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MALDI-TOF mass spectrometry as a diagnostic tool in human and veterinarian helminthology: a systematic review

Parasites & Vectors volume 12, Commodity number:245 (2019) Cite this commodity

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Abstract

Groundwork

Matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry (MS) has become a widely used technique for the rapid and accurate identification of bacteria, mycobacteria and certain fungal pathogens in the clinical microbiology laboratory. Thus far, only few attempts take been fabricated to apply the technique in clinical parasitology, particularly regarding helminth identification.

Methods

We systematically reviewed the scientific literature on studies pertaining to MALDI-TOF MS as a diagnostic technique for helminths (cestodes, nematodes and trematodes) of medical and veterinary importance. Readily available electronic databases (i.eastward. PubMed/MEDLINE, ScienceDirect, Cochrane Library, Spider web of Science and Google Scholar) were searched from inception to 10 Oct 2018, without restriction on year of publication or language. The titles and abstracts of studies were screened for eligibility by two independent reviewers. Relevant articles were read in total and included in the systematic review.

Results

A total of 84 peer-reviewed articles were considered for the terminal analysis. Near papers reported on the application of MALDI-TOF for the study of Caenorhabditis elegans, and the technique was primarily used for identification of specific proteins rather than entire pathogens. Since 2015, a minor number of studies documented the successful apply of MALDI-TOF MS for species-specific identification of nematodes of homo and veterinary importance, such as Trichinella spp. and Dirofilaria spp. However, the quality of available information and the number of examined helminth samples was low.

Conclusions

Data on the use of MALDI-TOF MS for the diagnosis of helminths are scarce, merely recent evidence suggests a potential office for a reliable identification of nematodes. Time to come research should explore the diagnostic accuracy of MALDI-TOF MS for identification of (i) adult helminths, larvae and eggs shed in faecal samples; and (ii) helminth-related proteins that are detectable in serum or body fluids of infected individuals.

Groundwork

In clinical and laboratory diagnostic settings, mass spectrometry (MS) has been utilized for several decades equally an arroyo for protein-centred analysis of samples in medical chemical science [1, 2] and haematology laboratories [iii]. In 1975, Anhalt & Fenselau [4] proposed, for the first time, the modification of matrix-assisted laser desorption/ionization fourth dimension-of-flight (MALDI-TOF) MS as a method to characterize bacteria. Indeed, it was demonstrated that unlike bacterial species show specific poly peptide mass spectra, which can be used for rapid identification.

During the past decade, MALDI-TOF MS has been widely introduced every bit a diagnostic technique in microbiology laboratories, where information technology has replaced nigh other tools (due east.g. phenotypic tests, biochemical identification and agglutination kits) as the starting time-line pathogen identification method due to its high diagnostic accuracy, robustness, reliability and rapid turn-around time [five]. MALDI-TOF MS is at present routinely employed for identification of bacteria [5,vi,7,8], mycobacteria [5, 9] and some fungi [eight]. More recently, MALDI-TOF MS has been practical in research settings for the detection and identification of viruses [ten], protozoans and arthropods [11, 12]. In clinical practice, a specific quantity is brought on a target plate (east.g. culture-grown pathogen). Side by side, the target plate is pre-treated with a chemical reagent (and so-called matrix, e.grand. α-cyano-4-hydroxycinnamic acid) and subjected to a mass spectrometer for further assay. The MALDI-TOF apparatus, which is commercially bachelor through dissimilar manufacturers [thirteen, 14], uses laser to disperse and ionize the analyte into different molecules, which motion through a vacuum driven by an electric field before reaching a detector membrane. The fourth dimension-of-flight of the various molecules depends on their mass and their electrical charge. The specific time-of-flying data are assembled, resulting in specific spectra that are compared to a commercial database, which allows for a rapid identification of the infectious agent and diagnostic accurateness, the latter of which is commonly expressed as a score.

MALDI-TOF MS has several strengths if compared to other diagnostic tools, such as polymerase chain reaction (PCR) assays. Once the mass spectrometer and the respective databases are available in a laboratory, individual pathogen identification is cheap, and the sample grooming procedure does neither require highly skilled technicians nor complex additional laboratory infrastructure. Of note, MALDI-TOF MS is considerably less prone to contamination and results are bachelor within a few minutes. However, constant ability supply is a prerequisite, which limits the suitability of the technique in resources-constrained settings. Yet, information technology should exist noted that MALDI-TOF MS is no longer restricted to high-income countries as it is increasingly available in reference laboratories in sub-Saharan Africa and elsewhere [xv,16,17,18,19].

MALDI-TOF does not e'er require culture-grown colonies of a given pathogen. Instead, information technology can also be employed to identify microorganisms direct from positive blood civilization broths [6] with high diagnostic accuracy [7]. Recently, Yang et al. [xx] proposed a new framework to analyse MALDI-TOF spectra of bacterial mixtures (instead of but a single pathogen) and to directly characterize each component without purification procedures. Hence, this procedure might become available to be employed straight on other torso fluids (e.g. urine, respiratory specimens and faecal samples), which would further increment its relevance in clinical practice [21, 22].

In contrast to clinical bacteriology, little research has been carried out pertaining to the application of MALDI-TOF MS for identification of parasites of human or veterinary importance [23]. Several studies utilized the technique on protozoan parasites such as Leishmania spp. [24,25,26], Giardia spp. [27], Cryptosporidium spp. [28], Trypanosoma spp. [29], Plasmodium spp. [xxx,31,32] and Dientamoeba spp. [33]. These studies used pre-treatment with ethanol and acetonitrile before subjecting the whole pathogens to MALDI-TOF assay. Additionally, the technique has been used for identification of ectoparasites and vectors, such as ticks [34,35,36,37], fleas [38,39,40,41] and mosquitoes [42,43,44,45,46,47,48,49]. In contrast to the experiments on protozoans, only selected parts of the ectoparasites and vectors (e.g. legs, thoraxes or wings) were used and subjected to the aforementioned extraction method. A farther novel approach to apply MALDI-TOF MS in clinical parasitology is the identification of specific serum peptides that are detectable in parasite-infected individuals [50].

Helminth infections caused past nematodes (e.g. Ascaris lumbricoides, hookworm, Strongyloides stercoralis and Trichuris trichiura), cestodes (e.chiliad. Taenia spp.) and trematodes (e.k. Fasciola spp. and Schistosoma spp.) account for a considerable global burden of disease and are among the virtually mutual infections in marginalized populations in the tropics and subtropics [51]. Indeed, according to estimates put forth past the Global Burden of Disease (GBD) Study, 3.35 million disability-adapted life years (DALYs) were attributable to intestinal nematode infections and schistosomiasis in 2017 [52].

Diagnosis is pivotal for constructive treatment but requires at to the lowest degree a basic laboratory infrastructure, light microscopes and well-trained laboratory technicians who might not exist available in remote areas of tropical and subtropical countries. In loftier-resource settings, in contrast, cognition on microscopic identification of helminths is waning in many laboratories. Information technology is surprising that the potential applicability of MALDI-TOF MS equally a diagnostic tool for helminths of homo and veterinary importance has not yet been systematically assessed, in particular considering the technique has been successfully employed for identification of nematode institute pathogens [53,54,55,56,57,58]. Hence, the goal of this systematic review was to summarize the bachelor information on MALDI-TOF MS awarding for diagnosis of helminths of medical and veterinary importance, and to provide recommendations for future enquiry needs.

Methods

Search strategy

A systematic literature review was performed to identify all relevant scientific studies pertaining to MALDI-TOF MS every bit a diagnostic identification technique in medical and/or veterinary helminthology. The inquiry was performed co-ordinate to the guidance expressed in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement [59].

The following electronic databases were systematically searched: MEDLINE/PubMed, ScienceDirect-Embase, Cochrane Library, Web of Science and Google Scholar. All studies published from inception to x Oct 2018 were eligible for inclusion without linguistic communication restrictions. The bibliographies of all eligible documents were hand-searched for additional references. Conference abstracts or book capacity detected through these databases and additional library searches were also considered. The search strategy comprised keywords related to the MALDI-TOF MS technique (e.one thousand. "MALDI-TOF" and "matrix-assisted light amplification by stimulated emission of radiation desorption/ionization fourth dimension-of-flying") and helminthology (e.g. "helminth", "nematode", "cestode" and "trematode"). The full search strategies for every database are provided in Additional file 1 and the PRISMA checklist in Additional file ii.

Eligibility screening

After the systematic literature search, all duplicates were removed. Titles and abstracts of potentially eligible studies were screened to identify manuscripts relevant to the inquiry question. Scientific reports on helminths of either plants or insects as well as studies on symbiotic bacteria of helminths were excluded for this review. However, we kept all publications related to the soil nematode Caenorhabditis elegans, every bit it is used as a model organism for biomedical research. Additionally, studies pertaining to MALDI-TOF/TOF tandem MS were excluded, as this is a unlike modification of the MALDI-TOF MS technique, which is not routinely employed in clinical microbiology laboratories, merely rather in research laboratory use for accurate characterization or sequencing of components similar amino acids, metabolites, saccharides, etc. [lx,61,62].

Data extraction and assay

The literature search was performed past the commencement author of this manuscript (MF). All titles and abstracts were so independently reviewed past the first and the final writer (MF and SLB) for inclusion and any disagreement was discussed until consensus was reached. All extracted manuscripts were analysed using a reference director software (Mendeley; http://world wide web.mendeley.com).

Results

Search results, number and year of publication of eligible studies

The search procedure and results obtained are shown in Fig. i. In brief, the initial literature search yielded 329 published studies, with an additional two abstracts identified through further search. Following removal of 142 duplicates, a total of 189 articles were assessed in more detail, of which 66 studies were excluded based on the analysis of the respective titles and abstracts. A total-text assay was carried out on the remaining 123 studies; 39 articles were finally excluded because their telescopic was outside the current enquiry question. Hence, 84 articles were included, and these were published between 1997 and 2018. Figure ii shows the number of publications, stratified past year of publication. The heterogeneity of data reported in the articles precluded any meaningful meta-assay (Additional file 3).

Fig. ane
figure 1

PRISMA diagram for a systematic review examining the application of MALDI-TOF mass spectrometry equally potential tool in diagnostic man and veterinary helminthology

Full size epitome

Fig. 2
figure 2

Publications in the peer-reviewed literature pertaining to the application of MALDI-TOF mass spectrometry for identification of helminths or specific pathogen-related components, as revealed past a systematic review, stratified by yr of publication

Full size image

Specific applications of MALDI-TOF MS

The first two manuscripts published in 1997 described structural analyses of glycosphingolipids found in Ascaris suum and C. elegans [63, 64]. Indeed, 95% of all eligible studies used MALDI-TOF MS for identification of specific components rather than for the identification of entire pathogens (Fig. 2). It was only in 2015 when a written report on MALDI-TOF MS equally diagnostic tool for direct identification of Dirofilaria spp. became bachelor [65]. Presently thereafter followed a proof-of-concept study utilizing MALDI-TOF MS for identification and differentiation of Trichinella spp. and some narrative reviews mentioning the lack of information on MALDI-TOF in helminthology [32, 66, 67]. Still, most studies focused on distinct analyses of specific components, such as peptides [66,67,68,69,70,71,72,73,74,75,76,77,78,79,eighty,81,82,83,84,85,86], proteins [69, 87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114], lipids [61, 62, 115,116,117,118,119,120,121,122,123,124], carbohydrates [125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143] and nucleic acids [144] in a research context. Hence, MALDI-TOF was mainly applied to study and compare the proteome or the peptidome of dissimilar helminth species, and almost reports focused on C. elegans. For example, Husson et al. [74] employed a new approach combining liquid chromatography with MALDI-TOF MS to map and differentiate the neuropeptide profiles of C. elegans and the closely related species C. briggsae.

The ii studies aiming at an identification of entire pathogens provided prove that MALDI-TOF MS could reliably differentiate between species inside the genus Trichinella [67] and Dirofilaria [65], respectively. In the study by Mayer-Scholl et al. [67], nine species and three genotypes of Trichinella isolated from mice, domestic pigs, wild boars and guinea pigs were utilized to create an in-house database with 27 raw spectra generated per specimen. All tested isolates could be distinguished with high diagnostic accuracy. The report by Pshenichnaya et al. [65], which had simply been published as a conference abstract, investigated five Dirofilaria repens and five D. immitis specimens, the causative agents of human and veterinary dirofilariasis, and reported that these could exist well differentiated by MALDI-TOF MS. However, information were express regarding the origin of the written report samples, the quality of the spectra obtained by MALDI-TOF and the repeatability of the results. Notwithstanding, during the revision of this systematic review, Pshenichnaya et al. [145] published their work on dirofilariasis in a peer-reviewed periodical and provided too data for ii dissimilar species of Ascaris (i.eastward. A. suum and A. lumbricoides). These helminths could be differentiated past MALDI-TOF based on specific peaks and protein spectra patterns later a cell lysis using the Sepsityper Kit 50 (Bruker Daltonics; Bremen, Federal republic of germany) and a poly peptide extraction with seventy% formic acid and acetonitrile. However, this study has several limitations, and it remains unclear whether calibration steps or assessments of the repeatability and reproducibility of the analyses were performed. An additional newspaper, published in 2017, reported on MALDI-TOF MS application for cyathostomin helminths, a very diverse group of intestinal parasites infecting horses [66]. These so-called "small strongyles" bear witness a high degree of resistance against benzimidazole anthelminthics and may lead to astringent equine enteropathy, colic and decease [146]. The study examined several species belonging to the cyathostomin helminths (e.g. Coronocyclus coronatus, C. labiatus and C. labratus) and establish distinct protein spectra among developed helminths of dissimilar species [66]. These findings were recently confirmed and substantiated past another study on the application of MALDI-TOF for differentiation of cyathostomins, which was published in April 2019 [147].

Discussion

We systematically reviewed the available literature pertaining to the application of MALDI-TOF MS for identification of helminthic pathogens of human and veterinary importance. While the technique has been successfully employed for many major classes of pathogens (eastward.grand. bacteria, mycobacteria and fungi), information on its utilise in diagnostic helminthology are scarce. Several studies reported on the differential assay of specific components, such as proteins, peptides or lipids with MALDI-TOF MS techniques, but only ii recent manuscripts and one conference abstract provided 'proof-of-concept' evidence of its potential utility in diagnosing and differentiating helminth species of medical or veterinarian relevance.

The majority of articles identified in this systematic review focused on poly peptide-centred analyses of helminth samples. It is of import to mention that some of the MALDI-TOF MS devices employed in these studies had been subjected to modifications that are not commonly available in routine clinical laboratories. Additionally, these experiments frequently employed a circuitous sample pre-handling comprising a protein separation past high pressure liquid chromatography (HPLC) or electrophoresis. Yet, some recent proof-of-concept studies take shown that MALDI-TOF MS is also capable of diagnosing entire helminthic pathogens and differentiating similar species within the same genus based on an analysis of their individual poly peptide spectra [66, 67]. Considering no helminths are currently included in commercially bachelor MALDI-TOF MS identification databases, private in-house databases need to exist created through generation of primary spectra libraries, ideally post-obit established guidelines and protocols that are similar to those employed past the manufacturers of commercially available mass spectrometers [148]. Indeed, previous studies have described the sensitive, reliable and highly reproducible identification of helminths that crusade plant infections and have ended that MALDI-TOF MS should be more than widely employed as a 'rapid detection tool' [54,55,56,57,58]. Ahmad et al. [56], for example, reported on the suitability of MALDI-TOF MS to differentiate harmless and juvenile infective stages of single plant nematodes, as these showed unique, characteristic poly peptide peak patterns. These studies should be considered equally relevant because constitute-parasitic nematodes can sometimes also be found in human stool samples [149, 150]. In Brazil, for example, eggs of the root-knot nematode Meloidogyne spp. were detected in human faeces using a microscopic sedimentation method [151]. Future studies should likewise employ MALDI-TOF on serum, equally a recent written report reported the detection of specific proteins in serum of mice infected with Schistosoma japonicum [50].

While helminth infections pose a considerable brunt on human and beast health [152], an accurate diagnosis of these conditions is frequently challenging. Indeed, elementary diagnostic tools such equally stool microscopy for soil-transmitted helminth infections are of express value if the infection intensity is depression and highly sensitive diagnostic techniques such equally PCR-based assays are only available in selected reference laboratories exterior endemic areas [153]. In loftier-income countries, in dissimilarity, knowledge regarding standard diagnostic parasitology is waning and differentiation of closely related helminth species based on their microscopic morphology requires skilled laboratory technicians [154]. Moreover, some infections cannot be reliably distinguished with standard diagnostic techniques. A prominent example are infections caused past cestodes of the genus Taenia [155], which may cause a relatively harmless intestinal infection if cysts of Taenia saginata or T. solium are orally ingested with meat of cattle or pig. While eggs of T. saginata are not infectious to humans, T. solium eggs can atomic number 82 to the potentially fatal disease (neuro-)cysticercosis. While the correct diagnosis has important implications for handling, patient direction and potential contact screening (intestinal carriage of adult T. solium worms poses an increased risk of cysticercosis for close contacts, such every bit family members), it is incommunicable to distinguish both species based on the identical morphology of their eggs under a microscope. Molecular tools can reach an accurate differentiation of the ii species, but are only available in research settings [155,156,157]. Sometimes, proglottids of adult worms are also passed in the faeces. While a distinct differentiation is possible based on the uterine branches within a proglottid, misidentification using this approach has been reported in clinical practise [158]. Hence, achieving a species-specific differentiation based on MALDI-TOF MS would contribute to an enhanced, more reliable identification, and time to come studies should thus accost this issue. Like considerations hold also true for other infective agents that tin hardly be differentiated by other methods (due east.g. different Echinococcus species), novel species (e.g. hybrid species of Schistosoma spp., which accept recently been reported from Corsica, France [159]) and notoriously difficult-to-detect infections (east.g. strongyloidiasis). An overview of pathogens for which evolution of MALDI-TOF MS identification protocols would appear particularly promising is summarized in Table 1.

Tabular array one Current parasitological techniques, related challenges and research needs for a potential application of MALDI-TOF MS as diagnostic tool for major helminths of human being and veterinary importance

Total size table

Information technology is important to consider the fixative in which a parasitological sample is stored. Both formaldehyde and ethanol are commonly used to enable a long-term storage of biological specimens, just this may lead to profound changes of the protein structure [160], which is likely to influence on the results of MALDI-TOF examinations carried out on such samples. The virtual impossibility to dilate nucleic acids from formaldehyde-containing solutions [161] due to fragmentation of the single components [162] renders most PCR tests useless on these sample types, but MALDI-TOF analyses of protein spectra might still be possible, albeit with different spectra if compared to native samples. Hence, futurity studies should evaluate this technique on different kinds of fixatives and on samples that take been stored for prolonged periods.

The present review identified only a few successful studies that employed MALDI-TOF MS to diagnose helminths. Limitations include the complicated pre-treatment procedures employed in some studies and the rather incomplete data presentation in one of the more than clinically oriented research projects [65]. New research is needed to determine whether this technique might become a clinically meaningful addendum to the current prepare of diagnostic options. However, experiences made in clinical bacteriology, mycobacteriology, mycology every bit well as with ectoparasites (east.thou. ticks) and vectors (e.g. mosquitoes) [12, 37, 163] are promising. Whereas MALDI-TOF MS is mainly used on civilisation-grown colonies for identification of bacteria and mycobacteria, the goal in helminthology will be to provide a species-specific diagnosis based on either macroscopic elements or eggs and larvae that are present in stool samples (or other trunk fluids and tissue samples). Hence, specific protocols will need to be elaborated to this end, which may include sample preparation, purification and concentration steps, including guidance on the near advisable sample preservation. Withal, such protocols accept been successfully developed in the by (e.1000. for identification of mycobacteria or moulds) [164, 165]. More recently, specific pre-treatment modifications take even immune to utilise MALDI-TOF MS on blood culture broths [166] and fresh urine samples for straight identification of bacteria [167]. Additionally, detection of parasites in circuitous samples (e.g. claret), should be considered (e.g. as an antigen exam for Wuchereria bancrofti [168] or for the detection of specific serum peptides [169]).

Yet, much research and rigorous validation is nonetheless needed before MALDI-TOF MS might be employed directly on stool samples, and priority should thus exist given to (i) the institution of in-house main spectra library databases to allow for species-specific identification of selected helminths; (ii) the subsequent development of sample treatment protocols; (3) the validation of this technique on different clinical sample types; and (iv) the elaboration of MALDI-TOF MS to be employed on fixed samples.

Conclusions

The present systematic review elucidated that MALDI-TOF MS, which is at present routinely used in many clinical microbiology laboratories for identification of bacteria, fungi and mycobacteria, could potentially also be employed in the context of helminth diagnosis. Preliminary data propose that MALDI-TOF MS might hold promise as a futurity diagnostic tool for direct and rapid identification of pathogenic helminths in clinical samples with sufficient diagnostic accuracy. Further studies are needed to evaluate these concepts and to develop specific databases for helminth identification, followed by rigorous validation on well characterised clinical specimens.

Availability of data and materials

The search strategy and all manuscripts included in this systematic review are available inside the article and its boosted files.

Abbreviations

DALY:

disability-adjusted life twelvemonth

GBD:

Global Burden of Affliction (Report)

MALDI-TOF:

matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

MS:

mass spectrometry

PCR:

Polymerase chain reaction

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Acknowledgements

Not applicable.

Funding

This systematic review received financial support from the 'Landesforschungsförderprogramm des Saarlandes'.

Author information

Affiliations

  1. Institute of Medical Microbiology and Hygiene, Saarland Academy, Homburg/Saar, Federal republic of germany

    Maureen Feucherolles & Sören 50. Becker

  2. Grand duchy of luxembourg Constitute of Scientific discipline and Technology, Environmental Research and Innovation, Belvaux, Grand duchy of luxembourg

    Maureen Feucherolles

  3. Swiss Tropical and Public Wellness Constitute, Basel, Switzerland

    Sven Poppert, Jürg Utzinger & Sören L. Becker

  4. University of Basel, Basel, Switzerland

    Sven Poppert, Jürg Utzinger & Sören L. Becker

Contributions

MF conducted the systematic review of the literature and extracted data. MF and SLB independently assessed published manufactures for eligibility, analysed and discussed data and drafted the first version of the manuscript. SP and JU contributed to data estimation and revised the manuscript. All authors read and canonical the final manuscript.

Corresponding author

Correspondence to Sören 50. Becker.

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Competing interests

The authors declare that they have no competing interests.

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Additional files

Additional file 1.

Search strategies employed for our systematic review pertaining to the awarding of MALDI-TOF mass spectrometry as a diagnostic tool in man and veterinarian helminthology.

Additional file 2.

PRISMA checklist for a systematic review examining the application of MALDI-TOF mass spectrometry equally potential tool in diagnostic human and veterinary helminthology.

Additional file 3.

List of references included in the terminal review (n = 84 manufactures).

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Feucherolles, 1000., Poppert, S., Utzinger, J. et al. MALDI-TOF mass spectrometry every bit a diagnostic tool in human and veterinary helminthology: a systematic review. Parasites Vectors 12, 245 (2019). https://doi.org/10.1186/s13071-019-3493-9

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  • DOI : https://doi.org/10.1186/s13071-019-3493-9

Keywords

  • Diagnosis
  • Helminths
  • MALDI-TOF
  • Matrix-assisted laser desorption/ionization-time of flight
  • Neglected tropical diseases
  • Parasites

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