Neurological disorder in dairy cattle associated with consumption of beer residues contaminated with Aspergillus clavatus

A neurological syndrome in dairy cattle associated with consumption of moldy beer residues is described. The disease occurred on 1 farm in late June 2001, during winter. Six heifers and 1 cow out of 45 cattle were affected during a 3-week period. The affected animals died spontaneously or were euthanized approximately 2-14 days after the onset of clinical signs. The clinical signs were characterized by flaccid paralysis and gait abnormalities. Clinical signs were more pronounced after exercise and included stiff and unsteady gait, knuckling at the fetlocks of the hind limbs, frequent falling, inability to rise, muscular tremors, especially of the head and the hindquarters, and drooling. Main necropsy findings included degenerative and necrotic changes of the larger medial muscle groups of the hindquarters, i.e., adductor, pectineus, quadriceps femoris, rectus femuris, sartorius, semimembranosus, semitendinosus, and vastus medialis, and of the forequarters, including pectoralis descendens, pectoralis ascendens, and transversus pectoralis. The main histologic findings consisted of degenerative and necrotic neuronal changes (chromatolysis) of varying severity and extent affecting selected nuclei of the brainstem and neurons of the ventral horns of the spinal cord. Similar microscopic lesions were observed in the neurons of the spinal cord of 1 experimental sheep force-fed for 35 days with 1 kg/day of the same batch of foodstuff that was originally fed to the cattle. Coarse white or gray lumps, interpreted as mycelia, were observed in the beer by-product. Aspergillus clavatus was the dominant fungus isolated. Deaths ceased after the consumption of beer residue was discontinued. Recovery from illness was observed in 1 animal. The diagnosis was based on epidemiological data, clinical signs, necropsy findings, histological lesions, dosing trial, and mycology. A similar condition caused by consumption of barley by-products, sprouted wheat, corn sprouts, and beetroot screenings contaminated with A. clavatus has been reported in cattle and sheep worldwide.

Aspergillus fumigatus causes in vitro electrophysiological and morphological modifications in human nasal epithelial cells

The role of the airway epithelium in the development of invasive aspergillosis in immunocompromised hosts has rarely been studied although patients at risk for this infection frequently have epithelial damage. We developed an in vitro model of primary culture of human nasal epithelial cells (HNEC) in air-liquid interface, which allows epithelial cell differentiation and mimics in vivo airway epithelium. We subsequently tested 7-day and 24-hour Aspergillus fumigatus filtrates on the apical side of HNEC to know whether A. fumigatus, the main species responsible for invasive aspergillosis, produces specific damage to the epithelial cells. The results were compared with those obtained with non-pathogenic filamentous fungi. Seven-day culture filtrates of A. fumigatus and Penicillium chrysogenum induced electrophysiological modifications whatever the fungus tested. In contrast, only 24-hour A. fumigatus filtrates induced a specific decrease in transepithelial resistance, hyperpolarization of the epithelium, and cytoplasmic vacuolization of HNEC compared with both A. niger and Penicillium chrysogenum. The inhibition of the A. fumigatus effects with amiloride suggests that the 24-hour fungal filtrate acts through sodium channels of HNEC. These early modifications of the epithelial cells could facilitate colonization of the airways by A. fumigatus. To know whether the molecules involved are specific to A. fumigatus or simply produced more rapidly than by other filamentous fungi warrants further investigation. In this perspective, the primary culture of HNEC represents a suitable model to study the interactions between airway epithelial cells and A. fumigatus.

Intracranial perineural extension of invasive mycosis: a novel mechanism of disease propagation by Aspergillus fumigatus

We describe an immunocompetent woman who had refractory, invasive sphenoid sinus Aspergillus fumigatus infection for which there was radiologic evidence of intracranial perineural spread. The patient responded to a combination of antifungal and adjuvant recombinant cytokine therapy.

Clinical significance of extra-pulmonary involvement of invasive aspergillosis: a retrospective autopsy-based study of 107 patients

Disseminated aspergillus infection has a poor prognosis, but few reports have been published on extra-pulmonary involvement in aspergillosis. We reviewed 107 autopsy records of patients with invasive aspergillosis. Fifty-five patients had extra-pulmonary aspergillosis. Organs involved included heart, kidney, central nervous system, gastrointestinal tract, spleen, liver, thyroid gland and pancreas. Extra-pulmonary aspergillosis produces different manifestations according to involved organs. Risk factors associated with dissemination included cytotoxic chemotherapy within a month of death (P=0.0087). Lack of response to empiric or preemptive treatment of amphotericin B predicted IA dissemination (P=0.0328). To improve prognosis of IA, it is important to recognize clinical features of extra-pulmonary aspergillosis and to institute the aggressive anti-fungal treatment.

Use of real-time PCR on blood samples for diagnosis of invasive aspergillosis

We developed a new quantitative system for diagnosis of invasive pulmonary aspergillosis (IPA) using real-time automated polymerase chain reaction (PCR). Intra-assay and interassay precision rates for in vitro examination were 2.53% and 2.20%, respectively, and the linearity of this assay was obtained when there were >20 copies/well. We examined 323 samples taken from 122 patients with hematological malignancies, including 33 patients with IPA and 89 control patients. Blood samples were subjected to PCR antigen detection methods, using enzyme-linked immunosorbent assay (ELISA) and determination of plasma (1-->3)-beta-D-glucan (BDG) concentration. The sensitivities of PCR, ELISA, and BDG measurement for diagnosis of IPA were 79%, 58%, and 67%, respectively; the specificities were 92%, 97%, and 84%. Positive findings on PCR preceded those of computed tomography by -0.3+/-6.6 days, those of BDG measurement by 6.5+/-4.9 days, and those of ELISA by 2.8+/-4.1 days. Real-time PCR was sensitive for IPA diagnosis, and quantitation was accurate.

Pulmonary aspergillosis

Aspergillus species are ubiquitous in the environment and are inevitably inhaled into the airways. Inhalation of Aspergillus conidia or mycelium fragments may result in colonisation of the airways. In susceptible hosts colonisation may subsequently cause disease. Patients with pre-existent cavities may develop aspergillomas which may be quiescent or cause symptoms especially recurrent haemoptysis. Acute invasive disease is potentially lethal in patients who are vulnerable to infection due to underlying lung diseases or immunosuppression. In addition to its ability to colonise the human respiratory tract, Aspergillus has a significant potential to act as a powerful allergen resulting in Aspergillus asthma and allergic bronchopulmonary aspergillosis. The various presentations of pulmonary disease caused by Aspergillus are reviewed here, focusing primarily on clinical aspects rather than basic science.

Impaired antifungal effector activity but not inflammatory cell recruitment in interleukin-6-deficient mice with invasive pulmonary aspergillosis

A murine model of infection, in which immunocompetent or immunosuppressed interleukin-6-deficient (IL-6(-/-)) mice were infected intranasally with Aspergillus fumigatus conidia and were monitored for parameters of fungal colonization and innate and adaptive immunity, was used to assess the role of IL-6 in invasive pulmonary aspergillosis (IPA). The results indicate that IL-6(-/-) mice were more susceptible than wild-type mice to IPA. Susceptibility was associated with increased inflammatory pathology, decreased antifungal effector functions of phagocytes, and impaired development of protective type 1 responses. Exposure to exogenous IL-6 restored antifungal effector activity.

The pathobiology of Aspergillus fumigatus

Aspergillus fumigatus is the most prevalent airborne fungal pathogen in developed countries, and in immunocompromised patients causes a usually fatal invasive aspergillosis (IA). Understanding the pathobiology of this fungal species requires not only analysis of the putative fungal virulence factors that stimulate fungal growth and/or survival in the lung environment, but also knowledge of the immune factors containing A. fumigatus in the immunocompetent host that can be debilitated by immunosuppressive therapies, triggering IA. Although the incidence of IA has dramatically increased in recent years, progress in these areas has been limited and, as yet, a single, true virulence factor has not been identified and the mechanisms responsible for protective immunity against A. fumigatus have yet to be elucidated.

An overview of fungal infections

The incidence of fungal infections is increasing at an alarming rate, presenting an enormous challenge to healthcare professionals. This increase is directly related to the growing population of immunocompromised individuals, resulting from changes in medical practice such as the use of intensive chemotherapy and immunosuppressive drugs. HIV and other diseases which cause immunosuppression have also contributed to this problem. Superficial and subcutaneous fungal infections affect the skin, keratinous tissues and mucous membranes. Included in this class are some of the most frequently occurring skin diseases, affecting millions of people worldwide. Although rarely life threatening, they can have debilitating effects on a person's quality of life and may in some circumstances spread to other individuals or become invasive. Most superficial and subcutaneous fungal infections are easily diagnosed and readily amenable to treatment. Systemic fungal infections may be caused by either an opportunistic organism that infects an at-risk host, or may be associated with a more invasive organism that is endemic to a specific geographical area. Systemic infections can be life threatening and are associated with high morbidity and mortality. Because diagnosis is difficult and the causative agent is often confirmed only at autopsy, the exact incidence of systemic infections is difficult to determine. The most frequently encountered pathogens are Candida albicans and Aspergillus spp. but other fungi such as non-albicans Candida spp. are increasingly important.

Aspergillus and endobronchial abnormalities in lung transplant recipients

STUDY OBJECTIVE

To determine the relationship between aspergillus recovery from the airways of lung transplant recipients and the development of endobronchial abnormalities.

DESIGN

Retrospective case series.

SETTING

Tertiary-care hospital.

PATIENTS

All patients who underwent lung transplantation between December 1991 and June 1999.

MEASUREMENTS AND RESULTS

The study cohort included 38 patients. The primary end point was the bronchoscopic identification of an endobronchial abnormality. Aspergillus was isolated from the lungs of nine patients (23.7%). Most of these isolates occurred early after transplantation (mean, 8 weeks). Endobronchial abnormalities arose in seven of the patients (18.4%) and manifested as either exuberant granulation tissue or stricture formation. Six of the 9 (66.6%) patients with aspergillus developed airway lesions, compared to 1 of the 29 patients (3.4%) without aspergillus (p = 0.0002). Endobronchial abnormalities were 19.3 times more likely to occur in patients in whom aspergillus had previously been isolated. As a screening test for the subsequent diagnosis of an airway complication, the recovery of aspergillus had a sensitivity and specificity of 85.7% and 90.3%, respectively. These aspergillus-related endobronchial abnormalities were clinically relevant as evidenced by a mean increase of 25.9% in the FEV(1) after bronchoscopic intervention.

CONCLUSION

The early isolation of aspergillus from the airways of lung transplant recipients identifies patients at increased risk for the development of clinically significant endobronchial abnormalities.

Aspergillus valve endocarditis in patients without prior cardiac surgery

Aspergillus native valve endocarditis in patients who have not had cardiac surgery is uncommon. We report 3 cases and review 58 other adult patients reported in the English-language literature. Sixty-seven percent of the patients had underlying immunosuppression. The clinical features were fever (74%), embolic episodes (69%), a new or changing heart murmur (41%), and sudden visual loss (13%). Patients with mural endocarditis were more often immunosuppressed, especially due to solid organ transplants, but had lower frequency of heart murmurs and embolic episodes. Echocardiography revealed a vegetation in 78% of all the cases in which it was performed. Examination and culture of biopsy material often helped to establish a diagnosis of Aspergillus infection. Twenty-five patients had an antemortem diagnosis. These patients received a mean cumulative amphotericin B dose of 27 mg/kg. Twenty percent (3/15) of patients who received combined surgical and medical therapy survived, compared to none of those who received medical therapy alone (p = 0.08). Patients who survived were not immunosuppressed. We conclude that native valve aspergillus infective endocarditis is uniformly fatal without surgical intervention and antifungal therapy.

Invasive aspergillosis in a patient with MELAS syndrome

Invasive infection with the opportunistic fungus Aspergillus fumigatus predominantly affects people with impaired cell mediated immunity. The case of a 31 year old woman with no identified cause for immunosuppression who presented with severe refractory aspergillosis of the paranasal sinuses is reported. She subsequently developed clinical and molecular evidence of mitochondrial encephalomyopathy with lactic acidosis and stroke-like events (MELAS) syndrome. It is proposed that MELAS syndrome may represent an unusual risk factor for the development of invasive aspergillosis and mechanisms are supported by which mitochondrial dysfunction may predispose to this.

Fatal invasive aspergillosis complicating severe Plasmodium falciparum malaria

We report the first 2 cases of fatal invasive aspergillosis complicating severe malaria. In 2 nonimmune European adults without underlying disease, death was directly ascribable to invasive aspergillosis. We believe that transient malaria-induced immunosuppression allowed massive growth and overwhelming dissemination of preexisting Aspergillus colonization.

Amphotericin B with and without itraconazole for invasive aspergillosis: A three-year retrospective study

BACKGROUND

Treatment of invasive aspergillosis is frequently unsuccessful, so innovations in therapy are needed. Clinical studies demonstrate that itraconazole may be an effective alternative to amphotericin B. Itraconazole also has been combined with amphotericin B in animal models of aspergillosis, but this regimen produced antagonistic effects.

OBJECTIVES

To determine the role of itraconazole in the adjunctive treatment of invasive aspergillosis.

METHODS

A review was conducted of all patients with definite or probable aspergillosis from January 1995 to December 1997 who were treated with conventional amphotericin B alone or in combination with itraconazole.

RESULTS

Of 21 patients, 10 received amphotericin B and 11 received the combination. The two groups of patients were comparable clinically at baseline (including similar mean APACHE III scores). Both groups received similar doses and days of amphotericin B treatment. Of the patients who received combination therapy, nine (82%) were cured or improved, and of those who received only amphotericin B, five (50%) were cured or improved.

CONCLUSIONS

This study demonstrates that itraconazole and amphotericin B given together are not clinically antagonistic and that the promise of combination therapy for aspergillosis should be evaluated further in a randomized clinical trial.

Survival and prognostic factors of invasive aspergillosis after allogeneic bone marrow transplantation

To determine prognostic factors for survival in bone marrow transplant recipients with invasive aspergillosis (IA), we retrospectively reviewed 27 IA cases observed in our bone marrow transplantation unit between January 1994 and October 1994. On 30 September 1997, six patients were alive and disease-free. The median survival after IA diagnosis was 36 days. Of eight variables found to be related to survival according to the univariate analysis, graft-versus-host disease (GVHD) status at IA diagnosis (P = .0008) and the cumulative prednisolone dose taken during the week preceding IA diagnosis (CPDlw) (P < .0001) were selected by a backward stepwise Cox regression model. A three-stage classification was established: CPD1w of < or =7 mg/kg (3 of 8 patients died; 60-day survival rate, 88%), CPD1w of >7 mg/kg and no GVHD (9 of 10 patients died; 60-day survival rate, 20%), and CPD1w of >7 mg/kg and active acute grade 2 or more or extensive chronic GVHD (9 of 9 patients died; 30-day survival rate, 0) (P < .0001).

Ocular presentation and successful outcome of invasive sphenoid sinus aspergillosis in acute myelogenous leukemia

We report the case of a 73-year-old male with acute myelogenous leukemia, who progressively developed a cavernous sinus syndrome during the aplastic phase after induction chemotherapy. Although the clinical, serological and radiological findings suggested an invasive sphenoid sinus aspergillosis, endoscopic ethmoido-sphenoidectomy allowed definitive diagnosis of the infection. After surgery, fungal eradication and reversal of the neurophtalmological damage paralleled complete hematologic remission. The differential diagnoses of the patient ocular symptoms are discussed. Early recognition, prompt intervention and immunologic reconstitution are essential for successful outcome of paranasal mycoses in immunosuppressed patients.

Susceptibility of convalescent turkeys to pulmonary aspergillosis

Pulmonary lesions resulting from Aspergillus fumigatus inoculation were assessed in convalescent turkeys and compared with those in previously noninoculated (control) turkeys. In addition, lesions observed in small Beltsville white (SBW) turkeys were compared with those in broad-breasted white (BBW) turkeys challenged with the same inoculum. Turkeys were challenged by unilateral posterior thoracic air sac (PTAS) inoculation, rechallenged via the contralateral air sac after 5 wk, and then necropsied 1 wk later. Pulmonary lesions induced by the initial challenge had resolved in 6 of 10 SBW and 9 of 10 BBW turkeys. However, convalescence did not protect against pulmonary aspergillosis subsequent to rechallenge; 10 of 10 SBW and 9 of 10 BBW developed granulomatous pulmonary lesions on the side of reexposure. A greater proportion of control SBW turkeys developed pneumonia and airsacculitis following challenge as compared with the BBW breed. Lesions were limited to the lower respiratory tract in all turkeys and were confined to the ipsilateral lung and PTAS in the singly inoculated control turkeys. This study demonstrates that convalescence from pulmonary aspergillosis does not confer protection against rechallenge but may, instead, decrease resistance to subsequent infection.

Invasive pulmonary aspergillosis in a critically ill neonate: case report and review of invasive aspergillosis during the first 3 months of life

We report a fatal case of invasive pulmonary aspergillosis in a severely ill neonate and review 43 additional cases of invasive aspergillosis reported from 1955 through 1996 that occurred during the first 3 months of life. Eleven of the 44 patients had primary cutaneous aspergillosis, 10 had invasive pulmonary aspergillosis, and 14 had disseminated disease. Most infections were nosocomial in origin. Prematurity (43%); proven chronic granulomatous disease (14%); and a complex of diarrhea, dehydration, malnutrition, and invasive bacterial infections (23%) accounted for the majority of underlying conditions. At least 41% of the patients had received corticosteroid therapy before diagnosis, but only one patient had been neutropenic. Among patients who received medical and/or surgical treatment, outcome was relatively favorable, with an overall survival rate of 73%. Invasive aspergillosis may occur in neonates and young infants and warrants consideration under certain circumstances. Current therapeutic approaches consist of high-dose amphotericin B and appropriate surgical interventions.

Many faces of pulmonary aspergillosis

Aspergillus is a ubiquitous fungus. It is commonly isolated as an upper respiratory tract saprophyte and is the most frequent contaminant in laboratory specimens. Because species of aspergillus are omnipresent, one must be cautious in ascribing a causal role to the fungus obtained from patients. Aspergillus has low pathogenicity for humans and animals and rarely invades the immunologically competent host. Although the fungus can affect any organ system, the respiratory tract is involved in >90% of afflicted patients. Pulmonary aspergillosis, depending whether the host is atopic or immunosuppressed, may be classified under four categories: allergic or hypersensitivity syndromes, saprophytic colonization, invasive (infective) dissemination, and chemical or toxic pneumonitis. These entities differ clinically, radiologically, immunologically, and in their response to various therapeutic agents. An increased awareness, an aggressive approach to securing the diagnosis, and instituting early and appropriate therapy are needed to reduce the high morbidity and mortality caused by many of the aspergillus-related syndromes.

Pulmonary aspergillosis and invasive disease in AIDS: review of 342 cases

Aspergillosis is an infrequent but commonly fatal infection among HIV-infected individuals. We review 342 cases of pulmonary Aspergillus infection that have been reported among HIV-infected patients, with a focus on invasive disease. Invasive pulmonary aspergillosis usually occurs among patients with <50 CD4 cells/mm3. Major predisposing conditions include neutropenia and steroid treatment. Fever, cough, and dyspnea are each present in >60% of the cases. BAL is often suggestive, but biopsy specimens are necessary for definite diagnosis. Amphotericin B is the mainstay of treatment and mortality is > 80%. Avoiding neutropenia and judicious use of steroids may be helpful in prevention. Aggressive diagnostic approach, early initiation of treatment, adequate dosing of antifungals, and close follow-up may improve the currently dismal prognosis.

Aspergillus pericarditis with tamponade: report of a successfully treated case and review

We report a case of aspergillus pericarditis with tamponade complicating invasive pulmonary aspergillosis in a patient treated for acute lymphocytic leukemia. Prolonged antifungal therapy and aggressive surgical treatment cured the pericarditis, without relapse, despite the fact that the patient underwent autologous bone marrow transplantation. In a review of 28 other cases of aspergillus pericarditis, we found that this condition usually had occurred in severely immunocompromised patients and was always the result of contiguous dissemination of Aspergillus from the lung or myocardium. Tamponade was present in eight of 29 patients. Aspergillus antigen was detected in the pericardial fluid of all three patients whose fluid specimens were tested. Aspergillus pericarditis was diagnosed before death in 10 of 29 patients, all of whom had established premortem diagnoses of invasive aspergillosis at other sites and had received antifungal therapy. Three of the four survivors received combined medical and aggressive surgical therapies. The performance of echocardiography early during the course of invasive pulmonary aspergillosis, together with intensive combined therapies, might lower the high mortality associated with aspergillus pericarditis.

Endogenous Aspergillus endophthalmitis. Clinical features and treatment outcomes

OBJECTIVE

This study evaluated the clinical features and treatment outcomes in patients with endogenous Aspergillus endophthalmitis.

DESIGN

The study design was a multicenter retrospective chart review.

PARTICIPANTS

Ten patients (12 eyes) with culture-proven endogenous Aspergillus endophthalmitis treated by 1 of the authors were studied.

INTERVENTION

Intravitreous amphotericin B injection, pars plana vitrectomy, systemic amphotericin B therapy, and oral anti-fungal therapy were performed.

MAIN OUTCOME MEASURES

Elimination of endogenous Aspergillus endophthalmitis and Snellen visual acuity, best corrected, were measured.

RESULTS

All patients had a 1- to 3-day history of pain and marked loss of visual acuity in the involved eyes. Varying degrees of vitritis was present in all 12 eyes. In 8 of 12 eyes, a central macular chorioretinal inflammatory lesion was present. Four patients (six eyes) had associated pulmonary diseases and were receiving concurrent steroid therapy. One of these patients with chronic asthma also was abusing intravenous drugs. Overall, six patients (six eyes) had a history of intravenous drug abuse, whereas a seventh patient (one eye) was suspected of abusing intravenous drugs. Blood cultures and echocardiograms were negative for systemic aspergillosis. Management consisted of a pars plana vitrectomy in 10 of 12 eyes. Intravitreous amphotericin B was administered in 11 of 12 eyes. Systemic amphotericin B therapy was used in eight patients. One patient was treated with oral antifungal agents. In three eyes without central macular involvement, final visual acuities were 20/25 to 20/200. In eight eyes with initial central macular involvement, final visual acuities were 20/400 in three eyes and 5/200 or less in four eyes. Two painful eyes with marked inflammation, hypotony, and retinal detachment were enucleated.

CONCLUSIONS

Endogenous Aspergillus endophthalmitis usually has an acute onset of intraocular inflammation and often has a characteristic chorioretinal lesion located in the macula. Although treatment with pars plana vitrectomy and intravitreous amphotericin B is capable of eliminating the ocular infection, the visual outcome generally is poor, especially when there is direct macular involvement.

A fatal case of severe SLE complicated by invasive aspergillosis

We report on the case of a 25-year-old female with severe systemic lupus erythematosus (SLE) who presented with pancytopenia, fever, arthralgia and abdominal pain. After antibiotic treatment, the patient was afebrile for 3 days before her temperature rose again. Dyspnoea and cough pointed towards pneumonia which was confirmed by X-ray. Different antibiotics and the antimycotic agent fluconazol were given. The lupus flare was treated with high-dose prednisolone. After a couple of days, the dyspnoea increased and mechanical ventilation became necessary. Bronchoscopy and transbronchial biopsy revealed the diagnosis of invasive aspergilloses. Despite of an immediate treatment with amphotericin B, the patient died because of respiratory insufficiency. The literature on aspergillosis in SLE is reviewed and prophylactic, diagnostic and therapeutic options are discussed for this infectious complication which has an 80% mortality in patients with SLE.

Rabbit as an animal model of paranasal sinus mycoses

Paranasal sinus mycoses are endemic in rural populations of northern India. To study host-parasite interactions, we developed an animal model of paranasal sinus mycoses. After failure in small animals such as mice and rats, we used New Zealand white rabbits weighing 2.5-3 kg. Inoculum sizes consisted of 0.75-1.0 x 10(8), 0.75-1.0 x 10(7), 0.75-1.0 x 10(6) conidia of a clinical isolate of Aspergillus flavus. The inoculum was injected at a spot 0.5 cm in front of the alveolar process of the maxilla and 0.5 cm below the maxillary process of frontal bone and vertically to a depth of 0.5 cm across the bone directly into the nasal sinus. Paranasal sinus mycoses proven by culture and histopathology developed in 67% of animals injected with 0.75-1.0 x 10(8) conidia and 17% of animals with 0.75 x 10(7) conidia. No lesions were found in the group injected with 0.75-1.0 x 10(6) conidia. Precipitating antibody against culture filtrate antigen was found in rabbits with paranasal sinus mycoses. Therefore, rabbits can be used as an animal model to study paranasal sinus mycoses.

Chronic invasive aspergillosis in apparently immunocompetent hosts

Seventeen cases of invasive aspergillosis occurring since 1987 in apparently immunologically normal hosts have been reviewed: 9 of invasive sinus aspergillosis, 2 of isolated brain abscesses, 3 of pneumonia (1 in a patient who developed mediastinitis), 2 of lymph node aspergillosis, and 1 of osteomyelitis of the foot. Two of the 9 patients with sinus aspergillosis died; the rest were stable up to March 1993. They responded initially to combined surgical and medical therapy. Both patients with brain abscesses survived following surgery, but one had neurological sequelae. Both patients with pneumonia were well following therapy with amphotericin B; one also received itraconazole. The patient with mediastinitis died, but this disease was diagnosed late. The patients with lymph node involvement were lost to follow-up, as was the patient with osteomyelitis. Invasive aspergillosis may be common in Pakistan. Greater awareness would allow earlier diagnosis and therapy, thereby improving the outcome.

Invasive aspergillosis in human immunodeficiency virus-infected children

BACKGROUND

Aspergillosis is an uncommon yet serious opportunistic infection in patients with AIDS. It has been extensively reported in HIV-infected adult patients. To our knowledge there are no studies that describe the epidemiology, clinical manifestations and outcome of aspergillosis in a large HIV-infected pediatric population.

METHODS

We reviewed the records of all 473 HIV-infected children followed in the Pediatric Branch of the National Cancer Institute for 9 years from 1987 through 1995 for the presence of Aspergillus infection.

RESULTS

Seven (1.5%) patients developed invasive aspergillosis during the study period. All patients had low CD4 counts reflecting severe immunosuppression. Sustained neutropenia (> 7 days) or corticosteroid therapy as a predisposing factor for invasive aspergillosis was encountered in only two patients (28%). Invasive pulmonary aspergillosis developed in five patients and cutaneous aspergillosis in two. The most common presenting features in patients with pulmonary aspergillosis were fever, cough and dyspnea. Patients with cutaneous aspergillosis were diagnosed during life and successfully treated with amphotericin B and surgery, whereas diagnosis of pulmonary aspergillosis was made clinically in only one patient.

CONCLUSIONS

Aspergillosis is an uncommon but highly lethal opportunistic infection in HIV-infected children. Invasive pulmonary aspergillosis should be considered in the differential diagnosis in febrile, HIV-infected children with persistent pulmonary infiltrates.

Case report: pathomorphology of an experimental disseminated Aspergillus fumigatus infection in rabbits

In following a formerly successful protocol designed to produce antibodies to A. fumigatus (Fres) we observed a disseminated, lethal fungal infection in healthy, specific pathogen-free (SPF) rabbits. The pathomorphological findings included multiple miliary to avenaceous whitish nodules in the livers and kidneys, mycotic mesencephalitis, nephritis, hepatitis, myocarditis, hemorrhagic enteritis, and splenitis. The hyphae were surrounded by necrosis, which also occurred in the liver without the hyphae. Comparative gas chromatographic and metabolic investigations on this strain and some environmental A. fumigatus strains showed significant differences. The findings are discussed with particular reference to the pathogenicity of A. fumigatus.

Route of infections in bovine aspergillosis

Repeated DNA sequences were used to fingerprint strains of Aspergillus fumigatus isolated from a cow with disseminated systemic aspergillosis, cows with single aspergillosis lesions, calves aborted due to bovine aspergillosis, mothers of those calves, and cattle without aspergillosis. The analysis of the Southern blot hybridization patterns obtained suggested that: (i) the portal of entry of aspergillosis in cattle is the gastrointestinal tract, and (ii) infection of aborted calves is due to maternally derived strains. Cattle from the same farm slaughtered on the same day harbour the same strain, suggesting a contamination from feed material.

Allergic fungal sinusitis: clinicopathological characteristics

Allergic fungal sinusitis is a comparatively new disease entity in paranasal sinus mycoses. It is not a very rare condition, but diagnosis is difficult to establish. Of 28 consecutive cases of allergic nasal polyposis during a 2-year period, 11 patients had allergic fungal sinusitis and the diagnosis was based on the presence of type I hypersensitivity, eosinophilic mucus without tissue invasion of fungi on histopathology and detection of septate hyphae on direct microscopy. On culture, Aspergillus flavus was isolated from nine patients and A. fumigatus and A. niger from one patient each. Among patients with allergic fungal sinusitis, five had asthma, four had proptosis, of whom two had impaired vision, and all 11 patients had nasal obstruction. Eight patients described a history of recurrence. All patients underwent surgical clearance of the diseased sinuses and were given post-operative topical steroids to prevent recurrence.

Therapeutic outcome in invasive aspergillosis

A review of series of > or = 4 cases of invasive aspergillosis (total, 1,223 cases) was undertaken to establish the crude mortality and rate of response to therapy with amphotericin B in the major at-risk host groups. In association with pulmonary, sinus, and cerebral aspergillosis in immunocompromised patients, the crude mortality rates were 86%, 66%, and 99%, respectively. No untreated patient survived. Among 84 patients treated for 1-13 days, only one survived. Among those with invasive pulmonary aspergillosis treated for > or = 14 days, the response rates to amphotericin B deoxycholate were 83% (in cases of heart and renal transplantation), 54% (leukemia), 33% (bone marrow transplantation) and 20% (liver transplantation). Patients with AIDS mostly received both amphotericin B and itraconazole, and 37% of those treated for > or = 14 days responded to therapy. Substantial variation in outcome from series to series was related to underlying disease status, site of disease, and management. Invasive aspergillosis remains a devastating opportunistic infection despite current treatment.

[Are there pathogenicity factors in fungi?]

Since many years so-called pathogenicity or virulence factors of pathogenic bacteria have been studied intensively. Whereas these factors are produced especially by obligate but also facultative pathogenic bacteria, their presence and function in pathogenic fungi is still a matter of debate. In this minireview we summarize some data about possible pathogenicity factors of Cryptococcus neoformans, Aspergillus fumigatus and Candida albicans. The production of adhesins, proteases and capsules contributes to the virulence of these fungi. As fungal infections usually affect immunocompromised patients, the immune status of the host plays a decisive role in addition to the virulence factors produced by fungi.