Antifungal therapy of Aspergillus invasive otitis externa: efficacy of voriconazole and review

Hand contamination and hand hygiene knowledge and practices among commercial transport users after the SARS-CoV-2 virus (COVID-19) scare, Enugu State, Nigeria

Contaminated hands are one of the most common modes of microorganism transmission that are responsible for many associated infections in healthcare, food industries, and public places such as transportation parks. Public health approaches during COVID-19 pandemic have shown that hand hygiene practices and associated knowledge are critical measure to control the spread of infectious agent. Hence, assessment of commercial transport users' knowledge, belief and practices on hand hygiene, and potential contamination with infectious agents which is the aim of the study, aligns with general health concern of quantifying contamination risk levels to predict disease outbreaks. This study utilized a randomized sampling approach to select 10 frequently used commercial parks within two districts in the State: Enugu and Nsukka. The parameters analysed include a cross-sectional questionnaire survey, hand swab and hand washed samples collected from dominant hand of participants. A total of 600 participants responded to the questionnaire survey, while 100 participants' hand swabs were examined for microbial contamination. This study recorded a high prevalence of fungal (90.0%) and bacterial (87.0%) species; 20 species of fungus were identified with prevalence range of 1% to 14%; 21 bacterial species were isolated with prevalence range of 1% to 16%. These species were identified as either opportunistic, non-invasive, or pathogenic, which may constitute a health concern amongst immunocompromised individuals within the population. Aspergillus spp. (14%), was the most common fungal species that was exclusively found amongst Nsukka commercial users, while E. coli was the most prevalent isolated bacterial species amongst Nsukka (12%) and Enugu (20%) commercial park users. Prevalence of fungal contamination in Nsukka (94.0%; 47/50) and Enugu (86.0%; 43/50) were both high. Prevalence of bacterial contamination was higher in Enugu than Nsukka but not significantly (47[94.0%] vs. 40[80.0%], p = 0.583). A greater number of participants (99.3%) were aware of the importance of hand hygiene, however with low compliance rate aside "after using the toilet" (80%) and "before eating" (90%), other relevant hand washing and sanitizing practices were considered less important. With these observations, we can emphatically say that despite the COVID-19 scare, commercial park users within the sampled population do not efficiently practice quality hand wash and hygiene measures, hence, risking the widespread of infectious agents in situation of disease outbreak or among immunocompromised individuals.

Long-Term Follow-Up of a Case of Probable Aspergillus Skull Base Osteomyelitis With Galactomannan Test and Literature Review

We report a probable case of Aspergillus basicranial infection diagnosed by pathogenic serological examination presenting atypical initial manifestations, and highlight the importance of serological examination to avoid treatment delay and disease management. An 84-year-old diabetic patient presented with right peripheral nerve palsy, intolerable otalgia, hearing loss, dysphagia, hoarseness, and bucking. The patient was diagnosed a probable Aspergillus skull base osteomyelitis with cranial neuritis and meningitis of central nervous system. Galactomannan test was used in combination with 1-3-β-D-glucan and magnetic resonance imaging to follow-up during the continuous treatment of voriconazole. To date, the patient has remained in clinical remission for over 39 months but the drug cannot be stopped safely.

Case Report: The application of metagenomic next generation sequencing in diagnosing fungal malignant external otitis: a report of two cases

Background

Most of malignant external otitis (MEO) cases reported in the literature are attributed to Pseudomonas aeruginosa. Fungal infections in MEO are also likely but extremely rare. And conventional microbiology tests is difficult to diagnose.

Case description

Two patients were diagnosed with Fungal malignant external otitis (FMEO) due to Aspergillus by metagenomic Next-Generation Sequencing (mNGS) and recovered after comprehensive treatment including operation and voriconazole. The antifungal treatment was delayed due to repeated cultures of secretions being negative and pathological examination showed granulation tissue proliferation with extensive neutrophil infiltration.

Conclusion

mNGS might be helpful for patients suspected with FMEO, especially when conventional microbiology tests were negative.

[Research progress of necrotizing otitis externa]

Necrotizing otitis externa is a progressive infectious disease involving the external auditory canal and even the skull base, which can lead to serious complications and even death if not treated in time. In this paper, the latest advances in etiology, pathogenesis, clinical manifestations, diagnosis and treatment were reviewed based on previous literature, providing reference for clinical diagnosis, treatment and future research.

Rare Cause of Skull Base Osteomyelitis: A Challenging Diagnosis and Management With a Literature Review

This is a case of skull base osteomyelitis (SBO) caused by a rare fungal species, Scedosporium apiospermum. This is a clinical case report with a review of the literature. SBO is a potentially life-threatening infection of the temporal bone. The patient presented to our hospital with a two-month history of left otalgia, otorrhea and reduced hearing, after failed initial intravenous antibiotic therapy. Thorough examination and further investigation confirmed the diagnosis of SBO caused by a rare fungal species, S. apiospermum. The patient was subsequently started on a long-term course of antifungals which led to an improvement of symptoms. This case highlights the importance of early recognition and considering early antifungal treatment in patients with persistent otalgia and otorrhea, particularly in those who have failed to respond to intravenous antibiotics. Further research is needed to better understand the optimal timing and duration of antifungal therapy in these patients.

Invasive Fungal Otitis Media in Diabetic Patients: A Case-Based Review

BACKGROUND

Invasive fungal otitis media is clinically rare. The clinical features are often atypical in the early stages of the disease, and delayed treatment results in poor outcomes.

METHODS

In this study, we report 2 patients with invasive fungal otitis media with diabetes. The early diagnosis was confirmed by comprehensive methods such as laboratory tests and imaging examinations, and the condition was significantly improved by antifungal drugs and surgical treatment.

RESULTS

By reviewing the literature, we found that invasive fungal infections confined to the middle ear and mastoid were rarely reported, and the diagnosis and treatment were still controversial.

CONCLUSION

In this article, we summarized and evaluated the different diagnoses and treatment methods so as to better diagnose and improve the cure rate in the early stage of invasive fungal infection of the middle ear.

Relapsing Aspergillus otomycosis despite prolonged systemic antifungal therapy and resolution after topical voriconazole administration: A case report

We report a case of intractable Aspergillus otomycosis with multiple relapses despite conventional topical and systemic antifungal treatment, and adjunctive usage of hyperbaric oxygen therapy. Of note, otomycosis relapsed even after six months of continuous systemic antifungal treatment with therapeutic drug levels and without treatment interruption; and only resolved after application of topical voriconazole. (max. 75 words).

Osteoarticular Mycoses

Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.

Trends and Outcomes of Fungal Temporal Bone Osteomyelitis: A Scoping Review

INTRODUCTION

Temporal bone osteomyelitis is an invasive infection most often caused by bacteria and associated with high mortality. Fungal etiologies are rare and little is known of the predictors of disease severity and outcomes in fungal temporal bone osteomyelitis.

MATERIALS AND METHODS

A scoping review was performed to determine what is known from the literature on how clinical, diagnostic, and treatment characteristics relate to patient outcomes in fungal temporal bone osteomyelitis. Using PRISMA guidelines, three databases were searched to identify all published cases of fungal temporal bone osteomyelitis. Data were extracted from each study, including clinical, diagnostic, and treatment characteristics, and outcomes.

RESULTS

Sixty-eight studies comprising 74 individual cases of fungal temporal bone osteomyelitis were included. All studies were case reports. There were high rates of diabetes, facial nerve palsy, infectious complications, and need for surgical intervention, as well as a significant delay in the evaluation and diagnosis of fungal temporal bone osteomyelitis. Disease recovery was greater in patients presenting with otorrhea, comorbid diabetes, and in those without facial nerve palsy.

DISCUSSION

Many of the defining characteristics of fungal temporal bone osteomyelitis remain unknown, and future reports should focus on determining factors that improve timely diagnosis and treatment of fungal TBO in addition to identifying prognostic indicators for outcomes and survival.

Aspergillus Genus and Its Various Human Superficial and Cutaneous Features

Superficial and cutaneous aspergillosis is a rare fungal disease that is restricted to the outer layers of the skin, nails, and the outer auditory canal, infrequently invading the deeper tissue and viscera, particularly in immunocompromised patients. These mycoses are acquired through two main routes: direct traumatic inoculation or inhalation of airborne fungal spores into paranasal sinuses and lungs. Lesions are classified into three categories: otomycosis, onychomycosis, and cutaneous aspergillosis. Superficial and cutaneous aspergillosis occurs less frequently and therefore remains poorly characterized; it usually involves sites of superficial trauma-namely, at or near intravenous entry catheter site, at the point of traumatic inoculation (orthopaedic inoculation, ear-self-cleaning, schizophrenic ear self-injuries), at surgery incision, and at the site of contact with occlusive dressings, especially in burn patients. Onychomycosis and otomycosis are more seen in immunocompetent patients, while cutaneous aspergillosis is widely described among the immunocompromised individuals. This paper is a review of related literature.

Administration of 1% topical voriconazole drops was effective and safe in the treatment of refractory otomycosis without tympanic membrane perforation

BACKGROUND

Refractory otomycosis is a common condition that is difficult to treat.

OBJECTIVES

This study aimed to evaluate the effectiveness of 1% topical voriconazole drops in the treatment of otomycosis.

METHODS

This retrospective analysis was conducted from November 2017 to November 2019. Patients who had refractory otomycosis without tympanic membrane perforation confirmed by microbial culture and fluorescent staining were included in the study. All patients were treated with 1% topical voriconazole drops hourly at daytime for 2 weeks. Evaluation of effectiveness was conducted 1 month after the completion of topical voriconazole treatment. Before and after topical voriconazole treatment, hearing tests were performed in all patients.

RESULTS

Fifty-five patients were included in this study. The reasons for refractoriness were resistant recurrence to imidazole drugs (50 cases, 90.9%) and difficulty in cleaning the external auditory canal (5 cases, 9.1%). The most common strain was Aspergillus terreus (50.9%), followed by Aspergillus flavus (29.1%), Aspergillus niger (10.9%), and Aspergillus fumigatus (9.1%). After 2 weeks of treatment with 1% topical voriconazole drops, otomycosis in all patients was resolved. There was no significant change in bone conduction before and after topical voriconazole treatment (paired t-test, P = 0.5023; linear correlation analysis, R² = 0.98; equation, y = 1.003x-0.284). Adverse effects, such as blurred vision and phototoxicity, were not observed in any patient.

CONCLUSIONS

Administration of 1% topical voriconazole drops was effective and safe in the treatment of refractory otomycosis without tympanic membrane perforation within 2 weeks.

Agricultural systems as potential sources of emerging human mycoses caused by Trichoderma: a successful, common phylotype of Trichoderma longibrachiatum in the frontline

Trichoderma species are abundant in different agricultural habitats, but some representatives of this genus, mainly clade Longibrachiatum members are also emerging as causative agents of various human diseases with even fatal outcome. Strains of these species frequently show resistance to commonly used azole antifungals. Based on previous data it is hypothesized that Trichoderma isolates identified in human infections derive from environmental-including agricultural-origins. We examined Trichoderma longibrachiatum Rifai and Trichoderma bissettii Sandoval-Denis & Guarro strains recovered from four novel cases of human mycoses, along with isolates from previous case reports and different agricultural habitats, using multilocus phylogenetic analysis, BIOLOG Phenotype Microarrays and Etest. Strains attributed to T. bissettii were more abundant in both clinical and agricultural specimens compared to T. longibrachiatum. The majority of the isolates of both taxa could tolerate >256, >32 and >32 μg/ml fluconazole, itraconazole and posaconazole, respectively. None of the obtained results revealed characteristic differences between strains of clinical and agricultural origin, nor between the two taxa, supporting that agricultural environments may be significant sources of infections caused by these emerging human fungal pathogens. Furthermore, based on our findings we propose the re-classification of T. bissettii as T. longibrachiatum f. sp. bissettii.

A retrospective review and multi-specialty, evidence-based guideline for the management of necrotising otitis externa

BACKGROUND

Necrotising otitis externa is a progressive infection of the external auditory canal which extends to affect the temporal bone and adjacent structures. Progression of the disease process can result in serious sequelae, including cranial nerve palsies and death. There is currently no formal published treatment guideline.

OBJECTIVE

This study aimed to integrate current evidence and data from our own retrospective case series in order to develop a guideline to optimise necrotising otitis externa patient management.

METHODS

A retrospective review of necrotising otitis externa cases within NHS Lothian, Scotland, between 2013 and 2018, was performed, along with a PubMed review.

RESULTS

Prevalent presenting signs, symptoms and patient demographic data were established. Furthermore, features of cases associated with adverse outcomes were defined. A key feature of the guideline is defining at-risk patients with initial intensive treatment. Investigations and outcomes are assessed and treatment adjusted appropriately.

CONCLUSION

This multi-departmental approach has facilitated the development of a succinct, systematic guideline for the management of necrotising otitis externa. Initial patient outcomes appear promising.

Aspergillus necrotizing otitis externa with temporomandibulozygomatic involvement

INTRODUCTION

Aspergillus necrotizing otitis externa (NOE) is a rare disease, often associated with delayed diagnosis, the management of which is poorly defined.

SUMMARY

The authors report a case of Aspergillus flavus necrotizing otitis externa with temporomandibular arthritis and temporozygomatic osteomyelitis with Staphylococcal coinfection in a diabetic patient. The diagnosis and discontinuation of treatment were guided by PET-CT scan. A favourable course without sequelae was observed after repeated surgical curettage and 3 months of antifungal therapy.

DISCUSSION

Aspergillus flavus is the agent most commonly incriminated in NOE. Indirect diagnostic tests (serology) may be negative. The diagnosis is based on imaging-guided surgical biopsy with histological examination and standard and fungal microbiological culture. Treatment requires a combination of surgery and antifungal therapy. The duration of antifungal therapy is poorly defined and discontinuation of therapy can be guided by PET-CT scan.

Malignant Aspergillus flavus Otitis Externa with Jugular Thrombosis

We report a case of malignant otitis externa with jugular vein thrombosis caused by Aspergillus flavus. Magnetic resonance imaging revealed an unusual ink smudge pattern deep in a cervical abscess. The pattern was consistent with mycetoma and may be important for diagnosing these life-threatening infections.

Invasive Fungal Carotiditis: A Rare Manifestation of Cranial Invasive Fungal Disease: Case Series and Systematic Review of the Literature

Background

Rhinosinusitis, malignant otitis externa, and skull base osteomyelitis represent a spectrum of cranial invasive fungal disease (IFD). These syndromes have distinct characteristics, yet they may progress to involve similar structures, resulting in inflammation and invasion of the adjacent internal carotid artery (ICA). Invasive fungal carotiditis can have devastating consequences, including cerebral infarction, subarachnoid hemorrhage, and death.

Methods

We retrospectively studied all patients diagnosed with cranial IFD and carotid involvement at our institution from 2003 to 2018. We also searched Medline/PubMed for reports of Aspergillus or Mucorales cranial infections with ICA involvement. All cases with mycologic evidence of cranial IFD and radiographic or pathologic evidence of ICA involvement were included.

Results

We identified 78 cases of invasive fungal carotiditis between 1958 and 2018, including 4 cases at our own institution. Forty-one were caused by Aspergillus and 37 by Mucorales species. Presenting symptoms included vision changes (73%), cranial nerve palsy (69%), and headache (42%). Carotid events included occlusion, aneurysm formation, and vessel rupture. Cerebral infarcts occurred in 50% of cases. Mortality at 6 weeks, 12 weeks, and 2 years was 27%, 41%, and 71% respectively. The median time from symptom onset to death was 150 days for cases due to Aspergillus and 51 days for cases due to Mucorales species.

Conclusions

Invasive fungal carotiditis is a rare but morbid manifestation of cranial IFD. Early suspicion of IFD and administration of antifungal treatment, vascular imaging, and endovascular interventions should be considered to reduce the high mortality of this disease.

Hyperbaric Oxygen Reduces Aspergillus fumigatus Proliferation In Vitro and Influences In Vivo Disease Outcomes

Recent estimates suggest that more than 3 million people have chronic or invasive fungal infections, causing more than 600,000 deaths every year. Aspergillus fumigatus causes invasive pulmonary aspergillosis (IPA) in patients with compromised immune systems and is a primary contributor to increases in human fungal infections. Thus, the development of new clinical modalities as stand-alone or adjunctive therapy for improving IPA patient outcomes is critically needed. Here we tested the in vitro and in vivo impacts of hyperbaric oxygen (HBO) (100% oxygen, >1 atmosphere absolute [ATA]) on A. fumigatus proliferation and murine IPA outcomes. Our findings indicate that HBO reduces established fungal biofilm proliferation in vitro by over 50%. The effect of HBO under the treatment conditions was transient and fungistatic, with A. fumigatus metabolic activity rebounding within 6 h of HBO treatment being removed. In vivo, daily HBO provides a dose-dependent but modest improvement in murine IPA disease outcomes as measured by survival analysis. Intriguingly, no synergy was observed between subtherapeutic voriconazole or amphotericin B and HBO in vitro or in vivo with daily HBO dosing, though the loss of fungal superoxide dismutase genes enhanced HBO antifungal activity. Further studies are needed to optimize the HBO treatment regimen and better understand the effects of HBO on both the host and the pathogen during a pulmonary invasive fungal infection.

A Treatment Protocol for Management of Bacterial and Fungal Malignant External Otitis: A Large Cohort in Tehran, Iran

AIMS

High rates of negative microbiologic test results highlight the potential role of empiric antimicrobial agents in management of malignant otitis externa (MOE). This study investigates the clinical presentation, laboratory findings, and response to empiric treatment in a large group of patients admitted to a tertiary academic hospital in Tehran, Iran.

METHODS AND MATERIALS

We recruited 224 patients diagnosed with MOE in a prospective observation from 2009 through 2015. All patients received a 2-agent antibacterial regimen at baseline (phase I). Patients with no improvement within 10 days and/or nonresponders to a second course of antibacterials were switched to antifungals (phase II). Response to treatment was observed and documented in both groups.

RESULTS

All patients had physical symptoms for more than 12 weeks before admission. In total, 127 patients responded well to antibacterials. Eighty-seven out of 97 patients who were switched to antifungals had complete response to treatment; patients in the latter group had significantly higher A1C levels at baseline.

CONCLUSION

Our findings provide evidence to develop clinical guidelines that accelerate diagnosis and treatment of MOE to improve patient outcomes.

Scedosporium apiospermum: a rare cause of malignant otitis externa

A 79-year-old man, with a history of well-controlled diabetes mellitus, presented with left-sided otalgia. With an initial diagnosis of simple otitis externa, he was discharged on topical drops. He represented 2 months later with worsening otalgia and discharge. A diagnosis of malignant otitis externa was made based on clinical and radiological findings. Intravenous Tazocin and Gentamicin were given based on previous bacterial culture from ear swabs. The patient failed to improve and developed left-sided facial nerve palsy. His condition stabilised following a change in antimicrobial therapy and his management continued in the community on intravenous Meropenem with twice weekly aural toilet. Repeated nuclear medicine imaging failed to demonstrate resolution. A bony sequestration was removed from the external auditory canal in the outpatient clinic, which following extended culture grew Scedosporium apiospermum; his management was subsequently changed to oral Voriconazole. This led to rapid clinical improvement and disease resolution over a 6 -week period.

Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Aspergillus spp. invasive external otitis: favourable outcome with a medical approach

Aspergillus spp. invasive external otitis (IEO) is a rare infection. We performed a seven-year, single-centre retrospective study from 2007 to 2014 including all patients with proven Aspergillus spp. IEO. Twelve patients were identified. All patients had a poorly controlled diabetes mellitus and one underwent solid organ transplant. The most frequently isolated species was Aspergillus flavus (n = 10) and voriconazole was the first-line therapy in all cases, with a median length of treatment of 338.5 days (158-804 days). None of the patients underwent extensive surgery. The clinical outcome was excellent. However, otological sequelae were reported, including hearing impairment (n = 7) and facial palsy (n = 3).

Outcome predictors of treatment effectiveness for fungal malignant external otitis: a systematic review

The aim of this review is to summarise literature data on clinical aspects and traditional management of fungal malignant external otitis (FMEO), and to identify potential predictive factors of positive treatment outcome. Articles were initially selected based on their titles or abstracts. Full articles were then retrieved and further scrutinised according to predetermined criteria. Reference lists of selected articles were searched for any missed publications. The selected articles were methodologically evaluated. Of an initial 143 references, 14 were selected that focalised on the management of FMEO. The majority of studies demonstrated a correlation between treatment effectiveness, assessed as symptom resolution, and clinical and management variables: abstention from surgical debridement, absence of facial palsy, Aspergillus spp. as causative pathogen and absence of imaging findings at diagnosis and follow-up. The effectiveness of FMEO treatment depends on the assessment of cranial nerve state, the causative pathogen and imaging findings. Above all, absence of facial nerve palsy, Aspergillus spp. and absence of radiological signs at diagnosis and during follow-up correlate with symptom resolution. The fact that conservative treatment may be associated with a better outcome than surgical debridement could purely reflect that patients with more aggressive and advanced illness required debridement, whereas milder disease was treated conservatively. Thus, caution should be advised in the interpretation of data due to the need for further trials on the topic.

Chronic Invasive Aspergillus Sinusitis and Otitis with Meningeal Extension Successfully Treated with Voriconazole

Invasive aspergillosis (IA) is a severe disseminated fungal disease that occurs mostly in immunocompromised patients. However, central nervous system IA, combining meningitis and skull base involvement, does not occur only in groups with classic risk factors for IA; patients with chronic renal failure and diabetes mellitus are also at risk for more chronic forms. In both of our proven IA cases, voriconazole monotherapy was effective without surgery, and cerebrospinal fluid and serum 1,3-β-d-glucan test results were initially positive, in contrast to galactomannan antigen results.

The role of surgical debridement in different clinical manifestations of invasive aspergillosis

Invasive aspergillosis (IA) has a wide spectrum of clinical presentations and is associated with high mortality rates. Early initiation of systemic antimould therapy remains the most important measure to reduce mortality. Surgical debridement is an important additional therapeutic option mainly in cases of extrapulmonary IA. The main intention for surgical intervention in IA is to obtain material for diagnosis and antifungal susceptibility testing. There are, however, also therapeutic implications for surgical interventions in rare manifestation of IA such as endocarditis or mycotic aneurysm. Here, we will review the role of surgical interventions in the treatment of different clinical manifestations of IA.

Treatment of refractory Aspergillus otomycosis with voriconazole: case series and review

Background:

Voriconazole is a broad-spectrum azole exhibiting strong anti-Aspergillus activity and good long-term tolerance. However, the evidence for voriconazole efficacy against refractory Aspergillus otomycosis is weak.

Method:

We reviewed the medical records of patients with Aspergillus otomycosis treated with voriconazole from January 2008 to June 2012 in a Taiwanese regional hospital. Demographic data and information regarding underlying diseases, clinical features, treatment and outcome were assessed.

Results:

In total, 14 cases of Aspergillus otomycosis were treated with voriconazole, including 5 patients with Aspergillus invasive otitis externa. All patients had failed to respond to local treatment, antibiotics or topical agents. One case was lost to follow up. The symptoms of two patients recurred after voriconazole treatment: one patient received a second 12-week course of voriconazole and was cured; and symptoms of the other patient recurred after a second 12-week course of voriconazole, leading to surgical debridement. The remaining 11 patients were cured by voriconazole treatment without extensive surgical debridement.

Conclusion:

This study demonstrates that voriconazole can be a very effective and convenient therapeutic option for the management of refractory Aspergillus otomycosis.

Fungal malignant otitis externa with facial nerve palsy: tissue biopsy AIDS diagnosis

Fungal malignant otitis externa (FMOE) is a serious and potentially life-threatening condition that is challenging to manage. Diagnosis is often delayed due to the low sensitivity of aural swabs and many antifungal drugs have significant side effects. We present a case of FMOE, where formal tissue sampling revealed the diagnosis and the patient was successfully treated with voriconazole, in addition to an up to date review of the current literature. We would recommend tissue biopsy of the external auditory canal in all patients with suspected FMOE in addition to routine microbiology swabs.

Aspergillus osteomyelitis: epidemiology, clinical manifestations, management, and outcome

BACKGROUND

The epidemiology, pathogenesis, diagnosis, and management of Aspergillus osteomyelitis are not well understood.

METHODS

Protocol-defined cases of Aspergillus osteomyelitis published in the English literature were reviewed for comorbidities, microbiology, mechanisms of infection, clinical manifestations, radiological findings, inflammatory biomarkers, antifungal therapy, and outcome.

RESULTS

Among 180 evaluable patients, 127 (71%) were males. Possible predisposing medical conditions in 103 (57%) included pharmacological immunosuppression, primary immunodeficiency, and neutropenia. Seventy-three others (41%) had prior open fracture, trauma or surgery. Eighty (44%) followed a hematogenous mechanism, 58 (32%) contiguous infections, and 42 (23%) direct inoculation. Aspergillus osteomyelitis was the first manifestation of aspergillosis in 77%. Pain and tenderness were present in 80%. The most frequently infected sites were vertebrae (46%), cranium (23%), ribs (16%), and long bones (13%). Patients with vertebral Aspergillus osteomyelitis had more previous orthopedic surgery (19% vs 0%; P = 0.02), while those with cranial osteomyelitis had more diabetes mellitus (32% vs 8%; P = 0.002) and prior head/neck surgery (12% vs 0%; P = 0.02). Radiologic findings included osteolysis, soft-tissue extension, and uptake on T2-weighted images. Vertebral body Aspergillus osteomyelitis was complicated by spinal-cord compression in 47% and neurological deficits in 41%. Forty-four patients (24%) received only antifungal therapy, while 121 (67%) were managed with surgery and antifungal therapy. Overall mortality was 25%. Median duration of therapy was 90 days (range, 10-772 days). There were fewer relapses in patients managed with surgery plus antifungal therapy in comparison to those managed with antifungal therapy alone (8% vs 30%; P = 0.006).

CONCLUSIONS

Aspergillus osteomyelitis is a debilitating infection affecting both immunocompromised and immunocompetent patients. The most common sites are vertebrae, ribs, and cranium. Based upon this comprehensive review, management of Aspergillus osteomyelitis optimally includes antifungal therapy and selective surgery to avoid relapse and to achieve a complete response.

Osteomyelitis caused by Aspergillus species: a review of 310 reported cases

Aspergillus osteomyelitis is a rare infection. We reviewed 310 individual cases reported in the literature from 1936 to 2013. The median age of patients was 43 years (range, 0-86 years), and 59% were males. Comorbidities associated with this infection included chronic granulomatous disease (19%), haematological malignancies (11%), transplantation (11%), diabetes (6%), pulmonary disease (4%), steroid therapy (4%), and human immunodeficiency virus infection (4%). Sites of infection included the spine (49%), base of the skull, paranasal sinuses and jaw (18%), ribs (9%), long bones (9%), sternum (5%), and chest wall (4%). The most common infecting species were Aspergillus fumigatus (55%), Aspergillus flavus (12%), and Aspergillus nidulans (7%). Sixty-two per cent of the individual cases were treated with a combination of an antifungal regimen and surgery. Amphotericin B was the antifungal drug most commonly used, followed by itraconazole and voriconazole. Several combination or sequential therapies were also used experimentally. The overall crude mortality rate was 25%.

Aspergillus petrous apicitis associated with cerebral and peritubular abscesses in an immunocompetent man

Background:

Petrous apex aspergillosis is an uncommon and dangerous condition, with only four previously reported cases. As with other forms of petrous apicitis, the clinical symptoms are often non-specific and this contributes to diagnostic delay. This paper presents the first reported case of Aspergillus petrous apicitis associated with an intracranial or nasopharyngeal abscess.

Case report:

A 72-year-old man with chronic otorrhoea developed neuralgic headaches and progressive lower cranial nerve palsies despite antibiotic therapy. Imaging revealed petrous apicitis, a temporal lobe abscess and nasopharyngeal abscess. Analysis of biopsy tissue indicated invasive aspergillosis. The patient recovered on a protracted course of voriconazole in addition to medium-term antibiotic therapy.

Conclusion:

Invasive fungal disease should be considered early in the course of skull base osteomyelitis that is clinically unresponsive to empirical broad spectrum antibiotics. This paper highlights the role of tissue biopsy in diagnosis, and the efficacy of voriconazole therapy without the need for radical surgery.

Laboratory diagnosis of invasive aspergillosis: from diagnosis to prediction of outcome

Invasive aspergillosis (IA), an infection caused by fungi in the genus Aspergillus, is seen in patients with immunological deficits, particularly acute leukaemia and stem cell transplantation, and has been associated with high rates of mortality in previous years. Diagnosing IA has long been problematic owing to the inability to culture the main causal agent A. fumigatus from blood. Microscopic examination and culture of respiratory tract specimens have lacked sensitivity, and biopsy tissue for histopathological examination is rarely obtainable. Thus, for many years there has been a great interest in nonculture-based techniques such as the detection of galactomannan, β -D-glucan, and DNA by PCR-based methods. Recent meta-analyses suggest that these approaches have broadly similar performance parameters in terms of sensitivity and specificity to diagnose IA. Improvements have been made in our understanding of the limitations of antigen assays and the standardisation of PCR-based DNA detection. Thus, in more recent years, the debate has focussed on how these assays can be incorporated into diagnostic strategies to maximise improvements in outcome whilst limiting unnecessary use of antifungal therapy. Furthermore, there is a current interest in applying these tests to monitor the effectiveness of therapy after diagnosis and predict clinical outcomes. The search for improved markers for the early and sensitive diagnosis of IA continues to be a challenge.

Pseudomonas and Aspergillus interaction in malignant external otitis: risk of treatment failure

Malignant external otitis (MEO) is a rare infection of the temporal bone primarily affecting elderly patients and diabetics or immunocompromised individuals, which may have dismal prognosis if treatment is not prompt and adequate. Almost 95% of MEO cases reported in the literature are attributed to Pseudomonas aeruginosa, and this pathogen is isolated from aural drainage in > 90% of cases. However, in recent years fungal and polymicrobial temporal bone infections have been reported with increasing frequency. The aim of this paper is to discuss a possible pitfall in MEO treatment using an unusual clinical case. In this patient, bacteriological data positive for Pseudomonas delayed correct diagnosis of Aspergillus infection, which was obtained after surgical debridement and biopsy of the infra-temporal space.

Are systemic voriconazole and caspofungin ototoxic? An experimental study with rats

Objectives

To determine whether systemic administration of voriconazole and caspofungin causes ototoxicity.

Methods

This study was conducted on 32 healthy male Wistar albino rats. The baseline auditory brainstem response (ABR) thresholds of all animals were obtained under general anesthesia. Then, the rats were randomly divided into 4 groups (groups I-IV), each group consisting of 8 rats. Rats in group I were injected intraperitoneally with voriconazole 10 mg/kg/day for 7 days, and the rats in the group II were injected intraperitoneally with caspofungin 5 mg/kg/day for 7 days. Group III received 120 mg/kg/day gentamicin for 7 days. Group IV received saline for 7 days. The animals were then observed for 7 days, and on 14th day of the trial, posttreatment ABRs of both ears were recorded.

Results

We did not find any significant differences between pretreatment and posttreatment median ABR thresholds in the voriconazole, caspofungin, or saline groups. In the gentamicin group, there was a statistically significant difference between pretreatment and posttreatment ABR thresholds.

Conclusion

Caspofungin and voriconazole did not change ABR thresholds in speech frequencies after a 7-day-period of their administration. We believe that further animal studies must be performed after administration of these agents for a longer time period, and these findings must be consolidated with histopathological investigations.

Orbital aspergillosis: voriconazole - the new standard treatment?

Background/Aim

To describe a case of invasive orbital aspergillosis and evaluate treatments and outcomes.

Methods

A case report and review of orbital aspergillosis treatment with voriconazole in the English language literature.

Conclusion

Amphotericin B with debridement is the current standard of care for orbital aspergillosis; however, its prognosis is unfavorable. When compared to amphotericin B, voriconazole demonstrates a survival benefit, has less systemic toxicity, and is better tolerated by patients. While a prospective trial comparing amphotericin B to voriconazole in orbital aspergillosis is not feasible, there is evidence to support the use of voriconazole as primary therapy.

Multiple Aspergillus cerebellar abscesses in a middle-aged female: case report and literature review

Aspergillus abscesses in the cerebellum are extremely rare, and most cases are solitary. Here, we report the first case of multiple Aspergillus cerebellar abscesses in a 46-year-old female after one mastoidectomy, two craniectomies, and extended use of antibiotics. The possible pathogenesis of this unusual event is discussed. Good outcome was achieved by treatment with a combination of neurosurgical resection and voriconazole (VRC) administration, which we suggest is a potential management plan.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly. Suggestions or comments may be addressed to Jacyntha Sterling, Drug Information Specialist at Saint Francis Hospital, 6161 S Yale Ave, Tulsa, OK 74136 or e-mail: jasterling@saintfrancis.com .