Epidemiology of nosocomial fungal infections: invasive aspergillosis and the environment

Mycoviruses in Fungi: Carcinogenesis of Fungal Agents May Not Always Be Mycotoxin Related

Certain viruses have been found to induce diverse biological pathways to carcinogenesis, evidenced by the presence of viral gene products in some tumors. Despite the fact that many fungal agents contain mycoviruses, until recently, their possible direct effects on human health, including carcinogenesis and leukemogenesis, had not been explored. In this regard, most studies of fungal agents have rightly concentrated on their mycotoxin formation and effects. Recently, the direct role of yeasts and fungi in the etiology of cancers, including leukemia, have been investigated. While greater attention has been placed on the carcinogenic effects of Candida, the role of filamentous fungi in carcinogenesis has also been explored. Recent findings from studies using the enzyme-linked immunosorbent assay (ELISA) technique indicate that the plasma of patients with acute lymphoblastic leukemia (ALL) uniformly contains antibodies for a certain mycovirus-containing Aspergillus flavus, while controls are negative. The exposure of mononuclear leukocytes from patients with ALL in full remission, and long-term survivors, to the product of this organism was reported to result in the re-development of typical genetics and cell surface phenotypes characteristic of active ALL. Mycoviruses are known to be able to significantly alter the biological characteristics and functions of their host. The possible carcinogenic and leukemogenic role of mycoviruses, with and without their host, needs to be further investigated.

Quercetin alleviates gliotoxin-induced duckling tissue injury by inhibiting oxidative stress, inflammation and increasing heterophil extracellular traps release

Aspergillus fumigatus causes aspergillosis with high morbidity and mortality in the duck industry. As a vital virulence factor produced by A. fumigatus, gliotoxin (GT) is widely present in food and feed, threatening duck industry and human health. Quercetin is a polyphenol flavonoid compound from natural plants with anti-inflammatory and antioxidant functions. However, the effects of quercetin on ducklings with GT poisoning are unknown. The model of ducklings with GT poisoning was established, and the protective effects and molecular mechanisms of quercetin on ducklings with GT poisoning were investigated. Ducklings were divided into control, GT, and quercetin groups. A model of GT (2.5 mg/kg) poisoning in ducklings was successfully established. Quercetin protected GT-induced liver and kidney functions and alleviated GT-induced alveolar wall thickening in lungs, cell fragmentation, and inflammatory cell infiltration in liver and kidney. Quercetin decreased malondialdehyde (MDA) and increased superoxide dismutase (SOD) and catalase (CAT) after GT treatment. Quercetin significantly reduced GT-induced mRNA expression levels of inflammatory factors. Furthermore, quercetin increased GT-reduced heterophil extracellular traps (HETs) in serum. These results indicated that quercetin protected ducklings against GT poisoning by inhibiting oxidative stress, inflammation and increasing HETs release, which confirms the potential applicability of quercetin in treating GT-induced duckling poisoning.

Occurrence and control of fungi in water: New challenges in biological risk and safety assurance

Recently, the contamination of fungi in water has aroused widespread concern, which will pose a threat to water quality and safety, and raise diseases risk in the immunocompromised individuals. In this review, the characteristics and different physiological state of fungi in water are summarized. A comprehensive evaluation of the control efficiency and mechanism of waterborne fungi by the commonly used disinfection methods is provided as well. During the disinfection processes of chlorine, chlorine dioxide, chloramine and advanced disinfection processes (ADPs) such as O₃-based ADPs and UV-based ADPs, the fungal spores firstly lost their culturability, followed by membrane integrity, and the intracellular reactive oxygen species level increased at the same time, eventually the fungal spores were completely inactivated. The security strategies of drinking water against the contamination of fungi are also discussed in terms of water sources, water treatment plants and pipe network. Finally, future researches need to be explored are proposed: the rapid detection methods, the production laws and control of mycotoxin, and the outbreak conditions of fungi in water. Specifically, exploring efficient, safe and economical technologies, especially ADPs, is still the main direction in the disinfection of fungi in future studies. This review can offer a comprehensive understanding on the occurrence and control of fungi in water to fill the knowledge gap and provide guidance for the future research.

Assessing compliance of infection prevention mitigation strategies in hospital construction and renovation

Hospital-associated fungal infections from construction and renovation activities can be mitigated using an infection control risk assessment (ICRA) and implementation of infection prevention measures. The effectiveness of these measures depends on proper installation and maintenance. Consistent infection prevention construction rounding with feedback is key to ongoing compliance.

Epidemiological Characterization of Clinical Fungal Isolates from Pauls Stradinš Clinical University Hospital, Latvia: A 4-Year Surveillance Report

Nosocomial fungal infections are an emerging global public health threat that requires urgent attention and proper management. With the limited availability of treatment options, it has become necessary to understand the emerging epidemiological trends, mechanisms, and risk factors. However, very limited surveillance reports are available in the Latvian and broader European context. We therefore conducted a retrospective analysis of laboratory data (2017-2020) from Pauls Stradinš Clinical University Hospital (PSCUH), Riga, Latvia, which is one of the largest public multispecialty hospitals in Latvia. A total of 2278 fungal isolates were analyzed during the study period, with Candida spp. comprising 95% of the isolates, followed by Aspergillus spp. and Geotrichum spp. Amongst the Candida spp., C. albicans and C. glabrata made up about 75% of the isolates. The Department of Lung Diseases and Thoracic Surgery had the highest caseload followed by Intensive Care Department. Majority of the fungal isolates were collected from the bronchoalveolar lavage (37%), followed by urine (19%) and sputum (18%) samples. A total of 34 cases of candidemia were noted during the study period with C. albicans being the most common candidemia pathogen. Proper surveillance of emerging epidemiological trends serve as the most reliable and powerful cornerstone towards tackling this emerging threat.

Comparative genotyping and phenotyping of Aspergillus fumigatus isolates from humans, dogs and the environment

Background

Aspergillus fumigatus is a ubiquitous saprotrophic fungus and an opportunistic pathogen of humans and animals. Humans and animals can inhale hundreds of A. fumigatus spores daily. Normally this is harmless for humans, but in case of immunodeficiency, invasive pulmonary aspergillosis (IPA) can develop with a high mortality rate. A. fumigatus also causes non-invasive mycoses like sino-nasal aspergillosis (SNA) in dogs.

Results

In this study we compared A. fumigatus isolates from humans with suspected IPA, dogs with SNA, and a set of environmental isolates. Phylogenetic inference based on calmodulin (CaM) and beta-tubulin (benA) sequences did not reveal A. fumigatus sub-groups linked to the origin of the isolates. Genotyping and microsatellite analysis showed that each dog was infected by one A. fumigatus genotype, whereas human patients had mixed infections. Azole resistance was determined by antifungal susceptibility testing and sequencing of the cyp51A gene. A total of 12 out of 29 human isolates and 1 out of 27 environmental isolates were azole resistant. Of the azole resistant strains, 11 human isolates showed TR₃₄/L98H (n = 6) or TR46/Y121F/T289A (n = 5). Phenotypically, isolates from dogs were more variable in growth speed and morphology when compared to those isolated from human and the environment.

Conclusions

A. fumigatus from dogs with SNA are phenotypically very diverse in contrast to their environmental and human counterparts.

Phenotypic variability can be induced during the chronic infection process in the sinus of the dogs. The basis of this heterogeneity might be due to genomic differences and/or epigenetic variations.

Differences in dogs is a could be a result of within-host adaption and might be triggered by environmental factors in the sinus, however this hypothesis still needs to be tested.

Electronic supplementary material

The online version of this article (10.1186/s12866-018-1244-2) contains supplementary material, which is available to authorized users.

A polymicrobial fungal outbreak in a regional burn center after Hurricane Sandy

OBJECTIVE

To describe a polymicrobial fungal outbreak after Hurricane Sandy.

DESIGN

An observational concurrent outbreak investigation and retrospective descriptive review.

SETTING

A regional burn intensive care unit that serves the greater Baltimore area, admitting 350-450 burn patients annually.

PATIENTS

Patients with burn injuries and significant dermatologic diseases such as toxic epidermal necrolysis who were admitted to the burn intensive care unit.

METHODS

An outbreak investigation and a retrospective review of all patients with non-candida fungal isolates from 2009-2016 were performed.

RESULTS

A polymicrobial fungal outbreak in burn patients was temporally associated with Hurricane Sandy and associated with air and water permeations in the hospital facility. The outbreak abated after changes to facility design.

CONCLUSIONS

Our results suggest a possible association between severe weather events like hurricanes and nosocomial fungal outbreaks. This report adds to the emerging literature on the effect of severe weather on healthcare-associated infections.

RNA-Seq Profile Reveals Th-1 and Th-17-Type of Immune Responses in Mice Infected Systemically with Aspergillus fumigatus

With the increasing numbers of immunocompromised hosts, Aspergillus fumigatus emerges as a lethal opportunistic fungal pathogen. Understanding innate and acquired immunity responses of the host is important for a better therapeutic strategy to deal with aspergillosis patients. To determine the transcriptome in the kidneys in aspergillosis, we employed RNA-Seq to obtain single 76-base reads of whole-genome transcripts of murine kidneys on a temporal basis (days 0; uninfected, 1, 2, 3 and 8) during invasive aspergillosis. A total of 6284 transcripts were downregulated, and 5602 were upregulated compared to baseline expression. Gene ontology enrichment analysis identified genes involved in innate and adaptive immune response, as well as iron binding and homeostasis, among others. Our results showed activation of pathogen recognition receptors, e.g., β-defensins, C-type lectins (e.g., dectin-1), Toll-like receptors (TLR-2, TLR-3, TLR-8, TLR-9 and TLR-13), as well as Ptx-3 and C-reactive protein among the soluble receptors. Upregulated transcripts encoding various differentiating cytokines and effector proinflammatory cytokines, as well as those encoding for chemokines and chemokine receptors, revealed Th-1 and Th-17-type immune responses. These studies form a basic dataset for experimental prioritization, including other target organs, to determine the global response of the host against Aspergillus infection.

Use of Galactomannan Antigen and Aspergillus DNA Real-time Polymerase Chain Reaction as Routine Methods for Invasive Aspergillosis in Immunosuppressed Children in Greece

PURPOSE

Invasive aspergillosis (IA) remains a critical issue in immunosuppressed patients. Detection of galactomannan antigen (GM) in serum samples is included as a criterion of IA by the European Organization for the Research and Treatment of Cancer/Mycoses Study Group. Nevertheless, Aspergillus DNA detection by polymerase chain reaction (PCR) has not yet been included because clinical data validation is lacking. The present study describes the simultaneous performance of GM and PCR tests as routine methods for IA diagnosis.

METHODS

During the period January 2012 to December 2017, a total of 156 white children hospitalized in a tertiary children's hospital of Athens (97 boys and 59 girls; age range, 5 months-14 years) were examined as possible cases of IA. Patients were classified into 4 groups based on their underlying diseases: hematologic malignancies (107 of 156 [68.6%]), solid tumors (16 of 156 [10.2%]), primary immunodeficiency (12 of 156 [7.7%]), and hereditary immunodeficiency (21 of 156 [13.5%]). GM detection was made with the Platelia Aspergillus Ag kit (Bio-Rad Laboratories, Hercules, California). Sera with a cut-off index ≥0.5 on at least 2 separate blood collections were considered positive. Serum detection of Aspergillus DNA was conducted with real-time PCR MycAssay Aspergillus assay (Myconostica Ltd, Cambridge, United Kingdom). PCR positivity was determined by using a threshold of 38 cycles in at least 1 serum sample. Four or more successive samples per patient were tested.

FINDINGS

Overall, 28 of 156 patients (53 of 744 serum samples) were found positive. Eleven patients were positive using both methods (24 samples). Four children were positive only by PCR (6 samples), whereas 13 (23 samples) were positive only with GM in consecutive samples. Agreement of both methods, GM(+)/PCR(+) or GM(-)/PCR(-), was found in 139 patients (90% of total patients) and 715 samples (96.1% of total samples). The agreement of both methods was found: (1) 85% in patients with hematologic malignancies; (2) 100% in patients with solid tumors; (3) 97.5% in patients with primary immunodeficiency; and (4) 98.8% in patients with hereditary immunodeficiency. Overall disagreement was observed in 17 patients, in which the positive result in any of the 2 methods was estimated as true positive in conjunction with radiologic and other clinical findings.

IMPLICATIONS

The combination of GM and PCR, provided high diagnostic accuracy in consecutive samples (twice a week). Clinical, radiologic, and other laboratory findings should be taken into consideration in the evaluation of GM and PCR.

Acute Invasive Fungal Rhinosinusitis in Immunocompromised Patients: Role of an Early Diagnosis

Objective

The aims of the present study were to evaluate the clinical significance of the delay for surgical treatment and the prognostic value of other clinical, pathologic, and microbiological variables among hematologic patients affected by acute invasive fungal rhinosinusitis (AIFRS). Furthermore, we propose our early diagnosis and treatment protocol, reporting its 10-year results.

Study Design

Monocentric retrospective analysis.

Setting

The study was conducted from 2001 to 2017 at the University Hospital of Bologna, Italy.

Subjects and Methods

The impact of time to treatment and clinical, pathologic, and microbiological variables were analyzed among patients with histologically and microbiologically proven AIFRS. The outcomes of patients treated before the introduction of the early diagnosis protocol were compared with those treated afterward.

Results

Nineteen patients affected by AIFRS were eligible for the study. Treatment delay >4 days ( P = .002), infection caused by Mucorales ( P = .015), and extension of the disease were negative prognostic variables ( P = .017). The application of our protocol significantly reduced the delay for diagnosis and appropriate treatment by an average of 7.3 days ( P = .02).

Conclusion

The promptness of the diagnosis and surgical treatment may play a significant role in the management of AIFRS, as it appears to be significantly associated with the disease outcome. Our protocol may help to reduce the time required for diagnosis of high-risk hematologic patients.

Yeast Biofilm as a Bridge Between Medical and Environmental Microbiology Across Different Detection Techniques

Medical and environmental microbiology have two distinct, although very short, histories stemming, the first from the pioneering works of Sommelweiss, Pasteur, Lister and Koch, the second mainly from the studies of Bejerink and Winogradsky. These two branches of microbiology evolved and specialized separately producing distinct communities and evolving rather different approaches and techniques. The evidence accumulated in recent decades indicate that indeed most of the medically relevant microorganisms have a short circulation within the nosocomial environment and a larger one involving the external, i.e. non-nosocomial, and the hospital environments. This evidence suggests that the differences between approaches should yield to a convergent approach aimed at solving the increasing problem represented by infectious diseases for the increasingly less resistant human communities. Microbial biofilm is one of the major systems used by these microbes to resist the harsh conditions of the natural and anthropic environment, and the even worse ones related to medical settings. This paper presents a brief outline of the converging interest of both environmental and medical microbiology toward a better understanding of microbial biofilm and of the various innovative techniques that can be employed to characterize, in a timely and quantitative manner, these complex structures. Among these, micro-Raman along with micro-Brillouin offer high hopes of describing biofilms both at the subcellular and supercellular level, with the possibility of characterizing the various landscapes of the different biofilms. The possibility of adding a taxonomic identification of the cells comprising the biofilm is a complex aspect presenting several technical issues that will require further studies in the years to come.

Intra- and inter-individual variability of Aspergillus fumigatus reactive T-cell frequencies in healthy volunteers in dependency of mould exposure in residential and working environment

Invasive aspergillosis remains a deadly disease in immunocompromised patients, whereas the combination of an exaggerated immune response and continuous exposure lead to various hyperinflammatory diseases. This pilot study aimed to gain an overview of the intra- and inter-individual variability in Aspergillus fumigatus reactive T-helper cells in healthy adults and the correlation with environmental mould exposure. In this flow cytometric study, the frequencies of CD154⁺ A. fumigatus reactive T cells were evaluated in 70 healthy volunteers. All subjects completed a standardised questionnaire addressing their mould exposure. Subjects with intensive mould exposure in their professional or residential surrounding demonstrated considerably higher mean frequencies of A. fumigatus reactive T-helper and T-memory cells. Comparative evaluation of multiple measurements over time demonstrated relatively conserved reactive T-cell frequencies in the absence of major changes to the exposure profile, whereas those frequently exposed in professional environment or with changes to their risk score demonstrated a marked dependency of antigen reactive T-cell frequencies on recent mould exposure. This pilot study was the first to provide data on the intra-individual variability in A. fumigatus reactive T-cell frequencies and its linkage to mould encounter. Fungus reactive T cells are to be considered a valued tool for the assessment of environmental mould exposure.

Evaluating of fungal contamination in hospital wet cooling systems in Markazi province, Central Iran

OBJECTIVE

Fungal infections are common complication among hospitalized patients especially between who is immunocompromised. Wet cooling systems in the hospital environment play a critical role as a source of these infections. The aim of this study was survey of wet cooling system of hospitals for fungal contamination in Arak city.

MATERIALS AND METHODS

This study was conducted during May to September of 2016. Sampling was done as random. Samples were obtained from water and straw of 84 wet cooling systems of four hospitals in Arak city. Samples were cultured in Sabouraud dextrose agar medium contain of chloramphenicol. Identification of fungi was performed by Slide culture method.

RESULTS

From 84 wet cooling systems, 32 (38.1%) were contaminated with fungi. The highest fungal contamination was found in wards of oncology and CCU. The most prevalent of fungi isolated in this study were Aspergillus spp. and Candida spp., respectively.

CONCLUSION

The findings of this descriptive cross-sectional study clearly indicate, in wards of the hospital that used wet cooling systems, there was considerable fungal contamination, particularly Aspergillus contamination. These results highlight a clear need for greater attention to the use of non-aqueous or closed circulation cooling systems, especially where susceptible patients receive medical care.

Outbreak of Bloodstream Infection With the Mold Phialemonium Among Patients Receiving Dialysis at a Hemodialysis Unit

Background

Molds are a rare cause of disseminated infection among dialysis patients.

Objective.

We evaluated a cluster of intravascular infections with the mold Phialemonium among patients receiving hemodialysis at the same facility in order to identify possible environmental sources and prevent further infection.

Design.

Environmental assessment and case-control study.

Setting.

A hemodialysis center affiliated with a tertiary care hospital.

Methods.

We reviewed surveillance and clinical microbiology records and performed a blood culture survey for all patients. The following data for case patients were compared with those for control patients: underlying illness, dialysis characteristics, medications, and other possible exposure for 120 days prior to infection. Environmental assessment of water treatment, dialysis facilities, and heating, ventilation, and air-conditioning (HVAC) systems of the current and previous locations of the dialysis center was performed. Samples were cultured for fungus; Phialemonium isolates were confirmed by sequencing of DNA. Investigators observed dialysis access site disinfection technique.

Results.

Four patients were confirmed as case patients, defined as a patient having intravascular infection with Phialemonium species; 3 presented with fungemia, and 1 presented with an intravascular graft infection. All case patients used a fistula or graft for dialysis access, as did 12 (75%) of 16 of control patients (P = .54). Case and control patients did not differ in other dialysis characteristics, medications received, physiologic findings, or demographic factors. Phialemonium species were not recovered from samples of water or dialysis machines, but were recovered from the condensation drip pans under the blowers of the HVAC system that supplied air to the dialysis center. Observational study of 21 patients detected suboptimal contact time with antiseptic agents used to prepare dialysis access sites.

Conclusion.

The report of this outbreak adds to previous published reports of Phialemonium infection occurring in immunocompromised patients who likely acquired infection in the healthcare setting. Recovery of this mold from blood culture should be considered indicative of infection until proven otherwise. Furthermore, an investigation into possible healthcare-related environmental reservoirs should be considered.

Exploring ecological modelling to investigate factors governing the colonization success in nosocomial environment of Candida albicans and other pathogenic yeasts

Two hundred seventy seven strains from eleven opportunistic species of the genus Candida, isolated from two Italian hospitals, were identified and analyzed for their ability to form biofilm in laboratory conditions. The majority of Candida albicans strains formed biofilm while among the NCAC species there were different level of biofilm forming ability, in accordance with the current literature. The relation between the variables considered, i.e. the departments and the hospitals or the species and their ability to form biofilm, was tested with the assessment of the probability associated to each combination. Species and biofilm forming ability appeared to be distributed almost randomly, although some combinations suggest a potential preference of some species or of biofilm forming strains for specific wards. On the contrary, the relation between biofilm formation and species isolation frequency was highly significant (R² around 0.98). Interestingly, the regression analyses carried out on the data of the two hospitals separately were rather different and the analysis on the data merged together gave a much lower correlation. These findings suggest that, harsh environments shape the composition of microbial species significantly and that each environment should be considered per se to avoid less significant statistical treatments.

New advances in invasive aspergillosis immunobiology leading the way towards personalized therapeutic approaches

Invasive aspergillosis (IA) remains a devastating disease in immune compromised patients despite significant advances in our understanding of fungal virulence and host defense mechanisms. In this review, we summarize important research advances in the fight against IA with particular focus on early events in the interactions between Aspergillus fumigatus and the host that occur in the respiratory tract. Advances in understanding mechanisms of immune effector cell recruitment, antifungal effector mechanisms, and how the dynamic host-fungal interaction alters the local microenvironment to effect outcomes are highlighted. These advances illustrate exciting new therapeutic opportunities, but also emphasize the importance of understanding each unique fungus-host interaction for improving patient outcomes.

Fungi, Water Supply and Biofilms

Even though it has been studied for many years, water-related infectious risk still exists in both care and community environments due to the possible presence of numerous microorganisms such as bacteria, fungi and protists. People can be exposed directly to these microorganisms either through aerosols and water, after ingestion, inhalation, skin contact and entry through mucosal membranes, or indirectly usually due to pre-treatment of some medical devices. Species belonging to genera such as Aspergillus, Penicillium, Pseudallesheria, Fusarium, Cuninghamella, Mucor and in some particular cases Candida have been isolated in water from health facilities and their presence is particularly related to the unavoidable formation of a polymicrobial biofilm in waterlines. Fungi isolation methods are based on water filtration combined with conventional microbiology cultures and/or molecular approaches; unfortunately, these are still poorly standardized. Moreover, due to inappropriate culture media and inadequate sampling volumes, the current standardized methods used for bacterial research are not suitable for fungal search. In order to prevent water-related fungal risk, health facilities have implemented measures such as ultraviolet radiation to treat the input network, continuous chemical treatment, chemical or thermal shock treatments, or microfiltration at points of use. This article aims to provide an overview of fungal colonization of water (especially in hospitals), involvement of biofilms that develop in waterlines and application of preventive strategies.

In-hospital transfer is a risk factor for invasive filamentous fungal infection among hospitalized patients with hematological malignancies: a matched case-control study

OBJECTIVE

Immunocompromised patients now benefit from a longer life expectancy due to advanced medical techniques, but they are also weakened by aggressive treatment approaches and are at high risk for invasive fungal disease. We determined risk factors associated with an outbreak of invasive filamentous fungal infection (IFFI) among hospitalized hemato-oncological patients.

METHODS

A retrospective, matched, case-control study was conducted between January 1, 2009, and April 31, 2011, including 29 cases (6 proven, 8 probable, and 15 possible) of IFFI and 102 matched control patients hospitalized during the same time period. Control patients were identified from the hospital electronic database. Conditional logistic regression was performed to identify independent risk factors for IFFI.

RESULTS

Overall mortality associated with IFFI was 20.7% (8.0%-39.7%). Myelodysplastic syndrome was associated with a higher risk for IFFI compared to chronic hematological malignancies. After adjustment for major risk factors and confounders, >5 patient transfers outside the protected environment of the hematology ward increased the IFFI risk by 6.1-fold. The risk increased by 6.7-fold when transfers were performed during neutropenia.

CONCLUSION

This IFFI outbreak was characterized by a strong association with exposure to the unprotected environment outside the hematology ward during patient transfer. The independent associations of a high number of transfers with the presence of neutropenia suggest that affected patients were probably not sufficiently protected during transport in the corridors. Our study highlights that a heightened awareness of the need for preventive measures during the entire care process of at-risk patients should be promoted among healthcare workers.

Acute Central Nervous System Complications in Pediatric Acute Lymphoblastic Leukemia

BACKGROUND

The outcome of childhood acute lymphoblastic leukemia has improved because of intensive chemotherapy and supportive care. The frequency of adverse events has also increased, but the data related to acute central nervous system complications during acute lymphoblastic leukemia treatment are sparse. The purpose of this study is to evaluate these complications and to determine their long term outcome.

PATIENTS AND METHODS

We retrospectively analyzed the hospital reports of 323 children with de novo acute lymphoblastic leukemia from a 13-year period for acute neurological complications. The central nervous system complications of leukemic involvement, peripheral neuropathy, and post-treatment late-onset encephalopathy, and neurocognitive defects were excluded.

RESULTS

Twenty-three of 323 children (7.1%) suffered from central nervous system complications during acute lymphoblastic leukemia treatment. The majority of these complications (n = 13/23; 56.5%) developed during the induction period. The complications included posterior reversible encephalopathy (n = 6), fungal abscess (n = 5), cerebrovascular lesions (n = 5), syndrome of inappropriate secretion of antidiuretic hormone (n = 4), and methotrexate encephalopathy (n = 3). Three of these 23 children (13%) died of central nervous system complications, one from an intracranial fungal abscess and the others from intracranial thrombosis. Seven of the survivors (n = 7/20; 35%) became epileptic and three of them had also developed mental and motor retardation.

CONCLUSIONS

Acute central neurological complications are varied and require an urgent approach for proper diagnosis and treatment. Collaboration among the hematologist, radiologist, neurologist, microbiologist, and neurosurgeon is essential to prevent fatal outcome and serious morbidity.

Fungal Infections of the Spine

STUDY DESIGN

Review of the literature.

OBJECTIVE

To retrospectively examine the frequency of published fungal infections by species and the treatment algorithms used to eradicate the disease.

SUMMARY OF BACKGROUND DATA

Fungal infections of the spine present unique challenges to the modern multispecialty treatment team. Although rare in comparison with bacterial infections, fungal infections have been increasing in incidence over the past several decades. Evidences-based practice is limited to referencing smaller case series.

METHODS

MEDLINE, Scopus, and EMBASE searches were carried out by one of the authors as well as by the research desk at the University of Miami/Calder Memorial Library. We included peer-reviewed articles published between 1948 and September 2010; case reports, series, and reviews were all examined and compiled into a database.

RESULTS

A total of 130 articles, representing 157 cases, were included in the review. Aspergillus (60 cases, 38.2% of the total) and Candida species (36 cases, 22.9% of the total) were the 2 most common organisms. Surgery was associated with a greater survival rate than medical management alone in patients with Aspergillus (26.9% mortality in surgical patients; 60% in medically treated patients) and Candida (0% vs. 28.6%). Overall mortality was 19.3%. The overall recurrence rate was 7.4%. Amphotericin use was associated with a higher mortality rate than azoles.

CONCLUSION

Aspergillus is the most common published pathogen in fungal infections of the spine. Recent publications depicting the use of newer antifungal medications such as azoles report higher survival rates. Surgically treated patients in combination with antifungal therapy showed highest frequencies of patient survival in Aspergillus and Candida infections.

LEVEL OF EVIDENCE

3.

Antibody testing in aspergillosis--quo vadis?

Humans are constantly exposed to airborne Aspergillus spores. Most develop Aspergillus-specific antibodies by adulthood. Persons with chronic lung disease or Aspergillus airway colonization often have raised levels of Aspergillus-specific immunoglobululin G (IgG). It is not known whether this signifies an increased risk of future aspergillosis.Chronic and allergic forms of pulmonary aspergillosis are estimated to affect over three million people worldwide. Antibody testing is central to diagnosis of these conditions, with raised Aspergillus-specific IgG in chronic pulmonary aspergillosis and raised Aspergillus-specific IgE in allergic aspergillosis. Antibody levels are also used to monitor treatment response in these syndromes. Acute invasive disease is less common. There is a more limited role for antibody testing in this setting as immunosuppression often results in delayed or absent antibody response.Many methods exist to detect Aspergillus-specific antibodies, but there are limited published data regarding comparative efficacy and reproducibility. We discuss the comparative merits of the available tests in the various clinical settings and their suitability for use in the resource-poor settings where the majority of cases of aspergillosis are thought to occur. We summarize the gaps in existing knowledge and opportunities for further study that could allow optimal use of antibody testing in this field.

IL-1α signaling is critical for leukocyte recruitment after pulmonary Aspergillus fumigatus challenge

Aspergillus fumigatus is a mold that causes severe pulmonary infections. Our knowledge of how A. fumigatus growth is controlled in the respiratory tract is developing, but still limited. Alveolar macrophages, lung resident macrophages, and airway epithelial cells constitute the first lines of defense against inhaled A. fumigatus conidia. Subsequently, neutrophils and inflammatory CCR2+ monocytes are recruited to the respiratory tract to prevent fungal growth. However, the mechanism of neutrophil and macrophage recruitment to the respiratory tract after A. fumigatus exposure remains an area of ongoing investigation. Here we show that A. fumigatus pulmonary challenge induces expression of the inflammasome-dependent cytokines IL-1β and IL-18 within the first 12 hours, while IL-1α expression continually increases over at least the first 48 hours. Strikingly, Il1r1-deficient mice are highly susceptible to pulmonary A. fumigatus challenge exemplified by robust fungal proliferation in the lung parenchyma. Enhanced susceptibility of Il1r1-deficient mice correlated with defects in leukocyte recruitment and anti-fungal activity. Importantly, IL-1α rather than IL-1β was crucial for optimal leukocyte recruitment. IL-1α signaling enhanced the production of CXCL1. Moreover, CCR2+ monocytes are required for optimal early IL-1α and CXCL1 expression in the lungs, as selective depletion of these cells resulted in their diminished expression, which in turn regulated the early accumulation of neutrophils in the lung after A. fumigatus challenge. Enhancement of pulmonary neutrophil recruitment and anti-fungal activity by CXCL1 treatment could limit fungal growth in the absence of IL-1α signaling. In contrast to the role of IL-1α in neutrophil recruitment, the inflammasome and IL-1β were only essential for optimal activation of anti-fungal activity of macrophages. As such, Pycard-deficient mice are mildly susceptible to A. fumigatus infection. Taken together, our data reveal central, non-redundant roles for IL-1α and IL-1β in controlling A. fumigatus infection in the murine lung.

Aspergillus spp. are ubiquitous in the environment, and even though individuals are regularly exposed to fungal spores clinical invasive disease is a rare manifestation. In contrast, individuals with weakened immune systems develop severe disease, such as invasive pulmonary aspergillosis (IPA). IPA is associated with extremely poor prognoses and unacceptably high mortality rates. Knowledge gained from understanding how immunocompetent mammals control Aspergillus challenge will help develop new immunomodulatory strategies aimed at improving patient outcomes. It is well known that neutrophils and monocytes are crucial immune cells that act to limit fungal growth. Our work demonstrates a central role for the cytokine IL-1α in orchestrating the optimal recruitment of neutrophils and monocytes, whereas IL-1β and the inflammasome are more important in activation of anti-fungal activity of the monocytes. Moreover, our studies indicate that CCR2⁺ monocytes are required for optimal production of IL-1α in the lungs of A. fumigatus challenged mice. Thus, our data highlight a crucial role of the IL-1 cytokine in mediating anti-fungal immunity which might be harnessed to treat clinical cases of IPA.

The Role Played by Contaminated Surfaces in the Transmission of Nosocomial Pathogens

Studies in the 1970s and 1980s suggested that environmental surface contamination played a negligible role in the endemic transmission of healthcare-associated infections. However, recent studies have demonstrated that several major nosocomial pathogens are shed by patients and contaminate hospital surfaces at concentrations sufficient for transmission, survive for extended periods, persist despite attempts to disinfect or remove them, and can be transferred to the hands of healthcare workers. Evidence is accumulating that contaminated surfaces make an important contribution to the epidemic and endemic transmission ofClostridium difficile,vancomycin-resistant enterococci, methicillin-resistantStaphylococcus aureus, Acinetobacter baumannii, Pseudomonas aeruginosa,and norovirus and that improved environmental decontamination contributes to the control of outbreaks. Efforts to improve environmental hygiene should include enhancing the efficacy of cleaning and disinfection and reducing the shedding of pathogens. Further high-quality studies are needed to clarify the role played by surfaces in nosocomial transmission and to determine the effectiveness of different interventions in reducing associated infection rates.

Sinonasal risk factors for the development of invasive fungal sinusitis in hematological patients: Are they important?

Invasive fungal sinusitis (IFS) is a highly aggressive infection that can affect hematologic patients. The classically described general risk factors, however, do not fully explain the development of IFS in a small percentage of cases. This study examined the impact of anatomic sinonasal factors and environmental factors on the development of IFS in high-risk patients. Medical records and computed tomography (CT) scans of patients admitted to our institution who were at high risk of developing IFS were retrospectively reviewed. Twenty-seven patients of 797 fulfilled the inclusion criteria. Patients affected by IFS were compared with patients not affected to identify possible sinonasal and environmental risk factors of IFS. Seven patients were excluded because of the lack of adequate radiological images. Six of the 20 eligible patients were assigned to the study group of patients affected by IFS and the remaining 14 patients were assigned to the control group. All but one case developed the infection during the summer with a significantly higher mean environmental temperature (p = 0.002). Anatomic nasal alterations were found in all patients affected by IFS and were significantly more frequent than in the control group (p = 0.014). It would be advisable to have patients with hematologic risk factors of IFS, especially during the summer period, undergo endoscopic nasal assessment. Furthermore, a CT finding of anatomic nasal alterations, such as anterior nasal septum deviation causing nasal obstruction, should increase the suspicion of IFS in case of the occurrence of nasal symptoms.

Hospital environment and invasive aspergillosis in patients with hematologic malignancy

BACKGROUND

To determine whether there is a correlation between sources of Aspergillus spores in a high-efficiency particulate air (HEPA)-filtered environment and nosocomial invasive aspergillosis (IA), we performed a detailed environmental assessment and case review.

METHODS

From April to October 2004, 626 bioaerosol samples, 1,257 surface samples, and 607 water samples were obtained from 74 HEPA-filtered air hospital rooms occupied by 458 patients with hematologic malignancies. Samples were collected prospectively from the room before and after cleaning within 1 hour of patient admission or discharge. Aspergillus spp was isolated from 21 surface samples and 46 bioaerosol samples. Interestingly, Aspergillus spp was not isolated from any water samples.

RESULTS

Aspergillus spp was isolated from 21 surface samples and 46 bioaerosol samples. Interestingly, Aspergillus spp were not isolated from any water samples. The majority (90%) of the positive bioaerosol samples had ≤ 10 colony-forming units of Aspergillus/m3 of air. Only 2 patients developed nosocomial IA. No correlations were found between Aspergillus species isolated from the hospital rooms and those causing IA.

CONCLUSION

The risk of hematologic malignancy patients acquiring nosocomial aspergillosis from water or HEPA-filtered air is very low.

Aspergillus novoparasiticus: a new clinical species of the section Flavi

During a survey on the incidence of Aspergillus in clinical environments, we found some interesting isolates that were morphologically similar to Aspergillus parasiticus, but differed in the color of the colonies and in the pattern of their conidial ornamentation. In the present study, those isolates were characterized using a polyphasic approach. A phylogenetic analysis was carried out, based on partial fragments of the acetamidase (amdS) and O-methyltransferase (omtS) genes and the internal transcribed spacer (ITS) region of rDNA. This information was combined with a detailed morphological and physiological study that included aflatoxin production and assimilation profiles of different carbon and nitrogen sources. The phenotypic and genotypic results support the proposal of a new species, Aspergillus novoparasiticus, phylogenetically placed in a distinct sister clade to that of A. parasiticus. The former has lobate-reticulate conidia and does not produce aspergillic acid on AFPA or organic acids on CREA, while A. parasiticus has echinulate conidia and produces aspergillic and organic acids. In addition, this new species, as well as A. parasiticus, produces aflatoxins B1, B2, G1 and G2.

Aspergillosis: nosocomial or community-acquired?

Discrimination between nosocomial and community infections is important for investigation and prevention. Nosocomial and hospital-acquired infections require appropriate hospital control measures to avert additional cases. Nosocomial infections (NI) occur during hospitalization or are caused by microorganisms acquired during hospital stay. Such infections should not be evident when patients are admitted to the hospital. Furthermore, the definition of NI is based on epidemiological criteria, such as the time lapse between admission and onset, or microbiological criteria. This definition might be difficult to apply to invasive aspergillosis (IA) which often afflicts patients with severe immunosuppression or transplantation. Identification of the source may be difficult which could arise outside or inside the hospital. Another significant issue is the lack of valid and reproducible data on the incubation period. The incubation duration of IA is influenced by different individual or environmental determinants, including the severity of immunosuppression and air quality. The criteria of causality are also a means of discussing the contribution of hospital vs. community determinants of IA. The definition of nosocomial IA remains difficult. A better understanding of early events related to IA onset will help to prevent this disease for which the prognosis remains negative.

Evaluation of nucleic acid sequence based amplification using fluorescence resonance energy transfer (FRET-NASBA) in quantitative detection of Aspergillus 18S rRNA

We attempted to apply fluorescence resonance energy transfer technology to nucleic acid sequence-based amplification (FRET-NASBA) on the platform of the LightCycler system to detect Aspergillus species. Primers and probes for the Aspergillus 18S rRNA were newly designed to avoid overlapping with homologous sequences of human 18s rRNA. NASBA using molecular beacon (MB) showed non-specific results which have been frequently observed from controls, although it showed higher sensitivity (10(-2) amol) than the FRET. FRET-NASBA showed a sensitivity of 10(-1) amol and a high fidelity of reproducibility from controls. As FRET technology was successfully applied to the NASBA assay, it could contribute to diverse development of the NASBA assay. These results suggest that FRET-NASBA could replace previous NASBA techniques in the detection of Aspergillus.

Innate immunity to Aspergillus species

All humans are continuously exposed to inhaled Aspergillus conidia, yet healthy hosts clear the organism without developing disease and without the development of antibody- or cell-mediated acquired immunity to this organism. This suggests that for most healthy humans, innate immunity is sufficient to clear the organism. A failure of these defenses results in a uniquely diverse set of illnesses caused by Aspergillus species, which includes diseases caused by the colonization of the respiratory tract, invasive infection, and hypersensitivity. A key concept in immune responses to Aspergillus species is that the susceptibilities of the host determine the morphological form, antigenic structure, and physical location of the fungus. In this review, we summarize the current literature on the multiple layers of innate defenses against Aspergillus species that dictate the outcome of this host-microbe interaction.

Efficacy of copper-silver ionization in controlling biofilm- and plankton-associated waterborne pathogens

The study was to determine the efficacy of copper-silver ionization against the formation of Pseudomonas aeruginosa, Stenotrophomonas maltophilia, and Acinetobacter baumannii in biofilms and planktonic phases. At concentrations below the EPA limits, ionization has potential to control the three waterborne pathogens, in addition to Legionella, in hospital water systems for nosocomial infection control.

New approach for diagnosis of candidemia based on detection of a 65-kilodalton antigen

Nosocomial candidiasis is a major concern in tertiary care hospitals worldwide. This infection generally occurs in patients with degenerative and neoplastic diseases and is considered the fourth most frequent cause of bloodstream infections. Diagnosis of candidemia or hematogenous candidiasis has been problematic because clinical signs and symptoms are nonspecific, leading to delays in diagnosis and, consequently, delays in appropriate antifungal therapy. We developed an inhibition enzyme-linked immunosorbent assay (ELISA) for detection of a 65-kDa antigen in an experimental model of candidemia and for diagnosis of patients in intensive care units (ICUs) with suspected candidemia. An anti-65-kDa monoclonal antibody was tested for detection of the 65-kDa antigen produced by Candida albicans, Candida tropicalis, and Candida parapsilosis in murine candidemia models. The 65-kDa antigen was detected in sera at concentrations ranging from 0.012 to 3.25 microg/ml. A total of 20 human patients with candidemia were then evaluated with the inhibition ELISA using sequential sera. Sixteen (80%) patients had the 65-kDa antigen in concentrations ranging from 0.07 to 5.0 microg/ml. Sequential sera from patients with candidemia presented three different patterns of antigenemia of the 65-kDa molecule: (i) total clearance of antigenemia, (ii) initial clearance and relapse of antigenemia, and (iii) partial clearance of antigenemia. Our results indicate detection of the 65-kDa protein may be a valuable tool for the diagnosis of candidemia by C. albicans, C. tropicalis, and C. parapsilosis.

Rapid detection and quantification of Aspergillus fumigatus in environmental air samples using solid-phase cytometry

Aspergillus fumigatus is an ubiquitous fungus capable of causing severe infections such as aspergilloma, allergic bronchopulmonary aspergillosis, and invasive aspergillosis, especially in immunocompromised patients. Monitoring the number of Aspergillus fumigatus spores in the air is crucial for infection control. In the present study, a novel approach for the quantification of Aspergillus fumigatus, based on solid-phase cytometry (SPC) and immunofluorescent labeling, was developed. The sensitivity and specificity of the assay were confirmed by testing pure cultures. Paecilomyces variotii and Rhizopus stolonifer were codetected but could be excluded on the basis of morphology of the microcolonies. The SPC method has considerable advantages compared to the culture-based method, including its low detection limit (4 cells/m3), its speed (results are obtained within 24 h), and the straightforward microscopic identification of Aspergillus fumigatus. Additionally, comparison of results obtained with both methods demonstrated that they are equally accurate for the quantification of Aspergillus fumigatus in environmental air samples.

A study of air microbe levels in different areas of a hospital

Airborne transmission is an important route for many microbial pathogens in outdoor and indoor environments, including hospitals. A 2-year-long survey of bioaerosol quality in operating theatres (OT), hospital rooms (HR) and maternity wards (MW) at a hospital in Murcia, Spain, was performed. Total aerobic counts (TAC) and fungal load (FL) were assessed using a microbiological air sampler (MAS-100 single-stage impactor). While fungal levels were below 1 cfu/m(3) (0-7.33 cfu/m(3)) in OT, they were higher in MW (mean, 6.9 cfu/m(3); range 0.44-44.67 cfu/m(3)) and in HR (mean, 10.6 cfu/m(3); range, 0-266 cfu/m(3)). In OT the aerobic counts were considerably higher, with a mean of 25.6 cfu/m(3) (range, 1.67-157 cfu/m(3)). MW and HR also showed higher means for total aerobic counts compared to OT. Seasonal changes were not detected in mould and bacteria levels in OT. Hospital renovation occurred during this study and OT adjacent to renovated areas were closed. A survey of TAC and FL in OT resumed when renovation was completed. We observed an outstanding increase in FL (more than 100 cfu/m(3)), particularly Aspergillus spp., during this period, but no significant changes in TAC were observed after renovation.

[Aspergillus spp. in risk areas of transplant patients in a university hospital]

As a consequence of the increase in the number of immunocompromised patients, cases of aspergillosis, due to the opportunist character of this fungus, have increased considerably. Aspergillus fumigatus, Aspergillus flavus, and Aspergillus niger have been found in air and water samples of the majority of investigated hospitals. The aim of the present study was to investigate the presence of aspergilli in transplant patients areas at the Hospital Universitario of Bogotá, Colombia. Samples of air were collected using the MAS-100 Air Sampler from each of the investigated areas. A sample of 100 ml of water was also recovered from these areas. All samples were taken for triplicate and were cultured in 2% Sabouraud Dextrose Agar. The average of aspergilli in air samples was 2.8 CFU/l corresponding to A. flavus, A. niger, Aspergillus versicolor and Aspergillus terreus. In water samples, the average was 17.1 CFU/l corresponding to A. flavus and Aspergillus clavatus. Because potentially pathogenic Aspergillus species were found in the hospital areas were transplant patients are usually kept, active surveillance and a high clinical suspicion should be considered in those patients. Since Aspergillus infections haven't been found so far, a higher fungal load and other host factors might be needed to facilitate the infection.

The study of fungi in drinking water

The occurrence of fungi in drinking water has received increased attention in the last decades, and fungi are now generally accepted as drinking water contaminants. The knowledge about the occurrence and diversity of fungi in water has increased considerably from a low knowledge base. However, the relevance of waterborne fungi for water quality and human health is poorly understood and still conflicting. Scientific reports on effective treatment against fungi in water are also few. This article presents a review of the literature on fungal water studies, including some general results, and considerations of significance, limits, contradictions, precautions, and practical consequences.

Occurrence of fungi in water used at a haemodialysis centre

AIMS

The aim of this study was to identify and determine the diversity, occurrence and distribution of fungi in water used at a haemodialysis centre.

METHODS AND RESULTS

Samples in the hydraulic circuit for the distribution of the water, dialysate samples and samples of sterilization solution from dialysers were collected over a 3-month period, and 500 ml of each sample was filtered through membranes. All together 116 isolates of fungi were recovered from 89% of all water samples collected inside the haemodialysis unit, with prevalence of moulds in tap water samples and of yeasts in dialysate samples. Fusarium spp. was the most abundant genus found, whereas Candida parapsilosis was the predominant yeast species.

CONCLUSIONS

This study demonstrated that various fungi were present in the water system. These data suggest the inclusion of the detection and quantification of fungi in the water of haemodialysis.

SIGNIFICANCE AND IMPACT OF THE STUDY

The recovery of fungi from aqueous haemodialysis environments implies a potential risk for haemodialysis patients and indicates the need for continuous maintenance and monitoring. Further studies on fungi in haemodialysis water systems are required to investigate the organism ability to persist, their role in biofilm formation and their clinical significance.

[Isolation of filamentous fungi from water used in a hemodialysis unit]

Despite the relative frequency of opportunistic fungal infections among hemodialysis patients, the reservoirs for these microorganisms in the environment remain unknown, although some recent studies have made correlations with the water supply as their source. The objective of the present study was to monitor the mycological quality of the water system of a hemodialysis unit in the interior of the State of São Paulo, Brazil, over the period from April to July 2006. Fifteen samples of 1000 ml were collected from seven water distribution points using the membrane filtration technique (0.45 microm). A total of 116 filamentous fungus specimens were isolated, including 47 Trichoderma sp (40.5%), 29 Cladosporium sp (25%), 16 Aspergillus sp (13.8%) and 11 Fusarium sp (9.5%). The results suggest that the water supply for hemodialysis units should also be monitored for mycological contamination, and that effective prophylactic measures should be adopted for minimizing the exposure of these immunodeficient patients to contaminated water sources in the environment.

Occupational risk assessment of aspergillosis after renal transplantation

Returning to work after transplantation is a much-discussed topic today, especially as a measure to avoid permanent work disability. Many transplant patients regain their ability to work 2-6 months after transplantation. However, returning to work should not endanger their health. This means that occupational risks such as occupational exposure to Aspergillus spores must be evaluated. We evaluated the community-acquired aspergillosis risk and in particularly the occupational aspergillosis risk, using the example of a 39-year-old construction worker immunosuppressed after renal transplantation. On one hand the risk is linked to the exposure to microorganisms that the individual is likely to be subjected to, and on the other hand to the factors that modify his state of susceptibility or resistance to these infectious agents. The necessity of immunosuppressive therapy after transplantation elevates the aspergillosis risk, especially 1-6 months after transplantation. There are many professions in which exposure to Aspergillus spores can occur. The risk of acquiring aspergillosis at work exists, but is not quantifiable today. Nevertheless, the risk should be minimized during the period of vulnerability by preventive measures such as restriction of certain activities, changing work methods and reorganizing the work day to adapt to the risk, and wearing personal protective equipment, as well as attention to information about aspergillosis risk and about the likelihood of exposure in the patient's professional and leisure activities.

Bacterial and fungal counts in hospital air: comparative yields for 4 sieve impactor air samplers with 2 culture media

We compared the yields of 4 recently developed sieve impactor air samplers that meet international standard ISO 14698-1, using 2 growth media (tryptic soy agar and malt extract agar) in real conditions of use. Several hospital sites expected to have different densities of airborne microflora were selected in 2 hospitals. The Samplair MK2, Air Ideal, and Mas-100 samplers yielded higher bacterial counts than did the SAS Super-100 device (P<.05). No significant differences in fungal counts were noted between the 4 devices. The use of malt extract agar in addition to tryptic soy agar significantly improved the fungal yield.

Outdoor environmental levels of Aspergillus spp. conidia over a wide geographical area

Unfortunately, little information is available on the 'normal' air and water load of Aspergillus spores and their seasonal changes. We describe the air and water load of Aspergillus spores across the province of Madrid (Spain). We collected samples of air and water (332 samples of air and 148 of water) from selected points and taps (urban and rural environment) in summer, autumn, winter and spring. Temperature, wind speed and humidity at each point were obtained. We collected a total of 369 Aspergillus spp. isolates: 200 A. fumigatus, 94 A. niger, 40 A. flavus, 16 A. nidulans, two A. terreus, and 17 Aspergillus spp. We always found more isolates in the urban environment than in the rural environment (P=0.11). This was also true of A. fumigatus (P=0.014). The autumn collection yielded more isolates than that of the other seasons. The level of conidia in air varied from 0 to 85 c.f.u./m3: 6.4 c.f.u./m3 in summer, 12 in autumn, 2.5 in winter and 1.3 in spring. Changes in atmospheric parameters influenced the levels in air. None of the water samples were positive. Counts of Aspergillus spp. spores were always under 85 c.f.u./m3. Public water does not seem to contain Aspergillus spores.

Fungal infections of the spine

Fungal infections of the spine are relatively uncommon. Fungi such as Coccidioides immitis and Blastomyces dermatitidis are limited to specific geographical areas whereas cryptococcus, candida, and aspergillus are found worldwide. Candida and aspergillus are normal commensals of the body and produce disease in susceptible organisms when they gain access to the vascular system through intravenous lines, during implantation of prosthetic devices, or during surgery. For the other fungi, spinal involvement usually is the result of hematogenous or direct spread of organisms from an initial pulmonary source of infection. Involvement of the vertebral bodies can lead to vertebral compression fractures and gross deformity of the spine. Spread of infection along the anterior longitudinal ligament can lead to psoas or paravertebral abscesses. Early recognition of the disease requires a high index of suspicion, proper travel history, and a detailed physical examination. Treatment relies on the prompt institution of appropriate pharmacotherapy and constant monitoring of clinical progress. Resistance to medical therapy, spinal instability, and neurologic deficits are indications for débridement and stabilization with spinal fusion. Prognosis depends on the premorbid state of the patient, the type of fungal organism, and the timing of treatment.

LEVEL OF EVIDENCE

Level V (expert opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.