Self-administered, remote assessment of SARS-CoV-2 seroprevalence in health care workers.

BACKGROUND: Our objective was to safely and remotely assess longitudinal SARS-CoV-2 seroprevalence in at-risk health care workers at the onset of the epidemic. METHODS: Self-administered serologic testing was performed every 30 days up to 5 times using a point-of-care, lateral flow SARS-CoV-2 nucleocapsid IgG immunoassay in a cohort of at-risk health care workers (n = 339) and lower-risk controls (n = 100). RESULTS: Subjects were enrolled between 4/14/20-5/6/20 and most were clinicians (41%) or nurses (27%). Of 20 subjects who reported confirmed SARS-CoV-2 infection prior to (n = 5, 1%) or during the study (n = 15, 3%), half (10/20) were seropositive. Five additional subjects were seropositive and did not report documented infection. Estimated infection rates in health care workers did not differ from concurrent community rates. CONCLUSIONS: This remotely conducted, contact-free study did not identify serologic evidence of widespread occupational SARS-CoV-2 infection in health care workers.

Interventions to prevent iatrogenic anemia: a Laboratory Medicine Best Practices systematic review.

BACKGROUND: As many as 90% of patients develop anemia by their third day in an intensive care unit (ICU). We evaluated the efficacy of interventions to reduce phlebotomy-related blood loss on the volume of blood lost, hemoglobin levels, transfusions, and incidence of anemia. METHODS: We conducted a systematic review and meta-analysis using the Laboratory Medicine Best Practices (LMBP) systematic review methods for rating study quality and assessing the body of evidence. Searches of PubMed, Embase, Cochrane, Web of Science, PsychINFO, and CINAHL identified 2564 published references. We included studies of the impact of interventions to reduce phlebotomy-related blood loss on blood loss, hemoglobin levels, transfusions, or anemia among hospital inpatients. We excluded studies not published in English and studies that did not have a comparison group, did not report an outcome of interest, or were rated as poor quality. Twenty-one studies met these criteria. We conducted a meta-analysis if > 2 homogenous studies reported sufficient information for analysis. RESULTS: We found moderate, consistent evidence that devices that return blood from flushing venous or arterial lines to the patient reduced blood loss by approximately 25% in both neonatal ICU (NICU) and adult ICU patients [pooled estimate in adults, 24.7 (95% CI = 12.1-37.3)]. Bundled interventions that included blood conservation devices appeared to reduce blood loss by at least 25% (suggestive evidence). The evidence was insufficient to determine if these devices reduced hemoglobin decline or risk of anemia. The evidence suggested that small volume tubes reduced the risk of anemia, but was insufficient to determine if they affected the volume of blood loss or the rate of hemoglobin decline. CONCLUSIONS: Moderate, consistent evidence indicated that devices that return blood from testing or flushing lines to the patient reduce the volume of blood loss by approximately 25% among ICU patients. The results of this systematic review support the use of blood conservation systems with arterial or venous catheters to eliminate blood waste when drawing blood for testing. The evidence was insufficient to conclude the devices impacted hemoglobin levels or transfusion rates. The use of small volume tubes may reduce the risk of anemia.

Evaluation of the BioPlex 2200 syphilis total screen (IgG/IgM) with reflex to an automated rapid plasma reagin test.

BACKGROUND: We evaluated the recently FDA cleared BioPlex 2200 Syphilis Total Screen and automated rapid plasma reagin (RPR) assay for the detection of total (IgG/IgM) treponemal and non-treponemal antibodies in the reverse syphilis algorithm. METHODS: Prospectively submitted samples (n = 885) were assayed by both the IgG/IgM BioPlex Syphilis Screen and the original IgG BioPlex Syphilis Screen. The IgG screen reactive samples were reflexed to traditional RPR, and IgG/IgM screen reactive samples were reflexed to the automated RPR. Nonreactive RPR samples were tested by the Treponemal Pallidum Particle Agglutination test (TP-PA). Additional samples were collected (n = 404 total samples) to directly compare the automated and traditional RPR assays with each other. RESULTS: The sensitivity and specificity of the IgG/IgM screen with automated RPR was 95.6% (95% confidence interval [CI] 87.0-99.1) and 99.6% (CI 99.2-99.8) while the sensitivity and specificity of the BioPlex IgG screen with traditional RPR was 97.8% (CI 89.1-99.9) and 99.3% (CI 98.8-99.4). The sensitivity and specificity of the BioPlex RPR compared with traditional RPR was 95.8% (CI 93.9-97.0) and 94.1% (CI 89.4-91.1) and 95.3% (CI 92.6-97.1). The mean of the titer differences between the BioPlex RPR and the traditional RPR was 1.0 ± 0.9 SD titers. CONCLUSION: The addition of the detection of treponemal IgM antibodies to the IgG/IgM screen did not significantly affect the sensitivity and specificity compared to the original IgG screen. However, the addition of the comparable BioPlex RPR assay to the instrumentation significantly reduces the overall labor of syphilis screening and confirmation.

Anti-ENA antibody profiles in patients with hepatitis C virus infection.

BACKGROUND: The presence of antinuclear antibodies (ANA) has been described following hepatitis C virus (HCV). Very few studies have investigated the presence of anti-extractable nuclear antigens (ENA) in HCV infection. METHODS: The aim of this study was to assess the prevalence of ENA antibodies in 100 patients with HCV infection compared to the prevalence of ENA antibodies in 100 healthy control patients. Sera from patients were tested for ENA using a multiplex microbead immunoassay. Sera positive for ENA were subsequently tested for ANA using an indirect immunofluorescence assay and titered if positive. RESULTS: Fourteen (14%) of the 100 patients with HCV infection had anti-ENA antibodies: four each showed anti-SSA antibodies and anti-dsDNA antibodies, three each had RNP antibodies and Scl-70 antibodies, and one each had anti-SSB, centromere B, Sm, and Sm/RNP antibodies. Ten of the 14 patients positive for anti-ENA were positive by indirect immunofluorescence staining (IFA) with titers ranging from 1:40 to 1:160. Five had antinuclear patterns, one had combined antinuclear and cytoplasmic patterns, and four only had a cytoplasmic pattern. Three of the 100 healthy control patients had ANA positive titers (1:80 and 1:320) and anti-ENA antibodies: one anti-Scl-70 and two anti-RNP. CONCLUSION: The prevalence of anti-ENA antibodies was significantly higher in the patients with HCV infections than in the healthy controls. Other studies of anti-ENA profiles in patients with HCV infection have identified similar patterns of positivity for anti-SSA, anti-SSB, anti-dsDNA, anti-RNP, anti- Sm/RNP, Scl-70, centromere B, and anti-Sm.

Hemoglobin Providence (ß82 Lys > Asn, Asp) and lower-than-expected HbA1c in a nonadherent teenager with type 1 diabetes: a case report and literature review.

Endocrinologists should have a high index of suspicion for a Hb variant when the HbA1c is not consistent with other indices of glycemic control.

Anti-phospholipid Antibodies and Smoking: An Overview.

Antiphospholipid syndrome is characterized by the presence of antiphospholipid antibodies, specifically lupus anticoagulant, anticardiolipin antibodies, and anti-ß2 glycoprotein-I antibodies. Antiphospholipid syndrome can occur on its own or in association with other autoimmune diseases, most commonly systemic lupus erythematosus (SLE). A connection between cigarette smoking and anti-phospholipid antibodies (aPL) was first reported in the late1980s. Systemic lupus erythematosus patients with aPL are more likely to be smokers than those without aPL. These patients have a particularly high frequency of vascular events. Recently, a potential link between periodontitis, tobacco, and aPL has been proposed. Research has also suggested that periodontitis and Porphyromonas gingivalis infection are associated with citrullination through the action of peptidylarginine deiminase. A strong correlation between smoking and the presence of citrillunated autoantibodies, which are characteristic of rheumatoid arthritis, has also been observed. While many studies have investigated possible links between infection and aPL in patients with autoimmune diseases, the association of smoking with aPL has not been systematically examined. The fact that both aPL and tobacco are risk factors for thrombosis has complicated efforts to evaluate these factors separately. Also, there has been great variability in measurement techniques, and laboratories lack routine methods for differentiating transient and persistent aPL; both of these factors can make interpretation of autoantibody results quite challenging. This review summarizes the clinical evidence supporting a posited link between aPL and smoking, both in patients with a systemic autoimmune disease and in patients with other medical conditions.

Performance Characteristics of the Reverse Syphilis Screening Algorithm in a Population With a Moderately High Prevalence of Syphilis.

OBJECTIVES: With the recent introduction of automated treponemal tests, a new reverse syphilis algorithm has been proposed and now used by many clinical laboratories. We analyzed the impact of instituting the reverse screening syphilis algorithm in a laboratory that serves a geographic area with a moderately high prevalence of syphilis infection. METHODS: Serum samples sent for syphilis testing were tested using a treponemal enzyme immunoassay (EIA) as the screening assay. EIA reactive samples were tested by rapid plasma reagin (RPR) and titered to end point if reactive. RPR nonreactive samples were analyzed by the Treponema pallidum particle agglutination test (TP-PA). Pertinent medical records were reviewed for false-reactive screens and samples with evidence of past syphilis infection. RESULTS: Among 10,060 patients tested, 502 (5%) were reactive on the initial EIA screen. The RPR was reactive in 150 (1.5%). TP-PA testing determined that 103 (1.0%) were falsely reactive on initial EIA screen. The reverse screening algorithm, however, identified 242 (2.4%) with evidence of latent, secondary, or past syphilis, 21 of whom had no or unknown prior treatment with antibiotics. CONCLUSIONS: Despite a 1.0% false-reactive rate, the reverse syphilis algorithm detected 21 patients with possible latent syphilis that may have gone undetected by traditional syphilis screening.

ANA testing in the presence of acute and chronic infections.

Autoantibody testing is performed to help diagnose patients who have clinical symptoms suggestive of possible autoimmune diseases. Antinuclear antibodies (ANA) are present in many systemic autoimmune conditions such as systemic lupus erythematosus (SLE). However, a positive ANA test may also be seen with non-autoimmune inflammatory diseases, including both acute and chronic infections. When the ANA test is used as an initial screen in patients with non-specific clinical symptoms, such as fever, joint pain, myalgias, fatigue, rash, or anemia, the likelihood of a positive result due to infection will increase, especially in children. This article identifies acute and chronic infectious diseases that are likely to produce a positive ANA result and summarizes recent literature addressing both the causes and consequences of these findings.

Performance of a Tuberculosis Serologic Assay in Various Patient Populations.

OBJECTIVES: Detection of the humoral response to diagnose active tuberculosis has had varied success. We sought to further characterize the performance of a commercial serologic assay (Active TBDetect IgG ELISA; InBios International, Seattle, WA), which had demonstrated promising results in prior studies. METHODS: Blood specimens from patients with mycobacterial infections, autoimmune disorders, and documented nonmycobacterial infections were prospectively collected for testing by the Active TBDetect IgG ELISA. Pertinent medical records were reviewed. RESULTS: The sensitivity of the InBios IgG ELISA for active tuberculosis cases was 54.1% (20/37). Reactivity occurred in 24.1% (14/58) of nontuberculous mycobacterium cases, 10.4% (7/67) of nonmycobacterial infections, 10.5% (11/105) of autoimmune disorder cases, 8.7% (8/92) of noninfected patients, 14.3% (1/7) of patients with latent tuberculosis, and 10.7% (3/28) of control pediatric cases. Overall specificity was 87.5% (288/329). Receiver operator curve analysis demonstrated an area under the curve of 0.74. Reactivity with nontuberculous mycobacterium infection occurred with Mycobacterium avium-intracellulare complex, Mycobacterium chelonae/abscessus complex, Mycobacterium simiae, and Mycobacterium gordonae and was positively associated with having a positive acid-fast bacilli smear. CONCLUSIONS: This study confirmed the limitations of serodiagnosis for active tuberculosis, including poor sensitivity and increased reactivity with nontuberculous mycobacterium-positive patients.

Comparison of a combined nontreponemal (VDRL) and treponemal immunoblot to traditional nontreponemal and treponemal assays.

BACKGROUND: Serology is the mainstay for the diagnosis and management of patients with syphilis. Newer technologies such as immunoblotting are now available for the diagnosis of syphilis. METHODS: A commercial IgM/IgG immunoblot assay that detects both nontreponemal (VDRL-Venereal Disease Research Laboratory) and treponemal antibodies was compared with standard nontreponemal and treponemal assays. The immunoblot and T. pallidum particle agglutination assay (TP-PA) were performed on 198 samples. Ninety-seven samples were Rapid plasma reagin (RPR)-positive and one hundred one were RPR-negative. Positive RPR samples were titered by VDRL. RESULTS: The agreement, sensitivity, and specificity of the IgM/IgG VDRL results of the immunoblot compared to RPR were 74.2% (95% CI: 67.2-80.2), 77.3% (95% CI: 70.2-83.4), and 71.3% (95% CI: 64.4-77.1), respectively. The agreement, sensitivity, and specificity of the IgM/IgG treponemal immunoblot compared to TP-PA were 100% for all parameters, if the ten equivocal results were not used in the calculation. CONCLUSION: The treponemal portion of the ViraBlot IgM/IgG immunoblot compared well with the treponemal confirmation assay and could be a useful supplemental method to fluorescent treponemal antibody or TP-PA for the confirmation of syphilis. The addition of the detection of nontreponemal antibodies to the immunoblot assay, however, may not be of added benefit to the overall assay, due to decreased sensitivity and specificity compared to standard assays.

Comparison of a commercial dengue IgM capture ELISA with dengue antigen focus reduction microneutralization test and the Centers for Disease Control dengue IgM capture-ELISA.

Dengue (DENV) infection is caused by an arbovirus that is a member of the family Flaviviridae, genus Flavivirus. The diagnosis of acute dengue infection using clinical signs and symptoms can be difficult since the manifestations cannot be readily differentiated from other infections. Therefore the diagnosis of acute dengue infection depends upon laboratory assays. Dengue virus ELISAs have been designed for the detection of IgM and IgG antibodies in addition to nonstructural 1 (NS1) antigens. The InBios IgM Dengue ELISA was compared to the Antigen Focus Reduction Microneutralization Test (FRµNT90) and Centers for Disease Control Dengue IgM Capture-ELISA (CDC MAC-ELISA). The calculated sensitivity, specificity and agreement of the InBios ELISA compared to FRµNT90 and CDC MAC-ELISA was 88.7% (C.I. 81.4-93.7), 93.1% (C.I. 89.1-95.8) and 91.5% (C.I. 86.3-95.0), respectively. In summary the InBios IgM Dengue ELISA sensitivity and specificity is comparable to other commercially available IgM Capture-ELISAs.

Seasonality and prevalence of respiratory pathogens detected by multiplex PCR at a tertiary care medical center.

Respiratory tract infections (RTIs) are a leading cause of mortality and morbidity. Seasonality has been reported for many viruses, including influenza virus, respiratory syncytial virus (RSV), and the recently described human metapneumovirus (hMPV). We hypothesize that the availability of rapid, multiplex PCR diagnostics will provide better clinical care and new insights into the etiology and clinical spectrum of RTIs. We conducted a retrospective analysis of the incidence of respiratory pathogens at a 500-bed adult and 154-bed pediatric hospital tertiary care center. A total of 939 specimens from patients with an age range of 5 days to 91 years (median, 2 years) were tested by a multiplex respiratory pathogen PCR from November 14, 2011 to November 13, 2012. Sixty-five percent of specimens were positive for at least one pathogen. As the age of the patient increased, the positivity rate for the PCR decreased proportionately. Rhinoviruses/enteroviruses (Rhino/Entero) were the most prevalent (34.3 %) followed by RSV (19.2 %) and hMPV (6.2 %). Twelve percent of the positive samples were positive for multiple analytes, with Rhino/Entero and RSV being the most common combination. The peak months were September and May for Rhino/Entero infections, January for RSV and February for coronavirus. hMPV peaked 2 months after RSV, as has been observed recently in other studies. Multiplex PCR provides rapid diagnostic information that can be used to make knowledgeable clinical decisions and potentially reduce the use of antibiotics. Active respiratory PCR surveillance could also predict seasonal respiratory epidemics to allow for adequate planning of additional infection control measures.

Recreational vehicle water tanks as a possible source for legionella infections.

We investigated recreational vehicle (RV) water reservoirs in response to a case of pneumonia in which Legionella pneumophila was cultured both from the patient and a RV reservoir in which he travelled. Water samples processed and cultured at the CDC according to standard protocol were positive for Legionella spp. in 4/17 (24%) faucets, 1/11 (9%) water tanks from 4/20 (20%) RVs from three different campsites. Legionella spp. that were isolated included L. pneumophila (serogroups 1 and 6), L. anisa, L. feeleii, and L. quateriensis. Environmental controls from the potable water of the three campsites were culture-negative. A survey of maintenance practices by the RV users at the campsites revealed that chlorine disinfection of the water tanks was rarely performed. To prevent the possibility of Legionella infections, RV owners should implement regular chlorine disinfection of their water tanks and follow the recommended maintenance guidelines according to their owner's manuals.

Antituberculosis IgG antibodies as a marker of active Mycobacterium tuberculosis disease.

Anti-Mycobacterium tuberculosis IgG antibodies may aid in the diagnosis of active M. tuberculosis disease. We studied whether anti-M. tuberculosis IgG antibodies are elevated in active M. tuberculosis disease and assessed factors contributing to false-positive and -negative results. A retrospective study of 2,150 individuals tested by the QuantiFERON-TB Gold In-Tube (QFT-GIT) assay was conducted at the University of Utah, ARUP Laboratories, November 2008 to December 2010. All samples were tested with the InBios Active TbDetect antituberculosis (anti-TB) IgG antibody assay. Of 1,044 patients with a positive QFT-GIT, 59 (5.7%) were positive for M. tuberculosis antibodies. Fourteen of 1,106 (1.3%) with a negative or indeterminate QFT-GIT were positive for M. tuberculosis antibodies. M. tuberculosis antibody tests were positive in 61.5% with confirmed active M. tuberculosis disease and other mycobacterial infections. Over half of the false-negative M. tuberculosis antibody tests occurred in patients ≥ 90 years of age. False positives were seen in 12.9% of autoimmune patients. The odds ratio of being positive by the QFT-GIT and the InBios TB IgG assay increased with confirmed M. tuberculosis disease or highly suspected M. tuberculosis disease and was 86.7 (95% confidence interval [CI], 34.4 to 218.5) in these two groups compared to patients negative by both tests. Although anti-M. tuberculosis antibodies can be detected in patients with active M. tuberculosis disease, caution should be used with patients where immunoglobulin levels may be decreased or patients with autoantibodies.

Correlation of Chlamydia and Chlamydophila spp. IgG and IgM antibodies by microimmunofluorescence with antigen detection methods.

Correlation of serologic titers for Chlamydia trachomatis with other tests has been based on direct fluorescence antibody (DFA) testing and culture, but not on nucleic acid-based tests that are used for screening. We retrospectively reviewed the specificity of antibodies against C. trachomatis, Chlamydia psittaci, and Chlamydophila pneumoniae by microimmunofluorescence (MIF) when compared with DFA, culture, nucleic acid probe, and transcription-mediated amplification. Over a 6-year period, 226 cases had both MIF and one of these other methods performed for comparison. Agreement between C. trachomatis antigen or nucleic acid detection and MIF results was 87% (197/226). C. trachomatis serology had a negative predictive value of 98%, and 10.6% of cases were positive by serology and negative by antigen testing. Of the 13 patients who had a positive C. trachomatis antigen or nucleic acid test result, 9 had IgG and/or IgM titers highest against C. trachomatis, 3 had IgG titers highest against C. pneumoniae, and 1 had undetectable titers for the three chlamydial species. Twenty-five patients had positive IgG and/or IgM titers to C. trachomatis but negative antigen test results. Serologic testing can increase the sensitivity of detecting C. trachomatis infections.

Bartonella henselae infection of prosthetic aortic valve associated with colitis.

The diagnosis of infective endocarditis can be difficult, particularly with atypical presentation and negative blood cultures. A 61-year-old man with a porcine aortic valve presented with fever, intermittent confusion, diarrhea, and fatigue. In the community clinic setting, a colonoscopy performed for anemia demonstrated colitis. Symptoms progressed for months; elicitation of a history of significant kitten exposure and the finding of an axillary lymph node prompted testing for Bartonella henselae antibodies. High titer antibodies by indirect immunofluorescence assay indicated chronic B. henselae infection. Surgical valve replacement followed by prolonged doxycycline and rifampin led to cure. This case illustrates the complexities of infective endocarditis and is the first description B. henselae endocarditis associated with colitis in an immunocompetent adult.

Comparison of Western immunobloting to an enzyme-linked immunosorbent assay for the determination of anti-Bordetella pertussis antibodies.

During Bordetella pertussis infection, it has been established that an increase of anti-pertussis toxin (PT) and anti-filamentous hemagglutinin (FHA) antibodies occurs. Immunoblots from two manufacturers using FHA and PT antigens were compared with an enzyme-linked immunosorbent assay (ELISA) that used both FHA and PT. One manufacturer used two concentrations of PT bands for the IgG immunoblot, calibrated to the World Health Organization standard for PT in international units (IU/ml), 100 IU/ml (PT-100) and 8 IU/ml (PT). The second immunoblot kit measured antibodies to a single calibrated PT band. Both kits measured IgA antibodies, and one additionally measured IgM antibodies. Two of 41 (5%) ELISA IgM positives were confirmed positive by IgM immunoblotting, suggesting poor specificity of the IgM ELISA. The agreements of the IgG and IgA immunoblots with the ELISA ranged from 72.5% to 85.3%, with only 38 to 51% of IgA positives confirmed by immunoblotting and only 61 to 68% of IgG positives confirmed by immunoblotting. The two immunoblots correlated well with each other, with 91.7% and 94.3% agreement for IgG and IgA, respectively. When the FHA band was used with the PT band as the criterion for positivity, significant differences existed in specificity compared to the ELISA (IgG, 84.1% versus 33.3%; IgA, 82.4% versus 71.0%). When the positive IgA immunoblots (evidence of natural recent infection) were compared to the positive PT-100 IgG immunoblots (evidence of recent infection or vaccination), the PT-100 blot showed a 71% sensitivity in detecting natural recent infection. B. pertussis immunoblots, alone or in combination with ELISAs, can aid in the diagnosis of B. pertussis infection.

Limited utility of culture for Mycoplasma pneumoniae and Chlamydophila pneumoniae for diagnosis of respiratory tract infections.

We assessed the utility of culture for Mycoplasma pneumoniae and Chlamydophila pneumoniae to diagnose respiratory tract infections. Compared to PCR and IgM serology, culture was less sensitive and had extremely low yield. Culture is not recommended for these pathogens, and this method should be eliminated from routine practice.

A comparison of Brucella IgG and IgM ELISA assays with agglutination methodology.

Despite brucellosis having a low incidence rate in developed nations, it still remains the leading zoonotic disease in the world. Culturing of Brucella spp. provides good specificity but in cases where the fever is intermittent, sensitivity is problematic. This has led to the development of serological methods of detection. Brucella agglutination methods have been considered the serological gold-standard since their inception, although commercial Brucella IgG and IgM enzyme-linked immunosorbent assays are available to potentially aid in the diagnosis of the disease. In our study, anti-Brucella IgG and IgM assays were compared with agglutination. Individually the IgG assay tested had an accuracy of 56% and the IgM assay had an accuracy of 77%. These poor accuracies reinforce Centers for Disease Control's conclusion that nonagglutination tests should not be used to confirm brucellosis.

Evaluation of two immunoblot assays and a Western blot assay for the detection of antisyphilis immunoglobulin g antibodies.

In the present study, two immunoglobulin G (IgG) immunoblot assays and one IgG Western blot assay were compared to the rapid plasma reagin test (RPR), the fluorescent treponemal antibody absorption test (FTA-ABS), and the Treponema pallidum particle agglutination assay (TP-PA). The agreement levels of the Viramed, Virotech, and MarDx assays were 97.0%, 96.4%, and 99.4%, and the agreements of samples inconclusive by FTA-ABS and resolved by TP-PA were 91.7%, 83.3%, and 69.4%, respectively.