Aspergillosis update

A suppurative thyroiditis and perineal subcutaneous abscess related with aspergillus fumigatus: a case report and literature review

Background

Invasive aspergillosis is a complication in immunocompromised patients and commonly detected in patients with hematological malignancies, which mostly affect the lungs. Because of its high iodine content, rich blood supply and capsule, the thyroid is considered to be less prone to microbial invasion thus most infectious thyroiditis cases are caused by bacteria. However, a few case reports have described thyroid gland aspergilloses, most of which were due to disseminated invasive aspergillosis.

Case presentation

We first report a case of thyroid gland and subcutaneous labium majus aspergillosis in a Chinese patient who received long-term glucocorticoid treatment for systemic lupus erythematosus (SLE) and lupus nephritis, and then we reviewed 36 articles describing similar aspergillus infections in 41 patients.

Conclusion

We included 29 cases of diagnosed aspergillus thyroiditis and analyzed clinical findings, treatments and outcomes to provide clinical information for diagnosis and prognosis of thyroiditis caused by Aspergillus fumigatus.

Disseminated Aspergillosis due to Aspergillus niger in Immunocompetent Patient: A Case Report

Invasive aspergillosis is a major cause of morbidity and mortality in immunocompromised patients. Many cases of pulmonary, cutaneous, cerebral, and paranasal sinus aspergillosis in immunocompetent patient were defined in literature but disseminated aspergillosis is very rare. Here we present an immunocompetent case with extrapulmonary disseminated aspergillosis due to Aspergillus niger, totally recovered after effective antifungal treatment with voriconazole.

Primary invasive aspergillosis of the digestive tract: report of two cases and review of the literature

Background:

Disseminated aspergillosis is thought to occur as a result of vascular invasion from the lungs with subsequent bloodstream dissemination, and portals of entry other than sinuses and/or the respiratory tract remain speculative.

Methods:

We report two cases of primary aspergillosis in the digestive tract and present a detailed review of eight of the 23 previously-published cases for which detailed data are available.

Results and Conclusion:

These ten cases presented with symptoms suggestive of typhlitis, with further peritonitis requiring laparotomy and small bowel segmental resection. All cases were characterized by the absence of pulmonary disease at the time of histologically-confirmed gastrointestinal involvement with vascular invasion by branched Aspergillus hyphae. These cases suggest that the digestive tract may represent a portal of entry for Aspergillus species in immunocompromised patients.

Aspergillus hyphae in infected tissue: evidence of physiologic adaptation and effect on culture recovery

Microbiologic cultures of fungi are routinely incubated at ambient temperatures in room air, and the rate of recovery of Aspergillus species from clinical specimens is poor. Failure of current culture methods to mimic the physiologic temperature and low-oxygen environment found in hypha-laden infected tissue may underlie this poor recovery. Experiments were performed to compare the recovery of Aspergillus spp. incubated at 35 degrees C in 6% O(2)-10% CO(2) with that at 25 degrees C in room air. The samples tested included Aspergillus-infected tissue specimens from a dog model and human autopsies, experimental anaerobically stressed Aspergillus inocula, and 10,062 consecutive clinical specimens. Culture at 35 degrees C in 6% O(2)-10% CO(2) significantly enhanced the recovery of Aspergillus spp. from the infected autopsy tissue samples. Incubation at 35 degrees C alone resulted in approximately 10-fold-improved culture recovery from the experimentally stressed hyphae, and the 6% O(2)-10% CO(2) atmosphere independently favored growth under temperature-matched conditions. Finally, incubation at 35 degrees C (in room air) improved the overall recovery of Aspergillus spp. from clinical specimens by 31%. Culture at 35 degrees C in a microaerobic atmosphere significantly enhances the recovery of Aspergillus spp. from various sources. Aspergillus hyphae growing in infected tissue appear to be adapted to the physiologic temperature and hypoxic milieu.

Infectious diseases detected at autopsy at an urban public hospital, 1996-2001

Previous studies have demonstrated significant discrepancy rates between clinical and autopsy diagnoses. However, infectious diseases have not received emphasis in these studies. We conducted a study to determine whether the clinical and autopsy diagnoses of infectious diseases are concordant or discrepant and to determine discrepancy rates. Retrospective reviews of the records of 276 patients (adults, 182; fetuses and neonates, 94) who underwent autopsy during the years 1996 through 2001 were performed. Comparison of clinical and autopsy diagnoses was performed using the Goldman classification scheme. Of 182 adult patients, 137 (75.3%) had an infectious disease at autopsy. In 59 (43.1%) of 137 patients, the infectious disease diagnoses were unknown clinically. Of 94 fetuses and neonates, 45 (48%) had an infectious disease at autopsy. In 26 (58%) of 45 patients, the infectious disease diagnoses were unknown before death. There are substantial discrepancies between clinical and autopsy diagnoses of infectious diseases. In adults, acute bronchopneumonia is the infectious disease most often missed clinically; in fetuses and neonates, it is acute chorioamnionitis.

The significance of isolation of saprophytic molds from the lower respiratory tract in patients with cancer

BACKGROUND

Invasive infections caused by molds other than Aspergillus, Fusarium, and Zygomycetes have been reported sporadically in patients with leukemia and allogeneic bone marrow transplantation (BMT). However, the significance of lower respiratory tract cultures that are positive for these saprophytic molds in an unselected population of patients with cancer remains unclear.

METHODS

The authors evaluated the significance of respiratory specimens positive for saprophytic molds in patients with cancer using the criteria set by the European Organization for Research and Treatment of Cancer (EORTC)/Mycoses Study Group (MSG). They included the diagnostic category of indeterminate pulmonary invasive mold infection (IMI) for cases that met the criteria for probable IMI but had other pathogens concomitantly isolated from the respiratory tract.

RESULTS

Eighty-five cases with at least 1 positive culture were identified in 79 patients. Two cases were proven IMI, 29 were indeterminate IMI, 5 were possible IMI, and 49 were no IMI. All 38 cases from patients with solid tumors represented colonization compared with only 11 of the 47 cases (23%) from high-risk patients (P < 0.0001). The positive predictive value (PPV) of cultures was 0% in patients with solid tumors and ranged from 4.3% to 76.6%, depending on the analytic model used, in high-risk patients with leukemia and recipients of BMT. Cultures positive for Scedosporium spp. had a higher PPV (9.1-100%) than did cultures positive for non- Scedosporium spp. (2.8- 69.4%).

CONCLUSIONS

Adjustments of the EORTC/MSG criteria may be required for the diagnosis of invasive infections caused by saprophytic molds, especially non-Scedosporium spp., in patients with cancer.

In vitro interaction of caspofungin acetate with voriconazole against clinical isolates of Aspergillus spp

The interaction between caspofungin acetate and voriconazole was studied in vitro by using 48 clinical Aspergillus spp. isolates obtained from patients with invasive aspergillosis. MICs were determined by the NCCLS broth microdilution method. Synergy, defined as a fractional inhibitory concentration (FIC) index of <1, was detected in 87.5% of the interactions; an additive effect, defined as an FIC index of 1.0, was observed in 4.2% of the interactions; and a subadditive effect, defined as an FIC index of 1.0 to 2.0, was found in 8.3% of the interactions. No antagonism was observed. Animal models are required to validate the in vivo significance of these in vitro data presented for the combination of caspofungin and voriconazole.

The clinical spectrum of pulmonary aspergillosis

Aspergillus is a ubiquitous fungus that causes a variety of clinical syndromes in the lung, ranging from aspergilloma in patients with lung cavities, to chronic necrotizing aspergillosis in those who are mildly immunocompromised or have chronic lung disease. Invasive pulmonary aspergillosis (IPA) is a severe and commonly fatal disease that is seen in immunocompromised patients, while allergic bronchopulmonary aspergillosis is a hypersensitivity reaction to Aspergillus antigens that mainly affects patients with asthma. In light of the increasing risk factors leading to IPA, such as organ transplantation and immunosuppressive therapy, and recent advances in the diagnosis and treatment of Aspergillus-related lung diseases, it is essential for clinicians to be familiar with the clinical presentation, diagnostic methods, and approach to management of the spectrum of pulmonary aspergillosis.

Fungal infections in the immunocompromised host

In recent years many remarkable changes occurred in our way of life, producing opportunities for microbes. All these changes are related to the recent emergence of previously unrecognized diseases, or the resurgence of diseases that, at least in developed countries, were thought to be under control. This concept is reviewed regarding fungal infections and their agents in the immunocompromised host. The changing pattern of these infections, the portals of entry of fungi into the human host, fungal pathogenicity and the main predisposing factors are analyzed. Opportunistic fungal infections in cancer, organ transplant and acquired immunodeficiency syndrome patients are reviewed, specially candidiasis and aspergillosis.