Obtrusive aspergillosis : Update on routine analysis

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Obtrusive aspergillosis : Update on ordinary finding Jacques Bille, MD Institut of Microbiology University Hospital Lausanne, Switzerland

Invasive aspergillosis : refresh on customary conclusion The issues The ailment is developing Clinical signs/side effects are non particular Conventional determination is harsh or too late Non traditional analysis is "promising"

Invasive aspergillosis : refresh on routine determination The sickness is advancing A continuum of clinical introductions New (?) has Underdiagnosed bet mortem

Invasive aspergillosis : refresh on traditional conclusion Hope, WW, Walsh TJ, Denning DW. The intrusive and saprophytic disorders because of Aspergillus species. Therapeutic Mycology 2005, 43 : S 207-238

Invasive aspergillosis : refresh on routine finding Clinical signs/manifestations are non particular fever dyspnea non beneficial hack hemoptysis chest torment pleural rib In a legitimate host quickly dynamic

Invasive aspergillosis : refresh on customary conclusion Conventional determination • direct examination of tissue of aberrant clinical examples (sputum, BAL) sputum/BAL tissue unstained wet prep ± KOH routine stains Gram HE fungal stains GMS, PAS GMS, PAS fluorescent Calcofluor white dyes Uvitex 2B Blankophor

Invasive aspergillosis : refresh on ordinary analysis In: Hope et al., Lancet Infectious Diseases 5 : 609, 2005

Invasive aspergillosis : refresh on traditional determination Histopathologic conclusion of Aspergillosis Improvement by immunohistochemical recognition Monoclonal antibodies • WF-AF-1 (Dako) 1) • EB-A1 2) Sensitivity in culture-demonstrated cases : 89-94% Genus or species particular outcomes 1) Choi JK et al., Am J Clin Pathol 121 : 18, 2004 2) Pierard GE et al., Am J Clin Pathol 96 : 373, 1991 Verweij PE et al., Am J Clin Pathol 49 : 798, 1996

Invasive aspergillosis : refresh on ordinary finding In: Choi JK, Am J Clin Pathol 121 : 18, 2004

Invasive aspergillosis : refresh on traditional analysis Culture Isolation: Sabouraud (+ anti-toxins) Media blood agar, chocolate agar Identification : malt-separate, corn-dinner agar Czapek agar Incubation temperature 25-30°C  change ? athmosphere aerobic duration 2 a month and a half

Invasive aspergillosis : refresh on traditional determination In: Andreoni et al., Medical Mycology Atlas

Invasive aspergillosis : refresh on customary conclusion Culture • Can we enhance the affectability ? (in tissue) • What is the best roundabout example ? Sputum or BAL • What are the PPV of a positive culture for IA, and the affectability of culture to analyze IA ?

Invasive aspergillosis : refresh on customary conclusion Performance of a symptomatic test Caveat timing of inspecting - development of the illness per test versus per scene examination tolerant populace Prior antifungal prophylaxis or treatment

Invasive aspergillosis : refresh on routine determination Yield of culture for molds in histopathologic positive specimens n= culture positive Autopsy tests 23 12 52% Surgical or biopsy tissue 30 9 30% Tarrand JJ et al., Am J Clin Pathol 2003; 119 : 854

Invasive aspergillosis : refresh on ordinary finding Culture Can we improve ? Emulate physiologic termperature and diminished oxygen condition : 35°C, 6% O 2 - 10% CO 2  significant increment of Aspergillus spp from post-mortem examination tissue and different clinical samples (+ 31%) Tarrand JJ et al., J Clin Microbiol 2005; 43 : 382

Invasive aspergillosis : refresh on traditional finding Culture : BAL is superior to sputum (?) Overall affectability half Adapted from Reichenberger et al., Bone Marrow Transplantation 1999; 24 : 1195 Diagnostic yield of bronchoscopy example in histologically demonstrated IPA No. of cases Bronchoscopy demonstrative Albeda 1984 15 14 5 36 % Treger 1985 16 12 8 67 % Kahn 1986 17 27 13 48 % Saito 1988 18 9 0 0 % Levy 1992 11 16 9 56 % Mc Whinney 1993 19 12 6 50 % Saugier-Weber 1993 2 10 3 30 % Von Eiff 1995 12 12 6 50 % Horvath 1996 8 29 11 38 % Caillot 1997 20 18 8 45 % Baron 1998 4 13 8 61 % Reichenberger 1999 9 23 7 30 % Overall 195 84 43 %

Invasive aspergillosis : refresh on traditional analysis The Catch 22 of a positive sputum culture for Aspergillus low affectability for IA low specificity for IA Can we enhance ?

Invasive aspergillosis : refresh on routine conclusion How to build the PPV for IA of a positive sputum culture • at (high) chance patient • different positive specimens 1) • quantitative culture 1) 2) • utilization of a score 2) 3) 1) Nalesnik et al., J Clin Microbiol 1980; 11 : 370 2) Greub and Bille, Clin Microbiol Infect 1998; 4 : 710 3) Bouza and Muñoz, J Clin Microbiol 2005; 43 : 2075

Invasive aspergillosis : refresh on traditional determination Positive prescient estimation of a positive sputum culture for IA Highly factor (15-77%) Depends on host components allo BMT 60% leukemia + neutropenia 70-80% SOT 20-60% HIV/AIDS 14-20% Corticosteroids 20% Perfect et al. (MSG), Clin Infect Dis 2001; 33 : 1824 Yu et al., Am J Med 1986; 81 : 249 Horvath and Dummer, Am J Med 1996; 100 : 171

Invasive aspergillosis : refresh on routine analysis Prospective evaluation of the clinical signi-ficance of disengaging A.fumigatus by culture 404 A.fumigatus positive societies (260 patients) 90 (22.3%) from 31 (12%) patients with IA 6% if 1+ cult. 18% 2+ 38%  3+ 10% if 1-2 score 40% 3-4 70%  5 Bouza et al., J Clin Microbiol 2005; 43 : 2075 Score Criteria focuses Invasive procedure 1  2 + cultures 1 Leukemia 2 Corticosteroids 2 Neutropenia 5

Invasive aspergillosis : refresh on ordinary determination Radiology 2 intriguing late discoveries : Systematic CT • is more touchy than galactomannan for early recognition of IA 1) • reduces the measure of antifungal treatment when joined to GM screening 2) Angio CT has a higher specificity than CT for IA 3) 1) Weisser et al., Clinical Infectious Diseases 2005; 41 : 1143 2) Maertens et al., Clinical Infectious Diseases 2005; 41 : 1242 3) Sonnet et al., Am J Roentgenol 2005; 184 : 746

Invasive aspergillosis : refresh on traditional finding Conclusions Conventional analysis of IA is : imperfect key  class, species  AFST perfectible