FunDgnCaseStudies2005

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Published on October 4, 2007

Author: Maitane

Source: authorstream.com

Case Studies in Fungal Diagnostics 2005:  Case Studies in Fungal Diagnostics 2005 L. Joseph Wheat 4444 Decatur Blvd. Suite 300 Indianapolis, IN 46241 317 856 2681 www.miravistalabs.com Which Most Sensitive in PDH:  Which Most Sensitive in PDH Histopathology :  Histopathology Antigen Detection:  Antigen Detection Sensitivity in PDH:  Sensitivity in PDH Hc PCR in Haguric Specimens:  Hc PCR in Haguric Specimens Serum + Urine - Hag After SOT:  Serum + Urine - Hag After SOT 1st patient Recent liver transplant Prednisone, tacrolimus, mycophenylate, thymoglobulin Pneumonia 3 weeks post transplant Improving or antibiotics Hag serum 41.8, urine 0.6 2nd patient 2 months later- same story What is HARA?:  What is HARA? False-positive Hag Antigenemia:  False-positive Hag Antigenemia New 2nd Gen Assay :  New 2nd Gen Assay Heavy vs. Light Inoculum :  Heavy vs. Light Inoculum Acute v Subacute v Chronic:  Acute v Subacute v Chronic Slide13:  Urine Disseminated Pulmonary AIDS Others NIS Acute Sub-acute Chronic Sensitivity (%) 0 10 20 30 40 50 60 70 80 90 100 95% (75/79) 82% (14/17) 80% (8/10) 81% (26/32) 34% (22/65) 14% (2/14) How To ↑Sensitivity:  How To ↑Sensitivity 24 yo construction Demolished old house Fever, cough, SOB Urine Hag 0.9 BAL Improved Sensitivity Pulmonary Syndromes:  BAL Improved Sensitivity Pulmonary Syndromes What’s Likely Diagnosis? :  What’s Likely Diagnosis? 9 yo from Illinois 7 wk productive cough, SOB, 7 kg wt loss Azithro for CAP 6 weeks later: resp failure, diffuse pneumonia, papular rash Ceftriaxone + azithro Day 3 empyema→ decortication Day 4 yeast sputum & pleural fld→ampho B Day 6: Died Rapid Diagnosis Blastomycosis:  Rapid Diagnosis Blastomycosis Test Sensitivity KOH 29-83% Cytology 50-93% Antigen 93% Blasto Antigen Detection :  Blasto Antigen Detection Meaning of Persistent Hag? :  Meaning of Persistent Hag? Renal transplant with PDH on itra Haguria persists ↓ing renal function Infected allograft removed Hag Clearance=Cure?:  Hag Clearance=Cure? PDH in normal host Hag clearance serum 1 y urine 2 y When to stop Rx? Viable yeast→relapse Dead yeast→delayed Hag clearance Antigen During Relapse :  Antigen During Relapse Blasto 2 years earlier→60d itra Relapse→itra 2 mo before To 2nd relapse 4 mo later, ↑Ag=16.1 → 3rd course itra What Tests Are Indicated:  What Tests Are Indicated Findings 26 yo Afr-Amer man from Ohio, healthy Non-productive cough ACE 120 Differential Infection: Hc, TB Sarcoid Lymphoma Histo vs. Sarcoid:  Histo vs. Sarcoid Methods for Early Diagnosis:  Methods for Early Diagnosis Antibody Response Slow:  Antibody Response Slow Slide26:  Symptoms % Seropositive Patients 0 10 20 30 40 50 60 70 80 90 100 Severe Moderate None Mild Larrabee Am J Trop Med Hyg 1978 CF Titer vs Symptoms (N=437):  CF Titer vs Symptoms (N=437) p <0.0001 *High titer: >1:128 † † Chi-square for trend 37% 48% 55% 77% Heavy vs. Light Inoculum :  Heavy vs. Light Inoculum Acute pulmonary Few weeks High fungal burden Sensitivity Hag antigen 80% Antibody <25% Subacute pulmonary Months Low fungal burden Sensitivity Hag <25% Antibody 90% R/O Histo Before Rx Sarcoidosis :  R/O Histo Before Rx Sarcoidosis Antibodies: ID & CF Antigen: Urine & BAL Bronchoscopy: BAL: cytology, antigen & culture TBBx: fungal stain & culture Differential & Work-Up?:  Differential & Work-Up? Clinical 32 yo non-smoker Military, OH Chest pain CT → Differential Granuloma Malignancy Work-up? HcAg Negative=Role Serology:  HcAg Negative=Role Serology Urine Hag 0.5 Antibody M-band, CFY 1:16 Histopathology → Culture Not done! Histo After Anti-TNF:  Histo After Anti-TNF Findings 50 wm from Indiana RA MTX and steroids Infliximab 10 weeks Fever and hypoxia Hag urine 10.3 BAL yeast % Reactivation if >50% ST+ :  % Reactivation if >50% ST+ Group #/total Incidence % BMT 0/147 0 SOT 0/449 0 --Sero+ 0/48 0 --CXR+ 0/23 0 Literature AIDS ~1 Infliximab <0.1 Etanercept <0.01 Smoldering or New Exposure:  Smoldering or New Exposure Rationale <0.1% too low for reactivation Why not 50-80%? Rate ~ endemic rate < 60 d after start infliximab Too early to reactivate Implications Screen pre anti-TNF Hag & antibody Screen during high risk: Infliximab: first 6 mo Etanercept: first year Workup illness Pulmonary symptoms Fever &weight loss

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