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Performance of molecular and serologic tests for the diagnosis of scrub typhus.
PLoS Negl Trop Dis. 2020 11; 14(11):e0008747.PN

Abstract

Diagnosis of scrub typhus, caused by the bacterium Orientia tsutsugamushi, is challenging because of the overlap of its non-specific symptoms with other infections coupled with the lack of sufficient data on the performance of diagnostic tests. Early diagnosis of scrub typhus is crucial to improve outcomes and this study evaluates the diagnostic performance of various tests. The present study aims at assessing the accuracy of various rapid diagnostic tests, serologic tests, and nucleic acid amplification methods on well-characterized patient samples. Adult patients with acute febrile illness and manifestations suggestive of scrub typhus confirmed by positive PCR in the blood, eschar or tissue were characterized as cases. Patients with acute febrile illness and a confirmed alternate etiology such as culture-confirmed typhoid, smear/PCR positive for malaria, PCR/NS1 antigen positive for dengue, PCR positive for influenza, PCR/MAT positive for leptospirosis, PCR positive for spotted fever were characterized as controls with other infections. The healthy controls consisted of subjects from the same geographic region. We performed the following tests on blood samples for scrub typhus and calculated the sensitivity, specificity, positive predictive value, and negative predictive value: (1) Quantitative real time PCR using 47kDa gene (qPCR); (2) Conventional PCR using 56kDa gene (cPCR); (3) Loop-mediated isothermal amplification assay (LAMP assay); (4) Immunofluorescence assay (IFA); (5) Enzyme-linked immunosorbent assay (ELISA); (6) Weil-Felix test(WF test); and (7) Immunochromatographic Rapid Diagnostic Test (RDT).Among the 316 participants, 158 had confirmed scrub typhus (cases) and 158 were controls. ELISA and RDT detecting Orientia tsutsugamushi specific IgM antibodies had excellent discriminative potential with sensitivities and specificities of 92%, 94% and 92%, 92% respectively. The sensitivity and specificity of IFA were found to be 95% and 74% respectively. IgM serology had a false positivity rate of 8% with other acute febrile illnesses such as dengue, leptospirosis and spotted fever due to the nonspecific binding of the pentavalent IgM. LAMP assay had 91.7% sensitivity and 77.2% specificity while qPCR provided excellent sensitivity (97%) and perfect specificity. In conclusion, ELISA and RDT detecting Orientia tsutsugamushi specific IgM antibodies have excellent sensitivity and specificity while the accuracy of IFA is suboptimal for the diagnosis of scrub typhus. Given its perfect specificity and superior sensitivity, qPCR is preferred for diagnostic confirmation in reference laboratories particularly for diagnosis of early disease with less than 7 days duration. This study provides a comprehensive evaluation of all currently available diagnostic tests for scrub typhus.

Authors+Show Affiliations

Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India.Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India.Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India.Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India.Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India.Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India.Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India.Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India.Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India.Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India.Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India.Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India.Department of Clinical Virology, Christian Medical College, Vellore, Tamil Nadu, India.Department of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India.Department of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India.Department of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India.Department of Haematology, Christian Medical College, Vellore, Tamil Nadu, India.JSS Medical College, Mysuru, Karnataka India.JSS Medical College, Mysuru, Karnataka India.Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka, India.Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

33180784

Citation

Kannan, Kavitha, et al. "Performance of Molecular and Serologic Tests for the Diagnosis of Scrub Typhus." PLoS Neglected Tropical Diseases, vol. 14, no. 11, 2020, pp. e0008747.
Kannan K, John R, Kundu D, et al. Performance of molecular and serologic tests for the diagnosis of scrub typhus. PLoS Negl Trop Dis. 2020;14(11):e0008747.
Kannan, K., John, R., Kundu, D., Dayanand, D., Abhilash, K. P. P., Mathuram, A. J., Zachariah, A., Sathyendra, S., Hansdak, S. G., Abraham, O. C., Gunasekaran, K., Iyadurai, R., Abraham, A. M., Prakash, J. A. J., Yesudhason, B. L., Veeraraghavan, B., Kavitha, M. L., Jose, L. R., Sumana, M. N., ... Varghese, G. M. (2020). Performance of molecular and serologic tests for the diagnosis of scrub typhus. PLoS Neglected Tropical Diseases, 14(11), e0008747. https://doi.org/10.1371/journal.pntd.0008747
Kannan K, et al. Performance of Molecular and Serologic Tests for the Diagnosis of Scrub Typhus. PLoS Negl Trop Dis. 2020;14(11):e0008747. PubMed PMID: 33180784.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Performance of molecular and serologic tests for the diagnosis of scrub typhus. AU - Kannan,Kavitha, AU - John,Rebecca, AU - Kundu,Debasree, AU - Dayanand,Divya, AU - Abhilash,Kundavaram P P, AU - Mathuram,Alice Joan, AU - Zachariah,Anand, AU - Sathyendra,Sowmya, AU - Hansdak,Samuel G, AU - Abraham,O C, AU - Gunasekaran,Karthik, AU - Iyadurai,Ramya, AU - Abraham,Asha M, AU - Prakash,John Antony Jude, AU - Yesudhason,Binesh Lal, AU - Veeraraghavan,Balaji, AU - Kavitha,M L, AU - Jose,Linda R, AU - Sumana,M N, AU - Saravu,Kavitha, AU - Varghese,George M, Y1 - 2020/11/12/ PY - 2020/05/06/received PY - 2020/08/25/accepted PY - 2020/11/12/entrez PY - 2020/11/13/pubmed PY - 2021/1/26/medline SP - e0008747 EP - e0008747 JF - PLoS neglected tropical diseases JO - PLoS Negl Trop Dis VL - 14 IS - 11 N2 - Diagnosis of scrub typhus, caused by the bacterium Orientia tsutsugamushi, is challenging because of the overlap of its non-specific symptoms with other infections coupled with the lack of sufficient data on the performance of diagnostic tests. Early diagnosis of scrub typhus is crucial to improve outcomes and this study evaluates the diagnostic performance of various tests. The present study aims at assessing the accuracy of various rapid diagnostic tests, serologic tests, and nucleic acid amplification methods on well-characterized patient samples. Adult patients with acute febrile illness and manifestations suggestive of scrub typhus confirmed by positive PCR in the blood, eschar or tissue were characterized as cases. Patients with acute febrile illness and a confirmed alternate etiology such as culture-confirmed typhoid, smear/PCR positive for malaria, PCR/NS1 antigen positive for dengue, PCR positive for influenza, PCR/MAT positive for leptospirosis, PCR positive for spotted fever were characterized as controls with other infections. The healthy controls consisted of subjects from the same geographic region. We performed the following tests on blood samples for scrub typhus and calculated the sensitivity, specificity, positive predictive value, and negative predictive value: (1) Quantitative real time PCR using 47kDa gene (qPCR); (2) Conventional PCR using 56kDa gene (cPCR); (3) Loop-mediated isothermal amplification assay (LAMP assay); (4) Immunofluorescence assay (IFA); (5) Enzyme-linked immunosorbent assay (ELISA); (6) Weil-Felix test(WF test); and (7) Immunochromatographic Rapid Diagnostic Test (RDT).Among the 316 participants, 158 had confirmed scrub typhus (cases) and 158 were controls. ELISA and RDT detecting Orientia tsutsugamushi specific IgM antibodies had excellent discriminative potential with sensitivities and specificities of 92%, 94% and 92%, 92% respectively. The sensitivity and specificity of IFA were found to be 95% and 74% respectively. IgM serology had a false positivity rate of 8% with other acute febrile illnesses such as dengue, leptospirosis and spotted fever due to the nonspecific binding of the pentavalent IgM. LAMP assay had 91.7% sensitivity and 77.2% specificity while qPCR provided excellent sensitivity (97%) and perfect specificity. In conclusion, ELISA and RDT detecting Orientia tsutsugamushi specific IgM antibodies have excellent sensitivity and specificity while the accuracy of IFA is suboptimal for the diagnosis of scrub typhus. Given its perfect specificity and superior sensitivity, qPCR is preferred for diagnostic confirmation in reference laboratories particularly for diagnosis of early disease with less than 7 days duration. This study provides a comprehensive evaluation of all currently available diagnostic tests for scrub typhus. SN - 1935-2735 UR - https://www.unboundmedicine.com/medline/citation/33180784/Performance_of_molecular_and_serologic_tests_for_the_diagnosis_of_scrub_typhus_ L2 - https://dx.plos.org/10.1371/journal.pntd.0008747 DB - PRIME DP - Unbound Medicine ER -