Histoplasma capsulatum/Blastomyces dermatitidis, Molecular Detection, PCR
Clinical Information Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test
Infections with Blastomyces dermatitidis and Histoplasma capsulatum cause a variety of clinical manifestations ranging from self-limited, mild pulmonary illness to potentially life-threatening, disseminated disease. Patients at risk for disseminated disease include neonates and immunosuppressed individuals, particularly those with AIDS, hematologic malignancies, or a recent transplant. Primary infections are acquired through inhalation of microconidia that are present in the environment. In the United States, most cases of blastomycosis and histoplasmosis occur along the Ohio and Mississippi River valleys.
The gold standard for diagnosis of blastomycosis and histoplasmosis remains isolation of the organisms in culture. Although sensitive, recovery in culture and subsequent identification may require days to weeks. The organisms can be identified after growth in culture using traditional macro- and microscopic morphologic techniques or through the use of nucleic acid hybridization probes. Hybridization probe-based procedures are rapid and demonstrate good sensitivity and specificity from culture, although some cross-reactivity with relatively uncommon fungal organisms has been reported. Additional diagnostic tests that can be utilized for these organisms include stains, histopathology, serology, and antigen detection with each of these methods offering advantages and limitations depending on the stage of the illness and the status of the patient. Fungal stains (eg, calcofluor white) offer a rapid diagnostic approach, but demonstrate poor sensitivity and specificity. Serologic tests such as complement fixation and immunodiffusion are noninvasive, but are laborious, subjective, and may show low sensitivity, especially in immunocompromised hosts. Antigen detection also offers a noninvasive approach, but has been demonstrated to show cross-reactivity with antigens from closely related fungal species.
Molecular techniques have been established as sensitive and specific methods for the diagnosis of infectious diseases and have the added advantage of a rapid turnaround time for results. Due to the limitations of conventional diagnostic methods for blastomycosis and histoplasmosis, a single tube, real-time PCR assay was developed and verified for the detection and differentiation of Blastomyces dermatitidis and Histoplasma capsulatum directly from clinical specimens.
Rapid detection of Histoplasma capsulatum and Blastomyces dermatitidis DNA, as an aid in the rapid diagnosis of histoplasmosis and blastomycosis
A positive result for Histoplasma capsulatum indicates presence of Histoplasma DNA; a positive result for Blastomyces dermatitidis indicates presence of Blastomyces DNA.
A negative result indicates absence of detectable Histoplasma capsulatum and Blastomyces dermatitidis DNA. Fungal culture has increased sensitivity over this PCR assay and should always be performed when the PCR is negative.
Cautions Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances
This rapid PCR assay detects Histoplasma capsulatum and Blastomyces dermatitidis nucleic acid and, therefore, does not distinguish between the presence of viable, disease-related organisms and nucleic acid persisting from previous, treated disease. Test results should be correlated with patient symptoms and clinical presentation before a definitive diagnosis is made.
A negative result does not rule out the presence of Histoplasma capsulatum or Blastomyces dermatitidis because the organism may be present at levels below the limit of detection for this assay.
The sensitivity of the PCR assay from bronchoalveolar lavage (BAL) fluid is low and a negative result does not rule out infection.
Urine is not an acceptable source for this assay. Studies indicate that Histoplasma DNA is not routinely found in the urine of patients with disseminated histoplasmosis. Therefore, the Histoplasma antigen test is the recommended test for this specimen source.
Reference Values Describes reference intervals and additional information for interpretation of test results. May include intervals based on age and sex when appropriate. Intervals are Mayo-derived, unless otherwise designated. If an interpretive report is provided, the reference value field will state this.
Clinical References Provides recommendations for further in-depth reading of a clinical nature
1. Kauffman CA: Histoplasmosis. Clin Chest Med 2009;30:217-225
2. Wheat LJ, Freifeld AG, Kleiman MB, et al: Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis 2007;45:807-825
3. Chapman SW, Bradsher RW Jr, Campbell GD Jr, et al: Practice guidelines for the management of patients with blastomycosis. Infectious Diseases Society of America. Clin Infect Dis 2000;30:679-683