Why are so many cases of invasive aspergillosis missed?

Shared Vision for Improving Outcomes for Serious Fungal Diseases: Report of a Patient, Caregiver, and Clinician Summit

Background

Recently, increasing focus on patient input into research and healthcare improvements has fostered expanded patient-centered advocacy efforts. This first pan-fungal disease summit, part of the MYCology Advocacy, Research, & Education effort, brought together patients, caregivers, and mycology experts to better document patient experiences with invasive fungal disease (IFD) and establish priorities for mycology education, advocacy, and research.

Methods

Patients who had suffered from IFD, their caregivers, clinicians, industry representatives, government officials, and patient advocacy professionals were invited. Patients and caregivers shared their stories and struggles with IFD. Breakout sessions separated mycology experts from patients and caregivers for further discussions to identify commonalities and perceived gaps and to formulate recommendations. The 2 groups then reconvened to develop consensus recommendations.

Results

IFD patients and their caregivers shared experiences reflecting the typically lengthy prediagnosis, acute treatment, long-term treatment, and posttreatment recovery stages of IFD. They reported substantial physical, psychological, and financial burdens associated with the IFD experience, particularly related to delayed diagnoses. They reaffirmed a need for coordinated patient-centered education, peer support, and advocacy to document the burden of serious fungal infections. Mycology experts discussed strategies to address gaps in the mycology field, such as insufficient training, inadequate workforce support, and a need to partner more with patient groups.

Conclusions

A summit involving patients with IFD, family caregivers, and mycology experts identified a substantial nonclinical burden of disease associated with IFD. Patients and mycology experts prioritized several goals for education, advocacy, and research to raise awareness of IFD and improve outcomes.

Microbiological Diagnosis of Pulmonary Aspergillus Infections

As microbiological tests play an important role in our diagnostic algorithms and clinical approach towards patients at-risk for pulmonary aspergillosis, a good knowledge of the diagnostic possibilities and especially their limitations is extremely important. In this review, we aim to reflect critically on the available microbiological diagnostic modalities for diagnosis of pulmonary aspergillosis and formulate some future prospects. Timely start of adequate antifungal treatment leads to a better patient outcome, but overuse of antifungals should be avoided. Current diagnostic possibilities are expanding, and are mainly driven by enzyme immunoassays and lateral flow device tests for the detection of Aspergillus antigens. Most of these tests are directed towards similar antigens, but new antibodies towards different targets are under development. For chronic forms of pulmonary aspergillosis, anti-Aspergillus IgG antibodies and precipitins remain the cornerstone. More studies on the possibilities and limitations of molecular testing including targeting resistance markers are ongoing. Also, metagenomic next-generation sequencing is expanding our future possibilities. It remains important to combine different test results and interpret them in the appropriate clinical context to improve performance. Test performances may differ according to the patient population and test results may be influenced by timing, the tested matrix, and prophylactic and empiric antifungal therapy. Despite the increasing armamentarium, a simple blood or urine test for the diagnosis of aspergillosis in all patient populations at-risk is still lacking. Research on diagnostic tools is broadening from a pathogen focus on biomarkers related to the patient and its immune system.

Azole-Containing Agar Plates and Antifungal Susceptibility Testing for the Detection of Azole-Resistant Aspergillus Species in Hospital Environmental Samples

The indoor environment of hospitals should be considered as an important reservoir of azole resistant Aspergillus species. In this study, we evaluated azole-containing agar plates (ACAPs) and antifungal susceptibility testing (AFST) for the detection of azole-resistant Aspergillus species in hospital environmental samples. Between September 2021 and January 2022, environmental samples (108 instruments and 12 air) were collected from different wards of 4 educational hospitals in Mazandaran province, Iran. All samples were cultured using ACAPs. Recovered Aspergillus isolates were molecularly identified at species level using partial DNA sequencing of beta-tubulin gene. AFST of Aspergillus species was performed using the Clinical and Laboratory Standards Institute M38-A3 guideline. Screening for cyp51A mutations was also done. Overall, 18 (15.0%) isolates of Aspergillus species were recovered from ACAPs, of which Aspergillus tubingensis (50%) and Aspergillus fumigatus (38.9%) were the commonest species. No isolate of Aspergillus species grew on posaconazole (PCZ)-containing agar plates. Among the 18 Aspergillus isolated species from ACAPs, 83.3% were related to samples from instruments. Of the nine isolates of A. tubingensis, 22.2% and 44.4% isolates showed minimum inhibitory concentration (MIC) = 2 μg/mL against voriconazole (VCZ) and itraconazole, respectively; and 44.4% isolates showed MIC = 1 μg/mL against PCZ. Of the seven isolates of A. fumigatus, one (14.3%) was resistant to VCZ. This isolate showed F46Y, G54E, G138C, M172V, M220I, D255E, T289F, G432C, and G448S mutation in cyp51A. Our finding showed the emergence of high MICs in cryptic and non-fumigatus species of Aspergillus such as A. tubingensis and VCZ resistance in A. fumigatus in indoor environment of hospitals.

The SSS revolution in fungal diagnostics: speed, simplicity and sensitivity

INTRODUCTION

Fungal disease has historically presented a diagnostic challenge due to its often non-specific clinical presentations, relative infrequency and reliance on insensitive and time-intensive fungal culture.

SOURCES OF DATA

We present the recent developments in fungal diagnostics in the fields of serological and molecular diagnosis for the most clinically relevant pathogens; developments that have the potential to revolutionize fungal diagnosis through improvements in speed, simplicity and sensitivity. We have drawn on a body of evidence including recent studies and reviews demonstrating the effectiveness of antigen and antibody detection and polymerase chain reaction (PCR) in patients with and without concurrent human immunodeficiency virus infection.

AREAS OF AGREEMENT

This includes recently developed fungal lateral flow assays, which have a low cost and operator skill requirement that give them great applicability to low-resource settings. Antigen detection for Cryptococcus, Histoplasma and Aspergillus spp. are much more sensitive than culture. PCR for Candida spp., Aspergillus spp., Mucorales and Pneumocystis jirovecii is more sensitive than culture and usually faster.

AREAS OF CONTROVERSY

Effort must be made to utilize recent developments in fungal diagnostics in clinical settings outside of specialist centres and integrate their use into standard medical practice. Given the clinical similarities of the conditions and frequent co-infection, further study is required into the use of serological and molecular fungal tests, particularly in patients being treated for tuberculosis.

GROWING POINTS

Further study is needed to clarify the utility of these tests in low-resource settings confounded by a high prevalence of tuberculosis.

AREAS TIMELY FOR DEVELOPING RESEARCH

The diagnostic utility of these tests may require revision of laboratory work flows, care pathways and clinical and lab coordination, especially for any facility caring for the immunosuppressed, critically ill or those with chronic chest conditions, in whom fungal disease is common and underappreciated.

False positive Aspergillus galactomannan assay results caused by specific parenteral nutrition

In September 2022, the proportion of clinically false positive results with high index values for the galactomannan (GM) assay increased dramatically in our hospital and remained high until November 2022. We aimed to identify the possible causative agent that led to the dramatic increase in false positivity in GM assay. A case-control-control study was conducted, and patients admitted to two intensive care units between September and November 2022 were included. We defined each time point at which the GM assay was conducted in a patient as an episode and classified episodes into strong-positive (≥10.0 index; case), positive (control), and negative (<0.5 index; control) groups. We compared the medications administered in three groups and measured GM levels in relevant medications, including parenteral nutrition (PN). In total, 118 episodes in 33 patients were classified into three groups. There were 46 negative, 23 positive, and 49 strong-positive episodes, and there was a significant difference in the use of Winuf® PNs (P < .001) between the three groups. Forty episodes (82%) in the strong-positive group received Winuf®, compared with three (6.5%) in the negative group and one (4.3%) in the positive group (P < .001). All samples of Winuf® PNs used in the five patients whose GM results were repeatedly strong-positive were strongly positive for GM. False positivity in GM assay can be caused by the administration of specific PNs. A thorough investigation of prescribed medications should be considered when there is an abrupt increase in the proportion of strong-positive or positive GM results.

Dynamic full-field optical coherence tomography for live-cell imaging and growth-phase monitoring in Aspergillus fumigatus

Introduction

The diagnosis of cutaneous manifestations of deep mycoses relies on both histopathological and direct examinations. Yet, the current diagnostic criteria cannot prevent missed cases, including invasive aspergillosis, which requires the development of a novel diagnostic approach and imaging tools. We recently introduced the use of dynamic full-field optical coherence tomography (D-FF-OCT) in fungal diagnostics with a definition approaching that of conventional microscopy and the ability to return metabolic information regarding different fungal species. The present work focuses on subcellular dynamics and live-cell imaging of Aspergillus fumigatus with D-FF-OCT to follow the fungal growth stages.

Methods

The A. fumigatus ATCC 204305 quality-control strain was used for all imaging experiments, following incubation times varying between 24 and 72 h at 30°C in a humidified chamber on Sabouraud dextrose agar. Fungal growth was subsequently monitored with D-FF-OCT for up to 5 h at room temperature and following the pharmacological stress of either voriconazole, amphotericin B, or caspofungin gradient concentration.

Results

D-FF-OCT images allow not only the visualization of intracellular trafficking of vacuoles but also an evolving dynamic segmentation of conidiophores depending on the chronological development and aging of the hyphae or the effect of antifungal treatment. The same applies to conidial heads, with the most intense D-FF-OCT signal coming from vesicles, revealing a changing dynamic within a few hours only, as well as complete extinction following subsequent drying of the Sabouraud dextrose agar.

Discussion

These results provide additional data on the ability of D-FF-OCT to monitor some of the main life cycle processes, dynamics, and intracellular trafficking of vacuoles in A. fumigatus, with or without the effect of pharmacological stress. Such complementary metabolic information could help both clinicians and microbiologists in either mechanistic studies toward experimental mycology or the development of a potential D-FF-OCT-guided diagnosis of superficial fungal infections.

Metagenomic Next-Generation Sequencing Assists in the Diagnosis of Mediastinal Aspergillus fumigatus Abscess in an Immunocompetent Patient: A Case Report and Literature Review

Background

Aspergillus fumigatus is an opportunistic fungal pathogen, which is commonly found in lungs and rarely causes infections in mediastinum. Mediastinal Aspergillus abscess is a serious infectious condition, and is characterized by difficult diagnosis due to its clinical manifestations being nonspecific.

Case Presentation

Here, we report a case of a mediastinal Aspergillus fumigatus abscess in an immunocompetent patient. The patient was a 45-year-old woman who presented with a 20-day history of sore throat without any underlying diseases. Chest computed tomography (CT) showed a mass in the anterior superior mediastinum. Metagenomic next-generation sequencing (mNGS) identified Aspergillus fumigatus sequences in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) tissue, indicating the mediastinal Aspergillus fumigatus infection of this patient. The following mediastinal biopsy histological analysis and tissue fungi culture also suggested Aspergillus fumigatus infection, confirming the mNGS detection. The patient was diagnosed with mediastinal aspergillosis caused by Aspergillus fumigatus. After timely voriconazole treatment, the patient was discharged with good condition.

Conclusion

Our study presented a rare case with mediastinal Aspergillus fumigatus abscess in an immunocompetent patient. As a new clinical diagnostic method, mNGS could assist timely diagnosis and precise treatment of Aspergillus infection.

Invasive Cerebral Aspergillosis in Non-Neutropenic Patients: A Case Series from Western India

PURPOSE

Invasive cerebral aspergillosis (ICA) is a rare but fatal infection affecting neutropenic immunocompromised patients. Recently cases have been reported in non-neutropenic settings also. We hereby present a series of ICA cases in non-neutropenic patients diagnosed at our tertiary care centre in Western India between March to October 2021.

METHODS

All patients with clinico-radiological suspicion of CNS infections were analysed. Data regarding Clinico-radiological features, diagnosis, treatment and outcome were collected. After ruling out bacterial, viral and mycobacterial causes, appropriate samples were sent for KOH (potassium hydroxide) wet mount, fungal culture, histopathology and serum/CSF galactomannan.

RESULTS

A total of four patients were diagnosed with ICA with a mean age of 43.5 years. Three patients had significant comorbidities; Diabetes mellitus, chronic liver disease and COVID-19 pneumonia treated with dexamethasone, respectively. One patient had no known predisposing factor. Radiologically, one patient presented with a frontal brain abscess and two patients had multiple subcortical hyperintensities. Three patients were diagnosed based on CSF galactomannan (Platelia™ Aspergillus antigen, Bio-Rad, France) with OD >1 and one patient had high serum galactomannan (OD >2). CSF culture grew Aspergillus species in two patients. All patients were treated with Voriconazole. One patient recovered, and the remaining three succumbed due to delayed presentation and extensive cerebral involvement.

CONCLUSION

Even in non-neutropenic patients, a high index of suspicion is warranted for cerebral aspergillosis. CSF galactomannan can be considered a reliable marker for diagnosing ICA in non-neutropenic settings. Early diagnosis allows timely antifungal therapy, which could be a key to improving the outcomes.

Clinical characteristics, diagnosis, outcomes and lung microbiome analysis of invasive pulmonary aspergillosis in the community-acquired pneumonia patients

BACKGROUND

Invasive pulmonary aspergillosis (IPA) remains underestimated in patients with community-acquired pneumonia (CAP). This study aims to describe clinical features and outcomes of IPA in CAP patients, assess diagnostic performance of metagenomic next-generation sequencing (mNGS) for IPA and analyse lung microbiome via mNGS data.

METHODS

This retrospective cohort study included CAP patients from 22 April 2019 to 30 September 2021. Clinical and microbiological data were analysed. Diagnostic performance of mNGS was compared with traditional detection methods. The lung microbiome detected by mNGS was characterised and its association with clinical features was evaluated.

MAIN RESULTS

IPA was diagnosed in 26 (23.4%) of 111 CAP patients. Patients with IPA displayed depressed immunity, higher hospital mortality (30.8% vs 11.8%) and intensive care unit mortality (42.1% vs 17.5%) compared with patients without IPA. The galactomannan (GM) antigen test had the highest sensitivity (57.7%) in detecting the Aspergillus spp, followed by mNGS (42.3%), culture (30.8%) and smear (7.7%). The mNGS, culture and smear had 100% specificity, while GM test had 92.9% specificity. The microbial structure of IPA significantly differed from non-IPA patients (p<0.001; Wilcoxon test). Nineteen different species were significantly correlated with clinical outcomes and laboratory biomarkers, particularly for Streptococcus salivarius, Prevotella timonensis and Human betaherpesvirus 5.

CONCLUSIONS

Our results reveal that patients with Aspergillus infection tend to have a higher early mortality rate. The mNGS may be suggested as a complement to routine microbiological test in diagnosis of patients at risk of Aspergillus infection. The lung microbiota is associated with inflammatory, immune and metabolic conditions of IPA, and thus influences clinical outcomes.

Progress of polymer-based strategies in fungal disease management: Designed for different roles

Fungal diseases have posed a great challenge to global health, but have fewer solutions compared to bacterial and viral infections. Development and application of new treatment modalities for fungi are limited by their inherent essential properties as eukaryotes. The microorganism identification and drug sensitivity analyze are limited by their proliferation rates. Moreover, there are currently no vaccines for prevention. Polymer science and related interdisciplinary technologies have revolutionized the field of fungal disease management. To date, numerous advanced polymer-based systems have been developed for management of fungal diseases, including prevention, diagnosis, treatment and monitoring. In this review, we provide an overview of current needs and advances in polymer-based strategies against fungal diseases. We high light various treatment modalities. Delivery systems of antifungal drugs, systems based on polymers' innate antifungal activities, and photodynamic therapies each follow their own mechanisms and unique design clues. We also discuss various prevention strategies including immunization and antifungal medical devices, and further describe point-of-care testing platforms as futuristic diagnostic and monitoring tools. The broad application of polymer-based strategies for both public and personal health management is prospected and integrated systems have become a promising direction. However, there is a gap between experimental studies and clinical translation. In future, well-designed in vivo trials should be conducted to reveal the underlying mechanisms and explore the efficacy as well as biosafety of polymer-based products.

Clinical and Microbiological Characteristics of Aspergillosis at a Chinese Tertiary Teaching Hospital

BACKGROUND

Aspergillus spp. infection in immunocompromised patients results in increasing morbidity and mortality. This study investigated clinical and microbiological characteristics of aspergillosis in a Chinese tertiary teaching hospital.

METHODS

A total of 114 patients with aspergillosis were included over a 5-year period at Ruijin Hospital. In sum, 114 Aspergillus strains were isolated and identified at species level using matrix-assisted laser desorption ionization time-of-flight mass spectrometry, confirmed by ITS gene region and β-tubulin (BenA) gene sequencing. Sensititre YeastOne was used in vitro to test susceptibility to antifungal drugs: amphotericin B, itraconazole, voriconazole, posaconazole, isavuconazole, micafungin, anidulafungin, and caspofungin.

RESULTS

The median age of the patients was 61 (19) years, men accounted for 53.5% (n=61) of the sample, about 64% were immunocompromised, and 36% had underlying diseases. Pulmonary diseases accounted for 27.2%. Aspergillus isolates were mainly isolated from sputum (n=42, 36.8%). Antifungal therapy was administered to 106 (93.0%) patients and voriconazole (n=76, 66.7%) was the most frequently used as empirical therapy. Aspergillus fumigatus (n=69, 60.5%) was the most common species. There was a 73.7% concordance between MALDI-TOF MS and molecular identification. All Aspergillus isolates showed good susceptibility to anidulafungin and caspofungin.

CONCLUSION

Immunocompromised patients are an at-risk population for aspergillosis, and voriconazole was used as empirical therapy in Ruijin Hospital, China. A. fumigatus was the predominant Aspergillus species causing aspergillosis, and A. flavus - as non-A. fumigatus species are increasing - the second-leading cause of aspergillosis. Anidulafungin and caspofungin were the most active in vitro against the Aspergillus isolates tested. The MALDI-TOF MS method showed good accuracy for identification of common Aspergillus spp. In vitro antifungal-susceptibility testing is crucially important for decisions on effective therapy with aspergillosis.

Siderophores: a potential role as a diagnostic for invasive fungal disease

PURPOSE OF REVIEW

Invasive fungal diseases (IFDs) such as invasive aspergillosis continue to be associated with high morbidity and mortality while presenting significant diagnostic challenges. Siderophores are high-affinity Fe 3+ chelators produced by Aspergillus spp. and other fungi capable of causing IFD. Previously evaluated as a treatment target in mucormycosis, siderophores have recently emerged as new diagnostic targets for invasive aspergillosis and scedosporiosis. Here, we review the diagnostic potential of siderophores for diagnosing IFD, with a particular focus on invasive aspergillosis.

RECENT FINDINGS

The major secreted siderophore of A. fumigatus , triacetylfusarinine C (TAFC), has been successfully detected by mass spectrometry in serum, BALF and urine of patients with invasive aspergillosis, with promising sensitivities and specificities in single-centre studies. Intracellular uptake of siderophores has also been utilized for imaging, wherein fungal siderophores have been conjugated with the easy-to-produce radioactive isotope gallium-68 ( 68 Ga) to visualize infected body sites in PET. For the Scedosporium apiospermum complex, another siderophore N(α)-methyl coprogen B has been shown promising as a marker for airway colonization in early studies.

SUMMARY

Siderophores and particular TAFC have the potential to revolutionize diagnostic pathways for invasive aspergillosis and other mould infections. However, larger multicentre studies are needed to confirm these promising performances. Methods that allow rapid and cost-effective measurements in routine clinical practice need to be developed, particularly when TAFC is used as a biomarker in patient specimens.

Quantifying Deaths from Aspergillosis in HIV Positive People

Aspergillus spp. are ubiquitous and cause severe infections in immunocompromised patients. Less is known about its incidence and prognosis in patients with HIV/AIDS. We reviewed the mortality of invasive aspergillosis in HIV/AIDS patients. Pubmed, Embase and Medline databases were used to search for articles. Studies were excluded if they contained other aspergillosis risk factors, no original or patient survival data or were not in English. From 747 articles published, 54 studies and case reports were identified following reading, published between 1985 and 2021, with 54% papers prior to 2000 reporting 853 patients from 16 countries, none from Africa. 707 (83%) patients died with an average time from diagnosis to death of 77.5 days. Postmortem diagnosis was seen in 21% of deaths recorded. A national series from France of 242 cases of invasive aspergillosis diagnosed in life recorded a 3 month mortality of 68% pre-ART, falling to 31% after introduction of ART and voriconazole. CD4 count was recorded in 39 studies and ranged from 2 to >1000 cells/mm3; only 8 patients (1.8%) had a CD4 > 100 cells/mm3. Aspergillosis occurs in patients with HIV/AIDS and associated with high mortality but its slow progression should allow diagnosis and treatment with improved outcome.

Quandaries of deciding when to change first-line therapy in invasive pulmonary aspergillosis

We read the excellent viewpoint by Slavin et al. (J Antimicrob Chemother 2022; 77: 16-23) that draws upon the experience of an advisory board of notable experts to comprehensively address many of the clinical factors that drive the need for changes in antifungal therapy for invasive aspergillosis (IA). As noted by the authors, there remains a paucity of quality data to support many of the decisions faced by clinicians managing patients with IA. However, we would like to highlight several other important issues, not fully addressed in that viewpoint, that play an important role in deciding when to change antifungal therapy for IA.

Circulating microRNA sequencing revealed miRNome patterns in hematology and oncology patients aiding the prognosis of invasive aspergillosis

Invasive aspergillosis (IA) may occur as a serious complication of hematological malignancy. Delays in antifungal therapy can lead to an invasive disease resulting in high mortality. Currently, there are no well-established blood circulating microRNA biomarkers or laboratory tests which can be used to diagnose IA. Therefore, we aimed to define dysregulated miRNAs in hematology and oncology (HO) patients to identify biomarkers predisposing disease. We performed an in-depth analysis of high-throughput small transcriptome sequencing data obtained from the whole blood samples of our study cohort of 50 participants including 26 high-risk HO patients and 24 controls. By integrating in silico bioinformatic analyses of small noncoding RNA data, 57 miRNAs exhibiting significant expression differences (P < 0.05) were identified between IA-infected patients and non-IA HO patients. Among these, we found 36 differentially expressed miRNAs (DEMs) irrespective of HO malignancy. Of the top ranked DEMs, we found 14 significantly deregulated miRNAs, whose expression levels were successfully quantified by qRT-PCR. MiRNA target prediction revealed the involvement of IA related miRNAs in the biological pathways of tumorigenesis, the cell cycle, the immune response, cell differentiation and apoptosis.

Comparison of the Performance of Two Galactomannan Detection Tests: Platelia Aspergillus Ag and Aspergillus Galactomannan Ag Virclia Monotest

The use of nonculture-based biomarkers such as the determination of galactomannan is sought for the diagnosis of invasive aspergillosis. To investigate the comparative yield of two tests for the detection of galactomannan in patients with or without proven or probable invasive aspergillosis. Overall, 327 samples (327 patients) were analyzed in a retrospective/prospective study performed in 3 hospitals in Madrid, comparing the determination results in serum or bronchoalveolar lavage of two techniques for galactomannan detection, namely, Platelia Aspergillus Ag (Bio-Rad) and Aspergillus galactomannan Ag Virclia Monotest (Vircell S.L.), following the manufacturer's instructions. Both techniques can automate the process, but the second technique has the advantage of individual processing and assembly of each sample without the need for the additional expense of single-dose strips in controls. In total, 288 of the 327 tests performed showed concordant results between both techniques. The agreement between both methods was к = 0.722, and the correlation between indices was ρ = 0.718. Only 39 samples showed discordant results. In those 39 cases, there were 15 patients with proven or probable invasive aspergillosis criteria. For the samples with clinical criteria as a reference, the areas under the curve of the receiver operating characteristic (ROC) curve were 0.962 for Platelia and 0.968 for VirClia. The VirClia test has been proven to be an alternative for diagnosis due to its friendlier automated format than that of the usual Platelia routine test. The VirClia test also allows individual action and, therefore, a more immediate clinical response. IMPORTANCE Invasive mycoses are increasingly present in immunosuppressed or hospitalized patients with serious illnesses, leading to high rates of morbidity and mortality. Invasive aspergillosis is an infection caused, in a percentage greater than 50%, by the genus Aspergillus. It is vitally important to make an early diagnosis that leads to the application of antifungals in the initial stage of the infection. Therefore, tools are required to help with the early diagnosis of the infection. This comparative study of two enzyme immunoassays is based on the detection of galactomannan antigen in serum and bronchoalveolar lavage samples. A new design based on chemiluminescence and presented in an automated single-dose format is compared to a conventional ELISA technique marketed for years. The results obtained from the prospective and retrospective study indicate a high correlation and degree of agreement between both techniques, as well as in their diagnostic performance.

Estimated Incidence and Prevalence of Serious Fungal Infections in Morocco

Few data are published from Morocco on fungal disease, although numerous case reports attest to a wide range of conditions in the country. Here, we estimate for the first time the incidence and prevalence of serious fungal diseases in the country. Detailed literature searches in English and French were conducted for all serious fungal infections. Demographic and individual underlying condition prevalence or annual incidence were obtained from UNAIDS (HIV), WHO (TB) and other international sources. Deterministic modelling was then applied to estimate fungal disease burden. Morocco's population in 2021 was 36,561,800. Multiple publications describe various fungal diseases, but epidemiological studies are rare. The most frequent serious fungal infections were tinea capitis (7258/100,000) and recurrent vulvovaginal candidiasis (2794/100,000 females). Chronic pulmonary aspergillosis is also common at a prevalence of 19,290 (53/100,000) because of the relatively high rate of tuberculosis. The prevalence of asthma in adults exceeds one million, of whom fungal asthma (including allergic bronchopulmonary aspergillosis (ABPA)) probably affects 42,150 (115/100,000). Data are scant on candidaemia (estimated at 5/100,000), invasive aspergillosis (estimated at 4.1/100,000), HIV-related complications such as cryptococcal meningitis and Pneumocystis pneumonia and mucormycosis. Fungal keratitis is estimated at 14/100,000). Mycetoma and chromoblastomycosis are probably rare. Fungal disease is probably common in Morocco and diagnostic capacity is good in the teaching hospitals. These estimates need confirmation with methodologically robust epidemiological studies.

Water-Soluble Nystatin and Derivative

Fungal infections are increasingly causing more morbidity and mortality, especially for immunocompromised people. In recent years, there is growing evidence that new medicine-resistant fungal strains are posing added challenges in the clinic. Nystatin is a known antifungal from the polyene family. Due to Nystatin limited solubility and high toxicity, it is used mainly to treat oral and dermal fungal infections. In search for new Nystatin derivatives and formulations, we obtained amide derivatives and a deoxycholate formulation that were not described previously for this compound. Furthermore, we tested the potency of the derivatives and formulation by the USP(81) method and minimum inhibitory concentration of Candida albicans and Aspergillus niger. Additionally, the in vitro toxicity and stability were tested, and it was found that the ethanol amide derivative of Nystatin was fully water-soluble (up to 100 mg/mL) with the same potency of Nystatin but with 13.5 times lower toxicity. The ethanol amide derivative of Nystatin is a promising candidate for future drug development.

Clinical and Epidemiological Profile of Patients with Invasive Aspergillosis from a Fourth Level Hospital in Bogota, Colombia: A Retrospective Study

Invasive aspergillosis (IA) is a severe mycosis caused by Aspergillus species. The infection mainly affects immunocompromised patients with a significant clinical burden. This study aimed to determine the clinical and epidemiological characteristics of patients diagnosed with IA in a fourth level hospital in Colombia, as these data are scarce in the country. A retrospective, observational study, from a single center was conducted with 34 male and 32 female patients, between 1 month- and 90-year-old, diagnosed with proven (18.2%), probable (74.2%) and possible (7.6%) IA, during a 21-year period. The most frequent underlying conditions for IA were chemotherapy (39.4%) and corticosteroid use (34.8%). The lung was the most common affected organ (92.4%). Computed tomography (CT) imaging findings were mainly nodules (57.6%) and consolidation (31.8%). A low positive correlation was found between serum galactomannan and hospitalization length. Aspergillus fumigatus prevailed (73.3%) in sputum and bronchoalveolar lavage cultures. Most patients were hospitalized in general wards (63.6%) and treated with voriconazole (80.3%). Mortality rate was 15.2%. Common risk factors for IA were identified in the Colombian cohort, including medications and underlying diseases. However, their frequency differs from other countries, reinforcing the idea that local surveillance is essential and at-risk patients should be carefully monitored.

Spinal epidural abscess caused by Aspergillus spp masquerading as spinal tuberculosis in a person with HIV

Spinal epidural abscess caused by Aspergillus spp is a debilitating form of invasive aspergillosis that can easily be misdiagnosed as spinal tuberculosis due to shared risk factors and clinical features. In this Grand Round, we describe a case of thoracic aspergillus spinal epidural abscess in a patient with underlying HIV infection. The initial diagnostic consideration was that of spinal tuberculosis. Consequently, despite positive microbiological cultures of Aspergillus fumigatus, antifungal therapy was delayed until histopathological evaluation of the affected tissue confirmed the presence of fungal hyphae. The patient showed an initial favourable response after surgical removal of the infected focus, but unfortunately never returned to premorbid functioning. This case highlights the importance of early diagnosis, urgent surgery, and prompt antifungal therapy for the management of aspergillus spinal epidural abscesses. Associated morbidity and mortality can be substantially increased if physicians fail to recognise this condition and do not institute appropriate and timely surgical and medical treatment.

What Is the Part of Tropical Diseases Among Infectious Complications in Renal Transplant Recipients in the Amazon? A 12-Year Multicenter Retrospective Analysis in French Guiana

BACKGROUND

Infectious complications in kidney transplant recipients (KTRs) are well studied in temperate countries but remain barely known in tropical ones. The main objective of this study was to describe infection-related hospitalizations in patients living in the Amazon, where it has never been described.

METHODS

All KTRs residing in French Guiana between 2007 and 2018 were included retrospectively. Infection-related hospitalizations were collected in the main medical centers of the territory.

RESULTS

Eighty-two patients were included, and 42 were infected during the study period (51%). Eighty-seven infections were identified. The main sites of infection were urinary, in 29% of cases (25/87), and pulmonary, in 22% of cases (19/87). When documented (48/87), bacterial infections were predominant (35/48), followed by viral (8/48), fungal (4/48), and parasitic infections (1/48). Endemic so-called tropical infections accounted for 6% of infections (5/87). Histoplasma capsulatum was the most commonly isolated fungus (2/4).

CONCLUSIONS

This study suggests that the spectrum of infections in KTRs in French Guiana differs little from that of temperate countries. Nevertheless, some tropical infections are described. More studies on fungal infections in KTRs should be undertaken to clarify the weight of histoplasmosis in these patients.

Putative invasive pulmonary aspergillosis within medical wards and intensive care units: a 4-year retrospective, observational, single-centre study

Blot and colleagues have proposed putative invasive pulmonary aspergillosis (PIPA) definitions for troublesome diagnosis in suspected patients outside the classical criteria of immunosuppression. We retrospectively included in the study all admitted patients with an Aspergillus spp. positive culture within lower airway samples. Overall, Aspergillus spp. positivity in respiratory samples was 0.97 every 1000 hospital admissions (HA): 4.94 and 0.28/1000/HA, respectively, in intensive care units (ICUs) and medical wards (MW). 66.6% fulfilled PIPA criteria, and 33.4% were defined as colonized. 69.2% of PIPA diagnosis occurred in the ICU. Antifungal therapy was appropriate in 88.5% of subjects with PIPA and 37.5% of colonized, confirming the comparison between deads and lives. Patients with PIPA in the ICUs had more frequent COPD, sepsis or septic shock, acute kidney injury (AKI), needed more surgery, mechanical ventilation (MV), vasopressors, hemodialysis, blood or platelets transfusions. PIPA in MW had associated with a history of smoking, interstitial lung disease and inhaled steroid therapy. Overall mortality within 21 days was 50%: 54.2% in ICU, 36,8% in MW. Factors associated with death were length of hospitalization, influenza, pneumonia, liver transplant, AKI, ARDS, sepsis and septic shock. PIPA in the ICU had higher disease severity and needed more organ support than MW cases, despite that cases of PIPA in MW are emerging with trends difficult to demonstrate given the problematic diagnosis.

A single-centre, retrospective study of the incidence of invasive fungal infections during 85 years of autopsy service in Brazil

Autopsy continues to play an essential role in monitoring opportunistic fungal infections. However, few studies have analysed the historical trends of fungal infections in autopsies. Here, we analyse available data on fungal infections obtained from autopsy reports during 85 years of autopsies performed by the largest autopsy service in Brazil. All invasive fungal infections presented in autopsy reports between 1930 and 2015 were included. Of the 158,404 autopsy reports analysed, 1096 involved invasive fungal infections. In general, paracoccidioidomycosis (24%) was the most frequent infection, followed by candidiasis (18%), pneumocystosis (11.7%), cryptococcosis (11%), aspergillosis (11%) and histoplasmosis (3.8%). Paracoccidioidomycosis decreased after the 1950s, whereas opportunistic fungal infections increased steadily after the 1980s during the peak of the AIDS pandemic. The lung was the most frequently affected organ (73%). Disseminated infection was present in 64.5% of cases. In 26% of the 513 cases for which clinical charts were available for review, the diagnosis of opportunistic fungal infections was performed only at autopsy. Our unique 85-year history of autopsies showed a transition from endemic to opportunistic fungal infections in São Paulo, Brazil, reflecting increased urbanization, the appearance of novel diseases, such as AIDS in the 1980s, and advances in medical care over time.

Rapid Diagnosis of IPA Relied on Calcofluor White Fluorescence Staining: Two Cases Report

Invasive pulmonary aspergillosis (IPA) is a serious infectious disease with high mortality. However, the rapid diagnosis of IPA remains difficult since the microbiological evidence is difficult to obtain or time-consuming. Thus, we attempted to rapidly diagnose two pediatric cases with respiratory failure due to IPA via bronchoalveolar lavage fluid with Calcofluor White fluorescence staining, which has rarely been used before.

Pulmonary Aspergillosis in Patients with Suspected Ventilator-associated Pneumonia in UK ICUs

Rationale:Aspergillus infection in patients with suspected ventilator-associated pneumonia remains uncharacterized because of the absence of a disease definition and limited access to sensitive diagnostic tests.Objectives: To estimate the prevalence and outcomes of Aspergillus infection in adults with suspected ventilator-associated pneumonia.Methods: Two prospective UK studies recruited 360 critically ill adults with new or worsening alveolar shadowing on chest X-ray and clinical/hematological parameters supporting suspected ventilator-associated pneumonia. Stored serum and BAL fluid were available from 194 nonneutropenic patients and underwent mycological testing. Patients were categorized as having probable Aspergillus infection using a definition comprising clinical, radiological, and mycological criteria. Mycological criteria included positive histology or microscopy, positive BAL fluid culture, galactomannan optical index of 1 or more in BAL fluid or 0.5 or more in serum.Measurements and Main Results: Of 194 patients evaluated, 24 met the definition of probable Aspergillus infection, giving an estimated prevalence of 12.4% (95% confidence interval, 8.1-17.8). All 24 patients had positive galactomannan in serum (n = 4), BAL fluid (n = 16), or both (n = 4); three patients cultured Aspergillus sp. in BAL fluid. Patients with probable Aspergillus infection had a significantly longer median duration of critical care stay (25.5 vs. 15.5 d, P = 0.02). ICU mortality was numerically higher in this group, although this was not statistically significant (33.3% vs. 22.8%; P = 0.23).Conclusions: The estimated prevalence for probable Aspergillus infection in this geographically dispersed multicenter UK cohort indicates that this condition should be considered when investigating patients with suspected ventilator-associated pneumonia, including patient groups not previously recognized to be at high risk of aspergillosis.

Comparative performance evaluation of Wako β-glucan test and Fungitell assay for the diagnosis of invasive fungal diseases

The Fungitell assay (FA) and the Wako β-glucan test (GT) are employed to measure the serum/plasma 1,3-β-D-glucan (BDG), a well-known invasive fungal disease biomarker. Data to convincingly and/or sufficiently support the GT as a valuable alternative to the FA are yet limited. In this study, we evaluated the FA and the GT to diagnose invasive aspergillosis (IA), invasive candidiasis (IC), and Pneumocystis jirovecii pneumonia (PJP). The FA and GT performances were compared in sera of patients with IA (n = 40), IC (n = 78), and PJP (n = 17) with respect to sera of control patients (n = 187). Using the manufacturer’s cutoff values of 80 pg/mL and 11 pg/mL, the sensitivity and specificity for IA diagnosis were 92.5% and 99.5% for the FA and 60.0% and 99.5% for the GT, respectively; for IC diagnosis were 100.0% and 97.3% for the FA and 91.0% and 99.5% for the GT, respectively; for PJP diagnosis were 100.0% and 97.3% for the FA and 88.2% and 99.5% for the GT, respectively. When an optimized cutoff value of 7.0 pg/mL for the GT was used, the sensitivity and specificity were 80.0% and 97.3% for IA diagnosis, 98.7% and 97.3% for IC diagnosis, and 94.1% and 97.3% for PJP diagnosis, respectively. At the 7.0-pg/mL GT cutoff, the agreement between the assays remained and/or became excellent for IA (95.1%), IC (97.3%), and PJP (96.5%), respectively. In conclusion, we show that the GT performed as well as the FA only with a lowered cutoff value for positivity. Further studies are expected to establish the equivalence of the two BDG assays.