1
|
Fong H, Leid ZH, Debnath A. Approaches for Targeting Naegleria fowleri Using Nanoparticles and Artificial Peptides. Pathogens 2024; 13:695. [PMID: 39204295 PMCID: PMC11357329 DOI: 10.3390/pathogens13080695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 08/12/2024] [Accepted: 08/15/2024] [Indexed: 09/03/2024] Open
Abstract
Naegleria fowleri is a free-living amoeba which causes primary amoebic meningoencephalitis (PAM). Although PAM is rare, the fatality rate is staggering at over 97%. So, the importance of finding an effective treatment and cure for PAM caused by N. fowleri is a crucial area of research. Existing research on developing novel therapeutic strategies to counter N. fowleri infection is limited. Since the blood-brain barrier (BBB) presents an obstacle to delivering drugs to the site of infection, it is important to employ strategies that can effectively direct the therapeutics to the brain. In this regard, our review focuses on understanding the physiology and mechanisms by which molecules pass through the BBB, the current treatment options available for PAM, and the recent research conducted in the decade of 2012 to 2022 on the use of nanomaterials to enhance drug delivery. In addition, we compile research findings from other central nervous system (CNS) diseases that use shuttle peptides which allow for transport of molecules through the BBB. The approach of utilizing BBB shuttles to administer drugs through the BBB may open up new areas of drug discovery research in the field of N. fowleri infection.
Collapse
Affiliation(s)
| | | | - Anjan Debnath
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA 92093, USA; (H.F.); (Z.H.L.)
| |
Collapse
|
2
|
Cao X, Wang Y, Zhang Q, Chen L, Zhu Z, Yu Z, Jie H. Long-Term Follow-Up of a Case of Probable Aspergillus Skull Base Osteomyelitis With Galactomannan Test and Literature Review. EAR, NOSE & THROAT JOURNAL 2024:1455613241235561. [PMID: 38798043 DOI: 10.1177/01455613241235561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
We report a probable case of Aspergillus basicranial infection diagnosed by pathogenic serological examination presenting atypical initial manifestations, and highlight the importance of serological examination to avoid treatment delay and disease management. An 84-year-old diabetic patient presented with right peripheral nerve palsy, intolerable otalgia, hearing loss, dysphagia, hoarseness, and bucking. The patient was diagnosed a probable Aspergillus skull base osteomyelitis with cranial neuritis and meningitis of central nervous system. Galactomannan test was used in combination with 1-3-β-D-glucan and magnetic resonance imaging to follow-up during the continuous treatment of voriconazole. To date, the patient has remained in clinical remission for over 39 months but the drug cannot be stopped safely.
Collapse
Affiliation(s)
- Xihong Cao
- Department of Pharmacy, Science City Hospital of Sichuan Province, Mianyang, Sichuan, China
| | - Yating Wang
- Department of Otorhinolaryngology-Head and Neck Surgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Qingyu Zhang
- Radiology Department, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lijuan Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhengwen Zhu
- Department of Otorhinolaryngology-Head and Neck Surgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhenkun Yu
- Department of Otorhinolaryngology-Head and Neck Surgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Huang Jie
- Department of Otorhinolaryngology-Head and Neck Surgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| |
Collapse
|
3
|
Yang T, Cai Y, Zhu Y. Acute lymphoblastic leukemia with central nervous system Aspergillus infection: A case report and literature review. Exp Ther Med 2024; 27:46. [PMID: 38144920 PMCID: PMC10739171 DOI: 10.3892/etm.2023.12336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 11/16/2023] [Indexed: 12/26/2023] Open
Abstract
Ubiquitous in nature, Aspergillus rarely invades the brain to induce infection in general. However, in clinical practice, some patients with hematological malignancies or immunosuppression may suffer from Aspergillus infection of the central nervous system, which arises most commonly as a result of hematogenous dissemination from a pulmonary focus or direct extension from the paranasal sinus infection. Treatment is clinically challenging and the mortality rate is relatively high. Recently, a case diagnosed with acute lymphocytic leukemia was admitted to the Department of Neurosurgery, The First People's Hospital of Huzhou (First Affiliated Hospital of Huzhou University, Huzhou, China). During chemotherapy, space-occupying lesions were observed in the right occipital lobe of the patient, and lesion progression was captured. After treatment with surgery, an analysis of specimens collected from the patient was performed and was suggestive of Aspergillus infection. Following the symptomatic therapy with voriconazole, the patient's disease prognosis was favorable. The focus of infection due to pulmonary aspergillosis or Aspergillus sinusitis was not detected in the patient and the focus was not a common site of hematogenous infection. In addition, the patient exhibited no obvious clinical symptoms. In view of the above observations, the possibility of hospital-acquired infection was considered, to which clinicians should be alert.
Collapse
Affiliation(s)
- Tao Yang
- Department of Neurosurgery, The First People's Hospital of Huzhou (First Affiliated Hospital of Huzhou University), Huzhou, Zhejiang 313000, P.R. China
| | - Yong Cai
- Department of Neurosurgery, The First People's Hospital of Huzhou (First Affiliated Hospital of Huzhou University), Huzhou, Zhejiang 313000, P.R. China
| | - Yaping Zhu
- Department of Pathology, The First People's Hospital of Huzhou (First Affiliated Hospital of Huzhou University), Huzhou, Zhejiang 313000, P.R. China
| |
Collapse
|
4
|
Parambil RM, Thavara BD, Francis S, Valsan PM, Jose BV, Mangla V, Sreenivasan H, Cholakkal S. A Rare Case of COVID-19-Associated Solitary Aspergillus Brain Abscess. Asian J Neurosurg 2023; 18:336-341. [PMID: 37397043 PMCID: PMC10310437 DOI: 10.1055/s-0043-1768570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Surgically operated case of solitary Aspergillus brain abscess caused by Aspergillus fumigatus in coronavirus disease 2019 (COVID-19) patient is not reported. The authors report a case of 33-year-old diabetic female patient presented with generalized seizure followed by left hemiparesis. Patient was treated with steroids for COVID-19 pneumonia. Initial imaging revealed a right frontal lobe infarct that later confirmed as a case of frontal lobe abscess. Patient underwent craniotomy and thick yellow pus was drained. Abscess wall was excised. Postoperatively patient improved with Glasgow coma scale 15/15 and Medical Research Committee grade 5 power of all limbs. Microbiological examination of pus was done. The gram stain showed numerous pus cells with acute angle branching hyphae. Gomori methenamine silver (GMS) preparation showed filamentous black colored hyphae. Mycelial colonies appeared on chocolate agar after 48 hours of incubation. Cellophane tape mount from the plate showed conical shaped vesicle with conidia arising from the upper third of vesicle. Light green velvety colonies appeared on Sabouraud Dextrose Agar that later turned into smoky green. The isolate was identified as Aspergillus fumigatus . The hematoxylin and eosin stain of abscess wall section showed extensive areas of necrosis with few fungal hyphae. GMS stain of abscess wall showed fungal hyphae that are septate and showing acute angled branching which are consistent with Aspergillus species. Patient was treated with voriconazole. Imaging done after 8 months of surgery revealed no residue. Surgical excision of life-threatening solitary Aspergillus brain abscess along with antifungal medication voriconazole carries good result. The authors believe that decreased immunity in patient has contributed to the development of this rare disease. This is a rarest case of surgically operated solitary brain abscess caused by Aspergillus fumigatus in COVID-19 patient.
Collapse
Affiliation(s)
| | | | - Saji Francis
- Department of Pathology, Government Medical College, Kozhikode, Kerala, India
| | | | | | - Vishal Mangla
- Department of Neurosurgery, Government Medical College, Kozhikode, Kerala, India
| | | | - Shanavas Cholakkal
- Department of Neurosurgery, Government Medical College, Kozhikode, Kerala, India
| |
Collapse
|
5
|
Rupa V, Peter J, Michael JS, Thomas M, Irodi A, Rajshekhar V. Chronic Granulomatous Invasive Fungal Sinusitis in Patients With Immunocompetence: A Review. Otolaryngol Head Neck Surg 2023; 168:669-680. [PMID: 35503655 DOI: 10.1177/01945998221097006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 04/05/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We aimed to study the literature on chronic granulomatous invasive fungal sinusitis to elucidate the changing trends in the management of the disease. DATA SOURCES Using specific keywords, we searched the PubMed, PubMed Central, and Scopus databases over the past 50 years, which yielded 938 articles in the English language. REVIEW METHODS Scrutiny of 147 relevant articles revealed 15 homogenous case series (255 cases of histologically proven chronic granulomatous fungal sinusitis alone) and 8 heterogeneous case series (patients with other types of fungal sinusitis included), which were analyzed in detail (all with >5 cases each). CONCLUSIONS The disease typically affected middle-aged adults with immunocompetence. Most reports were from Sudan, India, and Saudi Arabia. A slowly progressive orbital, cheek, or palatal mass with proptosis (88.2%) or sinonasal symptoms (39.2%) was typical. Ethmoid (57.2%) and maxillary (51.4%) sinuses were chiefly affected with intracranial extension in 35.1%. Aspergillus flavus (64%) was the most frequent isolate reported. Endoscopic excision (78.8%) followed by azole therapy was the preferred treatment in recent reports. Orbital exenteration and craniotomy were infrequently performed. Complete resolution or improvement was reported in 91.3% of patients. Mortality ranged from 5.9% to 22.2%. There is a trend in the literature toward less radical and disfiguring surgery and preferential use of azoles, with good outcomes even in advanced cases. IMPLICATIONS FOR PRACTICE Chronic granulomatous fungal sinusitis should be diagnosed on the basis of well-defined histopathologic features. A combination of endoscopic sinus surgery and azole therapy usually yields good outcomes.
Collapse
Affiliation(s)
- Vedantam Rupa
- Department of Otorhinolaryngology, Christian Medical College Hospital, Vellore, India
| | - Jayanthi Peter
- Department of Ophthalmology, Christian Medical College Hospital, Vellore, India
| | | | - Meera Thomas
- Department of Pathology, Christian Medical College Hospital, Vellore, India
| | - Aparna Irodi
- Department of Radiology, Christian Medical College Hospital, Vellore, India
| | - Vedantam Rajshekhar
- Department of Neurological Sciences, Christian Medical College Hospital, Vellore, India
| |
Collapse
|
6
|
Griffiths JS, Orr SJ, Morton CO, Loeffler J, White PL. The Use of Host Biomarkers for the Management of Invasive Fungal Disease. J Fungi (Basel) 2022; 8:jof8121307. [PMID: 36547640 PMCID: PMC9784708 DOI: 10.3390/jof8121307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/03/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Invasive fungal disease (IFD) causes severe morbidity and mortality, and the number of IFD cases is increasing. Exposure to opportunistic fungal pathogens is inevitable, but not all patients with underlying diseases increasing susceptibility to IFD, develop it. IFD diagnosis currently uses fungal biomarkers and clinical risk/presentation to stratify high-risk patients and classifies them into possible, probable, and proven IFD. However, the fungal species responsible for IFD are highly diverse and present numerous diagnostic challenges, which culminates in the empirical anti-fungal treatment of patients at risk of IFD. Recent studies have focussed on host-derived biomarkers that may mediate IFD risk and can be used to predict, and even identify IFD. The identification of novel host genetic variants, host gene expression changes, and host protein expression (cytokines and chemokines) associated with increased risk of IFD has enhanced our understanding of why only some patients at risk of IFD actually develop disease. Furthermore, these host biomarkers when incorporated into predictive models alongside conventional diagnostic techniques enhance predictive and diagnostic results. Once validated in larger studies, host biomarkers associated with IFD may optimize the clinical management of populations at risk of IFD. This review will summarise the latest developments in the identification of host biomarkers for IFD, their use in predictive modelling and their potential application/usefulness for informing clinical decisions.
Collapse
Affiliation(s)
- James S. Griffiths
- Centre for Host-Microbiome Interactions, Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London, London WC2R 2LS, UK
| | - Selinda J. Orr
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast BT9 7BL, UK
| | | | - Juergen Loeffler
- Department of Internal Medicine II, University Hospital of Würzburg, 97070 Würzburg, Germany
| | - P. Lewis White
- Public Health Wales, Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK
- Correspondence:
| |
Collapse
|
7
|
Karaman S, Kebudi R, Kizilocak H, Karakas Z, Demirag B, Evim MS, Yarali N, Kaya Z, Karagun BS, Aydogdu S, Caliskan U, Ayhan AC, Bahadir A, Cakir B, Guner BT, Albayrak C, Karapinar DY, Kazanci EG, Unal E, Turkkan E, Akici F, Bor O, Vural S, Yilmaz S, Apak H, Baytan B, Tahta NM, Güzelkucuk Z, Kocak U, Antmen B, Tokgöz H, Fisgin T, Özdemir N, Gunes AM, Vergin C, Unuvar A, Ozbek N, Tugcu D, Bay SB, Tanyildiz HG, Celkan T. Central Nervous System Fungal Infections in Children With Leukemia and Undergoing Hematopoietic Stem Cell Transplantation: A Retrospective Multicenter Study. J Pediatr Hematol Oncol 2022; 44:e1039-e1045. [PMID: 36036521 DOI: 10.1097/mph.0000000000002499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 05/04/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Central nervous system fungal infections (CNSFI) are seen in patients with hematologic malignancies and have high morbidity and mortality. Because of their rarity, there is limited data on CNSFI in children with no established treatment protocols or guidelines. MATERIALS AND METHODS In this multicenter retrospective study, 51 pediatric patients with leukemia, 6 of whom had undergone bone marrow transplantation, with proven or probable CNSFI were evaluated. Fungal infections were defined as proven or probable based on European Organisation for Research and Treatment of Cancer criteria. Proven CNSFI was diagnosed by appropriate central nervous system (CNS) imaging or tissue sample findings in combination with positive microbiological results of cerebrospinal fluid. A positive culture, microscopic evidence of hyphae, a positive result of the galactomannan assays are defined as positive microbiological evidence. Probable CNSFI was defined as appropriate CNS imaging findings together with proven or probable invasive fungal infections at another focus without CNS when there is no other explanatory condition. Data was collected by using the questionnaire form (Supplemental Digital Content 1, http://links.lww.com/JPHO/A541 ). RESULTS Seventeen patients had proven, 34 patients had probable CNSFI. Headaches and seizures were the most common clinical findings. The median time between the onset of fever and diagnosis was 5 days. The most common fungal agent identified was Aspergillus . Sixteen patients received single-agent, 35 received combination antifungal therapy. Surgery was performed in 23 patients. Twenty-two patients (43%) died, 29 of the CNSFI episodes recovered with a 20% neurological sequelae. CONCLUSION CNSFIs should be considered in the differential diagnosis in patients with leukemia and refractory/recurrent fever, headache, neurologicalocular symptoms, and a radiologic-serological evaluation should be performed immediately. Early diagnosis and prompt management, both medical and surgical, are essential for improving clinical outcomes.
Collapse
Affiliation(s)
- Serap Karaman
- Division of Pediatric Hematology-Oncology, Istanbul Faculty of Medicine, Istanbul University
| | - Rejin Kebudi
- Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute
| | - Hande Kizilocak
- Division of Pediatric Hematology-Oncology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa
| | - Zeynep Karakas
- Division of Pediatric Hematology-Oncology, Istanbul Faculty of Medicine, Istanbul University
| | - Bengu Demirag
- Division of Pediatric Hematology-Oncology, University of Health Sciences Dr. Behcet Uz Children's Hospital
| | - Melike S Evim
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Uludağ University
| | - Nese Yarali
- Division of Pediatric Hematology-Oncology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital
| | - Zuhre Kaya
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Gazi University, Ankara
| | - Barbaros S Karagun
- Division of Pediatric Hematology-Oncology, Acibadem Adana Hospital, Adana
| | - Selime Aydogdu
- Division of Pediatric Hematology-Oncology, Altinbas University Bahcelievler Medical Park Hospital
| | - Umran Caliskan
- Division of Pediatric Hematology-Oncology, Meram University Faculty of Medicine, Konya
| | - Aylin C Ayhan
- Division of Pediatric Hematology-Oncology, Medeniyet University, Faculty of Medicine
| | - Aysenur Bahadir
- Division of Pediatric Hematology-Oncology, Karadeniz Technical University, Faculty of Medicine, Trabzon
| | - Betul Cakir
- Division of Pediatric Hematology-Oncology, Bezmiâlem Vakif University
| | - Burcak T Guner
- Division of Pediatric Hematology-Oncology, Izmir University of Health Sciences Tepecik Training and Research Hospital
| | - Canan Albayrak
- Division of Pediatric Hematology-Oncology, Ondokuz Mayis University, Faculty of Medicine, Samsun
| | - Deniz Y Karapinar
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Ege University
| | - Elif G Kazanci
- Division of Pediatric Hematology-Oncology, Health Sciences University Bursa High Specialist Training and Research Hospital, Bursa
| | - Ekrem Unal
- Division of Pediatric Hematology-Oncology, Erciyes University Faculty of Medicine, Kayseri
| | - Emine Turkkan
- Division of Pediatric Hematology-Oncology, University of Health Sciences, Okmeydani Training and Research Hospital
| | - Ferhan Akici
- Division of Pediatric Hematology-Oncology, University of Health Science Kanuni Sultan Süleyman Research and Training Hospital
| | - Ozcan Bor
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Sema Vural
- Division of Pediatric Hematology-Oncology, Health Sciences University Istanbul Sariyer Hamidiye Etfal Health Practice and Research Center, Istanbul
| | - Sebnem Yilmaz
- Division of Pediatric Hematology-Oncology, Dokuz Eylul University Faculty of Medicine, Izmir
| | - Hilmi Apak
- Division of Pediatric Hematology-Oncology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa
| | - Birol Baytan
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Uludağ University
| | - Neryal M Tahta
- Division of Pediatric Hematology-Oncology, University of Health Sciences Dr. Behcet Uz Children's Hospital
| | - Zeliha Güzelkucuk
- Division of Pediatric Hematology-Oncology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital
| | - Ulker Kocak
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Gazi University, Ankara
| | - Bulent Antmen
- Division of Pediatric Hematology-Oncology, Acibadem Adana Hospital, Adana
| | - Huseyin Tokgöz
- Division of Pediatric Hematology-Oncology, Meram University Faculty of Medicine, Konya
| | - Tunc Fisgin
- Division of Pediatric Hematology-Oncology, Altinbas University Bahcelievler Medical Park Hospital
| | - Nihal Özdemir
- Division of Pediatric Hematology-Oncology, University of Health Science Kanuni Sultan Süleyman Research and Training Hospital
| | - Adalet M Gunes
- Division of Pediatric Hematology-Oncology, Faculty of Medicine, Uludağ University
| | - Canan Vergin
- Division of Pediatric Hematology-Oncology, University of Health Sciences Dr. Behcet Uz Children's Hospital
| | - Aysegul Unuvar
- Division of Pediatric Hematology-Oncology, Istanbul Faculty of Medicine, Istanbul University
| | - Namik Ozbek
- Division of Pediatric Hematology-Oncology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital
| | - Deniz Tugcu
- Division of Pediatric Hematology-Oncology, Istanbul Faculty of Medicine, Istanbul University
| | - Sema B Bay
- Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute
| | - Hikmet G Tanyildiz
- Division of Pediatric Hematology-Oncology, Istanbul Faculty of Medicine, Istanbul University
| | - Tiraje Celkan
- Division of Pediatric Hematology-Oncology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa
| |
Collapse
|
8
|
A Systematic Review to Assess the Relationship between Disseminated Cerebral Aspergillosis, Leukemias and Lymphomas, and Their Respective Therapeutics. J Fungi (Basel) 2022; 8:jof8070722. [PMID: 35887477 PMCID: PMC9320744 DOI: 10.3390/jof8070722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/08/2022] [Accepted: 07/08/2022] [Indexed: 01/27/2023] Open
Abstract
Disseminated disease following invasive pulmonary aspergillosis (IPA) remains a significant contributor to mortality amongst patients with hematologic malignancies (HMs). At the highest risk of mortality are those with disseminated disease to the central nervous system, known as cerebral aspergillosis (CA). However, little is known about the risk factors contributing to disease amongst HM patients. A systematic review using PRISMA guidelines was undertaken to define HM patient subgroups, preventative measures, therapeutic interventions, and outcomes of patients with disseminated CA following IPA. The review resulted in the identification of 761 records, of which 596 articles were screened, with the final inclusion of 47 studies and 76 total patients. From included articles, the proportion of CA was assessed amongst HM patient subgroups. Further, pre-and post-infection characteristics, fungal species, and mortality were evaluated for the total population included and HM patient subgroups. Patients with acute myeloid leukemia and acute lymphoid lymphoma, patients receiving corticosteroids as a part of their HM therapeutic regimen, and anti-fungal prophylaxis constitute the top identified patient populations at risk for disseminated CA. Overall, information presented here indicates that measures for the prevention of IPA should be taken in higher-risk HM patient subgroups. Specifically, the type of anti-fungal therapy used should be carefully considered for those patients with IPA and increased risk for cerebral dissemination. Additional reports detailing patient characteristics are needed to define further the risk of developing disseminated CA from IPA in patients with HMs.
Collapse
|
9
|
Ullmann I, Aregger A, Leib SL, Zimmerli S. Caspofungin Cerebral Penetration and Therapeutic Efficacy in Experimental Cerebral Aspergillosis. Microbiol Spectr 2022; 10:e0275321. [PMID: 35435756 PMCID: PMC9241807 DOI: 10.1128/spectrum.02753-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 04/06/2022] [Indexed: 12/05/2022] Open
Abstract
Despite best available therapy, cerebral aspergillosis is an often-lethal complication of disseminated aspergillosis. There is an urgent need to expand the currently limited therapeutic options. In this study, we assessed cerebral drug exposure and efficacy of caspofungin (CAS) using a lethal infant rat model of cerebral aspergillosis. Eleven-day-old Wistar rats were infected by intracisternal injection of Aspergillus fumigatus conidia. Treatment started after 22 h and was continued for 10 days. Regimens were CAS 1 mg/kg/day intraperitoneally (i.p.), liposomal amphotericin B (L-AmB) 5 mg/kg/day i.p., and both drugs combined at the same dose i.p. Infected controls were given NaCl 0.85% i.p. Primary endpoints assessed were survival, cerebral fungal burden, galactomannan index, and drug concentrations in brain homogenate at 2, 3, 5, and 11 days after infection. Compared to those of controls (4.4 ± 2.7 days), survival times were increased by treatment with CAS alone (10.3 ± 1.7 days; P < 0.0001) and CAS combined with L-AmB (9.3 ± 2.8 days; P < 0.0001). In contrast, survival time of L-AmB-treated animals (4.3 ± 3.1 days) was not different from that of controls. Cerebral fungal burden and galactomannan index declined in all animals over time, without significant differences between controls and treated animals. CAS trough levels in brain tissue were between 0.84 and 1.4 μg/g, concentrations we show to be associated with efficacy. AmB trough levels in brain tissue were higher than the MIC of the A. fumigatus isolate. In summary, CAS concentrations in brain tissue suggest it may be therapeutically relevant and it significantly improved survival in this lethal model of cerebral aspergillosis in nonneutropenic rats. The clinical efficacy of CAS treatment for cerebral aspergillosis merits further study. IMPORTANCE Treatment options for cerebral aspergillosis, an often-lethal disease, are limited. The echinocandins (caspofungin is one of them) are not recommended treatment because their brain tissue penetration is often considered insufficient. In a nursing rat model of cerebral aspergillosis that mimics human disease, we found potentially therapeutically relevant concentrations of caspofungin in brain tissue and prolonged survival of caspofungin-treated animals. The efficacy of caspofungin in the treatment of cerebral aspergillosis documented here, if confirmed in other animal models (especially immunosuppressed murine models) and by using additional Aspergillus isolates across a range of CAS minimal effective concentrations (MECs), would suggest that caspofungin merits further study as a treatment option for patients suffering from aspergillosis disseminated to the brain.
Collapse
Affiliation(s)
- Irina Ullmann
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
- Clinic of General Internal and Emergency Medicine, Citizens Hospital Solothurn, Solothurn, Switzerland
| | - Andrea Aregger
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
- Center for Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Stephen L. Leib
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Stefan Zimmerli
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
10
|
Okoye CA, Nweze E, Ibe C. Invasive candidiasis in Africa, what is the current picture? Pathog Dis 2022; 80:6572357. [PMID: 35451463 DOI: 10.1093/femspd/ftac012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/23/2022] [Accepted: 04/20/2022] [Indexed: 11/14/2022] Open
Abstract
Invasive candidiasis is a serious, progressive, and potentially deadly infection that can affect the brain, heart, bones, eyes, and other parts of the body. It is associated with risk factors such as the use of indwelling medical devices and prolonged hospital stay, and broad-spectrum antibiotics use. It is especially seen in immunocompromised individuals such as patients with prolonged hospital stay, gastrointestinal surgery, haematological malignancies, and respiratory diseases. We have conducted a systematic search of literature using a select group of database and appropriate search words and found that in Africa, there are 18,293 documented/reported cases of invasive candidiasis in the last few decades (1976-2021) and 16,636(91%) were cases of candidaemia. South Africa had the highest number of reported cases - 15,002(82%), which may be due to underreporting of cases in other countries. HIV positive persons with invasive candidiasis in Africa accounted for 1,052(5.8%). C. albicans was the most frequently isolated species 6,328(32.6%), followed by Candida parapsilosis 5,910(30.4%), and Candida auris 1,505(7.8%). Due to the affordability and availability of blood culture, it was used for diagnosis in most of the studies examined, while a few studies combined other techniques and just 3 studies from 2 countries used serological tests. Echinocandins are recommended as first-line therapy but are only available in 12 countries and are highly priced. The use of fluconazole because of its availability and relatively inexpensive nature has led to increased resistance of Candida species to the drug.
Collapse
Affiliation(s)
- Chinonyelum A Okoye
- Departments of Microbiology, Faculty of Biological Sciences, Abia State University, Uturu, Nigeria
| | - Emeka Nweze
- Microbiology University of Nigeria Nsukka, Faculty of Biological Sciences, Enugu State, Nigeria
| | - Chibuike Ibe
- Departments of Microbiology, Faculty of Biological Sciences, Abia State University, Uturu, Nigeria
| |
Collapse
|
11
|
Shivasabesan G, Logan B, Brennan X, Lau C, Vaze A, Bennet M, Gorrie N, Mirdad F, Deveza R, Koo CM, McCluskey P, Macdonald P, Marriott D, Muthiah K, Dharan N. Disseminated Aspergillus lentulus infection in a heart transplant recipient: a case report. Clin Infect Dis 2022; 75:1235-1238. [PMID: 35275984 DOI: 10.1093/cid/ciac205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Indexed: 11/13/2022] Open
Abstract
We present the first published case of successfully treated disseminated Aspergillus lentulus infection in a solid organ transplant recipient with invasive pulmonary disease, endophthalmitis, and a cerebral abscess. This case highlights important challenges associated with treating Aspergillus lentulus, particularly regarding antifungal resistance and toxicities associated with long-term antifungal therapy.
Collapse
Affiliation(s)
| | - Bentley Logan
- Sydney Eye Hospital, Sydney, New South Wales, Australia
| | - Xavier Brennan
- St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Cindy Lau
- St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia.,School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Anagha Vaze
- Sydney Eye Hospital, Sydney, New South Wales, Australia.,Save Sight Institute, Faculty of Medicine & Health University of Sydney
| | - Michael Bennet
- St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia.,Department of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Natasha Gorrie
- St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Feras Mirdad
- St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Ricardo Deveza
- St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Chung Mo Koo
- St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Peter McCluskey
- Sydney Eye Hospital, Sydney, New South Wales, Australia.,Save Sight Institute, Faculty of Medicine & Health University of Sydney
| | - Peter Macdonald
- St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Deborah Marriott
- St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Kavitha Muthiah
- St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Nila Dharan
- St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia.,Kirby Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
12
|
Mody P, Wada P, Bloch KC, Lionakis MS, White KD, Maris AS, Snyder T, Steinhauer J, Humphries R. Gram stain to the rescue: a case report of cerebral phaeohyphomycosis by Cladophialophora bantiana in an immunocompetent 24-year-old. BMC Infect Dis 2022; 22:13. [PMID: 34983414 PMCID: PMC8725554 DOI: 10.1186/s12879-021-07008-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/22/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Fungal brain abscesses in immunocompetent patients are exceedingly rare. Cladophialophora bantiana is the most common cause of cerebral phaeohyphomycosis, a dematiaceous mold. Radiological presentation can mimic other disease states, with diagnosis through surgical aspiration and growth of melanized fungi in culture. Exposure is often unknown, with delayed presentation and diagnosis. CASE PRESENTATION We present a case of cerebral phaeohyphomycosis in a 24-year-old with no underlying conditions or risk factors for disease. He developed upper respiratory symptoms, fevers, and headaches over the course of 2 months. On admission, he underwent brain MRI which demonstrated three parietotemporal rim-enhancing lesions. Stereotactic aspiration revealed a dematiaceous mold on staining and the patient was treated with liposomal amphotericin B, 5-flucytosine, and posaconazole prior to culture confirmation. He ultimately required surgical excision of the brain abscesses and prolonged course of antifungal therapy, with clinical improvement. CONCLUSIONS Culture remains the gold standard for diagnosis of infection. Distinct microbiologic findings can aid in identification and guide antimicrobial therapy. While little guidance exists on treatment, patients have had favorable outcomes with surgery and combination antifungal therapy. In improving awareness, clinicians may accurately diagnose disease and initiate appropriate therapy in a more timely manner.
Collapse
Affiliation(s)
- Perceus Mody
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, 1301 Medical Center Dr., TVC 4524, Nashville, TN, 37232, USA.
| | - Paul Wada
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karen C Bloch
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Annapolis, MD, USA.,Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Annapolis, MD, USA
| | - Katie D White
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander S Maris
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, 1301 Medical Center Dr., TVC 4524, Nashville, TN, 37232, USA
| | - Tonya Snyder
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, 1301 Medical Center Dr., TVC 4524, Nashville, TN, 37232, USA
| | - Jennifer Steinhauer
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, 1301 Medical Center Dr., TVC 4524, Nashville, TN, 37232, USA
| | - Romney Humphries
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, 1301 Medical Center Dr., TVC 4524, Nashville, TN, 37232, USA
| |
Collapse
|
13
|
Zeng Z, Luo H, Huang K, Xue L, Liu H, Li X, Wang L, Cen H, Bi W, Zhang Y. Haemorrhagic cystitis following the administration of voriconazole in the treatment of central nervous system aspergillosis: a case report. J Int Med Res 2021; 48:300060520974924. [PMID: 33322999 DOI: 10.1177/0300060520974924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Central nervous system aspergillosis (CNS-A) is a rare and fatal fungal infection. Voriconazole is the recommended treatment for CNS-A. The therapeutic effect of voriconazole is good, but its use is limited due to adverse reactions. This case report describes a 37-year-old male patient that had previously been diagnosed with acute lymphoblastic leukaemia. He had received immunosuppressive agents for 1 year following a haematopoietic bone marrow transplant. He presented with a 1-month history of left limb weakness as well as recurrent fever. Brain magnetic resonance imaging showed that he had multiple cerebral infarctions. Subsequently, he was diagnosed with CNS-A by metagenomic next-generation sequencing. Voriconazole was added to his treatment regimen, but it resulted in severe haemorrhagic cystitis and possibly bladder rupture. The dose of voriconazole was adjusted and reparative bladder surgery was undertaken immediately. Eventually, the patient was successfully treated with voriconazole and there was no recurrence of symptoms after 1 year of follow-up. Haemorrhagic cystitis is a rare adverse drug reaction associated with voriconazole use. Based on the experience with this current case, physicians should be aware of urinary tract complications with voriconazole including haemorrhagic cystitis.
Collapse
Affiliation(s)
- Zhaohao Zeng
- Department of Neurology, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong Province, China
| | - Hong Luo
- Department of Neurology, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong Province, China
| | - Kunyu Huang
- Department of Pharmacy, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong Province, China
| | - Lianfang Xue
- Department of Pharmacy, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong Province, China
| | - Hui Liu
- Department of Pharmacy, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong Province, China
| | - Xiaoting Li
- Department of Neurology, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong Province, China
| | - Lu Wang
- Department of Neurology, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong Province, China
| | - Haimei Cen
- Department of Neurology, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong Province, China
| | - Wei Bi
- Department of Neurology, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong Province, China
| | - Yu Zhang
- Department of Neurology, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong Province, China
| |
Collapse
|
14
|
Meena DS, Kumar D, Bohra GK, Kumar G. Clinical manifestations, diagnosis, and treatment outcome of CNS aspergillosis: A systematic review of 235 cases. Infect Dis Now 2021; 51:654-660. [PMID: 33964485 DOI: 10.1016/j.idnow.2021.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/16/2021] [Accepted: 04/28/2021] [Indexed: 11/25/2022]
Abstract
Aspergillus is a ubiquitous ascomycete that can cause a variety of clinical presentations depending on immune status. Central nervous system aspergillosis is a fatal disease with non-specific clinical features. The aim of this systematic review was to evaluate the epidemiology, clinical features, diagnosis and therapeutic interventions in CNS aspergillosis patients. We also aimed to examine the possible predictors of mortality in neuroaspergillosis. Literature search was performed in Medline, PubMed, and Google scholar and all patients≥18 years with proven CNS aspergillosis were included. A total of 175 articles (235 patients) were included in the final analysis. Their mean age was 51 years and the majority were male (57.4%). Overall case-fatality was 45.1%. Aspergillus fumigatus was the most common species (70.8%) followed by A. flavus (18.6%). Corticosteroids (22.6%), malignancy (19.1%) and diabetes mellitus (14%) were the most common risk factors. Neuroimaging findings included cerebral abscess (70.2%), meningitis (14%), infarction (13.2%) and mycotic aneurysm (8.9%). Disseminated disease (29.2% vs 17.8%, p 0.03), CSF hypoglycorrhachia (48.1% vs 22.2%, P: 0.001) and heightened CSF galactomannan (3.62 vs 2.0ng/ml, p 0.05), were the factors associated with poor outcome in neuroaspergillosis. Persons infected with Aspergillus flavus (13.1% vs 3.1%, P: 0.01), and having been treated with Voriconazole (51.9% vs 29.2%, P: 0.004) were more likely to survive. Our review will provide insight into the different spectrums of CNS aspergillosis. Notwithstanding the promising role of Voriconazole, future work is required to ascertain the role of combination antifungal therapy.
Collapse
Affiliation(s)
- Durga Shankar Meena
- Department of Internal Medicine, All India Institute of Medical Sciences, 342005 Jodhpur, Rajasthan, India.
| | - Deepak Kumar
- Department of Internal Medicine, All India Institute of Medical Sciences, 342005 Jodhpur, Rajasthan, India.
| | - Gopal Krishana Bohra
- Department of Internal Medicine, All India Institute of Medical Sciences, 342005 Jodhpur, Rajasthan, India.
| | - Gaurav Kumar
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| |
Collapse
|
15
|
Kulkarni M, Sawant N, Kolapkar A, Huprikar A, Desai N. Borneol: a Promising Monoterpenoid in Enhancing Drug Delivery Across Various Physiological Barriers. AAPS PharmSciTech 2021; 22:145. [PMID: 33913042 DOI: 10.1208/s12249-021-01999-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/22/2021] [Indexed: 12/12/2022] Open
Abstract
Incorporation of permeation enhancers is one of the most widely employed approaches for delivering drugs across biological membranes. Permeation enhancers aid in delivering drugs across various physiological barriers such as brain capillary endothelium, stratum corneum, corneal epithelium, and mucosal membranes that pose resistance to the entry of a majority of drugs. Borneol is a natural, plant-derived, lipophilic, volatile, bicyclic monoterpenoid belonging to the class of camphene. It has been used under the names "Bing Pian" or "Long Nao" in Traditional Chinese Medicine for more than 1000 years. Borneol has been incorporated predominantly as an adjuvant in the traditional Chinese formulations of centrally acting drugs to improve drug delivery to the brain. This background knowledge and anecdotal evidence have led to extensive research in establishing borneol as a permeation enhancer across the blood-brain barrier. Alteration in cell membrane lipid structures and modulation of multiple ATP binding cassette transporters as well as tight junction proteins are the major contributing factors to blood-brain barrier opening functions of borneol. Owing to these mechanisms of altering membrane properties, borneol has also shown promising potential to improve drug delivery across other physiological barriers as well. The current review focuses on the role of borneol as a permeation enhancer across the blood-brain barrier, mucosal barriers including nasal and gastrointestinal linings, transdermal, transcorneal, and blood optic nerve barrier.
Collapse
|
16
|
Gunzer M, Thornton CR, Beziere N. Advances in the In Vivo Molecular Imaging of Invasive Aspergillosis. J Fungi (Basel) 2020; 6:jof6040338. [PMID: 33291706 PMCID: PMC7761943 DOI: 10.3390/jof6040338] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 02/07/2023] Open
Abstract
Invasive pulmonary aspergillosis (IPA) is a life-threatening infection of immunocompromised patients with Aspergillus fumigatus, a ubiquitous environmental mould. While there are numerous functioning antifungal therapies, their high cost, substantial side effects and fear of overt resistance development preclude permanent prophylactic medication of risk-patients. Hence, a fast and definitive diagnosis of IPA is desirable, to quickly identify those patients that really require aggressive antimycotic treatment and to follow the course of the therapeutic intervention. However, despite decades of research into this issue, such a diagnostic procedure is still not available. Here, we discuss the array of currently available methods for IPA detection and their limits. We then show that molecular imaging using positron emission tomography (PET) combined with morphological computed tomography or magnetic imaging is highly promising to become a future non-invasive approach for IPA diagnosis and therapy monitoring, albeit still requiring thorough validation and relying on further acceptance and dissemination of the approach. Thereby, our approach using the A. fumigatus-specific humanized monoclonal antibody hJF5 labelled with 64Cu as PET-tracer has proven highly effective in pre-clinical models and hence bears high potential for human application.
Collapse
Affiliation(s)
- Matthias Gunzer
- Institute for Experimental Immunology and Imaging, University Hospital, University Duisburg-Essen, 45147 Essen, Germany
- Leibniz-Institut für Analytische Wissenschaften-ISAS-e.V., 44227 Dortmund, Germany
- Correspondence: (M.G.); (N.B.); Tel.: +49-201-183-6640 (M.G.); +49-7071-29-87511 (N.B.)
| | - Christopher R. Thornton
- ISCA Diagnostics Ltd. and Biosciences, College of Life & Environmental Sciences, University of Exeter, Exeter EX4 4PY, UK;
| | - Nicolas Beziere
- Werner Siemens Imaging Center, Department of Preclinical Imaging and Radiopharmacy, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
- Correspondence: (M.G.); (N.B.); Tel.: +49-201-183-6640 (M.G.); +49-7071-29-87511 (N.B.)
| |
Collapse
|
17
|
Wirth F, Ishida K. Antifungal drugs: An updated review of central nervous system pharmacokinetics. Mycoses 2020; 63:1047-1059. [PMID: 32772402 DOI: 10.1111/myc.13157] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/23/2020] [Accepted: 08/02/2020] [Indexed: 01/06/2023]
Abstract
Invasive fungal infections (IFIs) in the central nervous system (CNS) are particularly hard to treat and are associated with high morbidity and mortality rates. Four chemical classes of systemic antifungal agents are used for the treatment of IFIs (eg meningitis), including polyenes, triazoles, pyrimidine analogues and echinocandins. This review will address all of these classes and discuss their penetration and accumulation in the CNS. Treatment of fungal meningitis is based on the antifungal that shows good penetration and accumulation in the CNS. Pharmacokinetic data concerning the entry of antifungal agents into the intracranial compartments are faulty. This review will provide an overview of the ability of systemic antifungals to penetrate the CNS, based on previously published drug physicochemical properties and pharmacokinetic data, for evaluation of the most promising antifungal drugs for the treatment of fungal CNS infections. The studies selected and discussed in this review are from 1990 to 2019.
Collapse
Affiliation(s)
- Fernanda Wirth
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Kelly Ishida
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| |
Collapse
|
18
|
Ruhnke M, Cornely OA, Schmidt-Hieber M, Alakel N, Boell B, Buchheidt D, Christopeit M, Hasenkamp J, Heinz WJ, Hentrich M, Karthaus M, Koldehoff M, Maschmeyer G, Panse J, Penack O, Schleicher J, Teschner D, Ullmann AJ, Vehreschild M, von Lilienfeld-Toal M, Weissinger F, Schwartz S. Treatment of invasive fungal diseases in cancer patients-Revised 2019 Recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Mycoses 2020; 63:653-682. [PMID: 32236989 DOI: 10.1111/myc.13082] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/05/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Invasive fungal diseases remain a major cause of morbidity and mortality in cancer patients undergoing intensive cytotoxic therapy. The choice of the most appropriate antifungal treatment (AFT) depends on the fungal species suspected or identified, the patient's risk factors (eg length and depth of granulocytopenia) and the expected side effects. OBJECTIVES Since the last edition of recommendations for 'Treatment of invasive fungal infections in cancer patients' of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) in 2013, treatment strategies were gradually moving away from solely empirical therapy of presumed or possible invasive fungal diseases (IFDs) towards pre-emptive therapy of probable IFD. METHODS The guideline was prepared by German clinical experts for infections in cancer patients in a stepwise consensus process. MEDLINE was systematically searched for English-language publications from January 1975 up to September 2019 using the key terms such as 'invasive fungal infection' and/or 'invasive fungal disease' and at least one of the following: antifungal agents, cancer, haematological malignancy, antifungal therapy, neutropenia, granulocytopenia, mycoses, aspergillosis, candidosis and mucormycosis. RESULTS AFT of IFDs in cancer patients may include not only antifungal agents but also non-pharmacologic treatment. In addition, the armamentarium of antifungals for treatment of IFDs has been broadened (eg licensing of isavuconazole). Additional antifungals are currently under investigation or in clinical trials. CONCLUSIONS Here, updated recommendations for the treatment of proven or probable IFDs are given. All recommendations including the levels of evidence are summarised in tables to give the reader rapid access to key information.
Collapse
Affiliation(s)
- Markus Ruhnke
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | | | - Nael Alakel
- Department I of Internal Medicine, Haematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Boris Boell
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation & Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Justin Hasenkamp
- Clinic for Haematology and Medical Oncology with Department for Stem Cell Transplantation, University Medicine Göttingen, Göttingen, Germany
| | - Werner J Heinz
- Schwerpunkt Infektiologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marcus Hentrich
- Hämatologie und Internistische Onkologie, Innere Medizin III, Rotkreuzklinikum München, München, Germany
| | - Meinolf Karthaus
- Department of Haematology & Oncology, Municipal Hospital Neuperlach, München, Germany
| | - Michael Koldehoff
- Klinik für Knochenmarktransplantation, Westdeutsches Tumorzentrum Essen, Universitätsklinikum Essen (AöR), Essen, Germany
| | - Georg Maschmeyer
- Department of Hematology, Onclogy and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Jens Panse
- Klinik für Onkologie, Hämatologie und Stammzelltransplantation, Universitätsklinikum Aachen, Aachen, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | - Jan Schleicher
- Klinik für Hämatologie Onkologie und Palliativmedizin, Katharinenhospital, Stuttgart, Germany
| | - Daniel Teschner
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew John Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Maria Vehreschild
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Zentrum für Innere Medizin, Infektiologie, Goethe Universität Frankfurt, Frankfurt am Main, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Bonn-Köln, Deutschland
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Florian Weissinger
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germany
| |
Collapse
|
19
|
Jindal S, Gupta A, Parihar R, Garg S. Aspergillus nidulans: A rare cause of brain abscess. APOLLO MEDICINE 2020. [DOI: 10.4103/am.am_34_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
20
|
Central Nervous System Infections Due to Aspergillus and Other Hyaline Molds. J Fungi (Basel) 2019; 5:jof5030079. [PMID: 31480311 PMCID: PMC6787746 DOI: 10.3390/jof5030079] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 02/06/2023] Open
Abstract
Central nervous system infections due to Aspergillus spp and other hyaline molds such as Fusarium and Scedosporium spp are rare but fatal conditions. Invasion of the central nervous system (CNS) tends to occur as a result of hematogenous dissemination among immunocompromised patients, and by local extension or direct inoculation secondary to trauma in immunocompetent hosts. Efforts should be directed to confirm the diagnosis by image-guided stereotactic brain biopsy when feasible. Non-culture methods could be useful to support the diagnosis, but they have not been validated to be performed in cerebral spinal fluid. Treatment of these infections is challenging given the variable susceptibility profile of these pathogens and the penetration of antifungal agents into the brain.
Collapse
|
21
|
Cojutti PG, Merelli M, Allegri L, Damante G, Bassetti M, Pea F. Successful and safe long-term treatment of cerebral aspergillosis with high-dose voriconazole guided by therapeutic drug monitoring. Br J Clin Pharmacol 2018; 85:266-269. [PMID: 30414213 DOI: 10.1111/bcp.13789] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/17/2018] [Accepted: 10/02/2018] [Indexed: 12/26/2022] Open
Abstract
We report the case of a patient who had cerebral aspergillosis after otorhinolaryngologic surgery and who was successfully and safely treated with high-dose voriconazole (200 mg q6h) for more than 1 year thanks to a TDM-guided approach coupled with pharmacological review and with genotyping of CYP2C19 polymorphisms. The findings support the idea that personalized medicine based on TDM coupled with the need of avoiding drug-drug interactions may be helpful for maximizing the net benefit (probability of efficacy vs. probability of adverse events) of voriconazole in the management of long-term treatment of cerebral aspergillosis.
Collapse
Affiliation(s)
- Pier Giorgio Cojutti
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Maria Merelli
- Clinic of Infectious Diseases, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Lorenzo Allegri
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Medical Genetic, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Giuseppe Damante
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Medical Genetic, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Matteo Bassetti
- Department of Medicine, University of Udine, Udine, Italy.,Clinic of Infectious Diseases, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Federico Pea
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| |
Collapse
|
22
|
Acute Stroke as First Manifestation of Cerebral Aspergillosis. J Stroke Cerebrovasc Dis 2018; 27:3289-3293. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 07/11/2018] [Accepted: 07/17/2018] [Indexed: 01/02/2023] Open
|
23
|
Faisal MS, Shaikh H, Khattab A, Albrethsen M, Fazal S. Cerebral aspergillosis in a patient on ibrutinib therapy-A predisposition not to overlook. J Oncol Pharm Pract 2018; 25:1486-1490. [PMID: 30045683 DOI: 10.1177/1078155218788717] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Ibrutinib has revolutionized the treatment of B-cell malignancies since its approval for chronic lymphocytic leukemia. It is also used in mantle cell lymphoma, diffuse large B-cell lymphoma, Waldenstrom's macroglobulinemia, among others. It is a Bruton's tyrosine kinase inhibitor that acts on B-cell receptor signaling pathway and predisposes to various infections due to its effects on neutrophils, monocytes and T cells. We present a case of cerebral invasive aspergillosis in a patient being treated with ibrutinib for relapsed chronic lymphocytic leukemia. It was hard to associate the condition to ibrutinib versus the chronic lymphocytic leukemia. The patient was successfully treated with a combination of voriconazole and micafungin, resulting in complete recovery and no residual deficits. This highlights the importance of recognizing the rare complication in those on ibrutinib and initiating the treatment immediately with appropriate antifungal agents to improve prognosis of this potentially fatal condition.
Collapse
Affiliation(s)
| | - Hira Shaikh
- 1 Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Ahmed Khattab
- 1 Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Mary Albrethsen
- 2 Department of Hematology-Oncology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Salman Fazal
- 2 Department of Hematology-Oncology, Allegheny Health Network, Pittsburgh, PA, USA
| |
Collapse
|
24
|
Stott KE, Hope W. Pharmacokinetics–pharmacodynamics of antifungal agents in the central nervous system. Expert Opin Drug Metab Toxicol 2018; 14:803-815. [DOI: 10.1080/17425255.2018.1492551] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Katharine E Stott
- Antimicrobial Pharmacodynamics and Therapeutics Laboratory, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics Laboratory, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| |
Collapse
|
25
|
Bodilsen J, Brouwer MC, Nielsen H, Van De Beek D. Anti-infective treatment of brain abscess. Expert Rev Anti Infect Ther 2018; 16:565-578. [PMID: 29909695 DOI: 10.1080/14787210.2018.1489722] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Brain abscess is an uncommon and potentially life-threatening infection of the CNS that can be caused by a range of different pathogens including bacteria, fungi, and parasites. A multidisciplinary approach is important and anti-infective treatment remains crucial. Here, we review anti-infective treatment of brain abscess. Areas covered: We used the terms '(Brain abscess[ti] AND (antibiotic* OR treatment)) NOT case report'), to conduct a search in the PubMed. Additional papers were identified by cross-reference checking and by browsing textbooks of infectious diseases and neurology. COMMENTARY Empiric treatment of bacterial brain abscess consists of cefotaxime and metronidazole with the addition of vancomycin if meticilline-resistant Staphylococcus aureus is suspected. For severely immuno-suppressed patients, for example transplant recipients, voriconazole and trimethoprim-sulfamethoxazole or sulfadiazine should be added. Increased knowledge of the pharmacokinetic profile of anti-infective treatments may help to improve the treatment of brain abscess. Future studies should address efficacy and safety of continuous abscess drainage, mode of anti-infective administration (continuous vs. bolus), and anti-infective treatments in immuno-suppressed patients.
Collapse
Affiliation(s)
- Jacob Bodilsen
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Matthijs C Brouwer
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Henrik Nielsen
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Diederik Van De Beek
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| |
Collapse
|
26
|
Szigeti ZM, Talas L, Palicz Z, Szentesi P, Hargitai Z, Csernoch L, Balla J, Pocsi I, Banfalvi G, Szeman-Nagy G. Murine model to follow hyphal development in invasive pulmonary aspergillosis. Appl Microbiol Biotechnol 2018; 102:2817-2825. [PMID: 29423632 DOI: 10.1007/s00253-018-8800-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 12/18/2022]
Abstract
Aspergillus fumigatus is an opportunistic pathogen, the leading cause of invasive and disseminated aspergillosis in systemic immunocompromised patients, and an important cause of mortality. The aim of the present study was to adapt a pulmonary aspergillosis murine model, to determine pathodynamical parameters quantitatively, and to follow the progression of fungal infection in vivo. The nasal inoculation of Aspergillus conidia in mice previously subjected to immunosuppression with cyclophosphamide (CP) turned out to be a more suitable model than that of immunosuppressed with hydrocortisone (HC). The following parameters were found to correlate quantitatively with the progress of the infection: (i) survival rate, (ii) weight loss of mice, (iii) infected focal plaque size, (iv) hyphal density, (v) hyphal length distribution of A. fumigatus, and the (vi) the histopathological status and scores. These parameters will be essential elements for the development of antifungal drugs and therapies, and important for the investigation of the pathogenicity in different strains of A. fumigatus.
Collapse
Affiliation(s)
- Zsuzsa M Szigeti
- Department of Biotechnology and Microbiology, Faculty of Science and Technology, University of Debrecen, 1 Egyetem Square, Debrecen, H-4002, Hungary
| | - Laszlo Talas
- Department of Biotechnology and Microbiology, Faculty of Science and Technology, University of Debrecen, 1 Egyetem Square, Debrecen, H-4002, Hungary
| | - Zoltan Palicz
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, H-4002, Hungary
| | - Peter Szentesi
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, H-4002, Hungary
| | - Zoltan Hargitai
- Department of Pathology, Kenezy Hospital, University of Debrecen, Debrecen, H-4031, Hungary
| | - Laszlo Csernoch
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, H-4002, Hungary
| | - Jozsef Balla
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, H-4002, Hungary
| | - Istvan Pocsi
- Department of Biotechnology and Microbiology, Faculty of Science and Technology, University of Debrecen, 1 Egyetem Square, Debrecen, H-4002, Hungary
| | - Gaspar Banfalvi
- Department of Biotechnology and Microbiology, Faculty of Science and Technology, University of Debrecen, 1 Egyetem Square, Debrecen, H-4002, Hungary.
| | - Gabor Szeman-Nagy
- Department of Biotechnology and Microbiology, Faculty of Science and Technology, University of Debrecen, 1 Egyetem Square, Debrecen, H-4002, Hungary
| |
Collapse
|
27
|
Turki AT, Rashidi-Alavijeh J, Dürig J, Gerken G, Rath PM, Witzke O. Successful treatment of cerebral aspergillosis: case report of a patient with T-cell large granular lymphocytic leukemia (T-LGL). BMC Infect Dis 2017; 17:797. [PMID: 29281994 PMCID: PMC5745601 DOI: 10.1186/s12879-017-2877-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 12/03/2017] [Indexed: 11/25/2022] Open
Abstract
Background Invasive aspergillosis involving patients with neutropenia or severe immunosuppression, such as patients with hematologic malignancies is associated with high mortality. Patients with T-cell large granular lymphocytic leukemia (T-LGL) on the other hand are considered to be less vulnerable for severe opportunistic fungal infection as their course of disease is chronic and marked by less violent cytopenia then in e.g. Aplastic Anemia. Only neutropenia is regarded as independent risk factor for severe opportunistic infection in T-LGL patients. Case presentation We report a case of a 53 year old patient with T-LGL, Immune-Thrombocytopenia (ITP) and combined antibody deficiency, who presented with fever and reduced general condition. The patient revealed a complicated infection involving the lungs and later the brain, with the presentation of vomiting and seizures. Broad microbiological testing of blood-, lung- and cerebrospinal fluid samples was inconclusive. In the absence of mycological proof, Aspergillus infection was confirmed by pathological examination of a brain specimen and finally successfully treated with liposomal amphotericin B and voriconazole, adopting a long-term treatment scheme. Conclusions Beyond typical problems in the clinical practice involving fungal infections and hematologic malignancies, this case of invasive aspergillosis in a patient with T-LGL illustrates caveats in diagnosis, therapy and follow-up. Our data support careful ambulatory monitoring for patients with T-LGL, even in the absence of neutropenia. Especially those patients with combined hematologic malignancies and immune defects are at risk. Long-term treatment adhesion for 12 months with sufficient drug levels was necessary for sustained clearance from infection.
Collapse
Affiliation(s)
- Amin T Turki
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany.
| | | | - Jan Dürig
- Department of Hematology, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Peter-Michael Rath
- Institute of Medical Microbiology, University Hospital Essen, Essen, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, Essen, Germany
| |
Collapse
|
28
|
Lee J, Kim SH, Kwon J, Yoon Y. Preexisting Cerebral Aspergillosis Successfully Treated After Liver Transplantation: A Case Report. Transplant Proc 2017; 49:2402-2405. [DOI: 10.1016/j.transproceed.2017.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/23/2017] [Indexed: 12/26/2022]
|
29
|
Tissue Distribution and Elimination of Isavuconazole following Single and Repeat Oral-Dose Administration of Isavuconazonium Sulfate to Rats. Antimicrob Agents Chemother 2017; 61:AAC.01292-17. [PMID: 28971866 PMCID: PMC5700325 DOI: 10.1128/aac.01292-17] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/23/2017] [Indexed: 12/18/2022] Open
Abstract
Quantitative whole-body autoradiography was used to assess the distribution and tissue penetration of isavuconazole in rats following single and repeated oral-dose administration of radiolabeled isavuconazonium sulfate, the prodrug of isavuconazole. Following a single-dose administration of radiolabeled isavuconazonium sulfate (labeled on the active moiety), radioactivity was detectable within 1 h postdose in 56 of 65 tissue/fluid specimens. The highest maximum concentrations (Cmax) were observed in bile and liver (66.6 and 24.7 μg eq/g, respectively). The lowest Cmax values were in bone and eye lens (0.070 and 0.077 μg eq/g, respectively). By 144 h postdose, radioactivity was undetectable in all tissues/fluids except liver (undetectable at 336 h) and adrenal gland tissues (undetectable at 672 h). Following daily administration for up to 21 days, 1-h-postdose Cmax values were the highest on or before day 14 in all except seven tissues/fluids, of which only rectum mucosa and small intestine mucosa had Cmax values >25% higher than all other 1-h-postdose values. For 24-h-postdose Cmax values, only large intestine, large intestine mucosa, and urine had the highest Cmax values at day 21. The penetration of single oral doses of unlabeled isavuconazole (25 mg/kg of body weight isavuconazonium sulfate) and voriconazole (50 mg/kg) into rat brain (assessed using liquid chromatography-tandem mass spectrometry) was also compared. Brain concentration/plasma concentration ratios reached approximately 1.8:1 and 2:1, respectively. These data suggest that isavuconazole penetrates most tissues rapidly, reaches a steady state in most or all tissues/fluids within 14 days, does not accumulate in tissues/fluids over time, and achieves potentially efficacious concentrations in the brain.
Collapse
|
30
|
McCarthy MW, Kalasauskas D, Petraitis V, Petraitiene R, Walsh TJ. Fungal Infections of the Central Nervous System in Children. J Pediatric Infect Dis Soc 2017; 6:e123-e133. [PMID: 28903523 DOI: 10.1093/jpids/pix059] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/04/2017] [Indexed: 01/03/2023]
Abstract
Although uncommon in children, fungal infections of the central nervous system can be devastating and difficult to treat. A better understanding of basic mycologic, immunologic, and pharmacologic processes has led to important advances in the diagnosis and management of these diseases, but their mortality rates remain unacceptably high. In this focused review, we examine the epidemiology and clinical features of the most common fungal pathogens of the central nervous system in children and explore recent advances in diagnosis and antifungal therapy.
Collapse
Affiliation(s)
- Matthew W McCarthy
- Division of General Internal Medicine, Weill Cornell Medicine of Cornell University, New York, New York
| | - Darius Kalasauskas
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany.,Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York
| | - Vidmantas Petraitis
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York.,Institute of Infectious Disease and Pathogenic Microbiology, Prienai, Lithuania
| | - Ruta Petraitiene
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York.,Institute of Infectious Disease and Pathogenic Microbiology, Prienai, Lithuania
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York.,Departments of Pediatrics, and Microbiology & Immunology, Weill Cornell Medicine of Cornell University, New York, New York
| |
Collapse
|
31
|
Curtis C, Zhang M, Liao R, Wood T, Nance E. Systems-level thinking for nanoparticle-mediated therapeutic delivery to neurological diseases. WILEY INTERDISCIPLINARY REVIEWS-NANOMEDICINE AND NANOBIOTECHNOLOGY 2016; 9. [PMID: 27562224 DOI: 10.1002/wnan.1422] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/27/2016] [Accepted: 07/17/2016] [Indexed: 12/27/2022]
Abstract
Neurological diseases account for 13% of the global burden of disease. As a result, treating these diseases costs $750 billion a year. Nanotechnology, which consists of small (~1-100 nm) but highly tailorable platforms, can provide significant opportunities for improving therapeutic delivery to the brain. Nanoparticles can increase drug solubility, overcome the blood-brain and brain penetration barriers, and provide timed release of a drug at a site of interest. Many researchers have successfully used nanotechnology to overcome individual barriers to therapeutic delivery to the brain, yet no platform has translated into a standard of care for any neurological disease. The challenge in translating nanotechnology platforms into clinical use for patients with neurological disease necessitates a new approach to: (1) collect information from the fields associated with understanding and treating brain diseases and (2) apply that information using scalable technologies in a clinically-relevant way. This approach requires systems-level thinking to integrate an understanding of biological barriers to therapeutic intervention in the brain with the engineering of nanoparticle material properties to overcome those barriers. To demonstrate how a systems perspective can tackle the challenge of treating neurological diseases using nanotechnology, this review will first present physiological barriers to drug delivery in the brain and common neurological disease hallmarks that influence these barriers. We will then analyze the design of nanotechnology platforms in preclinical in vivo efficacy studies for treatment of neurological disease, and map concepts for the interaction of nanoparticle physicochemical properties and pathophysiological hallmarks in the brain. WIREs Nanomed Nanobiotechnol 2017, 9:e1422. doi: 10.1002/wnan.1422 For further resources related to this article, please visit the WIREs website.
Collapse
Affiliation(s)
- Chad Curtis
- Department of Chemical Engineering, University of Washington, Seattle, WA, USA
| | - Mengying Zhang
- Molecular Engineering and Sciences Institute, University of Washington, Seattle, WA, USA
| | - Rick Liao
- Department of Chemical Engineering, University of Washington, Seattle, WA, USA
| | - Thomas Wood
- Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Elizabeth Nance
- Department of Chemical Engineering, University of Washington, Seattle, WA, USA.,Molecular Engineering and Sciences Institute, University of Washington, Seattle, WA, USA.,Department of Radiology, University of Washington, Seattle, WA, USA.,Center on Human Development and Disability, University of Washington, Seattle, WA, USA
| |
Collapse
|
32
|
Schmidt-Hieber M, Silling G, Schalk E, Heinz W, Panse J, Penack O, Christopeit M, Buchheidt D, Meyding-Lamadé U, Hähnel S, Wolf HH, Ruhnke M, Schwartz S, Maschmeyer G. CNS infections in patients with hematological disorders (including allogeneic stem-cell transplantation)-Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Oncol 2016; 27:1207-25. [PMID: 27052648 PMCID: PMC4922317 DOI: 10.1093/annonc/mdw155] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 03/24/2016] [Indexed: 12/22/2022] Open
Abstract
Diagnosis of CNS infections remains a great challenge in patients with hematological disorders since symptoms might both be masked and be mimicked by other conditions such as metabolic disturbances or consequences from antineoplastic treatment. Thus, awareness of this complication is crucial and any suspicion of a CNS infection should lead to timely and adequate diagnostics and treatment to improve the outcome in this population. Infections of the central nervous system (CNS) are infrequently diagnosed in immunocompetent patients, but they do occur in a significant proportion of patients with hematological disorders. In particular, patients undergoing allogeneic hematopoietic stem-cell transplantation carry a high risk for CNS infections of up to 15%. Fungi and Toxoplasma gondii are the predominant causative agents. The diagnosis of CNS infections is based on neuroimaging, cerebrospinal fluid examination and biopsy of suspicious lesions in selected patients. However, identification of CNS infections in immunocompromised patients could represent a major challenge since metabolic disturbances, side-effects of antineoplastic or immunosuppressive drugs and CNS involvement of the underlying hematological disorder may mimic symptoms of a CNS infection. The prognosis of CNS infections is generally poor in these patients, albeit the introduction of novel substances (e.g. voriconazole) has improved the outcome in distinct patient subgroups. This guideline has been developed by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) with the contribution of a panel of 14 experts certified in internal medicine, hematology/oncology, infectious diseases, intensive care, neurology and neuroradiology. Grades of recommendation and levels of evidence were categorized by using novel criteria, as recently published by the European Society of Clinical Microbiology and Infectious Diseases.
Collapse
Affiliation(s)
- M Schmidt-Hieber
- Department of Hematology, Oncology and Tumor Immunology, HELIOS Clinic Berlin-Buch, Berlin
| | - G Silling
- Department of Hematology, Oncology and Stem Cell Transplantation, University Hospital, Aachen, Medical Faculty, RWTH Aachen, Aachen
| | - E Schalk
- Department of Hematology and Oncology, Otto-von-Guericke University Hospital Magdeburg, Magdeburg
| | - W Heinz
- Department of Internal Medicine II, University Hospital Würzburg, Center of Internal Medicine, Würzburg
| | - J Panse
- Department of Hematology, Oncology and Stem Cell Transplantation, University Hospital, Aachen, Medical Faculty, RWTH Aachen, Aachen
| | - O Penack
- Department of Hematology, Oncology and Tumor Immunology, Charité University Medicine, Campus Virchow Clinic, Berlin
| | - M Christopeit
- Department of Stem Cell Transplantation, University Medical Center Hamburg Eppendorf, Hamburg
| | - D Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim
| | - U Meyding-Lamadé
- Department of Neurology, Hospital Nordwest Frankfurt, Frankfurt/M., Germany Brunei Neuroscience Stroke and Rehabilitation Centre, Jerudong, Brunei Darussalam Department of Neuroinfectiology, Otto-Meyerhof-Centre, University of Heidelberg, Heidelberg
| | - S Hähnel
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg
| | - H H Wolf
- Department of Hematology and Oncology, University Hospital Halle, Halle
| | - M Ruhnke
- Paracelsus Clinic Osnabrück, Osnabrück
| | - S Schwartz
- Department of Hematology and Oncology, Charité University Medicine, Campus Benjamin Franklin, Berlin
| | - G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Ernst von Bergmann Clinic, Potsdam, Germany
| |
Collapse
|
33
|
Chronic Invasive Aspergillus Sinusitis and Otitis with Meningeal Extension Successfully Treated with Voriconazole. Antimicrob Agents Chemother 2015; 59:7857-61. [PMID: 26392507 DOI: 10.1128/aac.01506-15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/17/2015] [Indexed: 01/23/2023] Open
Abstract
Invasive aspergillosis (IA) is a severe disseminated fungal disease that occurs mostly in immunocompromised patients. However, central nervous system IA, combining meningitis and skull base involvement, does not occur only in groups with classic risk factors for IA; patients with chronic renal failure and diabetes mellitus are also at risk for more chronic forms. In both of our proven IA cases, voriconazole monotherapy was effective without surgery, and cerebrospinal fluid and serum 1,3-β-d-glucan test results were initially positive, in contrast to galactomannan antigen results.
Collapse
|
34
|
Blyth CC, Gilroy NM, Guy SD, Chambers ST, Cheong EY, Gottlieb T, McGuinness SL, Thursky KA. Consensus guidelines for the treatment of invasive mould infections in haematological malignancy and haemopoietic stem cell transplantation, 2014. Intern Med J 2015; 44:1333-49. [PMID: 25482744 DOI: 10.1111/imj.12598] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Mould species represent the pathogens most commonly associated with invasive fungal disease in patients with haematological malignancies and patients of haemopoietic stem cell transplants. Invasive mould infections in these patient populations, particularly in the setting of neutropenia, are associated with high morbidity and mortality, and significantly increase the complexity of management. While Aspergillus species remain the most prevalent cause of invasive mould infections, Scedosporium and Fusarium species and the Mucormycetes continue to place a significant burden on the immunocompromised host. Evidence also suggests that infections caused by rare and emerging pathogens are increasing within the setting of broad-spectrum antifungal prophylaxis and improved survival times placing immunosuppressed patients at risk for longer. These guidelines present evidence-based recommendations for the antifungal management of common, rare and emerging mould infections in both adult and paediatric populations. Where relevant, the role of surgery, adjunctive therapy and immunotherapy is also discussed.
Collapse
Affiliation(s)
- C C Blyth
- School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia; Department of General Paediatrics, Princess Margaret Hospital for Children, Subiaco, Western Australia; PathWest Laboratory Medicine WA, Subiaco, Western Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Lemetayer JD, Dowling PM, Taylor SM, Papich MG. Pharmacokinetics and distribution of voriconazole in body fluids of dogs after repeated oral dosing. J Vet Pharmacol Ther 2015; 38:451-6. [DOI: 10.1111/jvp.12208] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 01/16/2015] [Indexed: 01/21/2023]
Affiliation(s)
- J. D. Lemetayer
- Small Animal Clinical Sciences; Western College of Veterinary Medicine; University of Saskatchewan; Saskatoon SK Canada
| | - P. M. Dowling
- Veterinary Biomedical Sciences; Western College of Veterinary Medicine; University of Saskatchewan; Saskatoon SK Canada
| | - S. M. Taylor
- Small Animal Clinical Sciences; Western College of Veterinary Medicine; University of Saskatchewan; Saskatoon SK Canada
| | - M. G. Papich
- Department of Molecular Biomedical Sciences; College of Veterinary Medicine; North Carolina State University; Raleigh NC USA
| |
Collapse
|
36
|
Abstract
The recent outbreak of exserohilum rostratum meningitis linked to epidural injections of methylprednisolone acetate has brought renewed attention to mold infections of the central nervous system (CNS). Although uncommon, these infections are often devastating and difficult to treat. This focused review of the epidemiologic aspects, clinical characteristics, and treatment of mold infections of the CNS covers a group of common pathogens: aspergillus, fusarium, and scedosporium species, molds in the order Mucorales, and dematiaceous molds. Infections caused by these pathogen groups have distinctive epidemiologic profiles, clinical manifestations, microbiologic characteristics, and therapeutic implications, all of which clinicians should understand.
Collapse
Affiliation(s)
- Matthew McCarthy
- From the Transplantation-Oncology Infectious Diseases Program, Departments of Medicine, Pediatrics, and Microbiology and Immunology (M.M., T.J.W.), and the Departments of Neurology, Neuroscience, and Neurosurgery (A.R.) and Pathology and Laboratory Medicine (A.N.S.), Weill Cornell Medical Center of Cornell University, New York; and the Infectious Diseases Department and Division of Internal Medicine, University of Texas M.D. Anderson Cancer Center, Houston (D.P.K.)
| | | | | | | | | |
Collapse
|
37
|
Maschmeyer G, Patterson TF. Our 2014 approach to breakthrough invasive fungal infections. Mycoses 2014; 57:645-51. [DOI: 10.1111/myc.12213] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 05/29/2014] [Accepted: 06/02/2014] [Indexed: 12/25/2022]
Affiliation(s)
- Georg Maschmeyer
- Department of Hematology, Oncology and Palliative Care; Klinikum Ernst von Bergmann; Academic Teaching Hospital of the Charité University Medicine of Berlin; Potsdam Germany
| | - Thomas F. Patterson
- Division of Infectious Diseases; San Antonio Center for Medical Mycology; The University of Texas Health Science Center at San Antonio; South Texas Veterans Health Care System; San Antonio TX USA
| |
Collapse
|
38
|
Broenen E, Mavinkurve-Groothuis A, Kamphuis-van Ulzen K, Brüggemann R, Verweij P, Warris A. Screening of the central nervous system in children with invasive pulmonary aspergillosis. Med Mycol Case Rep 2014; 4:8-11. [PMID: 24624324 DOI: 10.1016/j.mmcr.2014.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 01/31/2014] [Accepted: 02/03/2014] [Indexed: 10/25/2022] Open
Abstract
The existing guidelines regarding the management of invasive pulmonary aspergillosis do not recommend screening of the extra-pulmonary sites. Due to the fact that the presence of central nervous system (CNS) aspergillosis will influence treatment decisions regarding which antifungal to use and the aimed target concentrations of azoles in plasma, to be informed about dissemination of the infection to the CNS is absolutely necessary. We demonstrate the need for a structured approach to screening of pediatric patients for CNS aspergillosis.
Collapse
Affiliation(s)
- Emmi Broenen
- Department of Pediatrics, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Annelies Mavinkurve-Groothuis
- Department of Pediatrics, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Karin Kamphuis-van Ulzen
- Department of Radiology, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Roger Brüggemann
- Department of Clinical Pharmacy, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands ; Nijmegen Institute for Infection, Immunity and Inflammation, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Paul Verweij
- Department of Medical Microbiology, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands ; Nijmegen Institute for Infection, Immunity and Inflammation, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Adilia Warris
- Department of Pediatrics, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands ; Nijmegen Institute for Infection, Immunity and Inflammation, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| |
Collapse
|
39
|
Lass-Flörl C. Invasive fungal infections in pediatric patients: a review focusing on antifungal therapy. Expert Rev Anti Infect Ther 2014; 8:127-35. [DOI: 10.1586/eri.09.128] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
40
|
Kuyucu N. Amphotericin B use in children: conventional and lipid-based formulations. Expert Rev Anti Infect Ther 2014; 9:357-67. [DOI: 10.1586/eri.11.5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
41
|
Quantification of brain voriconazole levels in healthy adults using fluorine magnetic resonance spectroscopy. Antimicrob Agents Chemother 2013; 57:5271-6. [PMID: 23939898 DOI: 10.1128/aac.00394-13] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Voriconazole is more effective for aspergillosis infections with central nervous system involvement than other antifungal agents. The clinical efficacy of voriconazole for central nervous system infections has been attributed to its ability to cross the blood-brain barrier. However, pharmacokinetic studies are limited to plasma and cerebrospinal fluid, so it remains unclear how much of the drug enters the brain. Fluorinated compounds such as voriconazole can be quantified in the brain using fluorine-19 magnetic resonance spectroscopy (MRS). Twelve healthy adult males participated in a pharmacokinetic analysis of voriconazole levels in the brain and plasma. Open-label voriconazole was dosed per clinical protocol with a loading dose of 400 mg every 12 h on day 1, followed by 200 mg every 12 h administered orally over a 3-day period. MRS was performed before and after dosing on the third day. Voriconazole levels in the brain exceeded the MIC for Aspergillus. The brain/plasma ratios were 3.0 at steady state on day 3 (predose) and 1.9 postdose. We found that voriconazole is able to penetrate the brain tissue, which can be quantified using a noninvasive MRS technique. (This study has been registered at ClinicalTrials.gov under registration no. NCT00300677.).
Collapse
|
42
|
Schwartz S. [Diagnostic imaging methods and therapy options for cerebral aspergillosis]. Mycoses 2013; 55 Suppl 2:10-6. [PMID: 22519627 DOI: 10.1111/j.1439-0507.2012.02178.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Stefan Schwartz
- Medizinische Klinik III, Charité Campus Benjamin Franklin, Berlin, Deutschland.
| |
Collapse
|
43
|
Abstract
Central nervous system (CNS) infections—i.e., infections involving the brain (cerebrum and cerebellum), spinal cord, optic nerves, and their covering membranes—are medical emergencies that are associated with substantial morbidity, mortality, or long-term sequelae that may have catastrophic implications for the quality of life of affected individuals. Acute CNS infections that warrant neurointensive care (ICU) admission fall broadly into three categories—meningitis, encephalitis, and abscesses—and generally result from blood-borne spread of the respective microorganisms. Other causes of CNS infections include head trauma resulting in fractures at the base of the skull or the cribriform plate that can lead to an opening between the CNS and the sinuses, mastoid, the middle ear, or the nasopharynx. Extrinsic contamination of the CNS can occur intraoperatively during neurosurgical procedures. Also, implanted medical devices or adjunct hardware (e.g., shunts, ventriculostomies, or external drainage tubes) and congenital malformations (e.g., spina bifida or sinus tracts) can become colonized and serve as sources or foci of infection. Viruses, such as rabies, herpes simplex virus, or polioviruses, can spread to the CNS via intraneural pathways resulting in encephalitis. If infection occurs at sites (e.g., middle ear or mastoid) contiguous with the CNS, infection may spread directly into the CNS causing brain abscesses; alternatively, the organism may reach the CNS indirectly via venous drainage or the sheaths of cranial and spinal nerves. Abscesses also may become localized in the subdural or epidural spaces. Meningitis results if bacteria spread directly from an abscess to the subarachnoid space. CNS abscesses may be a result of pyogenic meningitis or from septic emboli associated with endocarditis, lung abscess, or other serious purulent infections. Breaches of the blood–brain barrier (BBB) can result in CNS infections. Causes of such breaches include damage (e.g., microhemorrhage or necrosis of surrounding tissue) to the BBB; mechanical obstruction of microvessels by parasitized red blood cells, leukocytes, or platelets; overproduction of cytokines that degrade tight junction proteins; or microbe-specific interactions with the BBB that facilitate transcellular passage of the microorganism. The microorganisms that cause CNS infections include a wide range of bacteria, mycobacteria, yeasts, fungi, viruses, spirochaetes (e.g., neurosyphilis), and parasites (e.g., cerebral malaria and strongyloidiasis). The clinical picture of the various infections can be nonspecific or characterized by distinct, recognizable clinical syndromes. At some juncture, individuals with severe acute CNS infections require critical care management that warrants neuro-ICU admission. The implications for CNS infections are serious and complex and include the increased human and material resources necessary to manage very sick patients, the difficulties in triaging patients with vague or mild symptoms, and ascertaining the precise cause and degree of CNS involvement at the time of admission to the neuro-ICU. This chapter addresses a wide range of severe CNS infections that are better managed in the neuro-ICU. Topics covered include the medical epidemiology of the respective CNS infection; discussions of the relevant neuroanatomy and blood supply (essential for understanding the pathogenesis of CNS infections) and pathophysiology; symptoms and signs; diagnostic procedures, including essential neuroimaging studies; therapeutic options, including empirical therapy where indicated; and the perennial issue of the utility and effectiveness of steroid therapy for certain CNS infections. Finally, therapeutic options and alternatives are discussed, including the choices of antimicrobial agents best able to cross the BBB, supportive therapy, and prognosis.
Collapse
Affiliation(s)
- A Joseph Layon
- Pulmonary and Critical Care Medicine, Geisinger Health System, Danville, Pennsylvania USA
| | - Andrea Gabrielli
- Departments of Anesthesiology & Surgery, University of Florida College of Medicine, Gainesville, Florida USA
| | | |
Collapse
|
44
|
Prakash G, Thulkar S, Arava SK, Bakhshi S. Cerebral aspergillus infection in pediatric acute lymphoblastic leukemia induction therapy. Indian J Med Paediatr Oncol 2013; 33:236-8. [PMID: 23580827 PMCID: PMC3618648 DOI: 10.4103/0971-5851.107104] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Angioinvasive pulmonary infection from filamentous fungi is not an uncommon occurrence in immunocompromised patients like acute lymphoblastic leukemia (ALL). Rarely, these lesions can spread via the hematogenous route and involve multiple visceral organs. We report a case of a 14-year-old boy with ALL who developed angioinvasive pulmonary aspergillosis early in the course of induction therapy, which was followed by hematogenous dissemination and formation of multiple brain abscesses. The patient was treated with intravenous amphotericin B. There was no response to the therapy and the patient succumbed to disseminated infection. Postmortem lung biopsy confirmed angioinvasive pulmonary aspergillosis. Poor penetration of amphotericin B across the blood-brain barrier could be one of the contributory factors for poor response to antifungal therapy. We discuss the various antifungal agents with respect to their penetration in brain.
Collapse
Affiliation(s)
- Gaurav Prakash
- Department of Medical Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | | | | | | |
Collapse
|
45
|
Lelièvre B, Legras P, Godon C, Franconi F, Saint-André JP, Bouchara JP, Diquet B. Experimental Models of Disseminated Scedosporiosis with Cerebral Involvement. J Pharmacol Exp Ther 2013; 345:198-205. [DOI: 10.1124/jpet.112.201541] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
46
|
Real-time treatment guidelines: considerations during the Exserohilum rostratum outbreak in the United States. Antimicrob Agents Chemother 2013; 57:1573-6. [PMID: 23384532 DOI: 10.1128/aac.00205-13] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
47
|
Galgóczy L, Tóth L, Virágh M, Papp T, Vágvölgyi CS. In vitro interactions of amantadine hydrochloride, R-(-)-deprenyl hydrochloride and valproic acid sodium salt with antifungal agents against filamentous fungal species causing central nervous system infection. ACTA BIOLOGICA HUNGARICA 2012; 63:490-500. [PMID: 23134606 DOI: 10.1556/abiol.63.2012.4.8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The mortality rates of fungal infections that affect the central nervous system are high in consequence of the absence of effective antifungal drugs with good penetration across the blood-brain barrier and the blood-cerebrospinal fluid barrier. In the present work in vitro antifungal activities of three good penetrating non-antifungal drugs (amantadine hydrochloride, R-(-)-deprenyl hydrochloride, valproic acid sodium salt) and their combinations with three antifungal agents (amphotericin B, itraconazole, terbinafine) were tested with broth microdilution method against eight fungal isolates belonging to Zygomycetes (Lichtheimia corymbifera, Rhizomucor miehei, Rhizopus microsporus var. rhizopodiformis, Saksenaeavasiformis) and Aspergillus genus (A. flavus, A. fumigatus, A. nidulans, A. terreus). These are known to be possible agents of central nervous fungal infections (CNFI). When used alone, the investigated nonantifungal drugs exerted slight antifungal effects. In their combinations with antifungal agents they acted antagonistically, additively and synergistically against zygomyceteous isolates. Primarily antagonistic interactions were revealed between the investigated drugs in case of Aspergilli, but additive and synergistic interactions were also observed. The additive and synergistic combinations allowed the usage of reduced concentrations of antifungal agents to inhibit the fungal growth in our study. These combinations would be a basis of an effective, less toxic therapy for treatment of CNFI.
Collapse
Affiliation(s)
- L Galgóczy
- Department of Microbiology, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary.
| | | | | | | | | |
Collapse
|
48
|
Kourkoumpetis TK, Desalermos A, Muhammed M, Mylonakis E. Central nervous system aspergillosis: a series of 14 cases from a general hospital and review of 123 cases from the literature. Medicine (Baltimore) 2012; 91:328-336. [PMID: 23117848 DOI: 10.1097/md.0b013e318274cd77] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Central nervous system (CNS) aspergillosis is a highly fatal infection. We review the clinical presentation, diagnosis, and outcome of this infection and present a case series of 14 consecutive patients with CNS aspergillosis admitted to Massachusetts General Hospital (MGH) from 2000 to 2011. We also review 123 cases reported in the literature during that time. We included only proven CNS aspergillosis cases conforming to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) definitions of invasive fungal infections. In the MGH case series, neutropenia, hematologic malignancies, autoimmune diseases requiring steroid treatment, and solid organ transplantation were the predominant comorbid conditions. Notably, all MGH patients were immunosuppressed, and more than half (n = 8) had a history of previous brain injury, unrelated to their index hospitalization. For most MGH patients (11 of 14), the lung was the primary focus of aspergillosis, while 2 had paranasal sinus involvement, and 1 had primary Aspergillus discitis. Among reported cases, paranasal sinuses (27.6%) and the lung (26.8%) were the primary foci of infection, whereas 22% of those cases had no obvious primary organ involvement. Although a selection bias should be considered, especially among published cases, our findings suggest that patients who underwent neurosurgery had improved survival, with MGH and literature patients having 25% and 28.6% mortality, respectively, compared to 100% and 60.4%, respectively, among patients who received only medical treatment. Although this was not the case among MGH patients, CNS aspergillosis can affect patients without significant immune suppression, as indicated by the high number of reported immunocompetent cases. In conclusion, mortality among CNS aspergillosis patients remains high, and the infection may be more common among patients with previous brain pathology. When indicated, neurosurgical procedures may improve prognosis.
Collapse
Affiliation(s)
- Themistoklis K Kourkoumpetis
- From the Department of Medicine, Infectious Disease Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. (Dr. Mylonakis' current affiliation is Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island.)
| | | | | | | |
Collapse
|
49
|
Cherian T, Giakoustidis A, Yokoyama S, Heneghan M, O’Grady J, Rela M, Wendon J, Heaton DN, Verma A. Treatment of Refractory Cerebral Aspergillosis in a Liver Transplant Recipient With Voriconazole: Case Report and Review of the Literature. EXP CLIN TRANSPLANT 2012; 10:482-6. [DOI: 10.6002/ect.2012.0028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
50
|
Janik-Moszant A, Matyl A, Rurańska I, Machowska-Majchrzak A, Kluczewska E, Szczepański T. Invasive fungal infection of the central nervous system in a patient with acute myeloid leukaemia. Pol J Radiol 2012; 77:54-7. [PMID: 22802867 PMCID: PMC3389958 DOI: 10.12659/pjr.882582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 01/19/2012] [Indexed: 11/20/2022] Open
Abstract
Background: Although the new intensive chemotherapeutic programs introduced recently into hematooncological therapies have led to a higher number of recoveries, persistent neutropenia favours the spread of severe infections, frequently fungal infections. Systemic fungal infections in patients treated for proliferative diseases of the hematopoietic system are characterised by a severe, progressing course and high morbidity. Case Reports: We present a case report that demonstrates the diagnostic problem of lesions in the central nervous system which developed following the fourth block of chemotherapy in an eight-year-old boy treated for acute myeloid leukaemia. The risk factors, high values of the inflammatory parameters and imaging results enabled us to diagnose a fungal infection of the central nervous system. Results: A fast improvement in the clinical condition of the patient after the applied antifungal therapy and the regression of lesions in the central nervous system shown in the imaging studies confirmed our final diagnosis.
Collapse
Affiliation(s)
- Anna Janik-Moszant
- Department of Pediatric Hematology and Oncology, Medical University of Silesia, Zabrze, Poland
| | | | | | | | | | | |
Collapse
|