Neutropenia Febril

1
What are we looking at? Challenges in the
diagnosis of Invasive Mould Diseases
Alessandro C. Pasqualottopasqualotto_at_santacasa.tc
he.brPorto Alegre, Brazil
2
Potential conflicts of interest

• Research Grants
• Myconostica, Pfizer, Merck, Sigma-Tau, CAPES,
  CNPq, Fungal Research Trust
• Travel Grants
• Pfizer, United Medical, Schering (now Merck),
  Bagó, Merck
• Speaker honoraria
• Pfizer, United Medical, Merck, Schering (now
  Merck), Biometrix

3
First assumption IFD are highly lethal diseases
4
plt0.001
Incidence 13.3 in lung transplant recipients
Xavier MO, Pasqualotto AC, et al. ECCMID 2009
5
Rapidly evolving diseases
4 days later
www.aspergillus.org.uk
6
Disseminated infection
www.aspergillus.org.uk
7
Second assumption We need to intervene asap
8
Early versus late intervention
Mortality rate ()
Von Eiff, et al. Respiration 1995 62 241-7
9
Early versus late intervention
Mortality rate ()
Von Eiff, et al. Respiration 1995 62 241-7
10
But how can we achieve such an early diagnosis?
11
A small black scar 2 days earlier serum
GM Patient died 1 day after this picture was
taken
12
A small black scar 2 days earlier serum
GM Patient died 1 day after this picture was
taken
Zygo A. flavus
13
MD Anderson Cancer Centre Necropsy study over a
15-years period

• IFD detected in 31 over 1,017 necropsies
• Antemortem diagnosis in only 25

Chamilos G, et al. Haematologica 2006 91 986-9
14
MD Anderson Cancer Centre Necropsy rate has
reduced over time

Chamilos G, et al. Haematologica 2006 91 986-9
15
By the way, what is the necropsy rate in your
institution?

• gt40
• 10-39
• 1-10
• lt1
• Are you kidding?

16
MD Anderson Cancer Centre Trends in the
prevalence of IFD

Chamilos G, et al. Haematologica 2006 91 986-9
17
No need to worry! CT scan and galactomannan are
there to help us out!
18
Halo sign surrounding a nodule
Caillot, et al. J Clin Oncol 1997 15 139-47
19
The sign is not specific for IA

• Vasculitis
• Metastasis
• Pseudomonas infections
• Zygomycosis and other angio-invasive infections

Greene RE, et al. Clin Infect Dis 2007 44 373-9
20
Absence of typical findings at chest CT scan

• COPD
• Steroids
• Other non-neutropenic patients / ICU
• Lung transplant recipients
• ? Monoclonal antibodies

21
Reversed halo sign Organising cryptogenic
pneumonia
Wahba H, et al. Clin Infect Dis 2008 46 1733-7
22
Reversed halo sign

• Review of 189 cases of invasive mould disease
• Overall frequency 4

Wahba H, et al. Clin Infect Dis 2008 46 1733-7
23
Reversed halo sign

• Review of 189 cases of invasive mould disease
• Overall frequency 4
• Zygomycosis 19
• Aspergillosis lt1
• Fusariosis 0 (plt0.01)

Wahba H, et al. Clin Infect Dis 2008 46 1733-7
24
Other predictors of zygomycosis

• gt10 nodules
• Pleural effusion
• Concomitant sinusitis
• Treatment with voriconazole

Chamilos G, et al. Clin Infect Dis 2005 41 60-6
25
Meta-analysis of GM testing
Low PPV High NPV
Pfeiffer CD, et al. Clin Infect Dis 2006 42
1417-27
26
Reproducibility
Caution with low ve indexes!
Upton A, et al. J Clin Microbiol 2005 43
4796-800
27
GM release by non-Aspergillus fungi

• Penicillium marneffei
• Geotricum capitatum
• Acremonium species
• Alternaria alternata
• Rhodotorula rubra
• Trichophyton species

• Paecilomyces variotii
• Botrytis tulipae
• Cladosporium species
• Exophiala dermatitidis

Aquino VR, Goldani LZ, Pasqualotto AC.
Mycopathologia 2007 163 191-202
28
Cross-reaction with GM testing

Xavier MO, Pasqualotto AC, Severo LC. Clin Vaccin
Immunol 2009 16 132-3
29
Clinical case

• 19 year-old man, refractory leukaemia
• Febrile neutropenia
• Amox-clav for E. Coli bacteremia

Maertens J, et al. Clin Infect Dis 2004 39
289-90
30
Clinical case

• 19 year-old man, refractory leukaemia
• Febrile neutropenia
• Amox-clav for E. Coli bacteremia
• Daily GM determination
• D1 after antibiotic GM index of gt1.5
• 5 ve tests afterwards

Maertens J, et al. Clin Infect Dis 2004 39
289-90
31
Clinical case

• 19 year-old man, refractory leukaemia
• Febrile neutropenia
• Amox-clav for E. Coli bacteremia
• Daily GM determination
• D1 after antibiotic GM index of gt1.5
• 5 ve tests afterwards
• Fluoroquinolone gradual reduction in GM index

Maertens J, et al. Clin Infect Dis 2004 39
289-90
32
Clinical case

• 1 wk later
• Pipe-tazo for appendicitis
• GM gt2.5 bilateral nodular infiltrate

Maertens J, et al. Clin Infect Dis 2004 39
289-90
33
Clinical case

• 1 wk later
• Pipe-tazo for appendicitis
• GM gt2.5 bilateral nodular infiltrate
• Probable IA (EORTC / MSG)
• Antifungal therapy meropenem
• Gradual ? in GM index

Maertens J, et al. Clin Infect Dis 2004 39
289-90
34
Clinical case

• 1 wk later
• Pipe-tazo for appendicitis
• GM gt2.5 bilateral nodular infiltrate
• Probable IA (EORTC / MSG)
• Antifungal therapy meropenem
• Gradual ? in GM index
• Necropsy leukaemia infiltrate
• Absence of IA

Maertens J, et al. Clin Infect Dis 2004 39
289-90
35
Meta-analysis of GM testing
Pfeiffer CD, et al. Clin Infect Dis 2006 42
1417-27
36
Specificity 94 Sensitivity 79 Marked
heterogeneity (particularly for sensitivity)
BAL PCR testing
Tuon FF. Rev Iberoam Micol 2007 24 89-94
37
PCR Critical points

• Variable sensitivity / specificity
• Lack of standardised targets / reagents
• Extraction method
• Platform (conventional PCR vs Real time)
• Poor understanding of DNA kinetics
• Not yet part of the EORTC/MSG criteria

De Pauw B, et al. Clin Infect Dis 2008 46
1813-21
38
Beta-Glucan

• Detected in IFDs caused by
• Candida and Aspergillus

Fungal cell wall
Phospholipid bilayer of the fungal cell membrane
?-(1,3)-glucan
?-(1,3)-glucan synthase
Ergosterol
Yoshida M, et al. J Med Veter Mycol 1997 35
371-4
39
Beta-Glucan

• Detected in IFDs caused by
• Candida and Aspergillus
• Trichosporon
• Fusarium
• Acremonium
• Saccharomyces
• Pneumocystis

Yoshida M, et al. J Med Veter Mycol 1997 35
371-4
40
There he is again, speaking about a test that
nobody uses in Brazil
41
The reality in Brazil

• A survey performed in collaboration with ANVISA
• 140 hospitals
• gt42,000 beds
• 65 teaching hospitals
• 90 belonging to the Sentinel Network

42
Complexity in hospital care

43
Is IFD a problem in your centre?
38.7
n140
44
Do you know your local epidemiology?
40.1
n140
45
Specialised media for fungi
19.7
n140
46
Aspergillus identification at the species level
58.5
n140
47
Fungal staining - biopsies
51.1
n140
48
Biopsy specimens are sent in formalin only?
26.0
n140
49
Access to high resolution CT
34.3
n140
50
Galactomannan
83.6
n140
51
The appropriateness or inappropriateness of
feelings is relative to the ground and to the
circumstances of those feelings Aristotle
The Doctrine of the Mean, 384-322 BC
52
Fight fire with fireMetallicaRide the
Lightning, 1984 AD
53
Invasive diagnostic interventions

• CT-guided percutaneous lung biopsy yield of
  70-100

Nosari A, et al. Haematologica 2003 88
1405-9 Crawford SW, et al. Transplantation 1989
48 266-71 Hoffer FA, et al. Pediatr Radiol 2001
31 144-52 Lass-Florl C, et al. Clin Infect Dis
2007 45 e1001-4
54
Invasive diagnostic interventions

• CT-guided percutaneous lung biopsy yield of
  70-100
• Platelets gt60,000/ml are required
• Pneumothorax 18
• Haemoptysis 3

Nosari A, et al. Haematologica 2003 88
1405-9 Crawford SW, et al. Transplantation 1989
48 266-71 Hoffer FA, et al. Pediatr Radiol 2001
31 144-52 Lass-Florl C, et al. Clin Infect Dis
2007 45 e1001-4
55
Invasive diagnostic interventions

• Transbronchial biopsies
• False-negative results are frequently seen

Lass-Florl C, Freund MC. In Aspergillosis from
diagnosis to prevention. Pasqulaotto AC, ed.
Springer, 2009
56
Invasive diagnostic interventions

• Open lung biopsies
• Provide larger samples of tissue with improved
  accuracy and specificity

Lass-Florl C, Freund MC. In Aspergillosis from
diagnosis to prevention. Pasqulaotto AC, ed.
Springer, 2009
57
Invasive diagnostic interventions

• Open lung biopsies
• Provide larger samples of tissue with improved
  accuracy and specificity
• Contradictory results
• Complication rate of 10-15

Lass-Florl C, Freund MC. In Aspergillosis from
diagnosis to prevention. Pasqulaotto AC, ed.
Springer, 2009
58
Invasive diagnostic interventions
Needle biopsy / Surgical resection
Peripheral lesions
Bilateral / multifocal disease
BAL
Focal lesions near the hilum / great vessels
Urgent thoracotomy and resection
Lass-Florl C, Freund MC. In Aspergillosis from
diagnosis to prevention. Pasqulaotto AC, ed.
Springer, 2009
59
Conclusion

• It is mostly but not all about IA
• Invasive mould diseases have to be
  differentiated from each other

60
Conclusion

• It is mostly but not all about IA
• Invasive mould diseases have to be
  differentiated from each other
• Diagnosis is the most challenging step in
  infectious diseases

61
Conclusion

• It is mostly but not all about IA
• Invasive mould diseases have to be
  differentiated from each other
• Diagnosis is the most challenging step in
  infectious diseases
• We need a better understanding on the performance
  of the available tests

62
Acknowledgments

• Mycology team
• Luiz Carlos Severo
• Valerio R Aquino
• Cecilia B Severo
• Luciana Guazelli
• Melissa Xavier
• Infection Control Dept
• Teresa Sukiennik