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Diagnosis of Breakthrough Fungal Infections in the Clinical Mycology Laboratory: An ECMM Consensus Statement. J Fungi (Basel) 2020; 6:jof6040216. [PMID: 33050598 PMCID: PMC7712958 DOI: 10.3390/jof6040216] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022] Open
Abstract
Breakthrough invasive fungal infections (bIFI) cause significant morbidity and mortality. Their diagnosis can be challenging due to reduced sensitivity to conventional culture techniques, serologic tests, and PCR-based assays in patients undergoing antifungal therapy, and their diagnosis can be delayed contributing to poor patient outcomes. In this review, we provide consensus recommendations on behalf of the European Confederation for Medical Mycology (ECMM) for the diagnosis of bIFI caused by invasive yeasts, molds, and endemic mycoses, to guide diagnostic efforts in patients receiving antifungals and support the design of future clinical trials in the field of clinical mycology. The cornerstone of lab-based diagnosis of breakthrough infections for yeast and endemic mycoses remain conventional culture, to accurately identify the causative pathogen and allow for antifungal susceptibility testing. The impact of non-culture-based methods are not well-studied for the definite diagnosis of breakthrough invasive yeast infections. Non-culture-based methods have an important role for the diagnosis of breakthrough invasive mold infections, in particular invasive aspergillosis, and a combination of testing involving conventional culture, antigen-based assays, and PCR-based assays should be considered. Multiple diagnostic modalities, including histopathology, culture, antibody, and/or antigen tests and occasionally PCR-based assays may be required to diagnose breakthrough endemic mycoses. A need exists for diagnostic tests that are effective, simple, cheap, and rapid to enable the diagnosis of bIFI in patients taking antifungals.
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Ruhnke M, Cornely OA, Schmidt-Hieber M, Alakel N, Boell B, Buchheidt D, Christopeit M, Hasenkamp J, Heinz WJ, Hentrich M, Karthaus M, Koldehoff M, Maschmeyer G, Panse J, Penack O, Schleicher J, Teschner D, Ullmann AJ, Vehreschild M, von Lilienfeld-Toal M, Weissinger F, Schwartz S. Treatment of invasive fungal diseases in cancer patients-Revised 2019 Recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Mycoses 2020; 63:653-682. [PMID: 32236989 DOI: 10.1111/myc.13082] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/05/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Invasive fungal diseases remain a major cause of morbidity and mortality in cancer patients undergoing intensive cytotoxic therapy. The choice of the most appropriate antifungal treatment (AFT) depends on the fungal species suspected or identified, the patient's risk factors (eg length and depth of granulocytopenia) and the expected side effects. OBJECTIVES Since the last edition of recommendations for 'Treatment of invasive fungal infections in cancer patients' of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) in 2013, treatment strategies were gradually moving away from solely empirical therapy of presumed or possible invasive fungal diseases (IFDs) towards pre-emptive therapy of probable IFD. METHODS The guideline was prepared by German clinical experts for infections in cancer patients in a stepwise consensus process. MEDLINE was systematically searched for English-language publications from January 1975 up to September 2019 using the key terms such as 'invasive fungal infection' and/or 'invasive fungal disease' and at least one of the following: antifungal agents, cancer, haematological malignancy, antifungal therapy, neutropenia, granulocytopenia, mycoses, aspergillosis, candidosis and mucormycosis. RESULTS AFT of IFDs in cancer patients may include not only antifungal agents but also non-pharmacologic treatment. In addition, the armamentarium of antifungals for treatment of IFDs has been broadened (eg licensing of isavuconazole). Additional antifungals are currently under investigation or in clinical trials. CONCLUSIONS Here, updated recommendations for the treatment of proven or probable IFDs are given. All recommendations including the levels of evidence are summarised in tables to give the reader rapid access to key information.
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Affiliation(s)
- Markus Ruhnke
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | | | - Nael Alakel
- Department I of Internal Medicine, Haematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Boris Boell
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation & Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Justin Hasenkamp
- Clinic for Haematology and Medical Oncology with Department for Stem Cell Transplantation, University Medicine Göttingen, Göttingen, Germany
| | - Werner J Heinz
- Schwerpunkt Infektiologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marcus Hentrich
- Hämatologie und Internistische Onkologie, Innere Medizin III, Rotkreuzklinikum München, München, Germany
| | - Meinolf Karthaus
- Department of Haematology & Oncology, Municipal Hospital Neuperlach, München, Germany
| | - Michael Koldehoff
- Klinik für Knochenmarktransplantation, Westdeutsches Tumorzentrum Essen, Universitätsklinikum Essen (AöR), Essen, Germany
| | - Georg Maschmeyer
- Department of Hematology, Onclogy and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Jens Panse
- Klinik für Onkologie, Hämatologie und Stammzelltransplantation, Universitätsklinikum Aachen, Aachen, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | - Jan Schleicher
- Klinik für Hämatologie Onkologie und Palliativmedizin, Katharinenhospital, Stuttgart, Germany
| | - Daniel Teschner
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew John Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Maria Vehreschild
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Zentrum für Innere Medizin, Infektiologie, Goethe Universität Frankfurt, Frankfurt am Main, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Bonn-Köln, Deutschland
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Florian Weissinger
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germany
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Tsai YH, Wang CH, Hsueh PR, Jean SS, Chen FL, Lee WS. Breakthrough invasive Trichosporon asahii infection in an uremic patient with systemic calciphylaxis complicating necrotizing fasciitis during echinocandin therapy for C. tropicalis. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2019; 52:676-678. [PMID: 31023578 DOI: 10.1016/j.jmii.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/27/2019] [Accepted: 04/01/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Yi-Hsuan Tsai
- Department of Family Medicine, Wan Fang Medical Center, Taipei Medial University, Taipei, Taiwan
| | - Cheng-Hui Wang
- Department of Laboratory Medicine, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan; School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Po-Ren Hsueh
- Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shio-Shin Jean
- Departments of Emergency, Wan Fang Medical Center and School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Fu-Lun Chen
- Division of Infectious Diseases, Departments of Internal Medicine, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wen-Sen Lee
- Division of Infectious Diseases, Departments of Internal Medicine, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Wang CH, Hsueh PR, Chen FL, Lee WS. Breakthrough fungemia caused by Rhodotorula mucilaginosa during anidulafungin therapy. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 52:674-675. [PMID: 29429866 DOI: 10.1016/j.jmii.2018.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Cheng-Hui Wang
- Department of Laboratory Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Po-Ren Hsueh
- Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; National Taiwan University College of Medicine, Taipei, Taiwan
| | - Fu-Lun Chen
- Division of Infectious Diseases, Department of Internal Medicine, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wen-Sen Lee
- Division of Infectious Diseases, Department of Internal Medicine, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Liu J, Mouhayar E, Tarrand JJ, Kontoyiannis DP. Fulminant Cryptococcus neoformans infection with fatal pericardial tamponade in a patient with chronic myelomonocytic leukaemia who was treated with ruxolitinib: Case report and review of fungal pericarditis. Mycoses 2018; 61:245-255. [PMID: 29280197 DOI: 10.1111/myc.12735] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/14/2017] [Accepted: 12/16/2017] [Indexed: 01/16/2023]
Abstract
Cryptococcus neoformans is a saprophytic fungal pathogen that can cause serious illness in immune-compromised hosts and it presents with a wide variety of clinical symptoms. We present a fatal case of fulminant C. neoformans infection presenting as pericardial tamponade in a 71-year-old male with chronic myelomonocytic leukaemia undergoing chemotherapy with the JAK-STAT inhibitor ruxolitinib. We also review the published cases of fungal pericarditis/tamponade. In addition to illustrating an atypical presentation of C. neoformans, this case highlights the risk for opportunistic fungal infections in patients with haematological malignancies, especially the ones treated with small molecule kinase inhibitors.
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Affiliation(s)
- Jing Liu
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Elie Mouhayar
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey J Tarrand
- Department of Clinical Microbiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lee CH, Liao KH, Lin HY, Lui TN, Ou TY, Lee WS. Cryptococcal meningitis complicated with a large abdominal cyst mimicking acute pancreatitis. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2014; 49:466-7. [PMID: 25074629 DOI: 10.1016/j.jmii.2014.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 05/23/2014] [Accepted: 06/12/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Chih-Hsun Lee
- Department of Neurosurgery, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan
| | - Kuo-Hsing Liao
- Department of Neurosurgery, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan.
| | - Hsin-Ying Lin
- Department of Neurosurgery, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan
| | - Tai-Ngar Lui
- Department of Neurosurgery, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan
| | - Tsong-Yih Ou
- Division of Infectious Diseases, Department of Internal Medicine, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan
| | - Wen-Sen Lee
- Division of Infectious Diseases, Department of Internal Medicine, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan.
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