Cutaneous infections due to opportunistic molds: uncommon presentations

A chemiluminescence-based heterogeneous asymmetric recombinase polymerase amplification assay for the molecular detection of mycotoxin producers

The analysis of mold in indoor air is a prominent topic but it is hardly dealt with. The most affected fields of this issue are residential- and occupational safety since mold can have a number of impacts on human health. To date the most used methods for quantification of microorganism contamination in indoor air are culture- or microscopy-based and are not capable of translating the on-site situation to analytical data reliably. Here we present a chemiluminescence-based method to detect mycotoxin producers through isothermal amplification of mycotoxin biosynthesis genes using glass and polycarbonate carriers. In this proof-of-principle study, zearalenone producers were aimed to be detected by heterogeneous asymmetric recombinase polymerase amplification (haRPA). For this, an appropriate lysis method for fungal spores was developed allowing rapid access to DNA. A system calibration with spores of Fusarium culmorum as zearalenone-producing organism resulted in an LOD of 2.7 × 10⁵ spores per ml. The system was shown to be specific for zearalenone producers. This work presents the first application of a heterogeneous isothermal amplification for rapid detection and quantification of mycotoxin producers. In the future, a multiplex detection can be possible by haRPA.

Coumarins: antifungal effectiveness and future therapeutic scope

The antifungals that are in current clinical practice have a high occurrence of a side effect and multidrug resistance (MDR). Researchers across the globe are trying to develop a suitable antifungal that has minimum side effect as well as no MDR issues. Due to serious undesired effects connected with individual antifungals, it is now necessary to introduce novel and effective drugs having numerous potentials to regulate complex therapeutic targets of several fungal infections simultaneously. Thus, by taking a lead from this subject, synthesis of potent antifungals from coumarin moiety could contribute to the development of promising antifungal. Its resemblance and structural diversity make it possible to produce an auspicious antifungal candidate. Due to the natural origin of coumarin, its presence in diversity, and their broad spectrum of pharmacological activities, it secures an important place for the researcher to investigate and develop it as a promising antifungal in future. This manuscript discusses the bioavailability of coumarin (natural secondary metabolic molecule) that has privileged scaffold for many mycologists to develop it as a broad-spectrum antifungal against several opportunistic mycoses. As a result, several different kinds of coumarin derivatives were synthesized and their antifungal properties were evaluated. This review compiles various coumarin derivatives broadly investigated for antifungal activities to understand its current status and future therapeutic scope in antifungal therapy.

Fusarium: The versatile pathogen

Fusarium is an emerging human opportunistic pathogen of growing importance, especially among immunosuppressed haematology patients due to an increased incidence of disseminated infections over the past two decades. This trend is expected only to continue due to the advances in medical and surgical technologies that will prolong the lives of the severely ill, making these patients susceptible to rare opportunistic infections. Production of mycotoxins, enzymes such as proteases, angio-invasive property and an intrinsically resistant nature, makes this genus very difficult to treat. Fusarium is frequently isolated from the cornea and less commonly from nail, skin, blood, tissue, Continuous Ambulatory Peritoneal Dialysis (CAPD) fluid, urine and pleural fluid. Conventional microscopy establishes the genus, but accurate speciation requires multilocus sequence typing with housekeeping genes such as internal transcribed spacer, translation elongation factor-1α and RPB1 and 2 (largest and second largest subunits of RNA polymerase), for which expansive internet databases exist. Identifying pathogenic species is of epidemiological significance, and the treatment includes immune reconstitution by granulocyte-colony-stimulating factor, granulocyte macrophage-colony-stimulating factor and a combination of the most active species - specific antifungals, typically liposomal amphotericin-B and voriconazole. However, patient outcome is difficult to predict even with in vitro susceptibility with these drugs. Therefore, prevention methods and antifungal prophylaxis have to be taken seriously for these vulnerable patients by vigilant healthcare workers. The current available literature on PubMed and Google Scholar using search terms 'Fusarium', 'opportunistic invasive fungi' and 'invasive fusariosis' was summarised for this review.

Disseminated cutaneous fusariosis in human immunodeficiency virus-infected patient and dramatic response with oral itraconazole

Fusarium species are known to cause disseminated cutaneous lesions in immunocompromised patients. Some cases of fusariosis are reported in patients infected with the human immunodeficiency virus. There are two reports in such patients with systemic comorbidities like lymphoma, neutropenia and infective port-a-catheter. Another reported patient had systemic fusariosis, without skin involvement. Diagnosis and treatment of cutaneous fusariosis is difficult and resistance to antifungals is a problem. Our patient was at an advanced human immunodeficiency virus infection stage with disseminated cutaneous fusariosis, without any systemic involvement, who responded completely to oral itraconazole.

A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology

The critical nature of the microbiology laboratory in infectious disease diagnosis calls for a close, positive working relationship between the physician/advanced practice provider and the microbiologists who provide enormous value to the healthcare team. This document, developed by experts in laboratory and adult and pediatric clinical medicine, provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions. This document presents a system-based approach rather than specimen-based approach, and includes bloodstream and cardiovascular system infections, central nervous system infections, ocular infections, soft tissue infections of the head and neck, upper and lower respiratory infections, infections of the gastrointestinal tract, intra-abdominal infections, bone and joint infections, urinary tract infections, genital infections, and other skin and soft tissue infections; or into etiologic agent groups, including arthropod-borne infections, viral syndromes, and blood and tissue parasite infections. Each section contains introductory concepts, a summary of key points, and detailed tables that list suspected agents; the most reliable tests to order; the samples (and volumes) to collect in order of preference; specimen transport devices, procedures, times, and temperatures; and detailed notes on specific issues regarding the test methods, such as when tests are likely to require a specialized laboratory or have prolonged turnaround times. In addition, the pediatric needs of specimen management are also emphasized. There is intentional redundancy among the tables and sections, as many agents and assay choices overlap. The document is intended to serve as a guidance for physicians in choosing tests that will aid them to quickly and accurately diagnose infectious diseases in their patients.

Idiopathic, Infectious and Reactive Lesions of the Ear and Temporal Bone

A number of infectious, inflammatory and idiopathic lesions develop within otologic tissues that may share similar clinical and/or microscopic features. This review first provides a working classification for otitis externa, and then otitis media and includes two recently described entities, eosinophilic otitis media and otitis media with ANCA-associated vasculitis. Next, the microscopic findings of a spectrum of otopathologic conditions are described, including post-inflammatory conditions such as tympanosclerosis and aural polyps, an overview of animate aural foreign body as well as iatrogenic aural foreign body reactions. Finally, a review of fungal disease affecting the ear with a brief synopsis of Candida auris, a recently described and virulent organism, is presented.

The Diagnosis and Treatment of Nail Disorders

BACKGROUND

Nail disorders can arise at any age. About half of all nail disorders are of infectious origin, 15% are due to inflammatory or metabolic conditions, and 5% are due to malignancies and pigment disturbances. The differential diagnosis of nail disorders is often an area of uncertainty.

METHODS

This review is based on publications and guidelines retrieved by a selective search in PubMed, including Cochrane reviews, meta-analyses, and AWMF guidelines.

RESULTS

Nail disorders are a common reason for derma - tologic consultation. They are assessed by clinical inspection, dermatoscopy, diagnostic imaging, microbiological (including mycological) testing, and histopathological examination. Some 10% of the overall population suffers from onychomycosis, with a point prevalence of around 15%. Bacterial infections of the nails are rarer than fungal colonization. High-risk groups for nail disorders include diabetics, dialysis patients, transplant recipients, and cancer patients. Malignant tumors of the nails are often not correctly diagnosed at first. For subungual melanoma, the mean time from the initial symptom to the correct diagnosis is approximately 2 years; this delay is partly responsible for the low 10-year survival rate of only 43%.

CONCLUSION

Evaluation of the nail organ is an important diagnostic instrument. Aside from onychomycosis, which is a common nail disorder, important differential diagnoses such as malignant diseases, drug side effects, and bacterial infections must be considered.

Epidemiology of dermatomycoses in Kerman province, southeast of Iran: A 10-years retrospective study (2004-2014)

OBJECTIVES

Superficial and cutaneous fungal infections (SCFIs) are an important public health problem and are common in tropical and subtropical countries. Pityriasis versicolor, dermatophytosis, erythrasma, onychomycosis, and otomycosis are the major diseases associated with SCFIs. The aim of this study was to evaluate the prevalence and causative agents of dermatomycoses over a period of 10 years in Kerman province, southeast of Iran.

METHODS

A number of 1782 subjects, including 1096 females and 686 males, with cutaneous disorders in their skin, nail, and hair suspected to have SCFIs participated in this study. The collected specimens were examined using direct microscopy examination, staining, culture on specific media and PCR-RFLP technique.

RESULTS

In total, 617 (34.62%) subjects had SCFIs, of whom 290 (47%) were female and 327 (53%) were male. Identified SCFIs included yeast infections, dermatophytosis, saprophyte onychomycosis, erythrasma, and otomycosis due to non-dermatophytic molds (NDMs). The highest prevalence of dermatomycoses was found among the 41-50-year and 31-40-year age groups. Tinea unguium was the most common clinical pattern of dermatomycoses, and T. mentagrophytes was the predominant agent. Also, Aspergillus spp. were the most common NDMs agents of onychomycosis and otomycosis.

CONCLUSIONS

This study summarized the epidemiological trends and etiologic agents of SCFIs in a 10-year period in Kerman, southeast of Iran. Consideration of the current epidemiologic trends in the prevalence and knowledge of the exact causative agents of SCFIs may play an important key role towards further investigations, diagnosis, and modification of current treatments.

Cutaneous phaeohyphomycosis in a hematopoietic stem cell transplant patient caused by Alternaria rosae: First case report

Alternaria species have been reported as a rare cause of fungal infection in organ and stem cell transplant recipients, but to date, no reports have been published of infection in humans caused by Alternaria rosae. Here, we report cutaneous A. rosae infection in a 66-year-old farmer with a history of primary myelofibrosis who had undergone allogeneic unrelated donor hematopoietic stem cell transplantation. Forty-nine days post transplant, he presented with a nodule on the thumb with no findings suggestive of disseminated infection. Pathology, culture, and molecular speciation showed the nodule was caused by cutaneous A. rosae. He had been on voriconazole as antifungal prophylaxis, but was found to have a subtherapeutic voriconazole level. He was switched to posaconazole based on published in vitro data showing its superior efficacy in Alternaria treatment. Susceptibility testing showed that the A. rosae isolate was indeed susceptible to posaconazole. His cutaneous lesion remained stable, but he died from respiratory failure secondary to lobar pneumonia. At lung autopsy, A. rosae was not identified in the lungs. We believe this to be the first published report, to our knowledge, of A. rosae infection in humans.

A manifestation of cutaneous aspergillosis in immunocompetent host: A rare presentation as forearm mass lesion

The Aspergillus species is a ubiquitous fungus, which can cause pathogenic and opportunistic fungal infections in the immunocompromised. This is an atypical occurrence in the host with an otherwise normal immune status. We report a case of an immunocompetent 45-year-old patient who developed cutaneous aspergillosis with a very benign course presenting simply with a gradually enlarging mass and none of the classical signs and symptoms. All prior laboratory examinations failed to detect or reproduce the organism or establish a diagnosis. Surgery was both diagnostic and therapeutic, to remove the mass which causes the patient pain and limitation of activity. This was to our advantage because the fungal elements were very well encapsulated and the mass was a well-organized conglomeration of cystic abscesses that even prolonged chemotherapy alone might not succeed in eradicating the infection.

Granulomatous disorders

Almost all granulomatous skin disorders can cause red lesions on the face. Such disorders may include many bacterial, fungal, or parasitic infections, noninfectious inflammatory disorders, foreign body reactions, and even neoplasms. Clinically, they usually present with papules, plaques, nodules, and/or abscesses, which may ulcerate. It may be helpful in their differential diagnosis to define certain clinical patterns, such as multiple and discrete papules, necrotic or umbilicated papules or nodules, annular plaques, vegetative plaques or tumors, verrucous plaques or tumors, abscesses and/or sinuses, and lymphocutaneous pattern. Some disorders, such as sarcoidosis, can cause a wide variety of lesions. We accept that cutaneous leishmaniasis is also among such great imitators.

Cutaneous Mycoses among Rice Farmers in Anambra State, Nigeria

Rice grain is one of the world's most important food crops, and its cultivation is a major occupation in Anambra State, Nigeria. These rice farmers are exposed to various agents that predispose them to cutaneous mycoses. The aim of this work was to screen rice farmers for lesions suggestive of cutaneous mycoses and to isolate and identify fungal agents associated with the infection. This survey was carried out between November 2009 and June 2011 in Anambra State, Nigeria. Clinical samples collected from 201 farmers with lesions suggestive of cutaneous mycoses were processed and the organisms identified. Questionnaires were used to obtain other necessary data and were statistically analyzed. Of the 2,580 rice farmers screened, 201 (7.79%) showed positive lesions. Organisms recovered included Microsporum audouinii, Microsporum ferrugineum, Trichophyton megnini, Trichophyton tonsurans, Trichophyton rubrum, Aspergillus terrus, Aspergillus candidus, Aspergillus scleriotorum, Aspergillus niger, Aspergillus flavus, Scopulariopsis sp., Chrysosporium sp., Eupenicillium javanicum, Fusarium sp., Penicillium aculeatum, and Penicillium pinophilum. At the end of this work, onychomycosis was observed to be the most prevalent with nondermatophyte molds now becoming very important agents of cutaneous mycoses among rice farmer.

A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)(a)

The critical role of the microbiology laboratory in infectious disease diagnosis calls for a close, positive working relationship between the physician and the microbiologists who provide enormous value to the health care team. This document, developed by both laboratory and clinical experts, provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions. Sections are divided into anatomic systems, including Bloodstream Infections and Infections of the Cardiovascular System, Central Nervous System Infections, Ocular Infections, Soft Tissue Infections of the Head and Neck, Upper Respiratory Infections, Lower Respiratory Tract infections, Infections of the Gastrointestinal Tract, Intraabdominal Infections, Bone and Joint Infections, Urinary Tract Infections, Genital Infections, and Skin and Soft Tissue Infections; or into etiologic agent groups, including Tickborne Infections, Viral Syndromes, and Blood and Tissue Parasite Infections. Each section contains introductory concepts, a summary of key points, and detailed tables that list suspected agents; the most reliable tests to order; the samples (and volumes) to collect in order of preference; specimen transport devices, procedures, times, and temperatures; and detailed notes on specific issues regarding the test methods, such as when tests are likely to require a specialized laboratory or have prolonged turnaround times. There is redundancy among the tables and sections, as many agents and assay choices overlap. The document is intended to serve as a reference to guide physicians in choosing tests that will aid them to diagnose infectious diseases in their patients.

[Fusariosis diagnosed in the laboratory of an UH in Tunisia: epidemiological, clinical and mycological study]

The genus Fusarium, initially known for its important agro-economic impact, is more and more often implicated in human pathology. In fact, multiples allergic, toxic and infectious manifestations are more reported in immunocompetent and immunocompromised hosts. The objective of our study was to analyse the epidemiological, mycological and clinical features of fusariosis reported in our CHU. Eighty-seven cases of Fusarium infections were collected: 34 cases of onychomycosis (39%), 26 cases of intertrigos (30%), 25 cases of keratomycosis (29%), one case of atypical invasive fusariosis due to Fusarium oxysporum species complex (FOSC) and one case of localized gingivolabial fusariosis due to Fusarium solani species complex (FSSC) in a patient with leukemia in phase of deep bone marrow aplasia, whose outcome was favorable after exiting of aplasia period and a treatment by amphotericine B. The case of pseudotumoral cutaneous fusariosis to F. oxysporum complicated with osteolysis and septic arthritis occurred in a pregnant woman without any immune deficit. The evolution was fatal in spite of prescription of multiple systemic antifungals. Concerning keratomycosis, Fusarium was the first agent responsible for these infections (43%). The corneal traumatism was found in 37.5% of cases and FSSC was the most isolated (72%). For superficial dermatomycosis, Fusarium was the third agent of onychomycosis in molds (25%). The most isolated species were FSSC (68%) and FOSC (20%). The intertrigo frequency was 0.07% and they were mostly caused by FSSC (84%) and FOSC (16%). Fusarium is an important cause of mold infections in our region. So, the species identification is useful because some species are resistant to the most common systemic antifungal agents.

[Fusarium in dermatology]

The relevance of infections with moulds in humans is increasing. Relevant genera are Alternaria, Cladosporium, Scopulariopsis, and Fusarium. Fusarium thereby is characterized by typical makroconidia and special makroscopical features. Known as pathogen in plants the fungi can also cause intoxications and - more seldom - infections, mainly in immunosuppressed patients. Problematic are infections of the eye, which were described in users of contact lenses, they are difficult to treat. Manifestations of skin fusariosis are necroses, ulcerations, papulo-pustular skin lesions as well as abscesses and paronychia. In immuno-compromised patients, these circumscribed lesions can merge into generalized infections. Thus, systemical fusariosis is one differential diagnosis in neutropenic fever. Thereby, systemic fusariosis is often associated with generalized papular and nodular skin lesions, which tend to ulcerate. In some cases, these lesions may be surrounded by a targetoid erythema. Altogether, the prognosis of systemic fusariosis is not favourable. Thus, early diagnosis of the disease is crucial and requires especially the dermatologist as medical consultant.

Cutaneous alternariosis in an adolescent patient

Cutaneous alternariosis is a rare infection typically observed only in immunocompromised adults, but we report here that the infection can occur in apparently healthy adolescents. We saw a clinically healthy adolescent boy who presented with cutaneous alternariosis 6 weeks after suffering a laceration to his right ankle. Treatment with itraconazole resulted in significant improvement after 1 month.

In vitro activities of fluconazole, itraconazole and voriconazole against otomycotic fungal pathogens

OBJECTIVE

To determine the causative pathogens of otomycosis, and to evaluate the in vitro activity of antifungal agents against these pathogens.

MATERIALS AND METHODS

A total of 96 fungal isolate were taken from 92 patients suspected of otomycosis. The in vitro activity of fluconazole, itraconazole and voriconazole against otomycotic pathogens was tested using the E-test method.

RESULTS

The most common pathogen was Aspergillus fumigatus (40.6 per cent), followed by A niger (35.4 per cent), A flavus (12.5 per cent) and Candida albicans (11.5 per cent). All Aspergillus species were found to be resistant to fluconazole (minimum inhibitory concentration > or =256 microg/ml). The mean minimum inhibitory concentrations of voriconazole for A fumigatus, A niger, A flavus and C albicans were significantly lower than those of itraconazole for the same pathogens.

CONCLUSION

This study found that the most common otomycotic fungal pathogen was A fumigatus, and that voriconazole had more potent in vitro activity than itraconazole against all Aspergillus species as well as against C albicans.

Swimming pools and fungi: an environmental epidemiology survey in Italian indoor swimming facilities

A growing number of people attend swimming facilities for recreational activities, rehabilitative treatments, or sport. Filamentous fungi and yeast can be isolated from contaminated air, water and surfaces and may represent a biological risk for employees and users. Here we investigated the occurrence of mycotic species, in a sample of Italian swimming pools (n = 10). Detection and identification of isolated species were achieved by cultural and morphological methods. Results revealed moderate mycotic titres and a high biodiversity. Penicillium spp., Aspergillus spp., Cladosporium spp. and Alternaria sp., were constantly detected in air and surfaces sampled by the swimming area, while pathogenic yeast Candida albicans was never detected. Fusarium spp. was the most common taxon isolated from surfaces. For one facility, we typed the genotypic profiles and studied, by genetic typing, the spatial and temporal distribution of isolates. Phylogenetic relationships between species were analysed by alignment of small ribosomal subunit RNA sequences.