Imaging Spectrum of Invasive Fungal and Fungal-like Infections

Invasive fungal and fungal-like infections contribute to substantial morbidity and mortality in immunocompromised individuals. The incidence of these infections is increasing-largely because of rising numbers of immunocompromised patients, including those with neutropenia, human immunodeficiency virus, chronic immunosuppression, indwelling prostheses, burns, and diabetes mellitus, and those taking broad-spectrum antibiotics. Invasive fungal pathogens include primary mycotic organisms such as Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, and Paracoccidioides brasiliensis, which are true pathogens and inherently virulent. Secondary mycotic organisms such as Candida and Aspergillus species, Cryptococcus neoformans, Pneumocystis jirovecii, and Mucorales fungi are opportunistic, less virulent pathogens. Nocardia and Actinomyces species are gram-positive bacteria that behave like fungi in terms of their growth pattern and cause fungal-like invasive indolent infections; thus, these organisms are included in this review. Fungal and fungal-like infections can affect a variety of organ systems and include conditions such as meningitis, sinusitis, osteomyelitis, and enteritis. As awareness of these infections increases, timely diagnosis and treatment will become even more important. Imaging has a critical role in the evaluation of disease activity, therapy response, and related complications. Using an organ-based approach with computed tomography, magnetic resonance imaging, and ultrasonography to gain familiarity with the appearances of these infections enables timely and accurate diagnoses. ^©RSNA, 2017.

Successful treatment with caspofungin of candiduria in a child with Wilms tumor; review of literature

Symptomatic candiduria often occurs in patients with indwelling bladder catheters or immunocompromised host. Isolation of Candida in urine in high-risk patients should primarily be considered as a marker for candidemia. Hematological and genitourinary malignancies are one of the main risk factors associated with Candida urinary tract infections (CUTI). Fluconazole is a choice for initial treatment of CUTI, but it is fluctuate depending on the patient's condition including renal failure, site of urinary infection and Candida species. Poor glomerular filtration is the main disadvantage echinocandins resulting in very low urinary concentrations. Therefore, echinocandins have prohibited their use in CUTI. Up to now, there are only 10 cases reported in the literatures with highly effective echinocandins in CUTI because of high concentrations in the tissue are needed to control invasive fungal disease. Herein, we report a candiduria followed by renal candidiasis caused by Candida albicans in a 6-year-old Iranian male with a history of Wilms tumor in left kidney. Direct examination of urine specimen revealed an infection due to budding yeast cells with numerous pseudohyphae and growths of C. albicans was reconfirmed by sequencing of ITS rDNA region. MICs in increasing order were as follows: caspofungin (0.016μg/ml), voriconazole (0.125μg/ml), amphotericin B (0.25μg/ml), itraconazole (0.5μg/ml) and fluconazole (2μg/ml). It seems that successful treatment with caspofungin owes achieved high renal tissue concentrations that are unrelated to glomerular filtration. In conclusion, predisposing factors for better outcome are more important than treatment of CUTI, therefore, management of UTI is essential for critically patients.

The multidrug resistance transporters CgTpo1_1 and CgTpo1_2 play a role in virulence and biofilm formation in the human pathogen Candida glabrata

The mechanisms of persistence and virulence associated with Candida glabrata infections are poorly understood, limiting the ability to fight this fungal pathogen. In this study, the multidrug resistance transporters CgTpo1_1 and CgTpo1_2 are shown to play a role in C. glabrata virulence. The survival of the infection model Galleria mellonella, infected with C. glabrata, was found to increase upon the deletion of either CgTPO1_1 or CgTPO1_2. The underlying mechanisms were further explored. In the case of CgTpo1_1, this phenotype was found to be consistent with the observation that it confers resistance to antimicrobial peptides (AMP), such as the human AMP histatin-5. The deletion of CgTPO1_2, on the other hand, was found to limit the survival of C. glabrata cells when exposed to phagocytosis and impair biofilm formation. Interestingly, CgTPO1_2 expression was found to be up-regulated during biofilm formation, but and its deletion leads to a decreased expression of adhesin-encoding genes during biofilm formation, which is consistent with a role in biofilm formation. CgTPO1_2 expression was further seen to decrease plasma membrane potential and affect ergosterol and fatty acid content. Altogether, CgTpo1_1 and CgTpo1_2 appear to play an important role in the virulence of C. glabrata infections, being at the cross-road between multidrug resistance and pathogenesis.

Proper Sterol Distribution Is Required for Candida albicans Hyphal Formation and Virulence

Candida albicans is an opportunistic fungus responsible for the majority of systemic fungal infections. Multiple factors contribute to C. albicans pathogenicity. C. albicans strains lacking CaArv1 are avirulent. Arv1 has a conserved Arv1 homology domain (AHD) that has a zinc-binding domain containing two cysteine clusters. Here, we explored the role of the CaAHD and zinc-binding motif in CaArv1-dependent virulence. Overall, we found that the CaAHD was necessary but not sufficient for cells to be virulent, whereas the zinc-binding domain was essential, as Caarv1/Caarv1 cells expressing the full-length zinc-binding domain mutants, Caarv1^C3S and Caarv1^C28S, were avirulent. Phenotypically, we found a direct correlation between the avirulence of Caarv1/Caarv1, Caarrv1^AHD, Caarv1^C3S, and Caarv1^C28S cells and defects in bud site selection, septa formation and localization, and hyphal formation and elongation. Importantly, all avirulent mutant strains lacked the ability to maintain proper sterol distribution. Overall, our results have established the importance of the AHD and zinc-binding domain in fungal invasion, and have correlated an avirulent phenotype with the inability to maintain proper sterol distribution.

Antifungal activity and influence of propolis against germ tube formation as a critical virulence attribute by clinical isolates of Candida albicans

OBJECTIVE

The potentiality to switch between yeast and hyphal morphologies plays an important role in the virulence of Candida albicans (C. albicans). The objective of the present study was to evaluate the chemical composition, antifungal activity and influence of propolis upon germ tube formation of C. albicans clinical isolates.

METHODS

The major compounds of propolis ethanolic extract (PEE) was revealed by gas chromatography-mass spectrometry (GC/MS) analysis. Broth microdilution method was used for determination of minimal inhibitory concentration (MIC) and minimal fungicidal concentration (MFC) of this extract. C. albicans isolates were exposed to sub-MIC concentrations of propolis and germ tube reduction percent (GRP) and morphological transition from yeast to filamentous form were monitored microscopically.

RESULTS

Phenolic compounds, aromatic acids, aliphatic acids, sugars and polycyclic aromatic hydrocarbons were the major compound classes in PEE. Mean of MIC and MFC values of PEE against C. albicans isolates were 360.6μg·mL^-1 and 1250.1μg·mL^-1, respectively. The increase in concentration led to a significant reduction in germ tube formation, so mean of GRP was 36.7±11.1 and 22±10.1 at concentration of ½ MIC and ¼ MIC of PEE, respectively.

CONCLUSIONS

In conclusion, the present study indicated that PEE has interesting potential as a therapeutic agent that targets germ tube formation by C. albicans as a critical virulence factor.

Candida tropicalis biofilm and human epithelium invasion is highly influenced by environmental pH

OBJECTIVE

The main goal of this study was to investigate the role of pH on Candida tropicalis virulence determinants, namely the ability to form biofilms and to colonize/invade reconstituted human vaginal epithelia.

METHODS

Biofilm formation was evaluated by enumeration of cultivable cells, total biomass quantification and structural analysis by scanning electron microscopy and confocal laser scanning microscopy. Candida tropicalis human vaginal epithelium colonization and invasiveness were examined qualitatively by epifluorescence microscopy and quantitatively by a novel quantitative real-time PCR protocol for Candida quantification in tissues.

RESULTS

The results revealed that environmental pH influences C. tropicalis biofilm formation as well as the colonization and potential to invade human epithelium with intensification at neutral and alkaline conditions compared to acidic conditions.

CONCLUSIONS

For the first time, we have demonstrated that C. tropicalis biofilm formation and invasion is highly influenced by environmental pH.

Antifungal activity of a β-peptide in synthetic urine media: Toward materials-based approaches to reducing catheter-associated urinary tract fungal infections

Catheter-associated urinary tract infections (CAUTI) are the most common type of hospital-acquired infection, with more than 30 million catheters placed annually in the US and a 10-30% incidence of infection. Candida albicans forms fungal biofilms on the surfaces of urinary catheters and is the leading cause of fungal urinary tract infections. As a step toward new strategies that could prevent or reduce the occurrence of C. albicans-based CAUTI, we investigated the ability of antifungal β-peptide-based mimetics of antimicrobial peptides (AMPs) to kill C. albicans and prevent biofilm formation in synthetic urine. Many α-peptide-based AMPs exhibit antifungal activities, but are unstable in high ionic strength media and are easily degraded by proteases-features that limit their use in urinary catheter applications. Here, we demonstrate that β-peptides designed to mimic the amphiphilic helical structures of AMPs retain 100% of their structural stability and exhibit antifungal and anti-biofilm activity against C. albicans in a synthetic medium that mimics the composition of urine. We demonstrate further that these agents can be loaded into and released from polymer-based multilayer coatings applied to polyurethane, polyethylene, and silicone tubing commonly used as urinary catheters. Our results reveal catheters coated with β-peptide-loaded multilayers to kill planktonic fungal cells for up to 21days of intermittent challenges with C. albicans and prevent biofilm formation on catheter walls for at least 48h. These new materials and approaches could lead to advances that reduce the occurrence of fungal CAUTI.

STATEMENT OF SIGNIFICANCE

Catheter-associated urinary tract infections are the most common type of hospital-acquired infection. The human pathogen Candida albicans is the leading cause of fungal urinary tract infections, and forms difficult to remove 'biofilms' on the surfaces of urinary catheters. We investigated synthetic β-peptide mimics of natural antimicrobial peptides as an approach to kill C. albicans and prevent biofilm formation in media that mimics the composition of urine. Our results reveal these mimics to retain structural stability and activity against C. albicans in synthetic urine. We also report polymer-based approaches to the local release of these agents within urinary catheter tubes. With further development, these materials-based approaches could lead to advances that reduce the occurrence of fungal urinary tract infections.

What nurses need to know about female genital mutilation

Female genital mutilation, also known as female circumcision (FGM/C) is a deep-rooted practice in some countries that needs to be addressed if the health needs of women and girls are to be met. FGM/C has no medical or health benefits. This article will discuss the different types of FGM/C, the law and legal implications and urological complications. Urology nurses need to be aware of what their medical roles and legal responsibilities are so that they are able to sensitively and holistically care for girls and women living with or at risk of FGM/C.

Antifungal potential of eugenyl acetate against clinical isolates of Candida species

The study evaluated the efficiency of eugenyl acetate (EA), a phytochemical in clove essential oil, against clinical isolates of Candida albicans, Candida parapsilosis, Candida tropicalis, and Candida glabrata. Minimum inhibitory concentrations (MIC) of EA against Candida isolates were in the range between 0.1% and 0.4% (v/v). Spot assay further confirmed the susceptibility of Candida isolates to the compound upon treatment with respective 1 × MIC. Growth profile measured in time kill study evidence that the compound at 1 × MIC and 1/2 × MIC retarded the growth of Candida cells, divulging the fungicidal activity. Light microscopic observation demonstrated that upon treated with EA, rough cell morphology, cell damage, and fragmented patterns were observed in C. albicans, C. parapsilosis, C. tropicalis, and C. glabrata. Furthermore, unusual morphological changes of the organism were observed in scanning electron microscopic study. Therefore, it is validated that the compound could cause cell damage resulting in the cell death of Candida clinical isolates. Eventually, the compound at sub-MIC (0.0125% v/v) significantly inhibited serum-induced germ tube formation by C. albicans. Eugenyl acetate inhibited biofilm forming ability of the organisms as well as reduced the adherence of Candida cells to HaCaT keratinocytes cells. In addition, upon treatment with EA, the phagocytic activity of macrophages was increased significantly against C. albicans (P < 0.05). The results demonstrated the potential of EA as a valuable phytochemical to fight against emerging Candida infections.

Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Fibrinogen Release and Deposition on Urinary Catheters Placed during Urological Procedures

PURPOSE

Catheter associated urinary tract infections account for approximately 40% of all hospital acquired infections worldwide with more than 1 million cases diagnosed annually. Recent data from a catheter associated urinary tract infection animal model has shown that inflammation induced by catheterization releases host fibrinogen, which accumulates on the catheter. Further, Enterococcus faecalis catheter colonization was found to depend on EbpA (endocarditis and biofilm-associated pilus), a fibrinogen binding adhesin. We evaluated this mechanism in a human model.

MATERIALS AND METHODS

Urinary catheters were collected from patients hospitalized for surgical or nonsurgical urological procedures. Catheters were subjected to immunofluorescence analyses by incubation with antifibrinogen antibody and then staining for fluorescence. Fluorescence intensity was compared to that of standard catheters. Catheters were incubated with strains of Enterococcus faecalis, Staphylococcus aureus or Candida to assess binding of those strains to fibrinogen laden catheters.

RESULTS

After various surgical and urological procedures, 50 catheters were collected. In vivo dwell time ranged from 1 hour to 59 days. All catheters had fibrinogen deposition. Accumulation depended on dwell time but not on surgical procedure or catheter material. Catheters were probed ex vivo with E. faecalis, S. aureus and Candida albicans, which bound to catheters only in regions where fibrinogen was deposited.

CONCLUSIONS

Taken together, these data show that urinary catheters act as a binding surface for the accumulation of fibrinogen. Fibrinogen is released due to inflammation resulting from a urological procedure or catheter placement, creating a niche that can be exploited by uropathogens to cause catheter associated urinary tract infections.

Catheter-associated candiduria: Risk factors, medical interventions, and antifungal susceptibility

BACKGROUND

Catheter-associated candiduria is a common clinical finding in hospitalized patients, especially in the intensive care unit. The objective of this study was to obtain demographic and clinical data regarding the prevalence of Candida spp in catheterized in-patients and the medical interventions provided to these patients in a northern Israeli hospital between 2011 and 2013.

METHODS

Isolation and identification of microorganisms were performed on 1,408 urine culture samples 48 hours after catheter insertion. Antifungal Etest susceptibility tests were carried out on every Candida-positive urine sample. Demographic and clinical data were gathered to determine risk factors and medical interventions.

RESULTS

Candiduria was detected in 146 catheterized in-patients out of the 1,408 patients included in this study. C albicans was detected in most cases (69.1%). Fever was observed in 52 (35.61%) patients, and leukocyturia was observed in 48 cases (32.87%). Diabetes mellitus was associated with C albicans candiduria. There were 93 patients (63.69%) who did not receive any medical intervention for their candiduria.

CONCLUSION

Candida is the second leading pathogen causing catheter-associated urinary tract infection or asymptomatic colonization, whereas previous studies showed Candida as the third leading pathogen. Clinical signs and symptoms, such as fever and laboratory tests, cannot distinguish between asymptomatic colonization and infection. Because the management of catheter-associated candiduria is still controversial, additional studies should be carried out.

Urinary tract infections: epidemiology, mechanisms of infection and treatment options

Urinary tract infections (UTIs) are a severe public health problem and are caused by a range of pathogens, but most commonly by Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis and Staphylococcus saprophyticus. High recurrence rates and increasing antimicrobial resistance among uropathogens threaten to greatly increase the economic burden of these infections. In this Review, we discuss how basic science studies are elucidating the molecular details of the crosstalk that occurs at the host-pathogen interface, as well as the consequences of these interactions for the pathophysiology of UTIs. We also describe current efforts to translate this knowledge into new clinical treatments for UTIs.

Clinical significance of the isolation of Candida species from hospitalized patients

In this study, we isolated and phenotypically identified 108 yeast strains from various clinical specimens collected from 100 hospitalized patients at three tertiary hospitals in São Luís-Maranhão, Brazil, from July to December 2010. The isolates were analyzed for their susceptibility to four of the most widely used antifungal agents in the surveyed hospitals, amphotericin B, fluconazole, 5-flucytosine and voriconazole. The species identified were Candida albicans (41.4%), Candida tropicalis (30.1%), C. glabrata (7.4%), Candida parapsilosis (5.5%), Candida krusei (4.6%), Cryptococcus neoformans (4.6%), Trichosporon spp . (3.7%), Candida norvegensis (0.9%), Rhodotorula glutinis (0.9%) and Pichia farinosa (0.9%). A higher isolation rate was observed in the following clinical specimens: urine (54 isolates; 50%), respiratory tract samples (21 isolates; 19.4%) and blood (20 isolates; 18.6%). Candida albicans isolates were 100% sensitive to all antifungal agents tested, whereas Candida krusei and Crytococcus neoformans displayed intermediate resistance to 5-flucytosine, with Minimal Inhibitory Concentration (MIC) values of 8 mg/mL and 16 mg/mL, respectively. Both strains were also S-DD to fluconazole with an MIC of 16 mg/mL. C. tropicalis was resistant to 5-flucytosine with an MIC of 32 μg/mL. This study demonstrates the importance of identifying the yeast species involved in community and nosocomial infections.

Urinary tract infections and Candida albicans

Introduction

Urinary tract candidiasis is known as the most frequent nosocomial fungal infection worldwide. Candida albicans is the most common cause of nosocomial fungal urinary tract infections; however, a rapid change in the distribution of Candida species is undergoing. Simultaneously, the increase of urinary tract candidiasis has led to the appearance of antifungal resistant Candida species. In this review, we have an in depth look into Candida albicans uropathogenesis and distribution of the three most frequent Candida species contributing to urinary tract candidiasis in different countries around the world.

Material and methods

For writing this review, Google Scholar –a scholarly search engine– (http://scholar.google.com/) and PubMed database (http://www.ncbi.nlm.nih.gov/pubmed/) were used. The most recently published original articles and reviews of literature relating to the first three Candida species causing urinary tract infections in different countries and the pathogenicity of Candida albicans were selected and studied.

Results

Although some studies show rapid changes in the uropathogenesis of Candida species causing urinary tract infections in some countries, Candida albicans is still the most important cause of candidal urinary tract infections.

Conclusions

Despite the ranking of Candida albicans as the dominant species for urinary tract candidiasis, specific changes have occurred in some countries. At this time, it is important to continue the surveillance related to Candida species causing urinary tract infections to prevent, control and treat urinary tract candidiasis in future.

Candidemia from an upper urinary tract infection complicated by candida endophthalmitis

A 51-year-old Japanese woman developed candidemia as an outpatient secondary to a Candida albicans upper urinary tract infection complicated by previously undiagnosed type 2 diabetes mellitus with poor glycemic control and ureterolithiasis. The patient did not have any risk factors typically associated with candidemia, such as an indwelling vascular catheter, parenteral nutrition or broad-spectrum antibiotic use. During the clinical course, her condition was complicated by unilateral candida endophthalmitis, which progressed despite the administration of systemic antifungal agents and ultimately required vitreous surgery. The etiology of candidemia in this patient and the reason she developed progressive ocular symptoms after starting antifungal treatment are reviewed.

IL22 regulates human urothelial cell sensory and innate functions through modulation of the acetylcholine response, immunoregulatory cytokines and antimicrobial peptides: assessment of an in vitro model

Human urinary disorders are generally studied in rodent models due to limitations of functional in vitro culture models of primary human urothelial cells (HUCs). Current HUC culture models are often derived from immortalized cancer cell lines, which likely have functional characteristics differ from healthy human urothelium. Here, we described a simple explant culture technique to generate HUCs and assessed their in vitro functions. Using transmission electron microscopy, we assessed morphology and heterogeneity of the generated HUCs and characterized their intercellular membrane structural proteins relative to ex vivo urothelium tissue. We demonstrated that our cultured HUCs are free of fibroblasts. They are also heterogeneous, containing cells characteristic of both immature basal cells and mature superficial urothelial cells. The cultured HUCs expressed muscarinic receptors (MR1 and MR2), carnitine acetyltransferase (CarAT), immunoregulatory cytokines IL7, IL15, and IL23, as well as the chemokine CCL20. HUCs also expressed epithelial cell-specific molecules essential for forming intercellular structures that maintain the functional capacity to form the physiological barrier of the human bladder urothelium. A subset of HUCs, identified by the high expression of CD44, expressed the Toll-like receptor 4 (TLR4) along with its co-receptor CD14. We demonstrated that HUCs express, at the mRNA level, both forms of the IL22 receptor, the membrane-associated (IL22RA1) and the secreted soluble (IL22RA2) forms; in turn, IL22 inhibited expression of MR1 and induced expression of CarAT and two antimicrobial peptides (S100A9 and lipocalin-2). While the cellular sources of IL22 have yet to be identified, the HUC cytokine and chemokine profiles support the concept that IL22-producing cells are present in the human bladder mucosa tissue and that IL22 plays a regulatory role in HUC functions. Thus, the described explant technique is clearly capable of generating functional HUCs suitable for the study of human urinary tract disorders, including interactions between urothelium and IL22-producing cells.

Hibiscus sabdariffa extract inhibits in vitro biofilm formation capacity of Candida albicans isolated from recurrent urinary tract infections

OBJECTIVE

To explore the prevention of recurrent candiduria using natural based approaches and to study the antimicrobial effect of Hibiscus sabdariffa (H. sabdariffa) extract and the biofilm forming capacity of Candida albicans strains in the present of the H. sabdariffa extract.

METHODS

In this particular study, six strains of fluconazole resistant Candida albicans isolated from recurrent candiduria were used. The susceptibility of fungal isolates, time-kill curves and biofilm forming capacity in the present of the H. sabdariffa extract were determined.

RESULTS

Various levels minimum inhibitory concentration of the extract were observed against all the isolates. Minimum inhibitory concentration values ranged from 0.5 to 2.0 mg/mL. Time-kill experiment demonstrated that the effect was fungistatic. The biofilm inhibition assay results showed that H. sabdariffa extract inhibited biofilm production of all the isolates.

CONCLUSIONS

The results of the study support the potential effect of H. sabdariffa extract for preventing recurrent candiduria and emphasize the significance of the plant extract approach as a potential antifungal agent.

A comparison of the microbiologic profile of indwelling versus external urinary catheters

We studied the microbiology reports of urine cultures collected from external (condom catheters) versus indwelling (Foley) catheters. The equal prevalence of Enterobacteriaceae and Enterococci in samples from both catheter types calls into question the practice of switching from indwelling to external catheters to decrease catheter-associated bacteriuria.

MiR-204/miR-211 downregulation contributes to candidemia-induced kidney injuries via derepression of Hmx1 expression

AIMS

This study was aimed to exploit the role of heme oxygenase Hmx1 and the potential miRNA mechanisms in the kidney injuries induced by urinary tract infection by Candida species/Candidemia.

MAIN METHODS

We employed a mouse model of systemic Candidiasis by injection of the Candida albicans strain SC5314 into C57BL/6 mice. Kidney injuries were assessed by measuring serum cystatin C (CysC), serum β2-microglobulin (β2-MG) and blood urea nitrogen (BUN). Validation of miRNA target gene was conducted by luciferase reporter gene assay, Western blot analysis and real-time RT-PCR.

KEY FINDINGS

We showed here that Candidemia caused significant downregulation of microRNAs miR-204 and miR-211. In sharp contrast, Hmx1 expression was remarkably upregulated, particularly at the protein level. Computational analysis predicted Hmx1 as a target gene for both miR-204 and miR-211 that share the same seed site sequence. We then experimentally validated the targeting relationship between miR-204/miR-211 and Hmx1, which explains the reciprocal changes of expression of miR-204/miR-211 and Hmx1 in Candidemia. Administration of miR-204/miR-211 mimics substantially downregulated Hmx1 and mitigated the severity of the kidney injuries induced by Candidemia, as reflected by improved renal glomerular filtration rate (GFR) determined by serum cystatin C (CysC), serum β2-microglobulin (β2-MG) and blood urea nitrogen (BUN). Knockdown of miR-204/miR-211 worsened while forced expression of miR-204/miR-211 ameliorated kidney injuries in mice with systemic Candidiasis.

SIGNIFICANCE

Our findings indicate that miR-204/miR-211 downregulation accounts at least partially for the Hmx1 upregulation and the miR-204/miR-211-Hmx1 signaling axis may contribute to immune-suppression in the host thereby the Candidemia-induced kidney dysfunction.

Glycerophosphocholine utilization by Candida albicans: role of the Git3 transporter in virulence

Candida albicans contains four ORFs (GIT1,2,3,4) predicted to encode proteins involved in the transport of glycerophosphodiester metabolites. Previously, we reported that Git1, encoded by ORF 19.34, is responsible for the transport of intact glycerophosphoinositol but not glycerophosphocholine (GroPCho). Here, we report that a strain lacking both GIT3 (ORF 19.1979) and GIT4 (ORF 19.1980) is unable to transport [(3)H]GroPCho into the cell. In the absence of a GroPCho transporter, C. albicans can utilize GroPCho via a mechanism involving extracellular hydrolysis. Upon reintegration of either GIT3 or GIT4 into the genome, measurable uptake of [(3)H]GroPCho is observed. Transport assays and kinetic analyses indicate that Git3 has the greater transport velocity. We present evidence that GDE1 (ORF 19.3936) codes for an enzyme with glycerophosphodiesterase activity against GroPCho. Homozygous deletion of GDE1 results in a buildup of internal GroPCho that is restored to wild type levels by reintegration of GDE1 into the genome. The transcriptional regulator, Pho4, is shown to regulate the expression of GIT3, GIT4, and GDE1. Finally, Git3 is shown to be required for full virulence in a mouse model of disseminated candidiasis, and Git3 sequence orthologs are present in other pathogenic Candida species. In summary, we have characterized multiple aspects of GroPCho utilization by C. albicans and have demonstrated that GroPCho transport plays a key role in the growth of the organism in the host.

Candida albicans Fungaemia following Traumatic Urethral Catheterisation in a Paraplegic Patient with Diabetes Mellitus and Candiduria Treated by Caspofungin

A 58-year-old paraplegic male, with long-term indwelling urethral catheter, developed catheter block. The catheter was changed, but blood-stained urine was drained intermittently. A long segment of the catheter was seen lying outside his penis, which indicated that the balloon of Foley catheter had been inflated in urethra. The misplaced catheter was removed and a new catheter was inserted correctly. Gentamicin 160 mg was given intravenously; meropenem 1 gram every eight hours was prescribed; antifungals were not given. Twenty hours later, this patient developed distension of abdomen, tachycardia, and hypotension; he was not arousable. Computed tomography of abdomen revealed inflamed uroepithelium of right renal pelvis and ureter, 4 mm lower ureteric calculus with gas in right ureter proximally, and vesical calculus containing gas in its matrix. Urine and blood culture yielded Candida albicans. Identical sensitivity pattern of both isolates suggested that the source of the bloodstream infection was most likely urine. Both isolates formed consistently high levels of biofilm formation in vitro as assessed using a biofilm biomass stain, and high levels of resistance to voriconazole were observed. Both amphotericin B and caspofungin showed good activity against the biofilms. HbA1c was 111 mmol/mol. This patient was prescribed human soluble insulin and caspofungin 70 mg followed by 50 mg daily intravenously. He recovered fully from candidemia.

Chronic prostatitis/chronic pelvic pain syndrome: the role of an antifungal regimen

Introduction

The role of fungal infection as a causative factor for prostatitis is currently underestimated. The aim of our work was to evaluate the response to an antifungal regimen in the setting of patients presenting with symptoms of chronic pelvic pain syndrome that have been refractory to treatment with antibiotics and alpha–blockers.

Material and methods

We included 1,000 consecutive patients. The inclusion criteria included failure of response to four consecutive weeks of antibiotic and alpha–blockers. The antifungal regimen was continued for two weeks. It included a low carbohydrate diet, the alkalinization of urine, and administration of fluconazole.

Results

The mean age of the patients was 34 years. Mean serum total PSA and PSA density (PSAd) were 0.6 ng/ml and 0.03 ng/ml/gram, respectively. The mean age, PSA, prostate volume, and PSAd for patients that showed good response were 33, 0.5, 17, and 0.031, respectively. Values for patients that did not show good response were 36, 0.8, 23, and 0.037, respectively (p <0.0001 for all of the variables). Improvement was observed in 80% of cases treated with the antifungal regimen.

Conclusions

Antifungal regimen should be considered for the majority of young adult men, presenting with chronic prostatitis/ chronic pelvic pain syndrome and incomplete response to antibiotics.

Evaluation of human body fluids for the diagnosis of fungal infections

Invasive fungal infections are a major cause of morbidity and mortality in immunocompromised patients. Because the etiologic agents of these infections are abundant in nature, their isolation from biopsy material or sterile body fluids is needed to document infection. This review evaluates and discusses different human body fluids used to diagnose fungal infections.

Candida urinary tract infection and Candida species susceptibilities to antifungal agents

The purpose of this study is to review Candida isolation from urine of urinary tract infection (UTI) patients over the recent 3 years at the Kobe University Hospital. We recorded the type of strain, the department where the patient was treated such as the intensive care unit (ICU), and combined isolation of Candida with other microorganisms. We investigated Candida isolation and susceptibilities to antifungal agents and analyzed the risk factors for combined isolation with other microorganisms. The most frequently isolated Candida was Candida albicans, which showed good (100%) susceptibilities to 5-fluorocytosine (5-FC) and fluconazole (FLCZ) but not to voriconazole (VRCZ), followed by C. glabrata. ICU was the greatest source of Candida-positive samples, and the most relevant underlying diseases of ICU patients were pneumonia followed by renal failure and post liver transplantation status. Combined isolation with other bacteria was seen in 27 cases (42.9%) in 2009, 25 (33.3%) in 2010 and 31 (31.3%) in 2011 and comparatively often seen in non-ICU patients. Other candidas than C. albicans showed significantly decreased susceptibility to FLCZ over these 3 years (P=0.004). One hundred (97.1%) of 103 ICU cases were given antibiotics at the time of Candida isolation, and the most often used antibiotics were cefazolin or meropenem. In conclusion, C. albicans was representatively isolated in Candida UTI and showed good susceptibilities to 5-FC, FLCZ and VRCZ, but other candidas than C. albicans showed significantly decreased susceptibility to FLCZ in the change of these 3 years.

Localized candidiasis in kidney presented as a mass mimicking renal cell carcinoma

Candida albicans is a ubiquitous fungus and infection of urinary tract by C. albicans can be originated from blood or retrograde infection. We reported a case of localized candidiasis in the kidney presenting as a mass. The patient was a 61-year-old male with a history of type 2 diabetes mellitus and urinary bladder urothelial carcinoma status post radical cystoprostatectomy with a neobladder three years ago. Pathology at that time also showed a prostatic adenocarcinoma (Gleason score 3 + 4) in addition to the high-grade urothelial carcinoma. Three month ago the patient presented with flank pain, chill, and increased white cell counts. Imaging study showed a large renal mass suspicious for a renal cell carcinoma. Radical nephrectomy was performed and found that there was a large pocket of pus in the retroperitoneum around the right kidney during the surgery. Intraoperative abscess cultures were positive for C. albicans. Pathology showed a 13.5 cm necrotic renal mass extending to the perinephric fat. Histologically the tumor showed necrotic granulomatous inflammation. Grocott stain in the surgical specimen was positive for pseudohyphae and yeast forms. The patient was initiated a course of fluconazole postoperatively and was feeling well.

Candida urinary tract infections--epidemiology, pathogenesis, diagnosis, and treatment: executive summary

The frequency of infection of the urinary tract due to Candida species is increasing in parallel with the rapid advances of medical progress, and these infections are now among the most common problems facing physicians. Despite this fact, much remains to be learned regarding the pathogenesis, diagnosis, and management of bloodborne (antegrade) kidney infections and ascending (retrograde) invasion of the urinary collecting system. The following is a summary of the in-depth analysis of available information from the literature provided in this journal supplement.