Braz, Lucia Maria Almeida

Hefford, Philip Michael

Lindoso, José Angelo Lauletta

Tahmasebi, Roozbeh

English

Cadernos Espinosanos (E-Journal)

Visceral Leishmaniasis diagnosis: a rapid test is amust at the hospital bedsideLucia Maria Almeida Braz0000-0000-0000-0000 ,I,* Roozbeh Tahmasebi0000-0000-0000-0000 ,II Philip Michael Hefford0000-0000-0000-0000 ,III José Angelo LaulettaLindoso0000-0000-0000-0000 I,IVI Instituto de Medicina Tropical, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR. II Escola Politecnica, Universidade de SaoPaulo, Sao Paulo, SP, BR. IIIUniversity Hospitals Plymouth NHS Trust, Plymouth, England. IV Instituto de Infectologia Emilio Ribas, Sao Paulo, SP, BR.Braz LMA, Tahmasebi R, Hefford PM, Lindoso JAL. Visceral Leishmaniasis diagnosis: a rapid test is a must at the hospital bedside. Clinics. 2020;75:e2036*Corresponding author. E-mail: lmabraz@usp.brAt the time of the widespread availability of rapiddiagnostic tests for SARS-CoV-2—the causative virus of theCOVID-19 pandemic—from drugstores throughout Brazil,there is a distinct lack of use of rapid diagnostic tests forvisceral leishmaniasis (VL) at the bedsides of hospitalizedpatients. These tests are mainly distributed by the Ministérioda Saúde do Brazil-MS (Ministry of Health) only to theLaboratórios Centrais de Saúde Publica - LACENs (CentralPublic Health Laboratories) and are predominantly providedto public hospitals.VL is the most severe form of leishmaniasis and it causeshigh morbidity and mortality in developing countries (1,2).Leishmania infantum chagasi is responsible for VL in theNew World, with typical clinical signs and symptoms of sple-nomegaly, hepatomegaly, and fever (3). VL can be life-threatening, and because 90% cases of VL occur in Brazil,reliable and rapid diagnosis of VL is required (4).As stated by the MS, VL case confirmation is based onclinical suspicion and positive laboratory diagnosis via eitherparasitological tests (PTs), which are dependent on invasiveprocedures such as bone marrow aspiration or biopsy, orserological tests such as indirect immunofluorescence (IFI) orimmunochromatographic tests (ITs) using rK39 recombinantantigens (5). The serological tests IFI and IT-rK39 have theadvantage of being minimally invasive and they can beperformed in large numbers (6).However, IFI requires a fluorescence microscope and istime consuming. The procedure of IT-rK39 takes only 10–15minutes and requires only 10–20 mL of the peripheral blood.It is a rapid and low-cost bedside test. The rK39 dipstick usedfor ITs is the product of a gene cloned from the Leishmaniagenus containing a 39-amino acid repeat conserved amongviscerotropic Leishmania species (7).The main brands of IT-rK39 that were previously providedby the Brazilian public health system consisted of KalazarDetectt (InBios International, Seattle, WA, USA), IT LEISHs(BIO-RAD Laboratories Inc., France), and OnSitet Leishma-nia IgG/IgM Combo test (CTK Biotech, USA), which havenow been replaced with the LSH Ab ECO test (EcoDiagnóstica, Nova Lima, MG, Brasil). Kalazar Detectt wasthe first rapid test for VL diagnosis that was adopted by theBrazilian public health system in 2009. It has a sensitivity andspecificity of 88.1% and 90.6%, respectively.In 2015, IT LEISHs replaced the Kalazar Detectt andshowed an improved sensitivity and specificity of 93% and97%, respectively (8). However, these IT-rK39 tests wouldusually present a lower accuracy when tested in patientscoinfected with HIV (9,10).In 2017, the OnSitet Leishmania IgG/IgM Combo testreplaced the IT LEISHs (8). Today, MS recommends using anew brand, the LSH Ab ECO test, a qualitative immunoassayfor the detection of antibodies (rK39) against VL in humanserum (11). The specificity for this test is equal to 100% (95%CI 0.93-1), indicating that it has high specificity for the rK39protein. The sensitivity presented by the LSH Ab ECO is 92%(95% CI 0.82-0.97) (11).LSH Ab ECO test was declared by the Agência Nacionalde Vigilância Sanitária-ANVISA (National Health Surveil-lance Agency) as a criterion for the laboratory confirmationof suspected cases of the disease. Therefore, suspicious patients,including those presenting with clinical signs compatible withdisease and those coming from a region with known occur-rence of transmission, alongside a positive rapid test, can beconsidered confirmed cases of VL based on clinical labora-tory criteria.The LSH Ab ECO test has technical specifications andexecution methodology similar to those of the brands usedbefore. According to the manufacturer, LSH Ab ECO, alateral flow chromatographic immunoassay used to detectclass G immunoglobulin for Leishmania donovani, uses recom-binant antigens in the test line and chicken anti-protein A inthe control line. It is easy to use and interpret. In accordancewith the manufacturer’s instructions and technical orienta-tion from SDP/IOM/FUNED no001/2019 (12), the procedureof the test is as follows: add 20 mL of serum/plasma or 1 dropof blood (10 mL) to the test strip pad, below the arrows. Ifserum, plasma, or blood is applied to the test strip hori-zontally on a flat surface, take the strip by the green label andplace it vertically, with the arrow pointing downwards, in atest tube or microwell containing 2–3 drops (150 mL) of thediluent buffer. If serum, plasma, or blood is applied to thetest strip vertically, add 2–3 drops (150 mL) of the diluentDOI: 10.6061/clinics/2020/e2036Copyright & 2020 CLINICS – This is an Open Access article distributed under theterms of the Creative Commons License (http://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in anymedium or format, provided the original work is properly cited.No potential conflict of interest was reported.Received for publication on May 27, 2020. Accepted for publica-tion on May 29, 20201EDITORIALbuffer to the base of the microwell or test tube and read thetest result after 10 minutes.It is important to highlight that this IT for rK39 isproduced by a Brazilian biotechnology industry located inthe state of Minas Gerais, Brazil, as the previously usedbrands were produced by industries situated outside of Brazil.This is an important achievement for the Brazilian healthsystem with regard to VL diagnosis.In summary, the test is suitable for use at the bedside,requires a minimal amount (10 mL) of peripheral blood, withno need of special equipment, and is simple to perform andread, with the results being available in 10 minutes.However, this simple dipstick test for rK39, distributed bythe Ministério da Saúde do Brazil to public laboratories, isnot available in some public hospitals, including Hospitaldas Clinicas da Faculdade de Medicina da Universidade deSão Paulo (HCFMUSP). Rapid test-rK39 is not even offeredby the majority of private laboratories and private hospitalsfor VL diagnosis. Even if it is provided, the turnaround timebetween sending the sample and receiving results is typicallya minimum of 24 hours; thus, it can hardly be deemed as a‘rapid test’ with any conviction.It is time to change the narrative and alter the distributiveflowchart of this test. It is necessary to use the rK39 IT atthe bedside of suspected VL patients across hospitals tothe greatest effect. Why not employ the technical skills of ateam who usually attend patient needs, such as nurses andnursing technicians, thereby ensuring that the rK39 IT trulydoes indeed become a rapid diagnostic bedside test? VLcan be lethal and patients simply cannot afford to wait fordiagnoses/treatments.’ AUTHOR CONTRIBUTIONSBraz LMA and Lindoso JAL designed the study, drafted and reviewed themanuscript. Tahmasebi R and Hefford PM reviewed the manuscript, alsofor English language. All of the authors have read and approved the contentof the manuscript.’ REFERENCES1. Dantas-Torres F, Brandão-Filho SP. Visceral leishmaniasis in Brazil: revisit-ing paradigms of epidemiology and control. Rev Inst Med Trop Sao Paulo.2006;48(3):151-6. https://doi.org/10.1590/S0036-466520060003000072. Elmahallawy EK, Sampedro Martinez A, Rodriguez-Granger J, Hoyos-Mallecot Y, Agil A, Navarro Mari JM, et al. Diagnosis of leishmaniasis.J Infect Dev Ctries. 2014;8(8): 961-72. https://doi.org/10.3855/jidc.43103. Natalia Souza DE G, Vera Demarchi A, Regina Maia S, Thelma O, LuciaMaria Almeida B. Unusual Clinical Manifestations of Leishmania (L.)infantum chagasi in an HIV-coinfected Patient and the Relevance of ITS1-PCR-RFLP: A Case Report. Iran J Parasitol. 2018;13(4):655-60.4. Godoy NS, Lima-Junior MSC, Lindoso JAL, Pereira-Chioccola VL, OkayTS, Braz LMA. A PCR and RFLP-based molecular diagnostic algorithmfor visceral leishmaniasis. Asian Pacific J Trop Medicine. 2020;13(2):62-70.https://doi.org/10.4103/1995-7645.2754145. Ministério da Saúde (BR). Guia de Vigilância em Saúde. Leishmaniosevisceral. 2016. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/guia_vigilancia_saude_1ed_atual.pdf6. Zijlstra EE, Nur Y, Desjeux P, Kahill EA, El-Hassan AM, Groen J. Diag-nosing visceral leishmaniasis with the recombinant K39 strip test:experience from the Sudan. Trop Med Int Health. 2001;6(2):108-13.https://doi.org/10.1046/j.1365-3156.2001.00680.x7. Singh S, Gilman-Sachs A, Chang KP, Reed SG. Diagnostic and prognosticvalue of K39 recombinant antigen in Indian leishmaniasis. J Parasitol.1995;81(6):1000-3. https://doi.org/10.2307/32840568. Freire ML, Assis TSM, Avelar DM, Rabello A, Cota G. Evaluation of a newbrand of immunochromatographic test for visceral leishmaniasis in Brazilmade available from 2018. Rev Inst Med Trop. 2018;60:e49. https://doi.org/10.1590/s1678-99462018600499. ter Horst R, Tefera T, Assefa G, Ebrahim AZ, Davidson RN, Ritmeijer K.Field evaluation of rK39 tests and direct agglutination test for diagnosis ofvisceral leishmaniasis in a population with high prevalence of humanimmunodeficiency vírus in Ethiopia. Am J Trop Med Hyg. 2009;80(6):929-34. https://doi.org/10.4269/ajtmh.2009.80.92910. Cota GF, de Sousa MR, de Freitas Nogueira BM, Gomes LI, Oliveira E,Assis TS, et al. Comparison of parasitological, serological, and moleculartests for visceral leishmaniasis in HIV-infected patients: a cross-sectionaldelayed-type study. Am J Trop Med Hyg. 2013;89(3):570-7. https://doi.org/10.4269/ajtmh.13-023911. Brasil. Ministério da Saúde. Processo no 25000.190487/2019-52. Secretariade Vigilância em Saúde. Departamento de Articulação Estratégica deVigilância em Saúde. Coordenação Geral de Laboratórios de SaúdePública. 14.11.201912. Instituto Octávio Magalhães - FUNED. Orientação Técnica. SDP/IOM/FUNED No 001/2019. Laboratório de Referência Nacional em Diagnósticoda Leishmaniose Visceral. Controle de Qualidade de Kits para Diag-nóstico da Leishmaniose Visceral Humana. Avaliação do teste rápidoimunocromatográfico LSH ab ECO da ECO Diagnóstica para o imuno-diagnóstico da leishmaniose visceral humana (LVH). Relatório Técnico.Belo Horizonte. Brasil. 5p. Julho de 2019.2A rapid test for visceral leishmaniasisBraz LMA et al.CLINICS 2020;75:e2036

Visceral Leishmaniasis diagnosis: a rapid test is a must at the hospital bedside

https://www.revistas.usp.br/clinics/article/download/171451/161498

Visceral Leishmaniasis diagnosis: a rapid test is a must at the hospital bedside

Abstract

Similar works

Full text

Available Versions

Cadernos Espinosanos (E-Journal)