Invasive mold infections in cancer patients: 5 years' experience with Aspergillus, Mucor, Fusarium and Acremonium infections

Unusual association of orbital tumour and rhino-orbital-cerebral mucormycosis

In developing tropical countries, rhino-orbital-cerebral mucormycosis has been a cause of severe morbidity and mortality during the COVID-19 pandemic. Classically, it develops as an aggressive angioinvasive destruction of nasal, orbital and cerebral involvement. Blindness is a major disabling complication. The association of mucor in cancer is linked with immunosuppression caused by radiation and/or chemotherapy. In this case report, we tried to explore the diverse possibilities of neck swelling, nasal discharge, ocular swelling and dimness of vision in a teenage boy. Rhabdomyosarcoma is a rare tumour of the soft tissue, connective tissue or bone. This type of unusual association or coexistence of rhabdomyosarcoma with mucormycetes is rarely seen in literature.

Patient Characteristics and Risk Factors in Invasive Mold Infections: Comparison from a Systematic Review and Database Analysis

Introduction

Diagnosis and treatment of invasive mold infections (IMI) can be challenging and IMI is a significant source of morbidity and mortality. Invasive aspergillosis (IA) and invasive mucormycosis (IM) are two of the most common mold infections. A better understanding of patient comorbidities and risk factors that predispose IMI may help clinicians to refine the difficult diagnostic and treatment process.

Methods

A systematic literature review (SLR) was conducted (January 2008–October 2019) for studies reporting comorbidities/risk factors of patients with IA or IM (Phase I), followed by an analysis on the Optum^® US EHR database of prominent risk factor cohorts based on SLR findings and expert opinion (Phase II). From the four identified patient cohorts: 1) patients undergoing solid organ transplant (SOT) and patients with 2) hematologic cancers, 3) diabetes, or 4) lung disease, rates of IA, IM, or concurrent IA and IM; patient comorbidities; and Charlson Comorbidity Index (CCI) scores were reported.

Results

The SLR included 88 studies, and 46 were used to select comorbidities/risk factors cohorts in IA and IM patients. The most important comorbidities/risk factors in IA and IM patients were diabetes, lung disease, hematological malignances, and SOT. In the Optum database (N=101,340,454 patients), IA rates were highest in lung transplant (10.81%) patients and IM rates were highest in intestine transplant (0.83%) patients, lung transplant (0.43%), and hematopoietic stem cell transplant (0.49%). CCI scores were elevated in all mold infection groups compared to the total Optum cohort.

Conclusion

The current study describes patient comorbidity and risk factors associated with IA and IM. These data can be used to refine clinical decision-making regarding when to suspect mold infections. Future research should focus on identifying whether patients respond differently to various antifungal treatments to determine if strategic recommendations should be made for certain patient groups.

Successful treatment of invasive fungal rhinosinusitis caused by Cunninghamella: A case report and review of the literature

BACKGROUND

Invasive fungal rhinosinusitis (IFR) caused by Cunninghamella is very rare but has an extremely high fatality rate. There have been only seven cases of IFR caused by Cunninghamella reported in English and, of these, only three patients survived. In this article, we present another case of IFR caused by Cunninghamella, in which the patient was initially treated successfully but then deteriorated due to a relapse of leukemia 2 mo later.

CASE SUMMARY

A 50-year-old woman presented with a 2-mo history of right ocular proptosis, blurred vision, rhinorrhea and nasal obstruction. Nasal endoscopic examination showed that the middle turbinate had become necrotic and fragile. Endoscopic sinus surgery and enucleation of the right orbital contents were performed successively. Additionally, the patient was treated with amphotericin B both systematically and topically. Secretion cultivation of the right eye canthus showed infection with Cunninghamella, while postoperative pathology also revealed fungal infection. The patient’s condition gradually stabilized after surgery. However, the patient underwent chemotherapy again due to a relapse of leukemia 2 mo later. Unfortunately, her leukocyte count decreased dramatically, leading to a fatal lung infection and hemoptysis.

CONCLUSION

Aggressive surgical debridements, followed by antifungal drug treatment both systematically and topically, are the most important fundamental treatments for IFR.

Retrospective review of immunocompromised children undergoing skin biopsy for suspected invasive infection: Analysis of factors predictive of invasive mold

OBJECTIVES

Cutaneous lesions are often the first marker of invasive mold infection, which can cause substantial morbidity in immunocompromised children. The purpose of this study was to describe the evaluation and outcomes of immunocompromised children who presented with findings requiring skin biopsy because of concern about invasive infection. In children who were biopsied, we sought to determine the factors predictive of invasive mold infection.

METHODS

A retrospective review was conducted at the Children's Hospital of Philadelphia. Patients included in the study were immunocompromised individuals younger than 26 years old who underwent skin biopsy by the inpatient dermatology consultation team between January 1, 2003, and March 15, 2015, because of development of new cutaneous lesions that were suspected of being invasive infection.

RESULTS

One hundred five encounters met the inclusion criteria. Fifty (47.6%) biopsied individuals had an infectious pathogen identified on histopathology or culture. Mold was the most common (36%) pathogen, followed by bacteria (32%) and yeast (26%). The presence of a single lesion (P = .001) and prior occlusion at the site of the lesion (P < .001) were associated with mold on biopsy. The combination of a single lesion, history of occlusion, and tissue necrosis on examination was highly predictive for invasive mold infection (86.3% [95% confidence interval 55.1-97.0%]). Of the 18 individuals with confirmed invasive mold infection, 13 (72%) underwent surgical resection, of whom 12 (92%) survived the 30-day follow-up period.

CONCLUSION

Skin biopsy enabled the detection of a pathogen that informed directed therapeutic interventions in nearly half of participants. Institutions caring for immunocompromised children should ensure adequate staffing of clinical personnel approved to perform skin biopsies.

Systemic Acremonium species infection in a dog

A 2-year-old female Magyar Viszla was referred with fever, lethargy, polyuria/polydipsia, and suspected systemic cryptococcosis. At presentation increased rectal temperature and enlarged lymph nodes were detected. Main laboratory abnormalities included lymphocytosis, eosinophilia, and mildly reduced urine specific gravity. Abdominal ultrasound was unremarkable. Lymph node cytology revealed mycotic infection. Acremonium species was isolated from urine as well as from a popliteal lymph node by fungal culture. Therapy with itraconazol (10 mg/kg p. o. q 12 h) was initiated based on susceptibility testing, but dosage had to be reduced by half due to adverse effects. Despite treatment, the dog developed progressive azotemia. Four months after initial presentation, the patient showed anorexia, lethargy, weight loss, diarrhea, vomitus, neurological signs, and severe azotemia and was euthanized. Acremonium species are emerging opportunistic mould fungi that can represent a potential threat for immunocompromised humans. In dogs, only two cases of systemic infection with this fungal species have been reported so far. This case highlights the fact that systemic fungal infections should be considered as a differential in cases of fever and lymphadenopathy.

Epidemiology and treatment approaches in management of invasive fungal infections

Over the past 20 years, the number of invasive fungal infections has continued to persist, due primarily to the increased numbers of patients subjected to severe immunosuppression. Despite the development of more active, less toxic antifungal agents and the standard use of antifungal prophylaxis, invasive fungal infections (especially invasive mold infections) continue to be a significant factor in hematopoietic cell and solid organ transplantation outcomes, resulting in high mortality rates. Since the use of fluconazole as standard prophylaxis in the hematopoietic cell transplantation setting, invasive candidiasis has come under control, but no mold-active antifungal agent (except for posaconazole in the setting of acute myelogenous leukemia and myelodysplastic syndrome) has been shown to improve the survival rate over fluconazole. With the advent of new azole and echinocandin agents, we have seen the emergence of more azole-resistant and echinocandin-resistant fungi. The recent increase in zygomycosis seen in the hematopoietic cell transplantation setting may be due to the increased use of voriconazole. This has implications for the empiric approach to pulmonary invasive mold infections when zygomycosis cannot be ruled out. It is imperative that an amphotericin B product, an antifungal that has never developed resistance in over 50 years, be initiated. The clinical presentations of invasive mold infections and invasive candidiasis can be nonspecific and the diagnostic tests insensitive, so a high index of suspicion and immediate initiation of empiric therapy is required. Unfortunately, our currently available serologic tests do not predict infection ahead of disease, and, therefore cannot be used to initiate “preemptive” therapy. Also, the Aspergillus galactomannan test gives a false negative result in patients receiving antimold prophylaxis, ie, virtually all of our patients with hematologic malignancy and hematopoietic cell transplant recipients. We may eventually be able to select patients at highest risk for invasive fungal infections for prophylaxis by genetic testing. However, with our current armamentarium of antifungal agents and widespread use of prophylaxis in high-risk groups (hematologic malignancy, hematopoietic cell transplantation), we continue to see high incidence and mortality rates, and our future hope lies in reversing the immunosuppression or augmenting the immune system of these severely immunocompromised hosts by developing and utilizing immunotherapy, immunoprophylaxis, and vaccines.

Acremonium kiliense: reappraisal of its clinical significance

A case of Acremonium kiliense peritonitis is described. Diagnosis was established by repeated isolation of the fungus from peritoneal dialysate and by its identification on the basis of morphological characteristics and sequencing of internal transcribed spacer (ITS) regions of ribosomal DNA (rDNA). This report and available literature suggest that A. kiliense may have a greater clinical significance than hitherto recognized.

Recurrent Acremonium infection in a kidney transplant patient treated with voriconazole: a case report

Acremonium infection is rare and associated with immunosuppression. A case of recurrent cutaneous Acremonium infection after short term voriconazole use is described. Surgical resection was the definitive therapy. Oral voriconazole was used in the treatment of Acremonium infection, but recurrence was associated with short therapy. Prolonged antifungal therapy and surgical resection are discussed for the treatment of localized lesions.

Infectious Disease Update: New Anti-Microbials

Effective antimicrobials are critical in controlling one of the most common conditions encountered in medicine, namely, skin and skin structure infections. Unfortunately, the identification of appropriate and novel antimicrobials is continually challenged by the emergence of antimicrobial resistance among bacteria, fungi, and parasites. This work will focus on describing novel antibacterials and antifungals approved by the United States Food and Drug Administration in the past 4 years.

Zygomycoses in patients with acute leukaemia

Zygomycoses are rare invasive mould infections which mainly occur in immunocompromised patients, especially during prolonged neutropenia. The high mortality rate is due to a high failure rate of both intravital diagnosis and treatment. Exact diagnosis requires microscopic examination and proof by culture. The treatment consists of amphotericin B and surgical debridement. We report four recent cases of zygomycosis among 89 patients with intensively treated acute leukaemia at our institution. Three cases were breakthrough infections since the patients were under voriconazole treatment prior to diagnosis of zygomycosis. Only one patient had premortal diagnosis (paranasal sinus infection) and showed clinical response with amphotericin B and surgical debridement. A review of the literature of these emerging fungal infections is given and is focused on patients with acute leukaemia. In addition, the importance of autopsy as a tool for quality control and epidemiological studies is pointed out.

Fusarium peritonitis concomitant to kidney transplantation successfully managed with voriconazole: case report and review of the literature

Fusarium infections in solid organ transplant recipients are often localized, occur later in the post-transplantation period, and have a better outcome than fusarial infections in patients with hematologic malignancies or bone marrow transplants. We report the first case of proven peritonitis caused by Fusarium species in a renal transplant recipient which is also the first successfully managed with voriconazole. We also review previously reported cases of fusarial infection in solid organ transplant recipients.

Primary cutaneous opportunistic mold infections in a pediatric population

OBJECTIVE

We sought to describe the features of cutaneous opportunistic mold infections in a general pediatric population.

METHODS

Computerized pathology records from Texas Children's Hospital in Houston during the years 1991 to 2000 were used to identify any biopsy specimens of skin diagnosed as having fungus or mold. The corresponding medical records were reviewed to identify cases of cutaneous opportunistic mold infections. Cases were limited to those with histologic confirmation of hyphae within the dermis or extending to the dermis.

RESULTS

A total of 11 cases in neonates and 22 cases in children and adolescents were identified. Prematurity and low birth weight were the major risk factors in the neonatal population. The nonneonatal cases mainly occurred in those with malignancies or undergoing transplantation. Mortality in neonates was 64%, but decreased to 18% in the nonneonatal population.

CONCLUSION

Our overview of cutaneous infection by opportunistic molds in a pediatric population highlights the risk factors, causative organisms, and outcome of this group of infections. Even in the presence of severe compromise of the immune system, children with primary cutaneous mold infections had a favorable outcome with appropriate diagnosis and therapy.

Clinical and epidemiological aspects of infections caused by fusarium species: a collaborative study from Israel

Fusarium infections are an important problem worldwide, commonly affecting immunocompromised individuals. We conducted a retrospective study in two Israeli tertiary medical centers of factors predisposing to infection by Fusarium spp. and their influence on the epidemiology and clinical outcome of this infection. Fusarium spp. were isolated from 89 patients with a median age of 57 years. Sixty-eight patients were considered immunocompetent. Seven patients had disseminated disease, 34 had locally invasive disease, and 48 had superficial infection. Most infections were limited and occurred mainly in lower limbs. Factors associated with in-hospital mortality were chronic renal failure, hematological malignancy, immunosuppression, disseminated infection, and positive blood culture. Multivariate analysis showed that chronic renal failure, hematological malignancy, burns, and disseminated infection were independently associated with mortality. A surge in the frequency of infections was noticed during the summer for patients from rural areas, involving mainly the eyes and lungs. At one of the hospitals (in a mountainous area), there was an increase in the isolation rate over time.

Newly discovered neutral glycosphingolipids in aureobasidin A-resistant zygomycetes: Identification of a novel family of Gala-series glycolipids with core Gal alpha 1-6Gal beta 1-6Gal beta sequences

We found for the first time that Zygomycetes species showed resistance to Aureobasidin A, an antifungal agent. A novel family of neutral glycosphingolipids (GSLs) was found in these fungi and isolated from Mucor hiemalis, which is a typical Zygomycetes species. Their structures were completely determined by compositional sugar, fatty acid, and sphingoid analyses, methylation analysis, matrix-assisted laser desorption ionization time-of-flight/mass spectrometry, and (1)H NMR spectroscopy. They were as follows: Gal beta 1-6Gal beta 1-1Cer (CDS), Gal alpha 1-6Gal beta 1-6Gal beta 1-1Cer (CTS), Gal alpha 1-6Gal alpha 1-6Gal beta 1-6Gal beta 1-1Cer (CTeS), and Gal alpha 1-6Gal alpha 1-6Gal alpha 1-6Gal beta 1-6Gal beta 1-1Cer (CPS). The ceramide moieties of these GSLs consist of 24:0, 25:0, and 26:0 2-hydroxy acids as major fatty acids and 4-hydroxyoctadecasphinganine (phytosphingosine) as the sole sphingoid. However, the glycosylinositolphosphoceramide families that are the major GSLs components in fungi were not detected in Zygomycetes at all. This seems to be the reason that Aureobasidin A is not effective for Zygomycetes as an antifungal agent. Our results indicate that the biosynthetic pathway for GSLs in Zygomycetes is significantly different from those in other fungi and suggest that any inhibitor of this pathway may be effective for mucormycosis, which is a serious pathogenic disease for humans.

Disseminated mucormycosis in a patient with acute myeloblastic leukemia misdiagnosed as infection by Enterococcus faecium

Mucormycosis is a rare complication in cancer patients. This report presents the case of a acute myeloblastic leukemia patient who developed an ascending paralysis due to disseminated mucormycosis. The presentation was unusual because the early symptoms were fever and pain, and the disease was misdiagnosed because of a concomitant infection by Enterococcus faecium.

The significance of isolation of saprophytic molds from the lower respiratory tract in patients with cancer

BACKGROUND

Invasive infections caused by molds other than Aspergillus, Fusarium, and Zygomycetes have been reported sporadically in patients with leukemia and allogeneic bone marrow transplantation (BMT). However, the significance of lower respiratory tract cultures that are positive for these saprophytic molds in an unselected population of patients with cancer remains unclear.

METHODS

The authors evaluated the significance of respiratory specimens positive for saprophytic molds in patients with cancer using the criteria set by the European Organization for Research and Treatment of Cancer (EORTC)/Mycoses Study Group (MSG). They included the diagnostic category of indeterminate pulmonary invasive mold infection (IMI) for cases that met the criteria for probable IMI but had other pathogens concomitantly isolated from the respiratory tract.

RESULTS

Eighty-five cases with at least 1 positive culture were identified in 79 patients. Two cases were proven IMI, 29 were indeterminate IMI, 5 were possible IMI, and 49 were no IMI. All 38 cases from patients with solid tumors represented colonization compared with only 11 of the 47 cases (23%) from high-risk patients (P < 0.0001). The positive predictive value (PPV) of cultures was 0% in patients with solid tumors and ranged from 4.3% to 76.6%, depending on the analytic model used, in high-risk patients with leukemia and recipients of BMT. Cultures positive for Scedosporium spp. had a higher PPV (9.1-100%) than did cultures positive for non- Scedosporium spp. (2.8- 69.4%).

CONCLUSIONS

Adjustments of the EORTC/MSG criteria may be required for the diagnosis of invasive infections caused by saprophytic molds, especially non-Scedosporium spp., in patients with cancer.

Emerging and less common fungal pathogens

Less common and emerging fungal pathogens are often resistant to conventional antifungal therapy and may cause severe morbidity and mortality in immunocompromised hosts. Some Scedosporium species may be completely resistant to antifungal therapy. Hyaline septated filamentous fungi, such as Fusarium species, Acremonium species, Paecilomyces species, and Trichoderma species, are increasingly reported as causing invasive mycoses refractory to amphotericin B therapy. Dematiaceous septated filamentous fungi, such as Bipolaris species may cause pneumonia, sinusitis, and CNS infections that are unresponsive to current medical interventions. Trichosporon spp are resistant to the fungicidal effects of amphotericin B. An increasing number of different members of the class Zygomycetes are reported as causing lethal infections, despite aggressive medical and surgical interventions. Infections due to these and other less common and emergent fungal pathogens will likely continue to develop in the settings of selective anti-fungal pressure, permissive environmental conditions, and an expanding population of immunocompromised hosts.

Case Report. Acremonium falciforme fungemia in a patient with acute leukaemia

We describe a case of Acremonium falciforme fungemia under treatment of fluconazole. A. falciforme is a common saprophyte. This fungus has been isolated from a patient's specimen, and the organism may have contributed to his death.

Fusarium infection after solid-organ transplantation

We describe a case of soft tissue infection caused by Fusarium species in a heart-liver transplant recipient, and review the cases of fusarial infection reported among solid-organ transplant (SOT) recipients. Unlike fusarial infection in patients with hematologic malignancies or bone marrow transplants, fusarial infection in SOT recipients tends to be localized, occurs later in the posttransplantation period, and has a better outcome. Surgical resection, when possible, and prolonged treatment with amphotericin provide the most effective form of therapy.

Case report. Mixed systemic mycosis with fatal outcome in a patient with acute myeloblastic leukaemia

Fungal infections represent an increasing problem in immunocompromised patients. The majority of cases are caused by one single fungal pathogen and infections with more than one fungus are very rare. Here we describe a case of combined infection with Aspergillus and a zygomycete species, involving the lungs, spleen and the brain and leading to fatal outcome in spite of early antimycotic therapy.