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HelpMayo Test ID ASPBA Aspergillus Antigen, Bronchoalveolar Lavage
Ordering Guidance
For serum specimens, order ASPAG / Aspergillus (Galactomannan) Antigen, Serum.
Specimen Required
Container/Tube: Sterile, leak-proof container
Note: Specimen trap collection containers (with suction catheters attached) will be rejected due to high-risk of leakage and contamination upon opening. Avoid use of these for bronchoalveolar lavage specimens.
Specimen Volume: 2 mL
Additional Information: If specimen transfer into an acceptable sterile container is necessary, perform specimen transfer in a biosafety cabinet. Place container in separate sealed plastic bag.
Useful For
Aiding in the diagnosis of invasive aspergillosis using bronchoalveolar lavage specimens
Assessing response to therapy
Method Name
Enzyme Immunoassay (EIA)
Reporting Name
Aspergillus Ag, BALSpecimen Type
LavageSpecimen Minimum Volume
1.5 mL
Specimen Stability Information
| Specimen Type | Temperature | Time | Special Container |
|---|---|---|---|
| Lavage | Refrigerated (preferred) | 14 days | |
| Frozen | 14 days |
Reject Due To
| Bronchial washing | Reject |
| Thick/viscous/mucoid specimens | Reject |
| Specimen in a non-leak proof container | Reject |
Clinical Information
Invasive aspergillosis (IA) is a severe infection that occurs in patients with prolonged neutropenia following transplantation or in conjunction with aggressive immunosuppressive regimens (eg, prolonged corticosteroid use, chemotherapy). The incidence of IA is reported to vary from 5% to 20% depending on the patient population. IA has an extremely high mortality rate of 50% to 80%, due in part to the rapid progression of the infection (ie, 1-2 weeks from onset to death). Approximately 30% of cases remain undiagnosed and untreated at death.
Definitive diagnosis of IA requires histopathological evidence of deep-tissue invasion or a positive culture. This evidence is often difficult to obtain due to the critically ill nature of the patient and the fact that severe thrombocytopenia often precludes the use of invasive procedures to obtain a quality specimen. The sensitivity of culture in this setting is low, reportedly ranging from 30% to 60% for bronchoalveolar lavage (BAL) fluid. Accordingly, the diagnosis is often based on nonspecific clinical symptoms (unexplained fever, cough, chest pain, dyspnea) in conjunction with radiologic evidence (computed tomography scan); a definitive diagnosis is often not established before fungal proliferation becomes overwhelming and refractory to therapy.
Recently, a serologic assay was approved by the US Food and Drug Administration for the detection of galactomannan, a molecule found in the cell wall of Aspergillus species. Serum galactomannan (Aspergillus antigen) can often be detected a mean of 7 to 14 days before other diagnostic clues become apparent, and monitoring of Aspergillus antigen can potentially allow initiation of preemptive antifungal therapy before life-threatening infection occurs.
The clinical utility of Aspergillus antigen testing in BAL specimens as an early prognostic indicator of IA has recently been assessed. These studies demonstrated equivalent or higher sensitivity compared to detection of Aspergillus antigen in serum.(1-4) This assay may be useful in the assessment of therapeutic response as antigen levels typically decline in response to effective antimicrobial therapy.
Reference Values
<0.5 Index
Interpretation
A positive result in bronchoalveolar lavage (BAL) fluid supports a diagnosis of invasive, pulmonary aspergillosis. Positive results should be considered in conjunction with other diagnostic procedures, such as microbiologic culture, histological examination of biopsy specimens, and radiographic evidence (see Cautions).
A negative result in BAL fluid does not rule out the diagnosis of invasive aspergillosis (IA). Patients at risk of IA should be monitored twice a week for Aspergillus antigen levels in serum until determined to be clinically unnecessary.
Aspergillus antigen levels typically decline in response to effective antimicrobial therapy.
Cautions
False-positive results are reported to occur at rates of 8% to 14% with this assay when performed on serum. Numerous foods (eg, pasta, rice, etc) contain galactomannan. It is thought that damage to the gut wall by cytotoxic therapy, irradiation, or graft-versus-host disease enables translocation of the galactomannan from the gut lumen into the blood and may be partially responsible for the high false-positive rate of this assay when serum is tested. Whether false-positive results in bronchoalveolar lavage (BAL) fluid are associated with the consumption of certain foods, as is observed in serum samples, remains to be determined.
Other genera of fungi such as Penicillium and Paecilomyces have shown reactivity with the rat EBA-2 monoclonal antibody used in the assay. These species are rarely implicated in invasive fungal disease. Specimens containing Histoplasma antigen may cross-react in the Aspergillus antigen assay. Cross-reactivity with Alternaria species has also been reported.
The specificity of the assay for Aspergillus species cannot exclude the involvement of other fungal pathogens with similar clinical presentations such as Fusarium, Alternaria, and Mucorales.
The performance of the assay has not been evaluated other specimen types such as urine or cerebrospinal fluid.
The assay may exhibit reduced detection of Aspergillus antigen in patients with chronic granulomatous disease or autosomal dominant hyper-IgE syndrome (formerly known as Job syndrome).
The concomitant use of antifungal therapy in some patients with invasive aspergillosis may result in reduced sensitivity of the assay.
False-positive results are possible in patients receiving PLASMA-LYTE for intravenous hydration or if PLASMA-LYTE is used during bronchoscopy for the collection of BAL fluid.
Clinical Reference
1. Park SY, Lee SO, Choi SH, et al: Aspergillus galactomannan antigen assay in bronchoalveolar lavage fluid for diagnosis of invasive pulmonary aspergillosis. J Infect. 2010 Dec;61(6):492-498
2. Husain S, Clancy CJ, Nguyen MH, et al: Performance characteristics of the platelia aspergillus enzyme immunoassay for detection of Aspergillus galactomannan antigen in bronchoalveolar lavage fluid. Clin Vaccine Immunol. 2008 Dec;15(12):1760-1763
3. Meersseman W, Lagrou K, Maertens J, et al: Galactomannan in bronchoalveolar lavage fluid: a tool for diagnosing aspergillosis in intensive care unit patients. Am J Respir Crit Care Med. 2008 Jan 1;177(1):27-34
4. Becker MJ, Lugtenburg EJ, Cornelissen JJ, Van Der Schee C, Hoogsteden HC, De Marie S: Galactomannan detection in computerized tomography-based bronchoalveolar lavage fluid and serum in haematological patients at risk for invasive pulmonary aspergillosis. Br J Haematol. 2003 May;121(3):448-457
5. Xavier MO, Pasqualotto AC, Cardoso ICE, Severo LC: Cross-reactivity of Paracoccidioides brasiliensis, Histoplasma capsulatum, and Cryptococcus species in the commercial Platelia Aspergillus enzyme immunoassay. Clin Vaccine Immunol. 2009 Jan;16(1):132-133
6. Thompson GR, Patterson TF: Aspergillus species. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 9th ed. Elsevier; 2020:3103-3116
Method Description
The Platelia Aspergillus enzyme immunoassay) is a 1-stage immunoenzymatic sandwich microplate assay that detects galactomannan in bronchoalveolar lavage specimens. The assay uses the rat monoclonal antibody EBA-2, which is directed against Aspergillus galactomannan. The monoclonal antibody is used to coat the wells of the microplate and bind the antigen and as the detector antibody in the conjugate reagent (peroxidase-linked monoclonal antibody).
Samples are heat-treated in the presence of EDTA to dissociate immune complexes and to precipitate proteins that could possibly interfere with the test. The treated samples and conjugate are added to the wells coated with the monoclonal antibody and incubated. A monoclonal antibody-galactomannan-monoclonal antibody/peroxidase complex is formed in the presence of Aspergillus antigen.
The strips are washed to remove any unbound material, and the substrate solution is added, which will react with the complex bound to the well to form a blue color reaction. The enzyme reaction is stopped by the addition of acid, which changes the blue color to yellow. The optical absorbance of specimens and controls is determined with a spectrophotometer set at 450 nm and 620/630 nm wavelengths.
Negative, cutoff (low-positive), and high-positive controls are analyzed each time the assay is performed. The presence or absence of Aspergillus (galactomannan) antigen in the test sample is determined by calculation of an index for the specimen. The index is the optical density (OD) value of the specimen divided by the mean OD of wells containing the cutoff control serum (low-positive control).(Package insert: Platelia Aspergillus EIA. Bio-Rad Laboratories; 10/2020)
Day(s) Performed
Monday through Friday, Sunday
Report Available
1 to 2 daysSpecimen Retention Time
14 daysPerforming Laboratory
Mayo Clinic Laboratories in Rochester
Test Classification
This test has been cleared, approved, or is exempt by the US Food and Drug Administration and is used per manufacturer's instructions. Performance characteristics were verified by Mayo Clinic in a manner consistent with CLIA requirements.CPT Code Information
87305
LOINC Code Information
| Test ID | Test Order Name | Order LOINC Value |
|---|---|---|
| ASPBA | Aspergillus Ag, BAL | 62467-6 |
| Result ID | Test Result Name | Result LOINC Value |
|---|---|---|
| 61009 | Aspergillus Ag, BAL | 62467-6 |