We evaluated the usefulness of an Aspergillus galactomannan (GM) test, a ␤-D-glucan (␤DG) test, and two different Aspergillus PCR assays of bronchoalveolar lavage fluid (BALF) samples for the diagnosis of chronic pulmonary aspergillosis (CPA). BALF samples from 30 patients with and 120 patients without CPA were collected. We calculated the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio for each test individually and in combination with other tests. The optical density index values, as determined by receiver operating characteristic analysis, for the diagnosis of CPA were 0.5 and 100 for GM and ␤DG testing of BALF, respectively. The sensitivity and specificity of the GM test, ␤DG test, and PCR assays 1 and 2 were 77.8% and 90.0%, 77.8% and 72.5%, 86.7% and 84.2%, and 66.7% and 94.2%, respectively. A comparison of the PCR assays showed that PCR assay 1 had a better sensitivity, a better negative predictive value, and a better negative likelihood ratio and PCR assay 2 had a better specificity, a better positive predictive value, and a better positive likelihood ratio. The combination of the GM and ␤DG tests had the highest diagnostic odds ratio. The combination of the GM and ␤DG tests on BALF was more useful than any single test for diagnosing CPA.KEYWORDS chronic pulmonary aspergillosis, Aspergillus galactomannan test, ␤-D-glucan test, Aspergillus PCR assays T he Aspergillus spp. are ubiquitous saprophytic fungi and are the pathogens most commonly responsible for pulmonary fungal disease worldwide. They cause a variety of diseases, including invasive and chronic aspergillosis and allergic disease (1). Chronic pulmonary aspergillosis (CPA) is classified into three major subtypes: chronic necrotizing pulmonary aspergillosis, chronic cavitary pulmonary aspergillosis, and chronic fibrosing pulmonary aspergillosis (2). However, these subtypes usually overlap and are difficult to differentiate clinically. Thus, many investigators refer to these subtypes merely as CPA (3)(4)(5)(6)(7)(8).CPA is a slowly progressive pulmonary syndrome caused by Aspergillus spp. It is saprophytic in persons with underlying pulmonary conditions such as old tuberculosis, pulmonary emphysema, and previous thoracic surgery (9). CPA is diagnosed by evaluating clinical symptoms, radiological findings, and the results from serum Aspergillus antibody testing and Aspergillus sp. culture. These diagnostic criteria are based on a

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Exophiala dermatitidis is a black fungus that rarely causes respiratory infection. We report a case of E . dermatitidis pneumonia with bronchiectasis that relapsed after 11 months of voriconazole (VRCZ) treatment in a rheumatoid arthritis (RA) patient with bronchiectasis. A 65‐year‐old woman with RA and abnormal findings on chest radiography was referred for assessment of chronic cough and increased sputum production. She underwent bronchoscopy, and E . dermatitidis was identified from bronchoalveolar lavage fluid (BALF). Exophiala dermatitidis chronic lower respiratory tract infection and pneumonia were diagnosed. Although her condition improved after 11 months of VRCZ treatment, chest computed tomography (CT) images showed worsening at five months after the cessation of VRCZ treatment and E . dermatitidis was again detected in BALF. Re‐administration of VRCZ for two years improved symptoms and chest CT images, and her condition is currently stable. In patients with bronchiectasis, E . dermatitidis pneumonia might require prolonged antifungal treatment.

Between 18 November and 3 December 2011, five renal transplant patients at the Department of Nephrology, Toho University Omori Medical Centre, Tokyo, were diagnosed with Pneumocystis pneumonia (PCP). We used molecular epidemiologic methods to determine whether the patients were infected with the same strain of Pneumocystis jirovecii. DNA extracted from the residual bronchoalveolar lavage fluid from the five outbreak cases and from another 20 cases of PCP between 2007 and 2014 were used for multilocus sequence typing to compare the genetic similarity of the P. jirovecii. DNA base sequencing by the Sanger method showed some regions where two bases overlapped and could not be defined. A next-generation sequencer was used to analyse the types and ratios of these overlapping bases. DNA base sequences of P. jirovecii in the bronchoalveolar lavage fluid from four of the five PCP patients in the 2011 outbreak and from another two renal transplant patients who developed PCP in 2013 were highly homologous. The Sanger method revealed 14 genomic regions where two differing DNA bases overlapped and could not be identified. Analyses of the overlapping bases by a next-generation sequencer revealed that the differing types of base were present in almost identical ratios. There is a strong possibility that the PCP outbreak at the Toho University Omori Medical Centre was caused by the same strain of P. jirovecii. Two different types of base present in some regions may be due to P. jirovecii's being a diploid species.

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