HEADQUARTERS4705 Decatur Blvd. | Indianapolis, Indiana 46241, USA miravistalabs.com

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ISSUE 1 | 2019 APRIL

FEATURED ARTICLE

MiraVista (MVD) Fungal Diagnostic Tests by L. Joseph Wheat, M.D.

I’m often contacted for advice on diagnosis of the endemic mycoses. Many physicians are unaware of these tests and publications describing their use for diagnosis.

For example, some believe the Histoplasma antigen test is performed only on urine. Others believe that antigen testing on serum is unnecessary. In fact, nearly half of the cases of acute pulmonary histoplasmosis would have been missed if only urine were tested (sensitivity 83% for combined serum and urine testing; 45% with urine alone (1). At least 5% of disseminated cases would be missed if only urine were tested (unpublished). Both urine and serum should be tested for maximum sensitivity. Antigen testing of CSF is the most sensitive method for diagnosis of Histoplasma meningitis (2;3). Detection of antigen in the bronchoalveolar lavage fluid (BAL) is useful for diagnosing pulmonary histoplasmosis (4).

Some also believe that Histoplasma antibody detection is not useful for diagnosis because most individuals from endemic areas have had histoplasmosis, and antibody tests would not differentiate active infection from previous exposure. Studies in Indianapolis, where 50% of residents are histoplasmin skin test positive, reported positive antibody results by immunodiffusion (ID) in 0.5% and by complement fixation (CF) in 5% (5). Skin test reactivity persists for life in most individuals while antibodies clear over a few years.

> READ MORE ON PG. 4

MIRAVISTA HISTORYDr. Lawrence Joseph Wheat, a Professor of Medicine and Infectious Disease at Indiana University School of Medicine from 1976 to 2002, led a research team to invent a unique antigen test to diagnose histoplasmosis. His team established the Histoplasmosis Reference Laboratory at IU in 1985 where Histoplasma antigen testing was offered as a referral service. With the emergence of AIDS, histoplasmosis became the leading cause for infection in endemic regions of the country and Dr. Wheat pioneered research evaluating diagnosis and treatment of histoplasmosis in AIDS as part of the NIH AIDS Clinical Trials Group.

> READ MORE ON PG. 3

INSIGHTSMiraVista HistoryFeatured ArticleCustomer & Technical Service UpdatesMeetings of Interest Company News

IN THIS ISSUE

MEETINGS OF INTEREST

FREQUENTLY ASKED QUESTION FROM CLIENTSHow should we ship the specimen?

ANSWER

Please ship specimens in a sterile leak proof container. All specimens should be labeled with each patients unique identifiers and should be shipped at a stable temperature for the specific test being ordered. Please refer to our Test Menu for detailed

shipping information by visiting www.miravistalabs.com.

WE’VE ADDED NEW HOURSWe have added evening and Saturday hours. This allows us to maintain same day TAT and

confirmatory testing.

NEW HOURS LABORATORYMonday, 8am – 5pm, Tuesday – Friday, 8am – 11pm, Saturday, 8:30am – 5pm

Business hours and Clinical Consultation: Monday – Friday 8am – 5pm

> Coccidioidomycosis Study Group, CSG 4/5 – 4/6, Sacramento, CA Dr. Wheat attending – http://coccistudygroup.com/

> Infectious Disease Society of America, ID Week 10/2 – 10/6, Washington, DC

> AACC 8/4 – 8/8, Anaheim, CA http://www.2019aacc.org/

CUSTOMER & TECHNICAL SERVICE UPDATES

HEADQUARTERS4705 Decatur Blvd. | Indianapolis, Indiana 46241, USA miravistalabs.com

866.490.9316

Construction is underway for our 24,000 square foot building expansion.

We will be hiring new team members in the coming year with expertise

in molecular biology and ASCP certified medical technicians. Please

check out website for opportunities to join our team.

COMPANY NEWS

EXECUTIVE BIOGRAPHY

Dr. Lawrence Joseph Wheat, Founder of MiraVista Diagnostics

Lawrence Joseph Wheat, MD (Dr. Joe Wheat) is an accomplished and widely published scientist with more than 40 years of focused expertise in the area of infectious diseases. He is recognized by the academic, medical and professional communities as the leading authority on serious fungal infections. In 2002, Dr. Wheat founded MiraVista Diagnostics and currently serves as its Medical Director and President. As a result of Dr. Wheat’s scientific developments, visionary leadership, high quality standards and dedication to excellent client service, MiraVista has earned the reputation as the industry’s premier reference laboratory for fungal diagnostics.

Prior to establishing MiraVista Diagnostics, Dr. Wheat served as a professor at the Indiana University Medical Center’s Infectious Diseases Division for more than 25 years. In addition to teaching medicine, Dr. Wheat was a prolific medical research scientist during his tenure. From 1976-2014, he published more than 300 scientific articles specifically related to fungal infection, hundreds more articles on broader infectious disease topics and authored chapters about histoplasmosis in several leading infectious disease and internal medicine books. Dr. Wheat’s groundbreaking research findings contributed to the development of the first histoplasmosis antigen test in 1986. Since then, he has continued to develop new generations of diagnostic tests for coccidioides (also known as valley fever fungus), histoplasma capsulatum and blastomyces dermatitidis.

Dr. Wheat received his medical degree from Indiana University Medical School where he also completed his internship, residency and fellowship in infectious diseases. He served on the editorial board of the Journal of Infectious Disease from 2002-2013 and is an active member of many professional organizations including the Infectious Disease Society of America, American Society of Microbiology, International Society for Human and Animal Mycology and Medical Mycology Society of the Americas. Dr. Wheat also served in the United States Air Force.

MIRAVISTA HISTORY

HEADQUARTERS4705 Decatur Blvd. | Indianapolis, Indiana 46241, USA miravistalabs.com

866.490.9316

Dr. Lawrence Joseph Wheat, a Professor of Medicine and Infectious Disease at Indiana University School of Medicine from 1976 to 2002, led a research team to invent a unique antigen test to diagnose histoplasmosis. His team established the Histoplasmosis Reference Laboratory at IU in 1985 where Histoplasma antigen testing was offered as a referral service. With the emergence of AIDS, histoplasmosis became the leading cause for infection in endemic regions of the country and Dr. Wheat pioneered research evaluating diagnosis and treatment of histoplasmosis in AIDS as part of the NIH AIDS Clinical Trials Group.

In 2002, his team left IU and founded MiraVista Diagnostics (MVD) to focus on research to improve diagnostic testing and provide rapid and accurate services. MVD expanded into veterinary medicine, offering similar tests for diagnosis of fungal infections in animals.

MiraVista Diagnostics researchers have since developed antigen tests for diagnosis of blastomycosis and coccidioidomycosis and refined their antigen tests to improve sensitivity and specificity. Our scientists also have developed antibody tests for diagnosis of fungal infections. This research has defined the role of these tests for management of these diseases. MiraVista Diagnostics now offers specific tests for diagnosis of aspergillosis, cryptococcosis and pan-fungal tests as a marker for serious fungal infection of any cause. MVD currently tests over 110,000 specimens annually and continues to expand its services and serve new customers. Dr. Wheat consults with Infectious Disease physicians and veterinarians in the United States and internationally, improving the outcome of their patients.

FEATURED ARTICLE

I’m often contacted for advice on diagnosis of the endemic mycoses. Many physicians are unaware of these tests and publications describing their use for diagnosis.

For example, some believe the Histoplasma antigen test is performed only on urine. Others believe that antigen testing on serum is unnecessary. In fact, nearly half of the cases of acute pulmonary histoplasmosis would have been missed if only urine were tested (sensitivity 83% for combined serum and urine testing; 45% with urine alone) (1). At least 5% of disseminated cases would be missed if only urine were tested (unpublished). Both urine and serum should be tested for maximum sensitivity. Antigen testing of CSF is the most sensitive method for diagnosis of Histoplasma meningitis (2;3). Detection of antigen in the bronchoalveolar lavage fluid (BAL) is useful for diagnosing pulmonary histoplasmosis (4).

Some also believe that Histoplasma antibody detection is not useful for diagnosis because most individuals from endemic areas have had histoplasmosis, and antibody tests would not differentiate active infection from previous exposure. Studies in Indianapolis, where 50% of residents are histoplasmin skin test positive, reported positive antibody results by immunodiffusion (ID) in 0.5% and by complement fixation (CF) in 5% (5). Skin test reactivity persists for life in most individuals while antibodies clear over a few years.

The newly described MVD IgG and IgM enzyme immunoassay (EIA), combined with antigen detection, improves the sensitivity for diagnosis of acute pulmonary histoplasmosis over antigen and antibody detection by ID or CF (6). The assay is quantitative and was useful for detecting seroconversion in these cases. Similarly, sensitivity for diagnosing Histoplasma meningitis by testing CSF increased from 78% to 98% by combining antigen and IgG/IgM antibody testing (2). Both antigen and MVD antibody EIA should be tested for maximum sensitivity.

Many are unaware of the MVD Coccidioides antigen detection assay or believe that its sensitivity is low. The limit of detection is the same in our Coccidioides and Histoplasma antigen assays, <0.2ng/mL. The clinical sensitivity in disseminated cases is somewhat lower, about 70% in coccidioidomycosis (7;8) and 90% in histoplasmosis (9). The reason for the lower clinical sensitivity in coccidioidomycosis is the lower fungal burden. For example, the lungs, liver, spleen, bone marrow, other tissues are often involved in disseminated histoplasmosis and fungemia is common. Isolated sites of dissemination to skin, bone, or CNS are more common in coccidioidomycosis and fungemia is rare. Larger unpublished studies indicate the sensitivity was 80% in disseminated cases, most of whom were immunocompromised, if both urine and serum were tested. Antigen detection in CSF is the most sensitive method (91%) for diagnosing Coccidioides meningitis (10).

The MVD Coccidioides IgG and IgM antibody EIA was introduced in 2017 (11). MVD EIA is more sensitive than ID or CF and is not impacted by immunocompromise (11). The assay is quantitative and useful for monitoring changes in antibody concentrations (unpublished). Sensitivity in CSF in Coccidioides meningitis is 73% (unpublished).

The MVD Blastomyces antigen EIA is the most sensitive method for diagnosing disseminated and pulmonary blastomycosis (12). Antigen also may be detected in CSF (13) in patients with meningitis and BAL fluid in patients with pneumonia (4). We have developed an IgG Blastomyces antibody EIA that is more sensitive than immunodiffusion (14). Combined antigen and MVD EIA antibody testing increased the sensitivity from 88% to 98%. This IgG test is available as “research use only (RUO)” pending completion of validation and requires preapproval by the laboratory director. The MVD Blastomyces antibody EIA is projected to be validated and offered routinely in mid-2019.

MiraVista (MVD) Fungal Diagnostic TestsL. Joseph Wheat, M.D.

HEADQUARTERS4705 Decatur Blvd. | Indianapolis, Indiana 46241, USA miravistalabs.com

866.490.9316

Reference List

(1) Swartzentruber S, Rhodes L, Kurkjian K, et al. Diagnosis of acute pulmonary histoplasmosis by antigen detection. Clin Infect Dis 2009 Dec 15;49(12):1878-82.

(2) Bloch KC, Myint T, Raymond-Guillen L, et al. Improvement in Diagnosis of Histoplasma Meningitis by Combined Testing for Histoplasma Antigen and Immunoglobulin G and Immunoglobulin M Anti-Histoplasma Antibody in Cerebrospinal Fluid. Clin Infect Dis 2018 Jan 6;66(1):89-94.

(3) Wheat J, Myint T, Guo Y, et al. Central nervous system histoplasmosis: Multicenter retrospective study on clinical features, diagnostic approach and outcome of treatment. Medicine (Baltimore) 2018 Mar;97(13):e0245.

(4) Hage CA, Davis TE, Fuller D, et al. Diagnosis of Histoplasmosis by Antigen Detection in BAL Fluid. Chest 2010 Mar;137(3):623-8.

(5) Wheat J, French ML, Kohler RB, et al. The diagnostic laboratory tests for histoplasmosis: analysis of experience in a large urban outbreak. Ann Intern Med 1982 Nov;97(5):680-5.

(6) Richer SM, Smedema ML, Durkin MM, et al. Improved Diagnosis of Acute Pulmonary Histoplasmosis by Combining Antigen and Antibody Detection. Clin Infect Dis 2016 Apr 1;62(7):896-902.

(7) Durkin M, Connolly P, Kuberski T, et al. Diagnosis of Coccidioidomycosis with Use of the Coccidioides Antigen Enzyme Immunoassay. Clin Infect Dis 2008 Oct 15;47(8):e69-e73.

(8) Durkin M, Estok L, Hospenthal D, et al. Detection of coccidioides antigenemia following dissociation of immune complexes. Clin Vaccine Immunol 2009 Oct; 16(10):1453-6.

(9) Hage CA, Ribes JA, Wengenack NL, et al. A multicenter evaluation of tests for diagnosis of histoplasmosis. Clin Infect Dis 2011 Sep;53(5):448-54.

(10) Kassis C, Zaidi S, Kuberski T, et al. Role of Coccidioides Antigen Testing in the Cerebrospinal Fluid for the Diagnosis of Coccidioidal Meningitis. Clin Infect Dis 2015 Nov 15;61(10):1521-6.

(11) Malo J, Holbrook E, Zangeneh T, et al. Enhanced Antibody Detection and Diagnosis of Coccidioidomycosis with the MiraVista IgG and IgM Detection Enzyme Immunoassay. J Clin Microbiol 2017 Mar;55(3):893-901.

(12) Connolly P, Hage CA, Bariola JR, et al. Blastomyces dermatitidis Antigen Detection by Quantitative Enzyme Immunoassay. Clin Vaccine Immunol 2012 Jan;19(1):53-6.

(13) Walkty A, Keynan Y, Karlowsky J, Dhaliwal P, Embil J. Central nervous system blastomycosis diagnosed using the MVista(R) Blastomyces quantitative antigen enzyme immunoassay test on cerebrospinal fluid: A case report and review of the literature. Diagn Microbiol Infect Dis 2018 Feb;90(2):102-4.

(14) Richer SM, Smedema ML, Durkin MM, et al. Development of a Highly Sensitive and Specific Blastomycosis Antibody Enzyme Immunoassay Using Blastomyces dermatitidis Surface Protein BAD-1. Clin Vaccine Immunol 2014 Feb;21(2):143-6.

(15) Connolly PA, Durkin MM, LeMonte AM, Hackett EJ, Wheat LJ. Detection of histoplasma antigen by a quantitative enzyme immunoassay. Clin Vaccine Immunol 2007 Dec;14(12):1587-91.

MVD Test Specimen Sensitivity Specificity RefHistoplasma antigen1 Urine-disseminated, AIDS

Serum-disseminated, AIDSCSF-meningitisBAL-pulmonary

97%100%78%94%

99%100%93%98%

(15)

Histoplasma IgG and IgM antibody Serum-pulmonary, acuteCSF-meningitis

89%82%

95%93%

(2;6)

Coccidioides antigen1 Urine-disseminated3

Serum-disseminated3

Urine or serum, disseminated3

CSF-meningitisBAL-pulmonary

51%72%80%91%ND2

98%100%ND100%ND

(10)

Coccidioides IgG and IgM antibody Serum-pulmonary,disseminatedCSF-meningitis3

88%73%

90%88%

(11)

Blastomyces antigen Urine-pulmonary or disseminatedSerum-pulmonary or disseminatedCSF-meningitis3

BAL

90%57%86%80%

99%ND2

ND98%

(4;12)

Blastomyces IgG antibody (RUO)4 Serum, pulmonary or disseminated 88% 99% (14)

1 Disseminated only, 2 ND-not determined, 3 unpublished; 4 RUO, research use only

HEADQUARTERS4705 Decatur Blvd. | Indianapolis, Indiana 46241, USA miravistalabs.com

866.490.9316