Revision and Update of the Consensus Definitions of Invasive Fungal Disease From the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium

The cyclase-associated protein contributes to antifungal susceptibility and virulence in Aspergillus fumigatus

Aspergillus fumigatus is the most prevalent pathogenic mould that contributes to high morbidity and mortality in immunocompromised patients. Here, we characterized the functions of the cyclase-associated protein (CAP) in A. fumigatus. To study the role of CAP in virulence and antifungal susceptibility of A. fumigatus, CAP gene knockout strain (ΔCAP) and complemented strain (R-ΔCAP) were constructed. ΔCAP showed a reduced growth rate, abnormal hyphal development, and increased susceptibility to cell wall-perturbing agents (Congo red, calcofluor white, and SDS), oxidative stress-inducing agents (H2O2 and menadione), calcineurin inhibitors (FK506 and CsA), and voriconazole (VRC) and itraconazole. Transcriptome analysis revealed that differentially expressed genes responsible for regulating growth, hyphal development, cell wall synthesis, stress responses and antifungal susceptibility were identified in ΔCAP. To identify CAP-interacting proteins, an A. fumigatus strain expressing the CAP protein fused with a C-terminus 6×his tag was constructed and designated Afcap6his. After extracting Afcap6his and Af293 proteins, actin and adenylate cyclase were identified by coimmunoprecipitation (co-IP) and liquid chromatography-tandem mass spectrometry (LC-MS/MS). Additionally, ΔCAP showed downregulated actin expression, AC-cAMP-PKA pathway activity and efflux pump genes (AfuMDR1, AfuMDR2, AfuMDR3, AfuMDR4, and cdr1B) expression as well as increased calcineurin activity. By using an invasive pulmonary aspergillosis (IPA) murine model, ΔCAP exhibited attenuated virulence and increased VRC therapeutic efficiency. Thus, CAP plays an important role in regulating antifungal susceptibility and virulence of A. fumigatus.

A case report of disseminated aspergillosis in an immunocompetent patient proven by choroid plexus biopsy

We present a case of disseminated aspergillosis diagnosed by choroid plexus biopsy in an immunocompeten 69-year-old male with decreased consciousness and a fever for more than three months. Brain magnetic resonance imaging showed ventriculitis and phlegmon in the paravertebral space. Chest computerized tomography revealed an air-crescent lesion in the upper lobe of the left lung. No microorganism was identified from the blood or CSF cultures. A choroid plexus biopsy was performed and the pathology findings were consistent with fungal abscess caused by invasive aspergillosis. Since disseminated aspergillosis in the immunocompetent patient is very rare, it was difficult to diagnose this invasive fungal infection in this case. Because the choroid plexus has many blood vessels, there is a high risk of bleeding during biopsy. This was a case in which adequate suspicion and an aggressive diagnostic approach were helpful in the management of a patient with an invasive fungal infection.

Evaluation of PERFORMANCE of the IMMY and Dynamiker Aspergillus Galactomannan lateral flow assays for the diagnosis of invasive Aspergillosis

Current laboratory diagnostic techniques for invasive aspergillosis (IA), such as fungal cultures and enzyme immunoassay (EIA) for the galactomannan antigen (GM), are limited by their low sensitivity, labor-intensive nature, and prolonged processing times. Some lateral flow assays (LFAs) have been developed for the diagnosis of IA; however, clinical validation and comparative studies are lacking. This study assessed the diagnostic performance of two CE-marked GM-LFAs, IMMY-GM-LFA and QuicGM-LFA. This retrospective study comprised 44 bronchoalveolar lavage fluid (BALF) and 127 serum samples obtained from 137 patients, 17 (9.9 %) of whom had proven or probable IA categorized using the revised EORTC/MSG criteria, between September 2020 and March 2021. The correlation coefficient between the IMMY-GM-LFA and GM-EIA was 0.95, while that between the QuicGM-LFA and GM-EIA was 0.90. Both LFAs GM indexes were significantly higher among those with proven/probable IA versus those with no IA and possible IA cases (BALF: 7.92 vs 0.18 and 14.05 vs 0.33; serum: 1.86 vs 0.26 and 5.75 vs 0.38 by IMMY and QuicGM-LFA, respectively. All p<0.05). In BALF samples, the area under the curve (AUC) for IMMY-GM-LFA and QuicGM-LFA were 0.93 and 0.96, respectively, with optimized GM cut-offs established at 1.2 for IMMY-GM-LFA and 0.78 for QuicGM-LFA. In serum samples, the AUC for IMMY-GM-LFA was 1.0, and for QuicGM-LFA was 0.9, with optimized cut-offs of 0.7 and 0.76, respectively. In conclusion, this study demonstrated that IMMY-GM and QuicGM-LFAs offer comparable alternatives to the Bio-Rad GM-EIA when testing BALF and serum samples with optimized thresholds.

Liposomal amphotericin B prophylaxis in paediatrics: a systematic review

BACKGROUND

Liposomal amphotericin B (LAmB) is widely used for prophylaxis in paediatric patients at high risk of invasive fungal diseases (IFD) but its use is off-label and there is significant variability in dosage and frequency. This systematic review was conducted to evaluate the published data on prophylactic LAmB use in the paediatric population and to present the reported proportions of breakthrough IFD and the associated toxicity profile.

METHODS

EMBASE, Medline, Web of Science and the Cochrane Database were systematically searched for primary research reporting on the use of LAmB as prophylaxis for IFD in the paediatric population up to 7 December 2023, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Twenty studies, comprising three clinical trials, 12 cohort studies, two point-prevalence surveys and three pharmacokinetic (PK) studies, with 2015 patients were included. A total of 717 cases presented individual patient data. Breakthrough IFD occurred in 7.2% (49/676). The most recognized side effects were hypokalaemia in 23.2% (125/538) and derangement of liver function tests in 15.0% (49/327). Discontinuation due to toxicity occurred in 6.0% (30/503) of patients. Of the four studies reporting PK data, two examined serum levels of LAmB, one analysed CSF levels and the remaining study peritoneal levels.

CONCLUSIONS

Despite widespread use of prophylactic LAmB, this systematic review highlights the paucity of paediatric data supporting its use. The heterogeneity observed in populations, dosing regimens and study design prevents conclusions being reached on its efficacy or the superiority of one dosing regimen. Overall, there is a clear need for further high-quality robust clinical data and targeted PK studies.

A Global Analysis of Cases of Mucormycosis Recorded in the European Confederation of Medical Mycology / International Society for Human and Animal Mycology (ECMM / ISHAM) Zygomyco.net Registry from 2009 to 2022

We analyzed mucormycosis data from the Zygomyco.net registry (2009-2022), encompassing cases from 16 countries. India, Russia and the Czech Republic provided the largest contributions. India reported the highest case number, consistent with its substantially higher incidence compared to that of high-income countries. Among the 382 patients with mucormycosis, 236 (61.8%) were male (male-to-female ratio 1.6). The median age was 48 years [interquartile range (IQR) 32-60]. There were 59 pediatric patients (median age ranging from < 1 month to 19 years). Diabetes mellitus type 2 was the most common underlying condition (39%), with significant geographic variation (> 70% of cases in India and Iran but only 6.9% in Europe). Hematologic malignancies (HM, 31.4%), the second most common underlying condition, were absent in India and Iran. The primary clinical presentations were rhino-orbito-cerebral mucormycosis (ROCM, 36.6%), pulmonary (33.2%) and cutaneous mucormycosis (17.5%). Patients with diabetes mellitus typically developed ROCM (55.9%), while pulmonary infections were more common in those with HM or hematopoietic cell transplantation (HCT) (47.5%, p < 0.001). Rhizopus was the leading fungal genus (58%), followed by Lichtheimia (13.7%) and Mucor (7%), with regional variations. Pulmonary infections in HM patients were linked to L. corymbifera and R. microsporus, while Apophysomyces spp. and Saksenaea spp. were more frequent in Indian healthcare-associated cutaneous cases. Concomitant infections were observed in 8.7% of patients with HM, complicating diagnosis and treatment. In most of them (57.1%), Aspergillus spp. was involved. Improved diagnostic practices, including direct microscopy and cultures, showed higher positivity rates, although PCR remained underutilized. Antifungal therapy, primarily with an amphotericin B formulation, combined with surgery, was the most common therapeutic approach. Overall mortality was high (47.8%), particularly in disseminated or advanced ROCM cases. Multivariable analysis identified older age, advanced ROCM, and HM/HCT as independent mortality risk factors (p < 0.05); whereas localized sinusitis and combined medical and surgical therapy were independently associated with improved outcomes (p < 0.006). This study underscores regional disparities in the mucormycosis epidemiology and species distribution. Improved early detection is needed, particularly in immunocompromised populations with HM. Enhanced surveillance and tailored public health strategies are crucial to address this ongoing global health threat.

Characteristics and Clinical Significance of Gut Microbiota in Patients with Invasive Pulmonary Aspergillosis

Gut microbiota acts on the lungs through the gut-lung axis and play an important role in lung diseases. However, there are no reports on the gut microbiota characteristics in patients with invasive pulmonary aspergillosis (IPA). We aimed to analyze changes in gut microbiota in IPA patients, correlate these changes with clinical indicators and disease prognosis, and explore the application value of these characteristic changes in diagnosing IPA. The objective was to provide a theoretical basis for preventing and treating individual immunity. We conducted metagenomic next-generation sequencing of fecal samples from 43 patients with IPA and 31 healthy controls to analyze changes in the gut microbiota of these patients. We also built a random forest model for diagnosing IPA based on the gut microbiota. Compared to healthy controls, IPA patients showed a decrease in gut microbiota diversity and metabolic levels. Changes in the microbiota were characterized by a significant reduction in anti-inflammatory species that produce short-chain fatty acids, such as Faecalibacterium, Blautia, Roseburia, Phocaeicola, and Bacteroides. In contrast, opportunistic pathogens, such as Enterococcus, Corynebacterium, Escherichia, Staphylococcus, Haemophilus, and Finegoldia, were significantly enriched. The classification model based on Clostridium fessum, Blautia wexlerae, Streptococcus pseudopneumoniae, Corynebacterium striatum, and Faecalibacterium prausnitzii showed high value in distinguishing patients with IPA from healthy controls. Patients with IPA exhibit gut microbiota imbalance. The gut microbiota can serve as a biomarker that helps in diagnosing IPA. Our findings support the potential use of gut microbiota as a target for IPA prevention and treatment.

Computed tomography for the diagnosis of HIV-associated gastro-intestinal histoplasmosis

INTRODUCTION

Disseminated histoplasmosis is one of the leading opportunistic infections among people living with human immunodeficiency virus (PLHIV) in Latin America. Intestinal involvement is common, but its computed tomography findings have not been properly described. We aimed to provide a computed tomography description of histoplasmosis intestinal involvement.

PATIENTS AND METHODS

We performed a retrospective observational study of patients with disseminated histoplasmosis and proven intestinal involvement.

RESULTS

A total of 18 patients with an available contrast-enhanced abdominal computed tomography (8 women, mean age 44 years) were included. Seventeen had intestinal parietal thickening (94 %), with a mean thickening of 14 mm, unifocal or multifocal, frequently circumferential (71 %). The most commonly affected segments were the cecum and right colon in 13/17 (76 %) of patients each. Adenomegaly was constant, mostly homogeneous.

CONCLUSION

These computed tomography features in patients with advanced HIV disease may be key findings for an early diagnosis in the absence of proven histoplasmosis.

Duration of systemic antifungal therapy for patients with invasive fungal diseases: A reassessment

Invasive fungal diseases are associated with significant morbidity and mortality, especially among immunocompromised patients, and often prompt for rapid and aggressive treatment aiming cure. Due to the expanding magnitude of patients burdened by chronic immunosuppression and affected by fungal diseases, the diversity of clinical settings has risen. This often results in prolonged therapy (induction, consolidation and maintenance) associated with potentially severe side effects, and clinicians face the challenging decisions of when and how to stop anti-fungal therapy. Adequate duration of therapy is poorly defined, hampered by the lack of dedicated trials to the question, the heterogeneity of cases (type of fungal pathogen, localization of infection, underlying host conditions) and various confounding factors that may influence the clinical response (e.g. persistence vs recovery of immunosuppression, impact of surgery). In this review, we aim to evaluate the existing data underlying the guidelines and recommendations of treatment duration for the most frequent invasive fungal diseases (cryptococcal meningitis, Pneumocystis pneumonia, invasive aspergillosis, invasive candidiasis and mucormycosis), as well as specific localizations of deep-seated diseases (osteo-articular or central nervous system diseases and endocarditis) and emerging considerations and strategies.

Incidence of Coronavirus Disease 2019-Associated Pulmonary Aspergillosis and Specialist Involvement in Its Diagnosis in Japan: A Nationwide Survey and Literature Review

BACKGROUND

Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) has been reported worldwide. However, studies in Japan are limited, and no study has evaluated the relationship between the incidence of CAPA and specialist involvement in its diagnosis.

OBJECTIVES

We aimed to obtain new epidemiological data on CAPA in Japan and evaluate the relationship between the incidence of CAPA and specialist involvement in its diagnosis.

METHODS

A survey was conducted among chief physicians at 760 training hospitals with at least 100 beds and accredited by the Japanese Respiratory Society or the Japanese Association for Infectious Diseases. Critical patients with COVID-19 diagnosed with CAPA between 1 January 2020 and 31 August 2023 were analysed. A literature review was conducted to evaluate the correlations between the incidence of CAPA and galactomannan (GM) testing and positivity rates.

RESULTS

Responses were obtained from 221 of the 760 hospitals (29.1%). The incidence of CAPA was 0.67% (69/10,276). Hospitals with patients with CAPA had significantly more pulmonologists and infectious disease specialists than those without patients with CAPA. A strong positive correlation was observed between the incidence of CAPA and the number of pulmonologists per critical patient with COVID-19 (r = 0.824, p < 0.001). The literature review showed that bronchoalveolar lavage fluid GM testing rate was a strong positive correlation with the incidence of CAPA (r = 0.527, p = 0.014).

CONCLUSIONS

For the diagnosis of CAPA, its recognition by specialists primarily involved in managing critical patients with COVID-19 seems essential.

Mechanism-Based Pharmacokinetic/Pharmacodynamic Model of Voriconazole for Predicting the Clinical Outcomes of Adult Patients With Invasive Aspergillosis

BACKGROUND

Voriconazole is the first-line therapy for invasive aspergillosis (IA). To determine the minimum inhibitory concentration of Aspergillus, a voriconazole pharmacokinetic-pharmacodynamic (PK-PD) model linked to galactomannan response was developed and evaluated, and its clinical correlation for IA treatment was elucidated.

METHODS

Adult patients with probable or definite IA and at least one serum voriconazole measurement were included. A two-compartment voriconazole PK model was linked to a previously described PD model of galactomannan response. PK and PD parameters were estimated using a nonparametric adaptive grid technique. The relationship between the ratio of voriconazole exposure that induced half-maximum galactomannan response (EC50) and the observed terminal galactomannan concentration was evaluated. The factors associated with the PK-PD parameters and mortality were also determined.

RESULTS

Between January 2013 and December 2022, 41 patients were prescribed voriconazole for IA. The 30-day mortality rate was 17%. A high correlation was found for the observed-predicted Bayesian posterior estimates of voriconazole and galactomannan levels. Moreover, a nonlinear relationship was identified between AUC:EC50 and terminal galactomannan. The factors associated with higher AUC:EC50 were intravenous administration and intubation. In the survival analysis, higher EC50 tended to be associated with mortality, higher AUC was significantly associated with increased mortality, and higher AUC:EC50 tended to be associated with higher mortality. After adjusting for the intravenous route, higher AUC and AUC:EC50 were not associated with mortality.

CONCLUSIONS

Individual EC50 estimation can provide insights into in vivo host and organism responses. Elevated EC50 showed comparable and unfavorable trends to higher minimum inhibitory concentration. Thus, determining EC50 might help guide individualized target serum voriconazole levels.

Global, Regional, and National Burden of Pulmonary Fungal Infections 1990-2021

Rationale: The lungs are the most prevalent site for invasive fungal infections, and the diagnosis and treatment of pulmonary fungal infections (PFIs) pose significant challenges, accompanied by a substantial disease burden. Global factors will likely enhance the risk of PFIs in the future. Assessing the global burden of PFIs is crucial for implementing appropriate measures for prevention and control. Objectives: To evaluate the burden of PFIs at the global, regional, and national levels from 1990 to 2021 and make projections for 2044. Methods: Data on deaths and disability-adjusted life years due to PFIs were extracted from the Global Burden of Disease database. Linear regression, complex inequality measures, and the Nordpred model were used for analysis and visualization. Measurements and Main Results: In 2021, the global incidence of PFIs was estimated at 5.62 million cases (95% uncertainty interval [UI], 4.93 to 6.40 million), with 45,542 deaths (95% UI, 39,299 to 51,944). The age-standardized mortality rate was 0.56 per 100,000 (95% UI, 0.48 to 0.64 per 100,000). From 1990 to 2021, the estimated annual percentage change was -1.03% (95% confidence interval, -1.13% to -0.93%), with an observed increase in mortality rates in low- and middle-income countries. The mortality rate significantly increased among individuals aged ⩾50 years. By 2044, more than 87,000 deaths are expected from PFIs, at a rate of about 0.58 per 100,000. Conclusions: PFIs represent a significant global challenge that warrants attention and necessitates international collaboration to collectively address this issue.

Viral and Fungal Infections Early After HLA-Mismatched Hematopoietic Stem Cell Transplantation Using Low-Dose Antithymocyte Globulin in High-Risk Patients With Hematological Malignancies Not in Remission

BACKGROUND

In vivo T-cell depletion with antithymocyte globulin (ATG), especially at high-doses has been shown to be associated with increased incidence of infections after allogeneic hematopoietic stem cell transplantation (HSCT). However, it remains unclear whether ATG, even at low-doses increases the risk of posttransplant infections in the high-risk HSCT setting.

PATIENTS AND METHODS

We conducted a single-center retrospective study of viral and fungal infections early after transplantation, using the data from 82 patients with hematological malignancies. Among them, 42 underwent HLA-mismatched HSCT using low-dose (2.5 mg/kg n = 41, 2.0 mg/kg n = 1) thymoglobulin (ATG patients), and 40 control patients received HSCT without ATG (non-ATG patients) during the same period. Cord blood transplantation patients were excluded. All ATG patients had hematological malignancies not in remission at the time of transplantation, and were considered to be at high-risk for posttransplant infections.

RESULTS

There were no appreciable between-group differences in the incidence of clinically significant cytomegalovirus infection (csCMVi), late-onset CMV reactivation after discontinuation of letermovir, invasive fungal diseases or Epstein-Barr virus (EBV)-associated posttransplant lymphoproliferative disease. Peak values of CMV antigenemia were almost equal in ATG and non-ATG patients. The prevention of csCMVi with letermovir was constant in the 2 groups. However, ATG patients showed earlier reactivation of CMV and higher incidence of EBV viremia than non-ATG patients. Among their underlying diseases, mature T-cell neoplasm was a significant risk factor for CMV/EBV reactivation.

CONCLUSION

The use of low-dose thymoglobulin in HLA-mismatched HSCT for nonremission hematological malignancies is a reasonable strategy under careful monitoring for viral reactivation.

Invasive fungal infection caused by Magnusiomyces capitatus in a pediatric patient with Burkitt lymphoma: Case report and review of literature

INTRODUCTION

invasive fungal infection is a serious problem in immunosuppressed patients, particularly those with hematological or oncological diseases. Recently, more cases of emerging pathogens, such as Magnusiomyces capitatus, have been reported.

CLINICAL CASE

a 4-year-old male diagnosed with stage IV sphenoidal Burkitt lymphoma, undergoing immunosuppressive treatment and with severe neutropenia, developed sepsis of abdominal origin, requiring admission to the Intensive Care Unit. He received empirical antibiotic and antifungal therapy, with isolation of M. capitatus in blood cultures and peritoneal fluid. Despite adjusting antifungal therapy, the patient died 15 days after due to the progression of the invasive fungal infection.

DISCUSSION

M. capitatus infections are reported more frequently in immunocompromised patients. A review of pediatric cases published in the literature identified a total of 16 cases (8 males and 8 females, median age 6 years). Most cases had an underlying hemato-oncological disease and were in an immunosuppressed state. In contradistinction to what is observed in adults, only three cases (18.8 %) had received antifungal prophylaxis. M. capitatus is a dimorphic yeast that is intrinsically resistant to echinocandins and has a significant mortality rate, both in studied series and in ours (50 %).

CONCLUSIONS

a rapid and accurate diagnosis of M. capitatus infection is essential to control invasive fungal infection, which could improve patient survival.

Post-surgical mediastinitis caused by Aspergillus calidoustus in a heart transplant recipient: A case report and review of the literature

Acute mediastinitis is a common infectious complication following heart transplant surgery. The etiology is typically bacterial, and the condition tends to have a favourable outcome with appropriate source control and antimicrobial treatment. Clinically, it often presents acutely, with early dehiscence of the surgical wound and systemic involvement, necessitating prompt surgical intervention. Fungal etiology is rare and usually associated with severely immunocompromised patients, conferring a dismal prognosis. Although most fungal infections are caused by Aspergillus fumigatus, the widespread use of azoles as prophylactic treatment has led to an increase in infections by unknown species and other azole-resistant fungi, posing a significant therapeutic challenge. We present the case of a 31-year-old heart transplant recipient who developed post-surgical mediastinitis due to Aspergillus calidoustus following a complicated postoperative course and humoral rejection. Despite appropriate antimicrobial therapy and source control, the infection progressed unfavourably.

A nationwide epidemiological survey of coronavirus disease 2019-associated pulmonary aspergillosis in Japan

BACKGROUND

Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a severe complication of COVID-19 with a poor prognosis. In this study, we aimed to analyze the nationwide epidemiology of CAPA in Japan.

METHODS

This nationwide retrospective study involved data of 98 patients with CAPA reported in 221 hospitals in Japan between January 2020 and August 2023, using both online and paper-based questionnaires. We investigated the clinical characteristics of CAPA, assessed outcomes using Kaplan-Meier curves, and identified independent predictors of 90-day mortality using Cox proportional hazards analysis.

RESULTS

The median age of the patients with CAPA was 71 years, and 71.4 % were men. The positivity rates for β-D-glucan and serum galactomannan antigen were 59.1 % and 68.4 %, respectively, while chest computed tomography revealed cavities in 25.5 % of patients. The 30-day and 90-day mortality rates were 50.0 % and 55.1 %, respectively. Kaplan-Meier analysis showed that the mortality rate of patients treated with echinocandin monotherapy was significantly higher than that of patients treated with other antifungals (log-rank test, p = 0.04). Multivariate analysis identified a neutrophil count of ≥10,000/μL (hazard ratio [HR]: 2.67, 95 % confidence interval [CI]: 1.49-4.89) and echinocandin monotherapy (HR: 2.06, 95 % CI: 1.01-3.93) as independent predictors of 90-day mortality. Patients treated with echinocandin monotherapy were older, and Aspergillus spp. was not isolated in half of these patients.

CONCLUSION

This study provides a comprehensive overview of CAPA in Japan. Appropriate antifungal therapy is essential to improve the prognosis of patients with CAPA.

Development and validation of a machine learning-based diagnostic model for identifying nonneutropenic invasive pulmonary aspergillosis in suspected patients: a multicenter cohort study

This study aims to develop and validate an optimized diagnostic model for nonneutropenic invasive pulmonary aspergillosis (IPA) among suspected cases. A cohort of 344 nonneutropenic suspected cases from 13 medical centers (August 2020 to February 2024) was analyzed. The cohort was divided into a training data set (70%) and a testing data set (30%) using stratified sampling based on the IPA diagnosis. Three machine learning models (a regularized logistic regression model, a support vector machine model, and a weighted ensemble model) were developed. SHapley Additive explanation (SHAP) method was used for model interpretation. Six predictor variables were finally selected: sputum Aspergillus culture, Aspergillus-specific IgG, imaging feature of cavity, serum galactomannan, critical condition, and plasma pentraxin 3. The weighted ensemble model, exhibiting the significantly higher specificity of 95.1% in internal cross-validation and 95.7% in testing among the three models, was selected as the optimal prediction model despite comparable discrimination capacity, calibration ability, and clinical applicability across all models. The risk score derived from SHAP values showed a highly significant correlation with the predicted probability of the weighted ensemble model (Spearman ρ = 0.974), achieving an area under the curve of 0.857 in internal cross-validation and 0.871 in external testing. Using the optimal cut-off value of 3, the risk score demonstrated sensitivity (68.8%) and specificity (87.5%) comparable to those of bronchoalveolar lavage fluid galactomannan (cut-off = 1.0). The diagnostic model and risk score could assist in identifying nonneutropenic IPA from suspected cases independently of invasive procedures, thereby enhancing clinical applicability.

IMPORTANCE

Although clinicians can screen out suspected cases through medical history inquiries, the diagnosis of nonneutropenic invasive pulmonary aspergillosis (IPA) from suspected cases remains a significant challenge. The study developed a novel diagnostic framework by integrating clinical parameters, imaging features, and laboratory biomarkers using machine learning techniques. The risk score, derived from SHapley Additive explanation values, exhibited a highly significant correlation with the predicted probability of the weighted ensemble model, demonstrating robust discrimination capacity and generalizability. The diagnostic model and risk score could assist in identifying nonneutropenic IPA from suspected cases independently of invasive procedures, thereby enhancing clinical applicability.

Disseminated Cunninghamella bertholletiae Infection From Latent Lower Limb Mass After Kidney Transplant: A Case Report

BACKGROUND

Cunninghamella bertholletiae (C. bertholletiae), a rare yet highly virulent species within the Mucorales order, predominantly affects individuals with compromised immune systems. Disseminated infections caused by this pathogen frequently lead to severe complications, underscoring the necessity for prompt diagnosis and aggressive therapeutic interventions. Invasive fungal diseases (IFDs) continue to be a major cause of morbidity and mortality among kidney transplant recipients, characterized by elevated incidence and mortality rates. The early and precise identification of fungal pathogens is crucial for optimizing patient outcomes.

CASE PRESENTATION

This report presents a case study of a 37-year-old male kidney transplant recipient who developed a disseminated C. bertholletiae infection from a latent lower limb lesion. Initially, he showed symptoms of high fever and dyspnea, leading to diagnoses of sepsis, severe pneumonia, acute respiratory distress syndrome, and allograft dysfunction. After surgery, he had recurrent pleural effusion and worsening pulmonary nodules. Metagenomic next-generation sequencing (mNGS) confirmed C. bertholletiae infection, and histopathology revealed mucormycosis with vascular invasion, thrombosis, and tissue necrosis. The patient underwent a 13-month antifungal treatment with amphotericin B lipid complex, posaconazole, and isavuconazole.

CONCLUSION

This case highlights the essential role of histopathology and mNGS in early detection of rare IFDs and stresses the need for a multidisciplinary approach combining surgery with antifungal therapy. The effective management of disseminated C. bertholletiae infection using a triple antifungal regimen offers important insights for future cases, underscoring the importance of early diagnosis and personalized treatment in immunocompromised patients.

Allogeneic hematopoietic cell transplantation with a combination of posttransplantation bendamustine and cyclophosphamide in refractory myeloid neoplasms

BACKGROUND

Prognosis after salvage allogeneic hematopoietic cell transplantation (HCT) in refractory myeloid malignant diseases is poor with no standard of care.

METHODS

A prospective single-arm study was conducted to evaluate if a combination of posttransplantation bendamustine and cyclophosphamide (PTBCy) facilitates augmented graft-vs-leukemia effect in this group of patients. The prospective study (NCT04943757) of HCT from all types of donors enrolled 50 patients with refractory myeloid neoplasms.

RESULTS

Cumulative incidence of engraftment was 88%; 76% had no measurable residual disease. Immune toxicity in the form of cytokine release syndrome was observed in 30%. Cumulative incidence of acute graft-vs-host disease (GVHD) Grade 2 through 4 was 20%. Cumulative incidence of moderate and severe chronic GVHD was 34%. Nonrelapse mortality was 20%. Relapse incidence was 62%, but median time to relapse was 245 days. Overall survival was 33% and event-free survival was 22%. In the multivariate analysis of event-free survival alternative donor (hazard ratio, 0.24; 95% CI, 0.11-0.52) and adverse genetic features (hazard ratio, 2.48; 95% CI, 1.26-4.88) were significant. PTBCy regimen was associated with unique immune reconstitution pattern with high levels of CD8+ effector memory T cells, PD-1L-positive monocytes, and granulocytes.

CONCLUSIONS

PTBCy GVHD prophylaxis is a promising approach for refractory myeloid neoplasms, which delays relapse after HCT and opens the window for posttransplant prophylaxis.

Retrospective Analysis of Fungal Isolations in Patients on Veno-Venous Extracorporeal Membrane Oxygenation: The Multicenter RANGER STUDY 2.0

Background: Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a progressively adopted life-sustaining intervention worldwide, particularly in the management of acute respiratory distress syndrome. Nevertheless, data concerning the prognostic significance of fungal isolation in this setting remain unclear. This study aims (i) to assess the incidence of fungal infection and colonization in a homogeneous cohort of V-V ECMO patients, and (ii) to evaluate the association between fungal infection or colonization and 1-year mortality, with a focus on the impact of specific fungal species. Methods: All consecutive adults admitted to the Intensive Care Units of five Italian university-affiliated hospitals and requiring V-V ECMO were screened. Exclusion criteria were age < 18 years, pregnancy, veno-arterial or mixed ECMO-configuration, incomplete records and survival < 24 h after V-V ECMO placement. A standard protocol of microbiological surveillance was applied and the distinction between different fungal species were made through in vivo and vitro tests. Cox-proportional hazards models, Kaplan-Meier curves and linear logistic regressions were applied for investigating mortality. Results: Two-hundred and seventy-nine V-V ECMO patients (72% male) were enrolled. The overall fungal isolation was 41% (n. 114): 23% infections and 18% colonizations. The overall 1-year mortality, among fungal isolations, was 40%, with no different risk in case of fungal infection (26 out of 63, 41%) (aHR 0.85, 95% CI [0.53-1.37], p-value 0.505) and colonization (20 out of 51, 39%) (aHR 0.86, 95%CI [0.51-1.43], p-value 0.556), as compared to patients never detecting fungi (68 out of 165, 41%, reference). According to the isolated mycotic species, as compared to Candida sp. group (reference), the risk of death was greater when different fungal species (e.g., Aspergillus sp. and Candida sp.) were concomitantly isolated in the same patient (OR 1.17, 95%CI [1.12-11.07], p-value 0.031. Conclusions: In the overall population, 23% V-V ECMO patients recorded 'late' fungal infections and 18% fungal colonizations, with a similar risk of death as compared to patients never experiencing fungi during the V-V ECMO course. The detection of concomitant different fungal species was an independent risk factor for 1-year mortality.

Efficacy and Safety of Amphotericin B Colloidal Dispersion for Patients with Invasive Fungal Disease and Febrile Neutropenia: A Registry-Based, Multicenter, Retrospective, Real-World Study

Purpose

This study aimed to explore the efficacy and safety of amphotericin B colloidal dispersion (ABCD) in treating patients with invasive fungal disease (IFD) or febrile neutropenia.

Patients and Methods

This study retrospectively included patients diagnosed with IFD or febrile neutropenia who received ABCD treatment from 22 hospitals. The efficacy and safety were evaluated at the end of ABCD treatment. The characteristics of patients diagnosed with possible, probable and proven IFD according to the revised EORTC-MSG criteria were then further analyzed to conduct sensitivity analysis.

Results

A total of 503 patients were enrolled in this study. Of these patients, 391 received ABCD treatment for a minimum of seven days, and the overall efficacy of ABCD was determined to be 71.87% (281/391). 183 patients were diagnosed with possible, probable and proven IFD, the ABCD efficacy of whom was 67.76% (124/183). The efficacy of ABCD in patients with hematologic malignancies, AIDS and diabetes was 70.10% (211/301), 88.24% (30/34), and 83.33% (10/12), respectively. In terms of various fungal species, the efficacy of ABCD in patients with Aspergillus, Mucorales and Candida infections was 62.96% (34/54), 80.49% (33/41) and 66.67% (22/33), respectively. For patients in the targeted therapy, diagnostic-driven therapy, and empirical therapy groups, the efficacy of ABCD was 76.92% (60/78), 70.17% (207/295), and 77.78% (14/18), respectively. The most common adverse events (AEs) were infusion reactions (30.22%, 152/503) and hypokalemia (38.97%, 196/503), with the majority of these AEs classified as grade 1-2. This study was registered with ClinicalTrials.gov, NCT05116059.

Conclusion

ABCD has demonstrated satisfactory therapeutic efficacy and safety in the treatment of IFD or febrile neutropenia.

Outcomes of Invasive Aspergillosis in Liver Transplant Recipients From an Institution Using Targeted Antifungal Prophylaxis and an Antifungal Stewardship Program

BACKGROUND

Recent evidence suggests liver transplant recipients (LiTRs) with invasive aspergillosis (IA) have lower rates of dissemination and mortality compared to historical data. However, contemporary data from other centers remain scarce. We aimed to evaluate modern IA outcomes at our institution, where targeted perioperative echinocandin prophylaxis and an active antifungal stewardship program (AFSP) have been implemented.

METHODS

This is a single-center retrospective analysis of patients who underwent liver transplantation between January 1, 2017 and June 30, 2022. During the study period, targeted anidulafungin perioperative prophylaxis was administered to patients considered high-risk for invasive fungal infection (IFI), and a multidisciplinary AFSP assisted with IFI diagnosis and management. Patients with proven and probable IA diagnosed post-operatively were identified using internationally accepted definitions. The primary outcomes were IA dissemination and 1-year all-cause mortality rates. Data were extracted from the electronic medical record and descriptive summary statistics were performed.

RESULTS

Six patients (6/377, 1.6%) met the inclusion criteria. Patients with IA were significantly more likely to be colonized with multidrug-resistant Gram-negative organisms compared to those without IA (50.0% vs. 12.1%, p = 0.006). The median time to IA diagnosis was 22 days post-transplant (IQR 5-109). No cases of dissemination were observed. One-year all-cause mortality was 16.7%.

CONCLUSION

Consistent with contemporary data, LiTRs had lower IA dissemination and mortality rates compared to earlier studies. These improved outcomes likely reflect a combination of modern advancements in liver transplantation, and we highlight two potentially modifiable interventions; targeted echinocandin prophylaxis and an AFSP. Further studies are needed to support their broader implementation.

Predictive nomogram for early detection of invasive fungal disease deterioration --- a 10-year retrospective cohort study

BACKGROUND

Invasive fungal disease (IFD) is characterized by its capacity to rapidly escalate to life-threatening conditions, even when patients are hospitalized. However, the precise prognostic significance of baseline clinical characteristics related to the progression outcome of IFD remains elusive.

METHODS

A retrospective cohort study spanning a duration of 10 years was conducted at two prominent tertiary teaching hospitals in Southern China. Patients with proven IFD were queried and divided into serious and non-serious groups based on the disease deterioration. To establish robust predictive models, patients from the first hospital were randomly assigned to either a training set or an internal validation set, while patients from the second hospital constituted an external test set. To analyze the potential predictors of IFD deterioration and identify independent predictors, the study employed the least absolute shrinkage and selection operator (LASSO) method in conjunction with binary logistic regressions. Based on the outcomes of this analysis, a predictive nomogram was constructed. The performance of the developed model was thoroughly evaluated using the training set, internal validation set, and external test set.

RESULTS

A total of 480 cases from the first hospital and 256 cases from the second hospital were included in the study. Among the 480 patients, 81 cases (16.9%) experienced deterioration, and out of those, 45 (55.6%) cases resulted in mortality. Seven independent predictors were identified and utilized to construct a predictive nomogram. The nomogram exhibited excellent predictive performance in all three sets: the training set, internal validation set, and external test set. The area under the receiver operating characteristic curve (AUC) for the training set was 0.88, for the internal validation set was 0.91, and for the external test set was 0.90. The Hosmer-Lemeshow test and Brier score indicated a high goodness of fit for the model. Furthermore, the calibration curve demonstrated a strong agreement between the predicted outcomes from the nomogram and the actual observations. Additionally, the decision curve analysis exhibited that the nomogram provided significant clinical net benefits in predicting IFD deterioration.

CONCLUSIONS

The study successfully identified seven independent predictors and developed a predictive nomogram for early assessment of the likelihood of IFD deterioration.

Quality improvement project to reduce beta-D-glucan turnaround times in an NHS pathology network

Beta-D-glucan (BDG) is a cell wall component of many fungi, detecting this in patients' serum permits early diagnosis of invasive fungal infections, particularly in patients with haematological malignancy. In critically ill patients in an intensive-care unit, where the prevalence of invasive fungal infection is lower, the high negative predictive value of BDG facilitates withholding or discontinuation of empirical antifungal therapy, contributing to antifungal stewardship. However, for the results of BDG testing to impact patient management, they need to be available within a clinically useful timeframe.The South West London Pathology (SWLP) network routinely sent samples for BDG testing from hospital trusts in our area to the UK Health Security Agency Mycology Reference Laboratory (MRL) at Bristol for analysis. In 2021, the mean turnaround time (TAT) was more than two times the 5-working-days standard stated in the SWLP user handbook. In this quality improvement project (QIP), we identified that the greatest delay was the MRL posting hardcopy reports. We investigated electronic reporting, first for all patient samples, and then only for intensive-care patients. However, we found that information technology (IT) and staffing limitations meant this was not viable.We then investigated commercial solutions and identified an innovative assay, which enabled the implementation of in-house BDG testing that was a good fit with our available staffing resource and laboratory environment. Our aim was to achieve at least 90% of BDG results authorised within 5 working days of sample receipt. Our QIP improved performance on this from 0.88% to 92.8% and reduced the mean TAT from 11.6 to 2.5 days and at lower unit cost. The change has been well received by our laboratory staff, and our pathology operational leads have had very positive feedback from our clinical teams and our antifungal steward.

Aspergillus fumigatus biology, immunopathogenicity and drug resistance

Aspergillus fumigatus is a saprophytic fungus prevalent in the environment and capable of causing severe invasive infection in humans. This organism can use strategies such as molecule masking, immune response manipulation and gene expression alteration to evade host defences. Understanding these mechanisms is essential for developing effective diagnostics and therapies to improve patient outcomes in Aspergillus-related diseases. In this Review, we explore the biology and pathogenesis of A. fumigatus in the context of host biology and disease, highlighting virus-associated pulmonary aspergillosis, a newly identified condition that arises in patients with severe pulmonary viral infections. In the post-pandemic landscape, in which immunotherapy is gaining attention for managing severe infections, we examine the host immune responses that are critical for controlling invasive aspergillosis and how A. fumigatus circumvents these defences. Additionally, we address the emerging issue of azole resistance in A. fumigatus, emphasizing the urgent need for greater understanding in an era marked by increasing antimicrobial resistance. This Review provides timely insights necessary for developing new immunotherapeutic strategies against invasive aspergillosis.

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

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

Alternaria Invasive Infection in Children With Hemato-Oncological Disease: A National Multicenter Report

Invasive fungal diseases significantly impact hemato-oncology pediatric patients, with Aspergillus and Candida being the primary culprits. However, pediatric Alternaria infections remain understudied. This study aims to characterize Alternaria infections in pediatric hemato-oncology cases nationwide. This retrospective multicenter observational study reviewed medical records from Israel's 5 largest tertiary pediatric centers between 2011 and 2023. We identified 22 patients aged 4 to 18 years with invasive Alternaria infection. Predominant diagnoses were acute lymphoid leukemia (55%) and acute myeloid leukemia (23%), with 86% presenting neutropenic fever. Alternaria infections manifested as invasive rhinosinusitis (77%), skin lesions resembling ecthyma (14%), and pulmonary infection (9%). Notably, 76% of sinusitis cases exhibited suggestive symptoms. Voriconazole treatment led to a 90% recovery rate, irrespective of surgery. Two fatalities were unrelated to the infections. This study, the largest on Alternaria infections in children, emphasizes their occurrence in leukemia patients with neutropenic fever, showcasing common clinical presentations and a favorable prognosis despite underlying diseases.

A Predictive Model for Diagnosis of Acute Invasive Fungal Rhinosinusitis Among High-Risk Patients

BackgroundAcute invasive fungal rhinosinusitis (AIFR) is a life-threatening disease mainly affecting immunocompromised patients. Early detection is therefore key to improving patient survival. To date, there are still no standard clinical criteria for AIFR diagnosis.ObjectiveThis study develops a predictive model that utilizes clinical presentation and computed tomography (CT) findings to diagnose AIFR.MethodsA retrospective cohort study was conducted on patients with high risk for AIFR at King Chulalongkorn Memorial Hospital over the past 15 years (2008-2022). We constructed several multivariate logistic regression models for AIFR diagnosis based on different subsets of variables from 3 categories: signs/symptoms, endoscopy, and CT imaging.ResultsThere were 67 AIFR-positive patients and 68 AIFR-negative patients. Combining variables from 3 categories, a 6-variable model (fever, visual loss, mucosal discoloration, crusting, mucosal loss of contrast, retroantral fat stranding) achieved the highest area under the receiver operating characteristic curve of 0.8900 (74.63% sensitivity, 89.71% specificity).ConclusionsWe proposed predictive models for AIFR diagnosis in high-risk patients using clinical variables. The models can be used to guide the decision for further management such as biopsy or surgical intervention.

Lateral Flow Device Aspergillus Routine Testing for Invasive Pulmonary Aspergillosis in Patients Who Are Critically Ill: A Multicenter Intensive Care Unit Cohort Study

Background

The incidence of invasive pulmonary aspergillosis (IPA) is rising among intensive care unit (ICU) patients, with early diagnosis and treatment being critical for survival. Lateral flow assays for Aspergillus antigen detection have recently been introduced, enabling rapid results within an hour and potentially supporting earlier clinical decision making and timely antifungal therapy.

Methods

This retrospective multicenter study included 180 ICU patients, 48 with IPA and 132 controls, across 9 treatment centers. Fungal infections were classified according to the FUNDICU criteria (Invasive Fungal Diseases in Adult Patients in Intensive Care Unit).

Results

Among the 180 patients, 48 were classified as having probable IPA, while 132 exhibited host factors and radiologic findings consistent with IPA but did not meet the FUNDICU criteria. In this cohort, the sensitivity and specificity of the bronchoalveolar lavage lateral flow device test for diagnosing probable IPA vs no IPA were 71% (95% CI, 56%-83%) and 98% (94%-100%), respectively. The area under the receiver operating characteristic curve was 0.84, indicating good diagnostic performance. The positive and negative likelihood ratios were 31.17 (10.03-96.80) and 0.30 (.19-.46), yielding a diagnostic odds ratio of 104 (30-360). The positive and negative predictive values were 92% (78%-98%) and 90% (84%-95%).

Conclusions

Lateral flow device testing may serve as a valuable tool for the rapid diagnosis of IPA in time-critical ICU settings. However, it is not sufficient to definitively rule out the disease, and a comprehensive diagnostic approach remains essential.

Impact of Invasive Fungal Diseases on Treatment Outcomes in Pediatric Acute Lymphoblastic Leukemia and Lymphoblastic Lymphoma: Insights From a Single-Center Study

BACKGROUND AND AIMS

Invasive fungal diseases (IFD) in children with newly diagnosed acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) are poorly characterized, especially in lower-middle-income countries (LMICs). This study aims to identify the incidence, risk factors, and outcomes of IFD in a pediatric cohort with ALL/LBL.

METHODS

We retrospectively analyzed pediatric patients diagnosed with ALL/LBL between January and December 2023 at a tertiary cancer center in India. Patients were risk-stratified and treated per the modified ICiCLe-ALL-14 protocol. IFDs were classified as proven, probable, and possible according to the revised EORTC/MSG consensus definition.

RESULTS

Among 407 patients, 392(96%) had ALL. The overall incidence of IFD was 25%, with probable/proven infections in 12%. Mold infections predominated (79 cases, 77%), followed by yeast infections (21 cases, 21%). In comparison with patients without IFDs, those with IFDs were more likely to have received dexamethasone (30 vs. 20%; p = 0.009), anthracycline (28 vs. 14%; p = 0.001) during induction and have central venous access (27 vs. 18%; p = 0.008). The 6-week mortality rate of patients with IFD was 15%, rising to 26% in probable/proven cases. Coexisting bacterial infection was associated with increased mortality (odds ratio: 19.2[95%CI: 3.5-105]; p = 0.001).

CONCLUSION

IFDs are common in newly diagnosed ALL/LBL patients in LMICs, particularly during early phases of therapy. These infections are associated with considerable mortality, often compounded by concomitant bacterial sepsis. Given these findings, consideration of antifungal prophylaxis is warranted to mitigate morbidity and mortality due to IFDs.

β-D-Glucan Testing in Candidemia: Determinants of Positivity and Association With Mortality

BACKGROUND

Serum 1,3-β-d-glucan (BDG) tests are frequently used for diagnosing invasive candidiasis. However, BDG tests remain negative in many patients with candidemia, and factors influencing the probability for positive test results are poorly understood.

OBJECTIVES

To study clinical and microbiological factors predictive of a positive BDG test, as well as the association of a positive BDG test with mortality in patients with candidemia.

METHODS

In a retrospective cohort of patients with candidemia, BDG was analysed by the Glucatell assay and the Wako Beta-Glucan Test. Predisposing conditions, focus of infection and other variables were retrieved from medical charts and laboratory databases. Their association with a positive BDG test, and the association between positive BDG and death was tested in univariate analysis and multivariable logistic regression.

RESULTS

We included 134 patients with candidemia. Positive BDG and a non-abdominal deep-seated focus of infection (e.g., hematogenously disseminated infection and deep mediastinal/pleural candidiasis) were positively correlated in univariate and multivariable analyses [Wako adjusted odds ratio 9.11 (95% CI 1.66-172, p = 0.039), Glucatell adjOR 9.14 (95% CI 1.66-172, p = 0.039)]. Having a positive BDG test increased the risk for 90 days mortality after controlling for potential confounders, mainly age, septic shock, and ICU admission [Wako adjOR 4.73 (95% CI 1.71-14.7, p = 0.0043), Glucatell adjOR 3.59 (95% CI 1.33-10.6, p = 0.015)].

CONCLUSIONS

In patients with candidemia, a positive BDG test is more common in the presence of a concomitant non-abdominal deep-seated infection. Patients with a positive BDG test have a higher 90-day mortality.

Features of Invasive Aspergillosis Caused by Aspergillus flavus, France, 2012-2018

Invasive aspergillosis (IA) caused by Aspergillus flavus remains poorly described. We retrospectively analyzed 54 cases of IA caused by A. flavus reported in France during 2012-2018. Among cases, underlying IA risk factors were malignancy, solid organ transplantation, and diabetes. Most (87%, 47/54) infections were localized, of which 33 were pleuropulmonary and 13 were ear-nose-throat (ENT) infection sites. Malignancy (70% [23/33]) and solid organ transplantation (21% [7/33]) were the main risk factors in localized pulmonary infections, and diabetes mellitus was associated with localized ENT involvement (61.5%, [8/13]). Fungal co-infections were frequent in pulmonary (36%, 12/33) but not ENT IA (0 cases). Antifungal monotherapy was prescribed in 45/50 (90%) cases, mainly voriconazole (67%, 30/45). All-cause 30-day case-fatality rates were 39.2% and 90-day rates were 47.1%, and rates varied according to risk factor, IA site, and fungal co-infections. Clinicians should remain vigilant for A. flavus and consider it in the differential diagnosis for IA.

Evaluation of the clinical characteristics and survival outcomes of invasive pulmonary aspergillosis patients

Background

Invasive pulmonary aspergillosis (IPA) is a severe infectious disease caused by Aspergillus spp. It is associated with high mortality, particularly in immunocompromised patients, as well as in those with COVID-19 pneumonia or critically ill individuals in intensive care units (ICUs). Accurate clinical diagnosis remains a significant challenge, often resulting in missed diagnoses.

Methods

This study evaluated IPA inpatients diagnosed through mycological evidence and clinical criteria over 12 months. Inclusion criteria required at least one positive mycological result, including a positive culture from bronchoalveolar lavage fluid (BALF) or high-quality sputum, or a positive galactomannan antigen (GM) test.

Results

A total of 216 patients were diagnosed with IPA, with a mortality rate of 68.5%. Hematologic malignancies were the primary underlying condition in 33.8% of cases. Voriconazole or posaconazole was used in 45% (98/216) of patients overall, but only 26% (32/121) of non-hematologic malignancy patients received these treatments. The 28-day survival rate for patients treated with Voriconazole/Posaconazole was 0.776 ± 0.038, compared to 0.421 ± 0.043 for untreated patients. Median survival was 130 days (95% CI, 35.3-224.7) for treated patients vs. 20 days (95% CI, 15.8-24.2) for untreated patients (p < 0.001). Biomarkers for IPA diagnosis demonstrated high diagnostic value, with area under the curve (AUC) values for GM, G, PCT, IL-6, WBC, NEU%, and D-dimer of 0.953, 0.983, 1.000, 0.999, 0.961, 0.996, and 1.000, respectively. GM levels >0.5 pg/ml had a positive predictive value of 52.9% (27/51), while positive mycological culture had a predictive value of 46.5% (33/71). Multivariable regression analysis identified several significant factors associated with in-hospital mortality: IPA (OR 7.509, 95% CI 4.227-13.339, p < 0.001), Voriconazole/Posaconazole treatment (OR 0.124, 95% CI 0.063-0.242, p < 0.001), ICU hospitalization (OR 5.280, 95% CI 1.549-18.002, p = 0.008), hematologic malignancy (OR 0.316, 95% CI 0.174-0.573, p < 0.001), and NEU% ≥87.25% (OR 3.409, 95% CI 1.455-7.990, p = 0.005).

Conclusion

Non-hematologic malignancy patients with IPA were frequently undertreated with antifungal therapy. A comprehensive diagnostic approach using biomarkers, CT, mycological evidence is crucial. Key risk factors for mortality include lack of Voriconazole/Posaconazole treatment, IPA diagnosis, ICU admission, non-hematologic malignancies, and elevated NEU%.

Mixed fungal infection of Actinomucor elegans and Aspergillus fumigatus in a person with severe fever with thrombocytopenia syndrome

In this report, a 69-year-old man with fever, thrombocytopenia, and hepatic and renal dysfunction presented to our hospital. His disease progression was rapid, and he became unconscious. The patient was diagnosed with severe fever with thrombocytopenia syndrome (SFTS). However, his inflammation markers continued to rise until a mixed fungal infection was detected. Metagenomic next-generation sequencing of blood detected elevated sequence numbers for Actinomucor elegans and Aspergillus fumigatus. The culture of the bronchoalveolar lavage fluid were positive for Aspergillus fumigatus and Escherichia coli. Infection was controlled after adjusting the antifungal regimens against Actinomucor elegans. The patient's condition gradually improved. This patient was diagnosed with possible mucormycosis. Reports of Mucorales infection associated with SFTS are rare. We hope that this case report will draw the attention of physicians in the area where SFTS occurs to figure out if patients with SFTS are susceptible to mucormycosis.

Fungal colonization before or after lung transplantation has no negative impact on survival or the development of chronic lung allograft dysfunction

Introduction

Long-term survival following lung transplantation (LTx) faces impediments due to chronic lung allograft dysfunction (CLAD), while infections hinder short-term survival. Fungal colonization and invasive fungal infections (IFI) are common within the first year after LTx. There is ongoing debate regarding the impact of such events on CLAD development and mortality. This study aims to investigate this matter further.

Methods

A total of 134 LTx recipients transplanted between 2011 and 2020 were included. The median follow-up time was 3.9 years. Fungal colonization and IFI were defined according to international consensus guidelines and were noted if present within the first 12 months after LTx.

Results

Postoperative fungal colonization was found in 101 patients, and 14 patients had an IFI within twelve months of transplantation. Nineteen patients were neither colonized nor infected. Out of the 115 patients with colonization or IFI, 61 patients had growth of a yeast such as Candida species (spp.). Fifty-six patients were colonized prior to LTx. Being colonized with fungus before or within the first 12 months post-LTx did not significantly affect survival or CLAD development.

Conclusions

The results of the current study indicate that fungal colonization either pre-transplantation or within the first 12 months after does not correlate with increased risks of mortality or CLAD development. These findings show that while fungal colonization is a common occurrence in LTx recipients, it does not predispose the patients of the cohort to adverse outcomes.

Fungal infection in patients treated with Bruton tyrosine kinase inhibitor-from epidemiology to clinical outcome: a systematic review

BACKGROUND

The Bruton tyrosine kinase inhibitor (BTKi) has emerged as a key treatment for B-cell lymphomas. Despite its efficacy in the treatment of malignancies, numerous cases of invasive fungal infections (IFI) have been reported in patients receiving ibrutinib, a first-generation BTKi. Cases of invasive aspergillosis have also been reported with acalabrutinib and zanubrutinib.

OBJECTIVES

The objective of this study was to provide an overview of the pathogens involved, the time of onset of infections and factors influencing survival.

METHODS

Data sources: PubMed, Embase and Web of Science databases were used, and the results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

STUDY ELIGIBILITY CRITERIA

Case reports, case series, clinical trials and cohort studies were included.

PARTICIPANTS

All reported cases of IFI in patients treated with BTKi were analysed. For case reports/case series, demographic, microbiological and outcome data were retrieved. Assessment of risk of bias: Given the significant heterogeneity in clinical trials/cohort studies, only epidemiological analysis was performed, without formal incidence analysis. Methods of data synthesis: Epidemiologic data were presented as descriptive statistics.

RESULTS

In total, 25 215 patients from 92 retrospective and prospective clinical trials/cohort studies and 211 patients from 115 case reports/case series were included. Among clinical trials/cohorts, 736 IFI were reported, including 234 candidiasis (31.8%), 227 aspergillosis (30.8%) and 124 Pneumocystis jirovecii pneumonia (PJP) (16.8%). Among the case reports/case series, 155 (73.5%) had chronic lymphocytic leukaemia, and 56 (26.5%) had other malignancies. The main IFI were aspergillosis (n = 107, 50.7%), cryptococcosis (n = 33, 15.6%), PJP (n = 26, 12.3%) and mucormycosis (n = 23, 10.9%). The median delay between the initiation of BTKi and IFI was 2.3, 4.0, 3.0 and 3.0 for aspergillosis, cryptococcosis, PJP and mucormycosis, respectively. The survival rate improved when BTKi was discontinued during infection.

CONCLUSIONS

Targeted therapies in lymphocytic malignancies raised new issues concerning infectious complications. Monitoring IFI in patients receiving second- and third-generation BTKi is crucial for improving the management of these manifestations.

Detection of fungal pathogens by a histomolecular approach using targeted-massive parallel sequencing on formalin-fixed tissues: a retrospective study

OBJECTIVES

Because fungal infections (FI) are frequently encountered by pathologists, it is crucial to improve fungal diagnosis on formalin-fixed paraffin-embedded tissues (FT). We aimed to investigate if a histomolecular approach using targeted-massive parallel sequencing (MPS) could help detect and identify fungi on FT when no mycological diagnosis is available on fresh tissue.

METHODS

Forty-nine FT from 48 patients with histopathological FI diagnosis but without mycological identification were retrospectively included. Histopathology defined the fungal pattern and the tissue injuries. Panfungal PCRs were performed using ITS-3/ITS-4 and MITS-2A/MITS-2B primers. Amplicons were sequenced using Sanger sequencing and targeted-MPS. Probabilities of fungal identification for both sequencing techniques and both primers were compared.

RESULTS

The median age was 57 years (Q1: 47; Q3: 64). Fungal cultures were performed in 22/49 (44.9%) samples but failed to identify the pathogenic fungi. Fungal identification by Sanger sequencing was successful in 17/49 (34.7%; [0.214-0.480]) FT; the probability of fungal identification was 32.7% (16/49; [0.195-0.458]) for ITS-3/ITS-4; and 22.4% (11/49; [0.108-0.341]) for MITS-2A/MITS-2B. Targeted-MPS was successful in 35/49 (71.4%; [0.588-0.841]) samples; the probability of fungal identification was 59.2% (29/49; [0.454-0.729]) for ITS-3/ITS-4 primers and 61.2% (30/49; [0.476-0.749]) for MITS-2A/MITS-2B. The probability of fungal identification by targeted-MPS (35/49 [71.4%]) was significantly higher than that of Sanger sequencing (17/49 [34.7%]; p < 0.0001). We assessed that this approach could have optimized care for 22/48 (45.8%) patients.

DISCUSSION

Integrated histomolecular diagnosis using targeted-MPS could secure diagnosis and help clinicians prescribe the most appropriate antifungal therapy in the absence of mycological identification.

Doubling of triazole resistance rates in invasive aspergillosis over a 10-year period, Belgium, 1 April 2022 to 31 March 2023

BackgroundDutch national treatment guidelines for fungal infections have been adapted based on surveillance findings of triazole resistance rates >10% in Aspergillus species isolates. In Belgium, nationwide resistance data have not been collected since 2011.AimOur objective was to evaluate changes in antifungal susceptibility among Aspergillus species isolates from patients with invasive aspergillosis.MethodsLaboratories across Belgium were invited to send all clinically relevant Aspergillus species isolates from patients diagnosed with invasive aspergillosis, collected between April 2022 and March 2023, to the National Reference Centre for Mycosis at UZ Leuven for identification and antifungal susceptibility testing.ResultsOverall, 29 clinical laboratories contributed 309 isolates from 297 patients. Median patient age was 66 years (range: 6 months-96 years). Among isolates, 61% (189/309) were from male patients. At species level, Aspergillus fumigatus isolates predominated (278/309, 90%), with a 9.7% (27/278) triazole resistance rate, compared to the 4.6% rate found in 2011. Of 27 resistant isolates, successful Cyp51A sequencing of 26 showed 20 with the TR34/L98H resistance mechanism. Across the country, local A. fumigatus triazole resistance rates varied. Among provinces in the Flanders region, Antwerp had the highest resistance rate (15.4%: 10/65; p = 0.082), Flemish Brabant (6/48) also had a rate >10%, while Limburg (2/46) had the lowest rate.ConclusionsGeographical differences in A. fumigatus triazole resistance rates stress the importance of implementing broad prospective surveillance initiatives, not limited to one region or one hospital. In Belgium, triazole resistance rates have doubled over 10 years, nearly attaining the 10% threshold, warranting re-evaluation of local empirical antifungal treatment regimen decisions.

Extra-pulmonary invasive fungal infection in a post-heart transplant patient

Infectious complications remain a lifelong risk after organ transplantation. Invasive fungal infections (IFIs), including fungal brain abscess, in these patients can be very morbid and fatal. Decreased host immunity due to lifelong immunosuppressive therapy is the single most important risk factor for IFIs. Unlike in the general population, IFIs are difficult to diagnose in immunosuppressed patients because of atypical presentations, low yield of pathogens from microbial cultures, and long turnaround time for culture results. Late diagnosis and delayed initiation of treatment may influence the final outcome.

A longitudinal study assessing Aspergillus polymerase chain reaction (PCR) performance through participation in external quality assessment schemes from 2019 to 2022

Aspergillus polymerase chain reaction (PCR) now employs standardised methodology and commercial options, with clinical performance validated through meta-analyses. The long-term availability of external quality assessment schemes drives performance and provides a currently untapped source of technical data. The Fungal PCR initiative and the Quality Control for Molecular Diagnostics (QCMD) combined forces to evaluate data from the Aspergillus PCR QCMD schemes between 2019 and 2022. Analysis showed inferior detection of non-fumigatus Aspergillus species (i.e.,Aspergillus niger) compared with A. fumigatus. Longitudinal evaluation showed the use of 'in-house' PCR methods by new participants when testing plasma generated lower positivity rates compared to commercial assays.

Development and evaluation of a Pan-Mucorales Real-time PCR and a multiplex Real-time PCR for detection and identification of Rhizopus arrhizus, Rhizopus microsporus, and Mucor spp. in clinical specimens

Mucormycosis is a life-threatening infection associated with high morbidity and mortality. Rapid and accurate diagnosis is essential for improving patient outcomes. Conventional diagnostic methods, such as histopathology and culture, are limited by low sensitivity and prolonged turnaround times, while commercial polymerase chain reaction (PCR) assays are costly and may lack specific genus or species targets. Here, we present a novel molecular diagnostic workflow to facilitate the rapid detection of Mucorales directly from clinical specimens. This workflow integrates two in-house in vitro diagnostic PCR assays: a real-time, qualitative Pan-Mucorales PCR, followed by a real-time multiplex genus/species-specific PCR targeting Rhizopus arrhizus, Rhizopus microsporus, and Mucor spp. Specificity of the assays was validated using cultured isolates of Mucorales, as well as non-Mucorales fungi and bacteria. The diagnostic performance was assessed across 166 clinical specimens (70 Mucorales-positive and 96 negative), confirmed by an in-house panfungal PCR and DNA sequencing protocol. Specimens studied included fresh and formalin-fixed paraffin-embedded tissues, fluid, bronchoalveolar lavage/washing fluid, fine needle aspirate, cerebrospinal fluid, and bone. The Pan-Mucorales PCR demonstrated 98.6% sensitivity and 100% specificity, while the multiplex genus/species-specific PCR assay yielded sensitivities of 93.8% for R. arrhizus, 70.8% for R. microsporus, and 75% for Mucor spp., each with 100% specificity. Concordance with the panfungal PCR (>99% for Pan-Mucorales PCR and >89% for multiplex PCR) was high, supporting the robustness of the workflow. This diagnostic approach has the potential to significantly reduce turnaround times, labor and costs, while streamlining the diagnostic process through timely, precise diagnostics.

IMPORTANCE

Mucorales fungi, identified collectively as a high-priority pathogen on the World Health Organization fungal priority pathogens list, are the causative agents of mucormycosis. Mortality is high (up to 80%), and early, accurate diagnosis is critical to enable timely initiation of targeted antifungal therapy and surgical debridement for source control to optimize patient outcomes. In our laboratory, as in many others, the current standard for the diagnosis of mucormycosis is histopathology and culture-based methods supplemented by panfungal PCR assay/DNA sequencing; however, this process may take 7 days, with considerable labor and cost implications. Here, we present two Mucorales-specific real-time PCR assays, which when used sequentially, reduce diagnostic turnaround time and costs to detect three common agents of mucormycosis-Rhizopus microsporus, Rhizopus arrhizus, and Mucor species. This approach not only improves diagnostic efficiency and integration into workflow but can facilitate surveillance through accurate genus- and species-level identification.

Management, Outcomes, and Predictors of Mortality of Cryptococcus Infection in Patients Without HIV: A Multicenter Study in 46 Hospitals in Australia and New Zealand

BACKGROUND

Limited data exist regarding outcomes of cryptococcosis in patients without human immunodeficiency virus (HIV), and few studies have compared outcomes of Cryptococcus gattii versus Cryptococcus neoformans infection.

METHODS

We conducted a retrospective study in 46 Australian and New Zealand hospitals to determine the outcomes of cryptococcosis in patients without HIV diagnosed between 2015 and 2019 and compared outcomes of C. gattii versus C. neoformans infections. Multivariable analysis identified predictors of mortality within 1 year.

RESULTS

Of 426 patients, 1-year all-cause mortality was 21%. Cryptococcus gattii infection was associated with lower mortality than C. neoformans (adjusted odds ratio [OR], 0.47; 95% confidence interval [CI], .23-.95), while severe neurological symptoms at presentation were the strongest predictor of death (adjusted OR, 8.46; 95% CI, 2.99-23.98). Almost all (99.5%) patients with central nervous system (CNS) infection received induction antifungal therapy versus 27.7% with isolated pulmonary cryptococcosis. The most common regimen in CNS disease was liposomal amphotericin B with flucytosine (93.8%; mean duration, 31 ± 13 days). Among patients with CNS cryptococcosis, C. gattii infection was associated with higher risk of immune reconstitution inflammatory response (C-IRIS) than C. neoformans (21% versus 3%, P < .001). Nineteen patients received amphotericin B-based re-induction therapy for suspected relapse, but none had microbiological relapse. Serum cryptococcal antigen positivity and lung imaging abnormalities resolved slowly (resolution at 1 year in 25% and 34% of patients, respectively).

CONCLUSIONS

Compared with C. neoformans, C. gattii infection demonstrated lower mortality but higher C-IRIS risk in CNS infection. Severe neurological symptoms were the strongest predictor of mortality.

Invasive Fungal Disease in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation in China: A Multicenter Epidemiological Study (CAESAR 2.0)

BACKGROUND

This study (China Assessment of Antifungal Therapy in Hematological Diseases [CAESAR 2.0]) aimed to provide updated epidemiological data on invasive fungal disease (IFD) in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT).

METHODS

This multicenter, real-world, observational study was conducted at 12 allo-HSCT centers in China between January and December 2021. Consecutive adult patients (aged ≥18 years) who underwent allo-HSCT with antifungal prophylaxis were included. IFD was diagnosed according to the 2019 criteria of the European Organization for Research and Treatment of Cancer and Mycoses Study Group (EORTC/MSG). Follow-up was completed by 31 December 2022.

RESULTS

A total of 2015 patients were included. Mold-active antifungal prophylaxis was used in 76.08%, most of whom received voriconazole (44.37%) or posaconazole (31.71%). The cumulative incidence of IFD (proven or probable) 1 year after allo-HSCT was 6.3%. Pathogens were identified in 47.97% of IFD cases and mainly included Candida spp. (17.89%), Mucorales (13.01%), Aspergillus spp. (8.94%), and Pneumocystis jirovecii (6.5%). Multivariate analysis identified the following factors associated with IFD: disease at advanced stage (hazard ratio, 2.55 [95% confidence interval, 1.58-4.12]; P < .001), absolute neutrophil count engraftment (≤28 days) (0.37 [15-.92]; P = .03), platelet engraftment (≤28 days) (0.41 [.27-.62]; P < .001), and acute graft-vs-host disease grade III-IV (2.97 [1.97-4.49]; P < .001). The IFD-attributable mortality rate was 48.28%.

CONCLUSIONS

Despite the widespread use of mold-active prophylaxis, the risk of IFD after allo-HSCT remains high. The most common pathogens are Candida spp., Mucorales, Aspergillus spp., and P. jirovecii.

Is neutropenia still the main risk factor for invasive aspergillosis? A contemporary university hospital retrospective cohort of invasive aspergillosis in neutropenic and non-neutropenic patients

INTRODUCTION

In times of mold active prophylaxis, invasive aspergillosis (IA) epidemiology is evolving. Presentation in non-neutropenic may differ from neutropenic. We investigated the cases of IA in our center with a focus on differences between neutropenic and non-neutropenic, and analyzed the impact of cryptic and non-fumigatus Aspergillus species.

METHODS

Retrospective observational study including all adult patients admitted to the Puerta de Hierro-Majadahonda Hospital between January 2018 and April 2024 with IA.

RESULTS

112 IA were identified. Only 11 (9.8%) had neutropenia as risk factor for IA. Most frequent risk factors were corticosteroids (77.2%), SOT (46.5%), SARS-CoV2 (29.7%) and CMV replication (28.7%). 89.3% were pulmonary IA with 6 cases (5.4%) of disseminated infection. A. fumigatus was the most frequent species 48 (51.6%). 13 cases (14%) were caused by cryptic Aspergillus spp. Non-neutropenic patients, compared to neutropenic patients, were more likely to have positive fungal cultures (83.2% versus 54.5%, p = 0.023[NS]), and not to present a halo sign (7.4% versus 45.5%, p = 0.003 [NS]). In addition, in non-neutropenic patients, compared to neutropenic patients, there was a trend towards a greater probability of positive GM from BAL (81.3% versus 66.7%, p = 0.304) and a trend towards a lower probability of positive serum GM (25.7% versus 45.5%, p = 0.137). 41/112 (36.6%) cases presented breakthrough IFI and in 51.2%, (21/41 cases), the isolate was resistant to the prior antifungal. One presented A. fumigatus with the TR34-L98H mutation.

CONCLUSION

Risk factors different than neutropenia are currently the most common in IA. The clinical presentation in non-neutropenic patients differs from neutropenic. Resistance to antifungals is emerging especially in breakthrough IA.

Safety and Effectiveness of Isavuconazole Treatment for Invasive Fungal Infections in Chinese Patients with Haematologic Diseases: A Case Series

Objective

Isavuconazole (ISZ), a newer antifungal agent approved for treating invasive aspergillosis and mucormycosis, has been available in China since 2022. However, real-world data on ISZ use among Chinese patients with hematological diseases remain limited. In this study, we present our experience with ISZ for invasive fungal infection (IFI) management in hematology patients.

Methods

Data on patient characteristics, ISZ administration variables, IFI treatment response to ISZ, and potential ISZ-associated adverse events in hematology patients from our center were retrospectively analyzed.

Results

A total of 25 hematology patients treated with ISZ were included. One (4.0%) patient had proven IFI, 13 (52.0%) had probable IFI, and the remaining 11 (44.0%) were classified as having possible IFI. ISZ was used as primary therapy in 8 cases (32.0%) and salvage therapy in 17 cases (68.0%). The switch to ISZ as salvage therapy was driven by refractoriness to primary therapy in 70.6% of cases and by refractoriness and intolerance to prior antifungal treatment in 29.4%. Clinical improvement was observed in 16 (64.0%) patients. Five patients died during hospitalization, and four discontinued therapy due to clinical deterioration. Adverse events potentially attributable to ISZ occurred in 5 patients (20.0%), including nephrotoxicity, hepatotoxicity, and blurred vision (1 case each), and with the remaining two cases involving combined hepatorenal toxicity.

Conclusion

ISZ demonstrates promising clinical efficacy and a favorable safety profile for IFI treatment in Chinese patients with hematologic diseases.

Risk stratification and impact of donor type on breakthrough invasive fungal infections in haematopoietic cell transplant with post-transplant cyclophosphamide and mould-active prophylaxis

Incidence of breakthrough proven-probable invasive fungal infections (b-PP-IFIs) in allogeneic haematopoietic cell transplant recipients (allo-HCT-r) receiving mould-active prophylaxis (MAP) and post-transplant cyclophosphamide (PT-Cy) is largely unknown. Retrospective study on allo-HCT-r, classified at high-risk for IFIs whether ≥1 of the following conditions was met: 1] active disease; 2] cord-blood; 3] previous transplant; 4] acute graft-versus-host-disease (a-GVHD) grade≥3; 5] mismatched-related or unrelated donor with neutropenia before transplant or grade-2 a-GVHD or Cytomegalovirus infection. Objectives were to estimate cumulative incidence function (CIF) of b-PP-IFIs, evaluate infection-related mortality (IRM) and predictive factors of b-PP-IFIs. Overall, 473 allo-HCT-r (n = 286 posaconazole, n = 187 voriconazole) were analysed: 64.7% were at high-risk, 81.6% received PT-Cy. Fifteen b-PP-IFIs occurred: 14/306 in high-risk, 1/167 in non-high-risk group. CIF of b-PP-IFIs in high-risk group was 2.0% (95%CI = 0.8-4.1%) at 30-day and 5.1% (95%CI = 2.9-8.2%) at 1-year post-transplant. The 1-year CIF of IRM was higher in allo-HCT-r with b-PP-IFIs compared to those without [46.7% (95%CI = 19.6-70%) vs. 8.2% (95%CI = 5.3-9.2%), Gray's test: p < 0.001]. In allo-HCT-r receiving PT-Cy, neutropenia before transplant [sHR 7.54 (95%CI = 1.81-31.43)] and chronic myeloproliferative disorders versus AML/MDS [sHR 7.72 (95%CI = 1.68-35.42)] increased risk of b-PP-IFIs, while donor type did not. MAP effectively prevented IFIs. PT-Cy conferred a comparable risk of b-PP-IFIs in matched compared to mismatched-transplants.

False-Positive Galactomannan Test Results in Multiple Myeloma

BACKGROUND/OBJECTIVES

Invasive pulmonary aspergillosis (IA) is a common infectious disease in patients with hematological diseases. The prevention, early detection, and establishment of treatment strategies for IA are important. The serum galactomannan antigen (GM) mycological test for IA diagnosis, included in the mycology criteria of the European Organization for Research and Treatment of Cancer-Invasive Fungal Infections Cooperative Group/National Institute of Allergy and Infectious Diseases Mycosis Study Group (EORTC/MSG), is widely used because of its high sensitivity and specificity. However, false-positive results are a concern.

METHODS

We retrospectively analyzed all GM tests performed at our department in the clinical practice setting between April 2003 and January 2012.

RESULTS

Of the 330 cases and 2155 samples analyzed, 540 (25%) were positive (≥0.5). Among the underlying diseases, positivity rates were the highest for multiple myeloma (MM), with 61.3%. By type, positivity rates for IgG, IgA, Bence-Jones protein, and IgD were 71.7%, 33.3%, 57.1%, and 34.6%, respectively. Seventeen out of eighteen cases that were GM-positive at MM diagnosis were false positives, according to the 2008 EORTC/MSG criteria. The IgG and GM values were not directly correlated. Of the seventeen false-positive cases identified, two developed IA during anti-myeloma treatments, and GM values did not become negative during the treatment in most cases.

CONCLUSIONS

Although subclinical IA may be included in a higher GM index, the results may be prone to false positives; particularly in IgG-type MM, the results should thus be interpreted cautiously.

Posaconazole versus fluconazole as primary antifungal prophylaxis for patients at high risk of invasive fungal infections receiving allogeneic hematopoietic stem cell transplantation

With the aim to reduce the incidence of invasive fungal infections (IFI) after allogeneic hematopoietic stem cell transplantation (allo-HSCT), the ECIL group recommends the use of drugs active against molds such as posaconazole instead of fluconazole in high-risk (HR) IFI patients. But data to support this recommendation are poor. The aim of this monocentric study was to compare retrospectively the use of fluconazole (n = 96) vs. posaconazole (n = 63), as primary antifungal prophylaxis within the first 90 days (D) post-transplant in a cohort of patients at HR-IFI (n = 159). HR-IFI was defined by the use of an alternative donor, post-transplant cyclophosphamide and/or sequential conditioning regimen, and/or an active disease at transplant or a previous allo-HSCT. Incidences of D90, 6-month, 1-year and 2-year CI of IFI as well as D90 primary prophylaxis failure (IFI resulting in the initiation of a curative antifungal therapy or a permanent discontinuation of the prophylaxis for toxicity) were similar between both groups. However, the number of probable/proven IFI that occurred between D0 and D90 was the double in the fluco group (9 vs. 4). Also, no proven IFI (vs. 4) or mucormycoses (vs. 1) or IFI related death (vs. 4) occurred in the posa group in the first 90 days. Posaconazole thus appears to be a good option to prevent IFI after allo-HSCT in patients at HR-IFI.

Clinical characteristics and treatment response of chronic disseminated candidiasis in patients with hematological disorders

Chronic disseminated candidiasis (CDC) is an invasive fungal infection typically affecting patients with hematological diseases and severe neutropenia, associated with increased mortality. However, there is a global shortage of clinical evidence on CDC. We retrospectively analyzed clinical data from 49 CDC patients over the past decade. Clinical characteristics of primary hematological diseases, CDC diagnosis, treatment and response evaluations were included. Clinical factors associated with CDC remission and patients' survival were analyzed. The majority of patients had hematological malignancies (n = 43, 87.8%), and 27 patients (55.1%) had persistent severe neutropenia for more than 10 days prior to CDC. CT scans revealed liver lesions in 44 patients, spleen lesions in 34 patients, and kidney lesions in 9 patients. Proven, probable and possible CDC was diagnosed in 5 (10.2%), 3 (6.1%) and 41 patients (83.7%), respectively, and treatment outcomes at 3 months included 5 complete response (CR, 10.2%), 34 partial response (PR, 69.4%) and 10 treatment failure (20.4%). Caspofungin treatment showed a trend towards improving CR/PR rate, while severe neutropenia > 20 days and proven diagnosis were significantly associated with 3-month treatment failure. Kaplan-Meier curve showed achieving CR/PR within 3 months did not significantly prolong OS compared to treatment failure patients (1197.6 days vs. 564.8 days, P = 0.074). Additionally, no patient deaths were directly attributed to CDC infection. Age > 45 years old and malignancy non-remission were prognostic factors of overall survival (OS). Furthermore, a prediction model identified severe neutropenia > 20 days, proven/probable diagnosis and concomitant bacteremia as risk factors to effectively predict treatment failure. Also, patients with a risk score < 0.203 in the model exhibited more rapid treatment response. After CDC symptoms onset, lymphocyte levels remained consistently higher in treatment failure patients, while the neutrophil-to-lymphocyte ratio was persistently higher in CR/PR patients. Our findings recommend CT scans for diagnosis and caspofungin as first-line therapy while continuing scheduled chemotherapy or bone marrow transplantation. Notably, risk factors identified by the prediction model could be used to predict treatment response.