Chest
Volume 121, Issue 4, April 2002, Pages 1171-1176
Journal home page for Chest

Clinical Investigations
INFECTION
Diagnosis of Invasive Pulmonary Aspergillosis Using Polymerase Chain Reaction-Based Detection of Aspergillus in BAL

https://doi.org/10.1378/chest.121.4.1171Get rights and content

Study objective

To assess the value of Aspergillus polymerase chain reaction (PCR) test performed on the BAL in diagnosing invasive pulmonary aspergillosis (IPA).

Design

Between January 1996 and 1997, we prospectively followed up 249 cancer patients with pulmonary infiltrates suggestive of pneumonia. Bronchoscopy with fungal stains, cultures, and PCR was performed on all patients. PCR was used for the detection of Aspergillus mitochondrial and alkaline protease gene DNA. The PCR products were visualized either directly on polyacrylamide gel or after Southern transfer and probing with specific probes for mitochondrial and alkaline protease DNA.

Results

The 249 patients consisted of 10 patients with proven IPA (tissue invasion), 22 patients with probable IPA (microbiologic culture), 18 patients with possible IPA (consistent clinical and radiologic findings), and 199 control patients with no evidence of IPA. PCR positivity was strongly associated with all forms of IPA (p < 0.002). The sensitivity, specificity, positive predictive value, and negative predictive value of PCR were 80%, 93%, 38%, and 99%, respectively, for proven IPA, and 64%, 93%, 52%, and 96%, respectively, for probable IPA. Southern blotting analysis did not improve the diagnostic yield of the PCR test.

Conclusion

PCR performed on BAL is associated with high specificity and negative predictive value for IPA. The low positive predictive value could be related to the transient colonizing presence of aspergilli in the respiratory tract. The sensitivity correlates with the certainty of the diagnosis based on tissue invasion.

Section snippets

Patient Enrollment

Between February 1996 and October 1997, 249 cancer patients with chest radiographic findings suggestive of pneumonia were prospectively evaluated. All patients underwent bronchoscopy, and the BAL fluid was sent for microscopy, cytology, and bacterial, viral, and fungal cultures. Information was obtained on all patients as to their age, gender, race, underlying diagnosis, and history of bone marrow transplant. In addition, further information pertaining to clinical manifestations of the

Characteristics of Patients

Most (165 patients, 66%) of the 249 cancer patients with pneumonia who were included in this study had hematologic malignancy (leukemia, lymphoma or myeloma). The mean age of the cohort of patients included in this study was 50 years (range, 15 to 86 years). Most (174 patients, 70%) received chemotherapy within 6 months prior to the onset of the pneumonia. Only 36% received high-dose steroids within 6 months of onset of the pneumonitis; 39% were neutropenic (< 500 neutrophils per microliter) at

Discussion

This prospective clinical trial shows that the PCR test using two sets of primers (alkaline protease and mitochondrial DNA) performed on BAL is highly useful in ruling out IPA in cancer patients presenting with pulmonary infiltrates and, therefore, is associated with a high negative predictive value. This test is also sensitive and highly specific for proven IPA in cancer patients.

Several studies4,5,6,7,8,9 have suggested that PCR (using different genes) performed on BAL could be useful in the

Conclusion

In conclusion, Aspergillus PCR test using alkaline protease gene and mitochondrial primers done on BAL is associated with high negative predictive value for IPA in cancer patients with pneumonia. Hence, a negative test result on BAL is useful in ruling out IPA. In addition, the test is sensitive and highly specific. However, the test is associated with a low positive predictive value. If IPA is considered in the differential diagnosis along with other infectious etiologies and bronchoscopy is

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