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Chang CC, Harrison TS, Bicanic TA, Chayakulkeeree M, Sorrell TC, Warris A, Hagen F, Spec A, Oladele R, Govender NP, Chen SC, Mody CH, Groll AH, Chen YC, Lionakis MS, Alanio A, Castañeda E, Lizarazo J, Vidal JE, Takazono T, Hoenigl M, Alffenaar JW, Gangneux JP, Soman R, Zhu LP, Bonifaz A, Jarvis JN, Day JN, Klimko N, Salmanton-García J, Jouvion G, Meya DB, Lawrence D, Rahn S, Bongomin F, McMullan BJ, Sprute R, Nyazika TK, Beardsley J, Carlesse F, Heath CH, Ayanlowo OO, Mashedi OM, Queiroz-Telles Filho F, Hosseinipour MC, Patel AK, Temfack E, Singh N, Cornely OA, Boulware DR, Lortholary O, Pappas PG, Perfect JR. Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM. THE LANCET. INFECTIOUS DISEASES 2024; 24:e495-e512. [PMID: 38346436 DOI: 10.1016/s1473-3099(23)00731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/02/2023] [Accepted: 11/13/2023] [Indexed: 03/21/2024]
Abstract
Cryptococcosis is a major worldwide disseminated invasive fungal infection. Cryptococcosis, particularly in its most lethal manifestation of cryptococcal meningitis, accounts for substantial mortality and morbidity. The breadth of the clinical cryptococcosis syndromes, the different patient types at-risk and affected, and the vastly disparate resource settings where clinicians practice pose a complex array of challenges. Expert contributors from diverse regions of the world have collated data, reviewed the evidence, and provided insightful guideline recommendations for health practitioners across the globe. This guideline offers updated practical guidance and implementable recommendations on the clinical approaches, screening, diagnosis, management, and follow-up care of a patient with cryptococcosis and serves as a comprehensive synthesis of current evidence on cryptococcosis. This Review seeks to facilitate optimal clinical decision making on cryptococcosis and addresses the myriad of clinical complications by incorporating data from historical and contemporary clinical trials. This guideline is grounded on a set of core management principles, while acknowledging the practical challenges of antifungal access and resource limitations faced by many clinicians and patients. More than 70 societies internationally have endorsed the content, structure, evidence, recommendation, and pragmatic wisdom of this global cryptococcosis guideline to inform clinicians about the past, present, and future of care for a patient with cryptococcosis.
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Affiliation(s)
- Christina C Chang
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia; Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, VIC, Australia; Centre for the AIDS Programme of Research in South Africa, Durban, South Africa.
| | - Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Tihana A Bicanic
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tania C Sorrell
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia
| | - Adilia Warris
- Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK; Department of Infectious Diseases, Great Ormond Street Hospital, London, UK
| | - Ferry Hagen
- Faculty of Science, Institute for Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, Netherlands; Department of Medical Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Rita Oladele
- College of Medicine, University of Lagos, Lagos, Nigeria
| | - Nelesh P Govender
- Institute of Infection and Immunity, St George's University London, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK; Department of Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sharon C Chen
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia; Centre for Infectious Diseases and Microbiology Laboratory Services, Institute for Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead, NSW, Australia
| | - Christopher H Mody
- Department of Microbiology, Immunology and Infectious Diseases, Department of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Andreas H Groll
- Infectious Disease Research Program, and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany; Center for Bone Marrow Transplantation, and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan; National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Taiwan
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Alexandre Alanio
- Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, Groupe de recherche Mycologie Translationnelle, Département de Mycologie, Université Paris Cité, Paris, France; Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | | | - Jairo Lizarazo
- Department of Internal Medicine, Hospital Universitario Erasmo Meoz, Faculty of Health, Univesidad de Pamplona, Cúcuta, Colombia
| | - José E Vidal
- Departmento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil; Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clinicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Instituto de Medicina Tropical, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Takahiro Takazono
- Department of Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan; Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Martin Hoenigl
- Division of Infectious Diseases, Translational Medical Mycology Research Unit, European Confederation of Medical Mycology Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria; BioTechMed, Graz, Austria
| | - Jan-Willem Alffenaar
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia; School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jean-Pierre Gangneux
- Institute for Health, Environment and Work Research-Irset, Inserm UMR_S 1085, University of Rennes, Rennes, France; Laboratory for Parasitology and Mycology, Centre National de Référence Mycoses Invasives et Antifongiques LA Asp-C, University Hospital of Rennes, Rennes, France
| | - Rajeev Soman
- Jupiter Hospital, Pune, India; Deenanath Mangeshkar Hospital, Pune, India; Hinduja Hospital, Mumbai, India
| | - Li-Ping Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai China
| | - Alexandro Bonifaz
- Hospital General de México, Dermatology Service, Mycology section, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Jeremy N Day
- Department of Clinical Microbiology and Infection, Royal Devon and Exeter University Hospital NHS Trust, Exeter, UK
| | - Nikolai Klimko
- Department of Clinical Mycology, Allergy and Immunology, I Mechnikov North Western State Medical University, Staint Petersburg, Russia
| | - Jon Salmanton-García
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Grégory Jouvion
- Histology and Pathology Unit, Ecole nationale vétérinaire d'Alfort, Maisons-Alfort, France; Dynamyc Team, Université Paris Est Créteil and Ecole nationale vétérinaire d'Alfort, Créteil, France
| | - David B Meya
- Infectious Diseases Institute, School of Medicine, College of Heath Sciences, Makerere University, Kampala, Uganda
| | - David Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Sebastian Rahn
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Brendan J McMullan
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Infectious Diseases, Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - Rosanne Sprute
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Tinashe K Nyazika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Justin Beardsley
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia
| | - Fabianne Carlesse
- Pediatric Department, Federal University of São Paulo, São Paulo, Brazil; Oncology Pediatric Institute-IOP-GRAACC, Federal Univeristy of São Paulo, São Paulo, Brazil
| | - Christopher H Heath
- Department of Microbiology, Fiona Stanley Hospital Network, PathWest Laboratory Medicine, Perth, WA, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia; UWA Medical School, Internal Medicine, The University of Western Australia, Perth, WA, Australia
| | - Olusola O Ayanlowo
- Dermatology Unit, Department of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
| | - Olga M Mashedi
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Mina C Hosseinipour
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA; UNC Project Malawi, Lilongwe, Malawi
| | - Atul K Patel
- Department of Infectious Diseases, Sterling Hospitals, Ahmedabad, India
| | - Elvis Temfack
- Africa Centers for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Nina Singh
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Oliver A Cornely
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany; Clinical Trials Centre Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Olivier Lortholary
- Université de Paris Cité, APHP, Service des Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants Malades, Centre d'Infectiologie Necker-Pasteur, Institut Imagine, Paris, France; Institut Pasteur, CNRS, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et Antifongiques, UMR 2000, Paris, France
| | - Peter G Pappas
- Mycoses Study Group Central Unit, Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA.
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2
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Rocha MF, Bain HDC, Stone N, Meya D, Darie L, Toma AK, Lunn MPT, Mehta AR, Coughlan C. Reframing the clinical phenotype and management of cryptococcal meningitis. Pract Neurol 2024:pn-2024-004133. [PMID: 38997136 DOI: 10.1136/pn-2024-004133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2024] [Indexed: 07/14/2024]
Abstract
Cryptococcal meningitis is an important global health problem, resulting from infection with the yeast Cryptococcus, especially Cryptococcus neoformans and Cryptococcus gattii, which cause a spectrum of disease ranging from pulmonary and skin lesions to life-threatening central nervous system involvement. The diagnosis and management of cryptococcal meningitis have substantially changed in recent years. Cryptococcal meningitis often occurs in people living with advanced HIV infection, though in high-income countries with robust HIV detection and treatment programmes, it increasingly occurs in other groups, notably solid-organ transplant recipients, other immunosuppressed patients and even immunocompetent hosts. This review outlines the clinical presentation, management and prognosis of cryptococcal meningitis, including its salient differences in people living with HIV compared with HIV-negative patients. We discuss the importance of managing raised intracranial pressure and highlight the advantages of improved multidisciplinary team working involving neurologists, infectious disease specialists and neurosurgeons.
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Affiliation(s)
- Maria Francisca Rocha
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hamish D C Bain
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Neil Stone
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Lucia Darie
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ahmed K Toma
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael P T Lunn
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Arpan R Mehta
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
- MRC Protein Phosphorylation & Ubiquitylation Unit, School of Life Sciences, University of Dundee, Dundee, UK
| | - Charles Coughlan
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
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3
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Wesley SR, Vates GE, Thornburg LL. Neurologic Emergencies in Pregnancy. Obstet Gynecol 2024; 144:25-39. [PMID: 38626451 DOI: 10.1097/aog.0000000000005575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/29/2024] [Indexed: 04/18/2024]
Abstract
Neurologic emergencies in pregnancy require prompt evaluation and early, focused intervention to improve neurologic outcomes for the affected person and to avoid further injury. Neurologic events in pregnancy, although rare, present a time of extreme risk of permanent injury for the person who is pregnant. Therefore, obstetric clinicians should be well versed in the risk factors for potential neurologic events and understand the symptoms and events that should prompt evaluation for a neurologic event. In addition, they should support other specialties in aggressive and early neurologic care for the patient to improve outcomes while assessing fetal well-being and care optimization for the dyad. Obstetric clinicians can uniquely provide knowledge of changes in pregnancy physiology that can increase the risk of neurologic events, as well as change the treatment of these events. For all patients with neurologic events, "time is brain." Therefore, it is important to be aware of changes in common presenting pregnancy concerns that should prompt evaluation for other pathogeneses. Finally, pregnancy care teams should be prepared to begin the initial stabilization and management of acute neurologic emergencies, including seizure, stroke, and meningitis, while seeking aid from other medical and neurologic specialists who can support their care and interventions. Early and aggressive interventions for individuals with neurologic events during pregnancy and postpartum are critical to the overall well-being of the dyad.
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Affiliation(s)
- Shaun R Wesley
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, and the Division of Neuroendocrine Disorders, Department of Neurosurgery, University of Rochester, Rochester, New York
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4
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Morris AJ, Kim HY, Nield B, Dao A, McMullan B, Alastruey-Izquierdo A, Colombo AL, Heim J, Wahyuningsih R, Le T, Chiller TM, Forastiero A, Chakrabarti A, Harrison TS, Bongomin F, Galas M, Siswanto S, Dagne DA, Roitberg F, Gigante V, Beardsley J, Sati H, Alffenaar JW, Morrissey CO. Talaromyces marneffei, Coccidioides species, and Paracoccidioides species-a systematic review to inform the World Health Organization priority list of fungal pathogens. Med Mycol 2024; 62:myad133. [PMID: 38935909 PMCID: PMC11210613 DOI: 10.1093/mmy/myad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/18/2023] [Accepted: 12/11/2023] [Indexed: 06/29/2024] Open
Abstract
The World Health Organization, in response to the growing burden of fungal disease, established a process to develop a fungal pathogen priority list. This systematic review aimed to evaluate the epidemiology and impact of infections caused by Talaromyces marneffei, Coccidioides species, and Paracoccidioides species. PubMed and Web of Sciences databases were searched to identify studies published between 1 January 2011 and 23 February 2021 reporting on mortality, complications and sequelae, antifungal susceptibility, preventability, annual incidence, and trends. Overall, 25, 17, and 6 articles were included for T. marneffei, Coccidioides spp. and Paracoccidioides spp., respectively. Mortality rates were high in those with invasive talaromycosis and paracoccidioidomycosis (up to 21% and 22.7%, respectively). Hospitalization was frequent in those with coccidioidomycosis (up to 84%), and while the duration was short (mean/median 3-7 days), readmission was common (38%). Reduced susceptibility to fluconazole and echinocandins was observed for T. marneffei and Coccidioides spp., whereas >88% of T. marneffei isolates had minimum inhibitory concentration values ≤0.015 μg/ml for itraconazole, posaconazole, and voriconazole. Risk factors for mortality in those with talaromycosis included low CD4 counts (odds ratio 2.90 when CD4 count <200 cells/μl compared with 24.26 when CD4 count <50 cells/μl). Outbreaks of coccidioidomycosis and paracoccidioidomycosis were associated with construction work (relative risk 4.4-210.6 and 5.7-times increase, respectively). In the United States of America, cases of coccidioidomycosis increased between 2014 and 2017 (from 8232 to 14 364/year). National and global surveillance as well as more detailed studies to better define sequelae, risk factors, outcomes, global distribution, and trends are required.
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Affiliation(s)
- Arthur J Morris
- Department of Microbiology, Auckland City Hospital, Te Toku Tumai, Grafton, Auckland, New Zealand
| | - Hannah Yejin Kim
- The University of Sydney, Infectious Diseases Institute (Sydney ID), New South Wales, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
| | - Blake Nield
- Department of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Aiken Dao
- The University of Sydney, Infectious Diseases Institute (Sydney ID), New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
- Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Brendan McMullan
- School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Infectious Diseases, Sydney Children’s Hospital, Randwick, New South Wales, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Arnaldo Lopes Colombo
- Departamento de Medicina, Division of Infectious Diseases, Hospital São Paulo, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Jutta Heim
- Global Antibiotics Research and Development Partnership, Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Retno Wahyuningsih
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Department of Parasitology, Faculty of Medicine, Universitas Kristen, Jakarta, Indonesia
| | - Thuy Le
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, USA
- Tropical Medicine Research Center for Talaromycosis, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Tom M Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Agustina Forastiero
- Department of Communicable Diseases Prevention, Control and Elimination, Pan American Health Organization,Washington, DC, USA
| | | | - Thomas S Harrison
- Institute for Infection and Immunity, and Clinical Academic Group in Infection and Immunity, St. George’s, University of London, and St. George’s University Hospitals NHS Foundation Trust, London, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Marcelo Galas
- Antimicrobial Resistance Special Program, Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization, Washington, DC, USA
| | - Siswanto Siswanto
- World Health Organization, South-East Asia Region Office, New Delhi, India
| | - Daniel Argaw Dagne
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Felipe Roitberg
- Department of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
| | - Valeria Gigante
- Impact Initiatives and Research Coordination Unit, Global Coordination Department, Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | - Justin Beardsley
- The University of Sydney, Infectious Diseases Institute (Sydney ID), New South Wales, Australia
- Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Hatim Sati
- Impact Initiatives and Research Coordination Unit, Global Coordination Department, Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | - Jan-Willem Alffenaar
- The University of Sydney, Infectious Diseases Institute (Sydney ID), New South Wales, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
| | - Catherine Orla Morrissey
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Victoria, Australia
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5
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Dao A, Kim HY, Halliday CL, Oladele R, Rickerts V, Govender MMed NP, Shin JH, Heim J, Ford NP, Nahrgang SA, Gigante V, Beardsley J, Sati H, Morrissey CO, Alffenaar JW, Alastruey-Izquierdo A. Histoplasmosis: A systematic review to inform the World Health Organization of a fungal priority pathogens list. Med Mycol 2024; 62:myae039. [PMID: 38935903 PMCID: PMC11210611 DOI: 10.1093/mmy/myae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/30/2023] [Accepted: 04/29/2024] [Indexed: 06/29/2024] Open
Abstract
Histoplasmosis, a significant mycosis primarily prevalent in Africa, North and South America, with emerging reports globally, poses notable health challenges, particularly in immunocompromised individuals such as people living with HIV/AIDS and organ transplant recipients. This systematic review, aimed at informing the World Health Organization's Fungal Priority Pathogens List, critically examines literature from 2011 to 2021 using PubMed and Web of Science, focusing on the incidence, mortality, morbidity, antifungal resistance, preventability, and distribution of Histoplasma. We also found a high prevalence (22%-44%) in people living with HIV, with mortality rates ranging from 21% to 53%. Despite limited data, the prevalence of histoplasmosis seems stable, with lower estimates in Europe. Complications such as central nervous system disease, pulmonary issues, and lymphoedema due to granuloma or sclerosis are noted, though their burden remains uncertain. Antifungal susceptibility varies, particularly against fluconazole (MIC: ≥32 mg/l) and caspofungin (MICs: 4-32 mg/l), while resistance to amphotericin B (MIC: 0.125-0.16 mg/l), itraconazole (MICs: 0.004-0.125 mg/l), and voriconazole (MICs: 0.004-0.125 mg/l) remains low. This review identifies critical knowledge gaps, underlining the need for robust, globally representative surveillance systems to better understand and combat this fungal threat.
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Affiliation(s)
- Aiken Dao
- Sydney Infectious Diseases Institute, The University of Sydney, Westmead, New South Wales, Australia
- Westmead Institute for Medical Research, Westmead, New South Wales, Australia
- Westmead Clinical School, Westmead Hospital, Westmead, New South Wales, Australia
| | - Hannah Yejin Kim
- Sydney Infectious Diseases Institute, The University of Sydney, Westmead, New South Wales, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- Department of Pharmacy, Westmead Hospital, Westmead, New South Wales, Australia
| | - Catriona L Halliday
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Rita Oladele
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos, Nigeria
| | | | - Nelesh P Govender MMed
- National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Infection and Immunity, St George’s University of London, London, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Jong-Hee Shin
- Department of Laboratory Medicine, Chonnam National University School of Medicine, Gwangju, South Korea
| | - Jutta Heim
- Scientific Advisory Committee, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Nathan Paul Ford
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Saskia Andrea Nahrgang
- Antimicrobial Resistance Programme, World Health Organization European Office, Copenhagen, Denmark
| | - Valeria Gigante
- AMR Division, World Health Organization, Geneva, Switzerland
| | - Justin Beardsley
- Sydney Infectious Diseases Institute, The University of Sydney, Westmead, New South Wales, Australia
- Westmead Institute for Medical Research, Westmead, New South Wales, Australia
- Westmead Clinical School, Westmead Hospital, Westmead, New South Wales, Australia
| | - Hatim Sati
- AMR Division, World Health Organization, Geneva, Switzerland
| | - C Orla Morrissey
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jan-Willem Alffenaar
- Sydney Infectious Diseases Institute, The University of Sydney, Westmead, New South Wales, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- Department of Pharmacy, Westmead Hospital, Westmead, New South Wales, Australia
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
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6
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Anis H, Shaik AB, Berjaoui C, Karabulut E, Tiwari A, Nazir A, Hamitoglu AE, Uwishema O. Rising meningitis in USA and Mexico: insights from the fatal outbreak. Ann Med Surg (Lond) 2024; 86:279-283. [PMID: 38222676 PMCID: PMC10783312 DOI: 10.1097/ms9.0000000000001463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/21/2023] [Indexed: 01/16/2024] Open
Abstract
Meningitis, an inflammatory disease affecting the meningeal layers of the brain and the spinal cord, poses a significant public health concern globally. Most meningitis cases are caused by viral infections, bacterial infections being the second most common cause, while fungal or parasitic infections are deemed rare. Despite the decrease in bacterial meningitis because of vaccination and treatment, a recent meningitis outbreak in the United States and Mexico highlighted ongoing challenges. The current meningitis outbreak is caused by a pathogenic fungus and is associated with surgical procedures performed under spinal anaesthesia as reported by the Centers for Disease Control and Prevention (CDC) on the 11 May of 2023. Around 20 cases with clinical suspicion of meningitis, including two fatalities, have been attributed to this rampant outbreak. Timely diagnosis, utilising diagnostic modalities such as lumbar puncture and pathogen detection methods, is crucial for appropriate management. Iatrogenic meningitis must be avoided by enhancing surveillance, infection control procedures, and adherence to aseptic practices. To lessen the effects of meningitis and enhance patient outcomes, the WHO's roadmap and preventive interventions, such as targeted immunisations, are essential.
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Affiliation(s)
- Heeba Anis
- Oli Health Magazine Organization, Research, and Education, Kigali, Rwanda
- Deccan College of Medical Sciences, Hyderabad, Telangana
| | - Akbar Basha Shaik
- Oli Health Magazine Organization, Research, and Education, Kigali, Rwanda
- Deccan College of Medical Sciences, Hyderabad, Telangana
| | - Christin Berjaoui
- Oli Health Magazine Organization, Research, and Education, Kigali, Rwanda
- Beirut Arab University, Faculty of Medicine, Beirut, Lebanon
| | - Ece Karabulut
- Oli Health Magazine Organization, Research, and Education, Kigali, Rwanda
- Faculty of Medicine, Karadeniz Technical University, Trabzon
| | - Angad Tiwari
- Oli Health Magazine Organization, Research, and Education, Kigali, Rwanda
- Maharani Laxmi Bai Medical College, Jhansi, Uttar Pradesh, India
| | - Abubakar Nazir
- Oli Health Magazine Organization, Research, and Education, Kigali, Rwanda
- King Edward Medical University, Lahore, Pakistan
| | - Ali Emir Hamitoglu
- Oli Health Magazine Organization, Research, and Education, Kigali, Rwanda
- Namik Kemal University, Faculty of Medicine, Tekirdag, Turkey
| | - Olivier Uwishema
- Oli Health Magazine Organization, Research, and Education, Kigali, Rwanda
- Faculty of Medicine, Karadeniz Technical University, Trabzon
- Clinton Global Initiative University, New York, NY
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7
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Reguera-Gomez M, Dores MR, Martinez LR. Innovative and potential treatments for fungal central nervous system infections. Curr Opin Microbiol 2023; 76:102397. [PMID: 37898052 DOI: 10.1016/j.mib.2023.102397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/12/2023] [Accepted: 09/25/2023] [Indexed: 10/30/2023]
Abstract
Fungal infections of the central nervous system (FI-CNS) are a problematic and important medical challenge considering that those most affected are immunocompromised. Individuals with systemic cryptococcosis (67-84%), candidiasis (3-64%), blastomycosis (40%), coccidioidomycosis (25%), histoplasmosis (5-20%), mucormycosis (12%), and aspergillosis (4-6%) are highly susceptible to develop CNS involvement, which often results in high mortality (15-100%) depending on the mycosis and the affected immunosuppressed population. Current antifungal drugs are limited, prone to resistance, present host toxicity, and show reduced brain penetration, making FI-CNS very difficult to treat. Given these limitations and the rise in FI-CNS, there is a need for innovative strategies for therapeutic development and treatments to manage FI-CNS in at-risk populations. Here, we discuss standards of care, antifungal drug candidates, and novel molecular targets in the blood-brain barrier, which is a protective structure that regulates movement of particles in and out of the brain, to prevent and combat FI-CNS.
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Affiliation(s)
- Marta Reguera-Gomez
- Department of Oral Biology, College of Dentistry, University of Florida, Gainesville, FL, USA
| | - Michael R Dores
- Department of Biology, Hofstra University, Hempstead, NY, USA
| | - Luis R Martinez
- Department of Oral Biology, College of Dentistry, University of Florida, Gainesville, FL, USA; Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA; Center for Immunology and Transplantation, Gainesville, FL, USA; Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL, USA.
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8
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Palackdkharry CS, Wottrich S, Dienes E, Bydon M, Steinmetz MP, Traynelis VC. The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis). PLoS One 2022; 17:e0274634. [PMID: 36178925 PMCID: PMC9524710 DOI: 10.1371/journal.pone.0274634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND & IMPORTANCE This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward. METHODS The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions. RESULTS Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic. DISCUSSION & CONCLUSION DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.
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Affiliation(s)
| | - Stephanie Wottrich
- Case Western Reserve School of Medicine, Cleveland, Ohio, United States of America
| | - Erin Dienes
- Arcsology®, Mead, Colorado, United States of America
| | - Mohamad Bydon
- Department of Neurologic Surgery, Orthopedic Surgery, and Health Services Research, Mayo Clinic School of Medicine, Rochester, Minnesota, United States of America
| | - Michael P. Steinmetz
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine Neurologic Institute, Cleveland, Ohio, United States of America
| | - Vincent C. Traynelis
- Department of Neurosurgery, Rush University School of Medicine, Chicago, Illinois, United States of America
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9
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Santiago-Burgos EJ, Stuckey PV, Santiago-Tirado FH. Real-time visualization of phagosomal pH manipulation by Cryptococcus neoformans in an immune signal-dependent way. Front Cell Infect Microbiol 2022; 12:967486. [PMID: 36211949 PMCID: PMC9538179 DOI: 10.3389/fcimb.2022.967486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 09/08/2022] [Indexed: 11/21/2022] Open
Abstract
Understanding of how intracellular pathogens survive in their host cells is important to improve management of their diseases. This has been fruitful for intracellular bacteria, but it is an understudied area in fungal pathogens. Here we start elucidating and characterizing the strategies used by one of the commonest fungal pathogens, Cryptococcus neoformans, to survive intracellularly. The ability of the fungus to survive inside host cells is one of the main drivers of disease progression, yet it is unclear whether C. neoformans resides in a fully acidified, partially acidic, or neutral phagosome. Using a dye that only fluoresce under acidic conditions to stain C. neoformans, a hypha-defective Candida albicans mutant, and the nonpathogenic Saccharomyces cerevisiae, we characterized the fungal behaviors in infected macrophages by live microscopy. The main behavior in the C. albicans mutant strain and S. cerevisiae-phagosomes was rapid acidification after internalization, which remained for the duration of the imaging. In contrast, a significant number of C. neoformans-phagosomes exhibited alternative behaviors distinct from the normal phagosomal maturation: some phagosomes acidified with subsequent loss of acidification, and other phagosomes never acidified. Moreover, the frequency of these behaviors was affected by the immune status of the host cell. We applied the same technique to a flow cytometry analysis and found that a substantial percentage of C. neoformans-phagosomes showed impaired acidification, whereas almost 100% of the S. cerevisiae-phagosomes acidify. Lastly, using a membrane-damage reporter, we show phagosome permeabilization correlates with acidification alterations, but it is not the only strategy that C. neoformans uses to manipulate phagosomal acidification. The different behaviors described here provide an explanation to the confounding literature regarding cryptococcal-phagosome acidification and the methods can be applied to study other intracellular fungal pathogens.
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Affiliation(s)
| | - Peter V. Stuckey
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN, United States
| | - Felipe H. Santiago-Tirado
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN, United States
- Eck Institute for Global Health, University of Notre Dame, Notre Dame, IN, United States
- Warren Center for Drug Discovery, University of Notre Dame, Notre Dame, IN, United States
- *Correspondence: Felipe H. Santiago-Tirado,
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10
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Ma X, Li J, Zhou D, Yang R. Direct economic burden of patients with tuberculous meningitis in western China. Acta Neurol Scand 2021; 144:535-545. [PMID: 34131900 DOI: 10.1111/ane.13485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/16/2021] [Accepted: 05/27/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To estimate the direct economic burden of tuberculous meningitis (TBM) in China for the first time. METHODS Patients who were first diagnosed with TBM from December 2015 to December 2018 in Western China Hospital were enrolled. We retrospectively collected data on demographic and clinical features, resource utilization, costs, and long-term outcomes. The patients were followed up for 15-53 months. We performed a cost-of-illness study and analyzed the cost contributors with a generalized linear model. RESULTS In total, the cases of 154 TBM patients (95 males, 59 females, aged 14-82 years) were reviewed. The average total direct cost per person was USD (United States dollars) 9,484 (range 1,822-67,285), with a mean direct medical cost of USD 8,901 (range 1,189-67,049). The average inpatient cost and drug cost after discharge were USD 6,837 (range 845-52,921) and USD 1,967 (range 0-60,423), respectively. The mean direct nonmedical cost was USD 583 (range 33-3,817), which accounted for 6.2% of the total direct cost. The average length of stay (LOS) in hospital was 25.0 days (range 6-152). A total of 117 of the patients (76.0%) had good outcomes (mRS = 0-2). There was no significant difference in the costs, LOS, or outcomes between rural and urban patients. Contributors to total direct cost were definite TBM, fever, coma, seizures, multidrug resistance, hydrocephalus, and poor long-term outcome. CONCLUSIONS Although the accessibility of medical resources in remote and rural regions has significantly improved in China, the cost of TBM imposes a catastrophic burden on patients.
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Affiliation(s)
- Xue‐Ping Ma
- West China School of Nursing Sichuan University / Department of Neurology West China Hospital, Sichuan University Chengdu China
| | - Jin‐Mei Li
- Department of Neurology West China Hospital, Sichuan University Chengdu China
| | - Dong Zhou
- Department of Neurology West China Hospital, Sichuan University Chengdu China
| | - Rong Yang
- Department of Neurology West China Hospital, Sichuan University Chengdu China
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11
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Mohzari Y, Al Musawa M, Asdaq SMB, Alattas M, Qutub M, Bamogaddam RF, Yamani A, Aldabbagh Y. Candida utilis and Stenotrophomonas maltophilia causing nosocomial meningitis following a neurosurgical procedure: A rare co-infection. J Infect Public Health 2021; 14:1715-1719. [PMID: 34700290 DOI: 10.1016/j.jiph.2021.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/23/2021] [Accepted: 10/07/2021] [Indexed: 11/19/2022] Open
Abstract
Candida utilis and Stenotrophomonas maltophilia co-infections connected to meningitis are uncommon. We describe a patient who developed C. utilis and S. maltophilia after undergoing neurosurgery and received effective nosocomial meningitis treatment. Multiple neurosurgeries were required for a 16-year-old girl due to complications. For probable nosocomial meningitis, she was treated with cefepime with vancomycin. Meropenem and liposomal amphotericin B were prescribed after her seizure and positive CSF culture for Candida utilis. Consequently, S. maltophilia was discovered in the CSF, and ceftazidime and trimethoprim-sulfamethoxazole were prescribed. The patient has been hemodynamically stable for the past two months, and consecutive CSF cultures have been negative. To the best of our knowledge, this is the first case of C. utilis and S. maltophilia co-infection that has been successfully handled.
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Affiliation(s)
- Yahya Mohzari
- Pharmacy Care Division, Clinical Pharmacy Section, King Saud Medical City, Riyadh, Saudi Arabia.
| | - Mohammed Al Musawa
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | | | - Majda Alattas
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia; Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Mohammed Qutub
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia; Pharmaceutical Care Division, Clinical Pharmacy Section, King Saud Medical City, Riyadh, Saudi Arabia
| | - Reem Faisal Bamogaddam
- Pharmaceutical Care Division, Clinical Pharmacy Section, King Saud Medical City, Riyadh, Saudi Arabia
| | - Amani Yamani
- Department of Infectious Diseases, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Yasser Aldabbagh
- Department of Infectious Diseases, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia; Department of Infectious Diseases, Al-Moosa Specialist Hospital, Al-Ahsa, Saudi Arabia
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12
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Agarkova AA, Tverskoi AV, Morozov VN, Tverskaya AV, Morozova EN, Mukhina TS. Evaluation of Rat Brain Morphology Following the Induction of Acute Meningitis Treated with Ceftriaxone. ARCHIVES OF RAZI INSTITUTE 2021; 76:1005-1012. [PMID: 35096336 PMCID: PMC8790968 DOI: 10.22092/ari.2021.355885.1733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/14/2021] [Indexed: 06/14/2023]
Abstract
The soft and delicate tissue of the brain, which is the center of our coordination, is protected by its surrounding layers. The disruption of these layers results in complicated situations and serious health problems. The brain has three protective layers of bone or skull tissue, the blood tissue layer, and finally the meningeal layer. The layer of blood tissue contains the blood vessels that are located between the skull and the meningeal membranes. If germs or foreign matter enter the fluid through the blood vessels under any circumstances and cause infection, the bones that protect the meninges will break and cause tissue damage. The present study aimed to assess the histological and immunohistochemical characteristics of the brain of rats that underwent induced acute purulent pneumococcal meningitis after antibiotic therapy with Ceftriaxone. A number of 20 white adult male Wistar rats were assigned to three groups. The first group (n=5) regarded as the control were injected with a saline solution into the subarachnoid space in an equivalent amount. The second and third groups of rats (n=5 and 10, respectively) were infected with acute purulent meningitis by the injection of 10 μl of Streptococcus pneumoniae (S. pneumonia) suspension into the subarachnoid space of the brain using a 23-G needle. The various areas of the brains of rats after meningitis induced by S. pneumoniae were examined after the treatment with Ceftriaxone. The S. pneumoniae culture was injected into the subarachnoid space in the area of the rhomboid fossa. Treatment started 18 h after the injection. On day 10, a repeated puncture was performed with the analysis of cerebrospinal fluid in order to confirm the absence of meningitis; thereafter, the animals were taken out of the experiment. No signs of meningitis were found on histological examination. Mild perivascular and pericellular focal edema were revealed with signs of overload of the lymphatic system in the brain and focal ischemic changes in neurons. The investigation of expression with caspase-3 revealed a positive reaction of individual neurons. A positive reaction with antibodies to NeuN and Doublecortin was detected in most neurons; moreover, Glial fibrillary acidic protein (GFAP)-positive astrocytes and their processes were visualized in all layers of the brain substance. The reaction with neuron-specific enolase (NSE), microtubule-associated protein 2 (MAP-2), CD 31, and CD 34 was negative. Typical structure and pictures pointed to an intact brain and purulent meningitis in the first and second groups. The microscopic image and the changes revealed during immunohistochemistry by dual corticosteroid antibodies and neuronal nuclear protein were characterized by predominantly cytoplasmic and perinuclear reactions, respectively. Some neurons are positive for caspase-3 and are related to changes in the characteristic of premature aging.
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Affiliation(s)
- A A Agarkova
- Belgorod State University, 308015, Russia, Belgorod, Pobeda St. 85
| | - A V Tverskoi
- Belgorod State University, 308015, Russia, Belgorod, Pobeda St. 85
| | - V N Morozov
- Belgorod State University, 308015, Russia, Belgorod, Pobeda St. 85
| | - A V Tverskaya
- Belgorod State University, 308015, Russia, Belgorod, Pobeda St. 85
| | - E N Morozova
- Belgorod State University, 308015, Russia, Belgorod, Pobeda St. 85
| | - T S Mukhina
- Belgorod State University, 308015, Russia, Belgorod, Pobeda St. 85
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13
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Yuan L, Chen F, Sun Y, Zhang Y, Ji X, Jin B. Candida meningitis in an infant after abdominal surgery successfully treated with intrathecal and intravenous amphotericin B: A case report. Medicine (Baltimore) 2021; 100:e27205. [PMID: 34664853 PMCID: PMC8448063 DOI: 10.1097/md.0000000000027205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/27/2021] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Studies on Candida infections in the central nervous system, especially in infants and young children that did or did not have postoperative surgery, are rarely reported. Thus far, intrathecal (i.t.) amphotericin B (AmB) is not routinely recommended as a therapy for Candida meningitis. We report the first case of Candida meningitis in an infant who underwent abdominal surgery and was successfully treated with i.t. and intravenous (i.v.) AmB in the mainland of China. PATIENT CONCERNS Candida meningitis was confirmed by culture and immunoserological tests in a 1-day-old girl after surgery. She was treated with fluconazole for 1 month, but the patient's symptoms showed no improvement. DIAGNOSES After surgery, the infant started having recurrent attacks of fever, and laboratory tests of the cerebrospinal fluid (CSF) revealed antigens of Candida tropicalis. CSF tests revealed a high total protein level and a low glucose level. She was diagnosed with a secondary Candida meningitis. INTERVENTIONS After azole therapy failure, intrathecal and intravenous AmB therapy were used as rescue therapies. OUTCOMES After nearly 2 months of AmB treatment, all repeat CSF cultures were negative, the infant was deemed stable and was discharged home, and she continued taking voriconazole orally as an outpatient. LESSONS The combination of i.t. and i.v. administration of AmB can provide a safe and effective alternative to managing this rare but severe disease.
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Affiliation(s)
- Lihua Yuan
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Chen
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yao Sun
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yong Zhang
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xing Ji
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Bo Jin
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
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14
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Nathan CL, Emmert BE, Nelson E, Berger JR. CNS fungal infections: A review. J Neurol Sci 2021; 422:117325. [PMID: 33516057 DOI: 10.1016/j.jns.2021.117325] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/23/2020] [Accepted: 01/19/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Cody L Nathan
- Departments of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian E Emmert
- Departments of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ernest Nelson
- Departments of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph R Berger
- Departments of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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15
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Kim JW, Chae SA, Kim SY, Lee NM, Yi DY, Yun SW, Lim IS. Trends in Pediatric Meningitis in South Korea during 2009 to 2017: Analysis of the Health Insurance Review and Assessment Service Database. ANNALS OF CHILD NEUROLOGY 2021. [DOI: 10.26815/acn.2020.00178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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16
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Zhang SS, Asghar S, Ye JX, Lin L, Ping QN, Chen ZP, Shao F, Xiao YY. A combination of receptor mediated transcytosis and photothermal effect promotes BBB permeability and the treatment of meningitis using itraconazole. NANOSCALE 2020; 12:23709-23720. [PMID: 33231242 DOI: 10.1039/d0nr04035e] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Fungal infections of the central nervous system (CNS) may lead to life-threatening meningitis. Itraconazole (ITZ) is an effective antifungal agent that can be used to treat various fungal infections; however, its poor solubility along with poor permeability of the blood-brain barrier (BBB) prevents it from treating meningitis. Receptor mediated transcytosis (RMT) shows modest efficacy in BBB crossing, while affinity and saturability of interactions between ligands and receptors account for the limited efficacy of RMT in crossing the BBB. Mild hyperthermia could temporarily disrupt the BBB to increase its permeability. Therefore, we speculated that the combination of mild hyperthermia with RMT could potentially increase BBB permeability of ITZ leading to improved efficacy in fungal meningitis. Here, we have constructed for the first time, apolipoprotein E (Apo E) mimicked peptide COG1410 modified polydopamine (PDA)-coated bovine serum albumin nanoparticles (ApoE-PDA@ITZ-NPs). Different levels of COG1410-modified NPs were prepared and characterized. ApoE-PDA@ITZ-NPs have a superior photothermal effect under 808 nm light irradiation and exhibited favorable plasma stability and photothermal stability. Moreover, the cellular uptake of nanoparticles increased with an increase in COG1410. H-ApoE-PDA@ITZ-NPs increased cellular uptake and in vitro BBB permeability by 4.2-fold and 4.8-fold, respectively, compared to the ITZ-NPs. Live imaging implied that H-ApoE-PDA@ITZ-NPs could significantly increase the distribution of ITZ in the brain under 808 nm light irradiation. Histopathological analysis of periodic acid-Schiff-stained brain sections of the H-ApoE-PDA@ITZ-NP treated C. albicans meningitis model indicated that H-ApoE-PDA@ITZ-NPs showed superior antifungal activity after 808 nm light irradiation. Hence, we report ApoE-PDA@ITZ-NPs in tandem with 808 nm irradiation as a novel strategy of RMT combination with a photothermal effect in enhancing BBB permeability to facilitate drug accumulation in the brain region and enhance the therapeutic efficacy of ITZ in meningitis.
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Affiliation(s)
- Shan-Shan Zhang
- Department of Pharmaceutics, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China.
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Sociodemographic factors associated with patients hospitalised for coccidioidomycosis in California and Arizona, State Inpatient Database 2005-2011. Epidemiol Infect 2020; 149:e127. [PMID: 33213547 PMCID: PMC8167904 DOI: 10.1017/s0950268820002836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Coccidioidomycosis is endemic in the Southwestern United States. Disseminated infection can be life-threatening and is responsible for hospitalisation and significant healthcare resource utilisation. There are limited data evaluating factors associated with hospitalisation for coccidioidomycosis. We conducted a cross-sectional study to assess incidence and factors associated with coccidioidomycosis-associated hospitalisation in California and Arizona. We analysed hospital discharge data obtained from the State Inpatient Dataset for California and Arizona between 2005 and 2011 and performed multivariable logistic regression examining factors associated with coccidioidomycosis-associated hospitalisation. During our time frame, we found 23 758 coccidioidomycosis-associated hospitalisations. Coccidioidomycosis incidence was over sixfold higher in Arizona compared to California (198.9 vs. 29.6/100 000 person-years). In our multivariable model, coccidioidomycosis-associated hospitalisation was associated with age group 40-49 years (referent group: age 18-29 years, adjusted odds ratio (aOR) = 1.50 (95% confidence interval (CI) 1.43-1.59)), African American race (referent group: Caucasian, aOR = 1.98 (95% CI 1.89-2.06)), residing in a large rural town (referent group: urban area, aOR = 2.28 (95% CI 2.19-2.39)), uncomplicated diabetes (aOR = 1.47 (95% CI 1.41-1.52)) chronic obstructive pulmonary disease (aOR = 1.59 (95% CI 1.54-1.65)) and higher number of comorbidities (aOR = 1.02 (95% CI 1.02-1.03) for each point in the Elixhauser score). Identifying persons at highest risk for hospitalisation with coccidioidomycosis may be helpful for future prevention efforts.
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Benedict K, Jackson BR, Chiller T, Beer KD. Estimation of Direct Healthcare Costs of Fungal Diseases in the United States. Clin Infect Dis 2020; 68:1791-1797. [PMID: 30204844 DOI: 10.1093/cid/ciy776] [Citation(s) in RCA: 242] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/06/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Fungal diseases range from relatively-minor superficial and mucosal infections to severe, life-threatening systemic infections. Delayed diagnosis and treatment can lead to poor patient outcomes and high medical costs. The overall burden of fungal diseases in the United States is challenging to quantify, because they are likely substantially underdiagnosed. METHODS To estimate the total, national, direct medical costs associated with fungal diseases from a healthcare payer perspective, we used insurance claims data from the Truven Health MarketScan 2014 Research Databases, combined with hospital discharge data from the 2014 Healthcare Cost and Utilization Project National Inpatient Sample and outpatient visit data from the 2005-2014 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. All costs were adjusted to 2017 dollars. RESULTS We estimate that fungal diseases cost more than $7.2 billion in 2017, including $4.5 billion from 75055 hospitalizations and $2.6 billion from 8993230 outpatient visits. Hospitalizations for Candida infections (n = 26735, total cost $1.4 billion) and Aspergillus infections (n = 14820, total cost $1.2 billion) accounted for the highest total hospitalization costs of any disease. Over half of outpatient visits were for dermatophyte infections (4981444 visits, total cost $802 million), and 3639037 visits occurred for non-invasive candidiasis (total cost $1.6 billion). CONCLUSIONS Fungal diseases impose a considerable economic burden on the healthcare system. Our results likely underestimate their true costs, because they are underdiagnosed. More comprehensive estimates of the public health impact of these diseases are needed to improve their recognition, prevention, diagnosis, and treatment.
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Affiliation(s)
- Kaitlin Benedict
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brendan R Jackson
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Karlyn D Beer
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
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Update on fungal infections of the central nervous system: emerging pathogens and emerging diagnostics. Curr Opin Infect Dis 2020; 32:277-284. [PMID: 30921084 DOI: 10.1097/qco.0000000000000541] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Fungal infections of the central nervous system (CNS) are relatively uncommon but associated with significant morbidity and mortality. We reviewed recent literature highlighting new approaches to management of these complex patients. RECENT FINDINGS Fungal infections are increasingly recognized as important causes of CNS disease in both immunocompromised and immunocompetent hosts. Globally, cryptococcal meningitis remains a leading cause of death in HIV-infected persons in resource-limited settings. Emerging fungal pathogens with increased virulence and resistance to numerous classes of antifungal agents have been identified and represent a management challenge. Newer diagnostic techniques focused on antigen detection or molecular amplification of fungal pathogens offer promise in the expediated diagnosis and treatment of CNS fungal infections. SUMMARY Meningitis and brain abscess because of invasive fungal pathogens are frequently fatal infections. Newer laboratory tests allowing antigen detection or molecular amplification from cerebrospinal fluid are more sensitive than culture and allow earlier initiation of effective therapy.
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Affiliation(s)
| | | | - Tiziana Ascione
- Department of Infectious Diseases, D. Cotugno Hospital, AORN Dei Colli, Naples, Italy
| | - Anna M Spera
- Department of Infectious Diseases, University of Salerno, Italy
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Abstract
Infectious meningitis can be caused by viral, bacterial or fungal pathogens. Despite widely available treatments, many types of infectious meningitis are still associated with significant morbidity and mortality. Delay in diagnosis contributes to poor outcomes. Cerebrospinal fluid cultures have been used traditionally but are time intensive and sensitivity is decreased by empiric treatment prior to culture. More rapid techniques such as the cryptococcal lateral flow assay (IMMY), GeneXpert MTB/Rif Ultra (Cepheid) and FilmArray multiplex-PCR (Biofire) are three examples that have drastically changed meningitis diagnostics. This review will discuss a holistic approach to diagnosing bacterial, mycobacterial, viral and fungal meningitis.
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Affiliation(s)
- Victoria Poplin
- Department of Medicine, University of Kansas, Kansas City, KS 66160, USA
| | - David R Boulware
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66160, USA
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22
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Efficacy of Cerebrospinal Fluid Beta-d-Glucan Diagnostic Testing for Fungal Meningitis: a Systematic Review. J Clin Microbiol 2020; 58:JCM.02094-19. [PMID: 31996446 DOI: 10.1128/jcm.02094-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 01/25/2020] [Indexed: 12/15/2022] Open
Abstract
Several case reports and cohort studies have examined the use of (1,3)-beta-d-glucan measurement with cerebrospinal fluid to diagnose fungal meningitis. This systematic review aims to characterize the evidence regarding cerebrospinal fluid (1,3)-beta-d-glucan measurement to detect fungal meningitis. We searched PubMed for (1,3)-beta-d-glucan and each of several distinct fungi, cerebrospinal fluid, and meningitis. Summary data including diagnostic performance (where applicable) were recorded. A total of 939 records were examined via a PubMed search. One hundred eighteen records remained after duplicates were removed, and 104 records were excluded, as they did not examine cerebrospinal fluid, included animals, or focused on nonfungal infections. Fourteen studies were included in this systematic review. A variety of fungi, including species of Candida, Aspergillus, Exserohilum, Cryptococcus, Histoplasma, and Coccidioides, were studied, although most were case reports. Diagnostic accuracy was examined in 5 studies. Cerebrospinal fluid (CSF) (1,3)-beta-d-glucan measurement showed >95% sensitivity in the corticosteroid injection-related outbreak of Exserohilum rostratum One study in Histoplasma meningitis found 53% (53/87) sensitivity and 87% (133/153) specificity, while another study of Cryptococcus meningitis found 89% (69/78) sensitivity and 85% (33/39) specificity. CSF (1,3)-beta-d-glucan testing may be useful, primarily as a nonspecific marker of fungal meningitis. Although the FDA black box warning states that Cryptococcus spp. do not make (1,3)-beta-d-glucan, the current evidence shows that (1,3)-beta-d-glucan is detectable in cryptococcal meningitis. Organism-specific testing should be used in conjunction with (1,3)-beta-d-glucan measurement.
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Trzoss M, Covel JA, Kapoor M, Moloney MK, Soltow QA, Webb PJ, Shaw KJ. Synthesis of analogs of the Gwt1 inhibitor manogepix (APX001A) and in vitro evaluation against Cryptococcus spp. Bioorg Med Chem Lett 2019; 29:126713. [PMID: 31668974 PMCID: PMC6901109 DOI: 10.1016/j.bmcl.2019.126713] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 12/14/2022]
Abstract
Fosmanogepix (APX001) is a first-in-class prodrug molecule that is currently in Phase 2 clinical trials for invasive fungal infections. The active moiety manogepix (APX001A) inhibits the novel fungal protein Gwt1. Gwt1 catalyzes an early step in the GPI anchor biosynthesis pathway. Here we describe the synthesis and evaluation of 292 new and 24 previously described analogs that were synthesized using a series of advanced intermediates to allow for rapid analoging. Several compounds demonstrated significantly (8- to 32-fold) improved antifungal activity against both Cryptococcus neoformans and C. gattii as compared to manogepix. Further in vitro characterization identified three analogs with a similar preliminary safety and in vitro profile to manogepix and superior activity against Cryptococcus spp.
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Affiliation(s)
- Michael Trzoss
- Amplyx Pharmaceuticals, 12730 High Bluff Dr #160, San Diego, CA 92130, United States.
| | - Jonathan A Covel
- Amplyx Pharmaceuticals, 12730 High Bluff Dr #160, San Diego, CA 92130, United States
| | - Mili Kapoor
- Amplyx Pharmaceuticals, 12730 High Bluff Dr #160, San Diego, CA 92130, United States
| | - Molly K Moloney
- Amplyx Pharmaceuticals, 12730 High Bluff Dr #160, San Diego, CA 92130, United States
| | - Quinlyn A Soltow
- Amplyx Pharmaceuticals, 12730 High Bluff Dr #160, San Diego, CA 92130, United States
| | - Peter J Webb
- Amplyx Pharmaceuticals, 12730 High Bluff Dr #160, San Diego, CA 92130, United States
| | - Karen Joy Shaw
- Amplyx Pharmaceuticals, 12730 High Bluff Dr #160, San Diego, CA 92130, United States.
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Smilnak GJ, Charalambous LT, Cutshaw D, Premji AM, Giamberardino CD, Ballard CG, Bartuska AP, Ejikeme TU, Sheng H, Verbick LZ, Hedstrom BA, Pagadala PC, McCabe AR, Perfect JR, Lad SP. Novel Treatment of Cryptococcal Meningitis via Neurapheresis Therapy. J Infect Dis 2019; 218:1147-1154. [PMID: 29788431 DOI: 10.1093/infdis/jiy286] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/11/2018] [Indexed: 11/14/2022] Open
Abstract
Cryptococcal meningitis (CM) has emerged as the most common life-threatening fungal meningitis worldwide. Current management involves a sequential, longitudinal regimen of antifungals; despite a significant improvement in survival compared with uniform mortality without treatment, this drug paradigm has not led to a consistent cure. Neurapheresis therapy, extracorporeal filtration of yeasts from cerebrospinal fluid (CSF) in infected hosts, is presented here as a novel, one-time therapy for CM. In vitro filtration of CSF through this platform yielded a 5-log reduction in concentration of the yeast and a 1-log reduction in its polysaccharide antigen over 24 hours. Additionally, an analogous closed-loop system achieved 97% clearance of yeasts from the subarachnoid space in a rabbit model over 4-6 hours. This is the first publication demonstrating the direct ability to rapidly clear, both in vitro and in vivo, the otherwise slowly removed fungal pathogen that directly contributes to the morbidity and mortality seen in CM.
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Affiliation(s)
- Gordon J Smilnak
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Lefko T Charalambous
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Drew Cutshaw
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Alykhan M Premji
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Charles D Giamberardino
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Christi G Ballard
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Andrew P Bartuska
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Tiffany U Ejikeme
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Huaxin Sheng
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | | | | | - Promila C Pagadala
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | | | - John R Perfect
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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Correa-Forero V, Pinilla-Monsalve GD, Valderrama-Chaparro JA, Amaya-Gonzalez P. Cryptococcal meningitis presenting as acute flaccid paralysis: A case report. J Infect Public Health 2019; 13:143-148. [PMID: 31350098 DOI: 10.1016/j.jiph.2019.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/23/2019] [Accepted: 06/09/2019] [Indexed: 01/18/2023] Open
Abstract
Cryptococcus is a cosmopolitan fungus with tropism for the nervous system and a higher prevalence of infection in immunosuppressed patients. Neurological compromise caused by this microorganism mainly debuts as a meningeal syndrome (headache, fever, neck stiffness) with predominant encephalic involvement. In this report we present the rare case of a non-HIV patient with flaccid paralysis and peripheral nerve involvement due to crytpococcal meningitis. This is a 53-years-old woman, with a past-medical history of diabetes, who presented with dysarthria, unilateral peripheral facial paralysis, asymmetric ascending quadriparesis, generalized hyporeflexia and urinary retention. Neuroimaging was initially reported as negative for vascular or demyelinating diseases. Electrophysiological studies were performed, and acute flaccid paralysis of undetermined etiology was defined as a temporal clinical diagnosis. Cerebrospinal fluid molecular analysis confirmed the presence of Cryptococcus neoformans var. gatti; posteriorly, antifungal treatment with amphotericin B and fluconazole was started. Polyneuroradiculopathy symptoms significantly improved over the in-hospital stay. In conclusion, spinal cord and peripheral nerve involvement by Cryptococcus is an infrequent cause of acute flaccid paralysis that should be considered in the differential diagnosis even in HIV-negative patients.
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Affiliation(s)
- Vanessa Correa-Forero
- Fundación Valle del Lili, Department of Internal Medicine, Cra. 98 No. 18-49, Cali, Colombia; Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia
| | - Gabriel D Pinilla-Monsalve
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia; Fundación Valle del Lili, Department of Neurology, Cra. 98 No. 18-49, Cali, Colombia
| | | | - Pablo Amaya-Gonzalez
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia; Fundación Valle del Lili, Department of Neurology, Cra. 98 No. 18-49, Cali, Colombia.
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26
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Denham ST, Wambaugh MA, Brown JCS. How Environmental Fungi Cause a Range of Clinical Outcomes in Susceptible Hosts. J Mol Biol 2019; 431:2982-3009. [PMID: 31078554 PMCID: PMC6646061 DOI: 10.1016/j.jmb.2019.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/18/2019] [Accepted: 05/01/2019] [Indexed: 12/11/2022]
Abstract
Environmental fungi are globally ubiquitous and human exposure is near universal. However, relatively few fungal species are capable of infecting humans, and among fungi, few exposure events lead to severe systemic infections. Systemic infections have mortality rates of up to 90%, cost the US healthcare system $7.2 billion annually, and are typically associated with immunocompromised patients. Despite this reputation, exposure to environmental fungi results in a range of outcomes, from asymptomatic latent infections to severe systemic infection. Here we discuss different exposure outcomes for five major fungal pathogens: Aspergillus, Blastomyces, Coccidioides, Cryptococcus, and Histoplasma species. These fungi include a mold, a budding yeast, and thermal dimorphic fungi. All of these species must adapt to dramatically changing environments over the course of disease. These dynamic environments include the human lung, which is the first exposure site for these organisms. Fungi must defend themselves against host immune cells while germinating and growing, which risks further exposing microbe-associated molecular patterns to the host. We discuss immune evasion strategies during early infection, from disruption of host immune cells to major changes in fungal cell morphology.
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Affiliation(s)
- Steven T Denham
- Division of Microbiology and Immunology, Pathology Department, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Morgan A Wambaugh
- Division of Microbiology and Immunology, Pathology Department, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Jessica C S Brown
- Division of Microbiology and Immunology, Pathology Department, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
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27
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Tsai WC, Lien CY, Lee JJ, Hsiao WC, Huang CR, Tsai NW, Chang CC, Lu CH, Chang WN. The clinical characteristics and therapeutic outcomes of cryptococcal meningitis in elderly patients: a hospital-based study. BMC Geriatr 2019; 19:91. [PMID: 30909914 PMCID: PMC6434878 DOI: 10.1186/s12877-019-1108-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/19/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The elderly, and especially those with an immuno-compromised status, are vulnerable to infectious diseases. The purpose of this study was to examine the clinical characteristics and therapeutic outcomes of cryptococcal meningitis (CM) in elderly patients in Taiwan. METHODS Ninety-nine adult patients with CM were identified during a 15-year study period (2002-2016), of whom 38 elderly (≥ 65 years) patients (16 men and 22 women, median age 72.9 years; range 65-86 years) were included for analysis. The clinical characteristics and therapeutic outcomes of these patients were analyzed and compared to non-elderly adult patients (< 65 years) with CM. RESULTS Among the 38 patients, diabetes mellitus was the most common underlying condition (15), followed by adrenal insufficiency (7), malignancy (6), hematologic disorders (5), chronic obstructive pulmonary disease (5), autoimmune diseases (3), liver cirrhosis (3) and acquired immunodeficiency syndrome (1). Altered consciousness (29), fever (21) and headache (17) were the leading clinical manifestations. Positive cerebrospinal fluid and blood cultures for Cryptococcus (C.) neoformans were found in 26 and 9 patients, respectively. There were significant differences in gender, altered consciousness and recent cerebral infarction between the elderly and non-elderly groups. The elderly group had a high mortality rate (36.8%, 14/38), and the presence of cryptococcemia was the most significant prognostic factor. CONCLUSIONS This study offers a preliminary view of the clinical characteristics of CM in the elderly. The results suggest that elderly patients (≥ 65 years) are more vulnerable to CM than adults aged < 65 years. Compared to the non-elderly group, the elderly group had female predominance, higher rates of altered consciousness and recent cerebral infarction as the clinical presentation. The presence of cryptococcemia was a significant prognostic factor in the elderly group. This study is limited by the small number of patients, and further large-scale studies are needed to better delineate this specific infectious syndrome.
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Affiliation(s)
- Wan-Chen Tsai
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan
| | - Chia-Yi Lien
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan
| | - Jun-Jun Lee
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan
- Department of Information Management, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Wen-Chiu Hsiao
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan
| | - Chi-Ren Huang
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan
| | - Nai-Wen Tsai
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan
| | - Chiung-Chih Chang
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan
| | - Cheng-Hsien Lu
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan
| | - Wen-Neng Chang
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan
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28
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Elkabti AB, Issi L, Rao RP. Caenorhabditis elegans as a Model Host to Monitor the Candida Infection Processes. J Fungi (Basel) 2018; 4:E123. [PMID: 30405043 PMCID: PMC6309157 DOI: 10.3390/jof4040123] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 10/31/2018] [Accepted: 11/01/2018] [Indexed: 02/07/2023] Open
Abstract
C. elegans has several advantages as an experimental host for the study of infectious diseases. Worms are easily maintained and propagated on bacterial lawns. The worms can be frozen for long term storage and still maintain viability years later. Their short generation time and large brood size of thousands of worms grown on a single petri dish, makes it relatively easy to maintain at a low cost. The typical wild type adult worm grows to approximately 1.5 mm in length and are transparent, allowing for the identification of several internal organs using an affordable dissecting microscope. A large collection of loss of function mutant strains are readily available from the C. elegans genetic stock center, making targeted genetic studies in the nematode possible. Here we describe ways in which this facile model host has been used to study Candida albicans, an opportunistic fungal pathogen that poses a serious public health threat.
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Affiliation(s)
| | - Luca Issi
- Worcester Polytechnic Institute, Worcester, MA 01609, USA.
| | - Reeta P Rao
- Worcester Polytechnic Institute, Worcester, MA 01609, USA.
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29
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Caceres A, Avila ML, Herrera ML. Fungal infections in pediatric neurosurgery. Childs Nerv Syst 2018; 34:1973-1988. [PMID: 30121829 DOI: 10.1007/s00381-018-3942-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Invasive mycosis of the central nervous system represent a diverse group of diseases that have gradually emerged as not only opportunistic infections in patients with immune susceptibility due to congenital and acquired deficiency, immunomodulation, solid organ and stem cell transplantation, hematological malignancies, and chronic steroid use but also in selected risk populations such as low weight preterm infants, patients with shunted hydrocephalus and external ventricular drainages, skull base surgery, and head injury. OBJECTIVES The purpose of this review is to familiarize the pediatric neurosurgeon with the most common mycosis and their clinical scenarios which can be encountered in the clinical practice, with special emphasis on clinical, radiological, and laboratory diagnosis beyond classical microorganism cultures as well as options in medical and surgical treatment given the high incidence of morbidity and mortality associated with these challenging entities. METHODS We conducted an online database review (Ovid, PubMed) gathering relevant English language literature published in the last 20 years with special emphasis on recent breakthroughs in the diagnosis and treatment of invasive mycosis of the CNS as well as reported cases within the pediatric neurosurgical literature and their surgical management. RESULTS Fungal agents capable of invading the CNS can behave as aggressive entities with rapid progression manifesting as overwhelming meningoencephalitis with vascular compromise or can lead to space-occupying lesions with abscess formation which require prompt diagnosis by either laboratory identification of the components of these biological agents and their host response or by obtaining tissue specimens for microbiological identification which may not be straightforward due to prolonged culture time. CONCLUSION Following a high degree of suspicion with prompt initiation of antifungal agents and reversal of potential immunosuppressant therapies along with neurosurgical evacuation of intracranial collections or removal of infected hardware (CSF shunts) can lead to more optimistic outcomes of these complex clinical scenarios.
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Affiliation(s)
- Adrian Caceres
- Neurosurgery Department, National Children's Hospital of Costa Rica, Paseo Colón y Calle 20 sur, San José, 10103, Costa Rica.
| | - Maria Luisa Avila
- Infectious Diseases Department, National Children's Hospital of Costa Rica, San José, Costa Rica
| | - Marco Luis Herrera
- Microbiology Division, Clinical Laboratory, National Children's Hospital of Costa Rica, San José, Costa Rica
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In Vitro and In Vivo Evaluation of APX001A/APX001 and Other Gwt1 Inhibitors against Cryptococcus. Antimicrob Agents Chemother 2018; 62:AAC.00523-18. [PMID: 29891599 PMCID: PMC6105804 DOI: 10.1128/aac.00523-18] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/04/2018] [Indexed: 01/21/2023] Open
Abstract
Cryptococcal meningitis (CM), caused primarily by Cryptococcus neoformans, is uniformly fatal if not treated. Treatment options are limited, especially in resource-poor geographical regions, and mortality rates remain high despite current therapies. Here we evaluated the in vitro and in vivo activity of several compounds, including APX001A and its prodrug, APX001, currently in clinical development for the treatment of invasive fungal infections. These compounds target the conserved Gwt1 enzyme that is required for the localization of glycosylphosphatidylinositol (GPI)-anchored cell wall mannoproteins in fungi. The Gwt1 inhibitors had low MIC values, ranging from 0.004 μg/ml to 0.5 μg/ml, against both C. neoformans and C. gattii APX001A and APX2020 demonstrated in vitro synergy with fluconazole (fractional inhibitory concentration index, 0.37 for both). In a CM model, APX001 and fluconazole each alone reduced the fungal burden in brain tissue (0.78 and 1.04 log10 CFU/g, respectively), whereas the combination resulted in a reduction of 3.52 log10 CFU/g brain tissue. Efficacy, as measured by a reduction in the brain and lung tissue fungal burden, was also observed for another Gwt1 inhibitor prodrug, APX2096, where dose-dependent reductions in the fungal burden ranged from 5.91 to 1.79 log10 CFU/g lung tissue and from 7.00 and 0.92 log10 CFU/g brain tissue, representing the nearly complete or complete sterilization of lung and brain tissue at the higher doses. These data support the further clinical evaluation of this new class of antifungal agents for the treatment of CM.
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