Successful treatment of primary cutaneous Aspergillus ustus infection with surgical debridement and a combination of voriconazole and terbinafine

CWI pathway participated in vegetative growth and pathogenicity through a downstream effector AflRlm1 in Aspergillus flavus

The cell wall is an essential dynamic structure for shielding fungus from environmental stress, and its synthesizing and remodeling are regulated by the cell wall integrity (CWI) pathway. Here, we explored the roles of a putative downstream effector AflRlm1 of CWI pathway in Aspergillus flavus. The results showed that AflRlm1 played a positive role in conidia production, sclerotium formation, aflatoxin biosynthesis, and pathogenicity. Furthermore, we provided evidence for the physical connection between AflRlm1 and AflSlt2 and determined the role of AflSlt2 in the phosphorylation of AflRlm1. Then, we discovered the importance of WSCs (cell wall integrity and stress response component) to the CWI signal and the process of AflRlm1 transferring to the nucleus after receiving the signal. Overall, this study clarified the transmission process of CWI signals and proves that the CWI pathway plays a key role in the development of A. flavus and the production of aflatoxin combined with transcriptome data analysis.

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Linked the CWI pathway from membrane receptors to transcription factors in A. flavus

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Found the phosphorylate activation and subcellular metastasis of AflRlm1 in stress

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Discovered the important role of AflRlm1 in aflatoxin biosynthesis

Study of the capacity of the essential oil of Lantana montevidensis to modulate the action of fluconazole on Candida albicans and Candida tropicalis strains

In recent decades, fungal infections have been increasing, as well as the indiscriminate use of large-scale antifungal. The objective of the present study was to characterize the chemical components of L. montevidensis leaf essential oil (EOLm) and evaluate its antifungal potential and fluconazole modulating activity against Candida strains. The essential oil was obtained by hydrodistillation and its chemical components were determined by Gas Chromatography coupled to Mass Spectrometry. The antifungal activity was determined by the microdilution method to determine the minimum inhibitory concentration. The modulatory activity of fluconazole by the oil (EOLm) was evaluated against the four Candida strains. Our results demonstrated a predominance of β-Caryophyllene (34.96%) and Germacrene D (25.49%), while (E)-Caryophyllene (0.08%) and δ-Cadinene (0.13%) were the minor constituents. For the antifungal activity, it was evidenced that the EOLm did not inhibit the growth of Candida albicans (CA LM 77 and CA INQS 40006) and Candida tropicalis (CT INCQS 40042 and CT LM 23), but, potentiated the effect of fluconazole in particular against C. tropicalis, although the FIC index indicates indifferent modulation for all strains tested. This study strongly suggests that administration of the fluconazole in combination with plant essential oils can provide a new opportunity to improve the outcome of the drug effect.

Invasive Aspergillosis Due to Aspergillus Section Usti: A Multicenter Retrospective Study

BACKGROUND

Aspergillus spp. of section Usti (A. ustus) represent a rare cause of invasive aspergillosis (IA). This multicenter study describes the epidemiology and outcome of A. ustus infections.

METHODS

Patients with A. ustus isolated from any clinical specimen were retrospectively identified in 22 hospitals from 8 countries. When available, isolates were sent for species identification (BenA/CaM sequencing) and antifungal susceptibility testing. Additional cases were identified by review of the literature. Cases were classified as proven/probable IA or no infection, according to standard international criteria.

RESULTS

Clinical report forms were obtained for 90 patients, of whom 27 had proven/probable IA. An additional 45 cases were identified from literature review for a total of 72 cases of proven/probable IA. Hematopoietic cell and solid-organ transplant recipients accounted for 47% and 33% cases, respectively. Only 8% patients were neutropenic at time of diagnosis. Ongoing antimold prophylaxis was present in 47% of cases. Pulmonary IA represented 67% of cases. Primary or secondary extrapulmonary sites of infection were observed in 46% of cases, with skin being affected in 28% of cases. Multiple antifungal drugs were used (consecutively or in combination) in 67% of cases. The 24-week mortality rate was 58%. A. calidoustus was the most frequent causal agent. Minimal inhibitory concentrations encompassing 90% isolates (MIC90) were 1, 8, >16, and 4 µg/mL for amphotericin B, voriconazole, posaconazole, and isavuconazole, respectively.

CONCLUSIONS

Aspergillus ustus IA mainly occurred in nonneutropenic transplant patients and was frequently associated with extrapulmonary sites of infection. Mortality rate was high and optimal antifungal therapy remains to be defined.

New species in Aspergillus section Usti and an overview of Aspergillus section Cavernicolarum

Aspergillus sections Usti and Cavernicolarum are accommodated in the subgenus Nidulantes. In the present study, a polyphasic approach using morphology and multi-gene phylogeny was applied to investigate the taxonomy of these two sections. Based on the phylogenetic analysis, Aspergillus section Usti includes 25 species, which can be assigned to four series: Calidousti, Deflecti, Monodiorum and Usti. Aspergillus sigarelli is newly described in this section and this species was isolated from a cigarette from PR China and belongs to series Calidousti. It is clearly distinct from other members in this series based on ITS, BenA, CaM and RPB2 sequences. Aspergillus section Usti members like A. calidoustus and A. granulosus are important opportunistic pathogens, it is speculative that more pathogenetic species will be found by using polyphasic taxonomy approaches. Aspergillus section Cavernicolarum includes five species, the growth rates on agar media and size and ornamentation of conidia are important characters for differentiating species in section Cavernicolarum.

Efficacy of Antifungal Monotherapies and Combinations against Aspergillus calidoustus

Invasive fungal infections due to Aspergillus calidoustus with decreased azole susceptibility are emerging in the setting of azole prophylaxis and are associated with poor outcomes. We assessed the in vitro activity of antifungal drugs used alone or in combinations against A. calidoustus and found a synergistic effect between voriconazole and terbinafine at concentrations within the therapeutic range. An invertebrate Galleria mellonella model of A. calidoustus infection tended to support the potential benefit of this combination.

Factors affecting patient outcome in primary cutaneous aspergillosis

Primary cutaneous aspergillosis (PCA) is an uncommon infection of the skin. There is a paucity of organized literature regarding this entity in regard to patient characteristics, associated Aspergillus species, and treatment modalities on outcome (disease recurrence, disease dissemination, and mortality).We reviewed all published reports of PCA from 1967 to 2015. Cases were deemed eligible if they included the following: patient baseline characteristics (age, sex, underlying condition), evidence of proven or probable PCA, primary treatment strategy, and outcome.We identified 130 eligible cases reported from 1967 to 2015. The patients were predominantly male (63.8%) with a mean age of 30.4 ± 22.1 years. Rates of PCA recurrence, dissemination, and mortality were 10.8%, 18.5%, and 31.5%, respectively. In half of the cases, there was an association with a foreign body. Seven different Aspergillus species were reported to cause PCA. Systemic antifungal therapy without surgery was the most common form of therapy (60% of cases). Disease dissemination was more common in patients with underlying systemic conditions and occurred on average 41.4 days after PCA diagnosis (range of 3-120 days). In a multivariate linear regression model of mortality including only patients with immunosuppressive conditions, dissemination and human immunodeficiency virus/acquired immune deficiency syndrome were statistically significantly associated with increased mortality.Nearly one-third of patients with PCA die with the disease. Dissemination and host status are critical in patient outcome.

Phaeohyphomycosis in Transplant Patients

Phaeohyphomycosis is caused by a large, heterogenous group of darkly pigmented fungi. The presence of melanin in their cell walls is characteristic, and is likely an important virulence factor. These infections are being increasingly seen in a variety of clinical syndromes in both immunocompromised and normal individuals. Transplant patients are especially at risk due their prolonged immunosuppression. There are no specific diagnostic tests for these fungi, though the Fontana-Masson stain is relatively specific in tissue. They are generally seen in a worldwide distribution, though a few species are only found in specific geographic regions. Management of these infections is not standardized due to lack of clinical trials, though recommendations are available based on clinical experience from case reports and series and animal models. Superficial infections may be treated without systemic therapy. Central nervous system infections are unique in that they often affect otherwise normal individuals, and are difficult to treat. Disseminated infections carry a high mortality despite aggressive therapy, usually with multiple antifungal drugs. Considerable work is needed to determine optimal diagnostic and treatment strategies for these infections.

Effective treatment of invasive Aspergillus fumigatus infection using combinations of topical and systemic antifungals in a severely burned patient

The authors describe an invasive Aspergillus fumigatus deep-burn wound infection in a severely burned patient that was successfully treated with a combination of topical terbinafine and systemic voriconazole antifungal therapy. To our knowledge, this is the first case report describing the effective control of an invasive deep-burn wound infection using this combination.

The role of surgical debridement in different clinical manifestations of invasive aspergillosis

Invasive aspergillosis (IA) has a wide spectrum of clinical presentations and is associated with high mortality rates. Early initiation of systemic antimould therapy remains the most important measure to reduce mortality. Surgical debridement is an important additional therapeutic option mainly in cases of extrapulmonary IA. The main intention for surgical intervention in IA is to obtain material for diagnosis and antifungal susceptibility testing. There are, however, also therapeutic implications for surgical interventions in rare manifestation of IA such as endocarditis or mycotic aneurysm. Here, we will review the role of surgical interventions in the treatment of different clinical manifestations of IA.

New taxa in Aspergillus section Usti

Based on phylogenetic analysis of sequence data, Aspergillus section Usti includes 21 species, inclucing two teleomorphic species Aspergillus heterothallicus (= Emericella heterothallica) and Fennellia monodii. Aspergillus germanicus sp. nov. was isolated from indoor air in Germany. This species has identical ITS sequences with A. insuetusCBS 119.27, but is clearly distinct from that species based on β-tubulin and calmodulin sequence data. This species is unable to grow at 37 °C, similarly to A. keveii and A. insuetus. Aspergillus carlsbadensis sp. nov. was isolated from the Carlsbad Caverns National Park in New Mexico. This taxon is related to, but distinct from a clade including A. calidoustus, A. pseudodeflectus, A. insuetus and A. keveii on all trees. This species is also unable to grow at 37 °C, and acid production was not observed on CREA. Aspergillus californicus sp. nov. is proposed for an isolate from chamise chaparral (Adenostoma fasciculatum) in California. It is related to a clade including A. subsessilis and A. kassunensis on all trees. This species grew well at 37 °C, and acid production was not observed on CREA. The strain CBS 504.65 from soil in Turkey showed to be clearly distinct from the A. deflectus ex-type strain, indicating that this isolate represents a distinct species in this section. We propose the name A. turkensis sp. nov. for this taxon. This species grew, although rather restrictedly at 37 °C, and acid production was not observed on CREA. Isolates from stored maize, South Africa, as a culture contaminant of Bipolaris sorokiniana from indoor air in Finland proved to be related to, but different from A. ustus and A. puniceus. The taxon is proposed as the new species A. pseudoustus. Although supported only by low bootstrap values, F. monodii was found to belong to section Usti based on phylogenetic analysis of either loci BLAST searches to the GenBank database also resulted in closest hits from section Usti. This species obviously does not belong to the Fennellia genus, instead it is a member of the Emericella genus. However, in accordance with the guidelines of the Amsterdam Declaration on fungal nomenclature (Hawksworth et al. 2011), and based on phylogenetic and physiological evidence, we propose the new combination Aspergillus monodii comb. nov. for this taxon. Species assigned to section Usti can be assigned to three chemical groups based on the extrolites. Aspergillus ustus, A. granulosus and A. puniceus produced ustic acid, while A. ustus and A. puniceus also produced austocystins and versicolorins. In the second chemical group, A. pseudodeflectus produced drimans in common with the other species in this group, and also several unique unknown compounds. Aspergillus calidoustus isolates produced drimans and ophiobolins in common with A. insuetus and A. keveii, but also produced austins. Aspergillus insuetus isolates also produced pergillin while A. keveii isolates produced nidulol. In the third chemical group, E. heterothallica has been reported to produce emethallicins, 5'-hydroxyaveranthin, emeheterone, emesterones, 5'-hydroxyaveranthin.

[Case of primary cutaneous Aspergillus caldioustus infection caused by nerve block therapy]

We report a case of primary cutaneous Aspergillus caldioustus infection caused by nerve block therapy. A 67-year-old Japanese woman had been treated with oral predonisolon and tacrolimus for adult-onset Still disease and interstitial pneumonia. She presented with a 2-month-history of the lesions on the left back. A biopsy specimen from the skin lesion revealed granulomatous inflammation with hyphae. Culture of the pus and the skin specimen confirmed the diagnosis of cutaneous Aspergillus infection. The sequence of β- tubulin gene was analyzed to confirm the mycological diagnosis and the causative agent was identified as A. caldioustus. The patient was treated with surgical removal of the lesions and oral 200 mg/day itraconazole but she died of infectious interstitial pneumonia due to Pneumocystis jiroveci and Cytomegalovirus infection Percutaneous infection may have been responsible for the incidence of localized infection. There was no evidence of systemic aspergillosis. A. caldioustus is an emerging opportunistic fungal pathogen in immunocompromised patients. Immunocompromised patients who have persistent traumatic atypical skin lesion need to be ruled out of such rare fungus infection. An opportunistic infection in Immunocompromised patients can be life-threatening and prompt treatment based on accurate diagnosis is important.

In vitro evaluation of the type of interaction obtained by the combination of terbinafine and itraconazole, voriconazole, or amphotericin B against dematiaceous molds

In vitro associations using the checkerboard microdilution method indicated lower MIC ranges and MIC median values for each drug (terbinafine, itraconazole, voriconazole, and amphotericin B) in association than those obtained for each single drug. Fractional inhibitory concentration index (FIC) results showed 100% synergism in the association of terbinafine with voriconazole, 96.5% in the association of terbinafine with amphotericin B, and 75.9% in the association of terbinafine with itraconazole. Drug combinations may be useful for treatment of dematiaceous mold infections as an alternative treatment to enhance the effectiveness of each drug.

Update on terbinafine with a focus on dermatophytoses

Since terbinafine was introduced on the world market 17 years ago, it has become the leading antifungal for the treatment of superficial fungal infections, aided by unique pharmacologic and microbiologic profiles. This article reviews mode of action, antimycotic spectrum and disposition profile of terbinafine. It examines the data, accumulated over 15 years, on the comparative efficacy of terbinafine (vs griseofulvin, itraconazole, fluconazole) in the management of the infections for which it is primarily indicated (eg, dermatophytoses) and provides a brief discussion on its use for the treatment of non-dermatophyte infections. Finally, the available data on the newest topical and systemic formulations are introduced.