Abstract
Pneumocystis pneumonia (PcP) is a major HIV-related illness caused by Pneumocystis jirovecii. Definitive diagnosis of PcP requires microscopic detection of P. jirovecii in pulmonary specimens. The objective of this study was to evaluate the usefulness of two serum markers in the diagnosis of PcP. Serum levels of (1–3)-beta-d-glucan (BG) and lactate dehydrogenase (LDH) were investigated in 100 HIV-positive adult patients and 50 healthy blood donors. PcP cases were confirmed using indirect immunofluorescence with monoclonal anti-Pneumocystis antibodies and nested-PCR to amplify the large subunit mitochondrial rRNA gene of P. jirovecii in pulmonary specimens. BG and LDH levels in serum were measured using quantitative microplate-based assays. BG and LDH positive sera were statistically associated with PcP cases (P ≤ 0.001). Sensitivity, specificity, positive/negative predictive values (PPV/NPV), and positive/negative likelihood ratios (PLR/NLR) were 91.3 %, 61.3 %, 85.1 %, 79.2 %, 2.359, and 0.142, respectively, for the BG kit assay, and 91.3 %, 35.5 %, 75.9 %, 64.7 %, 1.415 and 0.245, respectively, for the LDH test. Serologic markers levels combined with the clinical diagnostic criteria for PcP were evaluated for their usefulness in diagnosis of PcP. The most promising cutoff levels for diagnosis of PcP were determined to be 400 pg/ml of BG and 350 U/l of LDH, which combined with clinical data presented 92.8 % sensitivity, 83.9 % specificity, 92.8 % PPV, 83.9 % NPV, 5.764 PLR and 0.086 NLR (P < 0.001). This study confirmed that BG is a reliable indicator for detecting P. jirovecii infection. The combination between BG/LDH levels and clinical data is a promising alternative approach for PcP diagnosis.
Similar content being viewed by others
References
Barry SM, Johnson MA (2001) Pneumocystis carinii pneumonia: a review of current issues in diagnosis and management. HIV Med 2(2):123–132
Calderon EJ, Gutierrez-Rivero S, Durand-Joly I, Dei-Cas E (2010) Pneumocystis infection in humans: diagnosis and treatment. Expert Rev Anti Infect Ther 8(6):683–701
Huang L, Cattamanchi A, Davis JL et al (2011) International HIV-associated opportunistic pneumonias (IHOP) study; lung HIV study: HIV-associated Pneumocystis pneumonia. Proc Am Thorac Soc 8(3):294–300
Morris A, Lundgren JD, Masur H et al (2004) Current epidemiology of Pneumocystis pneumonia. Emerg Infect Dis 10(10):1713–1720
Walzer PD, Evans HE, Copas AJ, Edwards SG, Grant AD, Miller RF (2008) Early predictors of mortality from Pneumocystis jirovecii pneumonia in HIV-infected patients: 1985–2006. Clin Infect Dis 46(4):625–633
Arcenas RC, Uhl JR, Buckwalter SP et al (2006) A real-time polymerase chain reaction assay for detection of Pneumocystis from bronchoalveolar lavage fluid. Diagn Microbiol Infect Dis 54(3):169–175
Esteves F, Gaspar J, De Sousa B, Antunes F, Mansinho K, Matos O (2011) Clinical relevance of multiple single-nucleotide polymorphisms in Pneumocystis jirovecii pneumonia: development of a multiplex PCR-single-base-extension methodology. J Clin Microbiol 49(5):1810–1815
Holten-Andersen W, Kolmos HJ (1989) Comparison of methenamine silver nitrate and Giemsa stain for detection of Pneumocystis carinii in bronchoalveolar lavage specimens from HIV infected patients. APMIS 97(8):745–747
Lautenschlager I, Lyytikainen O, Jokipii L et al (1996) Immunodetection of Pneumocystis carinii in bronchoalveolar lavage specimens compared with methenamine silver stain. J Clin Microbiol 34(3):728–730
Matos O, Lundgren B, Caldeira L et al (2000) Evaluation of two nested polymerase chain reactions for diagnosis of Pneumocystis carinii pneumonia in immunocompromised patients. Clin Microbiol Infect 6(3):149–151
Morris AM, Masur H (2011) A serologic test to diagnose Pneumocystis pneumonia: are we there yet? Clin Infect Dis 53(2):203–204
Turner D, Schwarz Y, Yust I (2003) Induced sputum for diagnosing Pneumocystis carinii pneumonia in HIV patients: new data, new issues. Eur Respir J 21(2):204–208
Wakefield AE, Pixley FJ, Banerji S et al (1990) Detection of Pneumocystis carinii with DNA amplification. Lancet 336(8713):451–453
Matos O, Costa MC, Correia I et al (2006) Pneumocystis jiroveci infection in immunocompetent patients with pulmonary disorders, in Portugal. Acta Med Port 19(2):121–126
Matos O, Lundgren B, Caldeira L et al (1999) Evaluation of a nested PCR for detection of Pneumocystis carinii in serum from immunocompromised patients. J Eukaryot Microbiol 46(5):104S–105S
Desmet S, Van Wijngaerden E, Maertens J et al (2009) Serum (1–3)-beta-D-glucan as a tool for diagnosis of Pneumocystis jirovecii pneumonia in patients with human immunodeficiency virus infection or hematological malignancy. J Clin Microbiol 47(12):3871–3874
Djawe K, Huang L, Daly KR et al (2010) Serum antibody levels to the Pneumocystis jirovecii major surface glycoprotein in the diagnosis of P. jirovecii pneumonia in HIV+ patients. PLoS ONE 5(12):e14259
Finkelman MA (2010) Pneumocystis jirovecii infection: Cell wall (1–3)-B-D-glucan biology and diagnostic utility. Crit Rev Microbiol 36(4):271–281
Fox GN (1993) Elevated LDH and Pneumocystis carinii pneumonia. Am Fam Physician 47(7):1579–1582
Karageorgopoulos DE, Qu JM, Korbila IP, Zhu YG, Vasileiou VA, Falagas ME et al (2013) Accuracy of beta-d-glucan for the diagnosis of Pneumocystis jirovecii pneumonia: a meta-analysis. Clin Microbiol Infect 19(1):39–49
Nakamura H, Tateyama M, Tasato D et al (2009) Clinical utility of serum beta-D-glucan and KL-6 levels in Pneumocystis jirovecii pneumonia. Intern Med 48(4):195–202
Quist J, Hill AR (1995) Serum lactate dehydrogenase (LDH) in Pneumocystis carinii pneumonia, tuberculosis, and bacterial pneumonia. Chest 108(2):415–418
Tasaka S, Hasegawa N, Kobayashi S et al (2007) Serum indicators for the diagnosis of Pneumocystis pneumonia. Chest 131(4):1173–1180
Vogel M, Weissgerber P, Goeppert B et al (2011) Accuracy of serum LDH elevation for the diagnosis of Pneumocystis jiroveci pneumonia. Swiss Med Wkly 141:w13184
de Boer MG, Gelinck LB, van Zelst BD et al (2011) β-D-glucan and S-adenosylmethionine serum levels for the diagnosis of Pneumocystis pneumonia in HIV-negative patients: a prospective study. J Infect 62(1):93–100
Held J, Koch MS, Reischl U, Danner T, Serr A et al (2011) Serum (1→3)-beta-D-glucan measurement as an early indicator of Pneumocystis jirovecii pneumonia and evaluation of its prognostic value. Clin Microbiol Infect 17(4):595–602
Onishi A, Sugiyama D, Kogata Y et al (2012) Diagnostic accuracy of serum 1,3-beta-D-glucan for Pneumocystis jiroveci pneumonia, invasive candidiasis, and invasive aspergillosis: systematic review and meta-analysis. J Clin Microbiol 50(1):7–15
Sax PE, Komarow L, Finkelman MA et al (2011) AIDS Clinical Trials Group Study A5164 Team: Blood (1→ 3)-{beta}-D-Glucan as a diagnostic test for HIV-related Pneumocystis jirovecii pneumonia. Clin Infect Dis 53(2):197–202
Yasuoka A, Tachikawa N, Shimada K, Kimura S, Oka S (1996) (1→ 3) beta-D-glucan as a quantitative serological marker for Pneumocystis carinii pneumonia. Clin Diagn Lab Immunol 3(2):197–199
Odabasi Z, Mattiuzzi G, Estey E et al (2004) Beta-D-glucan as a diagnostic adjunct for invasive fungal infections: validation, cutoff development, and performance in patients with acute myelogenous leukemia and myelodysplastic syndrome. Clin Infect Dis 39(2):199–205
Persat F, Ranque S, Derouin F, Michel-Nguyen A, Picot S, Sulahian A (2008) Contribution of the (1→3)-beta-D-glucan assay for diagnosis of invasive fungal infections. J Clin Microbiol 46(3):1009–1013
Grover SA, Coupal L, Suissa S et al (1992) The clinical utility of serum lactate dehydrogenase in diagnosing Pneumocystis carinii pneumonia among hospitalized AIDS patients. Clin Invest Med 15(4):309–317
Esteves F, Gaspar J, de Sousa B, Antunes F, Mansinho K, Matos O (2012) Pneumocystis jirovecii multilocus genotyping in pooled DNA samples: a new approach for clinical and epidemiological studies. Clin Microbiol Infect 18(6):E177–E184
Esteves F, Gaspar J, Marques T et al (2010) Identification of relevant single-nucleotide polymorphisms in Pneumocystis jirovecii: relationship with clinical data. Clin Microbiol Infect 16(7):878–884
Esteves F, Gaspar J, Tavares A et al (2010) Population structure of Pneumocystis jirovecii isolated from immunodeficiency virus-positive patients. Infect Genet Evol 10(2):192–199
Iwanaga S (1993) The limulus clotting reaction. Curr Opin Immunol 5(1):74–82
Kaplan JE, Hanson DL, Navin TR, Jones JL (1998) Risk factors for primary Pneumocystis carinii pneumonia in human immunodeficiency virus-infected adolescents and adults in the United States: reassessment of indications for chemoprophylaxis. J Infect Dis 178(4):1126–1132
Matsumura Y, Ito Y, Iinuma Y et al (2012) Quantitative real-time PCR and the (1→3)-beta-D-glucan assay for differentiation between Pneumocystis jirovecii pneumonia and colonization. Clin Microbiol Infect 18(6):591–597
Teramoto S, Sawaki D, Okada S, Ouchi Y (2000) Markedly increased plasma (1→3)-beta-D-glucan is a diagnostic and therapeutic indicator of Pneumocystis carinii pneumonia in a non-AIDS patient. J Med Microbiol 49(4):393–394
Morris A, Sciurba FC, Norris KA (2011) Pneumocystis: a novel pathogen in chronic obstructive pulmonary disease? COPD 5(1):43–51
Shimizu Y, Sunaga N, Dobashi K et al (2009) Serum markers in interstitial pneumonia with and without Pneumocystis jirovecii colonization: a prospective study. BMC Infect Dis 9:47
Damiani C, Le Gal S, Lejeune D et al (2011) Serum (1- > 3)-beta-D-glucan levels in primary infection and pulmonary colonization with Pneumocystis jirovecii. J Clin Microbiol 49(5):2000–2002
Damiani C, Le Gal S, Da Costa C, Virmaux M, Nevez G, Totet A (2013) Combined quantification of pulmonary Pneumocystis jirovecii DNA and serum (1- > 3)-β-D-glucan for differential diagnosis of Pneumocystis pneumonia and Pneumocystis colonization. J Clin Microbiol 51(10):3380–3388
Acknowledgments
This research was supported by the scientific projects PTDC/SAU-MII/104231/2008 and PTDC/SAU-MIC/116716/2010 financed by Fundação para a Ciência e a Tecnologia (FCT).
We thank the Associates of Cape Cod, Inc. for providing the free BG detection kit.
Competing interests
The authors declare that they have no competing interests.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Esteves, F., Lee, CH., de Sousa, B. et al. (1–3)-Beta-D-glucan in association with lactate dehydrogenase as biomarkers of Pneumocystis pneumonia (PcP) in HIV-infected patients. Eur J Clin Microbiol Infect Dis 33, 1173–1180 (2014). https://doi.org/10.1007/s10096-014-2054-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10096-014-2054-6