Invasive infections caused by Blastoschizomyces capitatus and Scedosporium spp

Fungemia Due to Saprochaete capitata in a Non-Neutropenic Critically Ill Patient

Saprochaete capitata is an uncommon yeast species; its impact on non-neutropenic patients appears to be on the rise. We describe a case of S. capitata fungemia in a critically ill end-stage kidney disease (ESKD) patient on peritoneal dialysis. The patient presented with mesenteric ischemia and underwent several laparotomies during hospitalization. His hospital stay was complicated as fungemia developed and spread to multiple sites, which resulted in severe complications and ultimately led to fatal outcomes. S. capitata's diagnostic delay is a concern, but matrix-assisted laser desorption/Ionization time-of-flight (MALDI-TOF) mass spectrometry may help provide accurate identification. Our case highlights the need for prompt diagnosis and tailored antifungal therapy, especially when managing this challenging infection in immunocompromised patients.

Skin lesions by Scedosporium apiospermum and Nocardia pulmonary infection in an oncologic patient: a case report

BACKGROUND

Fungal infections, other than candidiasis and aspergillosis, are an uncommon entity. Despite this, emerging pathogens are a growing threat. In the following case report, we present the case of an immunocompromised patient suffering from two serious opportunistic infections in the same episode: the first of these, Nocardia multilobar pneumonia; and the second, skin infection by Scedosporium apiospermum. These required prolonged antibacterial and antifungal treatment.

CASE PRESENTATION

This case is a 71-year-old oncological patient admitted for recurrent pneumonias that was diagnosed for Nocardia pulmonary infection. Nervous system involvement was discarded and cotrimoxazole was started. Haemorrhagic skin ulcers in the lower limbs appeared after two weeks of hospital admission. We collected samples which were positive for Scedosporium apiospermum and we added voriconazole to the treatment. As a local complication, the patient presented a deep bruise that needed debridement. We completed 4 weeks of intravenous treatment with slow improvement and continued with oral treatment until the disappearance of the lesions occurs.

CONCLUSIONS

Opportunistic infections are a rising entity as the number of immunocompromised patients is growing due to more use of immunosuppressive therapies and transplants. Clinicians must have a high suspicion to diagnose and treat them. A fluid collaboration with Microbiology is necessary as antimicrobial resistance is frequent.

Invasive Fungal Infection Caused by Magnusiomyces capitatus in an Immunocompromised Pediatric Patient with Acute Lymphoblastic Leukemia in Mexico City: A Case Report

Magnusiomyces capitatus (also denominated “Geotrichum capitatum” and “the teleomorph stage of Saprochaete capitata”) mainly affects immunocompromised patients with hematological malignancies in rare cases of invasive fungal infections (IFIs). Few cases have been reported for pediatric patients with acute lymphoblastic leukemia (ALL), in part because conventional diagnostic methods do not consistently detect M. capitatus in infections. The current contribution describes a systemic infection in a 15-year-old female diagnosed with ALL. She arrived at the Children’s Hospital of Mexico City with a fever and neutropenia and developed symptoms of septic shock 4 days later. M. capitatus ENCB-HI-834, the causal agent, was isolated from the patient’s blood, urine, bile, and peritoneal fluid samples. It was identified with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and a phylogenetic reconstruction using internal transcribed spacer (ITS) and 28S ribosomal sequences. The phylogenetic sequence of M. capitatus ENCB-HI-834 clustered with other M. capitatus-type strains with a 100% identity. In vitro antifungal testing, conducted with the Sensititre YeastOne susceptibility system, found the following minimum inhibitory concentration (MIC) values (μg/mL): posaconazole 0.25, amphotericin B 1.0, fluconazole > 8.0, itraconazole 0.25, ketoconazole 0.5, 5-flucytosine ≤ 0.06, voriconazole 0.25, and caspofungin > 16.0. No clinical breakpoints have been defined for M. capitatus. This is the first clinical case reported in Mexico of an IFI caused by M. capitatus in a pediatric patient with ALL. It emphasizes the importance of close monitoring for a timely and accurate diagnosis of neutropenia-related IFIs to determine the proper treatment with antibiotics, antifungals, and chemotherapy for instance including children with ALL.

Saprochaete clavata Outbreak Infecting Cancer Center through Dishwasher

Saprochaete clavata is a pathogenic yeast responsible for rare outbreaks involving immunocompromised patients, especially those with hematologic malignancies. During February 2016–December 2017, we diagnosed S. clavata infections in 9 patients (8 with fungemia), including 3 within 1 month, at a cancer center in Marseille, France. The patients (median age 58 years), 4 of 9 of whom had acute myeloid leukemia, were hospitalized in 3 different wards. Ten environmental samples, including from 2 dishwashers and 4 pitchers, grew S. clavata, but no contaminated food was discovered. The outbreak ended after contaminated utensils and appliances were discarded. Whole-genome sequencing analysis demonstrated that all clinical and environmental isolates belonged to the same phylogenetic clade, which was unrelated to clades from previous S. clavata outbreaks in France. We identified a dishwasher with a deficient heating system as the vector of contamination.

Dishwashers as an Extreme Environment of Potentially Pathogenic Yeast Species

The study aimed to compare the yeast species diversity in the specific environment of dishwashers, taking into account the potential risk for users. Yeasts were isolated from ten dishwashers and from tap water supplied to the appliances. Samples were collected for mycological analyses at the beginning of each month, from February to May 2016. Four dishwasher sites (rubber seals, detergent dispensers, sprinklers, and water drains) were analyzed. The microfungi were identified by the standard procedures applied in mycological diagnostics. To confirm species identification, molecular analysis was performed based on the sequences of the D1/D2 region. The presence of microfungi was detected in 70% of the investigated appliances. Rubber seals, detergent dispensers, and water drains were the most frequently colonized elements. Thirty-five yeast strains were isolated in this study, of which twenty-seven were obtained from dishwashers and eight from tap water. The strains belonged to six genera and six species (Candida parapsilosis, Clavispora lusitaniae, Dipodascus capitatus, Exophiala dermatitidis, Meyerozyma guilliermondii, and Rhodotorula mucilaginosa). Most of the strains came from rubber seals. In this way, it was demonstrated that the dishwashers’ condition is sufficient as an ecological niche for microfungi.

Invasive Scedosporium and Lomentosora infections in the era of antifungal prophylaxis: A 20-year experience from a single centre in Spain

BACKGROUND

Non-Aspergillus mould infections such as those caused by Scedosporium apiospermum or Lomentospora prolificans are an emerging threat. Few studies have monitored their long-term incidence.

OBJECTIVES

To analyse the epidemiology, risk factors, clinical features and incidence of patients with proven and probable infections.

PATIENTS/METHODS

Patients admitted to Gregorio Marañón Hospital between 1998 and 2017 and from whom Scedosporium/Lomentospora was isolated were studied. Subjects were classified as having a probable/proven invasive fungal infection or colonization. Molecular identification and antifungal susceptibility testing of isolates causing infection were performed, as well as a description of the patients and incidence of infection.

RESULTS

One or more Scedosporium/Lomentospora isolates were identified in 67 patients. Sixteen (23.9%) patients had developed infection: 11 scedosporiosis and 5 lomentosporiosis. Stable incidence was observed throughout the study period. Most patients were immunosuppressed and the most common underlying diseases were haematologic malignancy (25%), solid organ transplantation (25%) and chronic corticoid therapy (25%). Breakthrough infection occurred in four patients, 2/11 (18.2%) cases of scedosporiosis and 2/5 (40%) of lomentosporiosis. Overall mortality was 54.5% (6/11) and 80% (4/5) in subjects with scedosporiosis and lomentosporiosis, respectively. High MICs of amphotericin B and remarkable inter-species susceptibility variability to triazoles was observed for most isolates.

CONCLUSIONS

In contrast to previous studies, the incidence of scedosporiosis and lomentosporiosis has not increased at our hospital over the years. The tendency to cause disseminated infection and a reduced susceptibility to most antifungal agents leads to high mortality.

Scedosporium Apiospermum: Rare Cause of Brain Abscess in an Immunocompetent Patient

Scedosporium apiospermum is a filamentous fungus causing a broad spectrum of clinical diseases especially in those who are immunocompromised. The common sites involved are lungs, skin, sinuses, eyes, bones, joints, and central nervous system (CNS). CNS is involved in invasive Scedosporiosis in the form of a cerebral abscess. An antecedent event of either near-drowning or history of some trauma is present in the majority of the cases where the patients' immune response remains intact. Prognosis is generally poor since the majority of the patients have coexistent medical morbidity. Surgical drainage followed by adjuvant antifungal, i.e., voriconazole therapy offers the best possible chance for survival in these patients. This case report discusses a rare event of brain abscess caused by S. apiospermum in an immunocompetent patient without any preceding precipitating factor.

Invasive Saprochaete capitata Infection in a Patient with Autosomal Recessive CARD9 Deficiency and a Review of the Literature

PURPOSE

Autosomal recessive (AR) CARD9 deficiency is an inherited immune disorder which results in impaired innate immunity against various fungi. Superficial and invasive fungal infections, mainly caused by Candida or Trichophyton species, are the hallmark of CARD9 deficiency. Together with the increasing number of CARD9-deficient patients reported, different pathogenic fungal species have been described such as Phialophora, Exophiala, Corynespora, Aureobasidium, and Ochroconis. Saprochaete capitata is an opportunistic infectious agent in immunocompromised patients and is a common cause of invasive fungal disease in patients with hematological malignancies. In this study, we investigated the causative genetic defect in a patient with S. capitata fungal infection which disseminated to lymph nodes and common bile duct.

METHODS

The identification of the isolated yeast strain was made by direct microscopic examination and confirmed by internal transcribed spacer (ITS) sequencing. We applied whole exome sequencing to search for the disease-causing mutation. Sanger sequencing was used to validate the mutation in the patient and his parents.

RESULTS

S. capitata was isolated from the biopsy specimen as the causative microorganism responsible for the invasive fungal disease in the patient. Whole exome sequencing revealed a homozygous c.883C > T, (p.Q295*) mutation in CARD9, confirmed by Sanger sequencing.

CONCLUSIONS

This is the first report of invasive Saprochaete infection associated with autosomal recessive (AR) CARD9 deficiency in the literature and thereby further extends the spectrum of fungal diseases seen in these patients.

Saprochaete Capitata Infection in an 80-Year Old Chronic Obstructive Pulmonary Disease (COPD) Patient: A Case Report

BACKGROUND:

The fungal disease caused by invasive fungus Saprochaete capitata is becoming an increasingly popular infection. Fungal pathogens mainly occur in patients with immunocompromised disorders such as hematologic malignancies, acute myeloid leukemia, transplant patients.

CASE REPORT:

In this study, we presented a COPD patient infected with S. capitata. At the first check, the patient showed cough, dyspnea, chest pain on both sides. The clinical laboratory test result was characterized with high White blood cell (12.8 G/L), HIV negative. The X ray showed bronchitis and emphysema. Bronchoscopy illustrated bronchial mucositis. CT scanner demonstrated pneumonia with fuzzy nodular lesions and thick interstitial organization in both lungs. The patient was treated with ciprofloxacin 800 mg/day; cefuroxime 2250 mmg/day. However, the fever appeared 2 weeks thereafter. The S. capitata was discovered in the bronchial fluid. The patient was then treated with fluconazole 400 mg/day for 14 days. At the end of treatment, all signs and symptoms of S. capitata infection disappeared and the patient recovered.

CONCLUSION:

This case study showed that S. capitata infection can occur in the COPD patients and fluconazole is a pertinent drug for treatment of the infection.

Magnusiomyces capitatus fungemia: The value of direct microscopy in early diagnosis

Two cases of fungemia caused by Magnusiomyces capitatus, an arthroconidial yeast-like fungus, in non-hematologic immunocompromised patients are described. Both patients died before definite diagnosis of M. capitatus was made. The report highlights that pending confirmation of the isolate by phenotypic and/or molecular methods, the characteristic morphologic features observed in Gram-stained smears of blood culture positive bottles can lead to early preliminary diagnosis, thus significantly reducing time required for initiating appropriate antifungal therapy.

Genome sequence of the opportunistic human pathogen Magnusiomyces capitatus

The yeast Magnusiomyces capitatus is an opportunistic human pathogen causing rare yet severe infections, especially in patients with hematological malignancies. Here, we report the 20.2 megabase genome sequence of an environmental strain of this species as well as the genome sequences of eight additional isolates from human and animal sources providing an insight into intraspecies variation. The distribution of single-nucleotide variants is indicative of genetic recombination events, supporting evidence for sexual reproduction in this heterothallic yeast. Using RNAseq-aided annotation, we identified genes for 6518 proteins including several expanded families such as kexin proteases and Hsp70 molecular chaperones. Several of these families are potentially associated with the ability of M. capitatus to infect and colonize humans. For the purpose of comparative analysis, we also determined the genome sequence of a closely related yeast, Magnusiomyces ingens. The genome sequences of M. capitatus and M. ingens exhibit many distinct features and represent a basis for further comparative and functional studies.

Association of bovine major histocompatibility complex (BoLA) gene polymorphism with colostrum and milk microbiota of dairy cows during the first week of lactation

BACKGROUND

The interplay between host genotype and commensal microbiota at different body sites can have important implications for health and disease. In dairy cows, polymorphism of bovine major histocompatibility complex (BoLA) gene has been associated with susceptibility to several infectious diseases, most importantly mastitis. However, mechanisms underlying this association are yet poorly understood. In the present study, we sought to explore the association of BoLA gene polymorphism with the dynamics of mammary microbiota during the first week of lactation.

RESULTS

Colostrum and milk samples were collected from multiparous Holstein dairy cows at the day of calving and days 1 and 6 after calving. Microbiota profiling was performed using high-throughput sequencing of the V1-V2 regions of the bacterial 16S rRNA genes and ITS2 region of the fungal ribosomal DNA. Polymorphism of BoLA genes was determined using PCR-RFLP of exon 2 of the BoLA-DRB3. In general, transition from colostrum to milk resulted in increased species richness and diversity of both bacterial and fungal communities. The most dominant members of intramammary microbiota included Staphylococcus, Ruminococcaceae, and Clostridiales within the bacterial community and Alternaria, Aspergillus, Candida, and Cryptococcus within the fungal community. Comparing the composition of intramammary microbiota between identified BoLA-DRB3.2 variants (n = 2) revealed distinct clustering pattern on day 0, whereas this effect was not significant on the microbiota of milk samples collected on subsequent days. On day 0, proportions of several non-aureus Staphylococcus (NAS) OTUs, including those aligned to Staphylococcus equorum, Staphylococcus gallinarum, Staphylococcus sciuri, and Staphylococcus haemolyticus, were enriched within the microbiota of one of the BoLA-DRB3.2 variants, whereas lactic acid bacteria (LAB) including Lactobacillus and Enterococcus were enriched within the colostrum microbiota of the other variant.

CONCLUSION

Our results suggest a potential role for BoLA-gene polymorphism in modulating the composition of colostrum microbiota in dairy cows. Determining whether BoLA-mediated shifts in the composition of colostrum microbiota are regulated directly by immune system or indirectly by microbiota-derived colonization resistant can have important implications for future development of preventive/therapeutic strategies for controlling mastitis.

A Case of Magnusiomyces capitatus Peritonitis Without Underlying Malignancies

Magnusiomyces capitatus is a rare cause of fungal infection in immunocompromised patients, mainly seen in hematological malignancies. M capitatus infections are extremely rare in immunocompetent patients, as it is part of normal human microbial flora. We are presenting an extremely rare case of M capitatus peritonitis in an otherwise immunocompetent patient who suffered from gastrointestinal leakage due to pancreatitis. Fungal identification was performed at reference laboratory by phenotypic characteristics and DNA sequencing of target internal transcribed spacer region of the rRNA gene and the D1-D2 domain of the large-subunit rRNA gene and susceptibility testing by Clinical and Laboratory Standards Institute guidelines (document M27-S4) broth dilution method. He was successfully treated with a combination of surgical repair and voriconazole single therapy.

Blastoschizomyces capitatus pulmonary infections in immunocompetent patients: case report, case series and literature review

Blastoschizomyces capitatus is an uncommon opportunistic yeast associated with infections in neutropaenic patients secondary to haematological malignancies, with a special predilection for the lungs. Globalisation and population migration impact on the epidemiology of infection with this organism but its effect on the immunocompetent population has rarely been described. We present here a case report, an overview of 11 other cases published between 2000 and 2016, and a comprehensive literature review of Blastoschizomyces pneumonia in the non-immunocompromised. The median age at diagnosis was 68 years (range 40-86 years) and more than half the cases reported a positive history of either current or past tobacco smoking. Six cases had either clinical or radiological evidence of chronic obstructive pulmonary disease and three had a history of prior treated tuberculosis. Fluconazole and itraconazole, alone or in combination, was the most utilised treatment. We conclude that unlike most other invasive yeast species, B. capitatus poses an infectious risk for immunocompetent patients, usually of middle to older age with risk factors for distorted lung architecture. Further research is warranted into the pathophysiology of Blastoschizomyces infections in the immunocompetent, including standardised treatment options.

Rare fungal infectious agents: a lurking enemy

In the expanding population of immunocompromised patients and those treated in intensive care units, rare fungal infectious agents have emerged as important pathogens, causing invasive infections associated with high morbidity and mortality. These infections may present either as de novo or as breakthrough invasive infections in high-risk patients with hematologic malignancies receiving prophylactic or empirical antifungal therapy or in patients with central venous catheters. Diagnosis and treatment are challenging. Physicians should have a high index of suspicion because early diagnosis is of paramount importance. Conventional diagnostic methods such as cultures and histopathology are still essential, but rapid and more specific molecular techniques for both detection and identification of the infecting pathogens are being developed and hopefully will lead to early targeted treatment. The management of invasive fungal infections is multimodal. Reversal of risk factors, if feasible, should be attempted. Surgical debridement is recommended in localized mold infections. The efficacy of various antifungal drugs is not uniform. Amphotericin B is active against most yeasts, except Trichosporon, as well as against Mucorales, Fusarium, and some species of Paecilomyces and dimorphic fungi. The use of voriconazole is suggested for the treatment of trichosporonosis and scedosporiosis. Combination treatment, though recommended as salvage therapy in some infections, is controversial in most cases. Despite the use of available antifungals, mortality remains high. The optimization of molecular-based techniques, with expansion of reference libraries and the possibility for direct detection of resistance mechanisms, is awaited with great interest in the near future. Further research is necessary, however, in order to find the best ways to confront and destroy these lurking enemies.

Isolation of the Rare Opportunistic Yeast Saprochaete capitata from Clinical Samples-Experience from a Tertiary Care Hospital in Southern India and a Brief Review of the Literature

Introduction

Saprochaete capitata (Teleomorph: Magnusiomyces capitatus) is a ubiquitous yeast found in environmental sources such as soil, water, air, plants and dairy products. It is also a part of the normal microbial flora in humans. The yeast is being increasingly reported as an opportunistic pathogen, especially in patients in the haemato-oncology setting, the infection being often mistakenly diagnosed as invasive candidiasis.

Aim

To review the epidemiological, clinical and microbiological features of six patients admitted in our hospital over a period of 10 years (from January 2007 to December 2016), from whom Saprochaete capitata was isolated.

Materials and Methods

A retrospective study was conducted and the epidemiological, clinical, imaging and microbiological data of the six patients were collected and analysed.

Results

The age of the six patients ranged from 19 years to 65 years with a median age of 53 years. There were two males and four females. In three out of the six patients, the isolation of S. capitata was considered clinically significant as the yeast was isolated repeatedly from blood and/or respiratory specimens and the clinical features could not be explained by any other alternative diagnosis. Haematological malignancy was the underlying disease in three out of the six patients while one patient was on triple immunosuppression following renal transplantation four years back. Three out of the six patients had severe neutropenia with Absolute Neutrophil Count (ANC) ≤ 500 at the time of isolation of S. capitata. Two patients with clinical features of fungal sepsis received antifungal therapy with Amphotericin B but succumbed within a short period of starting the therapy. The post renal transplant patient who presented with pneumonia recovered after treatment with a combination of Amphotericin B and Voriconazole.

Conclusion

Awareness regarding the epidemiological, clinical and microbiological aspects of invasive infections caused by S. capitata is essential for early recognition and appropriate management.

Yeasts

Yeasts are unicellular organisms that reproduce mostly by budding and less often by fission. Most medically important yeasts originate from Ascomycota or Basidiomycota. Here, we review taxonomy, epidemiology, disease spectrum, antifungal drug susceptibility patterns of medically important yeast, laboratory diagnosis, and diagnostic strategies.

An unusual case of urinary tract infection caused by Saprochaete capitata under anidulafungin treatment

Saprochaete capitata may cause uncommon severe infections, especially in immunocompromised patients. Here, we describe a rare case of urinary tract infection by S. capitata in a chronic kidney disease and diabetes mellitus patient, which occur during anidulafungin therapy. Mycological examinations of urine were positive to S. capitata identified by mass spectrometry and confirmed by ITS sequencing. Minimum inhibitory concentration (MIC) of the isolate for amphotericin B, fluconazole, itraconazole, voriconazole and, anidulafungin were 2, 16, 1, 1, and 8μg/mL, respectively. Presence of S. capitata infection was not known. Clinicians should be aware about these rare opportunistic fungal pathogens, particularly those with intrinsic or variable resistance to antifungals including echinocandins.

First case of invasive Magnusiomyces capitatus infection in Slovakia

Magnusiomyces capitatus (previously known as Geotrichum capitatum or Blastoschizomyces capitatus or Trichosporon capitatum) is a rare cause of fungal infection in immunocompromised patients. Most of these cases (87%) have been reported from the Mediterranean region, as it is extremely rare to recognize it in other regions. Here we report a first case of disseminated M. capitatus infection in Slovakia. The patient – 19 year old woman with myelodysplastic syndrome was diagnosed with M. capitatus fungemia after allogeneic stem cell transplantation. The infection occurred despite antifungal prophylaxis with micafungin, which was in vitro sensitive to the yeast. The treatment according to minimal inhibitory concentrations (micafungin, voriconazol) and granulocyte transfusions were administered. M. capitatus was cleared out from the bloodstream. However, patient died of multiple organ failure. Autopsy showed multiple lesions in organs, but did not prove presence of yeast by histopathology. M. capitatus was confirmed by polymerase chain reaction from all tested organs: heart, brain, lungs, spleen, liver and kidneys. We present the post mortem pictures showing the yeast lesions in affected organs. 2012 Elsevier Ltd. All rights reserved.

ESCMID and ECMM joint guidelines on diagnosis and management of hyalohyphomycosis: Fusarium spp., Scedosporium spp. and others

Mycoses summarized in the hyalohyphomycosis group are heterogeneous, defined by the presence of hyaline (non-dematiaceous) hyphae. The number of organisms implicated in hyalohyphomycosis is increasing and the most clinically important species belong to the genera Fusarium, Scedosporium, Acremonium, Scopulariopsis, Purpureocillium and Paecilomyces. Severely immunocompromised patients are particularly vulnerable to infection, and clinical manifestations range from colonization to chronic localized lesions to acute invasive and/or disseminated diseases. Diagnosis usually requires isolation and identification of the infecting pathogen. A poor prognosis is associated with fusariosis and early therapy of localized disease is important to prevent progression to a more aggressive or disseminated infection. Therapy should include voriconazole and surgical debridement where possible or posaconazole as salvage treatment. Voriconazole represents the first-line treatment of infections due to members of the genus Scedosporium. For Acremonium spp., Scopulariopsis spp., Purpureocillium spp. and Paecilomyces spp. the optimal antifungal treatment has not been established. Management usually consists of surgery and antifungal treatment, depending on the clinical presentation.

Epidemiology and outcome of systemic infections due to saprochaete capitata: case report and review of the literature

A case of systemic infection due to Saprochaete capitata in a patient with chronic lymphocytic leukemia is described. A review of the literature was conducted to identify all reported cases of this infection described between 1977 and August 2013. One hundred and four cases (included the present one) were identified. The median age of the patients was 56 years and 56% were males. Comorbidities included acute myeloid leukemia (52%), acute lymphoid leukemia (22%), other hematological malignancies (13%) and non-hematological diseases (9%). At the time of the infection, 82% of the patients were neutropenic. In 75% of the cases, the yeast was isolated from blood culture, in 25% from other sterile sites. Empirical treatment was done in 36% of the cases. Fifty-eight percent of the individual cases were treated with a combination or a sequential antifungal therapy. Amphotericin B was the antifungal drug most commonly used, followed by voriconazole and itraconazole. The overall crude mortality was 60%. Saprochaete capitata causes life-threatening infections in neutropenic patients. This comprehensive literature review may help the clinician to optimize the management of this rare infection.

Scedosporium apiospermum brain abscesses in an immunocompetent man with silicosis

We report a case of Scedosporium apiosporum brain abscesses in an immunocompetent 69-year-old man with a history of silicosis. Delayed diagnosis and institution of antifungal therapy was associated with neurological impairment, with subsequent complications resulting in death, highlighting the need for early diagnostic aspiration of brain abscesses non-responsive to antibiotics. We propose that, in the absence of identifiable immunosuppression, silicosis may have been a contributing factor to the development of central nervous system infection.

Emergence of Blastoschizomyces capitatus yeast infections, Central Europe

We report 5 cases of disseminated infection caused by Blastoschizomyces capitatus yeast in central Switzerland. The emergence of this yeast in an area in which it is not known to be endemic should alert clinicians caring for immunocompromised patients outside the Mediterranean region to consider infections caused by unfamiliar fungal pathogens.

Nosocomial outbreak of Blastoschizomyces capitatus associated with contaminated milk in a haematological unit

In July 2002, Blastoschizomyces capitatus was isolated from four neutropenic patients in a haematology unit. Two patients died due to disseminated infection while the other two had oropharyngeal colonisation. Nosocomial acquisition of the fungus was suspected and epidemiological and environmental studies were undertaken. To determine the potential source for the acquisition of the fungus, epidemiological relationships between the patients were investigated. We performed surveillance cultures on all patients and took environmental cultures of air, inanimate surfaces, food samples, blood products and chemotherapy drugs. No direct contact transmission between patients was found and B. capitatus was isolated only in vacuum flasks used for breakfast milk distribution. All isolates were compared by four independent molecular typing methods: pulsed-field gel electrophoresis, genomic DNA restriction endonuclease analysis, randomly amplified polymorphic DNA, and polymerase chain reaction fingerprinting using a single primer specific for one minisatellite or two microsatellite DNAs. Milk vacuum flasks and clinical strains were genetically indistinguishable by all typing techniques. Milk vacuum flasks were withdrawn from all hospital units and no further B. capitatus infection was detected. Our findings suggest that clonal dissemination of a single strain of B. capitatus from vacuum flasks used for milk distribution was responsible for this nosocomial outbreak in the haematological unit.

Breakthrough Saprochaete capitata infections in patients receiving echinocandins: case report and review of the literature

We report a rare case of a fatal Saprochaete capitata breakthrough infection in a patient with acute myeloid leukemia receiving empirical caspofungin therapy. S. capitata is an uncommon, yet emerging cause of invasive infections, especially in patients with haematological malignancies. Blood cultures from our patient yielded S. capitata which was found to be resistant, in vitro, to caspofungin. We consecutively reviewed all published cases of breakthrough infections caused by S. capitata in patients receiving echinocandins. S. capitata should be considered in those patients who remain febrile or who develop invasive mould infections while under echinocandin therapy.

Epidemiology of invasive mycoses in North America

The incidence of invasive mycoses is increasing, especially among patients who are immunocompromised or hospitalized with serious underlying diseases. Such infections may be broken into two broad categories: opportunistic and endemic. The most important agents of the opportunistic mycoses are Candida spp., Cryptococcus neoformans, Pneumocystis jirovecii, and Aspergillus spp. (although the list of potential pathogens is ever expanding); while the most commonly encountered endemic mycoses are due to Histoplasma capsulatum, Coccidioides immitis/posadasii, and Blastomyces dermatitidis. This review discusses the epidemiologic profiles of these invasive mycoses in North America, as well as risk factors for infection, and the pathogens' antifungal susceptibility.

Successful treatment of systemic Geotrichum capitatum infection by liposomal amphotericin-B, itraconazole, and voriconazole in a Japanese man

Severe systemic Geotrichum capitatum (G. capitatum) infection is rare, especially in Japan. G. capitatum infection has been reported mainly in immunocompromised patients and the prognosis is poor with a mortality rate of approximately 50-75%. Here, we report a Japanese case of systemic G. capitatum infection in a severe neutropenic patient who was receiving chemotherapy for acute myelogeneous leukemia with multilineage dysplasia. G. capitatum was isolated from blood cultures, and also formed multiple nodular lesions in lung fields. The infection was successfully cured with a combination of amphotericin B, itraconazole, and voriconazole.

Case of fatal Blastoschizomyces capitatus infection occurring in a patient receiving empiric micafungin therapy

We report the first case, to our knowledge, of Blastoschizomyces capitatus infection occurring in a patient receiving empirical echinocandin therapy for neutropenic fevers. Clinicians should consider B. capitatus infection in those neutropenic patients who remain febrile despite echinocandin therapy or who develop yeast bloodstream infections while receiving an echinocandin.

[Diagnosis of fungal pneumonia in the thoracic CT]

The importance of fungal infection of the lung in immunocompromised patients has increased substantially during the last decades. Numerically the most patients are those with neutropenia, e.g., patients with malignancies or solid organ and stem cell transplantation, chemotherapy, corticosteroid use and HIV infection. Although fungal infections can occur in immunocompetent patients, their frequency in this population is rare. The clinical symptoms such as fever accompanied with non-productive cough are unspecific. In some patients progression to hypoxemia and dyspnea may occur rapidly. In spite of improved antifungal therapy morbidity and mortality of these infections are still high. Therefore an early and non-invasive diagnosis is very important. That is why CT and even better High-Resolution-CT (HR-CT) is a very important modality in examining immunocompromised patients with a probability of fungal infection. CT is everywhere available and, as a non-invasive method, able to give the relevant diagnose efficiently. This paper should give an overview about the radiologic findings and possible differential diagnosis of diverse pulmonary fungal infections in CT. Pneumonias caused by Aspergillus, Cryptococcus, Candida, Histoplasma, Mucor and Geotrichum capitatum are illustrated.

[In vitro antifungal activity of voriconazole: New data after the first years of clinical experience]

Voriconazole has been developed to meet the increasing need for new and useful antifungal agents for the treatment of invasive mycoses. This review describes the spectrum of voriconazole antifungal activity based on data from in vitro studies published during the last three years. This survey demonstrates that voriconazole has a broad antifungal spectrum against the most common fungal pathogens being its action fungistatic for Candida and fungicidal for Aspergillus and other filamentous fungi. Overall, more than 95% of all Candida isolates tested are susceptible to voriconazole and less than 3% are resistant. Similar or even better activity rates have been described for Aspergillus, Cryptococcus and most of yeasts and moulds of medical importance. We also discuss the limitations related to the azole cross-resistance observed in some Candida glabrata isolates, the poor activity of voriconazole against Scedosporium prolificans, its activity against fungal biofilms and the great potential usefulness of combination of voriconazole with other antifungal drugs.

[Spectrum and risk factors of invasive fungal infection]

In recent years, invasive fungal infection has become a growing problem in immunosuppressed patients. Simultaneously, changes in medical practice, such as the use of anti-Candida prophylaxis with azoles, has led to a shift in the epidemiology of these infections from Candida spp. to Aspergillus and other filamentous molds. Moreover, new risk factors for invasive fungal infection have been identified and the time of onset is different from that seen a decade ago. Recognition of these trends in patients receiving novel immunosuppressive regimens has important implications for the clinical management of fungal infection in this population.

Combined voriconazole plus caspofungin therapy for the treatment of probable Geotrichum pneumonia in a leukemia patient

Infections by Geotrichum capitatum, occurring in leukemia patients, are rarely reported and generally are characterized by a poor prognosis. Here we reported a case of G. capitatum pneumonia in a patient with plasma cell leukemia, successfully treated with antifungal combination with voriconazole and caspofungin and supportive therapy.

Implantable cardioverter-defibrillator infection due to Scedosporium apiospermum

We report a case of implantable cardioverter-defibrillator infection due to Scedosporium apiospermum. This infection persisted despite systemic antifungal treatment with voriconazole and was controlled after removal of the foreign device and replacement of the involved tricuspid valve. This case underscores the importance of a combined surgical and medical approach for this complicated infection. Scedosporium species should be considered in the differential diagnosis of cardiac or intravascular device-related infections.