Polymerase Chain Reaction on Respiratory Tract Specimens of Immunocompromised Patients to Diagnose Pneumocystis Pneumonia: A Systematic Review and Meta-analysis.

BACKGROUND: This meta-analysis examines the comparative diagnostic performance of polymerase chain reaction (PCR) for the diagnosis of Pneumocystis pneumonia (PCP) on different respiratory tract samples, in both human immunodeficiency virus (HIV) and non-HIV populations. METHODS: A total of 55 articles met inclusion criteria, including 11 434 PCR assays on respiratory specimens from 7835 patients at risk of PCP. QUADAS-2 tool indicated low risk of bias across all studies. Using a bivariate and random-effects meta-regression analysis, the diagnostic performance of PCR against the European Organisation for Research and Treatment of Cancer-Mycoses Study Group definition of proven PCP was examined. RESULTS: Quantitative PCR (qPCR) on bronchoalveolar lavage fluid provided the highest pooled sensitivity of 98.7% (95% confidence interval [CI], 96.8%-99.5%), adequate specificity of 89.3% (95% CI, 84.4%-92.7%), negative likelihood ratio (LR-) of 0.014, and positive likelihood ratio (LR+) of 9.19. qPCR on induced sputum provided similarly high sensitivity of 99.0% (95% CI, 94.4%-99.3%) but a reduced specificity of 81.5% (95% CI, 72.1%-88.3%), LR- of 0.024, and LR+ of 5.30. qPCR on upper respiratory tract samples provided lower sensitivity of 89.2% (95% CI, 71.0%-96.5%), high specificity of 90.5% (95% CI, 80.9%-95.5%), LR- of 0.120, and LR+ of 9.34. There was no significant difference in sensitivity and specificity of PCR according to HIV status of patients. CONCLUSIONS: On deeper respiratory tract specimens, PCR negativity can be used to confidently exclude PCP, but PCR positivity will likely require clinical interpretation to distinguish between colonization and active infection, partially dependent on the strength of the PCR signal (indicative of fungal burden), the specimen type, and patient population tested.

Severe ocular Mpox in person living with advanced HIV treated with extended course of tecovirimat.

BACKGROUND: People living with HIV are disproportionately represented among people with severe mpox. Mild and self-limiting conjunctival involvement has been well-documented, and severe ocular complications, including keratitis, corneal scarring, and the associated loss of vision, are increasingly recognized. Tecovirimat is the first-line antiviral therapy for severe mpox, but data around the efficacy of systemic antiviral agents for mpox are limited, particularly in cases of ocular mpox. CASE REPORT: Here, we describe a case of sight-threatening necrotic blepharokeratoconjunctivitis in a person with advanced HIV, requiring an extended course of tecovirimat due to persistent mpox viral shedding for nearly 5 months.

Monkeypox-associated proctitis and rectal wall perforation.

Monkeypox is a viral zoonotic infection which has rapidly increased in incidence and spread globally since May 2022. There have been reports of rectal complications of monkeypox but so far these are not well not understood. Here, we describe a case of rectal pain in HIV-positive man with confirmed monkeypox. MRI on day 5 of hospital admission revealed proctitis with localised perforation. The patient was treated with tecovirimat, antibiotics, analgesia and laxatives and improved without requiring surgical intervention. All patients presenting with new rectal symptoms and deemed high-risk for monkeypox should be isolated and screened for the disease, and appropriate personal protective equipment should be worn by healthcare professionals caring for them. Clinicians should have a low threshold for cross-sectional imaging in patients with confirmed or suspected monkeypox who experience persistent and severe rectal symptoms or who become systemically unwell to investigate for complications such as perforation and abscess formation. The vast majority of monkeypox cases do not require antibiotics and their use should be reserved for patients who show signs of secondary bacterial infection or sepsis.

The Case for Fungal Keratitis to Be Accepted as a Neglected Tropical Disease.

Amongst the treatable cause of blindness among young people, fungal keratitis ranks high. There are an estimated 1,051,787 to 1,480,916 eyes affected annually, with 8-11% of patients having to have the eye removed. Diagnosis requires a corneal scraping, direct microscopy and fungal culture with a large number of airborne fungi implicated. Treatment involves the intensive application of antifungal eye drops, preferably natamycin, often combined with surgery. In low-resource settings, inappropriate corticosteroid eye drops, ineffective antibacterial therapy, diagnostic delay or no diagnosis all contribute to poor ocular outcomes with blindness (unilateral or bilateral) common. Modern detailed guidelines on fungal keratitis diagnosis and management are lacking. Here, we argue that fungal keratitis should be included as a neglected tropical disease, which would facilitate greater awareness of the condition, improved diagnostic capability, and access to affordable antifungal eye medicine.

Compliance with the Updated BASHH Recurrent Vulvovaginal Candidiasis Guidelines Improves Patient Outcomes.

Recurrent vulvovaginal candidiasis (RVVC) is a debilitating, chronic condition that affects over 138 million (6%) women of reproductive age annually. We performed a retrospective audit of RVVC referrals to our tertiary care Candida clinic to evaluate the impact of the significantly updated British Association of Sexual Health and HIV (BASHH) 2019 vulvovaginal candidiasis guidelines on patient outcomes, the principles of which were implemented at our centre at the onset of the guideline revision process in 2017. A total of 78 women referred with suspected RVVC in 2017-2020 were included. Their mean symptom duration prior to referral was 6.7 years. RVVC was the definitive diagnosis in 73% of cases. In the 27% of patients without RVVC, the most common diagnoses were acute VVC (29%), vulval eczema (14%), dry skin (14%) and vulvodynia (10%). Of those with RVVC, 60% were diagnosed with an additional diagnosis, most commonly vulval eczema or vulvodynia. Only 12% of women had been counselled on appropriate vulval skin care, the mainstay of RVVC management. Long-term antifungal suppression was initiated in 68% of women. Azole-resistant Candida, for which there is no licensed treatment available in the UK, was identified in 23% of women with RVVC. In the follow-up, 82% of patients reported good control of symptoms using antifungal suppression therapy and recommended skin care, 16% had partial symptom control with some "flare-ups" responding to treatment, none reported poor control and for 2% this information was not available. RVVC-related morbidity can be reduced by following the principles outlined in the BASHH guidelines.

An overview of using fungal DNA for the diagnosis of invasive mycoses.

INTRODUCTION: Fungal PCR has undergone considerable standardization and, together with the availability of commercial assays, external quality assessment schemes, and extensive performance validation data, is ready for widespread use for the screening and diagnosis of invasive fungal disease (IFD). AREAS COVERED: Drawing on the experience and knowledge of the leads of the various working parties of the Fungal PCR initiative, this review will address general considerations concerning the use of molecular tests for the diagnosis of IFD, before focusing specifically on the technical and clinical aspects of molecular testing for the main causes of IFD and recent technological developments. EXPERT OPINION: For infections caused by Aspergillus, Candida, and Pneumocystis jirovecii, PCR testing is recommended, and combination with serological testing will likely enhance the diagnosis. For other IFD (e.g. mucormycosis), molecular diagnostics represent the only non-classical mycological approach toward diagnoses, and continued performance validation and standardization have improved confidence in such testing. The emergence of antifungal resistance can be diagnosed, in part, through molecular testing. Next-generation sequencing has the potential to significantly improve our understanding of fungal phylogeny, epidemiology, pathogenesis, mycobiome/microbiome, and interactions with the host, while identifying novel and existing mechanisms of antifungal resistance and novel diagnostic/therapeutic targets.

Twelve lateral flow immunoassays (LFAs) to detect SARS-CoV-2 antibodies.

BACKGROUND: There are an abundance of commercially available lateral flow assays (LFAs) that detect antibodies to SARS-CoV-2. Whilst these are usually evaluated by the manufacturer, externally performed diagnostic accuracy studies to assess performance are essential. Herein we present an evaluation of 12 LFAs. METHODS: Sera from 100 SARS-CoV-2 reverse-transcriptase polymerase chain reaction (RT-PCR) positive participants were recruited through the FASTER study. A total of 105 pre-pandemic sera from participants with other infections were included as negative samples. RESULTS: At presentation sensitivity against RT-PCR ranged from 37.4 to 79% for IgM/IgG, 30.3-74% for IgG, and 21.2-67% for IgM. Sensitivity for IgM/IgG improved ≥ 21 days post symptom onset for 10/12 tests. Specificity ranged from 74.3 to 99.1% for IgM/IgG, 82.9-100% for IgG, and 75.2-98% for IgM. Compared to the EuroImmun IgG enzyme-linked immunosorbent assay (ELISA), sensitivity and specificity ranged from 44.6 to 95.4% and 85.4-100%, respectively. CONCLUSION: There are many LFAs available with varied sensitivity and specificity. Understanding the diagnostic accuracy of these tests will be vital as we come to rely more on the antibody status of a person moving forward, and as such manufacturer-independent evaluations are crucial.

Self-sampling of capillary blood for SARS-CoV-2 serology.

Serological testing is emerging as a powerful tool to progress our understanding of COVID-19 exposure, transmission and immune response. Large-scale testing is limited by the need for in-person blood collection by staff trained in venepuncture, and the limited sensitivity of lateral flow tests. Capillary blood self-sampling and postage to laboratories for analysis could provide a reliable alternative. Two-hundred and nine matched venous and capillary blood samples were obtained from thirty nine participants and analysed using a COVID-19 IgG ELISA to detect antibodies against SARS-CoV-2. Thirty eight out of thirty nine participants were able to self-collect an adequate sample of capillary blood (≥ 50 µl). Using plasma from venous blood collected in lithium heparin as the reference standard, matched capillary blood samples, collected in lithium heparin-treated tubes and on filter paper as dried blood spots, achieved a Cohen's kappa coefficient of > 0.88 (near-perfect agreement, 95% CI 0.738-1.000). Storage of capillary blood at room temperature for up to 7 days post sampling did not affect concordance. Our results indicate that capillary blood self-sampling is a reliable and feasible alternative to venepuncture for serological assessment in COVID-19.

The global incidence and diagnosis of fungal keratitis.

Fungal keratitis is a severe corneal infection that often results in blindness and eye loss. The disease is most prevalent in tropical and subtropical climates, and infected individuals are frequently young agricultural workers of low socioeconomic status. Early diagnosis and treatment can preserve vision. Here, we discuss the fungal keratitis diagnostic literature and estimate the global burden through a complete systematic literature review from January, 1946 to July, 2019. An adapted GRADE score was used to evaluate incidence papers-116 studies provided the incidence of fungal keratitis as a proportion of microbial keratitis and 18 provided the incidence in a defined population. We calculated a minimum annual incidence estimate of 1 051 787 cases (736 251-1 367 323), with the highest rates in Asia and Africa. If all culture-negative cases are assumed to be fungal, the annual incidence would be 1 480 916 cases (1 036 641-1 925 191). In three case series, 8-11% of patients had to have the eye removed, which represents an annual loss of 84 143-115 697 eyes. As fungal keratitis probably affects over a million people annually, an inexpensive, simple diagnostic method and affordable treatment are needed in every country.

Saliva Alternative to Upper Respiratory Swabs for SARS-CoV-2 Diagnosis.

PCR of upper respiratory specimens is the diagnostic standard for severe acute respiratory syndrome coronavirus 2 infection. However, saliva sampling is an easy alternative to nasal and throat swabbing. We found similar viral loads in saliva samples and in nasal and throat swab samples from 110 patients with coronavirus disease.