A century after its discovery, Chagas disease still represents a major neglected tropical threat. Accurate diagnostics tools as well as surrogate markers of parasitological response to treatment are research priorities in the field. The purpose of this study was to evaluate the performance of PCR methods in detection of Trypanosoma cruzi DNA by an external quality evaluation.
An international collaborative study was launched by expert PCR laboratories from 16 countries. Currently used strategies were challenged against serial dilutions of purified DNA from stocks representing T. cruzi discrete typing units (DTU) I, IV and VI (set A), human blood spiked with parasite cells (set B) and Guanidine Hidrochloride-EDTA blood samples from 32 seropositive and 10 seronegative patients from Southern Cone countries (set C). Forty eight PCR tests were reported for set A and 44 for sets B and C; 28 targeted minicircle DNA (kDNA), 13 satellite DNA (Sat-DNA) and the remainder low copy number sequences. In set A, commercial master mixes and Sat-DNA Real Time PCR showed better specificity, but kDNA-PCR was more sensitive to detect DTU I DNA. In set B, commercial DNA extraction kits presented better specificity than solvent extraction protocols. Sat-DNA PCR tests had higher specificity, with sensitivities of 0.05–0.5 parasites/mL whereas specific kDNA tests detected 5.10−3 par/mL. Sixteen specific and coherent methods had a Good Performance in both sets A and B (10 fg/µl of DNA from all stocks, 5 par/mL spiked blood). The median values of sensitivities, specificities and accuracies obtained in testing the Set C samples with the 16 tests determined to be good performing by analyzing Sets A and B samples varied considerably. Out of them, four methods depicted the best performing parameters in all three sets of samples, detecting at least 10 fg/µl for each DNA stock, 0.5 par/mL and a sensitivity between 83.3–94.4%, specificity of 85–95%, accuracy of 86.8–89.5% and kappa index of 0.7–0.8 compared to consensus PCR reports of the 16 good performing tests and 63–69%, 100%, 71.4–76.2% and 0.4–0.5, respectively compared to serodiagnosis. Method LbD2 used solvent extraction followed by Sybr-Green based Real time PCR targeted to Sat-DNA; method LbD3 used solvent DNA extraction followed by conventional PCR targeted to Sat-DNA. The third method (LbF1) used glass fiber column based DNA extraction followed by TaqMan Real Time PCR targeted to Sat-DNA (cruzi 1/cruzi 2 and cruzi 3 TaqMan probe) and the fourth method (LbQ) used solvent DNA extraction followed by conventional hot-start PCR targeted to kDNA (primer pairs 121/122). These four methods were further evaluated at the coordinating laboratory in a subset of human blood samples, confirming the performance obtained by the participating laboratories.
A century after its discovery, Chagas disease, caused by the parasite Trypanosoma cruzi, still represents a major neglected tropical threat. Accurate diagnostics tools as well as surrogate markers of parasitological response to treatment are research priorities in the field. The polymerase chain reaction (PCR) has been proposed as a sensitive laboratory tool for detection of T. cruzi infection and monitoring of parasitological treatment outcome. However, high variation in accuracy and lack of international quality controls has precluded reliable applications in the clinical practice and comparisons of data among cohorts and geographical regions. In an effort towards harmonization of PCR strategies, 26 expert laboratories from 16 countries evaluated their current PCR procedures against sets of control samples, composed by serial dilutions of T.cruzi DNA from culture stocks belonging to different lineages, human blood spiked with parasite cells and blood samples from Chagas disease patients. A high variability in sensitivities and specificities was found among the 48 reported PCR tests. Out of them, four tests with best performance were selected and further evaluated. This study represents a crucial first step towards device of a standardized operative procedure for T. cruzi PCR.
Citation: Schijman AG, Bisio M, Orellana L, Sued M, Duffy T, Mejia Jaramillo AM, et al. (2011) International Study to Evaluate PCR Methods for Detection of Trypanosoma cruzi DNA in Blood Samples from Chagas Disease Patients. PLoS Negl Trop Dis5(1): e931. https://doi.org/10.1371/journal.pntd.0000931
Editor: Ana Rodriguez, New York University School of Medicine, United States of America
Received: May 20, 2010; Accepted: December 1, 2010; Published: January 11, 2011
This is an open-access article distributed under the terms of the Creative Commons Public Domain declaration which stipulates that, once placed in the public domain, this work may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose.
Funding: Funding was provided by World Health Organization-Tropical Diseases Research, Panamerican Health Organization (WHO-TDR-PAHO), Universidad de las Naciones Unidas/Biotecnología para América Latina y el Caribe (UNU-BIOLAC), Consejo Nacional de Ciencias y Tecnología (CONICET) PIP 112-200801-09215, National Agency of Science and Technology, PICT 33955, Buenos Aires, Argentina. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
A century after its discovery  Chagas disease still represents a health threat to an estimated 28 million people in the Americas, being the second highest illness burden among neglected tropical diseases –. The infection by the protozoan Trypanosoma cruzi can be acquired from blood-sucking triatomine bugs, blood transfusion, transplacental transmission or by the oral contamination foodstuffs by infected triatomine faeces –.
Since 1990, a series of international initiatives based on vector control, systematic screening of blood donors in all endemic countries, and detection and treatment of congenital transmission have been launched for control and elimination of Chagas disease. These strategies have led to significant reduction in the number of infected people worldwide. According to information from 21 countries where the disease is endemic, the number of infected persons today is estimated to be 7,694,500, most of them at the chronic stage of disease –.
Traditional parasitological procedures, such as xenodiagnosis and haemoculture are laborious and time-consuming and show poor sensitivities in cases of low-level parasitaemias, limiting their usefulness in diagnosis and monitoring of drug efficacy –. Since the past decade, the application of polymerase chain reaction (PCR) to detect T. cruzi directly in blood samples has opened new possibilities for the diagnosis of infection and evaluation of trypanocidal chemotherapy in different clinical and epidemiological settings –. These PCR procedures have revealed highly variable levels of sensitivity and specificity, depending on a number of technical factors such as, the volume of sample collected, the conditions of conservation of the sample, the methods used to isolate DNA, the parasite sequences and primers selected, the reagents used as well as the thermo-cycling conditions. Variability in PCR sensitivity could also be in part explained by the intermittent presence and quantity of circulating parasites at the time of blood collection. In addition, molecular targets from strains belonging to six different T. cruzi discrete typing units (DTUs, ) with dissimilar DNA content and gene dosage , – have been used for molecular diagnosis by different laboratories. In addition, sequence polymorphisms within amplified fragments among strains from different DTUs may influence the efficiency of amplification –. Moreover, false negative findings due to interference of PCR inhibitory substances co-purified during lysis and DNA extraction of blood samples and false positive results mostly due to carry over DNA contamination ,  may arise.
In this context, the assessment of the performances of currently available PCR tests for detection of T. cruzi infection in blood samples and DNA control sets was launched by expert laboratories in PCR detection of T. cruzi infection from different countries of America and Europe. We aimed to compare the performance of currently used PCR strategies for detection of T. cruzi DNA in sets of blind samples, including purified DNA from reference culture stocks from different T. cruzi discrete typing units, human blood samples spiked with cultured parasite cells and clinical samples from seropositive and seronegative patients from different endemic countries, in order to select the best performing tests for validation.
Materials and Methods
The participating laboratories were selected on the basis of their expertise in current processing of clinical samples for PCR detection of T. cruzi DNA, facilities with pre-PCR and post-PCR working areas and sufficient financial support to enable sustainability of PCR work after conclusion of this study. Twenty six Laboratories from different countries of America and Europe participated in this study, one laboratory from Belgium, Bolivia, France, French Guiana, Mexico, Paraguay, Peru, Spain, United Kingdom, Uruguay, USA, Venezuela, two laboratories from Chile, three from Colombia, four from Argentina and five from Brazil.
Aiming to explore the highest extent of currently used PCR tests for detection of T. cruzi DNA, the participating laboratories were encouraged to carry out all available PCR strategies currently in use according to their own protocols and using their own financial resources (LbX1 to LbXN in Table 1, where LbX denotes laboratory and the number denotes a given test).
The organizing laboratory (LabMECh, INGEBI, Buenos Aires) was in charge of preparing characterised samples in three different sets (A, B and C), as described below.
Set A. This set consisted of ten-fold serial dilutions of T. cruzi DNA, plus three negative controls without DNA in bi-distilled sterile water. T. cruzi DNA was purified from epimastigote cells grown in LIT medium from stocks Silvio X10, Cl-Brener and CAN III, which are references for the discrete typing units T. cruzi I (DTU I), T. cruzi VI (DTU IIe) and T. cruzi IV (DTU IIa), respectively , . The identity of the DTUs was confirmed using a PCR algorithm targeting several nuclear genes, as detailed in Burgos and coworkers . T. cruzi DNA was extracted from parasite cultures using current chloroform- DNA extraction without vortexing during the procedure . The concentration and quality of DNA was measured at 260/280 nm in triplicate, using a Nanodrop 1000 spectrophotometer (ThermoFisher Scientific, Waltham, MA, USA). Each series of DNA samples was conformed by concentrations ranging from 10 fg/ul to 10−3 fg/ul.
Set B. This set contained seronegative human blood samples treated with Guanidine Hidrochloride 6M-EDTA 0.2 M buffer, pH 8.00  and spiked with ten-fold dilutions of cultured CL-Brener epimastigotes. One Guanidine Hidrochloride-EDTA treated blood sample without parasites was included as negative control. The samples were prepared as follows: a pool of human blood samples testing negative for T. cruzi infection in current serological methods and PCR was mixed with an equal volume of Guanidine Hidrochloride-EDTA buffer. An aliquot was withdrawn and spiked with 5 parasite cells/mL, homogenized, let stand overnight at room temperature, boiled the following day during 15 minutes , let stand at room temperature overnight and then stored at 4°C. The remaining non-spiked blood was treated in the same way and stored as a negative stock. One day later, the spiked Guanidine Hidrochloride-EDTA blood was used as starter for preparing 5 ten-fold serial dilutions, using as matrix the negative blood stock, to obtain samples ranging from 0.5 to 5.10−5 parasite equivalents/mL of blood.
Set C. This was a panel of 42 pre-characterized archived clinical blood samples stored in Guanidine Hidrochloride-EDTA buffer, including 10 from seronegative patients and 32 from seropositive patients from endemic regions of Argentina, Bolivia, Brazil and Paraguay. The seropositive panel was composed by patients at different phases of T. cruzi infection, namely, 2 immunosuppressed patients after heart transplantation, 23 indeterminate Chagas disease and 7 chronic Chagas disease patients with cardiac and/or digestive manifestations. They were selected from archived collections from the Serodiagnostic Laboratory for Chagas Disease, Federal University of Goias, Brazil, and from the organizing Lab. Diagnosis was based on their serological reactivity by at least two out of three routine serological methods (ELISA, IHA and Latex Agglutination tests) and clinical and electrocardiographic findings.
Samples from patients were obtained with written informed consent and approval of the Ethics Committee of the Rivadavia Hospital, Government of Buenos Aires city, Argentina and the Serodiagnostic Laboratory for Chagas Disease, Federal University of Goias, Goiania, Brazil. Furthermore, all samples were tested by two PCR tests performed on duplicate at the organizing laboratory, namely a hot-start PCR targeting kDNA according to Burgos et al , a Real time PCR targeting satellite DNA sequences and a Real time PCR targeting an internal amplification control, according to Duffy and coworkers , allowing confirmation of PCR negativity among seronegative samples and PCR positivity among a subgroup of the 32 seropositive samples (data not shown).
Each sample from set A, B and C was aliquoted and distributed into 1 ml Screw Top bar-coded tubes (Matrix Trackmates, UNITEK, USA) to each package. The packages were sent refrigerated to the participating laboratories (World Courier, Arg). Each laboratory received 50 µls of Set A and 500 µls of samples belonging to sets B and C.
Best Performing PCR Methods
Methods LbD2, LbD3 and LbQ: Solvent DNA extraction was carried out from 100 µl of Guanidine Hidrochloride-EDTA blood aliquots. Briefly, 100 µl aliquots were taken and well mixed with 100 µ l of phenol-chloroform-isoamylic alcohol (25∶24∶1) (phenol Tris–EDTA pH 8, USB Corporation, USA). After centrifugation for 3 min at 13000 rpm 150 µl of distilled water were added. The solution was mixed and centrifuged for 3 min at 13000 rpm. The aqueous phase was transferred to a clean tube, and a final extraction with 200 µ l of chloroform was performed. After centrifugation for 3 min at 13000 rpm the aqueous phase was transferred to a clean tube and mixed with 40 µg of rabbit liver glycogen (Sigma, USA). The DNA was precipitated with 200 µl of isopropyl alcohol during 30 minutes at −20°C. Then the solution was centrifuged at 13000 rpm for 15 min. The pellet was washed with 500 µl of 70% ethanol and centrifuged again 15 min at 13000 rpm. After discard the ethanol the pellet was allowed to dry during 10 min at 37°C. Finally the pellet was suspended in 50 µl 10 mM Tris-HCl, pH 8.5. DNA solution was stored at −20°C. Method LbF1: DNA isolation used a commercial kit (High Pure PCR Template preparation kit, Roche Applied Science) according to the manufacturer's protocol. DNA solution was stored at −20°C.
Method LbD3 was carried out in a MJR PTC-100 thermocycler (MJ Research, Watertown, MA, USA). Master mix was composed by 1X Taq platinum amplification buffer, 250 µM deoxynucleotide triphosphate solution (dNTPs), 3 mM MgCl2 solution, 1,5 U Taq Platinum (Invitrogen, Brazil), 0.5 µM sat-DNA specific primers TCZ-F (GCTCTTGCCCACAMGGGTGC) and TCZ-R (CCAAGCAGCGGATAGTTCAGG), 5 µl of template DNA and a quantity of water sufficient to give a final volume of 50 µl. Cycling parameters were one step of 3 min at 94°C; 40 cycles of 45 sec at 94°C, 1 min at 68°C and 1 min at 72°C and one final extension step of 10 min at 72°C, 182 bp Sat-DNA PCR products were analysed in 3% agarose gels (Invitrogen, Life Technologies, USA) stained with ethidium bromide.
Method LbQ was carried out in a MJR PTC-100 thermocycler (MJ Research, Watertown, MA, USA). Master mix was composed by 1X Taq platinum amplification buffer, 200 µ M dNTPs, 3 mM MgCl2 solution, 1,5 U Taq Platinum (Invitrogen, Brazil), 10 µM kDNA specific primers 121 (AAATAATGTACGGGKGAGATGCATGA) and 122 (GGTTCGATTGGGGTTGGTGTAATATA), 7.5 µl of template DNA and a quantity of water sufficient to give a final volume of 50 µl. Cycling parameters were one step of 3 min denaturation at 94°C; 2 cycles of 1 min at 97.5°C, 2 min at 64°C; 33 cycles of 1 min at 94°C, 1 min at 62°C and one final extension step of 10 min at 72°C, 330 bp kDNA PCR products were analysed in 2% agarose gels stained with ethidium bromide.
Method LbD2 was conducted using a Rotor Gene 3000 (Corbett Research, Sydney, Australia) Real Time thermocycler. Each PCR reaction contained 1X Qiagen QuantiTect Sybr-Green PCR Master Mix (Qiagen), 0.5 µM SatDNA specific primers TCZ-F (GCTCTTGCCCACAMGGGTGC) and TCZ-R (CCAAGCAGCGGATAGTTCAGG), 2 µl of template DNA and PCR-grade H2O (Qiagen) to a final volume of 20 µl. The amplification was conducted under the following cycling conditions after 15 min of denaturation at 95°C, PCR amplification was carried out for 50 cycles (95°C for 10 s, 55°C for 15 s and 72°C for 10 s). Fluorescence data collection was performed at 72°C at the end of each cycle. After quantification, a melt curve was made with 74–85°C raising by 0.5°C each step and waiting for 4 seconds afterwards acquiring on Green channel. Melting temperture (Tm) of the amplicon was 81°C. Finally, data were analyzed with Rotor-Gene 6000 Series Software 1.7 (Corbett Research).
Method LbF1 was conducted using a Rotor Gene 3000 (Corbett Research, Sydney, Australia) Real Time thermocycler. Each PCR reaction contained 1X PCR FastStart Universal Probe Master Master Mix (Roche), 0.75 µM SatDNA specific primers cruzi 1 (ASTCGGCTGATCGTTTTCGA) and cruzi 2 (AATTCCTCCAAGCAGCGGATA), 0.25 µM SatDNA specific probe cruzi 3 (CACACACTGGACACCAA), 2 µl of template DNA and PCR-grade H2O to a final volume of 20 µl. The amplification was conducted under the following cycling conditions, after 15 min of denaturation at 95°C, 45 cycles at 95°C for 10 s, 54°C for 60 s. Fluorescence data collection was performed at 54°C at the end of each cycle. Finally, data were analyzed with Rotor-Gene 6000 Series Software 1.7 (Corbett Research).
The possibility of contamination of the PCR reagents and of the solutions used to prepare DNA was carefully examined through the use of appropriate controls. Also two dilutions from DNA purified from Cl- Brener strain were analyzed in each round as strong positive and detection limit control, respectively.
An access database form was distributed to the participants to standardize reporting of results. Those laboratories performing more than one PCR test per sample sent a separate report for each test. The results were analyzed by using SAS Software and Microsoft Excel. Due to the exploratory nature of the study, a descriptive analysis of results is provided.
For set A, the following parameters were evaluated: 1) specificity (Sp): the proportion of negative PCR results in the three negative samples, 2) coherence: (Co) the ability of reporting positive PCR findings in a consecutive way, from the highest to the lowest detected DNA concentration for each series of DNA dilutions of parasite stocks and 3) the detection limits (DL) for each stock. A test was defined as Good Performing Method (GPM) if it was 100% specific and coherent and capable of detecting 10 fg/ul or less DNA for all parasite DTU stocks.
For set B the same parameters were evaluated: Sp, Co and DL. A test was defined as GPM if it was 100% specific and coherent and capable of detecting 5 parasite equivalents/mL of Guanidine Hidrochloride-EDTA treated blood or less.
For each sample of set C, a consensus PCR result was obtained on the basis of the reports by GPM tests in sets A and B, as done in other PCR interlaboratory studies . A sample was considered PCR positive by consensus if more than 50% of the GPM gave positive results and PCR negative if more than 50% of GPM tests gave negative results. Those samples for which 50% of the GPM methods gave positive reports and 50% gave negative ones were considered indeterminate.
The sensitivity, specificity, accuracy and kappa index of the different PCR tests were calculated by using 1) the above mentioned consensus PCR results and 2) the serological diagnosis as the reference methods.
Inter-observer kappa coefficients were calculated using GraphPad Software on-line statistical calculators (http://www.graphpad.com/quickcalcs/kappa1. cfm). Kappa values<0.01 indicate no concordance, those between 0.1 and 0.4 indicate weak concordance, those between 0.41 and 0.60 indicate clear concordance, those between 0.61 and 0.80 indicate strong concordance, and those between 0.81 and 1.00 indicate nearly complete concordance. Accuracy was calculated as reported .
Twenty six laboratories reported PCR results, using one to six different PCR tests (Table 1). The main sources of variability among laboratories and tests included DNA purification procedures using commercial kits (Kt) or in-house methods (IH), T. cruzi target and primer sequences, cycling instrumentation by conventional (C) or Real Time (RT) thermocyclers, cycling conditions, master mix compositions and trade marks of PCR kits (Kt) or reagents for IH master mixes.
A total of 48 PCR tests were reported for set A samples and 44 of them for sets B and C. Twenty eight tests targeted minicircle DNA, 24 of them amplified the 330 bp variable region and 4 amplified a 118 bp fragment from the constant region (Lb F2 and Lb G1 to G3, Table 1). Thirteen tests targeted the satellite DNA sequence (Sat-DNA), two targeted the 18s ribosomal RNA genes (18s rDNA), two amplified a fragment from the 24sα ribosomal RNA genes (24sα rDNA), one targeted the intergenic region of spliced-leader genes (SL-DNA) and two the mitochondrial gene for the subunit II of cytochrome oxidase (CO II-DNA) (Table 1).
Analysis of Set A
Table 2 shows the data obtained by the 48 PCR tests on DNA dilutions from the 3 parasite stocks representing DTUs I, IV and VI. The seven PCR tests targeting sequences other than Sat-DNA or kDNA failed to detect the most concentrated DNA sample (10 fg/ul) of one, two or all three parasite stocks (Tests C3, C4, C6, S1 and S3; Detection Limit = ND), or reported false positive findings in the negative controls without DNA (Tests C5 and U2) and thus were not included in the following analysis.
Out of the 41 tests based on kDNA (28 tests) or Sat-DNA sequences (13 tests), 25 (51.2%) provided specific and coherent results for all three parasite stocks (Sp = Y, Co = Y, Table 2). Fourteen of them targeted kDNA, representing 50% of the reported kDNA-PCR tests and 11 targeted Sat-DNA, representing 84.6% of Sat-DNA PCR tests. These data indicated that PCR tests based on Sat-DNA sequences were more specific than those based on kDNA. Figures 1A and 1B show the distribution of the detection limits (DL) of the above mentioned 11 Sat-DNA PCR and 14 kDNA PCR tests, respectively, for each T. cruzi stock.
Distribution of detection limits (DL) of specific and coherent PCR tests targeted to Sat-DNA (A) and kDNA sequences (B) for detecting serial dilutions of purified DNA from 3 parasite stocks (Set A) representative of T. cruzi DTU I (Silvio×10), DTU IV (Can III cl1) and DTU VI (Cl Brener). C. Distribution of detection limits (DL) of specific and coherent PCR tests targeted to Sat-DNA (black bars) and kDNA sequences (white bars) carried out from human blood spiked with serial dilutions of parasite cells (Set B).
Analysis of T. cruzi I DNA series: Nine out of 11 Sat-DNA- and all 14 kDNA-PCR tests were capable of detecting at least the most concentrated T. cruzi I DNA sample (Figure 1 A and B, grey bars) and 2 Sat-DNA and 8 kDNA-PCR tests could detect 0.1 fg/µl of T. cruzi I DNA. The lowest detection limit for T. cruzi I DNA was 0.01 fg/ul obtained by laboratory W using conventional kDNA-PCR (Table 2 and Figure 1B). Thus, kDNA- PCR tests were more sensitive than Sat-DNA PCR tests to detect T. cruzi I DNA.
Analysis of T. cruzi IV DNA series: 8 out of 11 Sat-DNA- and all 14 kDNA-PCR tests were capable of detecting the most concentrated T. cruzi IV DNA sample (Figure 1 A and B, black bars). The lowest detection limit (1 fg/µl) was reached by three Sat-DNA- and six kDNA-PCR tests, suggesting similar analytical sensitivities of methods based on both molecular targets to detect T. cruzi IV DNA.
Analysis of T. cruzi VI DNA series: All 11 Sat-DNA- and 13 out of 14 kDNA-PCR tests were capable of detecting the most concentrated T. cruzi VI DNA sample (Figure 1 A and B, white bars). The only test that did not detect Cl-Brener DNA amplified the constant kDNA region (G1, kDNAc, Table 2). The lowest detection limit (0.01 fg/µl) was obtained by 2 Sat-DNA PCR tests (Z and F1, Table 2) followed by 0.1 fg/µl obtained by 2 conventional kDNA-PCR tests (R and W, Table 2).
Overall, the reported PCR tests were less sensitive for detecting DNA from the T. cruzi IV reference stock. Twenty PCR tests showing specific and coherent results and detecting at least the most concentrated DNA samples from each of the parasite stocks were considered Good Performing Methods for Set A (bold fonts, Table 2). They comprised 53.8% of 13 Sat-DNA-PCR and 46.42% of 28 kDNA-PCR tests. Ten GPM tests used in-house (IH) PCR mixtures and 10 used commercial master mixes (Kt), representing 35.7% of the 28 IH and 76.9% of the 13 Kt PCR reagent mixes. In addition, 12 GPM used conventional amplification and eight used real time PCR (C and RT in Table 2), representing 38.7% of 31 C and 72.7% of 11 RT tests. These data showed that commercial master mixes and real time PCR offered better PCR performance in purified DNA samples.
Analysis of Set B
Out of the 44 PCR tests reported for spiked Guanidine Hidrochloride-EDTA blood samples, the three tests targeting sequences other than Sat-DNA or kDNA were not further analyzed, because they failed to detect the most concentrated sample (S1 and S3 tests) or showed false positive findings in the non-spiked control (U2 test) (Set B, Table 2).
Twenty five out of 41 PCR tests based on kDNA and Sat-DNA sequences showed specific, coherent results and detection limits of at least 5 par/ml (GPM, bold fonts, Table 2, Set B). They included 14 kDNA and 11 Sat-DNA PCR tests, representing 50% of 28 kDNA and 84.6% of 13 Sat-DNA based tests. Ten GPM used in-house extraction methods and 15 used DNA extraction kits, representing 41.6% of 24 IH and 62.5% of 24 Kt tests. Thus, methods using commercial DNA extraction and Sat-DNA as amplification target resulted in better performance. Procedures based on kDNA presented more variation in sensitivity than Sat-DNA tests (Figure 1C, white bars). The smallest detected concentration was 5×10−3 par/ml, recorded by three laboratories using conventional kDNA-PCR after DNA extractions with Chelex resine, a blood extraction kit or solvent extraction with Phenol (LbE, LbL1 and LbW, respectively, Table 1). Tests based on Sat-DNA presented sensitivities between 0.05 and 0.5 par/ml (10/11 tests, Figure 1C, black bars) with the only exception of one test based on solvent DNA extraction and IH conventional Sat-DNA PCR (C2, Table 1) that reached a detection limit of 5×10−5 par/mL (Table 2, and Figure 1C).
Analysis of Set C
Out of the 44 PCR tests performed on clinical samples of Set C, a 18s-rDNA PCR (S3) and a SL-DNA PCR (C6) tests did not detect any positive sample and the 24s α rDNA-PCR test (U2) had only 40% of specificity. Consequently, they were not included for subsequent analysis. The levels of agreement among the 41 remaining PCR tests on the reports for each clinical sample are presented in Table 3. For each sample, 3 series of consensus PCR results were calculated: 1) consensus based on the 28 kDNA-PCR tests, 2) consensus based on the 13 Sat-DNA PCR tests and 3) consensus based on the 16 tests defined as GPM in both sets A and B samples. The sensitivity of consensus kDNA-PCR was 65.62% (21 PCR positive/32 seropositive samples), that of consensus Sat-DNA was 62.5% (20 PCR positive/32 seropositive samples) and that of consensus GPM was 56.25% (B (18 PCR positive/32 seropositive samples) being 4 samples indeterminate (13, 18, 20, 21, Table 3) because the levels of agreement among GPM tests was 50%.
The individual performance of the 41 PCR tests was evaluated in comparison with the consensus PCR results reached by the 16 GPM in sets A and B (18 PCR positive, 20 PCR negative samples) and in comparison with serologic diagnosis (10 seronegative, 32 seropositive samples) (Table 4). There was a high variability among the performances of the different methods (Table 4). The median values of sensitivity, specificity and accuracy of the 41 tests were 72, 77.5 and 68.4%, respectively in comparison to consensus GPM PCR reports, and 59.4, 70 and 59.5%, respectively in comparison to serological diagnosis (Table 4).
Best Performing Methods
Four GPM showed the best operational parameters in set C (Table 4). Tests LbD2 and LbD3 used solvent DNA extraction followed by conventional hot-start and Real time PCR targeted to Sat-DNA, respectively (primer pairs TCZ-F/TCZ-R). Test LbF1 used a commercial kit for DNA extraction based on glass fiber columns and Real Time PCR targeted to Sat-DNA (primer pairs cruzi 1/cruzi 2 and TaqMan probe cruzi 3) and test LbQ used solvent DNA extraction and conventional hot-start PCR for kDNA (primer pairs 121/122).
The performance of these four tests was further evaluated at the coordinating laboratory on a subset of samples from seropositive and seronegative patients, analysed in four independent experiments (Table 5). Examples of the outputs of each method are shown in Figure 2. The degree of concordance among the reported results by the BPM was between 87.5% and 90.62%. This intralaboratory evaluation showed that the selected methods depicted similar operational parameters than when performed by the corresponding laboratories in the international study (Tables 4 and 6).
A. LbD2 ; B.LbD3, C. LbF1 and D. LbQ. The methods are described in Materials and Methods and Table 1. 6, 15: seropositive samples; 35; seronegative sample (Table 3). PC: Positive control: 10 fg/µl of T.cruzi VI. NC. Negative Control: Master Mixes devoid of DNA.
PCR technology has been widely used for the diagnosis and monitoring of disease progression and therapy outcome in many infectious diseases . Since 1989, PCR strategies have been developed aiming to analyse clinical samples infected with T. cruzi , . However, each laboratory has applied its own protocols and quality controls, making comparison of PCR based findings among different research groups and geographical regions not reliable. This international collaborative study is a crucial first step aiming at the evaluation of currently used PCR procedures for detection of T. cruzi infection, towards the assessment of a standard operative procedure.
Out of the 48 PCR tests reported by 26 laboratories, those targeting ribosomal, miniexon or CO II subunit gene sequences were not sensitive enough when challenged against 10 fg/µl or less of purified DNA from the 3 tested parasite stocks, to merit further consideration. Thus, these methods appeared not suitable for sensitive molecular diagnosis of Chagas disease in clinical settings. However, these parasitic targets are been widely used for genotyping parasite discrete typing units –, –, mitochondrial gene haplotypes  or miniexon based T. cruzi I genotypes –. In this regard, multicentric evaluation and standardization of PCR based genotyping methods for identification of T. cruzi DTUs is needed.
PCR Performance in Set A Samples
In set A, GPM included kDNA and sat-DNA PCR tests in similar proportions. However, Sat-DNA PCR tests were less sensitive than kDNA-PCR tests to detect T. cruzi I DNA. This is most likely due to the fact that T. cruzi DTU I harbors approximately four to ten-fold less number of satellite repeats than DTUs II, V and VI, which has been demonstrated by different molecular approaches , .
Regarding T. cruzi IV that also harbors a lower dosage for satellite sequences , similar analytical sensitivities of kDNA and Sat-DNA PCR tests were observed, being lower than that obtained for the other two tested DTU representative stocks. The genome size and relative DNA contents of Can III cl1 (116.44 Mb, 95% CI 110.4–122.63 and 1.090, respectively) and CL Brener (108.55 Mb, 95% CI 101.41–115.89 and 1.017) are similar , although Can III cl1 harbors about 5 fold less satellite repeats than CL-Brener . The relative contribution of the nucleus and kinetoplast has not been measured but normally, kDNA represents 20–25% of the total DNA content . There are no available data regarding the number of minicircles in the kinetoplast of Can III cl1, so it could be speculated that the lower analytical sensitivity of most PCR tests to detect DNA from this clone respect to the other ones, could be due to a lower minicircle copy dosage.
PCR Performance in Set B Samples
Set B allowed evaluation of the influence of DNA extraction procedures in the PCR performance. A 72.2% of DNA extraction methods based on commercial kits led to GPM in set B, whereas 57.8% of phenol-chlorophorm extracted DNA led to GPM reports. These findings indicated that Guanidine Hidrochloride-EDTA blood was suitable for DNA extraction using kits based on lysis buffers containing Guanidine salts.
Out of the 25 GPM in set B, 14 had a sensitivity of 0.05 par/ml, which should be adequate for diagnosis of infection in chronic patients . Indeed, the necessary detection limit in chronic Chagas disease has been stated as one parasite cell in 10 mL of blood .
PCR Performance in Set C Samples
Analysis of PCR performance in set C clinical samples showed that the four best performing tests presented strong concordance with respect to consensus PCR results obtained by the 16 tests defined as GPM in sets A plus B (kappa index between 0.7 and 0.8). Out of them, three tests targeted sat-DNA sequences and only one targeted kDNA. These data are in agreement with previous works showing that PCRs targeting Sat-DNA performed better than PCRs targeting kDNA sequences –, although kDNA based PCR has been more widely used .
Moreover, two of the sat-DNA best performing tests used Real Time PCR, one with a Sybr Green fluorescent dye (LbD2) and the other one with a TaqMan probe (LbF1). It must be pointed out that LbD2 and LbD3 tests were performed by the same laboratory. Out of the 16 GPM performed by 11 different laboratories, 3 laboratories performed two methods (LbD, LbK and LbP) and one lab developed 3 tests (LbG). These data point to laboratory dependence concerning PCR performance, which may be due to multiple factors including technical expertise, correct use of quality controls, instrumentation and reagents. For example, tests LbF1, LbS2 (GPM) and LbZ (not GPM) were all based on sat-DNA Real Time PCR using the same primer pair (cruzi 1 – cruzi 2), differing in the trade marks of the DNA extraction and Master Mix kits. Some tests shown as GPM in sets A+B had very low sensitivities in set C (LbK2, LbP2, LbV1, Table 4), suggesting that quality controls might have failed to distinguish false negative clinical samples.
A major drawback of most PCR tests is that they do not contain an internal amplification control (IAC). An IAC is a non target DNA sequence present in the same sample reaction tube, which is co-amplified simultaneously with the target sequence . In a PCR without an IAC, a negative result can indicate that the reaction was inhibited, as a result of the presence of inhibitory substances in the sample matrix. The presence of PCR inhibition in Guanidine Hidrochloride-EDTA treated blood samples has been described . The European Standardization Committee (CEN), in collaboration with International Standard Organization (ISO) has proposed a general guideline for PCR testing that requires the presence of IAC in the reaction mixture . Therefore, only IAC-containing PCRs should undergo multicentre collaborative trials, which is a prerequisite for validation.
Some other tests shown as GPM in sets A+B had very low specificities (LbI2, LbW, LbG2, LbG3, Table 4). Amplicon carry-over contamination is one of the most probable causes. PCR master mixes with dUTP and Uracil-DNA N-glycosylase (UNG) intended to abolish amplicon carry-over contamination were used in some tests (LbF, LbG, LbL, LbS, Table 1). Nevertheless, some of them did not show good specificity in set C (LbG2, LbG3, LbG4, LbL1, LbL2, Table 4), suggesting that problems during sample processing, such as sample to sample contamination could have arisen. The median values of the sensitivities obtained in testing the Set C samples with the 16 tests determined to be GPMs by testing the Set A and Set B samples varied considerably depending on the clinical characteristics of the persons from whom the Set C samples were drawn. Indeed, sensitivity was 100% (25-75p = 100−100) for immunosuppressed heart transplanted pts, 56.5% (25-75p = 39.1–66.3%) for asymptomatic and 57.1% (25-75p = 14–75%) for symptomatic chronic Chagas disease patients. These data point to the limitations of PCR strategies for diagnosis of patients at the chronic phase of disease. In addition, some of these samples had been stored at 4°C for at least two years before this PCR study; thus higher PCR positivity might be obtained in prospective clinical studies but it is unlikely that the current PCR methods will have a sensitivity comparable to serological assays for diagnosis of chronic Chagas disease.
The four BPM methods were transferred to the Coordinating laboratory, where they were evaluated in a subset of clinical samples, each one tested in four independent assays, obtaining good concordance and confirming the performance reported by the participating laboratories in the previous international study (Tables 5 and 6). Further work is still needed to validate them through prospective studies in different settings. In this regard, this collaborative evaluation constitutes a starting point towards technical improvement and development of an international standard operating procedure (SOP) for T.cruzi PCR. In this context, the BPMs could be recommended for alternative diagnostic support, such as in the following settings: a) post-treatment follow-up of patients to look for failure of therapy to achieve parasitologic response , –, , ; b) diagnosis of congenital Chagas disease in newborns in whom the presence of maternal anti-T. cruzi antibodies make serological studies useless , , ; c) early diagnosis of reactivation after organ transplantation of T.cruzi infected recipients under immunosuppressive therapy , , d) differential diagnosis of Chagas reactivation in patients with AIDS , and e) suspicion of oral transmission . Moreover it can be useful for post-treatment follow-up of experimental animals to look for failure of therapy to achieve parasitologic cure ; in diagnosis in naturally infected triatomines or triatomines used for xenodiagnosis, since it has been shown that PCR tests are much more sensitive than microscopic examination of intestinal contents , ; and diagnosis of T. cruzi infection in mammalian reservoirs for which serologic tools have not been developed .
We thank the collaboration of Sonia O. Lafon, linked to logistic work and delivery of sample panels to the participating laboratories.
This article is dedicated to the memory of Dr Mariano J. Levin, head of LabMECh, INGEBI-CONICET, died on February 28th, 2010, who dedicated his life to scientific research in Chagas disease and supported with great commitment and passion this collaborative work.
Conceived and designed the experiments: AGS MB LO MS TD FG SSE CB AL JL. Performed the experiments: MB TD AMMJ CC FA VV YQ SD GH IZ RHL EV TT ZSL LG DN MMR JEL JDR PZ MF MIJ GC CB. Analyzed the data: AGS MB LO MS TD AMMJ CC YQ SD GH IZ RHL EV TT ZSL LG DN MMR JEL JDR MF MIJ GC NA AMDC CIG KAV PY FT CR PD OTC CA GR PB AA FG AD CB AL. Contributed reagents/materials/analysis tools: AGS GH RHL AA AD AL JL. Wrote the paper: AGS MB LO MS TD SD CA PB CB AL. Organized and coordinated the multicentric study: AGS.
- 1. Chagas C (1909) Nova trypanossomiase humana. Estudos sobre a morfologia e o ciclo evolutivo do Schizotripanum cruzi n. gen., n. sp., agente etiológico de nova entidade mórbida do homem. Mem Inst Oswaldo Cruz 1: 159–218.C. Chagas1909Nova trypanossomiase humana. Estudos sobre a morfologia e o ciclo evolutivo do Schizotripanum cruzi n. gen., n. sp., agente etiológico de nova entidade mórbida do homem.Mem Inst Oswaldo Cruz1159218
- 2. WHO (2007) Reporte del grupo de trabajo científico sobre la enfermedad de Chagas. 96 p.WHO2007Reporte del grupo de trabajo científico sobre la enfermedad de Chagas.TDR/GTC/06 World Health Organization. 96 TDR/GTC/06 World Health Organization.
- 3. Coura JR, Dias JC (2009) Epidemiology, control and surveillance of Chagas disease: 100 years after its discovery. Mem Inst Oswaldo Cruz 104: Suppl 131–40.JR CouraJC Dias2009Epidemiology, control and surveillance of Chagas disease: 100 years after its discovery.Mem Inst Oswaldo Cruz104Suppl 13140
- 4. Brener Z (1962) Therapeutic activity and criterion of cure on mice experimentally infected with Trypanosoma cruzi. Rev Inst Med Trop Sao Paulo 4: 389–396.Z. Brener1962Therapeutic activity and criterion of cure on mice experimentally infected with Trypanosoma cruzi.Rev Inst Med Trop Sao Paulo4389396
- 5. Portela-Lindoso AA, Shikanai-Yasuda MA (2003) [Chronic Chagas' disease: from xenodiagnosis and hemoculture to polymerase chain reaction]. Rev Saude Publica 37: 107–115.AA Portela-LindosoMA Shikanai-Yasuda2003[Chronic Chagas' disease: from xenodiagnosis and hemoculture to polymerase chain reaction].Rev Saude Publica37107115
- 6. Gomes YM, Lorena VM, Luquetti AO (2009) Diagnosis of Chagas disease: what has been achieved? What remains to be done with regard to diagnosis and follow up studies? Mem Inst Oswaldo Cruz 104: Suppl 1115–121.YM GomesVM LorenaAO Luquetti2009Diagnosis of Chagas disease: what has been achieved? What remains to be done with regard to diagnosis and follow up studies?Mem Inst Oswaldo Cruz104Suppl 1115121
- 7. Moser DR, Kirchhoff LV, Donelson JE (1989) Detection of Trypanosoma cruzi by DNA amplification using the polymerase chain reaction. J Clin Microbiol 27: 1477–1482.DR MoserLV KirchhoffJE Donelson1989Detection of Trypanosoma cruzi by DNA amplification using the polymerase chain reaction.J Clin Microbiol2714771482
- 8. Avila HA, Pereira JB, Thiemann O, De Paiva E, DeGrave W, et al. (1993) Detection of Trypanosoma cruzi in blood specimens of chronic chagasic patients by polymerase chain reaction amplification of kinetoplast minicircle DNA: comparison with serology and xenodiagnosis. J Clin Microbiol 31: 2421–2426.HA AvilaJB PereiraO. ThiemannE. De PaivaW. DeGrave1993Detection of Trypanosoma cruzi in blood specimens of chronic chagasic patients by polymerase chain reaction amplification of kinetoplast minicircle DNA: comparison with serology and xenodiagnosis.J Clin Microbiol3124212426
- 9. Britto C, Cardoso MA, Vanni CM, Hasslocher-Moreno A, Xavier SS, et al. (1995) Polymerase chain reaction detection of Trypanosoma cruzi in human blood samples as a tool for diagnosis and treatment evaluation. Parasitology 110(Pt 3): 241–247.C. BrittoMA CardosoCM VanniA. Hasslocher-MorenoSS Xavier1995Polymerase chain reaction detection of Trypanosoma cruzi in human blood samples as a tool for diagnosis and treatment evaluation.Parasitology110Pt 3241247
- 10. Wincker P, Telleria J, Bosseno MF, Cardoso MA, Marques P, et al. (1997) PCR-based diagnosis for Chagas' disease in Bolivian children living in an active transmission area: comparison with conventional serological and parasitological diagnosis. Parasitology 114(Pt 4): 367–373.P. WinckerJ. TelleriaMF BossenoMA CardosoP. Marques1997PCR-based diagnosis for Chagas' disease in Bolivian children living in an active transmission area: comparison with conventional serological and parasitological diagnosis.Parasitology114Pt 4367373
- 11. Russomando G, de Tomassone MM, de Guillen I, Acosta N, Vera N, et al. (1998) Treatment of congenital Chagas' disease diagnosed and followed up by the polymerase chain reaction. Am J Trop Med Hyg 59: 487–491.G. RussomandoMM de TomassoneI. de GuillenN. AcostaN. Vera1998Treatment of congenital Chagas' disease diagnosed and followed up by the polymerase chain reaction.Am J Trop Med Hyg59487491
- 12. Solari A, Ortiz S, Soto A, Arancibia C, Campillay R, et al. (2001) Treatment of Trypanosoma cruzi-infected children with nifurtimox: a 3 year follow-up by PCR. J Antimicrob Chemother 48: 515–519.A. SolariS. OrtizA. SotoC. ArancibiaR. Campillay2001Treatment of Trypanosoma cruzi-infected children with nifurtimox: a 3 year follow-up by PCR.J Antimicrob Chemother48515519
- 13. Castro AM, Luquetti AO, Rassi A, Rassi GG, Chiari E, et al. (2002) Blood culture and polymerase chain reaction for the diagnosis of the chronic phase of human infection with Trypanosoma cruzi. Parasitol Res 88: 894–900.AM CastroAO LuquettiA. RassiGG RassiE. Chiari2002Blood culture and polymerase chain reaction for the diagnosis of the chronic phase of human infection with Trypanosoma cruzi.Parasitol Res88894900
- 14. Galvao LM, Chiari E, Macedo AM, Luquetti AO, Silva SA, et al. (2003) PCR assay for monitoring Trypanosoma cruzi parasitemia in childhood after specific chemotherapy. J Clin Microbiol 41: 5066–5070.LM GalvaoE. ChiariAM MacedoAO LuquettiSA Silva2003PCR assay for monitoring Trypanosoma cruzi parasitemia in childhood after specific chemotherapy.J Clin Microbiol4150665070
- 15. Schijman AG, Altcheh J, Burgos JM, Biancardi M, Bisio M, et al. (2003) Aetiological treatment of congenital Chagas' disease diagnosed and monitored by the polymerase chain reaction. J Antimicrob Chemother 52: 441–449.AG SchijmanJ. AltchehJM BurgosM. BiancardiM. Bisio2003Aetiological treatment of congenital Chagas' disease diagnosed and monitored by the polymerase chain reaction.J Antimicrob Chemother52441449
- 16. Zulantay I, Honores P, Solari A, Apt W, Ortiz S, et al. (2004) Use of polymerase chain reaction (PCR) and hybridization assays to detect Trypanosoma cruzi in chronic chagasic patients treated with itraconazole or allopurinol. Diagn Microbiol Infect Dis 48: 253–257.I. ZulantayP. HonoresA. SolariW. AptS. Ortiz2004Use of polymerase chain reaction (PCR) and hybridization assays to detect Trypanosoma cruzi in chronic chagasic patients treated with itraconazole or allopurinol.Diagn Microbiol Infect Dis48253257
- 17. Claes F, Deborggraeve S, Verloo D, Mertens P, Crowther JR, et al. (2007) Validation of a PCR-oligochromatography test for detection of Trypanozoon parasites in a multicenter collaborative trial. J Clin Microbiol 45: 3785–3787.F. ClaesS. DeborggraeveD. VerlooP. MertensJR Crowther2007Validation of a PCR-oligochromatography test for detection of Trypanozoon parasites in a multicenter collaborative trial.J Clin Microbiol4537853787
- 18. Diez M, Favaloro L, Bertolotti A, Burgos JM, Vigliano C, et al. (2007) Usefulness of PCR strategies for early diagnosis of Chagas' disease reactivation and treatment follow-up in heart transplantation. Am J Transplant 7: 1633–1640.M. DiezL. FavaloroA. BertolottiJM BurgosC. Vigliano2007Usefulness of PCR strategies for early diagnosis of Chagas' disease reactivation and treatment follow-up in heart transplantation.Am J Transplant716331640
- 19. Piron M, Fisa R, Casamitjana N, Lopez-Chejade P, Puig L, et al. (2007) Development of a real-time PCR assay for Trypanosoma cruzi detection in blood samples. Acta Trop 103: 195–200.M. PironR. FisaN. CasamitjanaP. Lopez-ChejadeL. Puig2007Development of a real-time PCR assay for Trypanosoma cruzi detection in blood samples.Acta Trop103195200
- 20. Britto CC (2009) Usefulness of PCR-based assays to assess drug efficacy in Chagas disease chemotherapy: value and limitations. Mem Inst Oswaldo Cruz 104: Suppl 1122–135.CC Britto2009Usefulness of PCR-based assays to assess drug efficacy in Chagas disease chemotherapy: value and limitations.Mem Inst Oswaldo Cruz104Suppl 1122135
- 21. Deborggraeve S, Coronado X, Solari A, Zulantay I, Apt W, et al. (2009) T. cruzi OligoC-TesT: a simplified and standardized polymerase chain reaction format for diagnosis of Chagas disease. PLoS Negl Trop Dis 3: e450.S. DeborggraeveX. CoronadoA. SolariI. ZulantayW. Apt2009T. cruzi OligoC-TesT: a simplified and standardized polymerase chain reaction format for diagnosis of Chagas disease.PLoS Negl Trop Dis3e450
- 22. Duffy T, Bisio M, Altcheh J, Burgos JM, Diez M, et al. (2009) Accurate real-time PCR strategy for monitoring bloodstream parasitic loads in chagas disease patients. PLoS Negl Trop Dis 3: e419.T. DuffyM. BisioJ. AltchehJM BurgosM. Diez2009Accurate real-time PCR strategy for monitoring bloodstream parasitic loads in chagas disease patients.PLoS Negl Trop Dis3e419
- 23. Zingales B, Andrade SG, Briones MR, Campbell DA, Chiari E, et al. (2009) A new consensus for Trypanosoma cruzi intraspecific nomenclature: second revision meeting recommends TcI to TcVI. Mem Inst Oswaldo Cruz 104: 1051–1054.B. ZingalesSG AndradeMR BrionesDA CampbellE. Chiari2009A new consensus for Trypanosoma cruzi intraspecific nomenclature: second revision meeting recommends TcI to TcVI.Mem Inst Oswaldo Cruz10410511054
- 24. Vargas N, Pedroso A, Zingales B (2004) Chromosomal polymorphism, gene synteny and genome size in T. cruzi I and T. cruzi II groups. Mol Biochem Parasitol 138: 131–141.N. VargasA. PedrosoB. Zingales2004Chromosomal polymorphism, gene synteny and genome size in T. cruzi I and T. cruzi II groups.Mol Biochem Parasitol138131141
- 25. Lewis MD, Llewellyn MS, Gaunt MW, Yeo M, Carrasco HJ, et al. (2009) Flow cytometric analysis and microsatellite genotyping reveal extensive DNA content variation in Trypanosoma cruzi populations and expose contrasts between natural and experimental hybrids. Int J Parasitol 39: 1305–1317.MD LewisMS LlewellynMW GauntM. YeoHJ Carrasco2009Flow cytometric analysis and microsatellite genotyping reveal extensive DNA content variation in Trypanosoma cruzi populations and expose contrasts between natural and experimental hybrids.Int J Parasitol3913051317
- 26. Telleria J, Lafay B, Virreira M, Barnabe C, Tibayrenc M, et al. (2006) Trypanosoma cruzi: sequence analysis of the variable region of kinetoplast minicircles. Exp Parasitol 114: 279–288.J. TelleriaB. LafayM. VirreiraC. BarnabeM. Tibayrenc2006Trypanosoma cruzi: sequence analysis of the variable region of kinetoplast minicircles.Exp Parasitol114279288
- 27. Ienne S, Pedroso A, Carmona EFR, Briones MR, Zingales B (2010) Network genealogy of 195-bp satellite DNA supports the superimposed hybridization hypothesis of Trypanosoma cruzi evolutionary pattern. Infect Genet Evol 10: 601–606.S. IenneA. PedrosoEFR CarmonaMR BrionesB. Zingales2010Network genealogy of 195-bp satellite DNA supports the superimposed hybridization hypothesis of Trypanosoma cruzi evolutionary pattern.Infect Genet Evol10601606
- 28. Ehrlich G, Greenberg S (1994) PCR-Based Diagnostics for Infectious Disease. Boston: Blackwell Scientific Publications. 698 p.G. EhrlichS. Greenberg1994PCR-Based Diagnostics for Infectious Disease.BostonBlackwell Scientific Publications698
- 29. Brisse S, Verhoef J, Tibayrenc M (2001) Characterisation of large and small subunit rRNA and mini-exon genes further supports the distinction of six Trypanosoma cruzi lineages. Int J Parasitol 31: 1218–1226.S. BrisseJ. VerhoefM. Tibayrenc2001Characterisation of large and small subunit rRNA and mini-exon genes further supports the distinction of six Trypanosoma cruzi lineages.Int J Parasitol3112181226
- 30. Burgos JM, Altcheh J, Bisio M, Duffy T, Valadares HM, et al. (2007) Direct molecular profiling of minicircle signatures and lineages of Trypanosoma cruzi bloodstream populations causing congenital Chagas disease. Int J Parasitol 37: 1319–1327.JM BurgosJ. AltchehM. BisioT. DuffyHM Valadares2007Direct molecular profiling of minicircle signatures and lineages of Trypanosoma cruzi bloodstream populations causing congenital Chagas disease.Int J Parasitol3713191327
- 31. Sambrook J, Russell D, editors. (2001) Molecular cloning: A Laboratory Manual. New York: Cold Spring Harbor Laboratory Press. J. SambrookD. Russell2001Molecular cloning: A Laboratory Manual.New YorkCold Spring Harbor Laboratory Press
- 32. Avila HA, Sigman DS, Cohen LM, Millikan RC, Simpson L (1991) Polymerase chain reaction amplification of Trypanosoma cruzi kinetoplast minicircle DNA isolated from whole blood lysates: diagnosis of chronic Chagas' disease. Mol Biochem Parasitol 48: 211–221.HA AvilaDS SigmanLM CohenRC MillikanL. Simpson1991Polymerase chain reaction amplification of Trypanosoma cruzi kinetoplast minicircle DNA isolated from whole blood lysates: diagnosis of chronic Chagas' disease.Mol Biochem Parasitol48211221
- 33. Britto C, Cardoso MA, Wincker P, Morel CM (1993) A simple protocol for the physical cleavage of Trypanosoma cruzi kinetoplast DNA present in blood samples and its use in polymerase chain reaction (PCR)-based diagnosis of chronic Chagas disease. Mem Inst Oswaldo Cruz 88: 171–172.C. BrittoMA CardosoP. WinckerCM Morel1993A simple protocol for the physical cleavage of Trypanosoma cruzi kinetoplast DNA present in blood samples and its use in polymerase chain reaction (PCR)-based diagnosis of chronic Chagas disease.Mem Inst Oswaldo Cruz88171172
- 34. Taha MK, Alonso JM, Cafferkey M, Caugant DA, Clarke SC, et al. (2005) Interlaboratory comparison of PCR-based identification and genogrouping of Neisseria meningitidis. J Clin Microbiol 43: 144–149.MK TahaJM AlonsoM. CafferkeyDA CaugantSC Clarke2005Interlaboratory comparison of PCR-based identification and genogrouping of Neisseria meningitidis.J Clin Microbiol43144149
- 35. Malorny B, Hoorfar J, Bunge C, Helmuth R (2003) Multicenter validation of the analytical accuracy of Salmonella PCR: towards an international standard. Appl Environ Microbiol 69: 290–296.B. MalornyJ. HoorfarC. BungeR. Helmuth2003Multicenter validation of the analytical accuracy of Salmonella PCR: towards an international standard.Appl Environ Microbiol69290296
- 36. Sturm NR, Degrave W, Morel C, Simpson L (1989) Sensitive detection and schizodeme classification of Trypanosoma cruzi cells by amplification of kinetoplast minicircle DNA sequences: use in diagnosis of Chagas' disease. Mol Biochem Parasitol 33: 205–214.NR SturmW. DegraveC. MorelL. Simpson1989Sensitive detection and schizodeme classification of Trypanosoma cruzi cells by amplification of kinetoplast minicircle DNA sequences: use in diagnosis of Chagas' disease.Mol Biochem Parasitol33205214
- 37. Marcet PL, Duffy T, Cardinal MV, Burgos JM, Lauricella MA, et al. (2006) PCR-based screening and lineage identification of Trypanosoma cruzi directly from faecal samples of triatomine bugs from northwestern Argentina. Parasitology 132: 57–65.PL MarcetT. DuffyMV CardinalJM BurgosMA Lauricella2006PCR-based screening and lineage identification of Trypanosoma cruzi directly from faecal samples of triatomine bugs from northwestern Argentina.Parasitology1325765
- 38. Cardinal MV, Lauricella MA, Ceballos LA, Lanati L, Marcet PL, et al. (2008) Molecular epidemiology of domestic and sylvatic Trypanosoma cruzi infection in rural northwestern Argentina. Int J Parasitol. MV CardinalMA LauricellaLA CeballosL. LanatiPL Marcet2008Molecular epidemiology of domestic and sylvatic Trypanosoma cruzi infection in rural northwestern Argentina.Int J Parasitol
- 39. Bisio M, Cura C, Duffy T, Altcheh J, Giganti SO, et al. (2009) Trypanosoma cruzi discrete typing units in Chagas disease patients with HIV co-infection. Rev Biomed 20: 166–178.M. BisioC. CuraT. DuffyJ. AltchehSO Giganti2009Trypanosoma cruzi discrete typing units in Chagas disease patients with HIV co-infection.Rev Biomed20166178
- 40. Lewis MD, Ma J, Yeo M, Carrasco HJ, Llewellyn MS, et al. (2009) Genotyping of Trypanosoma cruzi: systematic selection of assays allowing rapid and accurate discrimination of all known lineages. Am J Trop Med Hyg 81: 1041–1049.MD LewisJ. MaM. YeoHJ CarrascoMS Llewellyn2009Genotyping of Trypanosoma cruzi: systematic selection of assays allowing rapid and accurate discrimination of all known lineages.Am J Trop Med Hyg8110411049
- 41. Burgos JM, Diez M, Vigliano C, Bisio M, Risso M, et al. (2010) Molecular identification of Trypanosoma cruzi discrete typing units in end-stage chronic Chagas heart disease and reactivation after heart transplantation. Clin Infect Dis 51: 485–495.JM BurgosM. DiezC. ViglianoM. BisioM. Risso2010Molecular identification of Trypanosoma cruzi discrete typing units in end-stage chronic Chagas heart disease and reactivation after heart transplantation.Clin Infect Dis51485495
- 42. de Freitas JM, Augusto-Pinto L, Pimenta JR, Bastos-Rodrigues L, Goncalves VF, et al. (2006) Ancestral genomes, sex, and the population structure of Trypanosoma cruzi. PLoS Pathog 2: e24.JM de FreitasL. Augusto-PintoJR PimentaL. Bastos-RodriguesVF Goncalves2006Ancestral genomes, sex, and the population structure of Trypanosoma cruzi.PLoS Pathog2e24
- 43. Herrera C, Bargues MD, Fajardo A, Montilla M, Triana O, et al. (2007) Identifying four Trypanosoma cruzi I isolate haplotypes from different geographic regions in Colombia. Infect Genet Evol 7: 535–539.C. HerreraMD BarguesA. FajardoM. MontillaO. Triana2007Identifying four Trypanosoma cruzi I isolate haplotypes from different geographic regions in Colombia.Infect Genet Evol7535539
- 44. Cura CI, Mejia-Jaramillo AM, Duffy T, Burgos JM, Rodriguero M, et al. (2010) Trypanosoma cruzi I genotypes in different geographical regions and transmission cycles based on a microsatellite motif of the intergenic spacer of spliced-leader genes. Int J Parasitol. CI CuraAM Mejia-JaramilloT. DuffyJM BurgosM. Rodriguero2010Trypanosoma cruzi I genotypes in different geographical regions and transmission cycles based on a microsatellite motif of the intergenic spacer of spliced-leader genes.Int J Parasitol
- 45. Elias MC, Vargas NS, Zingales B, Schenkman S (2003) Organization of satellite DNA in the genome of Trypanosoma cruzi. Mol Biochem Parasitol 129: 1–9.MC EliasNS VargasB. ZingalesS. Schenkman2003Organization of satellite DNA in the genome of Trypanosoma cruzi.Mol Biochem Parasitol12919
- 46. de Souza W (2003) Novel cell biology of Trypanosoma cruzi. In: Tyler KM, Miles MA, editors. American Trypanosomiasis. Boston: Springer. pp. 13–24.W. de Souza2003Novel cell biology of Trypanosoma cruzi.KM TylerMA MilesAmerican TrypanosomiasisBostonSpringer1324
- 47. Kirchhoff LV, Votava JR, Ochs DE, Moser DR (1996) Comparison of PCR and microscopic methods for detecting Trypanosoma cruzi. J Clin Microbiol 34: 1171–1175.LV KirchhoffJR VotavaDE OchsDR Moser1996Comparison of PCR and microscopic methods for detecting Trypanosoma cruzi.J Clin Microbiol3411711175
- 48. Virreira M, Torrico F, Truyens C, Alonso-Vega C, Solano M, et al. (2003) Comparison of polymerase chain reaction methods for reliable and easy detection of congenital Trypanosoma cruzi infection. Am J Trop Med Hyg 68: 574–582.M. VirreiraF. TorricoC. TruyensC. Alonso-VegaM. Solano2003Comparison of polymerase chain reaction methods for reliable and easy detection of congenital Trypanosoma cruzi infection.Am J Trop Med Hyg68574582
- 49. Ramirez JD, Guhl F, Umezawa ES, Morillo CA, Rosas F, et al. (2009) Evaluation of adult chronic Chagas' heart disease diagnosis by molecular and serological methods. J Clin Microbiol 47: 3945–3951.JD RamirezF. GuhlES UmezawaCA MorilloF. Rosas2009Evaluation of adult chronic Chagas' heart disease diagnosis by molecular and serological methods.J Clin Microbiol4739453951
- 50. Hoorfar J, Cook N, Malorny B, Wagner M, De Medici D, et al. (2004) Diagnostic PCR: making internal amplification control mandatory. Lett Appl Microbiol 38: 79–80.J. HoorfarN. CookB. MalornyM. WagnerD. De Medici2004Diagnostic PCR: making internal amplification control mandatory.Lett Appl Microbiol387980
- 51. Anonymous (2002b) Microbiology of Food and Animal Feeding Stuffs –Polymerase Chain Reaction (PCR) for the Detection of Foodborne Pathogens – General Method Specific Requirements. Anonymous2002bMicrobiology of Food and Animal Feeding Stuffs –Polymerase Chain Reaction (PCR) for the Detection of Foodborne Pathogens – General Method Specific Requirements.Draft International Standard ISO/DIS 22174. Berlin, Germany. Draft International Standard ISO/DIS 22174. Berlin, Germany.
- 52. Alarcon de Noya B, Diaz-Bello Z, Colmenares C, Ruiz-Guevara R, Mauriello L, et al. (2010) Large urban outbreak of orally acquired acute Chagas disease at a school in Caracas, Venezuela. J Infect Dis 201: 1308–1315.B. Alarcon de NoyaZ. Diaz-BelloC. ColmenaresR. Ruiz-GuevaraL. Mauriello2010Large urban outbreak of orally acquired acute Chagas disease at a school in Caracas, Venezuela.J Infect Dis20113081315
- 53. Miyamoto CT, Gomes ML, Marangon AV, de Araujo SM, Bahia MT, et al. (2008) Usefulness of the polymerase chain reaction for monitoring cure of mice infected with different Trypanosoma cruzi clonal genotypes following treatment with benznidazole. Exp Parasitol 120: 45–49.CT MiyamotoML GomesAV MarangonSM de AraujoMT Bahia2008Usefulness of the polymerase chain reaction for monitoring cure of mice infected with different Trypanosoma cruzi clonal genotypes following treatment with benznidazole.Exp Parasitol1204549
- 54. Zulantay I, Apt W, Gil LC, Rocha C, Mundaca K, et al. (2007) The PCR-based detection of Trypanosoma cruzi in the faeces of Triatoma infestans fed on patients with chronic American trypanosomiasis gives higher sensitivity and a quicker result than routine xenodiagnosis. Ann Trop Med Parasitol 101: 673–679.I. ZulantayW. AptLC GilC. RochaK. Mundaca2007The PCR-based detection of Trypanosoma cruzi in the faeces of Triatoma infestans fed on patients with chronic American trypanosomiasis gives higher sensitivity and a quicker result than routine xenodiagnosis.Ann Trop Med Parasitol101673679