Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America

The active metabolite hydroxyitraconazole has substantially higher in vivo free fraction and free concentrations compared to itraconazole

Itraconazole (ITCZ) is a triazole antifungal agent that is metabolized to many products. Hydroxyitraconazole (OH-ITCZ) is the major metabolite with antifungal activity comparable to that of ITCZ. Protein-free drug concentration has been reported to be a better biomarker for pharmacodynamics compared with total drug concentration. We developed an assay for quantification of free ITCZ and free OH-ITCZ concentrations using ultra-high-performance liquid chromatography coupled to tandem mass spectrometry (UHPLC-MS/MS) with equilibrium dialysis. The assay fulfilled the requirements of the US Food and Drug Administration guideline for assay validation, with lower limit of quantification of 0.025 and 0.25 ng/mL for free ITCZ and OH-ITCZ, respectively, than previous studies. Using this validated assay, we measured plasma free ITCZ and OH-ITCZ concentrations in 18 samples of 11 adult patients who received oral ITCZ between July 2016 and November 2022 at Oita University Hospital, and compared the in vivo percent free fraction and free concentration between the two compounds. Average plasma free concentrations and percent free fraction in 18 samples were, respectively, 0.188 ± 0.123 ng/mL and 0.024 ± 0.016 % for ITCZ, and 1.449 ± 1.017 ng/mL and 0.251 ± 0.109 % for OH-ITCZ, indicating that OH-ITCZ was 8.52-fold higher in percent free fraction and 10.42-fold higher in free concentration compared to ITCZ. Given that OH-ITCZ and ITCZ have similar in vitro antifungal activity, OH-ITCZ may contribute more to in vivo antifungal efficacy than ITCZ, suggesting that monitoring OH-ITCZ would be more beneficial.

Lymphocyte subsets and the increased risk for opportunistic infections in severe restrictive anorexia nervosa

Restrictive anorexia nervosa (AN-R) is characterized not only by psychiatric manifestations but also by significant medical complications. Patients commonly exhibit immune alterations, potentially increasing their susceptibility to infections. While direct evidence linking AN-R to heightened rates of opportunistic infections remains inconclusive, clinical observations suggest a higher incidence of complications and delayed febrile response in patients with infections. Concurrently, malnutrition, a frequent cause of secondary immunodeficiencies, exacerbates this susceptibility by compromising immune function. This paper investigates the immunological profiles of two patients with long-term AN-R who developed severe infections: one with disseminated Mycobacterium kansasii and the other with a co-infection of pulmonary Aspergillus fumigatus and Mycobacterium celatum. These cases, alongside data collected from previously published case reports summarized in this study, highlight the impact of altered immune function associated with mentioned population. The paper aims to explain the underlying mechanisms of immune dysfunction. Proactive monitoring of immune status and incorporating such assays into clinical practice may benefit early detection, effective management, and ultimately, improved outcomes.

Percutaneous Endoscopic Debridement and Drainage as a First-Line Diagnosis and Management Intervention for Spondylodiscitis: A Novel Treatment Algorithm

BACKGROUND AND OBJECTIVES

Spondylodiscitis (SD) is an infection of the intervertebral disk. In the nonseptic, MRI-positive patient without focal deficits, current guidelines recommend computed tomography-guided biopsy (CTGB) for pathogen identification. Yet, pathogen positivity from CTGB is low (37%). Percutaneous endoscopic debridement and drainage (PEDD) may improve pathogen identification and reduce pain. We aimed to evaluate the utility of PEDD as the first-line intervention for the diagnosis and management of SD.

METHODS

Demographic characteristics, perioperative outcomes, intraoperative data, and microbiological data were collected through retrospective chart review from 9 consecutive adult patients with suspected SD managed with PEDD between 2021 and 2024. Patients were followed postoperatively until no longer seen in clinic. Paired t -tests were used to compare Visual Analog Pain Scale and morphine milligram equivalents change after intervention.

RESULTS

The mean age was 56.4 years (SD: 10.0) with 7 male patients (77.8%). The mean follow-up was 7.1 months (SD: 9.6). On presentation, back pain was reported in 100% and lower extremity weakness and paresthesia in 33.3%; 77.8% of patients were treated with antibiotics preoperatively. The mean operative duration was 87.7 minutes (SD: 21.2). The mean estimated blood loss was 16.9 mL (SD: 20.7). The mean length of stay was 9.6 days (SD: 9.9). There were no intraoperative or postoperative complications associated with PEDD. Successful pathogen identification was achieved in 88.9%. The mean time to pathogen identification was 5.5 days (SD: 5.2). All patients had postoperative pain relief. There was a significant reduction in Visual Analog Pain Score postoperatively from 9.2 to 3.2 ( P < .001). This pain reduction was also associated with a significant reduction in morphine milligram equivalents from 32.7 to 29.5 ( P < .001).

CONCLUSION

We demonstrate that PEDD is a safe and effective procedure for the management of SD. PEDD may improve pathogen identification compared with CTGB while simultaneously reducing pain and opioid requirements. These data suggest that PEDD may be considered as a first-line intervention for SD. Further prospective studies are required to inform guidelines.

Prognostic Value of Serum and Bronchoalveolar Lavage Fluid Galactomannan Levels in Invasive Aspergillosis: An 8-Year Experience at a Tertiary Cancer Center

Background: Invasive aspergillosis (IA) is a life-threatening fungal infection that primarily affects immunocompromised individuals and has high morbidity and mortality rates, necessitating timely diagnosis and treatment. This study aimed to evaluate the prognostic utility of serum and bronchoalveolar lavage (BAL) fluid galactomannan levels, as well as galactomannan kinetics, in patients with IA. Methods: We retrospectively reviewed the medical records of patients who were diagnosed with proven or probable IA from March 2016 to April 2024 at a tertiary cancer center. The collected data included patient characteristics, baseline and peak galactomannan levels in serum and BAL fluid, galactomannan trends, and clinical outcomes. Subgroup analyses were performed to assess the prognostic value of dual-source galactomannan positivity (positive serum and BAL fluid galactomannan levels). Results: Elevated baseline serum galactomannan levels independently predicted treatment non-response (p = 0.039) and 12-week all-cause mortality (p < 0.001). Peak serum and BAL fluid galactomannan levels were strongly associated with poor clinical outcomes (p < 0.01). Compared to single-source galactomannan positivity, dual-source galactomannan positivity was linked to reduced treatment response (22% vs. 43%, p = 0.01) and higher IA-attributable mortality (52% vs. 27%, p = 0.002). Patients with neutropenia had poorer outcomes compared to patients without neutropenia, but neutrophil recovery dramatically improved survival (25% vs. 69% mortality, p < 0.0001). Early galactomannan kinetics and malignancy type had limited prognostic value. Conclusions: Our findings highlight the potential role of galactomannan as a key biomarker for early prognostication for IA. The strong association between galactomannan levels and clinical outcomes suggests its utility in identifying high-risk patients who may benefit from more aggressive management. Further studies are needed to introduce a nuanced and context-specific use of galactomannan into clinical practice and assess its role as a prognostic biomarker.

Survey of current national and international guidance to reduce risk of aspergillosis in hospitals

Aspergillus spp. are most commonly associated with disease in the severely immunocompromised host and those with chronic chest disease. The scope of patients at risk is expanding, including intensive care (inclusive of severe viral pneumonia), trauma, burns and major surgery. As exposure or colonization is a prerequisite to Aspergillus-related disease, this has prompted a global review of preventative measures recommended in healthcare establishments. This global review includes 75 documents from 24 countries, categorized into clinical, infection prevention and control, and building-related guidance for prevention of invasive aspergillosis (IA). We overview the IA incubation period and different acceptable levels of airborne Aspergilli in protected environments (PEs), including critical care and operating rooms. Few documents cover all aspects of prevention, prophylaxis, avoidance, preventative measures and monitoring (environmental and clinical). A multi-disciplinary approach is required to identify and minimize the multiple risks and ensure adequate preventative measures. Most building-related guidance addresses construction and internal hospital alterations, but we also review the importance of good management of the healthcare environment (including ventilation systems) and uncertainties of environmental monitoring. We highlight the differences in standards recommended for protective patient environments including the critical care environment. The large capital investment required for PEs is often limited to patient groups most at risk. Single document comprehensive guidance is lacking, and many countries provide no guidance. Reduction in healthcare-associated acquisition of invasive aspergillosis during vulnerable inpatient episodes requires heightened awareness of patients at risk, careful risk assessment and attentive maintenance of the general hospital environment.

Voriconazole in the management of invasive pulmonary aspergillosis in patients with severe liver disease: balancing efficacy and hepatotoxicity

Patients with severe liver disease (SLD) are prone to developing invasive pulmonary aspergillosis (IPA) due to immunodeficiency and microbial translocation, leading to high mortality rates. Although voriconazole is the first-line treatment for IPA, its use in patients with SLD is challenging due to the risk of hepatotoxicity. In this population, reduced hepatic blood flow and enzyme activity, compromised bile excretion, and increased intestinal permeability collectively affect voriconazole metabolism, resulting in a prolonged half-life, drug accumulation, and higher incidence of adverse events (AEs). Therapeutic drug monitoring (TDM) is essential to optimize voriconazole therapy, ensuring plasma concentrations within the therapeutic range (1.0-5.0 mg/L) while minimizing toxicity risks. This review highlights the risk factors for IPA in patients with SLD, the mechanisms of voriconazole-induced hepatotoxicity, its pharmacokinetics in this population, and current research on dose optimization. We emphasize the necessity of closely monitoring voriconazole plasma concentration, liver function, and inflammatory markers during treatment. For patients with SLD, we recommend a loading dose of 200 mg every 12 hours, with subsequent maintenance doses reduced to 1/4-1/3 of the standard dose, though the evidence remains limited. We call for large-scale clinical trials to define optimal dosing, efficacy, and safety of voriconazole for IPA in patients with SLD, providing clinicians with clearer treatment guidelines and improving patient outcomes.

Exploring Broad-Spectrum Antimicrobial Nanotopographies: Implications for Bactericidal, Antifungal, and Virucidal Surface Design

Inspired by the natural defense strategies of insect wings and plant leaves, nanostructured surfaces have emerged as a promising tool in various fields, including engineering, biomedical sciences, and materials science, to combat bacterial contamination and disrupt biofilm formation. However, the development of effective antimicrobial surfaces against fungal and viral pathogens presents distinct challenges, necessitating tailored approaches. Here, we aimed to review the recent advancements of the use of nanostructured surfaces to combat microbial contamination, particularly focusing on their mechano-bactericidal and antifungal properties, as well as their potential in mitigating viral transmission. We comparatively analyzed the diverse geometries and nanoarchitectures of these surfaces and discussed their application in various biomedical contexts, such as dental and orthopedic implants, drug delivery systems, and tissue engineering. Our review highlights the importance of preventing microbial attachment and biofilm formation, especially in the context of rising antimicrobial resistance and the economic impact of biofilms. We also discussed the latest progress in materials science, particularly nanostructured surface engineering, as a promising strategy for reducing viral transmission through surfaces. Overall, our findings underscore the significance of innovative strategies to mitigate microbial attachment and surface-mediated transmission, while also emphasizing the need for further interdisciplinary research in this area to optimize antimicrobial efficacy and address emerging challenges.

Profiling Drug Susceptibility and Species Identification of Aspergillus Isolates From Patients With Superficial Infection

BACKGROUND

Aspergillus infections pose significant challenges in clinical management due to rising resistance rates and limited diagnostic accuracy. Superficial infections, particularly in immunocompetent individuals, are often understudied, despite their prevalence in specific populations.

OBJECTIVES

This study aimed to characterise the distribution and antifungal susceptibility patterns of Aspergillus isolates from a tertiary hospital in Shandong, China, and evaluate the performance of matrix-assisted laser desorption time-of-flight (MALDI-TOF) mass spectrometry versus multi-gene sequencing for species identification.

PATIENTS/METHODS

A total of 120 Aspergillus isolates were collected from patients with localised aspergillosis (nails, external auditory canal, cornea, sub-throat secretions) between 2020 and 2021. Species identification was performed using MALDI-TOF and multi-gene sequencing (ITS, BenA, CaM, RPB2). Antifungal susceptibility testing was conducted for micafungin, azoles (itraconazole, voriconazole, posaconazole, fluconazole), and amphotericin B following standard protocols.

RESULTS

Species Identification: MALDI-TOF identified 52.5% of isolates to the species level, whereas multi-gene sequencing achieved 100% accuracy. Aspergillus terreus was the most prevalent species (38.3%). Antifungal Susceptibility: Micafungin showed the highest resistance rate (40%), followed by amphotericin B (reduced susceptibility in 31.7%). Azoles demonstrated low resistance (3.3%-6.7%) except for fluconazole (21.7%). Clinical Correlates: Superficial infections were most common in middle-aged/elderly patients (68.3%), frequently linked to external trauma (41.7%) or environmental exposure (35.8%).

CONCLUSIONS

Multi-gene sequencing outperformed MALDI-TOF for Aspergillus identification. A. terreus dominance and micafungin resistance highlight regional epidemiological trends. Natamycin and nystatin remain cost-effective first-line topical options. Enhanced surveillance in trauma-prone and environmentally exposed populations is warranted.

The GPCR antagonist PPTN synergizes with caspofungin providing increased fungicidal activity against Aspergillus fumigatus

Fungal pathogens pose a serious threat to human health, with Candida and Aspergillus spp. representing some of the most significant opportunistic invaders. Aspergillus fumigatus causes aspergillosis, one of the most prevalent fungal diseases of humans. There is a limited number of drugs available to combat these infections, and antifungal drug resistance is on the rise. In this manuscript, we show 4-[4-(4-Piperidinyl) phenyl]-7-[4-(-(trifluoromethyl) phenyl]-2-naphthalenecarboxylic acid (PPTN), a highly specific antagonist of the human P2Y14 receptor, is a promising antifungal adjuvant against diverse fungal pathogens. PPTN interacts with caspofungin (CAS), ibrexafungerp, voriconazole (VOR), and amphotericin against A. fumigatus CAS- and VOR-resistant clinical isolates, and also CAS against Candida spp and Cryptococcus neoformans. The combination of PPTN and CAS increases cell death in A. fumigatus. In the model yeast Saccharomyces cerevisiae, heterozygous deletion of genes involved in chromatin remodeling results in PPTN hypersensitivity, and in A. fumigatus, PPTN can have increased fungicidal activity when combined with the histone deacetylase inhibitor trichostatin A and the DNA methyltransferase inhibitor 5-azacytidine. Finally, PPTN has reduced toxicity to human immortalized cell lineages and partially clears A. fumigatus conidia infection in A549 pulmonary epithelial cells. Our results indicate that PPTN is a novel adjuvant antifungal drug against fungal diseases caused by A. fumigatus and Candida spp.

IMPORTANCE

Invasive fungal infections have a high mortality rate, causing more deaths annually than tuberculosis or malaria. Aspergillus fumigatus is the main etiological agent of aspergillosis, one of the most prevalent and deadly fungal diseases. There are few therapeutic options for treating this disease, and treatment commonly fails due to host complications or the emergence of antifungal resistance. Drug repurposing, where existing drugs are deployed for other clinical indications, has increasingly been used in the process of drug discovery. Here, we show that 4-[4-(4-Piperidinyl) phenyl]-7-[4-(-(trifluoromethyl) phenyl]-2-naphthalenecarboxylic acid (PPTN), a highly specific antagonist of the human P2Y14 receptor, when combined with caspofungin (CAS), ibrexafungerp, voriconazole (VOR), and amphotericin can increase the fungicidal activity against not only A. fumigatus CAS- and VOR-resistant clinical isolates but also CAS against Candida spp.

Metagenomic next-generation sequencing identifies native valve Aspergillus fumigatus endocarditis with cerebral involvement: a case report

Aspergillus endocarditis is a rare but highly fatal condition, particularly in immunocompromised patients. This case report describes a 74-year-old male with native valve Aspergillus fumigatus endocarditis and intracranial infection. Diagnosis was complicated by atypical presentation and negative blood cultures, but metagenomic next-generation sequencing (mNGS) enabled rapid identification of the pathogen. This case is notable for being the first to document Aspergillus fumigatus endocarditis with cerebral involvement confirmed by mNGS, highlighting the importance of early diagnosis and advanced diagnostic tools in improving outcomes.

A Case Report of Acute Lymphoblastic Leukemia Complicated by Naso-Ophthalmic Mucormycosis

Rhinocerebral mucormycosis, an invasive fungal infection caused by Mucorales species, typically involves the paranasal sinuses, orbits, and central nervous system. Known for its aggressive nature, the infection often leads to severe complications and a high risk of mortality. Common risk factors include uncontrolled diabetes mellitus, immunosuppression, prolonged use of glucocorticoids, and hematologic malignancies. Patients with hematologic malignancies are particularly susceptible to this infection due to compromised immune function. This case report details an instance of acute lymphoblastic leukemia complicated by naso-ocular encephalomycosis, providing a comprehensive overview of its clinical presentation, diagnostic approach, therapeutic management, and prognosis. Additionally, preventive measures and early diagnosis are important in patients with hematologic malignancies.

Aspergillus fumigatus Bloodstream Infection in the Absence of Classic Risk Factors: Expanding the Spectrum of Invasive Aspergillosis

We report an unusual case of Aspergillus fumigatus fungemia in a 65-year-old male with multiple comorbidities including, human immunodeficiency virus (HIV), chronic obstructive pulmonary disease (COPD), diabetes mellitus, hepatitis C, and metastatic small cell lung cancer on chemotherapy. He presented with pneumonia and acute hypoxic respiratory failure requiring intubation. The patient developed septic shock and a peripherally inserted central catheter (PICC-line)-associated methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia treated with intravenous (IV) cefazolin. Blood cultures unexpectedly revealed A. fumigatus despite a lack of classic risk factors, other than advanced acquired immune deficiency syndrome (HIV/AIDS), such as prolonged neutropenia or stem cell transplantation. Suspected sources included disseminated infection from the lungs and/or the infected PICC line. This case highlights the diagnostic and therapeutic challenges of invasive aspergillosis, a rarely reported and poorly understood entity with a high mortality rate. Further studies are needed to better characterize the epidemiology, risk factors, and optimal management of Aspergillus fungemia in diverse immunocompromised populations.

Hyper IgE Syndromes: Understanding, Management, and Future Perspectives: A Narrative Review

Background and Aim

Hyper IgE syndromes (HIES) are rare primary immunodeficiency characterized by susceptibility to specific infections, eczema, and elevated IgE levels. Pathogenic mutations in STAT3, IL6R, IL6ST, ERBB2IP, PGM3, ZNF431, SPINK5, TGFBR1/2, and CARD11 have been identified as genetic factors contributing to phenotypes of HIES lead to hindered differentiation and activity, aberrant signaling cascades and disrupting immune regulation. HIES present a diverse clinical symptoms, challenging diagnosis and management; understanding its pathophysiology, genetics, and immunological abnormalities offer hope for improved outcomes. In this review we aim to provide a comprehensive understanding of the condition and also discuss latest updates on pathological features, clinical spectrum and its variability, immunological abnormalities, inheritance patterns, new candidate genes, challenges, management strategies, epidemiology and future directions of HIES.

Methods

This review conducted an extensive search of information from multiple databases, including PubMed, Scopus, WHO, and ClinVar to ensure comprehensive coverage. Preference was given to articles published recently to capture the latest research and developments. Endnote was employed as a reference manager. The relevant literature was meticulously reviewed to address the objectives of the study.

Results

Missense, nonsense, and frameshift variants are commonly observed in HIES. Understanding these genetic mutations is key to diagnosing and managing conditions such as Hyper-IgE recurrent infection syndromes (linked to IL6R, STAT3, and ZNF341 mutations), Atopy associated with ERBIN mutations which links STAT3 and TGF-β pathway, Immunodeficiency 23 (caused by PGM3 mutations), Netherton syndrome (resulting from SPINK5 mutations), and Loeys-Dietz syndrome (related to TGFBR mutations). Each year, new genes and variants responsible for this type of immune deficiency are added to the list.

Conclusion

Although rare, HIES significantly impacts patients due to its complex medical manifestations and need for lifelong management. Identifying casual variants is essential for effective clinical management of these complex conditions.

1-methylnicotinamide modulates IL-10 secretion and voriconazole metabolism

Background

Inflammatory diseases impair the hepatic metabolism of voriconazole (VRC). 1-Methylnicotinamide (1-MNA), a common final metabolite of nicotinamide in the liver, has demonstrated anti-inflammatory effects in recent studies. This study investigated the impact of 1-MNA on VRC metabolism in the liver.

Method

Mice with a systemic inflammatory response induced by lipopolysaccharide (LPS) were intragastrically administered 1-MNA, and their VRC metabolic capacity was evaluated. Kupffer cells and primary hepatocytes were isolated, and flow cytometry along with molecular knockdown experiments were performed to explore the molecular mechanisms underlying improved drug metabolism. IL-10 knockout (IL-10-/-) mice were used to validate the role of IL-10 in enhancing hepatocyte VRC metabolism under inflammatory conditions.

Results

1-MNA promoted M2 polarization of liver Kupffer cells, stimulated IL-10 secretion, upregulated CYP2C38 expression in primary hepatocytes, and enhanced VRC metabolism. The mechanism by which IL-10 upregulated CYP2C38 appears to involve the inhibition of the nuclear transcription factor NF-κB (p65) in hepatocytes.

Conclusions

1-MNA regulated Kupffer cell polarization in an LPS-induced inflammatory environment, reduced the inflammatory inhibition of CYP2C38 expression in hepatocytes, and promoted VRC metabolism.

Decreased Frequency and Improved Outcomes in Invasive Aspergillosis Caused by Aspergillus terreus After the Introduction of Anti-Mold Azole Agents: A 30-Year Study at a Tertiary Cancer Center

Invasive aspergillosis (IA) is a significant cause of morbidity and mortality in patients with hematological malignancy (HM) and hematopoietic stem cell transplant (HSCT) recipients. Aspergillus terreus is associated with worse outcomes than non-terreus Aspergillus species. Since the introduction of anti-mold azoles in 2002, there have been limited data on the etiology of IA. We retrospectively compared characteristics, antifungal treatments, and outcomes between patients with HM or HSCT infected with A. terreus and those with non-terreus Aspergillus between July 1993 and July 2023. We also examined trends over time in rates of A. terreus and outcomes of this infection. A total of 699 patients with culture-documented IA were analyzed, 537 with non-terreus species and 162 with A. terreus. Types of underlying malignancy, neutropenia, graft-versus-host disease, and anti-mold prophylaxis were similar between the groups. ICU stays and mechanical ventilation were more common among patients with A. terreus (p = 0.002 and 0.003, respectively). The rate of A. terreus decreased significantly from 35.9% during 1993-2003 to 11.2% during 2004-2013 and 16.7% during 2014-2023 (p < 0.0001 each). IA caused by A. terreus showed significant improvements in response to therapy and in overall and IA-associated mortality in the last two decades compared to the first (p < 0.0001). In conclusion, the increased use of anti-mold azoles after 2003 improved outcomes for HM patients with IA caused by A. terreus.

Bjerkandera adusta Fungi as Causative Agent of Invasive Chronic Rhinosinusitis

We report an invasive mycosis case in Japan caused by Bjerkandera adusta, a fungal species not previously reported as a causative pathogen of invasive mycosis. B. adusta was identified by using phylogenetic analysis. Voriconazole was used successfully for treatment. Immunodeficient patients may be susceptible to infection by rare causative fungi.

New pharmacotherapeutic strategies for drug-resistant Candida infections: a review

INTRODUCTION

Candida species produce a wide array of infections ranging from mucocutaneous to systemic infections. Candida albicans remains the most common species identified; however, the non-albicans Candida species have continued to increase as the diagnosis and therapeutic regimens have progressed.

AREAS COVERED

This review with discussion of the various Candida species, especially the non-albicans species, some of the important mechanisms of resistance, and newer in vitro and clinical studies describing the recent and novel antifungal options such as rezafungin, ibrexafungerp, and oteseconazole, along with a novel antifungal, fosmanogepix.

EXPERT OPINION

Initial antifungal therapy is frequently obsolete due to the expansion of antifungal resistance. This is especially true with C. glabrata, C. krusei, and most recently with C. auris. The newer and novel antifungals discussed here will add valuable tools to our antifungal armamentarium to be able to appropriately and adequately treat and manage these difficult infections. Each of the antifungals has unique and novel properties that will expand the arsenal useful to treat these fungal infections in the years to come.

The clinical impact of primary granulocyte-colony stimulating factor prophylaxis in children with acute lymphoblastic leukemia who underwent induction chemotherapy

BACKGROUND

Data describing the risk factors for the occurrence of severe infections in acute lymphoblastic leukemia (ALL) patients following induction chemotherapy and the role of prophylactic granulocyte-colony stimulating factor (G-CSF) in the era of antimicrobials prophylaxis are limited.

METHODS

This study enrolled 188 children aged ≤18 years with newly diagnosed ALL who received Taiwan Pediatric Oncology Group ALL-2002 and 2013 treatments between January 1, 2010 and June 30, 2021. Prophylactic G-CSF was administered when a patient continues neutropenia after achieving the first bone marrow remission since June 1, 2015. Clinical factors were assessed for their association with severe infections.

RESULTS

From January 2010 to May 2015, 80 children experienced a total of 11 (13.5%) episodes of severe infections; while 10 (9.2%) episodes were reported to occur in 108 patients who received prophylactic G-CSF. Reduction of severe infections occurrence did not achieve statistical significance during prophylactic G-CSF administration in ALL patients. Compared with ALL-high risk (HR) and very high risk patients with no G-CSF prophylaxis, the use of G-CSF prophylaxis significantly reduced episodes of febrile neutropenia. Occurrence of grade III-IV intestinal ileus, grade II-III oral mucositis, prolonged neutropenia, central venous catheter (CVC) placement, or the requirement insulin therapy for hyperglycemia were associated with higher risk of bloodstream infections.

CONCLUSIONS

ALL-HR patients with G-CSF prophylaxis were associated with reduction of febrile neutropenia episodes. Occurrence of severe ileus, oral mucositis, hyperglycemia, CVC placement, or prolonged neutropenia were associated with severe infections in ALL patients receiving induction chemotherapy.

Review of neuroimaging findings of intracranial angioinvasive fungal infections

With increasing use of broad-spectrum antibiotics, advances in organ and stem-cell transplant therapy, and the continued diabetes mellitus II epidemic, as well as other risk factors, reports of fungal infections of the CNS have been increasing. The most lethal subset is the angioinvasive fungal infection. Aspergillus fumigatus, Mucor, and Fusarium tend to affect immunocompromised individuals depending on their risk factors. Exserohilum rostratum and Cladophialaphora species tend to infect immunocompetent individuals. Early diagnosis and treatment are imperative for improved outcomes and reduced morbidity and mortality. Clinical presentation is often nonspecific, while neuroimaging can be helpful for accurate diagnosis. CT of the head and/or the maxillofacial structures is the primary imaging modality. Once the infection begins to proliferate, areas of vasogenic and cytotoxic edema, with regional mass effect and shift of the midline structures may be seen. These findings, however, are often nonspecific and may also be seen in underlying neoplasm, inflammatory processes, and other intracranial infections. Characteristic findings on T1, T2, diffusion-weighted imaging (DWI), and gradient echo sequences (GRE) may help to further narrow the differential diagnoses. We present a review of neuroimaging findings that will aid the neuroradiologist in distinguishing intracranial angioinvasive fungal infections and lead to improved patient outcomes.

A PCR-Based Approach for Early Diagnosis of Head and Neck Aspergillosis: A Pilot Study

BACKGROUND

Aspergillosis is a fungal disease caused by the inhalation of fungal spores of the genus Aspergillus spp. This fungus mainly affects the lungs but can spread and infect the maxillofacial region through the bloodstream or inoculation of the fungus after extraction or endodontic treatment, especially in the upper posterior teeth. The disease has nonspecific clinical manifestations that hinder its early diagnosis. Although the Polymerase Chain Reaction (PCR) technique holds promise as a diagnostic tool for aspergillosis, anatomopathological analysis services do not routinely adopt this method.

OBJECTIVES

Therefore, the present study aimed to evaluate the applicability of PCR and standardise the techniques of preparation of biological samples for the detection of the three species: Aspergillus niger, Aspergillus fumigatus and Aspergillus flavus. Methods: Six samples of formalin-fixed, paraffin-embedded tissue (FFPE) with a histopathological diagnosis suggestive of aspergillosis were investigated using PCR. As a positive control for the PCR reaction, morphologically and genetically characterized cultures were used, with their sequences deposited at NCBI under accession codes MW837777 (A. fumigatus) and MW837779 (A. niger). The A. flavus culture used is reference RC 2053.

RESULTS

Four of the six samples evaluated were positive for Aspergillus spp., of which one was co-infected with A. fumigatus and A. flavus species, while two others were positive only for A. flavus, and one sample was positive only for A. fumigatus.

CONCLUSIONS

These findings suggest that PCR can be used as an auxiliary method for diagnosing aspergillosis. However, this was a pilot study, and expansion of the sample size and the evaluation of PCR in comparison with other diagnostic tests for aspergillosis are essential to determine the accuracy of the method.

The mitochondrial protein Bcs1A regulates antifungal drug tolerance by affecting efflux pump expression in the filamentous pathogenic fungus Aspergillus fumigatus

Aspergillus fumigatus is the predominant pathogen responsible for aspergillosis infections, with emerging drug-resistant strains complicating treatment strategies. The role of mitochondrial functionality in fungal resistance to antifungal agents is well-documented yet not fully understood. In this study, the mitochondrial protein Bcs1A, a homolog of yeast Bcs1, was found to regulate colony growth, ion homeostasis, and the response to antifungal drugs in A. fumigatus. Microscopic observations revealed substantial colocalization of Bcs1A-GFP fusion protein fluorescence with mitochondria. Bcs1A deletion compromised colony growth and the utilization of non-fermentable carbon sources, alongside causing abnormal mitochondrial membrane potential and reduced reactive oxygen species production. These findings underscore Bcs1A's vital role in maintaining mitochondrial integrity. Phenotypic analysis and determinations of minimum inhibitory concentrations indicated that the Δbcs1A mutant was more resistant to various antifungal agents, such as azoles, terbinafine, and simvastatin, compared to wild-type strain. RNA sequencing and RT-qPCR analysis highlighted an upregulation of multiple efflux pumps in the Δbcs1A mutant. Furthermore, loss of the principal drug efflux pump, mdr1, decreased azole tolerance in the Δbcs1A mutant, suggesting that Bcs1A's modulated of azoles response via efflux pump expression. Collectively, these results establish Bcs1A as essential for growth and antifungal drug responsiveness in A. fumigatus mediated through mitochondrial regulation.IMPORTANCEDrug resistance presents a formidable obstacle in the clinical management of aspergillosis. Mitochondria are integral to various biochemical pathways, including those involved in fungi drug response, making mitochondrial proteins promising therapeutic targets for drug therapy. This study confirms that Bcs1A, a mitochondrial respiratory chain protein, is indispensable for mitochondrial functionality and multidrug tolerance in Aspergillus fumigatus. Mutation of Bcs1A not only leads to a series of drug efflux pumps upregulated but also shows that loss of the primary efflux pump, mdr1, partial reduction in drug tolerance in the Bcs1A mutant, highlighting that Bcs1A's significant influence on mitochondria-mediated drug resistance.

Unlocking Trehalose's versatility: A comprehensive Journey from biosynthesis to therapeutic applications

For over forty years, a sugar of rare configuration known as trehalose (two molecules of glucose linked at their 1-carbons), has been recognised for more than just its roles as a storage compound. The ability of trehalose to protect an extensive range of biological materials, for instance cell lines, tissues, proteins and DNA, has sparked considerable interest in the biotechnology and pharmaceutical industries. Currently, trehalose is now being investigated as a promising therapeutic candidate for human use, as it has shown potential to reduce disease severity in various experimental models. Despite its diverse biological effects, the precise mechanism underlying this observation remain unclear. Therefore, this review delves into the significance of trehalose biosynthesis pathway in the development of novel drug, investigates the inhibitors of trehalose synthesis and evaluates the binding efficiency of T6P with TPS1. Additionally, it also emphasizes the knowledge about the protective effect of trehalose on modulation of autophagy, combating viral infections, addressing the conditions like cancer and neurodegenerative diseases based on the recent advancement. Furthermore, review also highlight the trehalose's emerging role as a surfactant in delivering monoclonal antibodies that will further broadening its potential application in biomedicines.

Cerebrospinal fluid galactomannan detection for the diagnosis of central nervous system aspergillosis: a diagnostic test accuracy systematic review and meta-analysis

BACKGROUND

Cerebrospinal fluid (CSF) galactomannan is an adjunctive test for central nervous system (CNS) aspergillosis diagnosis with unclear diagnostic test characteristics.

OBJECTIVES

To evaluate the diagnostic test characteristics of CSF galactomannan in CNS aspergillosis.

METHODS

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase, Web of Science, and Scopus, from inception to 24 February 2023.

STUDY ELIGIBILITY CRITERIA

Prospective and retrospective studies with 1-group and 2-group designs using any galactomannan assay on CSF to diagnose CNS aspergillosis.

PARTICIPANTS

Adult and/or paediatric patients with CNS aspergillosis.

TEST(S)

Galactomannan testing on CSF specimens.

REFERENCE STANDARD

European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium (EORTC/MSGERC) diagnostic criteria, or equivalent.

ASSESSMENT OF RISK OF BIAS

QUADAS-2 assessment in duplicate.

METHODS OF DATA SYNTHESIS

Bivariate restricted maximum likelihood estimation random-effects meta-analysis, summarized using forest and summary receiver operating characteristic plots; bivariate meta-regression models to investigate heterogeneity; and subgroup and sensitivity analyses to explore subgroup effects and methodologic choices (PROSPERO registration: CRD42022296331; funding: none).

RESULTS

We included eight studies (n = 342 participants). The summary estimates of CSF galactomannan sensitivity and specificity were 69.0% (95% CI, 57.2-78.7%) and 94.4% (95% CI, 82.8-98.3%), respectively. Using meta-regression, galactomannan cut-off (p = 0.38), EORTC/MSGERC criteria version (p = 0.48), or whether the reference standard was defined as both proven and probable or only proven aspergillosis (p = 0.48) did not explain observed heterogeneity. No subgroup effects were demonstrated by analysing the EORTC/MSGERC criteria reference standard used (e.g. 2002 vs. 2008 definitions) or whether paediatric patients were included. Diagnostic sensitivity was improved using a galactomannan cut-off of 1.0, and by excluding high risk of bias and 1-group design studies.

DISCUSSION

CSF galactomannan is a highly specific but insensitive test for use as a component of CNS aspergillosis diagnosis. Few included studies, no prospective studies, and a high risk of bias are study limitations.

Invasive Trichoderma longibrachiatum infection in a neutropaenic patient

Invasive fungal infection is a life-threatening complication of chemotherapy and neutropaenia in the haematology population. Trichoderma species rarely cause human disease but have been reported to cause invasive infection in the immunosuppressed. We present a case of invasive Trichoderma longibrachiatum pulmonary infection with fatal outcome in a neutropaenic patient with acute myeloid leukaemia. 2012 Elsevier Ltd. All rights reserved.

Managing diagnostic complexity: Allergic bronchopulmonary aspergillosis (ABPA) mimicking asthma exacerbation and infections in pediatric cases

Allergic bronchopulmonary aspergillosis (ABPA) presents diagnostic hurdles in pediatrics due to its resemblance to asthma or infections. An 11-year-old girl, known for recurrent asthma-related hospitalizations, presented with ongoing cough and breathing issues. Initial asthma treatment provided temporary relief, but her reliance on oxygen spurred further investigation. Radiological assessments initially suggested infection, confirmed as Klebsiella pneumonia, but antibiotic treatment proved insufficient. Elevated eosinophils, IgE levels, and specific IgE for Aspergillus fumigatus hinted at ABPA. Confirmation led to a successful three-month oral steroid course, combining therapies for effective management. Distinguishing ABPA from asthma and infections demands a thorough approach for timely identification and treatment in pediatric cases.

Associated factors with voriconazole plasma concentration: a systematic review and meta-analysis

Background: Voriconazole plasma concentration exhibits significant variability and maintaining it within the therapeutic range is the key to enhancing its efficacy. We conducted a systematic review and meta-analysis to estimate the prevalence of patients achieving the therapeutic range of plasma voriconazole concentration and identify associated factors. Methods: Eligible studies were identified through the PubMed, Embase, Cochrane Library, and Web of Science databases from their inception until 18 November 2023. We conducted a meta-analysis using a random-effects model to determine the prevalence of patients who reached the therapeutic plasma voriconazole concentration range. Factors associated with plasma voriconazole concentration were summarized from the included studies. Results: Of the 60 eligible studies, 52 reported the prevalence of patients reaching the therapeutic range, while 20 performed multiple linear regression analyses. The pooled prevalence who achieved the therapeutic range was 56% (95% CI: 50%-63%) in studies without dose adjustment patients. The pooled prevalence of adult patients was 61% (95% CI: 56%-65%), and the pooled prevalence of children patients was 55% (95% CI: 50%-60%) The study identified, in the children population, several factors associated with plasma voriconazole concentration, including age (coefficient 0.08, 95% CI: 0.01 to 0.14), albumin (-0.05 95% CI: -0.09 to -0.01), in the adult population, some factors related to voriconazole plasma concentration, including omeprazole (1.37, 95% CI 0.82 to 1.92), pantoprazole (1.11, 95% CI: 0.17-2.04), methylprednisolone (-1.75, 95% CI: -2.21 to -1.30), and dexamethasone (-1.45, 95% CI: -2.07 to -0.83). Conclusion: The analysis revealed that only approximately half of the patients reached the plasma voriconazole concentration therapeutic range without dose adjustments and the pooled prevalence of adult patients reaching the therapeutic range is higher than that of children. Therapeutic drug monitoring is crucial in the administration of voriconazole, especially in the children population. Particular attention may be paid to age, albumin levels in children, and the use of omeprazole, pantoprazole, dexamethasone and methylprednisolone in adults. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023483728.

Occupational Lung Disease Causing Allergic Bronchopulmonary Aspergillosis: A Case Report

Aspergillus fumigatus can induce allergic bronchopulmonary aspergillosis (ABPA), an immunological hypersensitivity reaction that frequently exacerbates the symptoms of cystic fibrosis and asthma patients. Due to persistent symptoms, a considerable percentage of patients with ABPA in India, a country where tuberculosis is widespread, are initially misdiagnosed as having pulmonary tuberculosis. We present a case of ABPA in a male industry worker, who was diagnosed after one year of having symptoms and has successfully recovered since.

Investigation of antifungal susceptibility of Aspergillus species isolated from systemic clinical specimens by different methods

PURPOSE

Due to the potential for Aspergillus species to cause lethal infections and the rising rates of antifungal resistance, the significance of antifungal susceptibility tests has increased. We aimed to assess the sensitivities of Aspergillus species to amphotericin B (AMB), voriconazole (VOR), itraconazole (ITZ), and caspofungin (CAS) using disk diffusion (DD) and gradient diffusion (GD) methods and compare them with broth microdilution (BMD) as the reference susceptibility method.

METHODS

The study involved 62 Aspergillus fumigatus, 28 Aspergillus flavus, and 16 Aspergillus terreus isolates, totaling 106 Aspergillus isolates. BMD and DD methods were performed in accordance with CLSI M38-A2 and CLSI M51-A documents, respectively. The GD method utilized nonsupplemented Mueller Hinton agar (MHA) as the medium.

RESULTS

In the BMD method, the lowest minimal inhibitory concentration (MIC)90 or minimal effective concentration (MEC)90 values were observed for VOR and CAS (0.5 μg/mL and 0.06 μg/mL, respectively). AMB and ITZ MIC90 values were both 2 μg/mL. In our comparison of the GD method with the BMD method at ±2 dilution, we observed essential agreement rates of 91.6%, 99.1%, 100%, and 38.6% for AMB, VOR, ITZ, and CAS, respectively. When comparing DD and BMD methods, we found categorical agreement rates of 65.1%, 99.1%, 77.3%, and 100% for AMB, VOR, ITZ, and CAS, respectively. For GD and BMD methods, these rates were 79.2%, 99.1%, 87.8%, and 100%.

CONCLUSIONS

Given the high essential and categorical agreement rates, we posit that the GD method is a viable alternative to the BMD method for AMB, ITZ and VOR but not for CAS. In addition, the use of nonsupplemented MHA in the GD method proves advantageous due to its cost-effectiveness and widespread availability compared to other growth media.

Clinical application of voriconazole in pediatric patients: a systematic review

The purpose of this study was to review the literature on the clinical use of voriconazole (VRC) in pediatric patients. MEDLINE, Embase, PubMed, Web of Science, and Cochrane Library were searched from January 1, 2000, to August 15, 2023 for relevant clinical studies on VRC use in pediatric patients. Data were collected based on inclusion and exclusion criteria, and a systematic review was performed on recent research related to the use of VRC in pediatric patients. This systematic review included a total of 35 observational studies among which there were 16 studies investigating factors influencing VRC plasma trough concentrations (Ctrough) in pediatric patients, 14 studies exploring VRC maintenance doses required to achieve target range of Ctrough, and 11 studies focusing on population pharmacokinetic (PPK) research of VRC in pediatric patients. Our study found that the Ctrough of VRC were influenced by both genetic and non-genetic factors. The optimal dosing of VRC was correlated with age in pediatric patients, and younger children usually required higher VRC doses to achieve target Ctrough compared to older children. Establishing a PPK model for VRC can assist in achieving more precise individualized dosing in children.

The epidemiology of invasive fungal infections in transplant recipients

Transplant patients, including solid-organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients, are exposed to various types of complications, particularly rejection. To prevent these outcomes, transplant recipients commonly receive long-term immunosuppressive regimens that in turn make them more susceptible to a wide array of infectious diseases, notably those caused by opportunistic pathogens. Among these, invasive fungal infections (IFIs) remain a major cause of mortality and morbidity in both SOT and HSCT recipients. Despite the continuing improvement in early diagnostics and treatments of IFIs, the management of these infections in transplant patients is still complicated. Here, we provide an overview concerning the most recent trends in the epidemiology of IFIs in SOT and HSCT recipients by describing the prominent yeast and mold species involved, the timing of post-transplant IFIs and the risk factors associated with their occurrence in these particularly weak populations. We also give special emphasis into basic research advances in the field that recently suggested a role of the global and long-term prophylactic regimen in orchestrating various biological disturbances in the organism and conditioning the emergence of the most adapted fungal strains to the particular physiological profiles of transplant patients.

Pulmonary coinfection by Pneumocystis jirovecii and Aspergillus terreus in an ITP patient after corticosteroid therapy: A case report

Pneumocystis jirovecii pneumonia and invasive pulmonary aspergillosis are both life‐threatening opportunistic fungal infections. There are only few reports of coinfection by these two fungi in the literature, and Aspergillus fumigatus is the predominant Aspergillus species in the coinfection. We report here the first case of coinfection by Aspergillus terreus and P. jirovecii pneumonia and caspofungin can be an appropriate choice for salvage treatment of the coinfection. A 51‐year‐old man with a history of immune thrombocytopenia treated with prednisone over 2 months was admitted to emergency intensive care unit for acute respiratory failure and a cavity was found on chest computed tomography. Therefore, his trachea was immediately intubated. The patient was treated with a large spectrum of antibiotic regimen, consisting initially of imipenem/cilastatin, moxifloxacin and fluconazole followed by fluconazole, imipenem/cilastatin, vancomycin, trimethoprim–sulphamethoxazole (TMP‐SMZ) and azithromycin. When the polymerase chain reaction analysis of the bronchoalveolar lavage sample revealed P. jirovecii and A. terreus, all the antibiotics were stopped except TMP‐SMZ, and voriconazole was added. Two weeks later, the patient showed clinical improvement but radiological deterioration. Consequently, caspofungin was started for salvage therapy, then the patient showed gradual clinical improvement. He was discharged with oral voriconazole and TMP‐SMZ. The antifungal treatment was continued for 6 months until complete radiological absorption. In conclusion, early bronchoscopy with bronchoalveolar lavage fluid should be considered in order to diagnose and treat promptly in those treated with corticosteroids combined with immunocompromised and caspofungin could be an appropriate choice for salvage treatment of coinfection by P. jirovecii and A. terreus.

Association between voriconazole-induced visual hallucination and dopamine in an analysis of the food and drug administration (FDA) adverse event reporting system database

Voriconazole is a second-generation azole used to treat serious fungal infections. Visual hallucinations constitute a representative adverse event caused by voriconazole. However, its mechanism of action remains unclear. In patients with schizophrenia or Parkinson's disease, the frequency of visual hallucinations is associated with brain dopamine levels. This study investigated the frequency of visual hallucinations in patients treated with voriconazole alone or in combination with dopaminergic medicines or dopamine antagonists, using data collected from the Food and Drug Administration Adverse event Reporting System (FAERS). The frequency of visual hallucinations with voriconazole alone and in combination with a dopaminergic medicine (levodopa) or dopamine antagonists (risperidone and chlorpromazine) was compared using data from the FAERS between 2004 and 2023, using the reporting odds ratio (ROR) with relevant 95% confidence intervals (CI). The reference group comprised patients who had been administered voriconazole without dopaminergic medication or dopamine antagonists. Of the patients, 22,839, 90,810, 109,757, 6,435, 20, 83, and 26, respectively were treated with voriconazole, levodopa, risperidone, chlorpromazine, voriconazole plus levodopa, voriconazole plus risperidone, and voriconazole plus chlorpromazine. The occurrence of visual hallucinations increased when used in combination with levodopa (ROR = 12.302, 95% CI = 3.587-42.183). No increase in incidence was associated with the concomitant use of dopamine antagonists (risperidone, ROR = 1.721, 95% CI = 0.421-7.030; chlorpromazine, ROR = none, 95% CI = none). Dopaminergic medicine may increase the risk of visual hallucinations in patients treated with voriconazole. Whether voriconazole positively modulates dopamine production warrants further investigation using a translational research approach.

What do We Know about Cryptic Aspergillosis?

Cryptic Aspergillus species are increasingly recognized as pathogens involved in human disease. They are ubiquitarian fungi with high tenacity in their environment and can express various resistance mechanisms, often due to exposure to antifungal agents employed in agriculture and farming. The identification of such species is increasing thanks to molecular techniques, and a better description of this type of pathogen is granted. Nevertheless, the number of species and their importance in the clinical setting still need to be well studied. Furthermore, their cross-sectional involvement in animal disease, plants, and human activities requires a multidisciplinary approach involving experts from various fields. This comprehensive review aims to provide a sharp vision of the cryptic Aspergillus species, from the importance of correct identification to the better management of the infections caused by these pathogens. The review also accentuates the importance of the One Health approach for this kind of microorganism, given the interconnection between environmental exposure and aspergillosis, embracing transversely the multidisciplinary process for managing the cryptic Aspergillus species. The paper advocates the need for improving knowledge in this little-known species, given the burden of economic and health implications related to the diffusion of these bugs.

Primary Vocal Cord Aspergillosis Can Involve the Trachea and Bronchus in Previously Healthy Patients: A Case Report

Primary vocal cord aspergillosis is extremely rare in immunocompetent individuals, in whom lesions are mainly confined to the larynx, with the possibility of tracheal and bronchial infection largely ignored. In this article, we present a case of primary vocal cord aspergillosis involving the trachea and bronchus in a previously healthy 55-year-old woman. Our case highlights that vocal cord aspergillosis can involve the trachea and bronchus and that laryngoscopy alone may be insufficient to secure a comprehensive diagnosis in healthy patients presenting with hoarseness, pharyngalgia, and normal chest radiography. Furthermore, influenza B virus infection may be a risk factor for this rare disease.

An immunocompetent host with blood-disseminated Aspergillus versicolor spondylitis: a case report and literature review

Blood-disseminated Aspergillus spondylitis in immunocompetent individuals is rare. The clinical, imaging, and pathological manifestations of this condition are not specific. Therefore, this disease is prone to misdiagnosis and a missed diagnosis. Systemic antifungal therapy is the main treatment for Aspergillus spondylitis. We report a case of blood-disseminated Aspergillus versicolor spondylitis in a patient with normal immune function. The first antifungal treatment lasted for 4 months, but Aspergillus spondylitis recurred a few months later. A second antifungal treatment course was initiated for at least 1 year, and follow-up has been ongoing. Currently, there has been no recurrence.

Role of mitochondrial farnesyltransferase gene in the prevention of the food spoilage fungi Aspergillus flavus by the antimicrobial natural preservative perillaldehyde

Aspergillus flavus, one of the most widely distributed and abundant genus of Aspergillus worldwide, poses an evident threat as a source of food contamination in grains and cereals. Perillaldehyde (PAE), a volatile essential oil extracted from the stem and leaves of Perilla frutescens L., exhibits potent antifungal activity. In our study, we investigated the role of Cox10, a key enzyme in the heme A synthesis pathway crucial for maintaining mitochondrial function. We found that cox10 is a sensitive gene of A. flavus in response to PAE by gene expression assay and GFP fluorescent localization tagging, and then we found that the deletion of this gene affects the growth and development of A. flavus, but the drug resistance is elevated. Through transcriptome sequencing and its experimental validation, the molecular mechanisms of stress triggered by the deletion of cox10 were further clarified, such as the decrease in intracellular drug content due to the increase in the expression of drug efflux proteins, and the increase in the thickness of cell wall due to the increase in the content of cell wall chitin. Clearly, cox10 plays a critical role in regulating various cellular processes of A. flavus, including growth, reproduction, development, as well as pathogenicity and drug resistance. These significant findings establish a solid theoretical foundation for the development of environmentally friendly, safe, and effective antifungal agents to combat A. flavus contamination.

Factors influencing voriconazole plasma level in intensive care patients

Background

In clinical routine, voriconazole plasma trough levels (Cmin) out of target range are often observed with little knowledge about predisposing influences.

Objectives

To determine the distribution and influencing factors on voriconazole blood levels of patients treated on intensive- or intermediate care units (ICU/IMC).

Patients and methods

Data were collected retrospectively from patients with at least one voriconazole trough plasma level on ICU/IMC (n = 153) to determine the proportion of sub-, supra- or therapeutic plasma levels. Ordinal logistic regression analysis was used to assess factors hindering patients to reach voriconazole target range.

Results

Of 153 patients, only 71 (46%) reached the target range at the first therapeutic drug monitoring, whereas 66 (43%) patients experienced too-low and 16 (10%) too-high plasma levels. Ordinal logistic regression analysis identified the use of extra corporeal membrane oxygenation (ECMO), low international normalized ratio (INR) and aspartate-aminotransferase (AST) serum levels as predictors for too-low plasma levels.

Conclusion

Our data highlight an association of ECMO, INR and AST levels with voriconazole plasma levels, which should be considered in the care of critically ill patients to optimize antifungal therapy with voriconazole.

Osteomyelitis of Jaw Bone due to Aspergillosis in Post-COVID-19 Patients: An Observational Study

Background

In the second wave of COVID-19 pandemic, there has been an increase in number of cases with Post-COVID-19 fungal osteomyelitis of jaws. Aspergillosis was found to be one of the causes of osteomyelitis of jaw bones in these patients.

Aim

To evaluate the incidence and pattern of osteomyelitis of jaw due to aspergillosis in post-COVID-19 patients and to discuss the management protocol of the same.

Method

Data were obtained at our institution from the period of January 2021 to June 2021. Patients of all age groups with Post-COVID-19 osteomyelitis of jaw due to aspergillosis and those with combined aspergillosis and mucormycosis infection were included. Patients having rhino-orbito-cerebral fungal infection were excluded.

Results

A total of 47 patients reported to our center. Demographically the average age of the patients was 49.11 years with 72% being males. All 47 patients (N = 100%) had received steroids. 21 of them (N = 44.7%) had diabetes mellitus and 14 (N = 29.8%) patients had other comorbidities. Out of 47 patients, 42 (N = 89.7%) patients were diagnosed with aspergillosis and the remaining 5 (N = 10.3%) cases had a mixed fungal infection of mucormycosis and aspergillosis. On fungal culture Aspergillus flavus was the most common species detected followed by Aspergillus niger and Aspergillus fumigatus. All patients were treated with oral Voriconazole and local surgical debridement. Prompt laboratory testing such as a timely KOH mount, galactomannan test, beta-D-glucan test, histopathology of tissue specimens could help to give an early and definitive diagnosis. The mortality rate we encountered in this study was nil.

Conclusions

Early and definitive diagnosis and immediate initiation of antifungal drug therapy and surgical intervention will significantly reduce the rate of morbidity and mortality.

Establishing a pulmonary aspergillus fumigatus infection diagnostic platform based on RPA-CRISPR-Cas12a

In this study, we devised a diagnostic platform harnessing a combination of recombinase polymerase amplification (RPA) and the clustered regularly interspaced short palindromic repeats (CRISPR)/Cas12a system. Notably, this platform obviates the need for intricate equipment and finds utility in diverse settings. Two result display methods were incorporated in this investigation: the RPA-Cas12a-fluorescence method and the RPA-Cas12a-LFS (lateral flow strip). Upon validation, both display platforms exhibited no instances of cross-reactivity, with seven additional types of fungal pathogens responsible for respiratory infections. The established detection limit was ascertained to be as low as 102 copies/µL. In comparison to fluorescence quantitative PCR, the platform demonstrated a sensitivity of 96.7%, a specificity of 100%, and a consistency rate of 98.0%.This platform provides expeditious, precise, and on-site detection capabilities, thereby rendering it a pivotal diagnostic instrument amenable for deployment in primary healthcare facilities and point-of-care settings.

Invasive pulmonary and central nervous system aspergillosis in a child: A case report and literature review

RATIONALE

Children with haematological malignancies have a higher risk of developing aggressive pulmonary aspergillosis and a higher mortality rate. The most common site of extrapulmonary aspergillosis in children is the central nervous system (CNS), and the death rate is higher when CNS is affected. Therefore, early diagnosis and treatment of invasive aspergillosis are essential for reducing mortality.

PATIENT CONCERNS

We report a case of an 8-year-old girl with acute lymphoblastic leukaemia who developed invasive pulmonary aspergillosis complicated by CNS aspergillosis. Aspergillus was confirmed by metagenomic sequencing of pathogenic microorganisms.

DIAGNOSES

Invasive pulmonary and central nervous system aspergillosis.

INTERVENTIONS

The patient was treated with combined systemic antifungal agents (voriconazole and liposomal amphotericin B) and intrathecal injection of amphotericin B.

OUTCOMES

The treatment was well tolerated and resulted in remarkable clinical and radiological head improvements.

LESSONS

Invasive aspergillosis has a high mortality rate and requires early diagnosis and treatment. Pathogenic microbial metagenomic sequencing is a convenient method to assist in the early diagnosis of aspergillosis. Voriconazole is the drug of choice for the treatment of invasive aspergillosis. When CNS aspergillosis occurs, it can be combined with other systemic antifungal drugs and intrathecal injection of amphotericin B.

Population Pharmacokinetics of Voriconazole and Dose Optimization in Elderly Chinese Patients

Voriconazole is commonly recommended as a first-line therapy for invasive aspergillosis infections. Elderly patients are susceptible to infectious diseases owing to their decreased physical function and immune system. Our study aims to establish a population pharmacokinetics model for elderly patients receiving intravenous voriconazole, and to optimize dosing protocols through a simulated approach. An accurate fit to the concentration-time profile of voriconazole was achieved by employing a 1-compartment model featuring first-order elimination. The typical clearance rate of voriconazole was found to be 3.22 L/h, with a typical volume of distribution of 194 L. The covariate analysis revealed that albumin (ALB), gamma-glutamyl transpeptidase, and direct bilirubin had significant impacts on voriconazole clearance. Additionally, body weight was found to be associated with the volume of distribution. Individualized dosing regimens were recommended for different ALB levels based on population pharmacokinetics model prediction. The proposed dosing regimens could provide a rationale for dosage individualization, improve the clinical outcomes, and minimize drug-related toxicities.

Uncovering a Novel cyp51A Mutation and Antifungal Resistance in Aspergillus fumigatus through Culture Collection Screening

BACKGROUND

Aspergillus fumigatus is an important concern for immunocompromised individuals, often resulting in severe infections. With the emergence of resistance to azoles, which has been the therapeutic choice for Aspergillus infections, monitoring the resistance of these microorganisms becomes important, including the search for mutations in the cyp51A gene, which is the gene responsible for the mechanism of action of azoles. We conducted a retrospective analysis covering 478 A. fumigatus isolates.

METHODS

This comprehensive dataset comprised 415 clinical isolates and 63 isolates from hospital environmental sources. For clinical isolates, they were evaluated in two different periods, from 1998 to 2004 and 2014 to 2021; for environmental strains, one strain was isolated in 1998, and 62 isolates were evaluated in 2015. Our primary objectives were to assess the epidemiological antifungal susceptibility profile; trace the evolution of resistance to azoles, Amphotericin B (AMB), and echinocandins; and monitor cyp51A mutations in resistant strains. We utilized the broth microdilution assay for susceptibility testing, coupled with cyp51A gene sequencing and microsatellite genotyping to evaluate genetic variability among resistant strains.

RESULTS

Our findings reveal a progressive increase in Minimum Inhibitory Concentrations (MICs) for azoles and AMB over time. Notably, a discernible trend in cyp51A gene mutations emerged in clinical isolates starting in 2014. Moreover, our study marks a significant discovery as we detected, for the first time, an A. fumigatus isolate carrying the recently identified TR46/F495I mutation within a sample obtained from a hospital environment. The observed cyp51A mutations underscore the ongoing necessity for surveillance, particularly as MICs for various antifungal classes continue to rise.

CONCLUSIONS

By conducting resistance surveillance within our institution's culture collection, we successfully identified a novel TR46/F495I mutation in an isolate retrieved from the hospital environment which had been preserved since 1998. Moreover, clinical isolates were found to exhibit TR34/L98H/S297T/F495I mutations. In addition, we observed an increase in MIC patterns for Amphotericin B and azoles, signaling a change in the resistance pattern, emphasizing the urgent need for the development of new antifungal drugs. Our study highlights the importance of continued monitoring and research in understanding the evolving challenges in managing A. fumigatus infections.

Pharmacological management of invasive mold infections in solid organ transplant recipients

INTRODUCTION

Solid organ transplant (SOT) recipients face an increased susceptibility to invasive fungal infection (IFI) due to filamentous fungi. Post-transplant invasive aspergillosis (IA) and mucormycosis are related to exceedingly high mortality rates and graft loss risk, and its management involve a unique range of clinical challenges.

AREAS COVERED

First, the current treatment recommendations for IA and mucormycosis among SOT recipients are critically reviewed, including the supporting evidence. Next, we discussed particular concerns in this patient population, such as drug-drug interactions (DDIs) between triazoles and post-transplant immunosuppression or treatment-related toxicity. The role for immunomodulatory and host-targeted therapies is also considered, as well as the theoretical impact of the intrinsic antifungal activity of calcineurin inhibitors. Finally, a personal opinion is made on future directions in the pharmacological approach to post-transplant IFI.

EXPERT OPINION

Despite relevant advances in the treatment of mold IFIs in the SOT setting, such as the incorporation of isavuconazole (with lower incidence of DDIs and better tolerability than voriconazole), there remains a large room for improvement in areas such as the position of combination therapy or the optimal strategy for the reduction of baseline immunosuppression. Importantly, future studies should define the specific contribution of newer antifungal agents and classes.

Skull base infections, their complications, and management

OBJECTIVE

Our review aims to summarize the current literature on skull base infections (SBIs) and retrospectively analyze any such cases encountered at our institution.

DESIGN

A literature search was conducted using online databases PubMed, MEDLINE, and ResearchGate with the terms "skull base osteomyelitis," "temporal bone osteomyelitis," "skull base infections," "necrotizing otitis media," and "SBO". References from the resulting manuscripts were reviewed for relevant articles. A search of our electronic health records using the same key terms was also performed to identify patients with a tissue biopsy-confirmed diagnosis of skull base infections. Patients with an indeterminate diagnosis or inaccessible/poor imaging were excluded.

SETTING

A level one trauma and major tertiary academic medical center.

PARTICIPANTS

All patients treated at the University of California Davis Health System with a confirmed diagnosis of skull base infections from January 2005 to November 2020.

MAIN OUTCOME MEASURES

Imaging results, symptoms, treatment, morbidity, and mortality.

RESULTS

Our literature search yielded 59 articles ranging from 1982 to 2021. A retrospective search of our electronic health records identified two cases of skull base infections.

CONCLUSION

Skull base infections have no pathognomonic findings. A multimodal approach with computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine is necessary to characterize the disease process in addition to a biopsy for definitive diagnosis. Other diagnoses can mimic SBI on imaging, such as nasopharyngeal carcinoma and inflammatory pseudotumor. Culture-guided antimicrobial treatment and surgery are mainstay therapies. Other adjuvant strategies currently lack the robust evidence necessary to characterize their risks and benefits.

Chronic Pulmonary Aspergillosis: Clinical Presentation and Management

Chronic pulmonary aspergillosis (CPA) refers to a number of clinical syndromes resulting from the presence and local proliferation of Aspergillus organisms in the lungs of patients with chronic lung disease. CPA is more common than was realized two decades ago. Recognition remains poor, despite recent studies from many countries highlighting the high prevalence in at-risk populations. In low- and middle-income countries, CPA may be misdiagnosed and treated as tuberculosis (TB). In addition, CPA may develop following successful TB treatment. The coronavirus disease pandemic has resulted in significant disruption to provision of TB care, likely leading to more extensive lung damage, which could increase the risk for CPA.Although CPA refers to various syndromes, the classic presentation is that of chronic cavitary pulmonary aspergillosis, which manifests as one or more progressive cavities with or without a fungal ball, accompanied by systemic and respiratory symptoms for at least 3 months. Diagnosis relies on Aspergillus immunoglobulin G in serum, as sputum culture lacks sensitivity. Differential diagnosis includes mycobacterial infection, bacterial lung abscess or necrotizing pneumonia, lung cancer, and endemic fungi.The aim of antifungal treatment in CPA is to improve symptoms and quality of life, and to halt progression, and possibly reverse radiological changes. Current recommendations suggest treatment for 6 months, although in practice many patients remain on long-term treatment. Improvement may manifest as weight gain and improvement of symptoms such as productive cough, hemoptysis, and fatigue. Surgical management should be considered in cases of diagnostic uncertainty, in significant hemoptysis, and when there is concern for lack of response to therapy. Itraconazole and voriconazole are the first-line azoles, with more experience now accumulating with posaconazole and isavuconazole. Side effects are frequent and careful monitoring including therapeutic drug monitoring is essential. Intravenous antifungals such as echinocandins and amphotericin B are used in cases of azole intolerance or resistance, which often develop on treatment. Relapse is seen after completion of antifungal therapy in around 20% of cases, mostly in bilateral, high-burden disease.Several research priorities have been identified, including characterization of immune defects and genetic variants linked to CPA, pathogenetic mechanisms of Aspergillus adaptation in the lung environment, the contribution of non-fumigatus Aspergillus species, and the role of new antifungal agents, immunotherapy, and combination therapy.

High-Risk Neutropenic Fever and Invasive Fungal Diseases in Patients with Hematological Malignancies

Invasive fungal diseases (IFDs) still represent a relevant cause of mortality in patients affected by hematological malignancies, especially acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS) undergoing remission induction chemotherapy, and in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. Mold-active antifungal prophylaxis (MAP) has been established as a standard of care. However, breakthrough IFDs (b-IFDs) have emerged as a significant issue, particularly invasive aspergillosis and non-Aspergillus invasive mold diseases. Here, we perform a narrative review, discussing the major advances of the last decade on prophylaxis, the diagnosis of and the treatment of IFDs in patients with high-risk neutropenic fever undergoing remission induction chemotherapy for AML/MDS and allo-HSCT. Then, we present our single-center retrospective experience on b-IFDs in 184 AML/MDS patients undergoing high-dose chemotherapy while receiving posaconazole (n = 153 induction treatments, n = 126 consolidation treatments, n = 60 salvage treatments). Six cases of probable/proven b-IFDs were recorded in six patients, with an overall incidence rate of 1.7% (6/339), which is in line with the literature focused on MAP with azoles. The incidence rates (IRs) of b-IFDs (95% confidence interval (95% CI), per 100 person years follow-up (PYFU)) were 5.04 (0.47, 14.45) in induction (n = 2), 3.25 (0.0013, 12.76) in consolidation (n = 1) and 18.38 (3.46, 45.06) in salvage chemotherapy (n = 3). Finally, we highlight the current challenges in the field of b-IFDs; these include the improvement of diagnoses, the expanding treatment landscape of AML with molecular targeted drugs (and related drug-drug interactions with azoles), evolving transplantation techniques (and their related impacts on IFDs' risk stratification), and new antifungals and their features (rezafungin and olorofim).

Distribution of Aspergillus species and risk factors for aspergillosis in mainland China: a systematic review

Background

Aspergillus, a widespread fungus in the natural environment, poses a significant threat to human health by entering the human body via the airways and causing a disease called aspergillosis. This study comprehensively analyzed data on aspergillosis in published articles from mainland China to investigate the prevalence of Aspergillus, and risk factors, mortality rate, and underlying condition associated with aspergillosis.

Methods

Published articles were retrieved from Google Scholar, PubMed, and Science Direct online search engines. In the 101 analyzed studies, 3558 Aspergillus isolates were meticulously collected and classified. GraphPad Prism 8 was used to statistically examine the epidemiology and clinical characteristics of aspergillosis.

Results

Aspergillus fumigatus was prominently reported (n = 2679, 75.14%), followed by A. flavus (n = 437, 12.25%), A. niger (n = 219, 6.14%), and A. terreus (n = 119, 3.33%). Of a total of 9810 patients, 7513 probable cases accounted for the highest number, followed by confirmed cases (n = 1956) and possible cases (n = 341). In patients, cough emerged as the most common complaint (n = 1819, 18.54%), followed by asthma (n = 1029, 10.48%) and fever (1024, 10.44%). Of total studies, invasive pulmonary aspergillosis (IPA) was reported in 47 (45.53%) studies, exhibiting an increased prevalence in Beijing (n = 12, 25.53%), Guangdong (n = 7, 14.89%), and Shanghai (n = 6, 12.76%). Chronic pulmonary aspergillosis (CPA) was reported in 14 (13.86%) studies. Among the total of 14 studies, the occurrence of CPA was 5 (35.71%) in Beijing and 3 (21.42%) in Shanghai. Allergic bronchopulmonary aspergillosis (ABPA), was reported at a lower frequency (n = 8, 7.92%), Guangdong recorded a relatively high number (n = 3, 37.5%), followed by Beijing (n = 2, 25.0%), and Shanghai (n = 1, 12.5%). Percentage of death reported: IPA had the highest rate (n = 447, 68.87%), followed by CPA (n = 181, 27.88%) and ABPA (n = 14, 2.15%). Among the aspergillosis patients, 6220 had underlying conditions, including chronic lung disease (n = 3765, 60.53%), previous tuberculosis (n = 416, 6.68%), and organ transplant or organ failure (n = 648, 10.41%). Aspergillosis was also found in patients using corticosteroid therapy (n = 622, 10.0%).

Conclusion

This review sheds light on the prevalence patterns of Aspergillus species, risk factors of aspergillosis, and gaps in surveillance that could be helpful for the control and treatment of aspergillosis and guide the researchers in future studies.

Registration

This systematic review was prospectively registered on PROSPERO: Registration ID CRD42023476870.

Native mitral valve fungal endocarditis caused by Aspergillus fumigatus: A case report

INTRODUCTION

Aspergillus endocarditis is a rare fungal infection associated with a poor prognosis. Most cases of Aspergillus endocarditis involve prosthetic valves, with native valve involvement being rarely reported.

CASE PRESENTATION

A 53-year-old asian female patient presented with fever, chills, dyspnea, generalized fatigue, and significant weight loss one month after undergoing left lower lobectomy for a pulmonary abscess. Echocardiogram showed a large mobile vegetation with a broad base on the anterior leaflet of the mitral valve, resembling atrial myxoma. Despite negative blood cultures, circulating DNA of Aspergillus fumigatus was detected by metagenome Next Generation Sequencing, prompting the initiation of empiric antifungal therapy with voriconazole. Emergency surgery, involving thorough debridement and mitral valve replacement, was successfully performed. Indefinite fungal suppression therapy with oral voriconazole is continued to mitigate the risk of recurrence. The patient survived with no signs of Aspergillus disease recurrence for four years.

CLINICAL DISCUSSION

Diagnosis of Aspergillus endocarditis requires a high index of suspicion and is often delayed due to consistently negative results from blood cultures. Non-culture-based methods, particularly metagenome Next-Generation Sequencing, play a crucial role in early diagnosis and therapeutic decision-making. Surgical debridement and valve replacement are imperative for survival in cases of Aspergillus endocarditis. Voriconazole should be considered the primary fungicidal agent for its treatment. Moreover, lifelong fungal suppression therapy is strongly recommended for all survivors to ensure long-term survival and minimize the risk of recurrence.

CONCLUSION

Despite grim prognosis associated with Aspergillus endocarditis, patients can attain long-term survival through meticulous surgical debridement and lifelong antifungal therapy.