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Matsuo T, Wurster S, Jiang Y, Sasaki K, Tarrand J, Lewis RE, Kontoyiannis DP. Invasive fusariosis in patients with leukaemia in the era of mould-active azoles: increasing incidence, frequent breakthrough infections and lack of improved outcomes. J Antimicrob Chemother 2024; 79:297-306. [PMID: 38073151 DOI: 10.1093/jac/dkad377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/17/2023] [Indexed: 02/02/2024] Open
Abstract
OBJECTIVES Historically, patients with leukaemia and invasive fusariosis (IF) have experienced poor outcomes in the setting of persistent immunosuppression. Herein, we retrospectively reviewed the incidence, presentation and outcomes of IF that are scarcely studied in contemporary cohorts of leukaemia patients. METHODS We identified adult leukaemia patients with proven or probable IF at MD Anderson Cancer Center during 2009-21. Independent risk factors for 42 day mortality after IF diagnosis were determined using a multivariable logistic regression model. Combined with historical data, the annual IF incidence density over the past 23 years was estimated using Poisson regression analysis. RESULTS Among 140 leukaemia patients with IF (114 proven), 118 patients (84%) had relapsed/refractory leukaemia and 124 (89%) had neutropenia at IF diagnosis. One hundred patients (71%) had pulmonary IF, 88 (63%) had disseminated IF and 48 (34%) had fungaemia. Coinfections were common (55%). Eighty-nine patients (64%) had breakthrough IF to mould-active triazoles. Most patients (84%) received combination antifungal therapy. Neutrophil recovery [adjusted OR (aOR), 0.04; 95% CI, 0.01-0.14; P < 0.0001], pulmonary IF (aOR, 3.28; 95% CI, 1.11-9.70; P = 0.032) and high SOFA score (aOR, 1.91 per 1-point increase; 95% CI, 1.47-2.50; P < 0.0001) were independent predictors of 42 day mortality outcomes. From 1998 to 2021, IF incidence density increased significantly at an annual ratio of 1.03 (95% CI, 1.01-1.06; P = 0.04). CONCLUSIONS IF is predominantly seen in patients with relapsed/refractory leukaemia and increasingly seen as a breakthrough infection to mould-active triazoles. Despite frequent combination antifungal therapy, high mortality rates have persisted in patients with lasting neutropenia.
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Affiliation(s)
- Takahiro Matsuo
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sebastian Wurster
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ying Jiang
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Tarrand
- Section of Clinical Microbiology and Virology, Division of Pathology and Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Russell E Lewis
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
Invasive fusariosis is a serious invasive fungal disease, affecting immunocompetent and, more frequently, immunocompromised patients. Localized disease is the typical clinical form in immunocompetent patients. Immunocompromised hosts at elevated risk of developing invasive fusariosis are patients with acute leukemia receiving chemotherapeutic regimens for remission induction, and those undergoing allogeneic hematopoietic cell transplant. In this setting, the infection is usually disseminated with positive blood cultures, multiple painful metastatic skin lesions, and lung involvement. Currently available antifungal agents have poor in vitro activity against Fusarium species, but a clear-cut correlation between in vitro activity and clinical effectiveness does not exist. The outcome of invasive fusariosis is largely dependent on the resolution of immunosuppression, especially neutrophil recovery in neutropenic patients.
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Affiliation(s)
- Marcio Nucci
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Grupo Oncoclínicas, Rio de Janeiro, Brazil
| | - Elias Anaissie
- CTI Clinical Trial and Consulting, Cincinnati, Ohio, USA
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3
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O'Keeffe JC, Singh N, Slavin MA. Approach to diagnostic evaluation and prevention of invasive fungal disease in patients prior to allogeneic hematopoietic stem cell transplant. Transpl Infect Dis 2023; 25 Suppl 1:e14197. [PMID: 37988269 DOI: 10.1111/tid.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/15/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023]
Abstract
In recent years, advancements in the treatment landscape for hematological malignancies, such as acute myeloid leukemia and acute lymphoblastic leukemia, have significantly improved disease prognosis and overall survival. However, the treatment landscape is changing and the emergence of targeted oral therapies and immune-based treatments has brought forth new challenges in evaluating and preventing invasive fungal diseases (IFDs). IFD disproportionately affects immunocompromised hosts, particularly those undergoing therapy for acute leukemia and allogeneic hematopoietic stem cell transplant. This review aims to provide a comprehensive overview of the pretransplant workup, identification, and prevention of IFD in patients with hematological malignancy. The pretransplant period offers a critical window to assess each patient's risk factors and implement appropriate prophylactic measures. Risk assessment includes evaluation of disease, host, prior treatments, and environmental factors, allowing a dynamic evaluation that considers disease progression and treatment course. Diagnostic screening, involving various biomarkers and radiological modalities, plays a crucial role in early detection of IFD. Antifungal prophylaxis choice is based on available evidence as well as individual risk assessment, potential for drug-drug interactions, toxicity, and patient adherence. Therapeutic drug monitoring ensures effective antifungal stewardship and optimal treatment. Patient education and counselling are vital in minimizing environmental exposures to fungal pathogens and promoting medication adherence. A well-structured and individualized approach, encompassing risk assessment, prophylaxis, surveillance, and patient education, is essential for effectively preventing IFD in hematological malignancies, ultimately leading to improved patient outcomes and overall survival.
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Affiliation(s)
- Jessica C O'Keeffe
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Nikhil Singh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
- Department of Pharmacy, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Monica A Slavin
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
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4
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Cuervo-Maldonado SI, Álvarez-Rodríguez JC, Cubides CL, Barrera JC, Montañez-Abril JD, Vergara-Vela EP, Saavedra-Trujillo CH, López-Mora MJ, Mora-Figueroa GE, Celis-Ramírez A, Jaramillo-Calle RM, Parra-Medina R. Fusariosis in cancer patients: 13 case series report and literature review. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2023; 43:41-56. [PMID: 37721903 PMCID: PMC10588968 DOI: 10.7705/biomedica.6925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/07/2023] [Indexed: 09/20/2023]
Abstract
The fusariosis is an opportunistic mycosis caused by Fusarium spp. Its clinical presentation depends on the immunological status of the host, especially in patients with hematooncological diseases, whose manifestations vary from localized to invasive fungal infections. Skin or blood culture helps to guide combined antifungal treatment with amphotericin B and voriconazole. Here, we present 13 cases in a period of eleven years of patients with cancer who developed disseminated fusariosis and their outcomes, together with a review of the related literature. In this series of cases, mortality was 61.5 % (8/13), despite the use of the antifungal. Out of the 13 cases, 11 had hematological neoplasia and 2 solid neoplasia. The most determinant risk factor was profound neutropenia. Skin involvement and positive blood cultures in most cases allowed combined treatment prescription. Persistent febrile neutropenia associated with skin lesions, onychomycosis, nodules, or lung masses lead to suspicion of Fusarium spp. fungal invasive infection. The aim of this series of cases is to remind healthcare professionals that oncological patients with deep and persistent febrile neutropenia can develop fusariosis.
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Affiliation(s)
- Sonia Isabel Cuervo-Maldonado
- Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia; Grupo de Infectología, Instituto Nacional de Cancerología, Bogotá, D.C., Colombia; Grupo de Investigación en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia.
| | - José Camilo Álvarez-Rodríguez
- Grupo de Infectología, Instituto Nacional de Cancerología, Bogotá, D.C., Colombia; Grupo de Investigación en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia.
| | - Cristian Leonardo Cubides
- Grupo de Infectología, Instituto Nacional de Cancerología, Bogotá, D.C., Colombia; Grupo de Investigación en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia.
| | - Juan Camilo Barrera
- Grupo de Infectología, Instituto Nacional de Cancerología, Bogotá, D.C., Colombia; Grupo de Investigación en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia.
| | - Juan Diego Montañez-Abril
- Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia; Grupo de Investigación en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia.
| | | | - Carlos Humberto Saavedra-Trujillo
- Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia; Grupo de Enfermedades Infecciosas, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia.
| | - María José López-Mora
- Grupo de Investigación en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia; Grupo de Infectología, Clínica de Marly, Bogotá, D.C., Colombi.
| | | | - Adriana Celis-Ramírez
- Grupo de Investigación Celular y Molecular de Microorganismos Patógenos (CeMoP), Universidad de los Andes, Bogotá, D.C., Colombia.
| | | | - Rafael Parra-Medina
- Grupo de Investigación Patología Oncológica INC, Instituto Nacional de Cancerología, Bogotá, Colombia.
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Grizante Barião PH, Cayún Y, Sepúlveda M, Tonani L, Gonçalves de Almeida OG, Cornejo P, Dias N, Santos C, von Zeska Kress MR. MALDI-TOF MS: A Quick Method to Detect the Susceptibility of Fusarium spp. Clinical Isolates to Amphotericin B. Microorganisms 2023; 11:1834. [PMID: 37513006 PMCID: PMC10383446 DOI: 10.3390/microorganisms11071834] [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: 06/21/2023] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
Disseminated fusariosis is treated with amphotericin B and voriconazole. To determine adequate therapy, the minimal inhibitory concentration (MIC) is used. However, MIC analysis is based on visual observation and requires a long period of fungal incubation. The measure of the minimal profile change concentration (MPCC) using MALDI-TOF MS is a quick spectral method that has presented good results in determining the antimicrobial resistance of yeasts. However, there is a lack of information on filamentous fungi. In the present work, 13 Fusarium spp. clinical isolates and two reference strains were used. MIC was obtained according to the M38-A2 protocol of the Clinical Laboratory Standards Institute, while MPPC was obtained following the initial steps of the M38-A2 protocol. Both Biotyper and the Rstudio environment were used to analyze mass spectra. For some fungal strains, the data obtained from the software MALDI Biotyper Compass 4.1 led to fuzzy heatmaps resulting in difficult interpretation, while heatmaps obtained using Rstudio tools generated better MPCC resolutions. Herein, 86.6% of the AMB MPCC values were highly correlated with the gold-standard AMB MIC. MALDI-TOF MS is a prominent tool used to determine MPCCs quicker, cost-effectively, and more accurately for Fusarium spp. strains. However, better statistical analyses could help measure the technique's limit detection.
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Affiliation(s)
- Patrícia Helena Grizante Barião
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão, Ribeirão Preto 14040-903, SP, Brazil
- Programa de Doctorado en Ciencias Mención Biología Celular y Molecular Aplicada, Universidad de La Frontera, Temuco 4811-230, Chile
| | - Yasna Cayún
- Department of Chemical Science and Natural Resources, Universidad de La Frontera, Temuco 4811-230, Chile
| | - Marcela Sepúlveda
- Programa de Doctorado en Ciencias de Recursos Naturales, Universidad de La Frontera, Temuco 4811-230, Chile
| | - Ludmilla Tonani
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão, Ribeirão Preto 14040-903, SP, Brazil
| | - Otavio Guilherme Gonçalves de Almeida
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão, Ribeirão Preto 14040-903, SP, Brazil
| | - Pablo Cornejo
- Escuela de Agronomía, Facultad de Ciencias Agronómicas y de los Alimentos, Pontificia Universidad Católica de Valparaíso, Quillota 2260-000, Chile
| | - Nathalia Dias
- Scientific and Technological Bioresource Nucleus (BIOREN), Universidad de La Frontera, Temuco 4811-230, Chile
| | - Cledir Santos
- Department of Chemical Science and Natural Resources, Universidad de La Frontera, Temuco 4811-230, Chile
| | - Marcia Regina von Zeska Kress
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão, Ribeirão Preto 14040-903, SP, Brazil
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6
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Guarana M, Nucci M. Should patients with acute myeloid leukemia treated with venetoclax-based regimens receive antifungal prophylaxis? Leuk Res 2023; 131:107341. [PMID: 37327641 DOI: 10.1016/j.leukres.2023.107341] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/18/2023]
Abstract
Invasive fungal disease (IFD) is a major complication in patients with acute myeloid leukemia (AML) receiving intensive induction chemotherapy, and the use of anti-mold prophylaxis is considered standard of care. On the other hand, the use of anti-mold prophylaxis in AML patients receiving less-intensive venetoclax-based regimens is not well established, basically because the incidence of IFD may not be high enough to justify primary antifungal prophylaxis. Furthermore, dose adjustments in venetoclax are needed because of drug interactions with azoles. Finally, the use of azoles is associated with toxicity, including liver, gastrointestinal and cardiac (QT prolongation) toxicity. In a setting of low incidence of invasive fungal disease, the number needed to harm would be higher than the number needed to treat. In this paper we review the risk factors for IFD in AML patients receiving intensive chemotherapeutic regimens, the incidence and risk factors for IFD in patients receiving hypomethylating agents alone, and in patients receiving less-intensive venetoclax-based regimens. We also discuss potential problems with the concomitant use of azoles, and present our perspective on how to manage AML patients receiving venetoclax-based regimens without primary antifungal prophylaxis.
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Affiliation(s)
- Mariana Guarana
- University Hospital, Universidade Federal do Rio de Janeiro, Brazil
| | - Marcio Nucci
- University Hospital, Universidade Federal do Rio de Janeiro, Brazil; Grupo Oncoclínicas, Brazil.
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7
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Park H, Bae S, Kim MJ, Chong YP, Kim SH, Choi SH, Lee SO, Kim YS, Jung J. Clinical characteristics and outcomes of invasive and non-invasive fusariosis in South Korea. Mycoses 2023; 66:211-218. [PMID: 36349480 DOI: 10.1111/myc.13544] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/22/2022] [Accepted: 11/04/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Invasive fusariosis mainly affects immunocompromised patients including haematopoietic stem cell transplant recipients and those with haematologic malignancy. There are limited studies on invasive fusariosis in the Asia-Pacific region. OBJECTIVE To describe the clinical characteristics and outcomes of invasive and non-invasive fusariosis in South Korea. PATIENTS/METHODS From 2005 to 2020, patients with fusariosis who met the revised European Organisation for Research and Treatment of Cancer and the Mycoses Study Group criteria for the definition of proven or probable invasive fusariosis, and those with non-invasive fusariosis were retrospectively reviewed in a tertiary medical centre in Seoul, South Korea. RESULTS Overall, 26 and 75 patients had invasive and non-invasive fusariosis, respectively. Patients with invasive fusariosis commonly had haematologic malignancy (62%), were solid organ transplant recipients (23%), and had a history of immunosuppressant usage (81%). In non-invasive fusariosis, diabetes mellitus (27%) and solid cancer (20%) were common underlying conditions. Disseminated fusariosis (54%) and invasive pulmonary disease (23%) were the most common clinical manifestations of invasive fusariosis; skin infection (48%) and keratitis (27%) were the most common manifestations of non-invasive fusariosis. Twenty-eight-day and in-hospital mortalities were high in invasive fusariosis (40% and 52%, respectively). In multivariate analysis, invasive fusariosis (adjusted odds ratio, 9.6; 95% confidence interval 1.3-70.8; p = .03) was an independent risk factor for 28-day mortality. CONCLUSIONS Patients with invasive fusariosis were frequently immunocompromised, and more than half had disseminated fusariosis. Invasive fusariosis was associated with poor prognosis.
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Affiliation(s)
- Hyejin Park
- Department of Infectious Diseases, Bumin Hospital, Seoul, South Korea.,Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seongman Bae
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
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Non- Aspergillus Hyaline Molds: A Host-Based Perspective of Emerging Pathogenic Fungi Causing Sinopulmonary Diseases. J Fungi (Basel) 2023; 9:jof9020212. [PMID: 36836326 PMCID: PMC9964096 DOI: 10.3390/jof9020212] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
The incidence of invasive sino-pulmonary diseases due to non-Aspergillus hyaline molds is increasing due to an enlarging and evolving population of immunosuppressed hosts as well as improvements in the capabilities of molecular-based diagnostics. Herein, we review the following opportunistic pathogens known to cause sinopulmonary disease, the most common manifestation of hyalohyphomycosis: Fusarium spp., Scedosporium spp., Lomentospora prolificans, Scopulariopsis spp., Trichoderma spp., Acremonium spp., Paecilomyces variotii, Purpureocillium lilacinum, Rasamsonia argillacea species complex, Arthrographis kalrae, and Penicillium species. To facilitate an understanding of the epidemiology and clinical features of sino-pulmonary hyalohyphomycoses in the context of host immune impairment, we utilized a host-based approach encompassing the following underlying conditions: neutropenia, hematologic malignancy, hematopoietic and solid organ transplantation, chronic granulomatous disease, acquired immunodeficiency syndrome, cystic fibrosis, and healthy individuals who sustain burns, trauma, or iatrogenic exposures. We further summarize the pre-clinical and clinical data informing antifungal management for each pathogen and consider the role of adjunctive surgery and/or immunomodulatory treatments to optimize patient outcome.
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9
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Chen BC, Kline AS, Torriani FJ. Severe cutaneous fusariosis in a patient with refractory acute myeloid leukemia. IDCases 2023; 32:e01743. [PMID: 36938339 PMCID: PMC10014258 DOI: 10.1016/j.idcr.2023.e01743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/05/2023] [Accepted: 03/06/2023] [Indexed: 03/09/2023] Open
Affiliation(s)
- Benjamin C. Chen
- Division of Infectious Diseases and Global Public Health, Department of Internal Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA
- Correspondence to: Division of Infectious Diseases and Global Public Health, 9500 Gilman Drive, La Jolla, CA 92093-0507, USA.
| | - Ahnika S. Kline
- Division of Infectious Diseases and Global Public Health, Department of Internal Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA
- Division of Laboratory and Genomic Medicine, Department of Pathology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Francesca J. Torriani
- Division of Infectious Diseases and Global Public Health, Department of Internal Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA
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Hannemann M, Wilmes D, Dombrowski F, Löffler J, Kaminski A, Hummel A, Ulm L, Bohnert J, Rickerts V, Springer J, Lode HN, Ehlert K. Splenic rupture and fungal endocarditis in a pediatric patient with invasive fusariosis after allogeneic hematopoietic stem cell transplantation for aplastic anemia: A case report. Front Pediatr 2022; 10:1060663. [PMID: 36533236 PMCID: PMC9755516 DOI: 10.3389/fped.2022.1060663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Invasive mold infections are a well-known and life-threatening condition after allogeneic hematopoietic stem cell transplantation (HSCT). While Aspergillus species are recognized as predominant pathogens, Fusarium species should also be considered due to their broad environmental distribution and the expected poor outcome of invasive fusariosis. Particularly, splenic rupture as a complication of disseminated disease has not been reported yet. CASE PRESENTATION Two weeks after allogeneic HSCT for severe aplastic anemia, a 16-year-old boy presented with painful, erythematous skin nodules affecting the entire integument. As disseminated mycosis was considered, treatment with liposomal amphotericin B and voriconazole (VCZ) was initiated. Invasive fusariosis was diagnosed after histological and previously unpublished polymerase chain reaction-based examination of skin biopsies. Microbiological tests revealed Fusarium solani species. Despite stable neutrophil engraftment and uninterrupted treatment with VCZ, he developed mold disease-associated splenic rupture with hypovolemic shock and fungal endocarditis. The latter induced a cardiac thrombus and subsequent embolic cerebral infarctions with unilateral hemiparesis. Following cardiac surgery, the patient did not regain consciousness because of diffuse cerebral ischemia, and he died on day +92 after HSCT. CONCLUSION Invasive fusariosis in immunocompromised patients is a life-threatening condition. Despite antimycotic treatment adapted to antifungal susceptibility testing, the patient reported here developed uncommon manifestations such as splenic rupture and fungal endocarditis.
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Affiliation(s)
- Maurice Hannemann
- Department of Pediatric Hematology and Oncology, University Medicine Greifswald, Greifswald, Germany
| | - Dunja Wilmes
- Division for Mycotic and Parasitic Agents and Mycobacteria, Robert Koch Institute, Berlin, Germany
| | - Frank Dombrowski
- Institute of Pathology, University Medicine Greifswald, Greifswald, Germany
| | - Jürgen Löffler
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Alexander Kaminski
- Department for Heart and Vascular Surgery, Klinikum Karlsburg, Karlsburg, Germany
| | - Astrid Hummel
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
| | - Lena Ulm
- Institute of Microbiology, University Medicine Greifswald, Greifswald, Germany
| | - Jürgen Bohnert
- Institute of Microbiology, University Medicine Greifswald, Greifswald, Germany
| | - Volker Rickerts
- Division for Mycotic and Parasitic Agents and Mycobacteria, Robert Koch Institute, Berlin, Germany
| | - Jan Springer
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Holger N Lode
- Department of Pediatric Hematology and Oncology, University Medicine Greifswald, Greifswald, Germany
| | - Karoline Ehlert
- Department of Pediatric Hematology and Oncology, University Medicine Greifswald, Greifswald, Germany
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11
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Bupha-Intr O, Butters C, Reynolds G, Kennedy K, Meyer W, Patil S, Bryant P, Morrissey CO. Consensus guidelines for the diagnosis and management of invasive fungal disease due to moulds other than Aspergillus in the haematology/oncology setting, 2021. Intern Med J 2021; 51 Suppl 7:177-219. [PMID: 34937139 DOI: 10.1111/imj.15592] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Invasive fungal disease (IFD) due to moulds other than Aspergillus is a significant cause of mortality in patients with malignancies or post haemopoietic stem cell transplantation. The current guidelines focus on the diagnosis and management of the common non-Aspergillus moulds (NAM), such as Mucorales, Scedosporium species (spp.), Lomentospora prolificans and Fusarium spp. Rare but emerging NAM including Paecilomyces variotii, Purpureocillium lilacinum and Scopulariopsis spp. are also reviewed. Culture and histological examination of tissue biopsy specimens remain the mainstay of diagnosis, but molecular methods are increasingly being used. As NAM frequently disseminate, blood cultures and skin examination with biopsy of any suspicious lesions are critically important. Treatment requires a multidisciplinary approach with surgical debridement as a central component. Other management strategies include control of the underlying disease/predisposing factors, augmentation of the host response and the reduction of immunosuppression. Carefully selected antifungal therapy, guided by susceptibility testing, is critical to cure. We also outline novel antifungal agents still in clinical trial which offer substantial potential for improved outcomes in the future. Paediatric recommendations follow those of adults. Ongoing epidemiological research, improvement in diagnostics and the development of new antifungal agents will continue to improve the poor outcomes that have been traditionally associated with IFD due to NAM.
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Affiliation(s)
- Olivia Bupha-Intr
- Department of Infection Services, Wellington Regional Hospital, Wellington, New Zealand
| | - Coen Butters
- Department of General Paediatric and Adolescent Medicine, John Hunter Children's Hospital, Newcastle, New South Wales, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Gemma Reynolds
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
| | - Karina Kennedy
- Department of Infectious Diseases and Microbiology, Canberra Hospital and Health Services, Canberra, Australian Capital Territory, Australia.,ANU Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Wieland Meyer
- Molecular Mycology Research Laboratory, Centre for Infectious Diseases and Microbiology, Westmead Clinical School and Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Institute for Medical Research, Sydney, New South Wales, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, New South Wales, Australia
| | - Sushrut Patil
- Malignant Haematology and Stem Cell Transplantation Service, Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Penelope Bryant
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Infectious Diseases, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Catherine O Morrissey
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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12
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Nucci M, Barreiros G, Akiti T, Anaissie E, Nouér SA. Invasive Fusariosis in Patients with Hematologic Diseases. J Fungi (Basel) 2021; 7:jof7100815. [PMID: 34682236 PMCID: PMC8537065 DOI: 10.3390/jof7100815] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/18/2021] [Accepted: 09/24/2021] [Indexed: 02/07/2023] Open
Abstract
Fusarium species are filamentous fungi widely encountered in nature, and may cause invasive disease in patients with hematologic conditions. Patients at higher risk are those with acute leukemia receiving induction remission chemotherapy or allogeneic hematopoietic cell transplant recipients. In these hosts, invasive fusariosis presents typically with disseminated disease, fever, metastatic skin lesions, pneumonia, and positive blood cultures. The prognosis is poor and the outcome is largely dependent on the immune status of the host, with virtually a 100% death rate in persistently neutropenic patients, despite monotherapy or combination antifungal therapy. In this paper, we will review the epidemiology, clinical manifestations, diagnosis, and management of invasive fusariosis affecting patients with hematologic diseases.
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Affiliation(s)
- Marcio Nucci
- Department of Internal Medicine, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
- Correspondence:
| | - Gloria Barreiros
- Mycology Laboratory, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil; (G.B.); (T.A.)
| | - Tiyomi Akiti
- Mycology Laboratory, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil; (G.B.); (T.A.)
| | - Elias Anaissie
- CTI Clinical Trial & Consulting Services, Cincinnati, OH 41011, USA;
| | - Simone A. Nouér
- Department of Infectious Diseases, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil;
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13
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Yao YF, Feng J, Liu J, Chen CF, Yu B, Hu XP. Disseminated infection by Fusarium solani in acute lymphocytic leukemia: A case report. World J Clin Cases 2021; 9:6443-6449. [PMID: 34435010 PMCID: PMC8362567 DOI: 10.12998/wjcc.v9.i22.6443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/07/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In recent years, the rate of immunosuppressed patients has increased rapidly. Invasive fungal infections usually occur in these patients, especially those who have had hematological malignances and received chemotherapy. Fusariosis is a rare pathogenic fungus, it can lead to severely invasive Fusarium infections. Along with the increased rate of immune compromised patients, the incidence of invasive Fusarium infections has also increased from the past few years. Early diagnosis and therapy are important to prevent further development to a more aggressive or disseminated infection.
CASE SUMMARY We report a case of a 19-year-old male acute B-lymphocytic leukemia patient with fungal infection in the skin, eyeball, and knee joint during the course of chemotherapy. We performed skin biopsy, microbial cultivation, and molecular biological identification, and the pathogenic fungus was finally confirmed to be Fusarium solani. The patient was treated with oral 200 mg voriconazole twice daily intravenous administration of 100 mg liposomal amphotericin B once daily, and surgical debridement. Granulocyte colony-stimulating factor was administered to expedite neutrophil recovery. The disseminated Fusarium solani infection eventually resolved, and there was no recurrence at the 3 mo follow-up.
CONCLUSION Our case illustrates the early detection and successful intervention of a systemic invasive Fusarium infection. These are important to prevent progression to a more aggressive infection. Disseminate Fusarium infection requires the systemic use of antifungal agents and immunotherapy. Localized infection likely benefits from surgical debridement and the use of topical antifungal agents.
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Affiliation(s)
- Yu-Fang Yao
- Department of Dermatology & Venereology, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Jia Feng
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Jie Liu
- Department of Dermatology & Venereology, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Chao-Feng Chen
- Department of Dermatology & Venereology, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Bo Yu
- Department of Dermatology & Venereology, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Xiao-Ping Hu
- Department of Dermatology & Venereology, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
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14
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Pourbaix A, Lafont Rapnouil B, Guéry R, Lanternier F, Lortholary O, Cohen JF. Smoking as a Risk Factor of Invasive Fungal Disease: Systematic Review and Meta-Analysis. Clin Infect Dis 2021; 71:1106-1119. [PMID: 31900476 DOI: 10.1093/cid/ciaa001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/01/2020] [Indexed: 01/23/2023] Open
Abstract
To investigate the association between smoking and invasive fungal disease (IFD), we searched MEDLINE and Web of Science for studies published until September 2018. Two authors independently performed study selection and data extraction. Relative risks (RRs) were pooled using random-effects meta-analysis. We included 25 studies (18 171 participants; 2527 IFD cases). The meta-analysis showed an increased risk of IFD in smokers (RR 1.41 [95% confidence interval 1.09-1.81]; P = .008). The risk of IFD was higher in retrospective than in prospective studies (RR 1.93 [1.28-2.92] vs. 1.02 [0.78-1.34]; P = .04), in studies with multivariate adjustment compared to studies with univariate analysis (RR 2.15 [1.27-3.64] vs. 1.15 [0.88-1.51]; P = .06), and in studies published after 2002 (RR 2.08 [1.37-3.15] vs. 0.95 [0.75-1.22]; P = .008); other subgroup characteristics did not significantly influence the association in metaregression. Smoking cessation strategies should be implemented, especially in patients who are already at risk for IFD.
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Affiliation(s)
- Annabelle Pourbaix
- Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants malades Hospital, APHP, Paris University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Baptiste Lafont Rapnouil
- Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants malades Hospital, APHP, Paris University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Romain Guéry
- Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants malades Hospital, APHP, Paris University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Fanny Lanternier
- Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants malades Hospital, APHP, Paris University, Sorbonne Paris Cité, Imagine Institute, Paris, France.,Institut Pasteur, Molecular Mycology Unit, National Reference Center for Invasive Mycoses and Antifungals, UMR, CNRS, Paris, France
| | - Olivier Lortholary
- Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants malades Hospital, APHP, Paris University, Sorbonne Paris Cité, Imagine Institute, Paris, France.,Institut Pasteur, Molecular Mycology Unit, National Reference Center for Invasive Mycoses and Antifungals, UMR, CNRS, Paris, France
| | - Jérémie F Cohen
- Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants malades Hospital, APHP, Paris University, Sorbonne Paris Cité, Imagine Institute, Paris, France.,Inserm U1153, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris University, Paris, France
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15
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Fernández-Cruz A, Semiglia MA, Guinea J, Martínez-Jiménez MDC, Escribano P, Kwon M, Rodríguez-Macías G, Chamorro-de-Vega E, Rodríguez-González C, Navarro R, Galar A, Sánchez-Carrillo C, Díez-Martín JL, Muñoz P. A retrospective cohort of invasive fusariosis in the era of antimould prophylaxis. Med Mycol 2020; 58:300-309. [PMID: 31231772 DOI: 10.1093/mmy/myz060] [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: 02/13/2019] [Revised: 04/06/2019] [Accepted: 05/12/2019] [Indexed: 12/28/2022] Open
Abstract
Mould-active prophylaxis is affecting the epidemiology of invasive mycoses in the form of a shift toward less common entities such as fusariosis. We analyze the characteristics of invasive fusariosis and its association to antifungal prophylaxis in a retrospective cohort (2004-2017) from a tertiary hospital in Madrid, Spain. Epidemiological, clinical, microbiological, and antifungal consumption data were retrieved. Isolates were identified to molecular level, and antifungal susceptibility was tested. Eight cases of invasive fusariosis were diagnosed. Three periods were identified according to incidence: <2008 (three cases), 2008-2013 (zero cases), >2014 (five cases). All except one case involved breakthrough fusariosis. During the earliest period, the episodes occurred while the patient was taking itraconazole (two) or fluconazole (one); more recently, while on micafungin (three) or posaconazole (one). Early cases involved acute leukemia at induction/consolidation, recent cases relapsed/refractory disease (P = .029). Main risk factor for fusariosis (62.5%) was prolonged neutropenia (median 44 days). Galactomannan and beta-D-glucan were positive in 37.5% and 100% of cases, respectively. All isolates except F. proliferatum presented high minimal inhibitory concentrations (MICs) against the azoles and lower MIC to amphotericin B. Most patients received combined therapy. Mortality at 42 days was 62.5%. Resolution of neutropenia was associated with survival (P = .048). Invasive fusariosis occurs as breakthrough infection in patients with hematologic malignancy, prolonged neutropenia, and positive fungal biomarkers. Recent cases were diagnosed in a period of predominant micafungin use in patients who had more advanced disease and protracted neutropenia and for whom mortality was extremely high. Resolution of neutropenia was a favorable prognostic factor.
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Affiliation(s)
- Ana Fernández-Cruz
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
| | - María Auxiliadora Semiglia
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
| | - Jesús Guinea
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - María Del Carmen Martínez-Jiménez
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
| | - Pilar Escribano
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
| | - Mi Kwon
- Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain.,Hematology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Gabriela Rodríguez-Macías
- Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain.,Hematology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Esther Chamorro-de-Vega
- Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain.,Pharmacy Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Carmen Rodríguez-González
- Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain.,Pharmacy Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Raquel Navarro
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
| | - Alicia Galar
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
| | - Carlos Sánchez-Carrillo
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
| | - José Luis Díez-Martín
- Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain.,Hematology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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16
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Disseminated fusariosis in a patient with bone marrow aplasia. An Bras Dermatol 2020; 95:609-614. [PMID: 32723611 PMCID: PMC7563018 DOI: 10.1016/j.abd.2019.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/15/2019] [Indexed: 11/30/2022] Open
Abstract
Fusariosis is a superficial or systemic infection, which occurs mainly in immunocompromised hosts, especially in patients with hematological neoplasia; 70%–75% of the cases present cutaneous manifestations. The disseminated form is rare and difficult to diagnose; even with specific treatment, the evolution is usually fatal. Currently, it is considered an emerging disease; in some centers, it is the second most common cause of invasive mycosis, after aspergillosis. The authors describe a case of a female patient with idiopathic bone marrow aplasia and disseminated fusariosis, who initially appeared to benefit from voriconazole and amphotericin B; however, due to persistent neutropenia, her clinical condition deteriorated with fatal evolution.
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17
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Zhao C, Wang Q, Wang Y, Yan CH, Xu LP, Zhang XH, Liu KY, Huang XJ, Sun YQ. [Non-aspergillus molds infection after allogeneic stem cell transplantation: clinical analysis of 24 cases and outcomes]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:624-629. [PMID: 32942814 PMCID: PMC7525166 DOI: 10.3760/cma.j.issn.0253-2727.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Indexed: 11/13/2022]
Abstract
Objective: To analyze the clinical characteristics and outcomes of non-aspergillus molds infection (NAMI) patients who underwent allogeneic stem cell transplantation. Methods: Total 24 patients diagnosed as proven or probable non-aspergillus molds infection after allo-HSCT at the Peking University Institute of Hematology from January 2010 to December 2016 were retrospectively reviewed. Results: Among the 24 non-aspergillus molds infection patients, 22 (91.6%) underwent haploidentical stem cell transplantation, while 1 (4.2%) underwent matched-sibling donor transplantation, and 1 (4.2%) underwent HLA-matched unrelated donor transplantation. Ten (41.7%) patients were diagnosed as proven NAMI, and 14 (58.3%) were probable NAMI. The median time to NAMI diagnosis was 188 (2-856) d after transplantation. Five (20.8%) patients had Mucorales infection, 14 (58.3%) Rhizopus infection, 3 (12.5%) had Absidia orchidis infection, and 2 (8.3%) had Scedosporium apiospermum infection. The response rate at was 38.9% (7/18) in 18 patients who adjusted antifungal therapy based on the etiology. After a median 229 (2-2280) days follow-up after diagnosis, the 2-year overall survival was (24.0±14.5) %. Conclusion: The major pathogen of NAMI after allo-HSCT was Rhizopus, and the mortality of NAMI after allo-HSCT was very high due to lack of early effective therapy.
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Affiliation(s)
- C Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Q Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing 100044, China
| | - Y Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - C H Yan
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - L P Xu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - X H Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - K Y Liu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - X J Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y Q Sun
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
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18
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Samrah S, Sweidan A, Aleshawi A, Ayesh M. Fusarium-Induced Cellulitis in an Immunocompetent Patient With Sickle Cell Disease: A Case Report. J Investig Med High Impact Case Rep 2020; 8:2324709620934303. [PMID: 32539466 PMCID: PMC7298209 DOI: 10.1177/2324709620934303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Fungal infections due to Fusarium species are mostly
present in immunocompromised and patients with poorly controlled
diabetes mellitus. We report a case of lower extremity skin infection
caused by Fusarium species in a 61-year-old woman
diagnosed with sickle cell disease. Single skin ulceration caused by
Fusarium species can result from fungal
inoculation into damaged tissue, so any condition that damages the
skin can be considered as a risk factor for inoculation. Long-standing
sickle cell disease may develop vaso-occlusion in the skin that can
produce lower extremity ulcers and myofascial syndromes. The mechanism
is not completely characterized, but compromised blood flow,
endothelial dysfunction, thrombosis, inflammation, and delayed healing
are thought to contribute to locally compromised tissue that may
eventually lead to opportunistic infection such as in our case. Other
factors contribute to the pathophysiology of lower extremity ulcers
such as diabetes mellitus, with the resulting peripheral vascular
ischemia causing poor circulation to the lower extremity, and
peripheral neuropathy, which can make patients with diabetes unaware
of minor trauma leading to the development of skin infections.
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Affiliation(s)
- Shaher Samrah
- Jordan University of Science and Technology, Irbid, Jordan
| | - Aroob Sweidan
- Jordan University of Science and Technology, Irbid, Jordan
| | | | - Mahmoud Ayesh
- Jordan University of Science and Technology, Irbid, Jordan
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19
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Chien SH, Liu YC, Liu CJ, Ko PS, Wang HY, Hsiao LT, Chiou TJ, Liu JH, Gau JP. Invasive mold infections in acute leukemia patients undergoing allogeneic hematopoietic stem cell transplantation. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2019; 52:973-982. [DOI: 10.1016/j.jmii.2018.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 10/28/2022]
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20
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Therapeutic Challenges of Non- Aspergillus Invasive Mold Infections in Immunosuppressed Patients. Antimicrob Agents Chemother 2019; 63:AAC.01244-19. [PMID: 31481441 DOI: 10.1128/aac.01244-19] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
While Aspergillus spp. remain the major cause of invasive mold infections in hematologic cancer patients and transplant recipients, other opportunistic molds, such as Mucorales, Fusarium, and Scedosporium spp. are increasingly encountered in an expanding population of patients with severe and prolonged immunosuppression. High potential for tissue invasion and dissemination, resistance to multiple antifungals and high mortality rates are hallmarks of these non-Aspergillus invasive mold infections (NAIMIs). Assessment of drug efficacy is particularly difficult in the complex treatment scenarios of NAIMIs. Specifically, correlation between in vitro susceptibility and in vivo responses to antifungals is hard to assess, in view of the multiple, frequently interrelated factors influencing outcomes, such as pharmacokinetic/pharmacodynamic parameters determining drug availability at the site of infection, the net state of immune suppression, delay in diagnosis, or surgical debulking of infectious foci. Our current therapeutic approach of NAIMIs should evolve toward a better integration of the dynamic interactions between the pathogen, the drug and the host. Innovative concepts of experimental research may consist in manipulating the host immune system to induce a specific antifungal response or targeted drug delivery. In this review, we discuss the challenges in the management of NAIMIs and provide an update about the latest advances in diagnostic and therapeutic approaches.
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21
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Wang L, Wang Y, Hu J, Sun Y, Huang H, Chen J, Li J, Ma J, Li J, Liang Y, Wang J, Li Y, Yu K, Hu J, Jin J, Wang C, Wu D, Xiao Y, Huang X. Clinical risk score for invasive fungal diseases in patients with hematological malignancies undergoing chemotherapy: China Assessment of Antifungal Therapy in Hematological Diseases (CAESAR) study. Front Med 2019; 13:365-377. [PMID: 30604166 DOI: 10.1007/s11684-018-0641-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 04/25/2018] [Indexed: 01/22/2023]
Abstract
Invasive fungal disease (IFD) is a major infectious complication in patients with hematological malignancies. In this study, we examined 4889 courses of chemotherapy in patients with hematological diseases to establish a training dataset (n = 3500) by simple random sampling to develop a weighted risk score for proven or probable IFD through multivariate regression, which included the following variables: male patients, induction chemotherapy for newly diagnosed or relapsed disease, neutropenia, neutropenia longer than 10 days, hypoalbuminemia, central-venous catheter, and history of IFD. The patients were classified into three groups, which had low (0-10, ~1.2%), intermediate (11-15, 6.4%), and high risk ( > 15, 17.5%) of IFD. In the validation set (n = 1389), the IFD incidences of the groups were ~1.4%, 5.0%, and 21.4%. In addition, we demonstrated that antifungal prophylaxis offered no benefits in low-risk patients, whereas benefits were documented in intermediate (2.1% vs. 6.6%, P = 0.007) and high-risk patients (8.4% vs. 23.3%, P = 0.007). To make the risk score applicable for clinical settings, a pre-chemo risk score that deleted all unpredictable factors before chemotherapy was established, and it confirmed that anti-fungal prophylaxis was beneficial in patients with intermediate and high risk of IFD. In conclusion, an objective, weighted risk score for IFD was developed, and it may be useful in guiding antifungal prophylaxis.
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Affiliation(s)
- Ling Wang
- Blood & Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Ying Wang
- Blood & Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Jiong Hu
- Blood & Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Yuqian Sun
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University, People's Hospital, Beijing, 100044, China
| | - He Huang
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, 310003, China
| | - Jing Chen
- Department of Hematology-Oncology, Shanghai Children's Medical Center, Shanghai, 200127, China
| | - Jianyong Li
- Department of Hematology, Jiangsu Province Hospital, Nanjing, 210029, China
| | - Jun Ma
- Harbin Hematologic Tumor Institution, Harbin, 150010, China
| | - Juan Li
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Yingmin Liang
- Department of Hematology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Jianmin Wang
- Department of Hematology, Changhai Hospital of the Second Military Medical University, Shanghai, 200082, China
| | - Yan Li
- Department of Hematology, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China
| | - Kang Yu
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, 325000, China
| | - Jianda Hu
- Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Jie Jin
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, 310003, China
| | - Chun Wang
- Department of Hematology, The First People's Hospital of Shanghai, Shanghai, 200080, China
| | - Depei Wu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Yang Xiao
- Department of Hematology, The General Hospital of Guangzhou Military Command of PLA, Guangzhou, 510010, China
| | - Xiaojun Huang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University, People's Hospital, Beijing, 100044, China.
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Fluorine-18-fluorodeoxyglucose PET/CT in hematopoietic stem cell transplant patients with fusariosis: initial findings of a case series review. Nucl Med Commun 2018; 39:545-552. [PMID: 29652746 DOI: 10.1097/mnm.0000000000000834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Fusariosis is an opportunistic fungal infection that affects mostly leukemic and hematopoietic stem cell transplant patients. Locally invasive and disseminated infection may occur. Treatment is challenging, and besides evaluation of immune status, one also needs to take into account organ involvement to predict the duration and prognosis. OBJECTIVE The aim of this study was to present the findings and clinical follow-up from a series of cases of Fusarium spp. infections in patients subjected to hematopoietic stem cell transplant evaluated with one or more fluorine-18-fluorodeoxyglucose (18F-FDG) PET/CT scans, according to the source of clinical culture sample (blood or wound secretion). RESULTS Ten patients were included. In this series, 18F-FDG PET/CT was able to detect osteomyelitis in three patients. CONCLUSION Although having a small number of patients and lack of standard approach, 18F-FDG PET/CT seemed useful to discriminate uncomplicated cases of primary bloodstream infections and detect occult foci of metastatic infection in patients with positive cutaneous lesions cultures.
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Lien MY, Chou CH, Lin CC, Bai LY, Chiu CF, Yeh SP, Ho MW. Epidemiology and risk factors for invasive fungal infections during induction chemotherapy for newly diagnosed acute myeloid leukemia: A retrospective cohort study. PLoS One 2018; 13:e0197851. [PMID: 29883443 PMCID: PMC5993235 DOI: 10.1371/journal.pone.0197851] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 05/09/2018] [Indexed: 11/19/2022] Open
Abstract
This study investigated the epidemiology and risk factors associated with invasive fungal infections (IFIs) during induction chemotherapy in a cohort of Taiwanese patients with newly-diagnosed acute myeloid leukemia (AML). IFIs are a significant complication in the management of immunocompromised cancer patients; such infections are associated with a high incidence of morbidity and mortality, particularly in many South-Asian countries, where IFI rates are increasing. We retrospectively analyzed IFI incidence data from 105 patients with newly diagnosed AML at a single center undergoing their first course of induction chemotherapy without primary antifungal prophylaxis between November 2008 and December 2014. Of 21 cases documented as proven/provable IFIs 16 (76%) were invasive aspergillosis, 2 (10%) were mucormycosis infections, and 3 (14%) were proven yeast infections. The lung was the most commonly affected site (n = 16; 76%); 2 patients (10%) developed fungal sinusitis. IFI cases were more often males (P = 0.020). In multivariate analysis, patients with neutropenia lasting>30 days were more than twice as likely to develop IFI (OR, 2.24 [95% CI, 2.81-31.11], P<0.001). We also confirmed patients with smoker and receiving parenteral nutrition during chemotherapy were significant associated with IFIs. Our findings suggest that antifungal prophylaxis should be considered for patients with AML during induction chemotherapy, particularly in patients from Southeastern Asia, an area of potentially high IFI rates. We recommend that clinicians determine which patients receiving induction chemotherapy for AML are at high risk of developing IFI, to allow for targeted therapeutic prophylaxis.
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Affiliation(s)
- Ming-Yu Lien
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung City, Taiwan, R.O.C
- Graduate Institute of Basic Medical Science, China Medical University, Taichung City, Taiwan, R.O.C
| | - Chia-Hui Chou
- Division of Infection Disease, Department of Internal Medicine, China Medical University Hospital, Taichung City, Taiwan, R.O.C
| | - Ching-Chan Lin
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung City, Taiwan, R.O.C
| | - Li-Yuan Bai
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung City, Taiwan, R.O.C
- Clinic of Hematology and Oncology, Department of Internal Medicine, Graduate Institute of Clinical Medicine, China Medical University, Taichung City, Taiwan, R.O.C
| | - Chang-Fang Chiu
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung City, Taiwan, R.O.C
- Clinic of Hematology and Oncology, Department of Internal Medicine, Graduate Institute of Clinical Medicine, China Medical University, Taichung City, Taiwan, R.O.C
| | - Su-Peng Yeh
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung City, Taiwan, R.O.C
- Clinic of Hematology and Oncology, Department of Internal Medicine, Graduate Institute of Clinical Medicine, China Medical University, Taichung City, Taiwan, R.O.C
- * E-mail: (MWH); (SPY)
| | - Mao-Wang Ho
- Division of Infection Disease, Department of Internal Medicine, China Medical University Hospital, Taichung City, Taiwan, R.O.C
- * E-mail: (MWH); (SPY)
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24
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Gomez SM, Caniza M, Fynn A, Vescina C, Ruiz CD, Iglesias D, Sosa F, Sung L. Fungal infections in hematopoietic stem cell transplantation in children at a pediatric children's hospital in Argentina. Transpl Infect Dis 2018; 20:e12913. [PMID: 29679436 DOI: 10.1111/tid.12913] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 12/24/2017] [Accepted: 01/07/2018] [Indexed: 12/12/2022]
Abstract
Our primary objective was to describe the incidence of proven or probable invasive fungal infections (IFIs), a devastating complication of hematopoietic stem cell transplant (HSCT), in HCST in a middle-income country. Secondary objectives were to describe factors associated with IFIs and outcomes. In this single center retrospective study, pediatric patients who underwent a first allogeneic or autologous HSCT from 1998 to 2016 were included. Of the 251 HSCT recipients: 143 transplants were allogeneic and 108 were autologous. Overall, 23 (9%) experienced an IFI, mostly due to yeasts (83%). IFIs were more common in allogeneic HSCT (18/143, 13%) than in autologous HSCT (5/108, 5%; P = .045). Of the 23 patients with IFIs, 14 (61%) died, but only 1 directly from IFI (pulmonary aspergillosis). Overall survival at 3 years was 0.42 ± 0.11 in patients with IFIs and 0.60 ± 0.37 in those without IFIs (P = .049). In Argentina, IFIs during HSCT are common. Recipients of allogeneic HSCT are at higher risk, and IFI is associated with reduced overall survival. Future work should focus on interventions to reduce and improve IFI outcomes in children undergoing transplants in low- and middle-income countries.
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Affiliation(s)
- Sergio M Gomez
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Miguela Caniza
- Global Pediatric Medicine, Infectious Diseases. St. Jude Children's Cancer Research Hospital, Memphis, TN, USA
| | - Alicira Fynn
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Cecilia Vescina
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Clau-Dia Ruiz
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Daniela Iglesias
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Fernanda Sosa
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
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25
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Fusarium Endophthalmitis, Unusual and Challenging Infection in an Acute Leukemia Patient. Case Rep Hematol 2018; 2018:9531484. [PMID: 29725549 PMCID: PMC5872658 DOI: 10.1155/2018/9531484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/09/2018] [Accepted: 02/27/2018] [Indexed: 01/30/2023] Open
Abstract
Invasive fungal infections bring serious mortality and morbidity during the treatment of acute myeloid leukemia. Especially, mold infections are challenging, and each case is unique in feature. These cases are usually fatal, and there is no consensus regarding optimal treatment. AML patients receive antifungal prophylaxis and may further require IFI (invasive fungal infection) treatments, but fusarium mold infections are often unrecognized and could be overlooked. In this case report, we try to emphasize the importance of this infection with a high-risk AML patient.
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26
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De La Cruz O, Silveira FP. Respiratory Fungal Infections in Solid Organ and Hematopoietic Stem Cell Transplantation. Clin Chest Med 2017; 38:727-739. [PMID: 29128021 DOI: 10.1016/j.ccm.2017.07.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Respiratory fungal infections are associated with high morbidity and mortality in hematopoietic stem cell (HSCT) and solid organ (SOT) transplant recipients, and are caused primarily by molds. Aspergillus is the most common pathogen. The net state of immunosuppression plays a major role in the risk of respiratory fungal infections after transplantation. Clinical presentation can be atypical and diagnosis can be delayed due to low sensitivity of diagnostic methods or inability to obtain adequate specimens. Fungal infections in HSCT and SOT carry a higher risk of dissemination. New prophylaxis strategies have changed the epidemiology of fungal infections in this patient population.
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Affiliation(s)
- Oveimar De La Cruz
- Department of Medicine, Division of Infectious Diseases, Virginia Commonwealth University, VMI Building, Suite 205, 1000 East Marshall Street, Richmond, VA 23298, USA
| | - Fernanda P Silveira
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, 3601 Fifth Avenue, Suite 3A, Pittsburgh, PA 15213, USA.
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27
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Al-Hatmi AMS, Bonifaz A, Ranque S, Sybren de Hoog G, Verweij PE, Meis JF. Current antifungal treatment of fusariosis. Int J Antimicrob Agents 2017; 51:326-332. [PMID: 28705676 DOI: 10.1016/j.ijantimicag.2017.06.017] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 04/28/2017] [Accepted: 06/24/2017] [Indexed: 12/12/2022]
Abstract
Fungi of the genus Fusarium are well known as major plant pathogens and soil inhabitants, but also cause a broad spectrum of human infections. Fusariosis is the second most common mould infection after aspergillosis, and keratitis is the most encountered implantation infection in immunocompetent individuals. Natamycin is active against Fusarium species both in vitro and in vivo, and is used along with voriconazole as the mainstay of treatment for Fusarium keratitis. Onychomycosis is treated with terbinafine, voriconazole and sometimes itraconazole. Cure is possible despite high in vitro minimum inhibitory concentrations (MICs). Recently, disseminated infections have increased dramatically, mainly affecting severely immunocompromised patients. The remarkable intrinsic resistance of Fusarium species to most antifungal agents results in high mortality rates in this patient population. Recovery of neutropenia is essential for patient survival and treatment should include voriconazole or amphotericin B as first-line and posaconazole as salvage therapy.
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Affiliation(s)
- Abdullah M S Al-Hatmi
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands; Directorate General of Health Services, Ministry of Health, Ibri Hospital, Ibri, Oman; Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands.
| | - Alexandro Bonifaz
- Hospital General de México, 'Dr. Eduardo Liceaga', Mexico City, Mexico
| | - Stephane Ranque
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, IHU-Méditerranée Infection, Marseille, France
| | - G Sybren de Hoog
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands; Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands; Basic Pathology Department, Federal University of Paraná State, Curitiba, Paraná, Brazil; Biological Sciences Department, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Paul E Verweij
- Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands; Department of Medical Microbiology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jacques F Meis
- Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands; Department of Medical Microbiology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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28
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Lass-Flörl C, Cuenca-Estrella M. Changes in the epidemiological landscape of invasive mould infections and disease. J Antimicrob Chemother 2017; 72:i5-i11. [PMID: 28355462 DOI: 10.1093/jac/dkx028] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Although a wide variety of pathogens are associated with invasive mould diseases, Aspergillus spp. have historically been one of the most common causative organisms. Most invasive mould infections are caused by members of the Aspergillus fumigatus species complex and an emerging issue is the occurrence of azole resistance in A. fumigatus, with resistance to amphotericin B documented in other Aspergillus spp. The epidemiology of invasive fungal disease has shifted in recent years as non-A. fumigatus Aspergillus spp. and other moulds have become progressively more important, although there are no consolidated data on the prevalence of less common species of moulds. The incidence of mucormycosis may have been underestimated, which is a potential concern since species belonging to the order Mucorales are more resistant to antifungal agents than Aspergillus spp. All species of Mucorales are unaffected by voriconazole and most show moderate resistance in vitro to echinocandins. Fusarium spp. may be the second most common nosocomial fungal pathogen after Aspergillus in some tertiary hospitals, and show a susceptibility profile marked by a higher level of resistance than that of Aspergillus spp. Recently, Scedosporium aurantiacum has been reported as an emerging opportunistic pathogen, against which voriconazole is the most active antifungal agent. Other mould species can infect humans, although invasive fungal disease occurs less frequently. Since uncommon mould species exhibit individual susceptibility profiles and require tailored clinical management, accurate classification at species level of the aetiological agent in any invasive fungal disease should be regarded as the standard of care.
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Affiliation(s)
- Cornelia Lass-Flörl
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstraße 41, 6020 Innsbruck, Austria
| | - Manuel Cuenca-Estrella
- Department of Mycology, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Ctra. Majadahonda-Pozuelo Km 2, Majadahonda, Madrid, Spain
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Abstract
Immunocompromised patients are at high risk for invasive fungal infections (IFIs); although Aspergillus remains the most common IFI caused by molds, other fungi, such as Mucorales, dematiaceous molds, and Fusarium spp, are being seen with increasing frequency. Presentations can vary, but sinopulmonary and disseminated infections are common. Our understanding of the pathogenesis of these infections is rudimentary. Fungal cultures and histopathology remain the backbone of diagnostics, as no good serologic markers are available. Polymerase chain reaction tests are being developed but currently remain investigational. Management of these infections is usually multidisciplinary, requiring surgical debridement along with antifungal therapy.
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30
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Borman AM, Fraser M, Palmer MD, Szekely A, Houldsworth M, Patterson Z, Johnson EM. MIC Distributions and Evaluation of Fungicidal Activity for Amphotericin B, Itraconazole, Voriconazole, Posaconazole and Caspofungin and 20 Species of Pathogenic Filamentous Fungi Determined Using the CLSI Broth Microdilution Method. J Fungi (Basel) 2017; 3:E27. [PMID: 29371545 PMCID: PMC5715917 DOI: 10.3390/jof3020027] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 01/21/2023] Open
Abstract
For filamentous fungi (moulds), species-specific interpretive breakpoints and epidemiological cut-off values (ECVs) have only been proposed for a limited number of fungal species-antifungal agent combinations, with the result that clinical breakpoints are lacking for most emerging mould pathogens. In the current study, we have compiled minimum inhibitory concentration (MIC) data for 4869 clinical mould isolates and present full MIC distributions for amphotericin B, itraconazole, voriconazole, posaconazole, and caspofungin with these isolates which comprise 20 species/genera. In addition, we present the results of an assessment of the fungicidal activity of these same five antifungal agents against a panel of 123 mould isolates comprising 16 of the same species.
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Affiliation(s)
- Andrew M Borman
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
| | - Mark Fraser
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
| | - Michael D Palmer
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
| | - Adrien Szekely
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
| | - Marian Houldsworth
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
| | - Zoe Patterson
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
| | - Elizabeth M Johnson
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
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31
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de León-Borrás R, DelPilar-Morales E, Rivera-Pérez N, Pallens-Feliciano M, Tirado-Gómez M, González-Sepúlveda L, Bertrán-Pasarell J. Factors Associated to Invasive Fungal Infection in Hispanic Patients with Hematological Malignancies. BOLETIN DE LA ASOCIACION MEDICA DE PUERTO RICO 2017; 109:43-48. [PMID: 29861498 PMCID: PMC5980240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Fungal infections represent a serious complication for immunosuppressed patients resulting in an increased morbidity and mortality. A non-concurrent prospective study was performed to evaluate the factors associated to invasive fungal infection (IFI) in patients with hematological malignancies admitted to the University Hospital in San Juan, Puerto Rico from January 1st, 2011 through June 15th, 2014. The medical records of 84 patients were evaluated. Fifty-nine patients with IFI and twenty-five without IFI. The majority were men between 35 to 55 years old. The main hematological diagnosis was acute myelogenous leukemia (AML) followed by acute lymphoblastic leukemia (ALL). Seventy-percent developed IFI. The most common fungi were C. albicans followed by non-albicans species, Fusarium and, Aspergillus species, respectively. About 63% of the patients with AML and 81% without AML had IFI. Those who received steroids were more likely to develop IFI. After adjusting for AML and age, the odds of IFI among patients using steroids were 3.33 higher than those not using steroids. Patients who were exposed to different antifungal medication had 72% lower odds to develop IFI.
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Affiliation(s)
- Rafael de León-Borrás
- Division of Infectious Diseases, Department of Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | - Esteban DelPilar-Morales
- Division of Infectious Diseases, Department of Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | - Nicole Rivera-Pérez
- Division of Infectious Diseases, Department of Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | - Mara Pallens-Feliciano
- Division of Infectious Diseases, Department of Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | - Maribel Tirado-Gómez
- Division of Hematology Oncology, Department of Medicine, University of Puerto Rico School of Medicine, San Juan Puerto Rico
| | | | - Jorge Bertrán-Pasarell
- Division of Infectious Diseases, Department of Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
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32
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Hyperglycemia as a possible risk factor for mold infections-the potential preventative role of intensified glucose control in allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2016; 52:657-662. [PMID: 27941771 DOI: 10.1038/bmt.2016.306] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 10/04/2016] [Accepted: 10/12/2016] [Indexed: 12/11/2022]
Abstract
Diabetes mellitus (DM) is well-known as a disorder that increases the risk of infectious diseases. Various reports have shown that innate immunity is impaired in patients with DM, which is considered to be a major cause of increased risk of infectious diseases. However, there is a paucity of data about the actual risk of mold infections in patients with DM. Several treatment procedures, such as solid organ transplantation and hematopoietic stem cell transplantation (HSCT), are intrinsically associated with a high risk of mold infections and also correlated with an increased risk of post-transplant DM. Therefore, we could assume that organ transplant recipients or HSCT recipients with DM are at quite high risk of mold infections. Here, we aim to summarize the information about the increased risk of mold infections in patients with DM, and propose possible interventions such as intensive glucose control to reduce this risk in patients with DM.
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33
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Douglas AP, Slavin MA. Risk factors and prophylaxis against invasive fungal disease for haematology and stem cell transplant recipients: an evolving field. Expert Rev Anti Infect Ther 2016; 14:1165-1177. [PMID: 27710140 DOI: 10.1080/14787210.2016.1245613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Due to increasing intensity and complexity of therapies and longer survivorship, many patients with haematologic malignancy (HM) are at risk of invasive fungal disease (IFD). Mortality from IFD is high and treatment of an episode of IFD results in an excess length of hospital stay and costs and delays delivery of curative therapy of the underlying haematologic condition. Therefore, prevention and early recognition and treatment of IFD are crucial. Areas covered: Risk factors particular to certain HMs and haematopoietic stem cell transplantation, as well as those risk factors universal to all HM groups are examined. Expert commentary: Risk stratification identifies those patients who would benefit most from mould active versus yeast active prophylaxis and those who can be safely managed with monitoring and clinically driven interventions for IFD. This approach aids in antifungal stewardship.
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Affiliation(s)
- Abby P Douglas
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , Melbourne , VIC , Australia
| | - Monica A Slavin
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , Melbourne , VIC , Australia.,b Victorian Infectious Diseases Service , Royal Melbourne Hospital , Melbourne , VIC , Australia.,c Department of Medicine , University of Melbourne , Melbourne , VIC , Australia
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Chowdhary A, Masih A, Sharma C. Azole Resistance in Moulds—Approach to Detection in a Clinical Laboratory. CURRENT FUNGAL INFECTION REPORTS 2016. [DOI: 10.1007/s12281-016-0265-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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35
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Delia M, Monno R, Giannelli G, Ianora AAS, Dalfino L, Pastore D, Capolongo C, Calia C, Tortorano A, Specchia G. Fusariosis in a Patient with Acute Myeloid Leukemia: A Case Report and Review of the Literature. Mycopathologia 2016; 181:457-63. [PMID: 27008433 DOI: 10.1007/s11046-016-9987-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 02/01/2016] [Indexed: 12/12/2022]
Abstract
Fusarium spp. causes infections mostly in patients with prolonged neutropenia. We describe the case of a disseminated Fusarium solani infection in a patient with acute myeloid leukemia which never reached complete remission during its clinical course. The patient had profound neutropenia and developed skin nodules and pneumonia in spite of posaconazole prophylaxis. F. solani was isolated from blood and skin biopsy, being identified from its morphology and by molecular methods. By broth dilution method, the strain was resistant to azoles, including voriconazole and posaconazole, and to echinocandins. MIC to amphotericin B was 4 mg/L. The patient initially seemed to benefit from therapy with voriconazole and amphotericin B, but, neutropenia perduring, his clinical condition deteriorated with fatal outcome. All efforts should be made to determine the correct diagnosis as soon as possible in a neutropenic patient and to treat this infection in a timely way, assuming pathogen susceptibility while tests of antimicrobial susceptibility are pending. A review of the most recent literature on invasive fungal infections is reported.
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Affiliation(s)
- Mario Delia
- Department of DETO, University of Bari, Bari, Italy
| | - Rosa Monno
- Department SMBNOS, University of Bari, Bari, Italy.
| | | | | | | | | | | | - Carla Calia
- Department SMBNOS, University of Bari, Bari, Italy
| | - Annamaria Tortorano
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
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Lockwood MB, Crescencio JCR. Adventitious sporulation in Fusarium: The yeast that were not. IDCases 2015; 3:5-7. [PMID: 26793480 PMCID: PMC4719800 DOI: 10.1016/j.idcr.2015.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/20/2015] [Accepted: 10/20/2015] [Indexed: 11/06/2022] Open
Abstract
In immunocompromised patients, Fusarium species cause infections that lead to high mortality. Our case report describes a case of disseminated fusariosis in a neutropenic patient with AML after myelosuppressive chemotherapy, and a neutropenic multiple myeloma patient with Fusarium fungemia awaiting stem cell collection. Both cases highlight the fact that Fusarium can grow as yeast-like structures in the blood causing a delay in diagnosis, and that Fusarium has a tendency to be a resistant organism. Fusarium was only susceptible to amphotericin B in both cases, but we chose to continue treatment with voriconazole in the first case with disseminated infection, despite culture results, in view of his good clinical response. Despite high mortality rates in disseminated infection, our two patients had good outcomes.
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Affiliation(s)
- Matthew B Lockwood
- University of Arkansas for Medical Sciences, Department of Internal Medicine, Little Rock, AR, USA
| | - Juan Carlos Rico Crescencio
- University of Arkansas for Medical Sciences, Department of Internal Medicine, Little Rock, AR, USA; University of Arkansas for Medical Sciences, Division of Infectious Disease, Little Rock, AR, USA; University of Arkansas for Medical Sciences, Myeloma Institute, Little Rock, AR, USA
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37
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International Evaluation of MIC Distributions and Epidemiological Cutoff Value (ECV) Definitions for Fusarium Species Identified by Molecular Methods for the CLSI Broth Microdilution Method. Antimicrob Agents Chemother 2015; 60:1079-84. [PMID: 26643334 DOI: 10.1128/aac.02456-15] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 11/23/2015] [Indexed: 11/20/2022] Open
Abstract
The CLSI epidemiological cutoff values (ECVs) of antifungal agents are available for various Candida spp., Aspergillus spp., and the Mucorales. However, those categorical endpoints have not been established for Fusarium spp., mostly due to the difficulties associated with collecting sufficient CLSI MICs for clinical isolates identified according to the currently recommended molecular DNA-PCR-based identification methodologies. CLSI MIC distributions were established for 53 Fusarium dimerum species complex (SC), 10 F. fujikuroi, 82 F. proliferatum, 20 F. incarnatum-F. equiseti SC, 226 F. oxysporum SC, 608 F. solani SC, and 151 F. verticillioides isolates originating in 17 laboratories (in Argentina, Australia, Brazil, Canada, Europe, Mexico, and the United States). According to the CLSI guidelines for ECV setting, ECVs encompassing ≥97.5% of pooled statistically modeled MIC distributions were as follows: for amphotericin B, 4 μg/ml (F. verticillioides) and 8 μg/ml (F. oxysporum SC and F. solani SC); for posaconazole, 2 μg/ml (F. verticillioides), 8 μg/ml (F. oxysporum SC), and 32 μg/ml (F. solani SC); for voriconazole, 4 μg/ml (F. verticillioides), 16 μg/ml (F. oxysporum SC), and 32 μg/ml (F. solani SC); and for itraconazole, 32 μg/ml (F. oxysporum SC and F. solani SC). Insufficient data precluded ECV definition for the other species. Although these ECVs could aid in detecting non-wild-type isolates with reduced susceptibility to the agents evaluated, the relationship between molecular mechanisms of resistance (gene mutations) and MICs still needs to be investigated for Fusarium spp.
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Ocampo-Garza J, Herz-Ruelas M, Chavez-Alvarez S, Gómez-Flores M, Vera-Cabrera L, Welsh-Lozano O, Gallardo-Rocha A, Escalante-Fuentes W, Ocampo-Candiani J. Disseminated fusariosis with endophthalmitis after skin trauma in acute lymphoblastic leukaemia. J Eur Acad Dermatol Venereol 2015; 30:e121-e123. [DOI: 10.1111/jdv.13392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J. Ocampo-Garza
- Dermatology Department; University Hospital “Dr. José Eleuterio González”; Universidad Autónoma de Nuevo León; Monterrey México
| | - M.E. Herz-Ruelas
- Dermatology Department; University Hospital “Dr. José Eleuterio González”; Universidad Autónoma de Nuevo León; Monterrey México
| | - S. Chavez-Alvarez
- Dermatology Department; University Hospital “Dr. José Eleuterio González”; Universidad Autónoma de Nuevo León; Monterrey México
| | - M. Gómez-Flores
- Dermatology Department; University Hospital “Dr. José Eleuterio González”; Universidad Autónoma de Nuevo León; Monterrey México
| | - L. Vera-Cabrera
- Dermatology Department; University Hospital “Dr. José Eleuterio González”; Universidad Autónoma de Nuevo León; Monterrey México
| | - O. Welsh-Lozano
- Dermatology Department; University Hospital “Dr. José Eleuterio González”; Universidad Autónoma de Nuevo León; Monterrey México
| | - A. Gallardo-Rocha
- Dermatology Department; University Hospital “Dr. José Eleuterio González”; Universidad Autónoma de Nuevo León; Monterrey México
| | - W.G. Escalante-Fuentes
- Dermatology Department; University Hospital “Dr. José Eleuterio González”; Universidad Autónoma de Nuevo León; Monterrey México
| | - J. Ocampo-Candiani
- Dermatology Department; University Hospital “Dr. José Eleuterio González”; Universidad Autónoma de Nuevo León; Monterrey México
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Stempel JM, Hammond SP, Sutton DA, Weiser LM, Marty FM. Invasive Fusariosis in the Voriconazole Era: Single-Center 13-Year Experience. Open Forum Infect Dis 2015; 2:ofv099. [PMID: 26258156 PMCID: PMC4525012 DOI: 10.1093/ofid/ofv099] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 06/26/2015] [Indexed: 11/12/2022] Open
Abstract
Invasive fusariosis is an aggressive fungal disease among immunocompromised patients. Mortality remains high in the voriconazole era. Combination therapy should be studied systematically for fusariosis. Background. Invasive fusariosis remains an aggressive, albeit infrequent infection in immunocompromised patients. Methods. We identified all cases of invasive fusariosis between January 2002 and December 2014. We recorded patient characteristics including clinical presentation, treatment, and outcomes at 6 and 12 weeks after diagnosis, as well as species identification and antifungal drug susceptibilities. Results. Fifteen patients were diagnosed with proven (12, 80%) or probable (3, 20%) fusariosis. Median age was 60 years (range, 26–78), and 10 patients were male. Underlying conditions included hematological malignancies (13, 87%), juvenile idiopathic arthritis (1, 7%), and third-degree burns (1, 7%). Five patients underwent hematopoietic stem-cell transplantation before diagnosis. Six patients (40%) received systemic glucocorticoids, and 11 patients (73%) had prolonged neutropenia at the time of diagnosis. Clinical presentations included the following: skin/soft tissue infection (8, 53%), febrile neutropenia (4, 27%), respiratory tract infection (2, 13%), and septic arthritis (1, 7%). Twelve patients were treated with voriconazole: 6 (40%) with voriconazole alone, 4 (27%) with voriconazole and terbinafine, and 2 (13%) with voriconazole, terbinafine, and amphotericin. One patient (7%) was treated with terbinafine alone, and another with micafungin alone. Four patients underwent surgical debridement (4, 27%). Susceptibility testing was performed on 9 isolates; 8 demonstrated voriconazole minimum inhibitory concentrations ≥4 µg/mL. The cumulative probability of survival was 66.7% and 53.3% at 6 and 12 weeks after diagnosis. Conclusions. Mortality associated with invasive fusariosis remains high. Cumulative mortality at our center was lower than previous reports despite elevated voriconazole minimum inhibitory concentrations. Combination therapy should be studied systematically for fusariosis.
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Affiliation(s)
| | - Sarah P Hammond
- Brigham and Women's Hospital ; Harvard Medical School ; Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Deanna A Sutton
- Fungus Testing Laboratory , University of Texas Health Science Center , San Antonio, Texas
| | | | - Francisco M Marty
- Brigham and Women's Hospital ; Harvard Medical School ; Dana-Farber Cancer Institute , Boston, Massachusetts
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