Practice Guidelines for the Diagnosis of COVID-19-Associated Pulmonary Aspergillosis in an Intensive Care Setting.

Coronavirus disease-2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a new disease characterized by secondary Aspergillus mold infection in patients with COVID-19. It primarily affects patients with COVID-19 in critical state with acute respiratory distress syndrome, requiring intensive care and mechanical ventilation. CAPA has a higher mortality rate than COVID-19, posing a serious threat to affected individuals. COVID-19 is a potential risk factor for CAPA and has already claimed a massive death toll worldwide since its outbreak in December 2019. Its second wave is currently progressing towards a peak, while the third wave of this devastating pandemic is expected to follow. Therefore, an early and accurate diagnosis of CAPA is of utmost importance for effective clinical management of this highly fatal disease. However, there are no uniform criteria for diagnosing CAPA in an intensive care setting. Therefore, based on a review of existing information and our own experience, we have proposed new criteria in the form of practice guidelines for diagnosing CAPA, focusing on the points relevant for intensivists and pulmonary and critical care physicians. The main highlights of these guidelines include the role of CAPA-appropriate test specimens, clinical risk factors, computed tomography of the thorax, and non-culture-based indirect and direct mycological evidence for diagnosing CAPA in the intensive care unit. These guidelines classify the diagnosis of CAPA into suspected, possible, and probable categories to facilitate clinical decision-making. We hope that these practice guidelines will adequately address the diagnostic challenges of CAPA, providing an easy-to-use and practical algorithm to clinicians for rapid diagnosis and clinical management of the disease.

A New and Highly Sensitive Serum Mannoprotein Lateral Flow Assay for Point-of-Care Diagnosis of Invasive Aspergillosis (Tripathy Method).

Background and objectives The mannoprotein lateral flow assay (MP-LFA) or Aspergillus-specific lateral flow device (AspLFD) is a novel rapid test for point-of-care diagnosis (PoC) of invasive aspergillosis (IA), but its routine clinical application is hampered due to low sensitivity (Sn) of the assay in serum. Therefore, this study aimed to develop a new method to enhance the Sn of the serum MP-LFA. Methodology In the new method (Tripathy method), we used direct heating of the serum without any dilution at 120°C for 15 minutes to purify the mannoprotein (MP) antigen of the Aspergillus. The MP-enriched serum supernatant obtained after centrifugation was loaded in an LFD cassette, and the results were read after 20 minutes using a digital cube reader. In parallel to our new method, AspLFD was performed according to the manufacturer's instructions. The diagnostic performance of the two methods was evaluated using paired sera of true IA patients (IA, n=18) and healthy subjects (controls, n=20). The positivity of the two methods was also evaluated in the sera of leukemia patients with possible/probable IA (possible/probable IA; n=23). Results The Tripathy method had a significantly higher sensitivity (88.9% versus 55.5%; p<0.05) and diagnostic odds ratio (72.0 versus 23.7) than the standard AspLFD method. In receiver operating characteristic curve analysis for differentiation between IA patients and controls, although the Tripathy method (area under curve; AUC: 0.894, p<0.001) and AspLFD method (AUC: 0.753, p<0.001) were significantly associated with IA, the AUC of the Tripathy method was significantly higher than that of the AspLFD method (0.894 versus 0.753; p<0.05). In the sera of possible/probable IA, MP-LFA by the Tripathy method had a significantly higher rate of positivity than the AspLFD method (39.0% versus 21.7%; p<0.05). Conclusion Our data show that the Tripathy method is a highly sensitive method of MP-LFA for the PoC diagnosis of IA in clinical settings.

Soluble endothelial cell adhesion molecules and their relationship to disease activity in Takayasu's arteritis.

OBJECTIVE: To investigate soluble (s) E-selectin, vascular cell adhesion molecule-1 (VCAM-1), and intercellular cell adhesion molecule-1 (ICAM-1), and their relationship to disease activity in Takayasu's arteritis (TA). METHODS: Levels of adhesion molecules were measured by enzyme immunoassay in the sera of 35 patients with TA, 17 healthy controls, and 15 patients with 12 months followup. RESULTS: Compared to controls, patients had elevated levels of sE-selectin (54.5 +/- 35.0 vs 36.4 +/- 13.0 ng/ml, p < 0.05), sVCAM-1 (280.9 +/- 267.6 vs 141.2 +/- 76.1 ng/ml, p < 0.05), and sICAM-1 (261.3 +/- 168.1 vs 198.3 +/- 74.3 ng/ml, p < 0.05). Compared to controls, patients with inactive TA also had elevated levels of sE-selectin (67.4 +/- 45.9 vs 36.4 +/- 13.0 ng/ml, p < 0.02), sVCAM-1 (327.6 +/- 327.8 vs 141.2 +/- 76.1 ng/ml, p < 0.02), and sICAM-1 (321.9 +/- 179.5 vs 198.3 +/- 74.3 ng/ml, p < 0.02). There was no difference between active TA and controls. sE-selectin had a trend towards increased levels in inactive versus active TA (67.4 +/- 45.9 vs 44.9 +/- 20.3 ng/ml p = 0.059), but there was no difference in sVCAM-1 and sICAM-1 levels between the groups. No adhesion molecule levels showed a change among followup patients. CONCLUSION: Patients with inactive TA have elevated levels of sE-selectin, sVCAM-1, and sICAM-1 that might indicate persistent vasculopathy in clinically inactive disease.

Interleukin 12 in Takayasu's arteritis: plasma concentrations and relationship with disease activity.

OBJECTIVE: To investigate plasma concentrations of interleukin 12 (IL-12) and their relationship with disease activity in patients with Takayasu's arteritis (TA). METHODS: IL-12 levels were determined by quantitative enzyme immunoassay in the plasma of 80 patients with TA, 25 age/sex matched healthy controls, and 15 followup patients with active TA on immunosuppressive therapy. RESULTS: Significantly increased levels of IL-12 were observed in patients with TA versus controls (90.6 +/- 365.3 vs 6.9 +/- 11.3 pg/ml; p < 0.05) and in patients with active versus inactive TA (168.7 +/- 507.0 vs 12.6 +/- 26.9 pg/ml; p = 0.005). The prevalence of IL-12 (the cytokine levels above cutoff value) was higher in patients than in controls [44% (35/80) vs 12% (3/25); p < 0.01] and in patients with active versus inactive TA [57% (23/40) vs 30% (40); p < 0.05]. Six of the 9 patients who became inactive on followup also had normalized levels of IL-12. CONCLUSION: The data indicate that IL-12 might be an important mediator of inflammation in TA.