune response. Of these patients, six developed probable IA, from which five died. The presence of serum IgG or IgA antibodies against seven Aspergillus recombinant antigens was assessed in patients with IA, using an enzyme-linked immunosorbent assay (ELISA). In parallel, the serum levels of galactomannan (GM) were also monitored, using the Platelia Aspergillus kit (Sanofi Pasteur, Marnes-la-Coquette, France). Superoxide dismutase (Sod) and 94 kDa were the most immunogenic antigens for IgA, while the IgG pattern of recognition changed from patient to patient. From our results we conclude that although follow-up of antibodies against these antigens should not be used as a diagnostic method, patients with IA do produce an immune response that may influence disease outcome.
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Affiliation(s)
- S Centeno-Lima
- Centro de Malária e Outras Doenças Tropicais, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal.
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Abstract
The management of invasive fungal infections has been hampered by the inability to diagnose the infection at an early stage of disease. Although proving the presence of infection by histology and culture remains the cornerstone of the diagnosis, non-culture based methods are becoming available that enable early detection. Molecular diagnosis by PCR appears very promising since fungal DNA can be detected in the blood of infected patients before conventional methods. Furthermore, a broad range of yeasts and molds can be identified to species level. Automation of sample preparation and use of real-time PCR systems will help standardize the procedure and reduce false positive results due to contamination. Promising assays for the detection of fungal antigens in serum have been commercialized, including detection systems for mannan (Candida) and galactomannan (Aspergillus). Circulating antigens can be detected at an early stage of infection, often before the onset of clinical symptoms. Antigen detection is limited to detecting only one genus and not enabling speciation. Furthermore, both PCR and antigen detection can be used to monitor the response of patients to treatment with anti-fungal agents. Although prospective screening of high-risk patients for the presence of circulating markers of fungal infection appears to be an appropriate strategy, studies are needed to help to establish the optimal approach to managing invasive fungal infections that incorporates the benefits of non-culture based methods.
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Affiliation(s)
- Z Erjavec
- Internal Medicine, Delfzicht Ziekenhuis, Delfzijl, The Netherlands
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34
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Perfect JR, Cox GM, Lee JY, Kauffman CA, de Repentigny L, Chapman SW, Morrison VA, Pappas P, Hiemenz JW, Stevens DA. The impact of culture isolation of Aspergillus species: a hospital-based survey of aspergillosis. Clin Infect Dis 2001; 33:1824-33. [PMID: 11692293 DOI: 10.1086/323900] [Citation(s) in RCA: 306] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2001] [Revised: 06/11/2001] [Indexed: 11/04/2022] Open
Abstract
The term "aspergillosis" comprises several categories of infection: invasive aspergillosis; chronic necrotizing aspergillosis; aspergilloma, or fungus ball; and allergic bronchopulmonary aspergillosis. In 24 medical centers, we examined the impact of a culture positive for Aspergillus species on the diagnosis, risk factors, management, and outcome associated with these diseases. Most Aspergillus culture isolates from nonsterile body sites do not represent disease. However, for high-risk patients, such as allogeneic bone marrow transplant recipients (60%), persons with hematologic cancer (50%), and those with signs of neutropenia (60%) or malnutrition (30%), a positive culture result is associated with invasive disease. When such risk factors as human immunodeficiency virus infection (20%), solid-organ transplantation (20%), corticosteroid use (20%), or an underlying pulmonary disease (10%) are associated with a positive culture result, clinical judgment and better diagnostic tests are necessary. The management of invasive aspergillosis remains suboptimal: only 38% of patients are alive 3 months after diagnosis. Chronic necrotizing aspergillosis, aspergilloma, and allergic bronchopulmonary aspergillosis have variable management strategies and better short-term outcomes.
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Affiliation(s)
- J R Perfect
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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Garcia ME, Caballero J, Cruzado M, Andrino M, Gonzalez-Cabo JF, Blanco JL. The value of the determination of anti-Aspergillus IgG in the serodiagnosis of canine aspergillosis: comparison with galactomannan detection. J Vet Med B Infect Dis Vet Public Health 2001; 48:743-50. [PMID: 11846019 DOI: 10.1046/j.1439-0450.2001.00504.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Diagnosis of canine aspergillosis is difficult using currently available methods. It often passes unnoticed or is diagnosed in the later phases of the disease. We developed an ELISA technique to detect anti-Aspergillus antibodies in canine serum using an Aspergillus antigenic mycelial extract, which could then be used for the diagnosis of canine aspergillosis. We used a cut-off of X + 3SD obtained from 20 control sera. The test was performed on 46 dogs with lesions indicating possible aspergillosis and gave nine positive results: one systemic mycosis, two discospondylitis, one uveitis, two bronchopulmonary processes and three rhinitis. We compared this methodology with the PLATELIA technique in the follow-up of the affected dogs, obtaining the same limitations as in the diagnosis of human aspergillosis. We consider our ELISA technique using sera samples a speedy, safe and reliable method which enables us to follow up the evolution of the disease and the efficacy of the therapy chosen. A definitive diagnosis must still take into account the results of other tests such as clinical examination, radiographic studies, endoscopy and biopsy.
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Affiliation(s)
- M E Garcia
- Departamento Patologia Animal I, Facultad de Veterinaria, Universidad Complutense, Madrid, Spain
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Abstract
Antimicrobial-resistant bacteria (vancomycin-resistant enterococci and Staphylococcus aureus) have emerged as leading pathogens in liver transplant recipients. Liver transplant recipients have also been shown to be uniquely more susceptible to harboring extended-spectrum beta-lactamase-producing Enterobacteriaceae. The frequency of mycelial fungal infections has increased; however, effective prophylaxis and management of these infections remains suboptimal. Emerging reports have highlighted the morbidity due to novel herpesviruses in these patients. Finally, the emergence of ganciclovir resistance in cytomegalovirus has implications relevant for all solid organ transplant recipients.
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Affiliation(s)
- Nina Singh
- VA Medical Center, Infectious Disease Section, University Drive C, Pittsburgh, PA 15240, USA
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Abstract
The spectrum of major infections after transplantation has undergone a striking evolution. The epidemiologic trends in infectious diseases through the last decade have been most notable for a dramatic decrease in the incidence of several opportunistic infections, largely because of advances in prophylaxis against these pathogens. Paralleling these trends has been an exponential rise in the proportion of infections caused by antimicrobial-resistant bacteria. These multiresistant organisms have now emerged as leading pathogens at many transplant centers, and their management is a daunting challenge.
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Affiliation(s)
- N Singh
- Infectious Disease Section, Veterans Affairs Medical Center, Pittsburgh, Pennsylvania, USA
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Abstract
Patterns of bacterial infection have remained fairly static with Gram-positive bacteria predominating, although this varies between institutions and between patient populations. Similarly, antimicrobial resistance rates differ widely and reflect antibiotic use and exposure. Hence, each institution should devote microbiological resources to maintain surveillance and employ vigilance so that antimicrobial treatment protocols can be adapted to meet any new challenges. Most changes are being seen in the diagnosis of fungal infections, particularly aspergillosis, and the way in which it is being incorporated into treatment strategies.
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Affiliation(s)
- J. Peter Donnelly
- Department of Haematology, University Medical Center, St Radboud, Nijmegen, The Netherlands
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Abstract
Invasive aspergillosis in bone marrow transplant recipient is associated with a high mortality. Diagnosis is often delayed because the inflammatory response is blunted by immunosuppression. The gold standard of tissue biopsy is often considered too in invasive as the procedure is often complicated by bleeding and secondary infection. Recent finding on non-invasive tests such as serial measurement of peripheral blood galactomannan antigen or DNA appears to be promising. However, the limited availability of such tests and requirement for expertise are still hampering their use in routine clinical management. More often than not, initiation of antifungal therapy is empirical and based on suggestive radiological changes. Amphotericin B remains the gold standard of therapy but liposconal preparation may prove to be less nephrotoxic and equally effective. Treatment outcome depends more on the acceleration of the recovery of the immune system and the reduction of anti-GVHD therapy than the antifungal agent followed by surgical resection. The efficacy of many reported anti-aspergillosis prophylactic regimen has not been proved in randomized control trials. Despite the absence of data, such policy should still be considered in transplant units with high incidence of aspergillus or undergoing renovation.
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Affiliation(s)
- P L Ho
- Division of Infectious Diseases, Department of Microbiology, Queen Mary Hospital, University of Hong Kong, Pokfulam Road, Pokfulum, Hong Kong
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Abstract
The diagnosis of invasive fungal infection in patients undergoing solid organ or bone marrow transplantation remains a significant clinical challenge. Consideration of the epidemiology of these infections and host risk factors may be an important clue to a specific fungal diagnosis. Despite extensive investigation on methods such as serologic techniques to improve the rapid diagnosis of these infections, the diagnosis of invasive mycoses remains largely dependent on clinical presentation. For example, the signs and symptoms that result from angioinvasion of fungal organisms include pleuritic chest pain or hemoptysis. In a high-risk patient these findings can be important clues to invasive fungal infection. Cultures of opportunistic fungi in certain settings, such as Aspergillus in respiratory samples from immunosuppressed patients, may be associated with infection. Radiographic findings can also be useful to establish a diagnosis of infection. In patients with invasive aspergillosis as well as other angioinvasive moulds, chest CT scans may demonstrate lesions that are not visible on plain radiographs. Serodiagnosis of these infections remains largely investigational. Microbiological antifungal resistance has increasingly been reported, but in patients at high risk for serious fungal infection, including patients undergoing bone marrow and organ transplantation, antifungal resistance remains uncommon, particularly in Candida albicans. Higher doses of azoles should be used to treat patients with infections due to less susceptible yeasts and those with more serious infection. Prompt recognition of fungal infection combined with intensive antifungal therapy is needed for successful therapy.
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Affiliation(s)
- T F Patterson
- Department of Medicine, University of Texas Health Science Center at San Antonio, 78229-3900, USA.
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Abstract
Aspergillus fumigatus is one of the most ubiquitous of the airborne saprophytic fungi. Humans and animals constantly inhale numerous conidia of this fungus. The conidia are normally eliminated in the immunocompetent host by innate immune mechanisms, and aspergilloma and allergic bronchopulmonary aspergillosis, uncommon clinical syndromes, are the only infections observed in such hosts. Thus, A. fumigatus was considered for years to be a weak pathogen. With increases in the number of immunosuppressed patients, however, there has been a dramatic increase in severe and usually fatal invasive aspergillosis, now the most common mold infection worldwide. In this review, the focus is on the biology of A. fumigatus and the diseases it causes. Included are discussions of (i) genomic and molecular characterization of the organism, (ii) clinical and laboratory methods available for the diagnosis of aspergillosis in immunocompetent and immunocompromised hosts, (iii) identification of host and fungal factors that play a role in the establishment of the fungus in vivo, and (iv) problems associated with antifungal therapy.
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Affiliation(s)
- J P Latgé
- Laboratoire des Aspergillus, Institut Pasteur, 75015 Paris, France.
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