Global guideline for the diagnosis and management of rare mould infections: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology and the American Society for Microbiology

Posaconazole effectiveness in rare invasive fungal infections: A systematic literature review

INTRODUCTION

Mucormycosis, hyalohyphomycosis, chromoblastomycosis, and fungal mycetoma are rare invasive fungal infections (IFIs) that cause significant morbidity and mortality in immunocompromised patients. Few effective treatment options are available for these IFIs.

METHODS

We performed a systematic literature review of MEDLINE and Embase to identify studies published from 2005 (year of posaconazole approval) to 22 October 2022, reporting the efficacy/effectiveness of posaconazole monotherapy or combination therapy for treating mucormycosis, hyalohyphomycosis, chromoblastomycosis, and mycetoma. Positive outcomes or positive clinical outcomes were defined as reporting of a positive efficacy/effectiveness measure (i.e. no relapse, response, cure, radiological improvement, clinical/symptom improvement, or survived therapy).

RESULTS

Of 3207 articles identified (after removing duplicates), 533 articles (mostly case reports) were included. Positive clinical outcomes with posaconazole therapy were observed in most patients with mucormycosis (74.8%, 1197/1601), hyalohyphomycosis (58.5%, 62/106), chromoblastomycosis (90.5%, 19/21), and mycetoma (100%, 5/5). Overall survival was around 70% or greater across the IFIs examined. Positive response was higher in second-line monotherapy than first-line monotherapy in mucormycosis and chromoblastomycosis. Higher mortality was observed with combination therapy than monotherapy in mucormycosis and hyalohyphomycosis infections (except for first-line use in mucormycosis). Positive clinical outcome was 78.6% and overall survival was 78.6% in 323 coronavirus disease-associated mucormycosis infection cases.

CONCLUSIONS

Despite the rarity of these IFIs, substantial data have been published since posaconazole was initially approved in 2005, and the real-world case reports demonstrate that posaconazole is an effective therapeutic option alone or in combination for the treatment of these rare IFIs.

Successful management of Lomentospora prolificans septic arthritis and osteomyelitis in an immunocompetent child: A case report

Available online We report a case of limb-threatening Lomentospora prolificans elbow infection in a 3-year-old immunocompetent boy following a closed fracture. Resolution of infection was achieved following combined aggressive debridement, combined antifungal therapy, voriconazole-loaded bone cement, and antiseptic joint irrigation. This highlights the need for early diagnosis and multi-modal surgical, medical and other novel adjunctive therapies in managing these difficult-to-treat infections. Increased research and improved access to novel antifungal drugs are essential to enhance treatment options for intrinsically multidrug-resistant fungal infections.

A fatal case of fungemia due to Fusarium thapsinum in a patient with lung cancer

Fusarium thapsinum is an uncommon cause of invasive fungal disease. Only one case of a hematological patient has been described previously. Most of cases of Fusarium infection is keratitis affecting healthy people, but fungemia is usually produced in immunossupressed patients, especially in those with neutropenia and/or hematological malignancies. The treatment of this infection is difficult due to the fact that these fungi show high MICs to almost all antifungal drugs. We report a case of F. thapsinum fungemia with a fatal outcome, in a patient with lung cancer. The patient developed fever, mucositis and fungemia, and she rapidly worsened and died as a consequence of this infection.

Global guideline for the diagnosis and management of candidiasis: an initiative of the ECMM in cooperation with ISHAM and ASM

Candida species are the predominant cause of fungal infections in patients treated in hospital, contributing substantially to morbidity and mortality. Candidaemia and other forms of invasive candidiasis primarily affect patients who are immunocompromised or critically ill. In contrast, mucocutaneous forms of candidiasis, such as oral thrush and vulvovaginal candidiasis, can occur in otherwise healthy individuals. Although mucocutaneous candidiasis is generally not life-threatening, it can cause considerable discomfort, recurrent infections, and complications, particularly in patients with underlying conditions such as diabetes or in those taking immunosuppressive therapies. The rise of difficult-to-treat Candida infections is driven by new host factors and antifungal resistance. Pathogens, such as Candida auris (Candidozyma auris) and fluconazole-resistant Candida parapsilosis, pose serious global health risks. Recent taxonomic revisions have reclassified several Candida spp, potentially causing confusion in clinical practice. Current management guidelines are limited in scope, with poor coverage of emerging pathogens and new treatment options. In this Review, we provide updated recommendations for managing Candida infections, with detailed evidence summaries available in the appendix.

Role of liposomal amphotericin B in intensive care unit: an expert opinion paper

INTRODUCTION

Invasive fungal infections (IFI) are frequent in patients admitted to the intensive care unit (ICU). The use of first-line antifungals like triazoles or echinocandins may be limited by the global spread of multi-drug resistance species, drug-drug interactions, low organ penetration, and some safety concerns in case of multi-organ failure. Liposomal amphotericin B (L-AmB) is a polyene drug with a broad activity against mold and yeast and an acceptable safety profile. To outline the role of L-AmB in the treatment of IFI in critically ill patients, a panel of experts was invited to draw up an expert opinion paper on the appropriate place in therapy of L-AmB in different clinical scenarios of patients admitted to ICU.

METHODS

A multidisciplinary group of 16 specialists in infectious disease, microbiology, pharmacology, and intensive care elaborated an expert opinion document through a multi-step approach: (1) the scientific panel defined the items and wrote the statements on the management of IFI in ICU, (2) a survey was submitted to an external panel to express agreement or disagreement on the statements, and (3) the panel reviewed the survey and implemented the final document.

RESULTS

The final document included 35 statements that focused on epidemiology and microbiological rationale of the use of systemic L-AmB in critically ill patients and its potential role in specific clinical scenarios in the ICU.

CONCLUSION

Systemic L-AmB may represent an appropriate therapeutic choice for IFI in ICU patients with different underlying conditions, especially when the use of first-line agents is undermined. This expert opinion paper may provide a useful guide for clinicians.

Contribution of shotgun metagenomics in the diagnosis of a subcutaneous phaeohyphomycosis caused by Parathyridaria percutanea

Diagnosis of subcutaneous infection caused by Parathyridaria percutanea, a rare and emerging tropical fungal pathogen identified in an immunocompromised woman using clinical shotgun metagenomics.

Clinical Features of Invasive Fungal Disease in China Tertiary Hospital: A Prospective, Multicenter Study

Invasive fungal disease (IFD) has high morbidity and mortality, the spectrum of pathogenic fungi and high-risk groups have also changed. Fewer literature focus on the overall incidence of IFD in various departments of general hospitals. Among the adult inpatients in four Chinese tertiary hospitals located in Beijing, Shanghai, Nanning and Nanchang, proven or probable cases of IFD were included prospectively in this study between May 1, 2021 and May 1, 2022. The clinical data were collected and analyzed. A total of 330 patients (342 episodes) with 278 of proven and 64 of probable IFDs were included, including invasive candidiasis (IC) (132, 40.0%), cryptococcosis (64, 19.4%), invasive aspergillosis (IA) (54, 16.4%), Talaromyces marneffei (TsM) infection (43, 13.0%), Pneumocystis pneumonia (PCP) (16, 4.8%), mixed fungal infection (10, 3.0%), other mold or yeast infection. 37.9% occurred in elderly patients (age ≥ 65 years). Nosocomial infection accounted for 44.5%, the proportion of nosocomial infection was highest in patients with IC (81.8%). Diabetes (19.7%) was the most common underlying disease. 83.9% of the 342 episodes of IFD had evidence of fungal culture, while the proportion of microscopic examination and histopathology as mycological evidence was 26.9% and 3.5%, respectively. The cumulative all-cause mortality at 180 days after diagnosis of IFD was 38.5%. Age ≥ 65 years old (HR = 1.670, P = 0.009), ICU (HR = 2.002, P = 0.001), nosocomial infection (HR = 1.630, P = 0.016) and diabetes (HR = 1.679, P = 0.013) were associated with increased death in IFD patients. The prognosis of IFD patients was poor. Doctors should pay attention to nosocomial fungal infection especially in old and diabetes.

Clinical significance and antifungal susceptibility profile of 103 clinical isolates of Scedosporium species complex and Lomentospora prolificans obtained from NIH patients

Reduced susceptibility to antifungals is common among members of genera Scedosporium and Lomentospora, with optimal treatments still not fully defined. In vitro antifungal susceptibility results and clinical data do not comprehensively account for the advent of new Scedosporium species identified by molecular phylogenetics. Using Clinical and Laboratory Standards Institute (CLSI) methodology, we tested a total of 103 clinical isolates obtained from patients at the NIH Clinical Center. The most frequent species were Scedosporium apiospermum (63%) and Scedosporium boydii (11%), followed by Lomentospora prolificans (7%). The novel antifungal olorofim showed the lowest MICs against all Scedosporium spp. and L. prolificans, followed by micafungin. Among the triazoles, voriconazole showed lower MICs against Scedosporium spp. Amphotericin B and posaconazole demonstrated species-specific and inter-species variable activity. Itraconazole, isavuconazole, and terbinafine had higher MIC values against Scedosporium spp. and L. prolificans. Clinical data were retrospectively reviewed for 90 isolates, of which nine patients (28 isolates) had active disease/infection and received antifungal treatment that included voriconazole or posaconazole. Five of these patients (56%) died, while three patients (33%) with chronic granulomatous disease were cured following hematopoietic cell transplantation. In 24 patients (62 isolates), the presence of the fungus was considered airway colonization. In conclusion, our data support the existence of species-specific and inter-species differences in the antifungal susceptibility patterns among members of genera Scedosporium and L. prolificans. The novel investigational antifungal olorofim may be a promising therapy. Our clinical data suggest that host status and administration of antifungal therapy most effective for each Scedosporium species complex are important determinants of outcomes.IMPORTANCEUnderstanding the epidemiology and clinical spectrum of infections caused by Scedosporium species complex and Lomentospora prolificans is integral to improving outcomes, particularly in severely ill and immunocompromised patients. In vitro antifungal susceptibility testing can provide an estimate of antifungal activity against fungal pathogens. Our study showed that species-specific and inter-species differences exist in the distribution of antifungal susceptibility patterns between Scedosporium and L. prolificans. Our clinical data also highlight that host status, along with effective antifungal therapy, plays a crucial role in determining treatment outcomes.

Clinical Significance and Therapeutic Challenges of Scedosporium spp. and Lomentospora prolificans Isolates in a Single-Center Cohort of Lung Transplant Recipients

(1) Background: Emerging fungal infections associated with Scedosporium spp. and Lomentospora prolificans (S/L) are becoming more frequent and are very difficult to treat. Our objective was to analyze the frequency and management of S/L isolates in lung transplant (LTx) recipients, the patient outcomes and in vitro antifungal sensitivity. (2) Methods: We included all patients with S/L isolation during post-transplant follow-up. Data were collected from electronic medical records. All samples were cultivated on Sabouraud Chloramphenicol agar. Isolations of S/L were submitted to in vitro susceptibility tests. (3) Results: A total of 11 (2%) of the 576 LTx recipients included had at least one isolation of S/L. Classification for the 11 cases were colonization (4; 36%) and infection (7; 65%). Five infections were pulmonary (71%) and two were disseminated (29%). S. apiospermum complex was the most frequently occurring isolation in patients with pulmonary disease while L. prolificans was the most frequent in patients with disseminated disease. Ten patients were treated. The most frequent antifungal drugs used were voriconazole (n = 8) and terbinafine (n = 6). Seven patients (70%) received more than one drug. The mortality rate associated with L. prolificans isolation was 50% for colonization and 100% for disseminated disease. (4) Conclusions: Scedosporium spp. and L. prolificans infections are associated with high morbidity and mortality rates. New diagnostic and therapeutic tools are required to reduce the impact of these infections.

Fatal pneumonia with repeated detection of Talaromyces columbinus two years after haploidentical transplantation

Talaromyces columbinus was previously reported in two patients with lung infections under the name Penicillium piceum and one case of dual infection with Aspergillus calidoustus was recently reported.; currently, no treatment has been established. We identified a 61-year-old woman with fatal pneumonia with repeated detection of T. columbinus that developed two years after haploidentical transplantation using alemtuzumab for chronic myeloid leukemia in the blast phase. Seven months after transplantation, her minimal residual disease (MRD) turned positive. Thus, ponatinib was restarted, which resulted in MRD becoming negative again. Nine months after transplantation, she developed autoimmune hemolytic anemia (AIHA); treatment with prednisone (PSL) 35 mg was started. PSL was discontinued one year ten months after transplantation, but was resumed at 5 mg after relapse one year eleven months after transplantation. Two years after transplantation, she developed cough, and a CT scan showed bilateral pulmonary infiltrates. Initiation of antibiotics, voriconazole (VRCZ), posaconazole (PSCZ) and liposomal amphotericin B (L-AMB) did not improve her condition. Sputum culture detected Penicillium species, which was identified as T. columbinus by polymerase chain reaction (PCR). Since the minimal inhibitory concentration (MIC)/minimal effective concentration (MEC) ratio was lower for echinocandins, micafungin (MCFG) was added to L-AMB. However, the patient died of respiratory failure on day 38 of admission. This is the first reported case of T. columbinus infection in Japan. Managing this infection is challenging due to the lack of established diagnostic methods and treatments. Proactive diagnostic testing and case accumulation are needed.

Invasive Fungal Infection by Scedosporium apiospermum with Cerebral Involvement in a Pediatric Patient Affected by Chronic Granulomatous Disease After Hematopoietic Cell Transplant

A 5-year-old boy affected by chronic granulomatous disease (CGD) underwent two allogeneic hematopoietic cell transplants (HCT) from the same unrelated donor. The first HCT was complicated by prolonged fever and primary graft failure. While fully aplastic, the patient developed a disseminated infection by Scedosporium apiospermum involving the knee and parasternal skin (day +34 and +40 post-HCT). The patient was treated with voriconazole and granulocyte transfusions followed by a second HCT 80 days after the first HCT. At day +105, the patient developed fever, headache, and altered level of consciousness associated with multiple bilateral cerebral abscesses at magnetic resonance imaging. The serum B-D-glucan test was positive. Micafungin was added to voriconazole. Despite an initial clinical improvement, the patient developed hydrocephalus. Scedosporium apiospermum was cultured from cerebrospinal fluid. Liposomal amphotericin B, instead of micafungin, was combined with voriconazole as salvage therapy. Unfortunately, the patient developed uncal herniation and died at day +193 from HCT. This case shows that the prognosis of scedosporiosis remains poor despite adequate antifungal treatment. Noteworthy, the B-D-Glucan test is confirmed useful as a non-invasive marker for early diagnosis and may help the differential diagnosis of mycoses.

Disseminated fusariosis after allogenic hematopoietic stem cell transplantation: case report

In allogenic stem cell recipients, invasive fungal disease is a common yet dreaded complication with high mortality. Among these, fusariosis is especially complex to treat due to high intrinsic resistance and few antimycotic options, requiring close cooperation of all involved departments. We here report an instructive case of disseminated fusariosis after allogenic stem cell transplantation with fatal outcome despite maximum treatment.

Elevating fungal care: bridging Brazil's healthcare practices to global standards

Brazil faces unique challenges in managing invasive fungal infections (IFIs) due to diverse ecosystems, a rural workforce, and prevalent health conditions. In Europe, IFIs are primarily associated with transplantation, intensive care, and chronic diseases. Inspired by initiatives in the Caribbean and Latin America in 2019, efforts to map global diagnostic and treatment resources expanded to Africa, Europe, and Asia/Pacific. This study conducts a comparative analysis, mainly drawing data from Brazil and Europe, to investigate IFI epidemiology and management. Data were collected through online surveys distributed to Brazilian and European institutions, with collaborations from scientific organizations. Surveys covered institutional profiles, IFI diagnoses, accessibility to diagnostic techniques, and antifungal drugs. A comparative survey involving 96 Brazilian and 388 European institutions revealed variations in the perception and practices related to fungal pathogens. Differences in ranking and prevalence were observed, along with variations in diagnostic procedures, fluorescence dye usage, culture practices, antifungal medication availability, and technological approaches. Europe exhibited higher utilization rates for molecular diagnostic approaches, including PCR tests, and therapeutic drug monitoring (TDM) was more widespread in Europe compared with Brazil, indicating substantial differences in understanding and managing fungal infections. Customized IFI management is crucial, considering regional differences and addressing technological gaps like underutilized PCR. The study advocates for increased international collaboration, targeted training, and enhanced resources to foster a unified global approach in preventing, diagnosing, and treating IFI.

IMPORTANCE

This work is significant as it highlights the unique challenges Brazil faces in managing invasive fungal infections (IFIs) due to its diverse ecosystems and public health landscape. By comparing Brazil's situation with Europe-where IFIs are mainly linked to transplantation and intensive care-this study identifies key disparities in diagnostic and treatment practices. The findings reveal substantial differences in the availability and use of molecular diagnostics, antifungal drugs, and therapeutic drug monitoring, with Europe demonstrating more advanced practices. By mapping these variations, the study underscores the importance of tailored approaches to IFI management that consider regional differences and technological gaps. Ultimately, it calls for enhanced international collaboration, targeted training, and resource allocation to improve IFI outcomes globally, particularly in regions with limited access to advanced diagnostic tools and treatments.

American Society of Transplantation and Cellular Therapy Series: #8-Management and Prevention of Non-Aspergillus Molds in Hematopoietic Cell Transplantation Recipients

The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to create a guideline focusing on non-Aspergillus invasive molds, which are uncommon yet lethal invasive fungal diseases in the peri-hematopoietic cell transplant (HCT) period. We used a compendium-style approach by dissecting this broad, heterogeneous, and highly complex topic into a series of standalone frequently asked questions (FAQs) and tables. Adult and pediatric infectious diseases and HCT content experts developed, then answered FAQs, and finalized topics with harmonized recommendations. All the evidence for non-Aspergillus invasive mold infection is non-RCT and mostly level III, therefore there are no recommendation grades, and instead key references are provided. Through this format, this "8th" topic in the series focuses on the relevant risk factors, diagnostic considerations, prophylaxis, and treatment approaches relevant to rare mold infections in the pre- and post-transplant periods.

Clinical and Hospital Environmental Fusarium in Taiwan: Molecular Identification, Antifungal Susceptibilities, and Phylogenetic Analyses

BACKGROUND

Fusarium species are emerging pathogens known to cause both superficial and disseminated human infections. Aerosolized Fusarium species in healthcare settings have been associated with nosocomial fusariosis, particularly in patients with severe immunosuppression.

OBJECTIVES

To analyse the phylogenetic relationships of clinical and hospital environmental Fusarium isolates and assess their susceptibility to available antifungal agents.

METHODS

Clinical Fusarium isolates were procured from four hospitals in Taiwan, with environmental air and water sampling collected at Kaohsiung Chang Gung Memorial Hospital (KCGMH). All clinical and hospital environmental Fusarium isolates were identified through gene sequencing of translation elongation factor 1-α and internal transcribed spacer regions of ribosomal DNA. Antifungal susceptibility testing followed the CLSI M38-A3 broth microdilution method.

RESULTS

A total of 41 clinical and 4 hospital environmental Fusarium isolates were identified, belonging to five species complexes (SC): F. solani SC (FSSC) (62.8%), F. fujikuroi SC (FFSC) (14.0%), F. incarnatum-equiseti SC (11.6%), F. dimerum SC (7.0%), and F. oxysporum SC (4.7%). Phylogenetic analysis revealed that clinical Fusarium isolates from KCGMH were closely related to environmental Fusarium isolates from air samples at the same hospital. Amphotericin B exhibited high activity against most Fusarium species. With the exception of FFSC, other Fusarium SC demonstrated significantly elevated MIC values to itraconazole, voriconazole, posaconazole, and isavuconazole.

CONCLUSIONS

FSSC was the most prevalent SC in Taiwan, exhibiting higher MIC values for azoles than FFSC isolates. The clinical Fusarium isolates were observed to form clusters with the corresponding environmental isolates. The potential of airborne nosocomial infections in the healthcare environment cannot be overlooked.

Incidence of Breakthrough Fungal Infections in Patients With Isavuconazole Prophylaxis: A Systematic Review and Meta-analysis

Background

Isavuconazole (ISA) is a newer triazole that has activity against most mold species and has been utilized for prophylaxis as well as treatment in patients with hematologic malignancies (HM) and hematopoietic stem cell transplant (HSCT). However, several studies have documented breakthrough invasive fungal infections (bIFIs). Thus, we conducted a systematic review and meta-analysis to investigate the incidence of bIFIs among patients receiving ISA prophylaxis.

Methods

We conducted a systematic review and meta-analysis of the published literature using the concept of ISA, HSCT, and HM from 5 search engines. In patients with HSCT and HM, the pooled incidence of bIFI while undergoing ISA prophylaxis was calculated via the DerSimonian-Laird random effect model.

Results

The systematic review and meta-analysis included 35 and 19 studies, respectively. In total, 991 patients were identified as using ISA prophylaxis, and the majority had either acute myeloid leukemia or myelodysplastic syndrome (69.9%). The pooled incidence of proven/probable bIFI was 7% (95% CI, 4%-12%, I2 = 55%). The most common pathogen was Aspergillus species (43.1%), followed by Candida (22.4%) and Mucorales (12.1%). In 19 studies, mortality rates were documented and ranged between 0% and 100%; the majority of which were >50%.

Conclusions

In patients with HM or HSCT, we found a high incidence of bIFI while undergoing ISA prophylaxis, with high mortality. Given the lack of randomized clinical trials evaluating ISA in this indication, its role in prophylaxis remains unclear.

Impact of current clinical guidelines on the management of invasive fungal disease

Isavuconazole is a new broad-spectrum antifungal triazole with a better safety profile in terms of drug-drug interactions, adverse effects, and tolerance compared to other azoles. Increasing evidence supports the usefulness of isavuconazole in the treatment of invasive fungal diseases. In this review, we aim to analyze the influence of this new evidence on the main clinical guidelines. We reviewed the most recent consensus guidelines issued by the major infectious diseases societies worldwide, focusing on the novelties regarding the recommendations for the use of isavuconazole in different invasive fungal infections and management strategies. Isavuconazole has been included as first-line therapy for invasive aspergillosis, with slight differences in preference for voriconazole or isavuconazole depending on the clinical scenario. In mucormycosis, isavuconazole is considered an alternative first-line therapy to liposomal amphotericin B, especially in those patients with underlying renal impairment. Additionally, the use of isavuconazole is suggested in salvage scenario for both conditions, and the combination with other mold-active drugs is considered. The guidelines report the promising results obtained with the use of this drug for treating mycoses caused by other molds and rare yeasts, as well as endemic mycoses, but since solid evidence is still lacking, the recommendations in this area are generally weak. Isavuconazole is a suitable therapeutic option for invasive fungal infections, offering efficacy against a range of pathogens, including Aspergillus and fungi within the order Mucorales. Its safety profile and its favorable drug interaction profile make it a valuable alternative to traditional agents like voriconazole or liposomal amphotericin B in certain scenarios. However, continued research is essential to better understand its role in combination therapies and to assess its effectiveness against other fungal species.

Diagnosis and management of invasive fungal infections due to non-Aspergillus moulds

Invasive fungal infection (IFI) due to moulds other than Aspergillus are a significant cause of morbidity and mortality. Non-Aspergillus mould (NAM) infections appear to be on the increase due to an ever-expanding population of immunocompromised hosts. In this review, Mucorales, Scedosporium species, Lomentospora prolificans and Fusarium species are examined in detail, and the microbiology, risk factors, diagnosis and treatment of emerging NAMs such as Paecilomyces variotti, Purpureocillium lilacinum and Rasamsonia are summarized. The challenges in diagnosis are emphasized and the emerging importance of molecular methods is discussed. Treatment of IFI due to NAMs is a multi-pronged and multi-disciplinary approach. Surgery, correction of underlying risk factors, and augmentation of the host immune response are as important as antifungal therapy. Many of these NAMs are intrinsically resistant to the currently licensed antifungal agents, so selection of therapy needs to be guided by susceptibility testing. There are new antifungal agents in development, and these have the potential to improve the efficacy and safety of antifungal treatment in the future. Ongoing research is required to fully delineate the epidemiology of NAM infections, and to develop better diagnostic tools and treatments so that outcomes from these infections can continue to improve.

Clinical aspects and recent advances in fungal diseases impacting human health

Fungal diseases are of growing clinical concern in human medicine as the result of changes in the epidemiology, diversity in clinical presentation, emergence of new pathogens, difficulties in diagnosis and increasing resistance to antifungals of current available classes. There is a need for high disease awareness among the public and healthcare physicians, improvement in diagnostic methods and the development of drugs from new therapeutic classes with an improved resistance profile. In this article, we will explore some key aspects of fungal diseases in humans and provide a general overview of this important topic.

Extracutaneous sporotrichosis

SUMMARYSporotrichosis is a subacute-to-chronic infection endemic to tropical and subtropical regions. It usually involves subcutaneous tissue but can occasionally cause extracutaneous infections, especially in hyperendemic areas. Extracutaneous infections are classified based on the anatomic location of the lesion and the route of infection (primary or multifocal). The clinical forms are as follows: (i) pulmonary (primary or multifocal); (ii) osteoarticular (primary or multifocal); (iii) ocular (ocular adnexal lesions including eyelid lesions, conjunctivitis and dacryocystitis, and intraocular infections); (iv) central nervous system; and (v) mucosal (primary or disseminated). Multifocal clinical presentations are observed mainly in immunocompromised individuals. The diagnosis must be confirmed in the laboratory by mycological examination of the clinical samples. Itraconazole and amphotericin B are the most commonly used antifungal agents for treating pulmonary, osteoarticular, ocular, and mucosal forms. Treatment may include surgical excision of the initial lesions in pulmonary and osteoarticular forms. The treatment of neurological involvement is far from optimal and is associated with a high mortality rate despite long treatment periods.

Climate Change and Medical Mycology

This review explores how climate change influences fungal disease dynamics, focusing on emergence of new fungal pathogens, increased antifungal resistance, expanding geographic ranges of fungal pathogens, and heightened host susceptibility. Rising temperatures and altered precipitation patterns enhance fungal growth and resistance mechanisms, complicating treatment efforts. Climate-driven geographic shifts are expanding the range of diseases like Valley fever, histoplasmosis, and blastomycosis. Additionally, natural disasters exacerbated by climate change increase exposure to fungal pathogens through environmental disruptions and trauma. Many of those impacts affect primarily those already disadvantaged by social determinants of health putting them at increased risk for fungal diseases.

Dematiaceous Molds

Dematiaceous molds are darkly pigmented environmental molds found worldwide, especially prevalent in tropical and subtropical regions. Common genera include Bipolaris, Cladophialophora, Exophiala, and Alternaria. They cause disease in both immunocompetent and immunocompromised individuals, presenting as cutaneous infections, allergic sinusitis, pneumonia, and, rarely, disseminated infections. Contaminated medical products have also led to fungal meningitis outbreaks. Treatment typically involves itraconazole, voriconazole, or posaconazole, along with source control and reduction in immunosuppression, if possible. Newer antifungals may have a role in treatment. Mortality is high in disseminated disease, especially with Lomentospora prolificans in immunocompromised individuals, prompting global efforts to improve diagnostics and treatments.

Uncommon concurrent pulmonary infections: Aspergillus fumigatus and Lomentospora prolificans in an Anti-MDA5 antibody-positive dermatomyositis patient

A 59-year-old female with anti-MDA5 antibody-positive dermatomyositis was treated with prednisolone, tacrolimus, cyclophosphamide, tofacitinib, and plasma exchange. Five months post-treatment, elevated β-D-glucan levels and a pulmonary shadow on CT were noted. Aspergillus fumigatus was identified, leading to voriconazole initiation. A new pulmonary cavity lesion later revealed Lomentospora prolificans. Considering voriconazole resistance, terbinafine was added, resulting in clinical improvement. Vigilant infection monitoring is crucial during anti-MDA5 antibody-positive dermatomyositis treatment.

Antifungal Susceptibility of Melanized Fungi Isolated from CARD9 Deficient Patients: Implications for Treatment of Refractory Infections

BACKGROUND

Inherited genetic deficiencies in the Caspase-associated recruitment domain-containing protein 9 (CARD9) lead to increased susceptibility of patients to opportunistic melanized fungi. Such infections are recalcitrant, and the fungus possibly acquires resistance under therapy.

OBJECTIVE

To evaluate differences of in vitro antifungal susceptibility of strains of melanized fungi originating from patients with CARD9 deficiency versus strains from chronic patients with unclear genetic background.

METHODS

We analyzed a total of 118 isolates, including 33 from patients with CARD9 deficiency, 80 from chronic patients with other undefined immunological features, and 5 environmental strains, all collected between 1997 and 2021. All isolates were identified by sequencing the ITS spacer of the rDNA operon. Broth microdilution susceptibility tests were performed according to CLSI guidelines (M38-A3document).

RESULTS

MIC ranges of strains from infected patients having CARD9 deficiency and other individuals were mostly similar. However, comparing these two groups, the GM MICs of posaconazole, amphotericin B and fluconazole in the CARD9 group were statistically higher and the GM MICs of terbinafine lower than those of undefined genetic background group. The FICI of the CARD9 group were higher than those of the undefined group in the combination of caspofungin plus amphotericin B and amphotericin B plus fluconazole, but lower than the undefined group in the combination of itraconazole plus terbinafine.

CONCLUSIONS

The GM MICs for posaconazole, amphotericin B, and fluconazole were significantly elevated in the CARD9 group compared to the group with undefined chronic infections. For patients with refractory infections, conducting susceptibility testing before treatment can optimize the selection of the most effective therapeutic agent, and the combination therapy of caspofungin with amphotericin B or itraconazole may be considered the preferred treatment option.

Precision Medicine Approach Using Triple Combination Antifungal Therapy for Fusarium Brain Abscesses and Endocarditis in an Adult Burn Patient

We report a management strategy for disseminated Fusarium solani fungal infection in an adult 35% total body surface area burn patient with brain abscesses and concomitant pulmonic valve endocarditis resulting in the longest survival reported in a burn patient. Early in his hospital course, the patient was diagnosed with a Fusarium burn wound infection with concomitant fungemia and was treated with a prolonged course of intravenous (IV) antifungal monotherapy. Shortly thereafter, he developed focal neurologic deficits and was found to have brain abscesses on MRI. He underwent emergent craniotomy with debridement, and triple antifungal therapy was initiated. Transesophageal echocardiography demonstrated pulmonic valve vegetations, which resolved with triple antifungal therapy. Disseminated Fusarium solani infection is quite rare with mortality approaching 100%. Given the rarity of this disease process, there are no established antifungal treatment guidelines. However, this patient survived for approximately 1 year after diagnosis with treatment including source control via craniotomy and debridement coupled with prolonged courses of combination antifungal therapy (given the near pan-resistance of his fungal infection). Pharmacogenomic testing was utilized to establish the patient's metabolism of voriconazole and dosing adjusted accordingly to improve the efficacy of the combination therapy. To our knowledge, an adult burn patient surviving this length of time after Fusarium brain abscesses with disseminated infection has not been previously described.

Non-Candida mycosis in Gulf Cooperation Council (GCC) countries: perspective of a low-incidence region

BACKGROUND

Fungal pathogens are ubiquitous microorganisms that are implicated in a wide range of infections, affecting individuals with underlying health conditions and immune suppression therapy; however, immunocompetent individuals may also be at risk. Among these infections, many are caused by molds and yeasts other than Candida and are recognized in clinical practice, such as aspergillosis, mucormycosis, fusariosis, phaeohyphomycosis, and basidiobolomycosis, among others, each presents different clinical manifestations and requires clinical management specific to the site of involvement. Although pathogenic fungal contaminants and potential sources of mycosis in humans are plentiful in Gulf Cooperation Council (GCC) countries, epidemiological reports regarding mycosis in the region are scarce.

AIM

The aim of this review is to shed some light on the epidemiology of clinically associated molds and yeasts other than Candida and to survey all related case reports and epidemiological studies conducted in the GCC over the past 10 years.

METHODS

A comprehensive search of the Medline (PubMed) and Scopus databases was conducted using the following keywords: Aspergillosis, Mycosis, Mucormycosis, Fusarium, Kuwait, Bahrain, Saudi Arabia, Qatar, Oman and the United Arab Emirates. A timeframe was set to include only articles that were published from 2014 to 2024.

RESULTS

One hundred thirty-five of the 1563 articles examined fulfilled the purpose of this review. Most studies were in Saudi Arabia (45%), Qatar (18%) and Kuwait (16%). Mucormycosis, aspergillosis, phaeohyphomycosis and basidiobolomycosis were among the most commonly reported fungal infections in the GCC, with corresponding mortality rates of 53%, 37%, 69% and 24%, respectively. The average estimations of non-Candida fungal infections indicate a low regional incidence in comparison with global estimations.

CONCLUSION

Awareness and a high index of suspicion are warranted in successfully managing non-Candida mycosis. More specific immunological and molecular markers are needed for differential diagnosis to rule out fungal infections. Additionally, incorporating non-Candida mycosis-related antifungal resistance surveys in GCC national surveillance efforts should be enforced, especially when considering the increase in global mycosis rates.

Antifungal Policy and Practice Across Five Countries: A Qualitative Review

The burden of invasive fungal infections (IFIs) is increasing worldwide. National, regional, and local policies on IFI management should respond to the changing landscape. We assessed antifungal policies from five countries of varying size, IFI burden, and geography: the Netherlands, Italy, South Korea, China, and India. These countries were selected as a representative sample reflecting different types of economic and health systems that patients and providers access worldwide. This assessment focused on a comprehensive range of antifungal policy elements, including recognition and prioritization, awareness and education, prevention and monitoring, diagnosis and coordinated care, access to appropriate treatment, and diagnostic and treatment innovation. Although countries in this analysis all have some form of policy for IFI management, we have identified substantial gaps, including low prioritization of IFI diagnostics, omission of fungal pathogens from antimicrobial resistance policies, and a general lack of awareness and healthcare professional (HCP) training on IFI management. The gaps identified are intended to inform HCPs and policy- and decision-makers about aspects to consider in reducing the IFI burden for patients and health systems while demonstrating responsible antifungal stewardship.

Evaluation of a customised Sensititre YeastOne plate containing isavuconazole for antifungal susceptibility testing in Singapore

This study evaluated the performance of a customised Sensititre YeastOne (SYO) plate including isavuconazole (YIT) against existing practice (comprising SYO YO10 plate and isavuconazole gradient strip) in order to streamline the workflow for antifungal susceptibility testing in a tertiary hospital in Singapore. A total of 101 (51 yeasts and 50 moulds) clinical isolates were included for analysis. Isolates included in the study were recovered from a variety of body sites and reflected the case mix encountered in daily practice. Antifungal susceptibility testing was performed using three methods: YO10, YIT and gradient diffusion strip (for isavuconazole only). Reproducibility, essential agreement (EA) and categorical agreement (CA) were calculated. When YO10 and YIT plates were compared, the reproducibility was 100% for eight common antifungals. The CA was >97% for all antifungals except for amphotericin B (89.4%), but this was attributed to seven isolates with minimum inhibitory concentrations bordering the wild-type (WT) cut-off. The EA obtained when testing isavuconazole using YIT versus gradient diffusion was 77.2% overall, 90.2% for yeasts and 64% for moulds. In conclusion, the YIT plate is suitable for antifungal susceptibility testing of yeasts in our laboratory. Its use for mould isolates needs to be monitored further.

Invasive fungal disease in the immunocompromised host: changing epidemiology, new antifungal therapies, and management challenges

BACKGROUND

Invasive fungal disease (IFD) causes morbidity and mortality in immunocompromised hosts (ICHs). Based on increasing recognition of the impact of IFD on human disease, a recent WHO priority list identified key areas of need.

OBJECTIVES

This review examines changes in the epidemiology of IFD, in particular the emergence of antifungal-resistant pathogens and the current availability of rapid diagnostic tests and antifungal treatment options.

SOURCES

Literature between 2000 and January 2024 regarding fungal epidemiology, diagnostic tests, antifungal resistance, emerging fungal pathogens, and novel antifungal agents in both adult and paediatric ICH were reviewed.

CONTENT

We describe the changing epidemiology and continued burden and mortality of IFD in ICH. Furthermore, we discuss the emergence of antifungal-resistant organisms driven by new immunosuppressed populations, climate change, and antifungal exposure in the individual and environment. We highlight novel antifungal agents and how they will address current unmet needs.

IMPLICATIONS

The changing epidemiology and increased population at risk for IFD, lack of recognition or quantification of risks for IFD with new therapies, current gaps in the availability of rapid diagnostic tests, and the imminent availability of novel antifungals with distinct spectra of activity argue for improved availability of and access to rapid diagnostics, antifungal stewardship programmes, and global access to antifungal agents.

Molecular Identification and Antifungal Susceptibility of Fusarium spp. Clinical Isolates

BACKGROUND

Accurate identification of Fusarium species requires molecular identification. Treating fusariosis is challenging due to widespread antifungal resistance, high rates of treatment failure, and insufficient information relating antifungal susceptibility to the clinical outcome. Despite recent outbreaks in Mexico, there is limited information on epidemiology and antifungal susceptibility testing (AST).

OBJECTIVES

We aimed to analyse the distribution of Fusarium species from a referral centre in Mexico with DNA sequencing and to describe AST to the clinical outcome.

METHODS

We conducted a retrospective study on clinical isolates of Fusarium. They were identified by translation elongation factor-1α gene amplification and sequencing. AST was performed to determine minimal inhibitory concentrations (MICs).

RESULTS

A total of 35 Fusarium isolates from 26 patients were included. The most common was Fusarium solani species complex (FSSC) in 51.5%, of which Fusarium petroliphilum and Fusarium oxysporum species complex were the most frequent with 37% and 20%, respectively. AST did not show MICs above the epidemiological cut-off value. Fusariosis was diagnosed in 19 patients, mostly with hematologic neoplasm; the overall mortality rate was 32%.

CONCLUSIONS

Fusarium petroliphilum from the FSSC was found most frequently. Elevated mortality and MICs for all tested antifungals were found, with higher MIC50 among F. solani SC than F. oxysporum SC or F. fujikuroi SC.

Nomenclature for human and animal fungal pathogens and diseases: a proposal for standardized terminology

Medically important pathogenic fungi invade vertebrate tissue and are considered primary when part of their nature life cycle is associated with an animal host and are usually able to infect immunocompetent hosts. Opportunistic fungal pathogens complete their life cycle in environmental habitats or occur as commensals within or on the vertebrate body, but under certain conditions can thrive upon infecting humans. The extent of host damage in opportunistic infections largely depends on the portal and modality of entry as well as on the host's immune and metabolic status. Diseases caused by primary pathogens and common opportunists, causing the top approximately 80% of fungal diseases [D. W. Denning, Lancet Infect Dis, 24:e428-e438, 2024, https://doi.org/10.1016/S1473-3099(23)00692-8], tend to follow a predictive pattern, while those by occasional opportunists are more variable. For this reason, it is recommended that diseases caused by primary pathogens and the common opportunists are named after the etiologic agent, for example, histoplasmosis and aspergillosis, while this should not be done for occasional opportunists that should be named as [causative fungus] [clinical syndrome], for example, Alternaria alternata cutaneous infection. The addition of a descriptor that identifies the location or clinical type of infection is required, as the general name alone may cover widely different clinical syndromes, for example, "rhinocerebral mucormycosis." A list of major recommended human and animal disease entities (nomenclature) is provided in alignment with their causative agents. Fungal disease names may encompass several genera of etiologic agents, consequently being less susceptible to taxonomic changes of the causative species, for example, mucormycosis covers numerous mucormycetous molds.

Update on methods used for mycological testing: wide diversity and opportunities for improvement persist

Past analysis of laboratory methods used for mycology specimens revealed significant variation in practices, many of which fell short of recommended procedures. In 2016 these findings led to a set of recommendations for laboratories to consider modification of their methods where appropriate, to analyse current laboratory methods used by participants in the Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP) Mycology module, and to compare these to the 2016 recommendations. Seven test items, with 105-107 participants each, were analysed. Several laboratories (7-12%) did not handle specimens as recommended in an appropriate biological safety cabinet. Direct microscopy was not performed on tissue specimens 23-25% of the time. The most used staining method was potassium hydroxide with an optical brightener for fluorescent microscopy (49%) followed by Gram stain (33%). While 17-25% of laboratories used three or more media, use of four or more was uncommon (<3%). Between 9-13% of participants used only a single non-inhibitory medium for cultures. Urine specimens were incubated longer than recommended with 57% of laboratories incubating for >7days and 24% >21 days. Duration of incubation was shorter than recommended for several specimen types with 36% of skin specimens and 37-48% of tissue specimens being kept ≤21 days. For cultures kept >7 days, 13% were inspected daily, but for those incubating >14 days only 3%. The methods of several laboratories remain outside recommended practice. An updated set of recommendations are made.

Reassessment of the role of combination antifungal therapy in the current era

PURPOSE OF REVIEW

Given the high mortality and morbidity associated with invasive fungal diseases (IFDs), the use of combination antifungal therapies is often considered despite the dearth of data. This review aims to summarize the current state of literature of combination antifungal therapies, discussing the potential roles of newer antifungal combinations and key considerations for their clinical use.

RECENT FINDINGS

In infections other than cryptococcal meningitis or in the setting of empirical treatment for suspected azole-resistant Aspergillus infections, the utility of the combination antifungal approaches remains controversial given the paucity of well designed randomized controlled trials. Data on potential combined antifungal treatments have been primarily limited to in-vitro studies, animal models, case reports and/or observational studies. With availability of novel antifungal agents (e.g. ibrexafungerp, fosmanogepix), combination therapy to treat mould infections should be re-visited. A phase 2 clinical trial of ibrexafungerp combined with voriconazole to treat invasive pulmonary aspergillosis is on-going.

SUMMARY

There is a need to investigate the use of combination antifungal agents. This includes delineating the indication of these combined antifungal therapies and determining how to use them most appropriately in the clinical setting.

Two cases of fungemia due to Lomentospora prolificans in haematological patients with different outcome

Lomentospora prolificans is an uncommon cause of invasive fungal disease, but it is associated with high mortality because it is difficult to treat. Most of severe cases are produced in immunossupressed patients, especially in those with neutropenia and/or hematological malignancies. Resistance to the majority of antifungal agents can be still observed. Here we report two cases of L. prolificans fungemia with different outcome, since in one of these patients treatment with one of the new antifungals could be applied. Both patients were treated with different antifungal drugs, but only the second one survived due to therapy with fosmanogepix®. The current treatment is still based on a combination of conventional antifungal drugs, although in much cases this strategy is not sufficient. The introduction of new promising antifungal agents such as fosmanogepix® and olorofim® may open new perspectives in the treatment of invasive infections caused by L. prolificans, as in our patient.

Phaeohyphomycosis Due to Verruconis gallopava: Rare Indolent Pulmonary Infection or Severe Cerebral Fungal Disease?

INTRODUCTION

Phaeohyphomycoses are uncommon and poorly understood opportunistic fungal infections, characterized by a wide spectrum of clinical manifestations ranging from localized skin lesions to disseminated disease. Most frequent genera are Alternaria, Cladophialophora, Exophiala or Curvularia. Less common ones, such as Verruconis gallopava, initially described as responsible of encephalitis of turkeys, pose significant challenges for diagnosis and treatment.

MATERIAL AND METHODS

Following the description of a clinical case, we performed a comprehensive review of 48 cases of V. gallopava infection, a rarely reported species from 1986 to 2024.

RESULTS

Solid organ transplant recipients and patients with hematological malignancies are the population most at-risk. Clinical presentation is nonspecific but can be divided in two main entities, pulmonary and cerebral localizations. This later is associated with a mortality rate over 80% and was significantly more frequently reported in liver transplant recipients (p = 0.03). When tested, ß-D-glucans were positive in all cases. Antifungal susceptibility testing demonstrated low MICs for amphotericin B and all azoles but isavuconazole and fluconazole. Clinical outcomes support the use of amphotericin B, voriconazole, itraconazole and posaconazole as valid treatment options.

DISCUSSION

It is not known whether the cerebral cases are primary or secondary to pulmonary lesions. The indolent pulmonary lesions should prompt a complete work-up including biopsy with pathology and mycology expertise since the differential diagnosis is a cancer lesion.

Fusarium spp. causing invasive disease in humans: A case series from north India

Owing to their inherent resistance to different classes of antifungals, early identification of Fusarium spp. is crucial. In this study, 10 clinical isolates were included from patients with invasive fusariosis involving lungs, sinuses, or both. Clinico-radiological data were collected. Samples were processed by standard laboratory procedures. Three gene regions (ITS, TEF1, and RPB2) were amplified by PCR for multilocus sequencing. Fusarium MLST, FUSARIUM-ID, and FUSARIOID-ID databases were used for final identification. Antifungal susceptibility testing was performed by broth microdilution following CLSI M38-A3 and Sensititre™ YeastOne™ YO9 plate. Pulmonary involvement was seen in all patients, and sino-nasal involvement was present in six. Radiologically, consolidations and cavitations were present in eight and six cases, respectively. Halo sign was present in six; reverse halo sign was also found in three of them. Direct microscopy showed septate hyphae that were morphologically different from those found in aspergillosis. Results of the molecular identification were as follows: two Fusarium irregulare, one Fusarium pernambucanum, one Fusarium incarnatum, one Fusarium sp. FIESC 30, two Fusarium keratoplasticum, one Fusarium falciforme, one Fusarium pseudonygamai, and one Fusarium delphinoides. For both Fusarium solani (FSSC) and Fusarium incarnatum-equiseti (FIESC) species complexes, amphotericin B had the lowest minimum inhibitory concentrations (MICs). Importantly, for terbinafine, all FIESC isolates had low MICs, while FSSC isolates had high MICs. In some cases, early identification of Fusarium spp. is possible by means of morphology of hyphae on direct microscopy and findings on radiology. Molecular identification, at least to the species complex level, is crucial for the choice of antifungals.

Review of the novel antifungal drug olorofim (F901318)

There is clearly a need for novel antifungal agents, not only concerning spectrum, but also oral bioavailability, tolerability, and drug-drug interactions. There is growing concern for antifungal resistance for current available antifungals, mainly driven by environmental fungicide use or long-term exposure to antifungals, in the setting of mould-active prophylaxis or for chronic antifungal infections, such as chronic pulmonary aspergillosis. Moreover, the incidence of breakthrough infections is increasing, because of the introduction of (mould-active) prophylaxis (1-4). There is emergence of difficult to treat invasive fungal infections, such as those caused by Lomentospora prolificans, cryptic species of Aspergillus, Scedosporium and Coccidioides. Olorofim (F901318) is the first-in class of the orotomides, a novel antifungal class targeting dihydroorotate dehydrogenase (DHODH), a key enzyme in the biosynthesis of pyrimidines. Olorofim shows good in vitro and in vivo activity against Aspergillus species, rare and difficult to treat moulds and endemic dimorphic fungi, including azole- and amphotericin-resistant isolates. It lacks activity against yeasts and the Mucorales species. It is only orally available and shows very promising results in ongoing clinical trials. In this review we will describe the mechanism of action of olorofim, the spectrum of activity in vitro and in vivo, pharmacokinetics, pharmacodynamics, drug-drug interactions, resistance, and clinical outcomes.

Exploring the Siderophore Portfolio for Mass Spectrometry-Based Diagnosis of Scedosporiosis and Lomentosporiosis

Scedosporium apiospermum and Lomentospora prolificans secrete siderophores (iron scavengers) during hyphal proliferation. Siderophores are virulence factors and potential clinical biomarkers of invasive scedosporiosis and lomentosporiosis. Both strains secreted a uniform spectrum of siderophores, including coprogen B (CopB), N α-methyl-coprogen B, dimethyl-coprogen, and ferricrocin, with N α-methyl-coprogen B being the fastest secreted and most abundant coprogen. Under iron and zinc restriction, reflecting a nutrient-limited host environment, L. prolificans secreted 45 times more CopB than did S. apiospermum, presumably contributing to its higher virulence. This robust mobilization of CopB was further enhanced by zinc surplus. Additionally, two novel cyclic peptides, Scedocyclin A and B, were characterized inScedosporium boydii using the de novo sequencing tool CycloBranch. Utilizing matrix-assisted laser desorption/ionization, the portfolio of coprogens detected had limits of detection and quantitation of 4.9 and 14.6 fmol/spot in complex matrices, respectively, making them strong candidates for the next-generation, routine diagnosis of invasive scedosporiosis and lomentosporiosis through the Biotyper siderotyping.

The pathobiology of human fungal infections

Human fungal infections are a historically neglected area of disease research, yet they cause more than 1.5 million deaths every year. Our understanding of the pathophysiology of these infections has increased considerably over the past decade, through major insights into both the host and pathogen factors that contribute to the phenotype and severity of these diseases. Recent studies are revealing multiple mechanisms by which fungi modify and manipulate the host, escape immune surveillance and generate complex comorbidities. Although the emergence of fungal strains that are less susceptible to antifungal drugs or that rapidly evolve drug resistance is posing new threats, greater understanding of immune mechanisms and host susceptibility factors is beginning to offer novel immunotherapeutic options for the future. In this Review, we provide a broad and comprehensive overview of the pathobiology of human fungal infections, focusing specifically on pathogens that can cause invasive life-threatening infections, highlighting recent discoveries from the pathogen, host and clinical perspectives. We conclude by discussing key future challenges including antifungal drug resistance, the emergence of new pathogens and new developments in modern medicine that are promoting susceptibility to infection.

Reappraising Cladophialophora bantiana phaeohyphomycosis in France: retrospective nation-based study

BACKGROUND

Cladophialophora bantiana is one of the most virulent phaeohyphomycetes, typically causes non-angiogenic single (or sometimes multiple) cystic brain lesions, and has resulted in a mortality rate of up to 70%. Most C bantiana cases are described either in a series of isolated reports or in very small cohorts. The aim of this retrospective nation-based study was to share the data on C bantiana phaeohyphomycosis cases reported in France and French overseas territories over the past two decades to improve understanding of this disease.

METHODS

Patients with C bantiana infection were processed through the active surveillance programme of invasive fungal infections launched by the National Reference Center for Mycoses and Antifungals, Institut Pasteur (Paris, France), and the French Surveillance Network of Invasive Fungal Infections, which involved 29 hospitals from mainland France and overseas French territories. Only proven and probable cases of infection, according to the revised and updated consensus definitions from the European Organization for Research and Treatment of Cancer and Mycoses Study Group, were included in the study. Patients were diagnosed or confirmed, or both, using a polyphasic approach at the Institut Pasteur between 2002 and 2022. Patients were separated into two groups: those with CNS involvement and those with no CNS involvement. The primary outcome was the survival rate.

FINDINGS

A total of 23 patients with a C bantiana invasive infection were included during the study period (Jan 1, 2002, to Dec 31, 2022). The median age was 56 years in the CNS involvement group and 65 years in the non-CNS involvement group. Until 2021, the annual number of cases varied between zero and two, with six cases observed in 2022, the warmest year recorded in France since 1900. CNS involvement was observed in 15 (65%) patients, including three disseminated cases; skin and soft tissue involvement in seven (30%) patients and an isolated lung infection in one case. Diabetes was observed in five patients, and any immunodepression factor was observed in 14 (61%) of 23 patients. When considering only patients with CNS involvement, 9-month survival appeared higher in patients who underwent exeresis or large drainage (three [75%] of four patients vs three [27%] of 11 patients; p=0·24) and significantly higher in those treated for 2 or more weeks with triple antifungal therapy (liposomal amphotericin B plus posaconazole and flucytosine; seven [78%] of nine patients vs one [17%] of six patients; p=0·040). Two patients were treated with excision surgery alone (one patient with success, and the other patient lost to follow-up).

INTERPRETATION

This study shows that the clinical presentations and underlying medical conditions of C bantiana infections are more diverse than previously described. It also emphasises a significant difference in mortality rate between those with and without CNS involvement. The prognosis improved when surgery was performed and triple antifungal therapy was administered. Such rare and devastating invasive fungal infections should be managed by a multidisciplinary team.

FUNDING

Santé Publique France.

Successful Treatment of Disseminated Fusariosis in a 15-Month-old Boy With Refractory Acute Lymphoblastic Leukemia Using High-dose Voriconazole

BACKGROUND

Infections due to rare molds, such as Fusarium spp., cause severe and difficult-to-control diseases with increasing frequency. Data on fusariosis in children and on the use of voriconazole (VCZ), considered a drug of choice, are scarce in infants and children <2 years of age.

CASE PRESENTATION

We present the first, to our knowledge, pediatric case of disseminated mycosis due to Fusarium musae in a 15-month-old boy with relapsed/refractory acute lymphoblastic leukemia, diagnostics and outcome. Herein, at this severely immunocompromised patient, after prompt diagnosis, disseminated fusariosis was successfully treated with high-dose VCZ at a final dose of 15 mg/kg of body weight twice a day. This occurred by achieving adequate drug exposures as determined by drug susceptibility testing and followed by therapeutic drug monitoring without observed toxicity.

CONCLUSIONS

Appropriate diagnostic approach and timely administration of optimal antifungal therapy with VCZ were important for the successful treatment of disseminated fusariosis. Therapeutic drug monitoring, especially in <2-year-old children, is necessary to achieve sufficient drug exposure for optimal therapeutic response without toxicity.

Diagnosing fungal infections in clinical practice: a narrative review

BACKGROUND

Invasive fungal infections (IFI) present a major medical challenge, with an estimated 6.5 million cases annually, resulting in 3.8 million deaths. Pathogens such as Aspergillus spp. Candida spp. Mucorales spp. Cryptococcus spp. and other fungi species contribute to these infections, posing risks to immunocompromised individuals. Early and accurate diagnosis is crucial for effective treatment and better patient outcomes.

AREAS COVERED

This narrative review provides an overview of the current methods and challenges associated with diagnosing fungal diseases, including invasive aspergillosis and invasive candidiasis, as well as rare and endemic fungal infections. Various diagnostic techniques, including microscopy, culture, molecular diagnostics, and serological tests, are reviewed, highlighting their respective advantages and limitations and role in clinical guidelines. To illustrate, the need for improved diagnostic strategies to overcome existing challenges, such as the low sensitivity and specificity of current tests and the time-consuming nature of traditional culture-based methods, is addressed.

EXPERT OPINION

Current advancements in fungal infection diagnostics have significant implications for healthcare outcomes. Improved strategies like molecular testing and antigen detection promise early detection of fungal pathogens, enhancing patient management. Challenges include global access to advanced technologies and the need for standardized, user-friendly point-of-care diagnostics to improve diagnosis of fungal infections globally.