Metagenomic next-generation sequencing unveils invasive aspergillosis masquerading as miliary tuberculosis in a neutropenic leukemia patient: a case report.

Pulmonary invasive fungal infections (IFIs), particularly among immunocompromised individuals, are associated with substantial morbidity and mortality. This study aimed to evaluate the clinical profile, underlying risk factors, and diagnostic performance of the galactomannan (GM) antigen assay in the diagnosis of Invasive Pulmonary Aspergillosis (IPA). A cross-sectional observational study was conducted over 12 months at the Himalayan Institute of Medical Sciences, Dehradun, India. A total of 224 patients with suspected pulmonary IFIs were enrolled. Cases were classified as Proven, Probable, Possible, or No IFI based on the EORTC/MSG, Invasive Fungal Diseases in Adult Patients in Intensive Care Unit (FUNDICU) criteria. Respiratory and serum samples were analysed using direct potassium hydroxide (KOH) microscopy, fungal culture, and GM antigen detection via lateral flow assay. Diagnostic accuracy was determined using standard statistical analyses. Of the 224 patients, 46.4% were classified as Proven or Probable IFI, 34.8% as Possible, and 18.8% as No IFI. dyspnoea (p=0.002) was the most strongly associated symptom. Significant risk factors included asthma/COPD (52.9%, p=0.001), diabetes mellitus (36.5%, p=0.028), immunosuppression (37.5%, p<0.001). Fungal culture was positive in 30.3% of cases, with Aspergillus flavus and A. fumigatus as the predominant isolates. A bronchoalveolar lavage fluid (BALF) GM optical density index (ODI) cut-off of ≥1.0 achieved balanced sensitivity (55.56%) and specificity (75.86%). The GM assay in BALF at an ODI threshold of ≥1.0 showsmodest discriminative ability for the early detection of invasive pulmonary aspergillosis (IPA). Incorporating GM testing alongside conventional diagnostics enhances early identification and facilitates prompt antifungal therapy.

Technical aspects of uniportal video-assisted thoracoscopic sleeve resections: Where are the limits?

Selective lobar bronchial blockade following contralateral pneumonectomy.

In recent years, various biomarkers have been gradually applied on bronchoalveolar lavage (BAL) fluid for the diagnosis of invasive pulmonary aspergillosis (IPA). The objective of this study is to assess the value of the liquid-based cytopathology test (LCT) for improving the identification of IPA in BAL fluid from possible IPA patients, following special staining with periodic acid-Schiff staining (PAS) or Grocott's methenamine silver (GMS). A total of 47 consecutive possible IPA patients who underwent bronchoscopy with BAL fluid from January 2017 to December 2018 were included. 45 people had a pair of BAL fluid specimens and 2 patients had two BAL fluid specimens. The 49 pairs of BAL fluid specimens were processed for culture, tuberculosis acid fast staining smear, direct microbial smear, and LCT with special staining (PAS and GMS), respectively. Then, we compared the sensitivity and specificity of PAS and GMS in BAL fluid in high-risk patients. Among 47 possible IPA patients, 25 patients had proven/probable IPA, and 11 patients had other invasive fungal diseases. The sensitivity of GMS was higher than that of PAS (92.11% versus 81.58%; P = 0.175). The specificity of GMS was 81.82%, which was higher than that of PAS (81.82% versus 72.73%; P = 0.611). The negative predictive value (NPV) for PAS and GMS were 53.33% and 75.00%, respectively. The positive predictive value (PPV) for PAS and GMS were 91.18% and 94.59%, respectively. This study showed that special staining of LCT in BAL fluid may be a novel method for the diagnosis of IPA, and the GMS of LCT had higher sensitivity and specificity, which was superior to PAS.

To evaluate the value of (1, 3)-β-D-glucan (G test) in bronchoalveolar lavage fluid (BALF) in diagnosing and determining the therapeutic effects among the critically ill patients suspected with invasive pulmonary fungal infection (IPFI). Study was conducted between February 2010 and August 2011 in medical intensive care unit (MICU) of the Affiliated Hospital of Guiyang Medical College. Patients suspected of suffering from IPFI were enrolled. G tests of BALF and serum, and culture and microscopic examination of BALF were performed twice weekly.Clinical feature, mycological evidence and the results of G test were recorded. The results of IPFI were defined as "proven", "probable", "possible" and "non-IPFI". G test in BALF and serum was done with tachypleus amebocyte lysate. Positive G test was defined as cut-off index ≥20 ng/L in two consecutive measurements. Furthermore, the patients with positive G test received preemptive antifungal therapy with fluconazole or itraconazole. G tests of BALF and serum were respectively done on 7th day and 14th day of treatment. Ninety-eight patients were included. Among them, 10 patients were "proven" in whom the positive rate of BALF G test was 90.0%; 29 patients the results were considered as "probable" in whom the positive rate of BALF G test was 82.8%; in 32 patients the results were "possible" IPFI in whom the positive rate of BALF G test was 71.9%, 27 patients were "non-IPFI" in whom the positive rate of BALF G test was 7.4%. The positive rate of BALF G test was 84.6% (33/39), the positive rate of serum G test was 59.0% (23/39), the positive rate of culture of BALF was 41.0% (16/39), the positive rate of microscopic examination of BALF was 38.5% (15/39) in "proven" cases and "probable" cases. G test (cut-off ≥20 ng/L) of BALF had shown to have sensitivity, specificity, positive predictive value (PPV) of 84.6% (33/39), 92.6% (25/27), 94.3% (33/35), respectively, and negative predictive value (NPV) of 80.7% (25/31). The G test detection (cut-off ≥20 ng/L) in serum had shown to have sensitivity, specificity, PPV of 58.9% (23/39), 88.9% (24/27), 88.5%(23/26), respectively, and NPV of 60.0% (24/40), and the differences in sensitivity were statistically significant (P < 0.05). BALF G test assay tended to become positive earlier than the culture for 2-8 days with mean of (5.35 ± 2.26) days.Forty out of 56 G test positive patients were given preemptive antifungal therapy for 2 weeks, and there was a good response in 31 patients, but no response in 9 cases with 22.5% mortality. After treatment, the result of G test (ng/L) was lowered in patients with a good response in treatment group (BALF: 245.13 ± 43.84, 174.00 ± 13.01, 28.52 ± 7.38; serum: 93.26 ± 18.75, 72.15 ± 12.90, 37.37 ± 10.45, all P < 0.05). On the other hand, an elevated value suggested an unsatisfactory result in ineffective group (BALF: 267.58 ± 54.63, 309.71 ± 82.47, 486.72 ± 98.21; serum: 101.58 ± 12.75, 98.07 ± 27.45, 112.07 ± 19.21, all P < 0.05). There were significantly differences in the results of G tests on 7th day and 14th day between BALF G test and serum G test in both groups (all P < 0.05). It is suggested that BALF G test may be an useful test for early diagnosis of IPFI. Moreover, the dynamic change in G test values could be useful for assessing therapeutic response.

Invasive pulmonary aspergillosis (IPA) is frequent and often fatal in immunosuppressed patients. Timely diagnosis of IPA improves survival but is difficult to make. We examined the analytical and clinical validity of galactomannan (GM) testing of bronchoalveolar lavage (BAL) fluid in diagnosing IPA in a mixed population by retrospectively reviewing records of 251 consecutive at-risk patients for whom BAL fluid GM testing was ordered. The performance of the enzyme immunoassay was evaluated by using a range of index cutoffs to define positivity. Three samples were associated with proven IPA, 56 were associated with probable IPA, 63 were associated with possible invasive fungal disease (IFD), and 129 were associated with no IFD. Using a BAL fluid GM index of ≥0.8 (optimal optical density [OD] index cutoff identified by a receiver operating characteristic curve), the sensitivity in diagnosing proven and probable IPA was 86.4%, and the specificity was 90.7%. At this cutoff, positive and negative predictive values were 81% and 93.6%, respectively. However, an OD index value of ≥3.0 corresponded to a 100% specificity, thus ruling the disease in, irrespective of the pretest probability. Conversely, an OD index cutoff of <0.5 corresponded to a high sensitivity, virtually always ruling the disease out. For all values in between, the posttest probability of IPA depends largely on the prevalence of disease in the at-risk population and the likelihood ratio of the OD index value. Detection of GM in BAL fluid samples of patients at risk of IPA has an excellent diagnostic accuracy provided results are interpreted in parallel with clinico-radiological findings and pretest probabilities.

The rising number of immunocompromised people has increased concerns about fungal infections as a severe public health issue. Invasive pulmonary fungal infections (IPFIs) are prevalent and often fatal, particularly for those with weakened immune systems. Understanding IPFIs is crucial. The work aims to offer a concise overview of the field’s characteristics, main research areas, development paths, and trends. This study searched the Web of Science Core Collection on June 5, 2024, collecting relevant academic works from 2003 to 2023. Analysis was conducted using CiteSpace, VOSviewer, Bibliometrix Package in R, Microsoft Excel 2019, and Scimago Graphica. The study indicated that the USA, the University of Manchester, and Denning DW led in productivity and impact, while the Journal of Fungi topped the list in terms of publication volume and citations. High-frequency terms include “fungal infection,” “invasive,” “diagnosis,” and “epidemiology.” Keyword and trend analysis identified “influenza,” “COVID-19,” “invasive pulmonary aspergillosis,” and “metagenomic next-generation sequencing” as emerging research areas. Over the last 2 decades, research on IPFI has surged, with topics becoming more profound. These insights offer key guidance on current trends, gaps, and the trajectory of IPFI studies.

Invasive pulmonary aspergillosis (IPA) is a leading cause of morbidity and mortality in haematological malignancy patients and hematopoietic stem cell transplant recipients1. Detection of IPA represents a formidable diagnostic challenge and, in the absence of a 'gold standard', relies on a combination of clinical data and microbiology and histopathology where feasible. Diagnosis of IPA must conform to the European Organization for Research and Treatment of Cancer and the National Institute of Allergy and Infectious Diseases Mycology Study Group (EORTC/MSG) consensus defining "proven", "probable", and "possible" invasive fungal diseases2. Currently, no nucleic acid-based tests have been externally validated for IPA detection and so polymerase chain reaction (PCR) is not included in current EORTC/MSG diagnostic criteria.Identification of Aspergillus in histological sections is problematic because of similarities in hyphal morphologies with other invasive fungal pathogens3, and proven identification requires isolation of the etiologic agent in pure culture. Culture-based approaches rely on the availability of biopsy samples, but these are not always accessible in sick patients, and do not always yield viable propagules for culture when obtained.An important feature in the pathogenesis of Aspergillus is angio-invasion, a trait that provides opportunities to track the fungus immunologically using tests that detect characteristic antigenic signatures molecules in serum and bronchoalveolar lavage (BAL) fluids. This has led to the development of the Platelia enzyme immunoassay (GM-EIA) that detects Aspergillus galactomannan and a 'pan-fungal' assay (Fungitell test) that detects the conserved fungal cell wall component (1 →3)-β-D-glucan, but not in the mucorales that lack this component in their cell walls1,4. Issues surrounding the accuracy of these tests1,4-6 has led to the recent development of next-generation monoclonal antibody (MAb)-based assays that detect surrogate markers of infection1,5.Thornton5 recently described the generation of an Aspergillus-specific MAb (JF5) using hybridoma technology and its use to develop an immuno-chromatographic lateral-flow device (LFD) for the point-of-care (POC) diagnosis of IPA. A major advantage of the LFD is its ability to detect activity since MAb JF5 binds to an extracellular glycoprotein antigen that is secreted during active growth of the fungus only5. This is an important consideration when using fluids such as lung BAL for diagnosing IPA since Aspergillus spores are a common component of inhaled air. The utility of the device in diagnosing IPA has been demonstrated using an animal model of infection, where the LFD displayed improved sensitivity and specificity compared to the Platelia GM and Fungitell (1 → 3)-β-D-glucan assays7.Here, we present a simple LFD procedure to detect Aspergillus antigen in human serum and BAL fluids. Its speed and accuracy provides a novel adjunct point-of-care test for diagnosis of IPA in haematological malignancy patients.

Invasive fungal disease (IFD) early diagnosis improves hematological patient survival. Non-culture-based methods may reduce diagnostic time to identify IFD. As complex data on the value of 1,3-β-d-glucan (BDG) from bronchoalveolar lavage fluid (BALF) compared to serum for the most frequent invasive pulmonary aspergillosis (IPA) diagnosis are scarce, particularly including evaluation of potential factors adversely affecting BDG assay, we provided prospective single-center analysis evaluating 172 episodes of pulmonary infiltrates with BDG detection in BALF and serum samples collected in parallel among hematological patients from 2006 to 2015. Proven and probable IPA were documented in 13.4% of the episodes. Sensitivity (SEN), specificity (SPE), positive and negative predictive value (PPV; NPV), and diagnostic odds ratio (DOR) of the BDG assay using standard (80 pg/ml) cut-off for BALF were: 56.5%; 83.2%; 34.2%; 92.5%, and 6.5, respectively, and for serum were: 56.5%; 82.6%; 33.3%; 92.5%, and 6.2, respectively. The same BDG assay parameters employing a calculated optimal cut-off for BALF (39 pg/ml) were: 78.3%; 72.5%; 30.5%; 95.6%, and 9.5, respectively; and for serum (40 pg/ml) were: 73.9%; 69.1%; 27.0%; 94.5%, and 6.3, respectively. While identifying acceptable SEN, SPE, and DOR, yet low PPV of both BALF and serum BDG assay for IPA diagnosis, neither the combination of both materials nor the new optimal BDG cut-off led to significant test quality improvement. Absolute neutrophil count and aspirated BALF volume with a significant trend affected BDG assay performance. The BDG test did not outperform galactomannan assay.

Clinical experience with the impact of serum biomarkers for invasive fungal disease (IFD) varies markedly in hemato-oncology. Invasive pulmonary aspergillosis (IPA) is the most common manifestation, so we evaluated biomarkers in bronchoalveolar lavage (BAL) fluid. An Aspergillus-specific lateral-flow device (LFD), quantitative real-time PCR (qPCR), and the galactomannan (GM) test were used with 32 BAL fluid samples from 32 patients at risk of IPA. Eight patients had proven IPA, 3 had probable IPA, 6 had possible IPA, and 15 patients had no IPA by European Organization for Research and Treatment of Cancer Invasive Fungal Infections Cooperative Group/Mycoses Study Group of the National Institute of Allergy and Infectious Diseases (EORTC/MSG) criteria. The diagnostic accuracies of the tests were evaluated, and pairwise agreement between biomarkers was calculated. The diagnostic performance of the EORTC/MSG criteria was evaluated against the test(s) identified to be the most useful for IPA diagnosis. Using the EORTC/MSG criteria, the sensitivities of qPCR and LFD were 100% and the sensitivity of the GM test was 87.5% (GM test index cutoff, >0.8), with the tests having specificities of between 66.7 and 86.7%. The agreement between the results of qPCR and LFD was almost perfect (Cohen's kappa coefficient = 0.93, 95% confidence interval, 0.81 to 1.00). LFD and qPCR combined had a sensitivity of 100% and a specificity of 85.7%. Calcofluor staining and culture of all BAL fluid samples were negative for fungal infection. The median time from the start of mold-active antifungal therapy to the time of collection of BAL fluid was 6 days. Reversing roles and using dual testing by LFD and qPCR to classify cases, the EORTC/MSG criteria had a sensitivity of 83.3%. All three tests are useful for the diagnosis of IPA in BAL fluid samples. Despite the significant delays between the start of antifungal therapy and bronchoscopy, unlike microscopy and culture, the biomarkers remained informative. In particular, the combination of LFD and qPCR allows the sensitive and specific detection of IPA.

Intentional Occlusion of the Right Upper Lobe Bronchial Orifice to Tamponade Life-threatening Hemoptysis

Prevalence of putative invasive pulmonary aspergillosis in critically ill patients with COVID-19

The diagnosis of invasive pulmonary aspergillosis (IPA) diseases in non-neutropenic patients remains challenging. It is essential to develop optimal non-invasive or minimally invasive detection methods for the rapid and reliable diagnosis of IPA. Metagenomic next-generation sequencing (mNGS) in bronchoalveolar lavage fluid (BALF) can be a valuable tool for identifying the microorganism. Our study aims to evaluate the performance of mNGS in BALF in suspected IPA patients and compare it with other detection tests, including serum/BALF galactomannan antigen (GM) and traditional microbiological tests (BALF fungal culture and smear and lung biopsy histopathology). Ninety-four patients with suspicion of IPA were finally enrolled in our study. Thirty-nine patients were diagnosed with IPA, and 55 patients were non-IPA. There was significance between the IPA and non-IPA groups, such as BALF GM (P < 0.001), history of glucocorticoid use (P = 0.004), and pulmonary comorbidities (P = 0.002), as well as no significance of the other demographic data including age, sex, BMI, history of cigarette, blood GM assay, T-SPOT.TB, and NEUT#/LYMPH#. The sensitivity of the BALF mNGS was 92.31%, which was higher than that of the traditional tests or the GM assays. The specificity of BALF mNGS was 92.73%, which was relatively similar to that of the traditional tests. The AUC of BALF mNGS was 0.925, which presented an excellent performance compared with other traditional tests or GM assays. Our study demonstrated the important role of BALF detection by the mNGS platform for pathogen identification in IPA patients with non-neutropenic states, which may provide an optimal way to diagnose suspected IPA disease.

Diagnostics of Pulmonary Aspergillosis in Critically Ill Hematological and Non-Hematological Patients in the Intensive Care Unit By Combined Use of Galactomannan, 1-3-Beta-D-Glucan, Aspergillus Specific PCR and Conventional Culture in Concurrent Blood and Bronchoalveolar Lavage Samples — Results of a Multicenter Prospective Pilot Study

To the Editor: During the coronavirus disease 2019 (COVID-19) pandemic in China, cadaveric organ donation became drastically reduced, which exacerbated the waitlist morbidity and mortality of lung transplant (LTx) patients. We report a case where we were able to maximize the utilization of the lungs from a single cadaveric donor by performing a single left LTx for one recipient using the donor's left lung, and by bipartitioning the donor's right lung, we were able to perform bilateral lobar transplantation for another recipient. Recipient 1 was a 67-year-old female with Sjogren syndrome related interstitial fibrosis whose condition was complicated by superimposed bilateral pneumonia. Recipient 2 was a 67-year-old male with pulmonary fibrosis. In February 2020, the conditions of these two patients rapidly deteriorated. The organ donor was a 48-year-old male who developed cerebral hemorrhage during the COVID-19 pandemic. Three consecutive nucleic acid tests on bronchoalveolar lavage and rectal swabs from the donor were negative for COVID-19. The predicted total lung capacities (pTLC) were as follows: donor, 7.14 L; recipient 1, 4.37 L; recipient 2, 6.74 L. During the COVID 19 pandemic, organ donation activity became drastically reduced, and given the pTLC values shown above, we decided to bipartition the donor's right lung for bilateral lobar transplantation for recipient 1, and to use the donor's left lung for a single left LTx for recipient 2. The donor's right upper lobe was partitioned from the right middle and lower lobes. The left atrial cuff of the right lung was inspected and three separate openings were observed for the venous drainage corresponding to each of the three lobes. The atrial cuff on the right side was divided as follows: one part contained the right upper lobe pulmonary vein, while the other part contained the right middle and lower lobe pulmonary veins [Figure 1A–C]. The right pulmonary artery was divided distal to the posterior ascending artery. The right bronchial tree was divided at the level of the bronchus intermedius.Figure 1: (A) Bipartitioning of the donor right lung—division of the left pulmonary artery. (B) Donor right upper lobe. (C) Donor right middle and lower lobes. (D) Schematic diagram showing splitting of the donor lung. Recipient 1: Donor right lung was bipartitioned for bilateral lobar transplantation. Donor right upper lobe underwent right-to-left inversion for lobar transplantation. Donor right middle/lower lobes were implanted in the right chest. Recipient 2: Single left lung transplantation. (E) 3D reconstruction of bronchial tree after bilateral lobar transplant in recipient 1. (F) 3D reconstruction of vascular structures after bilateral lobar transplant in recipient 1. (G) CT chest of Recipient 1 before bilateral lobar transplantation. (H) CT chest of recipient 1 after bilateral lobar transplantation. CT: Computed tomography.Bilateral anterolateral thoracotomy was performed and veno-venous extracorporeal membrane oxygenation (ECMO) was established for recipient 1. After a right pneumonectomy, the donor's right middle/lower lobes were implanted. The recipient's right main bronchus was anastomosed to the donor's bronchus intermedius with continuous 4/0 polydioxanone (PDS). The recipient's right main pulmonary artery was anastomosed to the donor's interlobar pulmonary artery with continuous 5/0 prolene, taking into account the length of the bronchus, to ensure that there was neither undue tension, nor excessive length. The recipient's left atrium was anastomosed to the donor's atrial cuff (containing the veins draining the right middle and lower lobes) using continuous 4/0 prolene. Next, a left pneumonectomy was performed with preservation of a long length of the recipient left main pulmonary artery and bronchus. A "right-to-left inverted" lobar transplantation using the right upper lobe graft was performed by placing it inside the left chest after rotating 180° along the vertical axis. The recipient left main bronchus and the donor right upper lobe bronchus were trimmed, and anastomosed with 4/0 PDS; the recipient left main pulmonary artery was anastomosed to the donor right upper lobe pulmonary artery with 5/0 prolene; the recipient left superior pulmonary vein was anastomosed directly to the donor right superior pulmonary vein with 4/0 prolene. After inflation, both grafts appeared to fit well within the recipient chest cavity [Figure 1D]. ECMO was weaned on post-operative day (POD) 2, and the patient was extubated on POD 3. The patient was discharged on POD 33. Post-operative imaging confirmed patent airway and vascular anastomoses [Figure 1E–H]. Follow-up evaluation was made eight months after the operation, and the patient was well with no significant complications. Functional assessments are as follows: forced expiratory volume in 1 s 1.22 L (75% predicted), forced vital capacity 1.32 L (66% predicted), total lung capacity (TLC) 2.43 L (59% predicted), residual volume (RV) 1.28 L (70% predicted), RV/TLC 52.5% (124% predicted). The patient achieved 380 m on her 6-min walk test, with no desaturation. A transthoracic echocardiogram showed an ejection fraction of 63%. There was mild to moderate regurgitation, and a pulmonary artery systolic pressure of 54 mmHg. The bronchial anastomoses appeared satisfactory. A single left LTx was performed with intra-operative veno-arterial ECMO support for recipient 2, and good size match between the graft and the recipient was observed. ECMO was weaned on POD 3, and the patient was extubated on POD 4. The patient was discharged on POD 29. There were no complications at the 8-month follow-up. Pulmonary fibrosis patients may deteriorate rapidly, and they constitute the commonest group for cadaveric lobar transplantation.[1] Donor size-matching may be challenging because of the small chest cavities of these patients. Recipient 1 had bilateral pneumonia, and therefore single LTx was not suitable and she required bilateral lung transplantation. Recipient 2, however, was suitable for single LTx. By splitting the donor lungs as described, we maximized the utilization of the available organ at a time of severe donor scarcity, and we were able to perform transplantation for both recipients who were rapidly deteriorating. During the COVID-19 pandemic, the Chinese national guidelines were followed to reduce the risk of transmission of infection from organ donors.[2] Assessments include severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid test on at least two occasions, influenza A and B antigens, H7N9 nuclei acid testing, next generation sequencing of the lower respiratory tract samples, lower respiratory tract microbiologic culture, and computed tomography of the chest. For suspected SARS-CoV-2 patients, additional tests should be performed for nasal, sputum, lower respiratory tract, blood, and fecal samples. While graft downsizing by wedge resection is an option, when the donor/recipient pTLC mismatch exceeds 1 L, downsizing by lobectomy is recommended.[1] Couetil et al[3] first reported bipartitioning of a cadaveric donor left lung for bilateral lobar LTx. The use of inverted lobar LTx has been described in living lobar LTx, usually implanting a donor right lower lobe or middle lobe to the left side.[4] Recently, the Okayama group reported a case of lobar LTx with transplantation of a cadaveric right upper lobe to the left side.[5] The satisfactory early and mid-term post-transplant outcomes of our recipients demonstrate the feasibility of donor lung bipartitioning for lobar transplantation as a strategy to maximize donor lung utilization. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Conflicts of interest None.