Diagnostic accuracy of qPCR and microscopy for cutaneous leishmaniasis in rural Ecuador: A Bayesian latent class analysis

BackgroundClinical and laboratory diagnosis of cutaneous leishmaniasis (CL) is hampered by under-ascertainment of direct microscopy.MethodsThis study compared the diagnostic accuracy of qPCR on DNA extracted from filter paper to the accuracy of direct smear slide microscopy in participants presenting with a cutaneous lesion suspected of leishmaniasis to 16 rural healthcare centers in the Ecuadorian Amazon and Pacific regions, from January 2019 to June 2021. We used Bayesian latent class analysis to estimate test sensitivity, specificity, likelihood ratios (LR), and predictive values (PV) with their 95% credible intervals (95%CrI). The impact of sociodemographic and clinical characteristics on predictive values was assessed as a secondary objective.ResultsOf 320 initially included participants, paired valid test results were available and included in the diagnostic accuracy analysis for 129 from the Amazon and 185 from the Pacific region. We estimated sensitivity of 68% (95%CrI 49% to 82%) and 73% (95%CrI 73% to 83%) for qPCR, and 51% (95%CrI 36% to 66%) and 76% (95%CrI 65% to 86%) for microscopy in the Amazon and Pacific region, respectively. In the Amazon, with an estimated disease prevalence among participants of 73%, negative PV for qPCR was 54% (95%CrI 5% to 77%) and 44% (95%CrI 4% to 65%) for microscopy. In the Pacific, (prevalence 88%) the negative PV was 34% (95%CrI 3% to 58%) and 37% (95%CrI 3% to 63%). The addition of qPCR parallel to microscopy in the Amazon increases the observed prevalence from 38% to 64% (+26 (95%CrI 19 to 34) percentage points).ConclusionThe accuracy of either qPCR on DNA extracted from filter paper or microscopy for CL diagnosis as a stand-alone test seems to be unsatisfactory and region-dependent. We recommend further studies to confirm the clinically relevant increment found in the diagnostic yield due to the addition of qPCR. Cutaneous leishmaniasis is caused by the parasite Leishmania and is treated when a microscopy test confirms the presence of the parasite in a sample of the lesion. This test, however, is known to miss patients with cutaneous leishmaniasis. DNA diagnostic tests (like PCR) that detect the parasite's genetic material in the lesion, have been proposed to improve diagnosis. Filter paper preserves DNA at room temperature and allows samples to be transported from remote health centers to the PCR laboratory. The ability of microscopic and DNA testing to recognize leishmaniasis patients in real-life is complex to evaluate. We compared the performance of both tests using a statistical method that can evaluate both tests simultaneously without assuming that either test works perfectly. We found that PCR will be positive 68% of the time in a participant with leishmaniasis in the Amazon and 73% of the time in the Pacific region. In the Amazon, microscopy detects one out of every two cases, while it does in three out of every four cases in the Pacific. The addition of the PCR test can improve the number of participants with a diagnosis of leishmaniasis, mostly in the Amazon region.