Cryptococcal antigen detection in broncho-alveolar lavage fluid

Cryptococcal antigen detection in broncho-alveolar lavage fluid Abstract Cryptococcal antigen (CryAg) testing in serum and CSF is a clue diagnostic tool for cryptococcosis. In this study, we reviewed the performances of the CryAg detection (Premier EIA, Meridian) routinely performed in broncho-alveolar lavage fluid (BALF) during a 7-year period (2007–2013). CryAg was detected in 12 cases among 4650 BALF analyzed, while positive culture from BALF was detected in nine cases. We found sensitivity, specificity, positive and negative predictive values at 0.44–0.80 (according to the radio-clinical form), 0.99, 0.36, and 0.99, respectively. These results do not support the routine use of the test in BALF. Cryptococcosis, pneumonia, diagnosis, antigen Cryptococcosis is mainly acquired following inhalation of spores from the environment and is in fact originally pulmonary. Although this primo-infection seems to be mostly a- or pauci-symptomatic, it allows the fungus to remain quiescent in the alveoli before a possible reactivation due to immunosuppression, mainly induced by the human immunodeficiency virus (HIV) infection or immunosuppressive therapies.1,2 Neurological symptoms are then often predominant but pulmonary symptoms may sometimes be foreground, notably in HIV-negative patients.3,4 Mostly depending on the immune status of the patient, the clinical presentation and outcome of pulmonary cryptococcosis are highly variable, ranging from asymptomatic colonization to severe pneumonia with respiratory failure.5 In a consistent clinical context, a definitive diagnosis of pulmonary cryptococcosis relies on the positivity of cultures for Cryptococcus neoformans from bronchopulmonary specimens, sometimes anticipated by the demonstration of encapsulated yeasts on direct examination (Indian ink test). However, this may be difficult to achieve as it requires microscopic expertise and because concurrent microorganism growth may mask the presence of C. neoformans in cultures. Indeed, encapsulated yeasts may be missed due to the cellularity of the broncho-alveolar lavage fluid (BALF) or, by the contrary, some cells may be mistaken for yeasts leading to false-positive results. The culture, if it turns positive, requires at least 48 to 72 hours of incubation. Due to these limitations and because the cryptococcal antigen (CryAg) detection in serum and cerebrospinal fluid (CSF) is associated with excellent performances, it was tantalizing to test CryAg in broncho-pulmonary specimens.6 To the best of our knowledge, there are only four reports focused on this utilization.7–10 However, most of these studies have been performed before the advent of highly active antiretroviral therapy and/or analyzed a limited number of specimens. Thus, to assess whether the CryAg detection in BALF is currently a valuable adjunctive test, we retrospectively reviewed the data collected through a large number of BALF specimens subjected to the diagnosis of pulmonary fungal infection including the CryAg detection. During a 7-year period (2007–2013), the cryptococcal antigen was systematically assayed in BALF specimens referred to our lab, located in a French University Hospital in Paris, for pulmonary fungal infection diagnosis. After centrifugation (700 g for 5 min), we used the Premier EIA Cryptococcal Antigen (Meridian Bioscience, Paris, France) on the supernatant, with cut-offs similar to that used for other fluids (serum, CSF), respectively, <0.07 and >0.1 for negativity and positivity. In parallel, direct examination (Indian ink) was performed on the pellet, and the specimen was inoculated onto Sabouraud slants incubated at 30°C and 35°C for at least 15 days. For all of these patients, we collected clinical charts and data regarding the diagnosis of cryptococcosis, that is, C. neoformans positive culture of any clinical sample and/or CryAg detection in serum or CSF. According to these data, we differentiate three forms of cryptococcal lung disease: (i) Cryptococcal pneumonia, for which definitive diagnosis relied on a positive culture of a broncho-pulmonary specimen in patients with consistent clinical context, and a disseminated infection, was documented either with positive culture from another noncontiguous anatomical site(s) or a positive seric capsular antigen. (ii) Colonization was defined by a positive culture for C. neoformans from a BALF specimen in a patient with a radio-clinical form poorly evocative of a pulmonary cryptococcosis and the lack of any sign of disseminated infection. (iii) Possible pulmonary cryptococcosis was considered in patients with a positive BALF CryAg but negative Indian ink and culture results. During the study period, CryAg was screened in 4650 BALF (3839 patients). CryAg was detected in 12 cases (10 patients). Two of these patients were submitted to BAL twice (cases 4, 11). In addition, there were four patients classified as colonized and one with cryptococcal pneumonia who tested negative for the CryAg in the BALF. The clinical characteristics of those patients are presented in Table 1. According to the French law, the database was registered to the French Data Protection Authority (Commission Informatique et Liberté) under number 2086579. Table 1. Characteristics of patients with pulmonary cryptococcosis. BALF Patient Sex/Age Underlying Sites of Seric antigen/ disease isolationb dilution positivity Indian Culture CryAg Delay Positive ink BALF CryAg / definitive cryptococcosis diagnosis Treatment Outcome Definitive diagnosis of cryptococcal pneumonia 1 M/47 HIV infection Blood, CSF P/2048 P P P +9 d AmB + 5FC then FLC Survival 2 M/60 HIV infection Lungs P/64 N P P −3 d FLC Death 3 M/38 HIV infection CSF, Lungs, urine P/16000 P P P +6 d FLC Survival 4.1a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urine P/256 P P P +6 d AmB + 5FC then FLC Survival 5 M/69 Liver fibrosis CSF, Urine, Lungs N N P N +12 d FLC then AmB+5FC Death Cryptococcal pulmonary colonization 6 M/71 Lung fibrosis Lungs ND N P N NA FLC Survival 7 M/64 Alveolar-interstitial disease Lungs ND N P N NA LtF LtF 8 M/59 HIV infection Lungs N N P N NA FLC Survival 9 M/60 Diabetes mellitus Lungs N N P N NA FLC Survival Possible pulmonary cryptococcosis 4.2a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urines P/512 N N P +42 d AmB + 5FC then FLC Survival 10 M/40 HIV infection Blood, CSF, urines, Spleen biopsy P/4096 N N P +16 d AmB + 5FC then FLC Survival 11. 1a M/38 HIV infection CSF, Mediastinal node P/1024 N N P +8 mo AmB + 5FC then FLC Survival 11.2a P/512 N N P +11 mo 12 M/36 HIV- IVDA None ND N N P NA NT Death 13 F/66 Bronchial dilatation None ND N N P NA NT Survival 14 M/36 Allo-BMT, probable IPA None ND N N P NA NT Death 15 F/62 NHML None ND N N P NA NT Death BALF Patient Sex/Age Underlying Sites of Seric antigen/ disease isolationb dilution positivity Indian Culture CryAg Delay Positive ink BALF CryAg / definitive cryptococcosis diagnosis Treatment Outcome Definitive diagnosis of cryptococcal pneumonia 1 M/47 HIV infection Blood, CSF P/2048 P P P +9 d AmB + 5FC then FLC Survival 2 M/60 HIV infection Lungs P/64 N P P −3 d FLC Death 3 M/38 HIV infection CSF, Lungs, urine P/16000 P P P +6 d FLC Survival 4.1a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urine P/256 P P P +6 d AmB + 5FC then FLC Survival 5 M/69 Liver fibrosis CSF, Urine, Lungs N N P N +12 d FLC then AmB+5FC Death Cryptococcal pulmonary colonization 6 M/71 Lung fibrosis Lungs ND N P N NA FLC Survival 7 M/64 Alveolar-interstitial disease Lungs ND N P N NA LtF LtF 8 M/59 HIV infection Lungs N N P N NA FLC Survival 9 M/60 Diabetes mellitus Lungs N N P N NA FLC Survival Possible pulmonary cryptococcosis 4.2a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urines P/512 N N P +42 d AmB + 5FC then FLC Survival 10 M/40 HIV infection Blood, CSF, urines, Spleen biopsy P/4096 N N P +16 d AmB + 5FC then FLC Survival 11. 1a M/38 HIV infection CSF, Mediastinal node P/1024 N N P +8 mo AmB + 5FC then FLC Survival 11.2a P/512 N N P +11 mo 12 M/36 HIV- IVDA None ND N N P NA NT Death 13 F/66 Bronchial dilatation None ND N N P NA NT Survival 14 M/36 Allo-BMT, probable IPA None ND N N P NA NT Death 15 F/62 NHML None ND N N P NA NT Death AmB, amphotericin B; BALF, broncho-alveolar lavage fluid; CSF, cerebrospinal fluid; FLC, fluconazole; 5FC, flucytosine; HIV, human immunodeficiency virus; IPA, invasive pulmonary aspergillosis; LtF, lost to follow-up; N, negative; NA, not applicable; ND, not done; NHML, non-Hodgkin malignant lymphoma; NT, not treated; P, positive. aPatients 4 and 11 were subjected to BAL twice. bLung mean positive culture from a BALF specimen. View Large Table 1. Characteristics of patients with pulmonary cryptococcosis. BALF Patient Sex/Age Underlying Sites of Seric antigen/ disease isolationb dilution positivity Indian Culture CryAg Delay Positive ink BALF CryAg / definitive cryptococcosis diagnosis Treatment Outcome Definitive diagnosis of cryptococcal pneumonia 1 M/47 HIV infection Blood, CSF P/2048 P P P +9 d AmB + 5FC then FLC Survival 2 M/60 HIV infection Lungs P/64 N P P −3 d FLC Death 3 M/38 HIV infection CSF, Lungs, urine P/16000 P P P +6 d FLC Survival 4.1a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urine P/256 P P P +6 d AmB + 5FC then FLC Survival 5 M/69 Liver fibrosis CSF, Urine, Lungs N N P N +12 d FLC then AmB+5FC Death Cryptococcal pulmonary colonization 6 M/71 Lung fibrosis Lungs ND N P N NA FLC Survival 7 M/64 Alveolar-interstitial disease Lungs ND N P N NA LtF LtF 8 M/59 HIV infection Lungs N N P N NA FLC Survival 9 M/60 Diabetes mellitus Lungs N N P N NA FLC Survival Possible pulmonary cryptococcosis 4.2a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urines P/512 N N P +42 d AmB + 5FC then FLC Survival 10 M/40 HIV infection Blood, CSF, urines, Spleen biopsy P/4096 N N P +16 d AmB + 5FC then FLC Survival 11. 1a M/38 HIV infection CSF, Mediastinal node P/1024 N N P +8 mo AmB + 5FC then FLC Survival 11.2a P/512 N N P +11 mo 12 M/36 HIV- IVDA None ND N N P NA NT Death 13 F/66 Bronchial dilatation None ND N N P NA NT Survival 14 M/36 Allo-BMT, probable IPA None ND N N P NA NT Death 15 F/62 NHML None ND N N P NA NT Death BALF Patient Sex/Age Underlying Sites of Seric antigen/ disease isolationb dilution positivity Indian Culture CryAg Delay Positive ink BALF CryAg / definitive cryptococcosis diagnosis Treatment Outcome Definitive diagnosis of cryptococcal pneumonia 1 M/47 HIV infection Blood, CSF P/2048 P P P +9 d AmB + 5FC then FLC Survival 2 M/60 HIV infection Lungs P/64 N P P −3 d FLC Death 3 M/38 HIV infection CSF, Lungs, urine P/16000 P P P +6 d FLC Survival 4.1a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urine P/256 P P P +6 d AmB + 5FC then FLC Survival 5 M/69 Liver fibrosis CSF, Urine, Lungs N N P N +12 d FLC then AmB+5FC Death Cryptococcal pulmonary colonization 6 M/71 Lung fibrosis Lungs ND N P N NA FLC Survival 7 M/64 Alveolar-interstitial disease Lungs ND N P N NA LtF LtF 8 M/59 HIV infection Lungs N N P N NA FLC Survival 9 M/60 Diabetes mellitus Lungs N N P N NA FLC Survival Possible pulmonary cryptococcosis 4.2a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urines P/512 N N P +42 d AmB + 5FC then FLC Survival 10 M/40 HIV infection Blood, CSF, urines, Spleen biopsy P/4096 N N P +16 d AmB + 5FC then FLC Survival 11. 1a M/38 HIV infection CSF, Mediastinal node P/1024 N N P +8 mo AmB + 5FC then FLC Survival 11.2a P/512 N N P +11 mo 12 M/36 HIV- IVDA None ND N N P NA NT Death 13 F/66 Bronchial dilatation None ND N N P NA NT Survival 14 M/36 Allo-BMT, probable IPA None ND N N P NA NT Death 15 F/62 NHML None ND N N P NA NT Death AmB, amphotericin B; BALF, broncho-alveolar lavage fluid; CSF, cerebrospinal fluid; FLC, fluconazole; 5FC, flucytosine; HIV, human immunodeficiency virus; IPA, invasive pulmonary aspergillosis; LtF, lost to follow-up; N, negative; NA, not applicable; ND, not done; NHML, non-Hodgkin malignant lymphoma; NT, not treated; P, positive. aPatients 4 and 11 were subjected to BAL twice. bLung mean positive culture from a BALF specimen. View Large Five patients had a definitive diagnosis of cryptococcal pneumonia. In four cases, the infection was disseminated and has been diagnosed 6 days to 12 days before (cases 1, 3, 4.1, 5). Another patient was diagnosed with an isolated cryptococcal pneumonia, for which CryAg result anticipated the diagnosis of cryptococcosis by 3 days (case 2). All of these patients but one (case 5) had a positive CryAg result in their BALF, leading a sensitivity rate estimated at 0.80. Four patients were considered colonized (cases 6–9). All of these patients were negative for CryAg in BALF. One patient was immunocompromised. Two had underlying lung diseases (lung fibrosis and acute lung edema). It has already been reported that intercurrent pulmonary disease may favor the cryptococcal pulmonary colonization.11 It is possible that in such cases, the fungal load was low enough that the immunologic test remains negative. However, we cannot rule out the fact that this condition represents the first stage of an invasive infection, as it has been previously described.3 Such an outcome could have been stopped thanks to an early antifungal therapy initiated in three of these patients. Gathering active infection and colonization, sensitivity rate of testing CryAg in BALF drops at 0.44. Finally, seven patients (8 BALF) were considered to have a possible pulmonary cryptococcosis. One case corresponded to the follow-up a patient with definitive pulmonary cryptococcosis (case 4.2), and two patients suffered disseminated cryptococcosis (cases 10, 11). In these cases, one can hypothesize that the positivity of the BALF test could correspond to the effusion of the seric antigen which was positive at a high level in these patients. Finally, four patients had no other diagnostic tests positive for cryptococcosis (cases 12–15). In these cases, the culture was also negative for other basidiomycetous species such as Trichosporon or Rhodotorula, which are known to cross-react with the CryAg.12 None of these patients received antifungal therapy. One died the day after the BALF CryAg returned positive, preventing any definitive conclusion (case 15). Another died 20 days later due to a probable invasive aspergillosis (case 14). The other two survived more than 2 years, and none developed cryptococcosis. Taking these results together, four to seven results can be considered as false positive for the diagnosis of pulmonary cryptococcosis. Nevertheless, because the vast majority of patients without cryptococcosis had a negative BALF CryAg, the specificity of the test remained high at 0.99, while in contrast, the positive predictive value was lower, calculated at 0.36. Comparison of our results with those from previous studies is difficult since both the kit used and the definitions applied to classify the clinical forms differ (Table 2). However, with the exception of the study by Baughman et al., who used a personal cut-off for the kit they used, both the sensitivity and the positive predictive value appear insufficient. One can expect that the use of the more recently available immunochromatographic test would have enhanced the sensitivity.12,13 However, none of the manufacturers currently recommend the use of their kit for the detection of CryAg in BALF. Whether or not cryptococcal colonization could be detected based on the combination of positive culture and negative CryAg in the BALF needs additional studies. Thus, we considered that there is currently a limited interest in the routine detection of the cryptococcal antigen in BALF specimens. Table 2. Comparative analysis of studies focused on the evaluation of cryptococcal antigen detection in broncho-pulmonary specimens. Reference Kralovic et al.9 Baughman et al.7 Bottone et al.8 Takahashi et al.10 Present study Study period 1989–1994 Published in 1992 Published in 1998 1997–2002 2007–2013 Nb patients included 995 patients (1506 BALF) 271 patients (271 BALF) 51 (retrospective) + 220 (prospective) 39 patients 30 BALF and 9 IS 88 patients (88 BALF) 3839 patients (4650 BALF) CryAg test Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (CALAS, Meridian)b Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (Eiken Co., Tokyo, Japan) EIA (Premier EIA Cryptococcal Antigen, Meridian) Proven pulmonary cryptococcosisc 24 4 + 7a 3 2 5 Colonizationc NS 3 + 1a NS 0 4 Possible pulmonary cryptococcosisc 8 7 2 1 7 Sensitivity 0.71 1.00d ND ND 0.80/0.44e Specificity 0.99 0.98 ND ND 1.00 Positive predictive value 0.59 0.67 ND ND 0.36 Negative predictive value 0.99 1.00 ND ND 1.00 Reference Kralovic et al.9 Baughman et al.7 Bottone et al.8 Takahashi et al.10 Present study Study period 1989–1994 Published in 1992 Published in 1998 1997–2002 2007–2013 Nb patients included 995 patients (1506 BALF) 271 patients (271 BALF) 51 (retrospective) + 220 (prospective) 39 patients 30 BALF and 9 IS 88 patients (88 BALF) 3839 patients (4650 BALF) CryAg test Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (CALAS, Meridian)b Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (Eiken Co., Tokyo, Japan) EIA (Premier EIA Cryptococcal Antigen, Meridian) Proven pulmonary cryptococcosisc 24 4 + 7a 3 2 5 Colonizationc NS 3 + 1a NS 0 4 Possible pulmonary cryptococcosisc 8 7 2 1 7 Sensitivity 0.71 1.00d ND ND 0.80/0.44e Specificity 0.99 0.98 ND ND 1.00 Positive predictive value 0.59 0.67 ND ND 0.36 Negative predictive value 0.99 1.00 ND ND 1.00 BALF, broncho-alveolar lavage fluid; CryAg, cryptococcal antigen; IS, induced sputum; ND, not done. aThis study included a retrospective and a prospective part, for which the number of patients is given in first and second position, respectively. bWith a modified procedure. cAccording on our definitions see materials and methods. dUsing a cut-off value at 1/8. e0.80 for definitive cryptococcal pneumonia, 0.44 when including pulmonary cryptococcal colonization. View Large Table 2. Comparative analysis of studies focused on the evaluation of cryptococcal antigen detection in broncho-pulmonary specimens. Reference Kralovic et al.9 Baughman et al.7 Bottone et al.8 Takahashi et al.10 Present study Study period 1989–1994 Published in 1992 Published in 1998 1997–2002 2007–2013 Nb patients included 995 patients (1506 BALF) 271 patients (271 BALF) 51 (retrospective) + 220 (prospective) 39 patients 30 BALF and 9 IS 88 patients (88 BALF) 3839 patients (4650 BALF) CryAg test Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (CALAS, Meridian)b Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (Eiken Co., Tokyo, Japan) EIA (Premier EIA Cryptococcal Antigen, Meridian) Proven pulmonary cryptococcosisc 24 4 + 7a 3 2 5 Colonizationc NS 3 + 1a NS 0 4 Possible pulmonary cryptococcosisc 8 7 2 1 7 Sensitivity 0.71 1.00d ND ND 0.80/0.44e Specificity 0.99 0.98 ND ND 1.00 Positive predictive value 0.59 0.67 ND ND 0.36 Negative predictive value 0.99 1.00 ND ND 1.00 Reference Kralovic et al.9 Baughman et al.7 Bottone et al.8 Takahashi et al.10 Present study Study period 1989–1994 Published in 1992 Published in 1998 1997–2002 2007–2013 Nb patients included 995 patients (1506 BALF) 271 patients (271 BALF) 51 (retrospective) + 220 (prospective) 39 patients 30 BALF and 9 IS 88 patients (88 BALF) 3839 patients (4650 BALF) CryAg test Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (CALAS, Meridian)b Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (Eiken Co., Tokyo, Japan) EIA (Premier EIA Cryptococcal Antigen, Meridian) Proven pulmonary cryptococcosisc 24 4 + 7a 3 2 5 Colonizationc NS 3 + 1a NS 0 4 Possible pulmonary cryptococcosisc 8 7 2 1 7 Sensitivity 0.71 1.00d ND ND 0.80/0.44e Specificity 0.99 0.98 ND ND 1.00 Positive predictive value 0.59 0.67 ND ND 0.36 Negative predictive value 0.99 1.00 ND ND 1.00 BALF, broncho-alveolar lavage fluid; CryAg, cryptococcal antigen; IS, induced sputum; ND, not done. aThis study included a retrospective and a prospective part, for which the number of patients is given in first and second position, respectively. bWith a modified procedure. cAccording on our definitions see materials and methods. dUsing a cut-off value at 1/8. e0.80 for definitive cryptococcal pneumonia, 0.44 when including pulmonary cryptococcal colonization. View Large Acknowledgements The authors would like to thank the technical staff of the Laboratory of Parasitology-Mycology for excellent assistance. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and the writing of the paper. References 1. McQuiston TJ , Williamson PR . Paradoxical roles of alveolar macrophages in the host response to Cryptococcus neoformans . J Infect Chemother . 2012 ; 18 : 1 – 9 . Google Scholar CrossRef Search ADS PubMed 2. Williamson PR , Jarvis JN , Panackal AA et al. Cryptococcal meningitis: epidemiology, immunology, diagnosis and therapy . Nat Rev Neurol . 2017 ; 13 : 13 – 24 . Google Scholar CrossRef Search ADS PubMed 3. Meyohas MC , Roux P , Bollens D et al. Pulmonary cryptococcosis: localized and disseminated infections in 27 patients with AIDS. Clin Infect Dis . 1995 ; 21 : 628 – 633 . Google Scholar CrossRef Search ADS PubMed 4. Pappas PG . Cryptococcal infections in non-HIV-infected patients . Trans Am Clin Climatol Assoc . 2013 ; 124 : 61 – 79 . Google Scholar PubMed 5. Shirley RM , Baddley JW . Cryptococcal lung disease . Curr Opin Pulm Med . 2009 ; 15 : 254 – 260 . Google Scholar CrossRef Search ADS PubMed 6. Pfeiffer CD , Wong B . Diagnostic immunology . In: Hospenthal DR , Rinaldi MG , eds. Diagnosis and Treatment of Fungal Infections . New York City : Springer ; 2015 : 45 – 64 . Google Scholar CrossRef Search ADS 7. Baughman RP , Rhodes JC , Dohn MN , Henderson H , Frame PT . Detection of cryptococcal antigen in bronchoalveolar lavage fluid: a prospective study of diagnostic utility . Am Rev Respir Dis . 1992 ; 145 : 1226 – 1229 . Google Scholar CrossRef Search ADS PubMed 8. Bottone EJ , Sindone M , Caraballo V . Value of assessing cryptococcal antigen in bronchoalveolar lavage and sputum specimens from patients with AIDS. Mt Sinai J Med . 1998 ; 65 : 422 – 425 . Google Scholar PubMed 9. Kralovic SM , Rhodes JC . Utility of routine testing of bronchoalveolar lavage fluid for cryptococcal antigen . J Clin Microbiol . 1998 ; 36 : 3088 – 3089 . Google Scholar PubMed 10. Takahashi T , Goto M , Kanda T , Iwamoto A . Utility of testing bronchoalveolar lavage fluid for cryptococcal ribosomal DNA. J Int Med Res . 2003 ; 31 : 324 – 329 . Google Scholar CrossRef Search ADS PubMed 11. Subramanian S , Kherdekar SS , Babu PG , Christianson CS . Lipoid pneumonia with Cryptococcus neoformans colonisation . Thorax . 1982 ; 37 : 319 – 320 . Google Scholar CrossRef Search ADS PubMed 12. Rivet-Danon D , Guitard J , Grenouillet F et al. Rapid diagnosis of cryptococcosis using an antigen detection immunochromatographic test . J Infect . 2015 ; 70 : 499 – 503 . Google Scholar CrossRef Search ADS PubMed 13. McMullan BJ , Halliday C , Sorrell TC et al. Clinical utility of the cryptococcal antigen lateral flow assay in a diagnostic mycology laboratory . PLoS One . 2012 ; 7 : e49541 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2017. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Medical Mycology Oxford University Press

Cryptococcal antigen detection in broncho-alveolar lavage fluid

Medical Mycology , Volume 56 (6) – Aug 1, 2018

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Abstract

Abstract Cryptococcal antigen (CryAg) testing in serum and CSF is a clue diagnostic tool for cryptococcosis. In this study, we reviewed the performances of the CryAg detection (Premier EIA, Meridian) routinely performed in broncho-alveolar lavage fluid (BALF) during a 7-year period (2007–2013). CryAg was detected in 12 cases among 4650 BALF analyzed, while positive culture from BALF was detected in nine cases. We found sensitivity, specificity, positive and negative predictive values at 0.44–0.80 (according to the radio-clinical form), 0.99, 0.36, and 0.99, respectively. These results do not support the routine use of the test in BALF. Cryptococcosis, pneumonia, diagnosis, antigen Cryptococcosis is mainly acquired following inhalation of spores from the environment and is in fact originally pulmonary. Although this primo-infection seems to be mostly a- or pauci-symptomatic, it allows the fungus to remain quiescent in the alveoli before a possible reactivation due to immunosuppression, mainly induced by the human immunodeficiency virus (HIV) infection or immunosuppressive therapies.1,2 Neurological symptoms are then often predominant but pulmonary symptoms may sometimes be foreground, notably in HIV-negative patients.3,4 Mostly depending on the immune status of the patient, the clinical presentation and outcome of pulmonary cryptococcosis are highly variable, ranging from asymptomatic colonization to severe pneumonia with respiratory failure.5 In a consistent clinical context, a definitive diagnosis of pulmonary cryptococcosis relies on the positivity of cultures for Cryptococcus neoformans from bronchopulmonary specimens, sometimes anticipated by the demonstration of encapsulated yeasts on direct examination (Indian ink test). However, this may be difficult to achieve as it requires microscopic expertise and because concurrent microorganism growth may mask the presence of C. neoformans in cultures. Indeed, encapsulated yeasts may be missed due to the cellularity of the broncho-alveolar lavage fluid (BALF) or, by the contrary, some cells may be mistaken for yeasts leading to false-positive results. The culture, if it turns positive, requires at least 48 to 72 hours of incubation. Due to these limitations and because the cryptococcal antigen (CryAg) detection in serum and cerebrospinal fluid (CSF) is associated with excellent performances, it was tantalizing to test CryAg in broncho-pulmonary specimens.6 To the best of our knowledge, there are only four reports focused on this utilization.7–10 However, most of these studies have been performed before the advent of highly active antiretroviral therapy and/or analyzed a limited number of specimens. Thus, to assess whether the CryAg detection in BALF is currently a valuable adjunctive test, we retrospectively reviewed the data collected through a large number of BALF specimens subjected to the diagnosis of pulmonary fungal infection including the CryAg detection. During a 7-year period (2007–2013), the cryptococcal antigen was systematically assayed in BALF specimens referred to our lab, located in a French University Hospital in Paris, for pulmonary fungal infection diagnosis. After centrifugation (700 g for 5 min), we used the Premier EIA Cryptococcal Antigen (Meridian Bioscience, Paris, France) on the supernatant, with cut-offs similar to that used for other fluids (serum, CSF), respectively, <0.07 and >0.1 for negativity and positivity. In parallel, direct examination (Indian ink) was performed on the pellet, and the specimen was inoculated onto Sabouraud slants incubated at 30°C and 35°C for at least 15 days. For all of these patients, we collected clinical charts and data regarding the diagnosis of cryptococcosis, that is, C. neoformans positive culture of any clinical sample and/or CryAg detection in serum or CSF. According to these data, we differentiate three forms of cryptococcal lung disease: (i) Cryptococcal pneumonia, for which definitive diagnosis relied on a positive culture of a broncho-pulmonary specimen in patients with consistent clinical context, and a disseminated infection, was documented either with positive culture from another noncontiguous anatomical site(s) or a positive seric capsular antigen. (ii) Colonization was defined by a positive culture for C. neoformans from a BALF specimen in a patient with a radio-clinical form poorly evocative of a pulmonary cryptococcosis and the lack of any sign of disseminated infection. (iii) Possible pulmonary cryptococcosis was considered in patients with a positive BALF CryAg but negative Indian ink and culture results. During the study period, CryAg was screened in 4650 BALF (3839 patients). CryAg was detected in 12 cases (10 patients). Two of these patients were submitted to BAL twice (cases 4, 11). In addition, there were four patients classified as colonized and one with cryptococcal pneumonia who tested negative for the CryAg in the BALF. The clinical characteristics of those patients are presented in Table 1. According to the French law, the database was registered to the French Data Protection Authority (Commission Informatique et Liberté) under number 2086579. Table 1. Characteristics of patients with pulmonary cryptococcosis. BALF Patient Sex/Age Underlying Sites of Seric antigen/ disease isolationb dilution positivity Indian Culture CryAg Delay Positive ink BALF CryAg / definitive cryptococcosis diagnosis Treatment Outcome Definitive diagnosis of cryptococcal pneumonia 1 M/47 HIV infection Blood, CSF P/2048 P P P +9 d AmB + 5FC then FLC Survival 2 M/60 HIV infection Lungs P/64 N P P −3 d FLC Death 3 M/38 HIV infection CSF, Lungs, urine P/16000 P P P +6 d FLC Survival 4.1a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urine P/256 P P P +6 d AmB + 5FC then FLC Survival 5 M/69 Liver fibrosis CSF, Urine, Lungs N N P N +12 d FLC then AmB+5FC Death Cryptococcal pulmonary colonization 6 M/71 Lung fibrosis Lungs ND N P N NA FLC Survival 7 M/64 Alveolar-interstitial disease Lungs ND N P N NA LtF LtF 8 M/59 HIV infection Lungs N N P N NA FLC Survival 9 M/60 Diabetes mellitus Lungs N N P N NA FLC Survival Possible pulmonary cryptococcosis 4.2a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urines P/512 N N P +42 d AmB + 5FC then FLC Survival 10 M/40 HIV infection Blood, CSF, urines, Spleen biopsy P/4096 N N P +16 d AmB + 5FC then FLC Survival 11. 1a M/38 HIV infection CSF, Mediastinal node P/1024 N N P +8 mo AmB + 5FC then FLC Survival 11.2a P/512 N N P +11 mo 12 M/36 HIV- IVDA None ND N N P NA NT Death 13 F/66 Bronchial dilatation None ND N N P NA NT Survival 14 M/36 Allo-BMT, probable IPA None ND N N P NA NT Death 15 F/62 NHML None ND N N P NA NT Death BALF Patient Sex/Age Underlying Sites of Seric antigen/ disease isolationb dilution positivity Indian Culture CryAg Delay Positive ink BALF CryAg / definitive cryptococcosis diagnosis Treatment Outcome Definitive diagnosis of cryptococcal pneumonia 1 M/47 HIV infection Blood, CSF P/2048 P P P +9 d AmB + 5FC then FLC Survival 2 M/60 HIV infection Lungs P/64 N P P −3 d FLC Death 3 M/38 HIV infection CSF, Lungs, urine P/16000 P P P +6 d FLC Survival 4.1a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urine P/256 P P P +6 d AmB + 5FC then FLC Survival 5 M/69 Liver fibrosis CSF, Urine, Lungs N N P N +12 d FLC then AmB+5FC Death Cryptococcal pulmonary colonization 6 M/71 Lung fibrosis Lungs ND N P N NA FLC Survival 7 M/64 Alveolar-interstitial disease Lungs ND N P N NA LtF LtF 8 M/59 HIV infection Lungs N N P N NA FLC Survival 9 M/60 Diabetes mellitus Lungs N N P N NA FLC Survival Possible pulmonary cryptococcosis 4.2a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urines P/512 N N P +42 d AmB + 5FC then FLC Survival 10 M/40 HIV infection Blood, CSF, urines, Spleen biopsy P/4096 N N P +16 d AmB + 5FC then FLC Survival 11. 1a M/38 HIV infection CSF, Mediastinal node P/1024 N N P +8 mo AmB + 5FC then FLC Survival 11.2a P/512 N N P +11 mo 12 M/36 HIV- IVDA None ND N N P NA NT Death 13 F/66 Bronchial dilatation None ND N N P NA NT Survival 14 M/36 Allo-BMT, probable IPA None ND N N P NA NT Death 15 F/62 NHML None ND N N P NA NT Death AmB, amphotericin B; BALF, broncho-alveolar lavage fluid; CSF, cerebrospinal fluid; FLC, fluconazole; 5FC, flucytosine; HIV, human immunodeficiency virus; IPA, invasive pulmonary aspergillosis; LtF, lost to follow-up; N, negative; NA, not applicable; ND, not done; NHML, non-Hodgkin malignant lymphoma; NT, not treated; P, positive. aPatients 4 and 11 were subjected to BAL twice. bLung mean positive culture from a BALF specimen. View Large Table 1. Characteristics of patients with pulmonary cryptococcosis. BALF Patient Sex/Age Underlying Sites of Seric antigen/ disease isolationb dilution positivity Indian Culture CryAg Delay Positive ink BALF CryAg / definitive cryptococcosis diagnosis Treatment Outcome Definitive diagnosis of cryptococcal pneumonia 1 M/47 HIV infection Blood, CSF P/2048 P P P +9 d AmB + 5FC then FLC Survival 2 M/60 HIV infection Lungs P/64 N P P −3 d FLC Death 3 M/38 HIV infection CSF, Lungs, urine P/16000 P P P +6 d FLC Survival 4.1a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urine P/256 P P P +6 d AmB + 5FC then FLC Survival 5 M/69 Liver fibrosis CSF, Urine, Lungs N N P N +12 d FLC then AmB+5FC Death Cryptococcal pulmonary colonization 6 M/71 Lung fibrosis Lungs ND N P N NA FLC Survival 7 M/64 Alveolar-interstitial disease Lungs ND N P N NA LtF LtF 8 M/59 HIV infection Lungs N N P N NA FLC Survival 9 M/60 Diabetes mellitus Lungs N N P N NA FLC Survival Possible pulmonary cryptococcosis 4.2a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urines P/512 N N P +42 d AmB + 5FC then FLC Survival 10 M/40 HIV infection Blood, CSF, urines, Spleen biopsy P/4096 N N P +16 d AmB + 5FC then FLC Survival 11. 1a M/38 HIV infection CSF, Mediastinal node P/1024 N N P +8 mo AmB + 5FC then FLC Survival 11.2a P/512 N N P +11 mo 12 M/36 HIV- IVDA None ND N N P NA NT Death 13 F/66 Bronchial dilatation None ND N N P NA NT Survival 14 M/36 Allo-BMT, probable IPA None ND N N P NA NT Death 15 F/62 NHML None ND N N P NA NT Death BALF Patient Sex/Age Underlying Sites of Seric antigen/ disease isolationb dilution positivity Indian Culture CryAg Delay Positive ink BALF CryAg / definitive cryptococcosis diagnosis Treatment Outcome Definitive diagnosis of cryptococcal pneumonia 1 M/47 HIV infection Blood, CSF P/2048 P P P +9 d AmB + 5FC then FLC Survival 2 M/60 HIV infection Lungs P/64 N P P −3 d FLC Death 3 M/38 HIV infection CSF, Lungs, urine P/16000 P P P +6 d FLC Survival 4.1a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urine P/256 P P P +6 d AmB + 5FC then FLC Survival 5 M/69 Liver fibrosis CSF, Urine, Lungs N N P N +12 d FLC then AmB+5FC Death Cryptococcal pulmonary colonization 6 M/71 Lung fibrosis Lungs ND N P N NA FLC Survival 7 M/64 Alveolar-interstitial disease Lungs ND N P N NA LtF LtF 8 M/59 HIV infection Lungs N N P N NA FLC Survival 9 M/60 Diabetes mellitus Lungs N N P N NA FLC Survival Possible pulmonary cryptococcosis 4.2a M/67 Renal transplantation Blood, CSF, Bronchial aspiration, Skin biopsy, urines P/512 N N P +42 d AmB + 5FC then FLC Survival 10 M/40 HIV infection Blood, CSF, urines, Spleen biopsy P/4096 N N P +16 d AmB + 5FC then FLC Survival 11. 1a M/38 HIV infection CSF, Mediastinal node P/1024 N N P +8 mo AmB + 5FC then FLC Survival 11.2a P/512 N N P +11 mo 12 M/36 HIV- IVDA None ND N N P NA NT Death 13 F/66 Bronchial dilatation None ND N N P NA NT Survival 14 M/36 Allo-BMT, probable IPA None ND N N P NA NT Death 15 F/62 NHML None ND N N P NA NT Death AmB, amphotericin B; BALF, broncho-alveolar lavage fluid; CSF, cerebrospinal fluid; FLC, fluconazole; 5FC, flucytosine; HIV, human immunodeficiency virus; IPA, invasive pulmonary aspergillosis; LtF, lost to follow-up; N, negative; NA, not applicable; ND, not done; NHML, non-Hodgkin malignant lymphoma; NT, not treated; P, positive. aPatients 4 and 11 were subjected to BAL twice. bLung mean positive culture from a BALF specimen. View Large Five patients had a definitive diagnosis of cryptococcal pneumonia. In four cases, the infection was disseminated and has been diagnosed 6 days to 12 days before (cases 1, 3, 4.1, 5). Another patient was diagnosed with an isolated cryptococcal pneumonia, for which CryAg result anticipated the diagnosis of cryptococcosis by 3 days (case 2). All of these patients but one (case 5) had a positive CryAg result in their BALF, leading a sensitivity rate estimated at 0.80. Four patients were considered colonized (cases 6–9). All of these patients were negative for CryAg in BALF. One patient was immunocompromised. Two had underlying lung diseases (lung fibrosis and acute lung edema). It has already been reported that intercurrent pulmonary disease may favor the cryptococcal pulmonary colonization.11 It is possible that in such cases, the fungal load was low enough that the immunologic test remains negative. However, we cannot rule out the fact that this condition represents the first stage of an invasive infection, as it has been previously described.3 Such an outcome could have been stopped thanks to an early antifungal therapy initiated in three of these patients. Gathering active infection and colonization, sensitivity rate of testing CryAg in BALF drops at 0.44. Finally, seven patients (8 BALF) were considered to have a possible pulmonary cryptococcosis. One case corresponded to the follow-up a patient with definitive pulmonary cryptococcosis (case 4.2), and two patients suffered disseminated cryptococcosis (cases 10, 11). In these cases, one can hypothesize that the positivity of the BALF test could correspond to the effusion of the seric antigen which was positive at a high level in these patients. Finally, four patients had no other diagnostic tests positive for cryptococcosis (cases 12–15). In these cases, the culture was also negative for other basidiomycetous species such as Trichosporon or Rhodotorula, which are known to cross-react with the CryAg.12 None of these patients received antifungal therapy. One died the day after the BALF CryAg returned positive, preventing any definitive conclusion (case 15). Another died 20 days later due to a probable invasive aspergillosis (case 14). The other two survived more than 2 years, and none developed cryptococcosis. Taking these results together, four to seven results can be considered as false positive for the diagnosis of pulmonary cryptococcosis. Nevertheless, because the vast majority of patients without cryptococcosis had a negative BALF CryAg, the specificity of the test remained high at 0.99, while in contrast, the positive predictive value was lower, calculated at 0.36. Comparison of our results with those from previous studies is difficult since both the kit used and the definitions applied to classify the clinical forms differ (Table 2). However, with the exception of the study by Baughman et al., who used a personal cut-off for the kit they used, both the sensitivity and the positive predictive value appear insufficient. One can expect that the use of the more recently available immunochromatographic test would have enhanced the sensitivity.12,13 However, none of the manufacturers currently recommend the use of their kit for the detection of CryAg in BALF. Whether or not cryptococcal colonization could be detected based on the combination of positive culture and negative CryAg in the BALF needs additional studies. Thus, we considered that there is currently a limited interest in the routine detection of the cryptococcal antigen in BALF specimens. Table 2. Comparative analysis of studies focused on the evaluation of cryptococcal antigen detection in broncho-pulmonary specimens. Reference Kralovic et al.9 Baughman et al.7 Bottone et al.8 Takahashi et al.10 Present study Study period 1989–1994 Published in 1992 Published in 1998 1997–2002 2007–2013 Nb patients included 995 patients (1506 BALF) 271 patients (271 BALF) 51 (retrospective) + 220 (prospective) 39 patients 30 BALF and 9 IS 88 patients (88 BALF) 3839 patients (4650 BALF) CryAg test Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (CALAS, Meridian)b Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (Eiken Co., Tokyo, Japan) EIA (Premier EIA Cryptococcal Antigen, Meridian) Proven pulmonary cryptococcosisc 24 4 + 7a 3 2 5 Colonizationc NS 3 + 1a NS 0 4 Possible pulmonary cryptococcosisc 8 7 2 1 7 Sensitivity 0.71 1.00d ND ND 0.80/0.44e Specificity 0.99 0.98 ND ND 1.00 Positive predictive value 0.59 0.67 ND ND 0.36 Negative predictive value 0.99 1.00 ND ND 1.00 Reference Kralovic et al.9 Baughman et al.7 Bottone et al.8 Takahashi et al.10 Present study Study period 1989–1994 Published in 1992 Published in 1998 1997–2002 2007–2013 Nb patients included 995 patients (1506 BALF) 271 patients (271 BALF) 51 (retrospective) + 220 (prospective) 39 patients 30 BALF and 9 IS 88 patients (88 BALF) 3839 patients (4650 BALF) CryAg test Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (CALAS, Meridian)b Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (Eiken Co., Tokyo, Japan) EIA (Premier EIA Cryptococcal Antigen, Meridian) Proven pulmonary cryptococcosisc 24 4 + 7a 3 2 5 Colonizationc NS 3 + 1a NS 0 4 Possible pulmonary cryptococcosisc 8 7 2 1 7 Sensitivity 0.71 1.00d ND ND 0.80/0.44e Specificity 0.99 0.98 ND ND 1.00 Positive predictive value 0.59 0.67 ND ND 0.36 Negative predictive value 0.99 1.00 ND ND 1.00 BALF, broncho-alveolar lavage fluid; CryAg, cryptococcal antigen; IS, induced sputum; ND, not done. aThis study included a retrospective and a prospective part, for which the number of patients is given in first and second position, respectively. bWith a modified procedure. cAccording on our definitions see materials and methods. dUsing a cut-off value at 1/8. e0.80 for definitive cryptococcal pneumonia, 0.44 when including pulmonary cryptococcal colonization. View Large Table 2. Comparative analysis of studies focused on the evaluation of cryptococcal antigen detection in broncho-pulmonary specimens. Reference Kralovic et al.9 Baughman et al.7 Bottone et al.8 Takahashi et al.10 Present study Study period 1989–1994 Published in 1992 Published in 1998 1997–2002 2007–2013 Nb patients included 995 patients (1506 BALF) 271 patients (271 BALF) 51 (retrospective) + 220 (prospective) 39 patients 30 BALF and 9 IS 88 patients (88 BALF) 3839 patients (4650 BALF) CryAg test Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (CALAS, Meridian)b Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (Eiken Co., Tokyo, Japan) EIA (Premier EIA Cryptococcal Antigen, Meridian) Proven pulmonary cryptococcosisc 24 4 + 7a 3 2 5 Colonizationc NS 3 + 1a NS 0 4 Possible pulmonary cryptococcosisc 8 7 2 1 7 Sensitivity 0.71 1.00d ND ND 0.80/0.44e Specificity 0.99 0.98 ND ND 1.00 Positive predictive value 0.59 0.67 ND ND 0.36 Negative predictive value 0.99 1.00 ND ND 1.00 Reference Kralovic et al.9 Baughman et al.7 Bottone et al.8 Takahashi et al.10 Present study Study period 1989–1994 Published in 1992 Published in 1998 1997–2002 2007–2013 Nb patients included 995 patients (1506 BALF) 271 patients (271 BALF) 51 (retrospective) + 220 (prospective) 39 patients 30 BALF and 9 IS 88 patients (88 BALF) 3839 patients (4650 BALF) CryAg test Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (CALAS, Meridian)b Latex agglutination (CALAS, Meridian Diagnostics) Latex agglutination (Eiken Co., Tokyo, Japan) EIA (Premier EIA Cryptococcal Antigen, Meridian) Proven pulmonary cryptococcosisc 24 4 + 7a 3 2 5 Colonizationc NS 3 + 1a NS 0 4 Possible pulmonary cryptococcosisc 8 7 2 1 7 Sensitivity 0.71 1.00d ND ND 0.80/0.44e Specificity 0.99 0.98 ND ND 1.00 Positive predictive value 0.59 0.67 ND ND 0.36 Negative predictive value 0.99 1.00 ND ND 1.00 BALF, broncho-alveolar lavage fluid; CryAg, cryptococcal antigen; IS, induced sputum; ND, not done. aThis study included a retrospective and a prospective part, for which the number of patients is given in first and second position, respectively. bWith a modified procedure. cAccording on our definitions see materials and methods. dUsing a cut-off value at 1/8. e0.80 for definitive cryptococcal pneumonia, 0.44 when including pulmonary cryptococcal colonization. View Large Acknowledgements The authors would like to thank the technical staff of the Laboratory of Parasitology-Mycology for excellent assistance. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and the writing of the paper. References 1. McQuiston TJ , Williamson PR . Paradoxical roles of alveolar macrophages in the host response to Cryptococcus neoformans . J Infect Chemother . 2012 ; 18 : 1 – 9 . Google Scholar CrossRef Search ADS PubMed 2. Williamson PR , Jarvis JN , Panackal AA et al. Cryptococcal meningitis: epidemiology, immunology, diagnosis and therapy . Nat Rev Neurol . 2017 ; 13 : 13 – 24 . Google Scholar CrossRef Search ADS PubMed 3. Meyohas MC , Roux P , Bollens D et al. Pulmonary cryptococcosis: localized and disseminated infections in 27 patients with AIDS. Clin Infect Dis . 1995 ; 21 : 628 – 633 . Google Scholar CrossRef Search ADS PubMed 4. Pappas PG . Cryptococcal infections in non-HIV-infected patients . Trans Am Clin Climatol Assoc . 2013 ; 124 : 61 – 79 . Google Scholar PubMed 5. Shirley RM , Baddley JW . Cryptococcal lung disease . Curr Opin Pulm Med . 2009 ; 15 : 254 – 260 . Google Scholar CrossRef Search ADS PubMed 6. Pfeiffer CD , Wong B . Diagnostic immunology . In: Hospenthal DR , Rinaldi MG , eds. Diagnosis and Treatment of Fungal Infections . New York City : Springer ; 2015 : 45 – 64 . Google Scholar CrossRef Search ADS 7. Baughman RP , Rhodes JC , Dohn MN , Henderson H , Frame PT . Detection of cryptococcal antigen in bronchoalveolar lavage fluid: a prospective study of diagnostic utility . Am Rev Respir Dis . 1992 ; 145 : 1226 – 1229 . Google Scholar CrossRef Search ADS PubMed 8. Bottone EJ , Sindone M , Caraballo V . Value of assessing cryptococcal antigen in bronchoalveolar lavage and sputum specimens from patients with AIDS. Mt Sinai J Med . 1998 ; 65 : 422 – 425 . Google Scholar PubMed 9. Kralovic SM , Rhodes JC . Utility of routine testing of bronchoalveolar lavage fluid for cryptococcal antigen . J Clin Microbiol . 1998 ; 36 : 3088 – 3089 . Google Scholar PubMed 10. Takahashi T , Goto M , Kanda T , Iwamoto A . Utility of testing bronchoalveolar lavage fluid for cryptococcal ribosomal DNA. J Int Med Res . 2003 ; 31 : 324 – 329 . Google Scholar CrossRef Search ADS PubMed 11. Subramanian S , Kherdekar SS , Babu PG , Christianson CS . Lipoid pneumonia with Cryptococcus neoformans colonisation . Thorax . 1982 ; 37 : 319 – 320 . Google Scholar CrossRef Search ADS PubMed 12. Rivet-Danon D , Guitard J , Grenouillet F et al. Rapid diagnosis of cryptococcosis using an antigen detection immunochromatographic test . J Infect . 2015 ; 70 : 499 – 503 . Google Scholar CrossRef Search ADS PubMed 13. McMullan BJ , Halliday C , Sorrell TC et al. Clinical utility of the cryptococcal antigen lateral flow assay in a diagnostic mycology laboratory . PLoS One . 2012 ; 7 : e49541 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2017. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Medical MycologyOxford University Press

Published: Aug 1, 2018

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