Treatment of deep mycoses with itraconazole

In vitro activities of amphotericin B, caspofungin, itraconazole, posaconazole, and voriconazole against 45 clinical isolates of zygomycetes: comparison of CLSI M38-A, Sensititre YeastOne, and the Etest

We evaluated the activities of amphotericin B, itraconazole, voriconazole, caspofungin, and posaconazole against zygomycetes by CLSI M38-A, Etest and Sensititre. The most active drug was posaconazole, followed by amphotericin B and itraconazole. The correlation of the Etest and Sensititre with CLSI M38-A was moderate for posaconazole but poor for the others.

Fungal infections in patients with neutropenia: challenges in prophylaxis and treatment

Fungal infections are a leading cause of mortality in patients with neutropenia. Candidiasis and aspergillosis account for most invasive fungal infections. General prophylactic measures include strict hygiene and environmental measures. Haemopoietic growth factors shorten the duration of neutropenia and thus may reduce the incidence of fungal infections. Fluconazole is appropriate for antifungal prophylaxis and should be offered to patients with prolonged neutropenia, such as high-risk patients with leukaemia undergoing remission induction or consolidation therapy and high-risk stem cell transplant recipients. Empirical antifungal therapy is mandatory in patients with persistent febrile neutropenia who fail to respond to broad-spectrum antibacterials. Intravenous amphotericin B at a daily dose of 0.6 to 1 mg/kg is preferred whenever aspergillosis cannot be ruled out. Lipid formulations of amphotericin B have demonstrated similar efficacy and are much better tolerated. Fluconazole is the best choice for acute candidiasis in stable patients; amphotericin B should be used in patients with unstable disease. Use of fluconazole is restricted by the existence of resistant strains (Candida krusei and, to a lesser extent, C. glabrata). Amphotericin B still remains the gold standard for invasive aspergillosis. Lipid formulations of amphotericin B are effective in aspergillosis and because they are less nephrotoxic are indicated in patients with poor renal function. Itraconazole is an alternative in patients who have good intestinal function and are able to eat. Mucormycosis, trichosporonosis, fusariosis and cryptococcosis are less common but require specific management. New antifungal agents, especially new azoles, are under development. Their broad in vitro spectrum and preliminary clinical results are promising.

[Therapy of infections caused by dematiaceous fungi]

Since dematiaceous fungi belong to the group of rare infectious agents causing mycoses, therapeutic recommendations are mainly deduced from observations of single cases. In cases of eumycetoma or focal phaeohyphomycoses of the central nervous system (e.g. caused by Cladophialophora bantiana or Exophiala dermatitidis) and in certain cases of chromoblastomycoses, the resection in toto is the therapy of choice, which may be accompanied by antimycotic medication. As antimycotic therapy ex juvantibus in case of phaeohy-phomycoses, a simultaneous application of itraconazole and 5-fluorocytosine is presently most promising. The success depends on an adequate duration of therapy.

Diabetes mellitus, fever, proptosis, and rapid loss of vision

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[Disseminated aspergillosis and mucormycosis. A case report]

This paper reports a simultaneous pulmonary infection due to Aspergillus fumigatus and Rhizomucor pusillus which evolved to disseminated aspergillosis and mucormycosis in a leukaemic and neutropenic 40-year-old woman. Both fungi were cultured ante mortem from bronchial secretion. Although high doses of intravenous amphotericin B were administered, the course of the infection was fatal. At autopsy, aspergilli were demonstrated by histology in lungs and brain, and zygomycetes were found to have invaded liver and kidneys.

Four non-endemic New Zealand cases of chromoblastomycosis

The majority of cases of chromoblastomycosis are reported from tropical to subtropical countries; only one previous case being reported from New Zealand. Four non-endemic cases in Pacific Island patients are described. All of the New Zealand cases were caused by Fonsecaea pedrosoi. In the present report, one patient was successfully treated by excision of the lesion followed by skin grafting. Another was treated with 200 mg ketoconazole daily for 10 weeks with no obvious improvement. No follow-up on the treatment of this case nor of the remaining two patients is available. This disease must be included in the differential diagnosis in patients who present with chronic lesions affecting the skin and subcutaneous tissues.