Diagnostic Strategies for Invasive Fungal Infections in Patients With Hematologic Malignancies and Hematopoietic Stem Cell Transplant Recipients

Authors: Maxim Norkin MD, PhD 1 and John R. Wingard MD 1
View More View Less
  • 1 From the Division of Hematology/Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, Florida.

Invasive fungal infections (IFIs) frequently occur and are associated with high morbidity and mortality in patients with hematologic malignancies (HMs) and hematopoietic stem cell transplant (HSCT) recipients. Early diagnosis of IFI in these patients facilitates prompt institution of therapy and leads to improved clinical outcomes. This article reviews widely used methodologies for diagnosing IFIs in patients with HM and HSCT recipients. Advantages and limitations of radiologic studies; microbiologic and histopathologic techniques; fungal biomarker assays, including those for galactomannan antigen and β-(1-3)-D-glucan; and molecular assays that are available to establish an early diagnosis of clinically relevant invasive fungal infections are discussed. Recommendations are provided regarding effective use of these methodologies in clinical practice.

Because of prolonged neutropenia and severe immunosuppression, patients with hematologic malignancies (HMs) and hematopoietic stem cell transplant (HSCT) recipients are at high risk for invasive fungal infections (IFIs), which are associated with substantial mortality in patients with HMs and are the leading cause of infectious mortality in HSCT recipients. Early and accurate diagnosis of IFI can guide the most optimal treatment and lead to improved clinical outcomes.

Candida spp and Aspergillus spp are the most common fungal pathogens in HMs and HSCT recipients and are the subject of this article. Candida is a commensal organism, constituting part of the normal flora of the gastrointestinal tract, residing on oral and gut mucosal surfaces and skin. The most common portal of entry is through breaches in mucosa or through the skin. Locally invasive mucosal infections and fungemia are the most common Candida syndromes observed in this patient population. Less commonly, hepatosplenic candidiasis may occur. In contrast, Aspergillus is an air-borne organism, and the usual portal of entry is the nasal passages and respiratory tract. Pneumonia is the most common Aspergillus clinical syndrome, with sinusitis, orbital cellulitis, and disseminated infection less commonly seen.

Candida infections of the mucosa occur early and throughout the course of neutropenia and/or immunosuppressive therapy. Candida fungemia is rarely the cause of first neutropenic fever, but may be a cause of persistent or recurrent neutropenic fevers; it is not responsive to empiric antibiotics and is typically seen late during the first or second week of neutropenia or later. In contrast, invasive aspergillosis (IA) typically develops beyond 2 weeks of neutropenia in patients with acute leukemia,1 particularly those with antecedent cytopenias or iron overload.2 For HSCT recipients, the highest risk for IA occurs within 100 days after HSCT, particularly in patients with graft-versus-host disease (GVHD) requiring administration of high doses of systemic steroids. Widespread use of azole prophylaxis has led to a substantial decline in the incidence of invasive candidiasis.3 IA and other invasive mold infections have now emerged as the major type of IFI in patients with HMs and HSCT recipients.4

Diagnostic Approaches

Early diagnosis of IFI is often challenging and requires careful consideration of clinical, radiologic, and laboratory parameters. The EORTC/Invasive Fungal Infections Cooperative Group and the Mycoses Study Group defined 3 categories of IFI: proven, probable, and possible, which are based on diagnostic certainty.5 Proven IFI requires microbiologic and/or histopathologic confirmation. However, microbiologic and histopathologic techniques have suboptimal sensitivity and specificity, are time-consuming, and frequently require invasive approaches to obtain tissue for diagnosis. To minimize these shortcomings, current diagnostic algorithms of IFIs rely more on radiology and antigen and molecular testing of clinical samples. In many cases, these newer methodologies can be performed with less-invasive means, yet allow timely and accurate diagnosis of IFI, often without the need for more invasive procedures to obtain tissue samples for microbiologic and/or histopathologic confirmation.

Radiologic Studies

Radiology does not have a substantive role in the diagnosis of most Candida syndromes, except for hepatosplenic candidiasis. Characteristic nodular hypodensities, especially with a bull’s eye appearance, in the liver and/or spleen should lead to a strong suspicion for hepatosplenic candidiasis. Histopathologically, these lesions are composed principally of inflammatory cells and are not abscesses. Accordingly, the syndrome is often silent (and the lesions not apparent) during deep neutropenia, and may first manifest at the time of neutrophil recovery.

In contrast, radiologic imaging is important for diagnosing IA. Although chest radiography (CXR) is often used because of its ease of performance, its diagnostic accuracy is suboptimal in patients with neutropenia. Therefore, CT of the chest is preferred, because CXR can be normal in up to 10% of patients with pulmonary IA, whereas only 3% of chest CT scans are falsely negative.6 High-resolution CT scans have a sensitivity of greater than 85%, a high negative predictive value of greater than 85%, and an average time gain of 5 days compared with CXR, and the information provided often leads to changes in clinical management.7,8 The pulmonary abnormalities caused by IA are generally nodular. In most patients with IA, lung nodules are at least 1 cm in diameter,9 multiple, bilateral, and often peripherally located.10 More-specific CT imaging signs of IA include a “halo sign,” wherein the central nodular area of fungal invasion is surrounded by a ground glass-appearing hemorrhage or a crescent sign. The halo sign is seen early in the course of IA, and develops in nearly two-thirds of patients.11 Initiation of anti-mold therapy at the time of a halo sign is associated with improved survival.12,13 Consolidation, cavities, and air crescent signs are also seen later. In appropriate clinical settings and with supporting microbiology, radiologic abnormalities, such as a dense, well-circumscribed nodule; an air crescent sign; or a cavity, are used as components of the diagnostic criteria for IA.5 Recent studies note that other types of infiltrates are also frequently seen with IA, including localized air space consolidation14 and tree-in-bud and ground glass opacities in an airway-invasive form of pulmonary aspergillosis (as contrasted with the more classic angioinvasive form).15 The radiologic abnormalities of pulmonary mucormycosis are similar to those of IA; however, the presence of concomitant sinusitis, multiple (>10) nodules, pleural effusion, and a history of prior voriconazole prophylaxis are more frequently present in mucormycosis than IA.16,17

Serial CT scans can also be useful to monitor the response to antifungal therapy. It can take several weeks or even months for radiologic pulmonary abnormalities related to IFI to fully resolve, and in patients with neutropenia they typically worsen during the first 7 to 10 days of therapy, but subsequently improve with continued antifungal treatment.18 Clinicians should also be aware that parenchymal infiltrates and clinical symptoms may appear or get worse during the recovery from severe neutropenia or withdrawal of immunosuppressive therapy, even in the case of microbiological response, because of enhancement of a neutrophil-driven inflammatory response at the sites of tissue damage by fungal pathogens (also known as immune reconstitution syndrome). Discrepancies in radiologic and clinical responses can be also seen if superimposed infection by viral, bacterial, or another mold pathogen is present. In these situations, monitoring with serial serologic markers is helpful in identifying microbiologically responding patients with worsening clinical symptoms.19 Besides pulmonary abnormalities, other radiologic abnormalities suggestive of invasive infection in the sinuses, central nervous system infections, or liver or spleen abscesses in appropriate clinical context should alert the clinician to the possible diagnosis of IFI.5

Microbiologic and Histopathologic Techniques

Several relevant fungal pathogens can be isolated from peripheral blood, but the sensitivity of fungal blood cultures is low. For example, blood cultures remain negative in half of patients with disseminated candidiasis.20 Blood cultures are practically never positive in disseminated aspergillosis or mucormycosis.21 In patients with pulmonary IA, Aspergillus can be isolated from sputum, but in only 8% to 34% of cases; the diagnostic yield is increased to 45% to 62% when bronchoalveolar lavage (BAL) is performed and biomarker assays are performed on BAL samples (discussed later).22-24 In pulmonary mucormycosis, sputum cultures are positive in only 25% of cases and BAL does not increase the yield.25 The possibility of colonization by environmental fungi (such as Aspergillus spp) may lead to overdiagnosis and the risk of a false-positive diagnosis, particularly when upper respiratory secretions are used for diagnostic purposes. Identification of fungal elements invading tissue with associated inflammation or necrosis is considered to be a gold standard. Tissue biopsies of affected visceral organs typically do not produce false-positive results; however, these biopsies are frequently difficult to obtain because of the critical condition of the patient and the increased risk of bleeding because of concomitant severe thrombocytopenia, and false-negative results still occur because of inadequate sampling. In the presence of cutaneous involvement, punch biopsy of skin lesions often results in identification of the fungal pathogen, but fungal staining is important.

Visualization of yeasts or hyphae in tissue through microscopic examination should be followed by a culture to identify a specific organism, because morphologic identification alone is not sufficiently specific. Aspergillus is characterized by narrow, acute angle branching septated hypha, and in culture growth is visible within 3 days if the inoculum size is adequate. The hyphae of Fusarium in tissue look similar to those of Aspergillus. In tissue, the agents of mucormycosis have wider, ribbon-like, aseptate or pauci-septate hyphae, and these features help differentiate this pathogen from Aspergillus spp. Obtaining positive cultures from tissues infected by molds, particularly mucormycosis, is challenging given the difficulty of extracting viable fungi from infected tissues.26

Fungal Biomarker Assays

Because of the limitations of microbiologic techniques, noncultural methods such as galactomannan (GM) antigen; β-(1-3)-D-glucan (BDG) antigen; and PCR-based assays have been introduced,5,27-29 and the serum GM (Platelia Aspergillus, Bio-Rad Laboratories, Hercules, CA) and BDG (Fungitell, Associates of Cape Cod Inc., Falmouth, MA) assays have been evaluated in prospective studies. Both of these tests now are accepted as important diagnostic tests for the early detection of IFIs in patients with HMs and HSCT recipients.5

GM is a major component of the cell wall of Aspergillus spp and is released in the bloodstream during rapid growth of hyphae invading tissue. In patients with IA, serum GM positivity often precedes the development of clinical signs, radiologic abnormalities, or fungal growth in culture by up to a week.27 Besides Aspergillus spp, the serum GM assay also detects Penicillium spp, which rarely causes IFIs in humans in the Western Hemisphere. The validity of serum GM antigen monitoring has been evaluated in several retrospective and prospective studies with a wide range of reported sensitivities depending on the study population and definitions of the test positivity.27,30-38 In patients with HMs and HSCT recipients, the cutoff value of the serum GM antigen index has been established at 0.5 based on receiver operator characteristic analyses.39 In a meta-analysis, the GM assay in patients with HMs had a pooled specificity of 70% and sensitivity of 92%, and in HSCT recipients a pooled specificity of 86% and sensitivity of 82%.40 These estimates of sensitivity and specificity are based on serial testing of serum GM; the value of a single GM test result in patients with suspected IA is less accurate. Thus, the serum GM assay should be performed twice weekly prospectively in patients at high risk for IFI.13,41 The risk period for monitoring would correspond to neutropenia for patients with acute leukemia and the first 100 days after HSCT, or longer in the presence of persistent GVHD.

The serum GM assay also can provide prognostic utility. Very high GM levels at the beginning of antifungal therapy are associated with poorer prognosis than those with lower levels of positivity.42 Patients with IA whose GM tests become negative during the first 2 weeks of therapy have better survival compared with those with persistent GM positive tests.43

Although the biomarker tests offer great promise, they have limitations of both false-positive and false-negative test results. The accuracy of the GM assay can be affected by simultaneous use of piperacillin-tazobactam44,45 and amoxicillin-clavulanate46 because of the presence of trace GM in these antibiotic formulations, and the GM assay may remain falsely positive up to 5 days after discontinuation of these antibiotics. However, recent studies indicate fewer problems with false positivity with these antibiotics, presumably because of changes in manufacturing.47,48 The GM assay can also be falsely positive during an infection with Histoplasma capsulatum49 or Blastomyces dermatitidis50 because these microorganisms share cross-reactive antigens. Alternatively, the use of antifungal prophylaxis with agents having anti-mold activity could lead to falsely negative GM tests.31

Figure 1
Figure 1

Suggested diagnostic algorithm for evaluation of suspected pulmonary IFI in patients with HMs and HSCT recipients.

Abbreviations: BAL, bronchoalveolar lavage; GM, galactomannan; GMI, galactomannan index; HMs, hematologic malignancies; HSCT, hematopoietic stem cell transplant; IFI, invasive fungal infection.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 11, 8; 10.6004/jnccn.2013.0115

In addition to serum, GM can be detected in other body fluids that come in contact with infected tissues.51 The utility of the GM assay has been best studied in BAL samples. In patients with proven or probable IA, BAL GM has a high sensitivity of 90% to 94% and specificity of 79% to 94%,23,52 which exceeds the sensitivity and specificity of culture and microscopy23 and serum GM.24,53 This is important because historically bronchoscopy has a poor diagnostic yield for pulmonary IA, and the addition of transbronchial biopsy does not significantly increase the diagnostic yield but substantially increases the risk of complications, such as for bleeding or pneumothorax. However, studies indicate that the diagnostic yield of bronchoscopy can be increased from 22% to 30% up to 45% to 54% if the GM test is performed on BAL fluid.23,24 In the authors’ experience, one-third of patents who underwent bronchoscopy for suspected IA had the diagnosis confirmed by the BAL GM, despite negativity of all other mycological tests, including the serum GM.24 BAL and serum testing for Aspergillus biomarkers provide complementary information. Infection in some patients is detected through the serum GM and not BAL GM, and vice versa; sometimes GM is detected in both serum and BAL. This should not be surprising, because some forms of IA are angioinvasive, with GM principally secreted into the bloodstream, whereas others are airway, with GM principally secreted into respiratory secretions.

In contrast to the GM assay, the BDG assay detects the presence of numerous fungal pathogens, including Candida spp, Aspergillus spp, Pneumocystis spp, and Fusarium spp, with acceptable specificity and high sensitivity. However, like the GM assay, the BDG cannot detect the various agents of Mucormycosis spp or Cryptococcus spp.29 The strength of the BDG assay is the ability to detect a variety of the most common relevant fungal pathogens in patients with HMs and HSCT recipients; its weakness is its inability to discriminate which pathogen is detected. A recent meta-analysis, which included patients with HMs, showed that 2 consecutive positive BDG test results have the sensitivity of 50% and specificity of 99%, with positive and negative predictive values of 84% and 95%, respectively.54

Figure 2
Figure 2

Suggested diagnostic algorithm for evaluation of suspected sinus or orbital IFI in patients with HMs and HSCT recipients. aChest CT is recommended if suspicion of IFI is high.

Abbreviations: HMs, hematologic malignancies; HSCT, hematopoietic stem cell transplant; IFI, invasive fungal infection.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 11, 8; 10.6004/jnccn.2013.0115

Molecular Techniques

Molecular techniques most widely studied to date are primarily PCR assays for Aspergillus-specific DNA sequences or consensus sequences for a variety of fungal pathogens. A meta-analysis of PCR assays for IA showed that the sensitivity varied from 0.75 to 0.87 and the specificity varied from 0.87 to 0.75 depending on whether 1 or 2 consecutive positive samples were required, respectively.55 The data suggested that a single PCR-negative result could be sufficient to exclude a diagnosis of IA; however, 2 positive tests are required to best confirm the diagnosis. Despite good prospects for PCR assays, molecular techniques are not yet available for clinical use38 because of numerous methodological issues, particularly widespread environmental fungal contamination, difficulties in DNA extraction, and lack of standardization.56 PCR results are subject to significant variation depending on the choice of primers, DNA extraction techniques, and testing conditions, which adversely affect the reliability of test performance in different laboratories. Attempts to standardize PCR techniques for IA are now underway in Europe,57 and the expectations are that new molecular diagnostic techniques for several fungal pathogens will be available in upcoming years.

Practical Considerations and Conclusions

Early therapy for IFI improves outcomes. Therefore, when IFI is suspected, antifungal therapy should be promptly initiated and not delayed until a definitive diagnosis of IFI is made. Alongside initiating presumptive therapy, diagnostic assessment should be aggressively pursued, with appropriate use of imaging, microbiology, and serologic studies. Figures 1 and 2 offer a suggested diagnostic pathway. Because bacterial and fungal respiratory infections cannot be conclusively distinguished through imaging alone, antibiotics to cover gram-positive and gram-negative pathogens should also be started in acutely ill patients with HMs and HSCT recipients while diagnostic assessment proceeds. Once the diagnostic assessment is completed, adjustments to therapy should be made, and if bacterial causes are excluded, antibiotics can be discontinued. Clinicians must clearly understand the capabilities and limitations of each diagnostic approach for IFIs to appropriately use these methodologies (Table 1).

Table 1

Advantages and Limitations of Diagnostic Methodologies for IFI in Patients with HMs and HSCT Recipients

Table 1

The authors recommend using the new noninvasive biomarker diagnostic methods with serial monitoring along with clinical information to guide further evaluation and treatment decisions in patients suspected of IFI. The high negative predictive value of the biomarker assays makes it appropriate to withhold antifungal treatment in high-risk patients with persistent febrile neutropenia alone if they are receiving Candida prophylaxis, lack biomarker positivity, and have no clinical signs or imaging abnormalities suggestive of IFI.13 However, any high-risk patient with a nodular pulmonary infiltrate should be presumptively treated for mold IFI while definitive diagnostic assessment is being performed. The authors recommend bronchoscopic examination for testing of BAL samples for multiple pathogens and to include testing for GM. Addition of BAL GM testing dramatically improves the yield of bronchoscopy for diagnosis of IA and in patients with HMs and HSCT recipients with nodular pulmonary infiltrates. The authors do not ordinarily perform a lung biopsy. However, for sites other than lungs, tissue is often required for diagnosis if the serum markers are negative. Endoscopic examination of the sinuses with aspiration and biopsy, biopsy of dermal or subcutaneous lesions, or other invasive biopsy techniques should be considered as appropriate to establish or exclude the diagnosis of IFI and identify copathogens to guide treatment decisions, because radiologic findings can suggest but not establish the cause. However, even if invasive approaches fail to establish the diagnosis of IFI, in patients in whom strong clinical suspicion exists and relevant imaging abnormalities are seen, presumptive antifungal therapy should be considered for continuation, in the authors’ view if another cause cannot be established, given the diagnostic limitations of the microscopic examination and cultures, until a definitive diagnosis is established (Table 1).

Because of significant technical difficulties and disadvantages of invasive tissue biopsies and limitations of fungal microbiologic and histopathologic techniques, further development and clinical use of noninvasive assays have a great promise for improving the accuracy and promptness of IFI diagnosis in patients with HMs and HSCT. In the future, the hope is that molecular diagnostic techniques will help in diagnosing IFIs. The simultaneous use of different types of methodologies can offer complementary information to increase diagnostic accuracy, but is associated with higher costs and may require extra expertise, which may limit their use by clinical laboratories.

Dr. Norkin has disclosed that he has no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors. Dr. Wingard has disclosed that he is a consultant for Astellas Pharma US, Inc. and receives speaker’s honoraria from Pfizer Inc.

References

  • 1.

    Gerson SL, Talbot GH, Hurwitz S. Prolonged granulocytopenia: the major risk factor for invasive pulmonary aspergillosis in patients with acute leukemia. Ann Intern Med 1984;100:345351.

    • Search Google Scholar
    • Export Citation
  • 2.

    Kontoyiannis DP, Chamilos G, Lewis RE. Increased bone marrow iron stores is an independent risk factor for invasive aspergillosis in patients with high-risk hematologic malignancies and recipients of allogeneic hematopoietic stem cell transplantation. Cancer 2007;110:13031306.

    • Search Google Scholar
    • Export Citation
  • 3.

    Wingard JR, Leather H. A new era of antifungal therapy. Biol Blood Marrow Transplant 2004;10:7390.

  • 4.

    Kontoyiannis DP, Marr KA, Park BJ. Prospective surveillance for invasive fungal infections in hematopoietic stem cell transplant recipients, 2001-2006: overview of the Transplant-Associated Infection Surveillance Network (TRANSNET) database. Clin Infect Dis 2010;50:10911100.

    • Search Google Scholar
    • Export Citation
  • 5.

    De Pauw B, Walsh TJ, Donnelly JP. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) consensus group. Clin Infect Dis 2008;46:18131821.

    • Search Google Scholar
    • Export Citation
  • 6.

    Patterson TF, Kirkpatrick WR, White M. Invasive aspergillosis. Disease spectrum, treatment practices, and outcomes. I3 Aspergillus Study Group. Medicine (Baltimore) 2000;79:250260.

    • Search Google Scholar
    • Export Citation
  • 7.

    Heussel CP, Kauczor HU, Heussel GE. Pneumonia in febrile neutropenic patients and in bone marrow and blood stem-cell transplant recipients: use of high-resolution computed tomography. J Clin Oncol 1999;17:796805.

    • Search Google Scholar
    • Export Citation
  • 8.

    Barloon TJ, Galvin JR, Mori M. High-resolution ultrafast chest CT in the clinical management of febrile bone marrow transplant patients with normal or nonspecific chest roentgenograms. Chest 1991;99:928933.

    • Search Google Scholar
    • Export Citation
  • 9.

    Greene RE, Schlamm HT, Oestmann JW. Imaging findings in acute invasive pulmonary aspergillosis: clinical significance of the halo sign. Clin Infect Dis 2007;44:373379.

    • Search Google Scholar
    • Export Citation
  • 10.

    Milito MA, Kontoyiannis DP, Lewis RE. Influence of host immunosuppression on CT findings in invasive pulmonary aspergillosis. Med Mycol 2010;48:817823.

    • Search Google Scholar
    • Export Citation
  • 11.

    Greene R. The radiological spectrum of pulmonary aspergillosis. Med Mycol 2005;43(Suppl 1):S147154.

  • 12.

    Caillot D, Casasnovas O, Bernard A. Improved management of invasive pulmonary aspergillosis in neutropenic patients using early thoracic computed tomographic scan and surgery. J Clin Oncol 1997;15:139147.

    • Search Google Scholar
    • Export Citation
  • 13.

    Maertens J, Theunissen K, Verhoef G. Galactomannan and computed tomography-based preemptive antifungal therapy in neutropenic patients at high risk for invasive fungal infection: a prospective feasibility study. Clin Infect Dis 2005;41:12421250.

    • Search Google Scholar
    • Export Citation
  • 14.

    Nucci M, Nouer SA, Grazziutti M. Probable invasive aspergillosis without prespecified radiologic findings: proposal for inclusion of a new category of aspergillosis and implications for studying novel therapies. Clin Infect Dis 2010;51:12731280.

    • Search Google Scholar
    • Export Citation
  • 15.

    Bergeron A, Porcher R, Sulahian A. The strategy for the diagnosis of invasive pulmonary aspergillosis should depend on both the underlying condition and the leukocyte count of patients with hematologic malignancies. Blood 2012;119:18311837; quiz 1956.

    • Search Google Scholar
    • Export Citation
  • 16.

    Chamilos G, Marom EM, Lewis RE. Predictors of pulmonary zygomycosis versus invasive pulmonary aspergillosis in patients with cancer. Clin Infect Dis 2005;41:6066.

    • Search Google Scholar
    • Export Citation
  • 17.

    Kontoyiannis DP, Lionakis MS, Lewis RE. Zygomycosis in a tertiary-care cancer center in the era of Aspergillus-active antifungal therapy: a case-control observational study of 27 recent cases. J Infect Dis 2005;191:13501360.

    • Search Google Scholar
    • Export Citation
  • 18.

    Caillot D, Couaillier JF, Bernard A. Increasing volume and changing characteristics of invasive pulmonary aspergillosis on sequential thoracic computed tomography scans in patients with neutropenia. J Clin Oncol 2001;19:253259.

    • Search Google Scholar
    • Export Citation
  • 19.

    Miceli MH, Maertens J, Buve K. Immune reconstitution inflammatory syndrome in cancer patients with pulmonary aspergillosis recovering from neutropenia: proof of principle, description, and clinical and research implications. Cancer 2007;110:112120.

    • Search Google Scholar
    • Export Citation
  • 20.

    Berenguer J, Buck M, Witebsky F. Lysis-centrifugation blood cultures in the detection of tissue-proven invasive candidiasis. Disseminated versus single-organ infection. Diagn Microbiol Infect Dis 1993;17:103109.

    • Search Google Scholar
    • Export Citation
  • 21.

    Reimer LG, Wilson ML, Weinstein MP. Update on detection of bacteremia and fungemia. Clin Microbiol Rev 1997;10:444465.

  • 22.

    Wingard JR, Hiemenz JW, Jantz MA. How I manage pulmonary nodular lesions and nodular infiltrates in patients with hematologic malignancies or undergoing hematopoietic cell transplantation. Blood 2012;120:17911800.

    • Search Google Scholar
    • Export Citation
  • 23.

    Maertens J, Maertens V, Theunissen K. Bronchoalveolar lavage fluid galactomannan for the diagnosis of invasive pulmonary aspergillosis in patients with hematologic diseases. Clin Infect Dis 2009;49:16881693.

    • Search Google Scholar
    • Export Citation
  • 24.

    Nguyen MH, Leather H, Clancy CJ. Galactomannan testing in bronchoalveolar lavage fluid facilitates the diagnosis of invasive pulmonary aspergillosis in patients with hematologic malignancies and stem cell transplant recipients. Biol Blood Marrow Transplant 2011;17:10431050.

    • Search Google Scholar
    • Export Citation
  • 25.

    Kontoyiannis DP, Wessel VC, Bodey GP. Zygomycosis in the 1990s in a tertiary-care cancer center. Clin Infect Dis 2000;30:851856.

  • 26.

    Pagano L, Offidani M, Fianchi L. Mucormycosis in hematologic patients. Haematologica 2004;89:207214.

  • 27.

    Maertens J, Van Eldere J, Verhaegen J. Use of circulating galactomannan screening for early diagnosis of invasive aspergillosis in allogeneic stem cell transplant recipients. J Infect Dis 2002;186:12971306.

    • Search Google Scholar
    • Export Citation
  • 28.

    Florent M, Katsahian S, Vekhoff A. Prospective evaluation of a polymerase chain reaction-ELISA targeted to Aspergillus fumigatus and Aspergillus flavus for the early diagnosis of invasive aspergillosis in patients with hematological malignancies. J Infect Dis 2006;193:741747.

    • Search Google Scholar
    • Export Citation
  • 29.

    Ostrosky-Zeichner L, Alexander BD, Kett DH. Multicenter clinical evaluation of the (1-->3) beta-D-glucan assay as an aid to diagnosis of fungal infections in humans. Clin Infect Dis 2005;41:654659.

    • Search Google Scholar
    • Export Citation
  • 30.

    Wheat LJ. Rapid diagnosis of invasive aspergillosis by antigen detection. Transpl Infect Dis 2003;5:158166.

  • 31.

    Mennink-Kersten MA, Donnelly JP, Verweij PE. Detection of circulating galactomannan for the diagnosis and management of invasive aspergillosis. Lancet Infect Dis 2004;4:349357.

    • Search Google Scholar
    • Export Citation
  • 32.

    Herbrecht R, Letscher-Bru V, Oprea C. Aspergillus galactomannan detection in the diagnosis of invasive aspergillosis in cancer patients. J Clin Oncol 2002;20:18981906.

    • Search Google Scholar
    • Export Citation
  • 33.

    Maertens J, Verhaegen J, Lagrou K. Screening for circulating galactomannan as a noninvasive diagnostic tool for invasive aspergillosis in prolonged neutropenic patients and stem cell transplantation recipients: a prospective validation. Blood 2001;97:16041610.

    • Search Google Scholar
    • Export Citation
  • 34.

    Sulahian A, Boutboul F, Ribaud P. Value of antigen detection using an enzyme immunoassay in the diagnosis and prediction of invasive aspergillosis in two adult and pediatric hematology units during a 4-year prospective study. Cancer 2001;91:311318.

    • Search Google Scholar
    • Export Citation
  • 35.

    Pinel C, Fricker-Hidalgo H, Lebeau B. Detection of circulating Aspergillus fumigatus galactomannan: value and limits of the Platelia test for diagnosing invasive aspergillosis. J Clin Microbiol 2003;41:21842186.

    • Search Google Scholar
    • Export Citation
  • 36.

    Marr KA, Laverdiere M, Gugel A. Antifungal therapy decreases sensitivity of the Aspergillus galactomannan enzyme immunoassay. Clin Infect Dis 2005;40:17621769

    • Search Google Scholar
    • Export Citation
  • 37.

    Marr KA, Balajee SA, McLaughlin L. Detection of galactomannan antigenemia by enzyme immunoassay for the diagnosis of invasive aspergillosis: variables that affect performance. J Infect Dis 2004;190:641649.

    • Search Google Scholar
    • Export Citation
  • 38.

    Hope WW, Walsh TJ, Denning DW. Laboratory diagnosis of invasive aspergillosis. Lancet Infect Dis 2005;5:609622.

  • 39.

    Maertens JA, Klont R, Masson C. Optimization of the cutoff value for the Aspergillus double-sandwich enzyme immunoassay. Clin Infect Dis 2007;44:13291336.

    • Search Google Scholar
    • Export Citation
  • 40.

    Pfeiffer CD, Fine JP, Safdar N. Diagnosis of invasive aspergillosis using a galactomannan assay: a meta-analysis. Clin Infect Dis 2006;42:14171427.

    • Search Google Scholar
    • Export Citation
  • 41.

    Ji Y, Xu LP, Liu DH. Positive results of serum galactomannan assays and pulmonary computed tomography predict the higher response rate of empirical antifungal therapy in patients undergoing allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2011;17:759764.

    • Search Google Scholar
    • Export Citation
  • 42.

    Koo S, Bryar JM, Baden LR. Prognostic features of galactomannan antigenemia in galactomannan-positive invasive aspergillosis. J Clin Microbiol 2010; 48:12551260.

    • Search Google Scholar
    • Export Citation
  • 43.

    Woods G, Miceli MH, Grazziutti ML. Serum Aspergillus galactomannan antigen values strongly correlate with outcome of invasive aspergillosis: a study of 56 patients with hematologic cancer. Cancer 2007;110:830834.

    • Search Google Scholar
    • Export Citation
  • 44.

    Walsh TJ, Shoham S, Petraitiene R. 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;42:47444748.

    • Search Google Scholar
    • Export Citation
  • 45.

    Alhambra A, Cuetara MS, Ortiz MC. False positive galactomannan results in adult hematological patients treated with piperacillin-tazobactam. Rev Iberoam Micol 2007;24:106112.

    • Search Google Scholar
    • Export Citation
  • 46.

    Mattei D, Rapezzi D, Mordini N. False-positive Aspergillus galactomannan enzyme-linked immunosorbent assay results in vivo during amoxicillin-clavulanic acid treatment. J Clin Microbiol 2004;42:53625363.

    • Search Google Scholar
    • Export Citation
  • 47.

    Mikulska M, Furfaro E, Del Bono V. Piperacillin/tazobactam (Tazocin) seems to be no longer responsible for false-positive results of the galactomannan assay. J Antimicrob Chemother 2012;67:17461748.

    • Search Google Scholar
    • Export Citation
  • 48.

    Gerlinger MP, Rousselot P, Rigaudeau S. False positive galactomannan Platelia due to piperacillin-tazobactam. Med Mal Infect 2012;42:1014.

  • 49.

    Wheat LJ, Hackett E, Durkin M. Histoplasmosis-associated cross-reactivity in the BioRad Platelia Aspergillus enzyme immunoassay. Clin Vaccine Immunol 2007;14:638640.

    • Search Google Scholar
    • Export Citation
  • 50.

    Van Der Veer J, Lewis RJ, Emtiazjoo AM. Cross-reactivity in the Platelia Aspergillus enzyme immunoassay caused by blastomycosis. Med Mycol 2012;50:396398.

    • Search Google Scholar
    • Export Citation
  • 51.

    Klont RR, Mennink-Kersten MA, Verweij PE. Utility of Aspergillus antigen detection in specimens other than serum specimens. Clin Infect Dis 2004;39:14671474.

    • Search Google Scholar
    • Export Citation
  • 52.

    Guo YL, Chen YQ, Wang K. Accuracy of BAL galactomannan in diagnosing invasive aspergillosis: a bivariate metaanalysis and systematic review. Chest 2010;138:817824.

    • Search Google Scholar
    • Export Citation
  • 53.

    Becker MJ, Lugtenburg EJ, Cornelissen JJ. 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;121:448457.

    • Search Google Scholar
    • Export Citation
  • 54.

    Lamoth F, Cruciani M, Mengoli C. beta-Glucan antigenemia assay for the diagnosis of invasive fungal infections in patients with hematological malignancies: a systematic review and meta-analysis of cohort studies from the Third European Conference on Infections in Leukemia (ECIL-3). Clin Infect Dis 2012;54:633643.

    • Search Google Scholar
    • Export Citation
  • 55.

    Mengoli C, Cruciani M, Barnes RA. Use of PCR for diagnosis of invasive aspergillosis: systematic review and meta-analysis. Lancet Infect Dis 2009;9:8996.

    • Search Google Scholar
    • Export Citation
  • 56.

    Khot PD, Fredricks DN. PCR-based diagnosis of human fungal infections. Expert Rev Anti Infect Ther 2009;7:12011221.

  • 57.

    White PL, Mengoli C, Bretagne S. Evaluation of Aspergillus PCR protocols for testing serum specimens. J Clin Microbiol 2011;49:38423848.

If the inline PDF is not rendering correctly, you can download the PDF file here.

Correspondence: Maxim Norkin, MD, PhD, Division of Hematology/Oncology, Department of Medicine, University of Florida College of Medicine, PO Box 100278, Gainesville, FL 32610-0278. E-mail: norkinm@ufl.edu
  • View in gallery

    Suggested diagnostic algorithm for evaluation of suspected pulmonary IFI in patients with HMs and HSCT recipients.

    Abbreviations: BAL, bronchoalveolar lavage; GM, galactomannan; GMI, galactomannan index; HMs, hematologic malignancies; HSCT, hematopoietic stem cell transplant; IFI, invasive fungal infection.

  • View in gallery

    Suggested diagnostic algorithm for evaluation of suspected sinus or orbital IFI in patients with HMs and HSCT recipients. aChest CT is recommended if suspicion of IFI is high.

    Abbreviations: HMs, hematologic malignancies; HSCT, hematopoietic stem cell transplant; IFI, invasive fungal infection.

  • 1.

    Gerson SL, Talbot GH, Hurwitz S. Prolonged granulocytopenia: the major risk factor for invasive pulmonary aspergillosis in patients with acute leukemia. Ann Intern Med 1984;100:345351.

    • Search Google Scholar
    • Export Citation
  • 2.

    Kontoyiannis DP, Chamilos G, Lewis RE. Increased bone marrow iron stores is an independent risk factor for invasive aspergillosis in patients with high-risk hematologic malignancies and recipients of allogeneic hematopoietic stem cell transplantation. Cancer 2007;110:13031306.

    • Search Google Scholar
    • Export Citation
  • 3.

    Wingard JR, Leather H. A new era of antifungal therapy. Biol Blood Marrow Transplant 2004;10:7390.

  • 4.

    Kontoyiannis DP, Marr KA, Park BJ. Prospective surveillance for invasive fungal infections in hematopoietic stem cell transplant recipients, 2001-2006: overview of the Transplant-Associated Infection Surveillance Network (TRANSNET) database. Clin Infect Dis 2010;50:10911100.

    • Search Google Scholar
    • Export Citation
  • 5.

    De Pauw B, Walsh TJ, Donnelly JP. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) consensus group. Clin Infect Dis 2008;46:18131821.

    • Search Google Scholar
    • Export Citation
  • 6.

    Patterson TF, Kirkpatrick WR, White M. Invasive aspergillosis. Disease spectrum, treatment practices, and outcomes. I3 Aspergillus Study Group. Medicine (Baltimore) 2000;79:250260.

    • Search Google Scholar
    • Export Citation
  • 7.

    Heussel CP, Kauczor HU, Heussel GE. Pneumonia in febrile neutropenic patients and in bone marrow and blood stem-cell transplant recipients: use of high-resolution computed tomography. J Clin Oncol 1999;17:796805.

    • Search Google Scholar
    • Export Citation
  • 8.

    Barloon TJ, Galvin JR, Mori M. High-resolution ultrafast chest CT in the clinical management of febrile bone marrow transplant patients with normal or nonspecific chest roentgenograms. Chest 1991;99:928933.

    • Search Google Scholar
    • Export Citation
  • 9.

    Greene RE, Schlamm HT, Oestmann JW. Imaging findings in acute invasive pulmonary aspergillosis: clinical significance of the halo sign. Clin Infect Dis 2007;44:373379.

    • Search Google Scholar
    • Export Citation
  • 10.

    Milito MA, Kontoyiannis DP, Lewis RE. Influence of host immunosuppression on CT findings in invasive pulmonary aspergillosis. Med Mycol 2010;48:817823.

    • Search Google Scholar
    • Export Citation
  • 11.

    Greene R. The radiological spectrum of pulmonary aspergillosis. Med Mycol 2005;43(Suppl 1):S147154.

  • 12.

    Caillot D, Casasnovas O, Bernard A. Improved management of invasive pulmonary aspergillosis in neutropenic patients using early thoracic computed tomographic scan and surgery. J Clin Oncol 1997;15:139147.

    • Search Google Scholar
    • Export Citation
  • 13.

    Maertens J, Theunissen K, Verhoef G. Galactomannan and computed tomography-based preemptive antifungal therapy in neutropenic patients at high risk for invasive fungal infection: a prospective feasibility study. Clin Infect Dis 2005;41:12421250.

    • Search Google Scholar
    • Export Citation
  • 14.

    Nucci M, Nouer SA, Grazziutti M. Probable invasive aspergillosis without prespecified radiologic findings: proposal for inclusion of a new category of aspergillosis and implications for studying novel therapies. Clin Infect Dis 2010;51:12731280.

    • Search Google Scholar
    • Export Citation
  • 15.

    Bergeron A, Porcher R, Sulahian A. The strategy for the diagnosis of invasive pulmonary aspergillosis should depend on both the underlying condition and the leukocyte count of patients with hematologic malignancies. Blood 2012;119:18311837; quiz 1956.

    • Search Google Scholar
    • Export Citation
  • 16.

    Chamilos G, Marom EM, Lewis RE. Predictors of pulmonary zygomycosis versus invasive pulmonary aspergillosis in patients with cancer. Clin Infect Dis 2005;41:6066.

    • Search Google Scholar
    • Export Citation
  • 17.

    Kontoyiannis DP, Lionakis MS, Lewis RE. Zygomycosis in a tertiary-care cancer center in the era of Aspergillus-active antifungal therapy: a case-control observational study of 27 recent cases. J Infect Dis 2005;191:13501360.

    • Search Google Scholar
    • Export Citation
  • 18.

    Caillot D, Couaillier JF, Bernard A. Increasing volume and changing characteristics of invasive pulmonary aspergillosis on sequential thoracic computed tomography scans in patients with neutropenia. J Clin Oncol 2001;19:253259.

    • Search Google Scholar
    • Export Citation
  • 19.

    Miceli MH, Maertens J, Buve K. Immune reconstitution inflammatory syndrome in cancer patients with pulmonary aspergillosis recovering from neutropenia: proof of principle, description, and clinical and research implications. Cancer 2007;110:112120.

    • Search Google Scholar
    • Export Citation
  • 20.

    Berenguer J, Buck M, Witebsky F. Lysis-centrifugation blood cultures in the detection of tissue-proven invasive candidiasis. Disseminated versus single-organ infection. Diagn Microbiol Infect Dis 1993;17:103109.

    • Search Google Scholar
    • Export Citation
  • 21.

    Reimer LG, Wilson ML, Weinstein MP. Update on detection of bacteremia and fungemia. Clin Microbiol Rev 1997;10:444465.

  • 22.

    Wingard JR, Hiemenz JW, Jantz MA. How I manage pulmonary nodular lesions and nodular infiltrates in patients with hematologic malignancies or undergoing hematopoietic cell transplantation. Blood 2012;120:17911800.

    • Search Google Scholar
    • Export Citation
  • 23.

    Maertens J, Maertens V, Theunissen K. Bronchoalveolar lavage fluid galactomannan for the diagnosis of invasive pulmonary aspergillosis in patients with hematologic diseases. Clin Infect Dis 2009;49:16881693.

    • Search Google Scholar
    • Export Citation
  • 24.

    Nguyen MH, Leather H, Clancy CJ. Galactomannan testing in bronchoalveolar lavage fluid facilitates the diagnosis of invasive pulmonary aspergillosis in patients with hematologic malignancies and stem cell transplant recipients. Biol Blood Marrow Transplant 2011;17:10431050.

    • Search Google Scholar
    • Export Citation
  • 25.

    Kontoyiannis DP, Wessel VC, Bodey GP. Zygomycosis in the 1990s in a tertiary-care cancer center. Clin Infect Dis 2000;30:851856.

  • 26.

    Pagano L, Offidani M, Fianchi L. Mucormycosis in hematologic patients. Haematologica 2004;89:207214.

  • 27.

    Maertens J, Van Eldere J, Verhaegen J. Use of circulating galactomannan screening for early diagnosis of invasive aspergillosis in allogeneic stem cell transplant recipients. J Infect Dis 2002;186:12971306.

    • Search Google Scholar
    • Export Citation
  • 28.

    Florent M, Katsahian S, Vekhoff A. Prospective evaluation of a polymerase chain reaction-ELISA targeted to Aspergillus fumigatus and Aspergillus flavus for the early diagnosis of invasive aspergillosis in patients with hematological malignancies. J Infect Dis 2006;193:741747.

    • Search Google Scholar
    • Export Citation
  • 29.

    Ostrosky-Zeichner L, Alexander BD, Kett DH. Multicenter clinical evaluation of the (1-->3) beta-D-glucan assay as an aid to diagnosis of fungal infections in humans. Clin Infect Dis 2005;41:654659.

    • Search Google Scholar
    • Export Citation
  • 30.

    Wheat LJ. Rapid diagnosis of invasive aspergillosis by antigen detection. Transpl Infect Dis 2003;5:158166.

  • 31.

    Mennink-Kersten MA, Donnelly JP, Verweij PE. Detection of circulating galactomannan for the diagnosis and management of invasive aspergillosis. Lancet Infect Dis 2004;4:349357.

    • Search Google Scholar
    • Export Citation
  • 32.

    Herbrecht R, Letscher-Bru V, Oprea C. Aspergillus galactomannan detection in the diagnosis of invasive aspergillosis in cancer patients. J Clin Oncol 2002;20:18981906.

    • Search Google Scholar
    • Export Citation
  • 33.

    Maertens J, Verhaegen J, Lagrou K. Screening for circulating galactomannan as a noninvasive diagnostic tool for invasive aspergillosis in prolonged neutropenic patients and stem cell transplantation recipients: a prospective validation. Blood 2001;97:16041610.

    • Search Google Scholar
    • Export Citation
  • 34.

    Sulahian A, Boutboul F, Ribaud P. Value of antigen detection using an enzyme immunoassay in the diagnosis and prediction of invasive aspergillosis in two adult and pediatric hematology units during a 4-year prospective study. Cancer 2001;91:311318.

    • Search Google Scholar
    • Export Citation
  • 35.

    Pinel C, Fricker-Hidalgo H, Lebeau B. Detection of circulating Aspergillus fumigatus galactomannan: value and limits of the Platelia test for diagnosing invasive aspergillosis. J Clin Microbiol 2003;41:21842186.

    • Search Google Scholar
    • Export Citation
  • 36.

    Marr KA, Laverdiere M, Gugel A. Antifungal therapy decreases sensitivity of the Aspergillus galactomannan enzyme immunoassay. Clin Infect Dis 2005;40:17621769

    • Search Google Scholar
    • Export Citation
  • 37.

    Marr KA, Balajee SA, McLaughlin L. Detection of galactomannan antigenemia by enzyme immunoassay for the diagnosis of invasive aspergillosis: variables that affect performance. J Infect Dis 2004;190:641649.

    • Search Google Scholar
    • Export Citation
  • 38.

    Hope WW, Walsh TJ, Denning DW. Laboratory diagnosis of invasive aspergillosis. Lancet Infect Dis 2005;5:609622.

  • 39.

    Maertens JA, Klont R, Masson C. Optimization of the cutoff value for the Aspergillus double-sandwich enzyme immunoassay. Clin Infect Dis 2007;44:13291336.

    • Search Google Scholar
    • Export Citation
  • 40.

    Pfeiffer CD, Fine JP, Safdar N. Diagnosis of invasive aspergillosis using a galactomannan assay: a meta-analysis. Clin Infect Dis 2006;42:14171427.

    • Search Google Scholar
    • Export Citation
  • 41.

    Ji Y, Xu LP, Liu DH. Positive results of serum galactomannan assays and pulmonary computed tomography predict the higher response rate of empirical antifungal therapy in patients undergoing allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2011;17:759764.

    • Search Google Scholar
    • Export Citation
  • 42.

    Koo S, Bryar JM, Baden LR. Prognostic features of galactomannan antigenemia in galactomannan-positive invasive aspergillosis. J Clin Microbiol 2010; 48:12551260.

    • Search Google Scholar
    • Export Citation
  • 43.

    Woods G, Miceli MH, Grazziutti ML. Serum Aspergillus galactomannan antigen values strongly correlate with outcome of invasive aspergillosis: a study of 56 patients with hematologic cancer. Cancer 2007;110:830834.

    • Search Google Scholar
    • Export Citation
  • 44.

    Walsh TJ, Shoham S, Petraitiene R. 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;42:47444748.

    • Search Google Scholar
    • Export Citation
  • 45.

    Alhambra A, Cuetara MS, Ortiz MC. False positive galactomannan results in adult hematological patients treated with piperacillin-tazobactam. Rev Iberoam Micol 2007;24:106112.

    • Search Google Scholar
    • Export Citation
  • 46.

    Mattei D, Rapezzi D, Mordini N. False-positive Aspergillus galactomannan enzyme-linked immunosorbent assay results in vivo during amoxicillin-clavulanic acid treatment. J Clin Microbiol 2004;42:53625363.

    • Search Google Scholar
    • Export Citation
  • 47.

    Mikulska M, Furfaro E, Del Bono V. Piperacillin/tazobactam (Tazocin) seems to be no longer responsible for false-positive results of the galactomannan assay. J Antimicrob Chemother 2012;67:17461748.

    • Search Google Scholar
    • Export Citation
  • 48.

    Gerlinger MP, Rousselot P, Rigaudeau S. False positive galactomannan Platelia due to piperacillin-tazobactam. Med Mal Infect 2012;42:1014.

  • 49.

    Wheat LJ, Hackett E, Durkin M. Histoplasmosis-associated cross-reactivity in the BioRad Platelia Aspergillus enzyme immunoassay. Clin Vaccine Immunol 2007;14:638640.

    • Search Google Scholar
    • Export Citation
  • 50.

    Van Der Veer J, Lewis RJ, Emtiazjoo AM. Cross-reactivity in the Platelia Aspergillus enzyme immunoassay caused by blastomycosis. Med Mycol 2012;50:396398.

    • Search Google Scholar
    • Export Citation
  • 51.

    Klont RR, Mennink-Kersten MA, Verweij PE. Utility of Aspergillus antigen detection in specimens other than serum specimens. Clin Infect Dis 2004;39:14671474.

    • Search Google Scholar
    • Export Citation
  • 52.

    Guo YL, Chen YQ, Wang K. Accuracy of BAL galactomannan in diagnosing invasive aspergillosis: a bivariate metaanalysis and systematic review. Chest 2010;138:817824.

    • Search Google Scholar
    • Export Citation
  • 53.

    Becker MJ, Lugtenburg EJ, Cornelissen JJ. 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;121:448457.

    • Search Google Scholar
    • Export Citation
  • 54.

    Lamoth F, Cruciani M, Mengoli C. beta-Glucan antigenemia assay for the diagnosis of invasive fungal infections in patients with hematological malignancies: a systematic review and meta-analysis of cohort studies from the Third European Conference on Infections in Leukemia (ECIL-3). Clin Infect Dis 2012;54:633643.

    • Search Google Scholar
    • Export Citation
  • 55.

    Mengoli C, Cruciani M, Barnes RA. Use of PCR for diagnosis of invasive aspergillosis: systematic review and meta-analysis. Lancet Infect Dis 2009;9:8996.

    • Search Google Scholar
    • Export Citation
  • 56.

    Khot PD, Fredricks DN. PCR-based diagnosis of human fungal infections. Expert Rev Anti Infect Ther 2009;7:12011221.

  • 57.

    White PL, Mengoli C, Bretagne S. Evaluation of Aspergillus PCR protocols for testing serum specimens. J Clin Microbiol 2011;49:38423848.

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 217 83 0
PDF Downloads 33 19 1
EPUB Downloads 0 0 0