Renal abscesses in an AIDS patient caused by Aspergillus fumigatus

BACKGROUND

Aspergillus abscesses of the kidneys are very rare complications of AIDS which usually have fatal outcome. The 4 patients described in the literature, 2 of whom had bilateral involvement, died due to this opportunistic infection.

METHODS

Case report of a 33-year-old patient with AIDS in stage C3 and aspergillus abscesses of the kidney.

RESULTS

Successful treatment of bilateral aspergillus abscesses of the kidneys with purely conservative antimycotic measures. This was largely due to stabilization of the immune status by supplementing antiretroviral treatment with the proteinase inhibitor indinavir.

CONCLUSIONS

The options now available for improving immune status in AIDS also improve the treatment chances in renal aspergillosis.

Interactive mortality factors in common loons from Maritime Canada

Between August 1992 and November 1995, 31 moribund or dead common loons (Gavia immer) found in the three Maritime provinces of Canada (New Brunswick, Nova Scotia, Prince Edward Island) were necropsied. Eight of these birds were in good body condition and died acutely from drowning or trauma. The remaining 23 birds were in poor body condition and had either chronic lead poisoning, respiratory mycosis, or oil contamination of their plumage. Loons in poor body condition had significantly higher numbers of intestinal trematodes and significantly higher levels of total renal mercury than loons in good body condition. Therefore, poor body condition in many loons was associated with two or more concurrent potential disease processes, although we could not establish a cause-effect relationship among these processes in individual birds. These results suggest that mortality in chronically ill wild animals can result from synergism among several potentially debilitating agents present in their environment.

Disseminated aspergillus fumigatus infection: case report

A case of disseminated aspergillus fumigatus infection is reported in a 43 year old Ugandan female with no known immune system disorder(not neutropenic and HIV-1 sero negative). She presented with multiple cutaneous ulcers, recurrent empyema thoracis, a past history of intra-abdominal abscess and bowel infarction. Empirical treatment for tuberculosis was previously given without improvement. A diagnosis of aspergillus fumigatus based on a combination of tissue wet potassium hydroxide preparation, fungal culture and tissue histologic typing was made. Despite antifungal therapy with intravenous amphotericin B infusion in 5% dextrose, after a normal baseline renal function test, the patient died in the second week of admission. Autopsy showed disseminated aspergillosis involving the pleural space, pericardium, spleen, and meningitis in addition to the cutaneous sites. Disseminated aspergillus fumigatus infection in a non-immunocompromised is rare antemortem diagnosis. This case highlights the difficulty in making a diagnosis in the face of many endemic conditions with similar presentation.

New azole antifungals. 2. Synthesis and antifungal activity of heterocyclecarboxamide derivatives of 3-amino-2-aryl-1-azolyl-2-butanol

A series of 92 azole antifungals containing an amido alcohol unit was synthesized. The nature and substitution of the amide portion was systematically modified in search of improved antifungal activity, especially against filamentous fungi. The compounds were tested in vitro against a variety of clinically important pathogens and in vivo (po) in a murine candidosis model. Thiazole and thiophene carboxamides carrying both a substituted phenyl ring and a small alkyl group were best suited for activity against filamentous fungi. In a subset of these compounds, the amide portion was conformationally locked by means of a pyrimidone ring and it was proven that only an orthogonal orientation of the phenyl ring yields bioactive products. A tendency to display long plasma elimination half-lives was observed in both series. Two compounds, 74 and 107, representative of the open and cyclic amides, respectively, were chosen for further studies, based on their excellent activity in in vivo murine models of candidosis and aspergillosis. This work describes the SARs found within this series. The next paper displays the results obtained in a related series of compounds, the quinazolinones.

New azole antifungals. 3. Synthesis and antifungal activity of 3-substituted-4(3H)-quinazolinones

A series of azole antifungal agents featuring a quinazolinone nucleus have been subjected to studies of structure-activity relationships. In general, these compounds displayed higher in vitro activities against filamentous fungi and shorter half-lives than the structures described in our preceding paper. The most potent products in vitro carried a halogen (or an isostere) at the 7-position of the quinazolinone ring. Using a murine model of systemic candidosis, oral activity was found to be dependent on hydrophobicity, which, in turn, modulated the compound's half-life. The 7-Cl derivative, (1R,2R)-7-chloro-3-[2-(2, 4-difluorophenyl)-2-hydroxy-1-methyl-3-(1H-1,2, 4-triazol-1-yl)propyl]quinazolin-4(3H)-one (20, UR-9825), was selected for further testing due to its high in vitro activity, low toxicity, good pharmacokinetic profile, and ease of obtention. Compound 20 is the (1R,2R) isomer of four possible stereoisomers. The other three isomers were also prepared and tested. The enantiomer (1S,2S) and the (1R,2S) epimer were inactive, whereas the (1S,2R) epimer retained some activity. In vitro 20 was superior to fluconazole, itraconazole, SCH-42427, and TAK-187 and roughly similar to voriconazole and ER-30346. In vivo, 20 was only moderately active in a mouse model of systemic candidosis when administration was limited to the first day. This was attributed to its short half-life in that species (t1/2 = 1 h po). Protection levels comparable to or higher than those of fluconazole, however, were observed in systemic candidosis models in rat and rabbit, where the half-life of the compound was found to be 6 and 9 h, respectively. Finally, 20 showed excellent protection levels in an immunocompromised rat model of disseminated aspergillosis. The compound showed low toxicity signs when administered to rats at 250 mg/kg qd or at 100 mg/kg bid during 28 days.

Successful treatment of Aspergillus fungaemia in two children with acute lymphoblastic leukaemia

Aspergillus species can cause life-threatening infection in immunocompromised children. Pulmonary infections are the most common, and are usually acquired through inhalations of aspergillus spores in unfiltered air. Some patients acquire invasive aspergillus infection from endogenous spread of colonized para-nasal sinuses.

Magnetic resonance image detection of coincidental sphenoid sinus aspergillosis and pituitary microadenoma: a potential surgical disaster

While localizing the microadenoma in a patient with Cushing's disease on magnetic resonance imaging (MRI), fungal granuloma of the sphenoid sinus was coincidentally detected. This helped in the proper management of sphenoidal disease before undergoing trans-sphenoidal removal of the microadenoma, thus averting the possible catastrophe of direct intracranial spread of aspergillus infection.

[Nosocomial ventilator-associated pneumonias caused by Aspergillus fumigatus in non-immunosuppressed, non-neutropenic patients]

We observed three cases of severe ventilator-associated pneumonia due to Aspergillus fumigatus in non-immunosuppressed, non-neutropenic patients. Autopsy confirmed an angioinvasive pattern of spreading with septic foci. In all cases conditions associated with temporary immunodysfunction like underlying diseases, antecedent sepsis or pneumonia, coinfections or steroid therapy were present. Although Aspergillus fumigatus was isolated in all cases in cultures of tracheobronchial secretions, the correct diagnosis was not obtained during lifetime. Our cases demonstrate that pneumonia due to Aspergillus fumigatus must be taken into account also in this patient population.

Periantral soft-tissue infiltration and its relevance to the early detection of invasive fungal sinusitis: CT and MR findings

PURPOSE

Our goal was to illustrate the relevance of periantral soft-tissue infiltration to the early diagnosis of invasive fungal sinusitis and to describe variations in the appearance of normal periantral soft tissues.

METHODS

We reviewed two cases of pathologically proved invasive maxillary fungal sinusitis in which the sole imaging finding suggestive of invasive disease was periantral soft-tissue infiltration. Variations in the CT appearance of normal periantral soft tissues were studied in 112 patients by assessing the appearance of the fat planes along the anterior and posterior bony antral walls and by noting the presence of infraorbital and distal internal maxillary artery branch vessels within the anterior and posterior periantral fat planes, respectively.

RESULTS

None of the 112 patients had findings that suggested, or that could mimic, soft-tissue infiltration in the anterior periantral soft tissues. In only one (1%) of the 112 patients was there a loss of visibility of the posterior periantral fat plane that was not clearly attributable to the otherwise normal-appearing posterior periantral soft tissues.

CONCLUSION

Infiltration of the periantral fat planes may represent the earliest imaging evidence of invasive fungal disease. When encountered as the sole radiologic finding, periantral soft-tissue infiltration should suggest the possibility of invasive fungal sinusitis in the appropriate clinical setting.

Skull base osteitis following fungal sinusitis

Aspergillus sp. sinusitis is not uncommon in immunocompromised patients but is unusual in patients who are not immunocompromised. The disease may occur as a saprophytic condition, as an allergic sinusitis or as a potentially lethal invasive disease. The differentiation between non-invasive and invasive Aspergillus sp. sinusitis is crucial and this distinction is fully discussed. The treatment options are also considered. Invasive disease requires aggressive treatment with long-term antifungal agents in sufficient doses combined with wide surgical excision. We present a patient who presented with invasive Aspergillus fumigatus sinusitis and subsequently developed cranial neuropathies and skull base osteitis. She was initially treated with oral itraconazole (400 mg daily) for 18 months but due to lack of response this was changed to a new experimental oral azole (voriconazole) which was continued for a further 14 months. She has since remained well for the last five years.

Aspergillus fungal mass detected by transesophageal echocardiography

Cardiac fungal infections have become more prevalent and are being diagnosed with increasing frequency. The most common infective organism is Candida albicans, followed by Aspergillus fumigatus and Cryptococcus. Cardiac involvement is usually associated with endocarditis, myocarditis, pericarditis, or intracardiac fungal mass. Early diagnosis is imperative, as these patients have poor outcome once there is cardiac involvement. In this report we describe a patient in whom an intracardiac mass was detected with transesophageal echocardiography and confirmed to be aspergillus fungal ball at surgery.

Articular aspergillosis: two case reports and review of the literature

We report two cases of septic arthritis of the knee caused by Aspergillus: one by Aspergillus terreus in a cirrhotic patient and the other by Aspergillus fumigatus after vascular graft infection. The recovery of these organisms in synovial fluid should be considered as pathogenic, particularly in immunocompromised hosts. The pathogenic mechanism is discussed and the literature is reviewed.

[Endogenous Aspergillus endophthalmitis in AIDS]

BACKGROUND

We present the course of an endogenous Aspergillus endophthalmitis in a 38-year-old HIV-positive man. HISTORY AND CLINICAL SIGNS: The first examination because of a sudden visual loss in the right eye showed a central subretinal infiltration, peripheral vascular sheeting and retinal hemorrhages.

THERAPY AND OUTCOME

In spite of high-dose systemic antifungal therapy we could not prevent the penetration of the posterior wall of the eye and infiltration of adjacent orbital structures. Enucleation had to be performed.

CONCLUSIONS

In case of scleral involvement in Aspergillus endophthalmitis the necessity of enucleation has to be considered.

A new classification and diagnostic criteria for invasive fungal sinusitis

OBJECTIVE

To develop criteria for the diagnosis of invasive fungal sinusitis.

DESIGN

Review of the literature on invasive fungal sinusitis in the context of a population of 30 patients with fungal sinusitis and 24 patients with chronic bacterial sinusitis.

SETTING

Tertiary care medical center.

RESULTS

Our review revealed no consensus in the literature on the classification of the syndromes of invasive fungal sinusitis and no criteria for their diagnosis. Moreover, the existing syndromes of invasive fungal sinusitis lacked specificity and one of the more commonly cited syndromes, primary aspergillosis of the paranasal sinuses, is a granulomatous disease that occurs rarely outside Africa. Two of our 30 patients with fungal sinusitis had a previously unrecognized form of invasive disease. Both were middle-aged adults with well-controlled type 2 diabetes mellitus, apical orbital syndrome, and a similar course: proptosis resulting from fungal expansion out of an ethmoid sinus, a protracted illness of 6 months or longer, visual changes, late neurological symptoms reflecting cavernous sinus invasion, and death. The syndrome in these 2 patients is distinct from the syndrome of fulminant invasive fungal sinusitis, (eg, mucormycosis) with nasal eschar, intracerebral fungal dissemination by vascular invasion, and death in days, and the granulomatous form.

CONCLUSIONS

We conclude that there are 3 forms of invasive fungal sinusitis and propose that they be termed (1) granulomatous, (2) acute fulminant, and (3) chronic invasive. The latter category reflects the syndrome seen in our 2 patients. Furthermore, the following 2 diagnostic criteria for invasive fungal sinusitis are proposed: (1) sinusitis confirmed by radiological imaging and (2) histopathological evidence of hyphal forms within sinus mucosa, submucosa, blood vessels, or bone. The specificity of hyphae within sinus mucosa for tissue invasion was supported by the absence of stainable hyphae in the mucosa of patients with chronic bacterial sinusitis or in the mucosa of our described patients with allergic fungal sinusitis and mycetoma.

Infections in patients with cystic fibrosis following lung transplantation

BACKGROUND

There is controversy over whether colonization with drug-resistant organisms is a contraindication to lung transplantation.

METHODS

We undertook a retrospective review of the results of lung transplantation for patients with cystic fibrosis (CF) at Duke University Medical Center.

RESULTS

As of May 1996, 21 patients with CF underwent bilateral lung transplantation. The first patient died within 24 h of transplantation from sepsis due to Stenotrophomonas maltophilia. Of the remaining 20 patients, 17 (85%) are alive and in stable condition. The three deaths were related primarily to bronchiolitis obliterans at 4 and 18 months in two patients and to cytomegalovirus pneumonitis at 5 months in the other patient. The 17 surviving patients have been followed up for a mean of 13 months (range, 0.5 to 34 months). Most of them were colonized and infected with multidrug-resistant organisms before transplantation. Following transplantation, 11 patients had complications from infections. One patient had bacteremia due to a panresistant Burkholderia cepacia and was treated successfully. Two patients had bacteremia and wound infection due to Burkholderia gladioli, previously thought to be pathogenic only in plants. Both patients were treated successfully. Of the six patients with Aspergillus fumigatus isolated from cultures before transplantation, only one had invasive disease following transplantation and responded to treatment.

CONCLUSION

The organisms present before transplantation were not the primary cause of mortality in our patient population. Our findings suggest that lung transplantation should be considered in CF patients infected with multidrug-resistant organisms.