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Cherwonogrodzky JW, Kou TD, Rennie RR. Preliminary Evidence for the Role of Fungi, Specifically Chaetomium, in Gulf War Illness. Mil Med 2024:usae267. [PMID: 38829681 DOI: 10.1093/milmed/usae267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/26/2024] [Accepted: 05/06/2024] [Indexed: 06/05/2024] Open
Abstract
INTRODUCTION For veterans of the Persian Gulf War (1990-1991), dozens of possible causes for their illness have been proposed. We hypothesize that all may be correct. These may have weakened the immunity of the military personnel to fungal pathogens in the soil. These microbes, in turn, may have afflicted the veterans either directly by infection or indirectly by toxins. MATERIALS AND METHODS In 1990, the military (source confidential) provided the first author with soil samples from the Persian Gulf to determine if there were biothreats present. His team found that per gram of soil, there had few bacteria but many fungi. The National Centre for Human Mycotic Diseases (Edmonton) identified some of these fungi. They sent to the first author reference cultures of 12 pathogenic fungal species isolated from Canadian patients. Supernatant antigens of these fungi were used to assess if control and Gulf War Illness (GWI) patient sera had IgG antibodies against them. RESULTS Human sera were tested on pathogenic fungal supernatant antigens. Controls had low IgG titers against all 12 fungal sources. Gulf War Illness (GWI) patient sera had low IgG titers against 11 of the 12 fungal antigens. However, 12 of 28 GWI patient sera (43%, P ≤ .0002 compared to controls) had high IgG titers against one fungus, Chaetomium, supernatant antigen. CONCLUSIONS We suggest that the military personnel in the Persian Gulf War (1990-1991) may have had their immunity weakened from a variety of causes. The role of pathogenic fungi and/or their supernatant antigens or toxins as a contributing factor to GWI should be further investigated.
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Affiliation(s)
| | - Tzuyung D Kou
- Case Comprehensive Cancer Center, Case Western University School of Medicine, Cleveland, OH 44106, USA
| | - Robert R Rennie
- Faculty of Medicine and Dentistry, Mackenzie Health Science Centre, University of Alberta, Edmonton, Alberta T6G 2B7, Canada
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2
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Douglas AP, Stewart AG, Halliday CL, Chen SCA. Outbreaks of Fungal Infections in Hospitals: Epidemiology, Detection, and Management. J Fungi (Basel) 2023; 9:1059. [PMID: 37998865 PMCID: PMC10672668 DOI: 10.3390/jof9111059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 11/25/2023] Open
Abstract
Nosocomial clusters of fungal infections, whilst uncommon, cannot be predicted and are associated with significant morbidity and mortality. Here, we review reports of nosocomial outbreaks of invasive fungal disease to glean insight into their epidemiology, risks for infection, methods employed in outbreak detection including genomic testing to confirm the outbreak, and approaches to clinical and infection control management. Both yeasts and filamentous fungi cause outbreaks, with each having general and specific risks. The early detection and confirmation of the outbreak are essential for diagnosis, treatment of affected patients, and termination of the outbreak. Environmental sampling, including the air in mould outbreaks, for the pathogen may be indicated. The genetic analysis of epidemiologically linked isolates is strongly recommended through a sufficiently discriminatory approach such as whole genome sequencing or a method that is acceptably discriminatory for that pathogen. An analysis of both linked isolates and epidemiologically unrelated strains is required to enable genetic similarity comparisons. The management of the outbreak encompasses input from a multi-disciplinary team with epidemiological investigation and infection control measures, including screening for additional cases, patient cohorting, and strict hygiene and cleaning procedures. Automated methods for fungal infection surveillance would greatly aid earlier outbreak detection and should be a focus of research.
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Affiliation(s)
- Abby P. Douglas
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC 3000, Australia
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC 3084, Australia
| | - Adam G. Stewart
- Centre for Clinical Research, Faculty of Medicine, Royal Brisbane and Women’s Hospital Campus, The University of Queensland, Herston, QLD 4006, 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, Sydney, NSW 2145, Australia; (C.L.H.); (S.C.-A.C.)
| | - Sharon C.-A. Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Sydney, NSW 2145, Australia; (C.L.H.); (S.C.-A.C.)
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
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3
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Jin H, Zhang D, Yan Y, Yang C, Fang B, Li X, Shao Y, Wang H, Yue J, Wang Y, Cheng H, Shi Y, Qin F. Short-term application of chicken manure under different nitrogen rates alters structure and co-occurrence pattern but not diversity of soil microbial community in wheat field. Front Microbiol 2022; 13:975571. [PMID: 36160226 PMCID: PMC9490364 DOI: 10.3389/fmicb.2022.975571] [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: 06/22/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
Manure application is an effective way to improve the utilization efficiency of organic resources and alleviate the adverse effects of long-term application of chemical fertilizers. However, the impact of applying manure under different nitrogen rates on soil microbial community in wheat field remains unclear. Treatments with and without chicken manure application under three nitrogen rates (N 135, 180 and 225 kg⋅hm-2) were set in wheat field. Soil organic carbon, available nutrients, and abundance, diversity, structure and co-occurrence pattern of soil microbial community at wheat maturity were investigated. Compared with no manure application, chicken manure application increased the soil organic carbon and available phosphorus, while the effects on soil mineral nitrogen and available potassium varied with different nitrogen rates. Chicken manure application significantly increased soil bacterial abundance under the nitrogen fertilization of 135 and 225 kg⋅hm-2, increased soil fungal abundance under the nitrogen fertilization of 135 kg⋅hm-2, but decreased soil fungal abundance under the nitrogen fertilization of 180 and 225 kg⋅hm-2 (P < 0.05). There was no significant difference in alpha diversity indices of soil microbial communities between treatments with and without chicken manure application under different nitrogen rates (P > 0.05). Chicken manure application and its interaction with nitrogen rate significantly changed soil bacterial and fungal community structures (P < 0.05). There were significantly different taxa of soil microbial communities between treatments with and without chicken manure application. Chicken manure application reduced the ecological network complexity of soil bacterial community and increased that of soil fungal community. In summary, the responses of soil available nutrients and microbial abundance to applying chicken manure varied with different nitrogen rates. One growing season application of chicken manure was sufficient to alter the soil microbial community structure, composition and co-occurrence pattern, whereas not significantly affected soil microbial community diversity.
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Affiliation(s)
- Haiyang Jin
- Wheat Research Institute, Henan Academy of Agricultural Sciences, Zhengzhou, China
| | - Deqi Zhang
- Wheat Research Institute, Henan Academy of Agricultural Sciences, Zhengzhou, China
| | - Yaqian Yan
- College of Agronomy, Henan Agricultural University, Zhengzhou, China
| | - Cheng Yang
- Wheat Research Institute, Henan Academy of Agricultural Sciences, Zhengzhou, China
| | - Baoting Fang
- Wheat Research Institute, Henan Academy of Agricultural Sciences, Zhengzhou, China
| | - Xiangdong Li
- Wheat Research Institute, Henan Academy of Agricultural Sciences, Zhengzhou, China
| | - Yunhui Shao
- Wheat Research Institute, Henan Academy of Agricultural Sciences, Zhengzhou, China
| | - Hanfang Wang
- Wheat Research Institute, Henan Academy of Agricultural Sciences, Zhengzhou, China
| | - Junqin Yue
- Wheat Research Institute, Henan Academy of Agricultural Sciences, Zhengzhou, China
| | - Yanjing Wang
- Wheat Research Institute, Henan Academy of Agricultural Sciences, Zhengzhou, China
| | - Hongjian Cheng
- Wheat Research Institute, Henan Academy of Agricultural Sciences, Zhengzhou, China
| | - Yanhua Shi
- Wheat Research Institute, Henan Academy of Agricultural Sciences, Zhengzhou, China
| | - Feng Qin
- Wheat Research Institute, Henan Academy of Agricultural Sciences, Zhengzhou, China
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4
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Yang Y, Shi Y, Fang J, Chu H, Adams JM. Soil Microbial Network Complexity Varies With pH as a Continuum, Not a Threshold, Across the North China Plain. Front Microbiol 2022; 13:895687. [PMID: 35733957 PMCID: PMC9207804 DOI: 10.3389/fmicb.2022.895687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/27/2022] [Indexed: 11/22/2022] Open
Abstract
There has been little study on the biogeographical patterns of microbial co-occurrence, especially in agricultural soils. Here we investigated the biogeographical patterns and major drivers of co-occurrence network topological structure, and the relative abundance of keystone taxa for soil bacterial and fungal communities using high-throughput sequencing on a set of 90 samples across a 1,092 km transect in wheat fields of the North China Plain (NCP). We found that pH was the most important environmental factor driving network topology and relative abundance of keystone taxa. For the metacommunity composed of both bacteria and fungi, and for the bacterial community alone, lower soil pH was associated with a more complex microbial network. However, the network for fungi showed no strong trend with soil pH. In addition, keystone taxa abundance was positively correlated with ecosystem function and stability, and best explained by pH. Our results present new perspectives on impacts of pH on soil microbial network structure across large scales in agricultural environments. This improved knowledge of community processes provides a step toward understanding of functioning and stability of agricultural ecosystems.
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Affiliation(s)
- Ying Yang
- School of Geography and Ocean Science, Nanjing University, Nanjing, China
| | - Yu Shi
- State Key Laboratory of Crop Stress Adaptation and Improvement, School of Life Sciences, Henan University, Kaifeng, China
| | - Jie Fang
- School of Geography and Ocean Science, Nanjing University, Nanjing, China
| | - Haiyan Chu
- State Key Laboratory of Soil and Sustainable Agriculture, Institute of Soil Science, Chinese Academy of Sciences, Nanjing, China
| | - Jonathan M. Adams
- School of Geography and Ocean Science, Nanjing University, Nanjing, China
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5
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Liu X, Song Y, Li R. The use of combined PCR, fluorescence in situ hybridisation and immunohistochemical staining to diagnose mucormycosis from formalin-fixed paraffin-embedded tissues. Mycoses 2021; 64:1460-1470. [PMID: 34674327 DOI: 10.1111/myc.13382] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop a comprehensive diagnostic system for mucormycosis from formalin-fixed paraffin-embedded tissues, consisting of own-designed real-time polymerase chain reaction (PCR) assays, fluorescence in situ hybridisation, and immunohistochemical staining. METHODS We designed 11 primers and probes for specific real-time PCR assays based on genome sequences, and validated the specificity by Aspergillus, Fusarium, Scedosporium, Lomentospora, Cryptococcus and Candida species. Formalin-fixed paraffin-embedded (FFPE) tissues from forty-four mouse model infected by above fungi were collected and extracted DNA by laser capture microdissection (LCM) and direct extraction methods for real-time PCR assays. In addition, seventeen clinical specimens histopathologically proven for mucormycosis were included for specific detection with the new diagnostic system. RESULTS The real-time PCR assays allowed detection of a minimum of 10 CFU/ml equivalent gDNA of each species. No cross-reaction with gDNA among species was noted. From mouse model specimens, the sensitivity of real-time PCR in samples extracted with LCM versus direct extraction method was 100% versus 91.43% at Mucorales level and 80% versus 45.71% at species level, respectively. The specificity was 100%. From clinical samples, LCM combined with real-time PCR can test 88.24% (15/17) of Mucorales. Sensitivities of fluorescence in situ hybridisation (FISH) and immunohistochemical staining (IHC) were 70.59% and 41.18%, respectively. Combined LCM-RT-PCR, FISH and IHC yielded positive results in all samples. CONCLUSIONS The combination diagnostic system we developed is a culture-independent and robust method which enables rapid species identification from FFPE tissues for timely diagnosis of mucormycosis.
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Affiliation(s)
- Xiao Liu
- Department of Dermatology and Venerology, Peking University First Hospital, Beijing, China.,Research Center for Medical Mycology, Peking University, Beijing, China.,National Clinical Research Center for Skin and Immune Diseases, Beijing, China.,Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Peking University First Hospital, Beijing, China
| | - Yinggai Song
- Department of Dermatology and Venerology, Peking University First Hospital, Beijing, China.,Research Center for Medical Mycology, Peking University, Beijing, China.,National Clinical Research Center for Skin and Immune Diseases, Beijing, China.,Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Peking University First Hospital, Beijing, China
| | - Ruoyu Li
- Department of Dermatology and Venerology, Peking University First Hospital, Beijing, China.,Research Center for Medical Mycology, Peking University, Beijing, China.,National Clinical Research Center for Skin and Immune Diseases, Beijing, China.,Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Peking University First Hospital, Beijing, China
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6
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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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7
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Abstract
Both space and time are key factors that regulate microbial community, but microbial temporal variation is often ignored at a large spatial scale. In this study, we compared spatial and seasonal effects on bacterial and fungal diversity variation across an 878-km transect and found direct evidence that space is far more important than season in regulating the soil microbial community. Partitioning the effect of season, space and environmental variables on microbial community, we further found that fast-changing environmental factors contributed to microbial temporal variation. The relative importance of spatial and temporal variability in shaping the distribution of soil microbial communities at a large spatial scale remains poorly understood. Here, we explored the relative importance of space versus time when predicting the distribution of soil bacterial and fungal communities across North China Plain in two contrasting seasons (summer versus winter). Although we found that microbial alpha (number of phylotypes) and beta (changes in community composition) diversities differed significantly between summer and winter, space rather than season explained more of the spatiotemporal variation of soil microbial alpha and beta diversities. Environmental covariates explained some of microbial spatiotemporal variation observed, with fast-changing environmental covariates—climate variables, soil moisture, and available nutrient—likely being the main factors that drove the seasonal variation found in bacterial and fungal beta diversities. Using random forest modeling, we further identified a group of microbial exact sequence variants (ESVs) as indicators of summer and winter seasons and for which relative abundance was associated with fast-changing environmental variables (e.g., soil moisture and dissolved organic nitrogen). Together, our empirical field study’s results suggest soil microbial seasonal variation could arise from the changes of fast-changing environmental variables, thus providing integral support to the large emerging body of snapshot studies related to microbial biogeography. IMPORTANCE Both space and time are key factors that regulate microbial community, but microbial temporal variation is often ignored at a large spatial scale. In this study, we compared spatial and seasonal effects on bacterial and fungal diversity variation across an 878-km transect and found direct evidence that space is far more important than season in regulating the soil microbial community. Partitioning the effect of season, space and environmental variables on microbial community, we further found that fast-changing environmental factors contributed to microbial temporal variation.
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8
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Velasco J, Revankar S. CNS Infections Caused by Brown-Black Fungi. J Fungi (Basel) 2019; 5:jof5030060. [PMID: 31295828 PMCID: PMC6787688 DOI: 10.3390/jof5030060] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 12/20/2022] Open
Abstract
Central nervous system (CNS) infections caused by brown-black or dematiaceous fungi are distinctly rare and represent a small proportion of infections termed phaeohyphomycoses. However, these are becoming more commonly reported. Though many fungi have been implicated in disease, most cases are caused by only a few species, Cladophialophora bantiana being the most common. Most of the fungi described are molds, and often cause infection in immunocompetent individuals, in contrast to infection with other more common molds such as Aspergillus, which is usually seen in highly immunocompromised patients. Diagnosis is challenging, as there are no specific tests for this group of fungi. In addition, these infections are often refractory to standard drug therapies, requiring an aggressive combined surgical and medical approach to improve outcomes, yet mortality remains high. There are no standardized treatments due to a lack of randomized clinical trials, though guidelines have been published based on available data and expert opinion.
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Affiliation(s)
- Jon Velasco
- Detroit Medical Center, Wayne State University, Detroit, MI 48201, USA
| | - Sanjay Revankar
- Division of Infectious Diseases, Department of Medicine, Wayne State University, 3990 John R. Street, 5 Hudson, Detroit, MI 48201, USA.
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9
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Cao J, Gao S, Chen J, Zhu B, Min R, Wang P. The preparation and clinical application of diagnostic DNA microarray for the detection of pathogens in intracranial bacterial and fungal infections. Exp Ther Med 2018; 16:1304-1310. [PMID: 30116379 PMCID: PMC6090218 DOI: 10.3892/etm.2018.6312] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 05/11/2018] [Indexed: 12/31/2022] Open
Abstract
The present study prepared 2 types of DNA diagnostic chips based on 16S ribosomal DNA (rDNA) and 18S-28S rDNA, and evaluated their values in the detection of pathogens in intracranial bacterial/fungal infections. A total of 14 probes of bacteria (Klebsiella pneumonia, Acinetobacter baumannii, Pseudomonas aeruginosa, Escherichia coli, Haemophilus influenza, Stenotrophomonas maltophilia, Neisseria meningitidis, Enterobacter spp., Enterococcus faecalis, Enterococcus faecium, Listeria monocytogenes, Staphylococcus aureus, Streptococcus pneumonia and coagulase negative staphylococcus) and 4 probes of fungi (Candida albicans, Candida tropicalis, Candida glabrata and Cryptococcus neoformans), determined frequently in cerebrospinal fluid (CSF), were designed and used for preparation of microarrays. CSF samples from 88 patients with clinically suspected intracranial infection and standard strains were used to evaluate the chips. The same samples were also analyzed by culture and sequencing. The results demonstrated that the sensitivity, specificity and false-positive rate of the microarray assay compared with culture method were 100 vs. 68.3% (P<0.05), 97.1 vs. 100%, and 2.9 vs. 0%, respectively. The minimum concentration of detection with the chips was 10 cfu ml-1 for bacteria and 100 cfu ml-1 for fungi. The specificity of the probes was confirmed, and no cross-reaction was detected in the present study. Furthermore, 13 cases were positive in the microarray and negative in culture. However, 4 cases were not identified as clear pathogens and only positive in the 16S probe sites. The diagnostic DNA microarray for intracranial infections has proven to be more rapid and sensitive, and it may be a better option for clinical application than culture methods.
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Affiliation(s)
- Jingrong Cao
- Department of Clinical Laboratory, Xuanwu Hospital of Capital Medical University, Beijing 100053, P.R. China
| | - Shichao Gao
- Department of Clinical Laboratory, Xuanwu Hospital of Capital Medical University, Beijing 100053, P.R. China
| | - Jing Chen
- Department of Microbiology, Health Occupation College of Jiangxi, Nanchang, Jiangxi 330201, P.R. China
| | - Bin Zhu
- Department of Technical Quality, Shanghai BaiO Technology Co., Ltd., Shanghai 200233, P.R. China
| | - Rong Min
- Department of Clinical Laboratory, Xuanwu Hospital of Capital Medical University, Beijing 100053, P.R. China
| | - Peichang Wang
- Department of Clinical Laboratory, Xuanwu Hospital of Capital Medical University, Beijing 100053, P.R. China
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10
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Gade L, Hurst S, Balajee SA, Lockhart SR, Litvintseva AP. Detection of mucormycetes and other pathogenic fungi in formalin fixed paraffin embedded and fresh tissues using the extended region of 28S rDNA. Med Mycol 2018; 55:385-395. [PMID: 27630252 DOI: 10.1093/mmy/myw083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 04/11/2016] [Indexed: 01/04/2023] Open
Abstract
Molecular methods of detection based on DNA-sequencing of the internal transcribed spacer 1 and 2 (ITS1 and ITS2) or 5΄ end region of 28S (D1-D2 region) of ribosomal RNA gene (rDNA) have been used extensively for molecular identification and detection of fungal infections. However, these regions are not always informative for identification of mucormycetes and other rare fungal pathogens as they often contain large introns, heterogenic regions, and/or cannot be PCR-amplified using broad range fungal PCR primers. In addition, because of the difficulties of recovering intact fungal DNA from human specimens, smaller regions of DNA are more useful for the direct detection of fungal DNA in tissues and fluids. In this study, we investigated the utility of 12F/13R PCR primers targeting a 200-230 bp region of the extended 28S region of rDNA for molecular identification of fungal DNA in formalin fixed paraffin embedded tissues and other clinical specimens. We demonstrated that this region can be successfully used for identification of all genera and some species of clinically relevant mucormycetes, as well as other medically important fungi, such as Aspergillus, Fusarium, Coccidioides, and Cryptococcus. We also demonstrated that PCR amplification and direct sequencing of the extended 28S region of rDNA was more sensitive compared to targeting the ITS2 region, as we were able to detect and identify mucormycetes and other fungal pathogens in tissues from patients with histopathological and/or culture evidence of fungal infections that were negative with PCR using ITS-specific primers.
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Affiliation(s)
- Lalitha Gade
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - Steven Hurst
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - S Arunmozhi Balajee
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Shawn R Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA
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11
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Zhang K, Adams JM, Shi Y, Yang T, Sun R, He D, Ni Y, Chu H. Environment and geographic distance differ in relative importance for determining fungal community of rhizosphere and bulk soil. Environ Microbiol 2017; 19:3649-3659. [PMID: 28752936 DOI: 10.1111/1462-2920.13865] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 07/10/2017] [Accepted: 07/21/2017] [Indexed: 11/30/2022]
Abstract
Rhizospheric fungi play major roles in both natural and agricultural ecosystems. However, little is known about the determinants of their diversity and biogeographic patterns. Here, we compared fungal communities in rhizosphere and bulk soils of wheat fields in the North China Plain. The rhizosphere had a lower fungal diversity (observed OTUs and Chao1) than bulk soil, and a distinct fungal community structure in rhizosphere compared with bulk soil. The relative importance of environmental factors and geographic distance for fungal distribution differed between rhizosphere and bulk soil. Environmental factors were the primary cause of variations in total fungal community and major fungal phyla in bulk soil. By contrast, fungal communities in soils loosely attached to roots were predictable from both environmental factors and influences of geographic distance. Communities in soils tightly attached to roots were mainly determined by geographic distance. Our results suggest that both contemporary environment processes (present-day abiotic and biotic environment characters) and historical processes (spatial isolation, dispersal limitation occurred in the past) dominate variations of fungal communities in wheat fields, but their relative importance of all these processes depends on the proximity of fungal community to the plant roots.
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Affiliation(s)
- Kaoping Zhang
- State Key Laboratory of Soil and Sustainable Agriculture, Institute of Soil Science, Chinese Academy of Sciences, 71 East Beijing Road, Nanjing 210008, China.,University of Chinese Academy of Sciences, Beijing 100049, China
| | - Jonathan M Adams
- Department of Biological Sciences, Seoul National University, Seoul 151, Gwanak, Republic of Korea
| | - Yu Shi
- State Key Laboratory of Soil and Sustainable Agriculture, Institute of Soil Science, Chinese Academy of Sciences, 71 East Beijing Road, Nanjing 210008, China
| | - Teng Yang
- State Key Laboratory of Soil and Sustainable Agriculture, Institute of Soil Science, Chinese Academy of Sciences, 71 East Beijing Road, Nanjing 210008, China.,University of Chinese Academy of Sciences, Beijing 100049, China
| | - Ruibo Sun
- State Key Laboratory of Soil and Sustainable Agriculture, Institute of Soil Science, Chinese Academy of Sciences, 71 East Beijing Road, Nanjing 210008, China.,Center for Agricultural Resources Research, Institute of Genetic and Developmental Biology, Chinese Academy of Sciences, 286 Huaizhong Road, Shijiazhuang Hebei 050021, China
| | - Dan He
- State Key Laboratory of Soil and Sustainable Agriculture, Institute of Soil Science, Chinese Academy of Sciences, 71 East Beijing Road, Nanjing 210008, China.,Key Laboratory of Vegetation Restoration and Management of Degraded Ecosystems, South China Botanical Garden, Chinese Academy of Sciences, 723 Xingke Road, Tianhe Guangzhou 510650, China
| | - Yingying Ni
- State Key Laboratory of Soil and Sustainable Agriculture, Institute of Soil Science, Chinese Academy of Sciences, 71 East Beijing Road, Nanjing 210008, China.,University of Chinese Academy of Sciences, Beijing 100049, China
| | - Haiyan Chu
- State Key Laboratory of Soil and Sustainable Agriculture, Institute of Soil Science, Chinese Academy of Sciences, 71 East Beijing Road, Nanjing 210008, China
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12
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Abstract
In mid-September 2012, the largest healthcare-associated outbreak in U.S. history began. Before it was over, 751 patients were reported with fungal meningitis, stroke, spinal or paraspinal infection, or peripheral osteoarticular infection, and 64 (8.5%) died. Most patients had undergone epidural injection, and a few osteoarticular injection, of methylprednisolone acetate that had been manufactured at the New England Compounding Center (NECC). The offending pathogen in most cases was Exserohilum rostratum, a brown-black soil organism that previously was a rare cause of human infection. Three lots of methylprednisolone were contaminated with mold at NECC; the mold from unopened bottles of methylprednisolone was identical by whole-genome sequencing to the mold that was isolated from ill patients. Early cases manifested as meningitis, some patients suffered posterior circulation strokes, and later cases were more likely to present with localized infection at the injection site, including epidural abscess or phlegmon, vertebral diskitis or osteomyelitis, and arachnoiditis with intradural involvement of nerve roots. Many patients with spinal or paraspinal infection required surgical intervention. Recommendations for treatment evolved over the first few weeks of the outbreak. Initially, combination therapy with liposomal amphotericin B and voriconazole was recommended for all patients; later, combination therapy was recommended only for those who were most ill, and voriconazole monotherapy was recommended for most patients. Among those patients who continued antifungal therapy for at least 6 months, outcomes for most appeared to be successful, although a few patients remain on therapy.
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13
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Extensive Exserohilum infection in a burn patient. JAAD Case Rep 2016; 1:188-90. [PMID: 27051726 PMCID: PMC4808727 DOI: 10.1016/j.jdcr.2015.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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14
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Vijayakumar R, Saleh Al-Aboody M, Sandle T. A review of melanized (black) fungal contamination in pharmaceutical products-incidence, drug recall and control measures. J Appl Microbiol 2016; 120:831-41. [DOI: 10.1111/jam.12888] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 06/22/2015] [Accepted: 06/22/2015] [Indexed: 12/17/2022]
Affiliation(s)
- R. Vijayakumar
- Department of Medical Laboratory; College of Science AlZulfi; Majmaah University; AlZulfi Saudi Arabia
| | - M. Saleh Al-Aboody
- Department of Medical Laboratory; College of Science AlZulfi; Majmaah University; AlZulfi Saudi Arabia
| | - T. Sandle
- Microbiology; Bio Products Laboratory; Elstree Hertfordshire UK
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15
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Lyons JL, Zhang SX. Current laboratory approaches to diagnosis of CNS fungal infections. Future Microbiol 2016; 11:175-7. [PMID: 26849164 DOI: 10.2217/fmb.15.138] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jennifer L Lyons
- Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Sean X Zhang
- Microbiology Laboratory, Johns Hopkins Hospital, Baltimore, MD, USA.,Division of Medical Microbiology, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
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16
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Levetin E, Horner WE, Scott JA. Taxonomy of Allergenic Fungi. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 4:375-385.e1. [PMID: 26725152 DOI: 10.1016/j.jaip.2015.10.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/19/2015] [Accepted: 10/16/2015] [Indexed: 12/11/2022]
Abstract
The Kingdom Fungi contains diverse eukaryotic organisms including yeasts, molds, mushrooms, bracket fungi, plant rusts, smuts, and puffballs. Fungi have a complex metabolism that differs from animals and plants. They secrete enzymes into their surroundings and absorb the breakdown products of enzyme action. Some of these enzymes are well-known allergens. The phylogenetic relationships among fungi were unclear until recently because classification was based on the sexual state morphology. Fungi lacking an obvious sexual stage were assigned to the artificial, now-obsolete category, "Deuteromycetes" or "Fungi Imperfecti." During the last 20 years, DNA sequencing has resolved 8 fungal phyla, 3 of which contain most genera associated with important aeroallergens: Zygomycota, Ascomycota, and Basidiomycota. Advances in fungal classification have required name changes for some familiar taxa. Because of regulatory constraints, many fungal allergen extracts retain obsolete names. A major benefit from this reorganization is that specific immunoglobulin E (IgE) levels in individuals sensitized to fungi appear to closely match fungal phylogenetic relationships. This close relationship between molecular fungal systematics and IgE sensitization provides an opportunity to systematically look at cross-reactivity and permits representatives from each taxon to serve as a proxy for IgE to the group.
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Affiliation(s)
- Estelle Levetin
- Faculty of Biological Science, University of Tulsa, Tulsa, Okla.
| | | | - James A Scott
- Division of Occupational & Environmental Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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17
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Development of a Multilocus Sequence Typing System for Medically Relevant Bipolaris Species. J Clin Microbiol 2015. [PMID: 26202112 DOI: 10.1128/jcm.01546-15] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Multilocus sequence typing (MLST) is the gold standard genotyping technique for many microorganisms. This classification approach satisfies the requirements for a high-resolution, standardized, and archivable taxonomic system. Here, we describe the development of a novel MLST system to assist with the investigation of an unusual cluster of surgical site infections caused by Bipolaris spp. in postoperative cardiothoracic surgery (POCS) patients during January 2008 to December 2013 in the southeastern United States. We also used the same MLST system to perform a retrospective analysis on isolates from a 2012 Bipolaris endophthalmitis outbreak caused by a contaminated product. This MLST system showed high intraspecies discriminatory power for Bipolaris spicifera, B. hawaiiensis, and B. australiensis. Based on the relatedness of the isolates, the MLST data supported the hypothesis that infections in the POCS cluster were from different environmental sources while confirming that the endophthalmitis outbreak resulted from a point source, which was a contaminated medication.
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18
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Davoudi S, Graviss LS, Kontoyiannis DP. Healthcare-associated outbreaks due to Mucorales and other uncommon fungi. Eur J Clin Invest 2015; 45:767-73. [PMID: 25989947 DOI: 10.1111/eci.12467] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/16/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Healthcare-associated outbreaks of fungal infections, especially with uncommon and emerging fungi, have become more frequent in the past decade. MATERIALS AND METHOD Here, we reviewed the history and definition of healthcare-associated outbreaks of uncommon fungal infections and discussed the principles of investigating, containing and treatment of these outbreaks. RESULTS In case of these uncommon diseases, occurrence of two or more cases in a short period is considered as an outbreak. Contaminated medical devices and hospital environment are the major sources of these outbreaks. Care must be taken to differentiate a real infection from colonization or contamination. Defining and identifying cases, describing epidemiologic feature of cases, finding and controlling the source of the outbreak, treating patients, and managing asymptomatic exposed patients are main steps for outbreak elimination. These fungal outbreaks are not only difficult to detect but also hard to treat. Early initiation of appropriate antifungal therapy is strongly associated with improved outcomes in infected patients. Choice of antifungal drugs should be made based on spectrum, pharmacodynamic and pharmacokinetic characteristics and adverse effects of available drugs. Combination antifungal therapy and surgical intervention may be also helpful in selected cases. CONCLUSIONS A multidisciplinary approach and close collaboration between all key partners are necessary for successful control of fungal outbreaks.
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Affiliation(s)
- Setareh Davoudi
- Department of Infectious Diseases, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Linda S Graviss
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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19
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Not over yet: fungal infections following methyl prednisolone injections smoulder on. J Clin Microbiol 2015; 52:3506-7. [PMID: 25143420 DOI: 10.1128/jcm.01634-14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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20
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Utility of real-time PCR for detection of Exserohilum rostratum in body and tissue fluids during the multistate outbreak of fungal meningitis and other infections. J Clin Microbiol 2014; 53:618-25. [PMID: 25520443 DOI: 10.1128/jcm.02443-14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Exserohilum rostratum was the major cause of the multistate outbreak of fungal meningitis linked to contaminated injections of methylprednisolone acetate produced by the New England Compounding Center. Previously, we developed a fungal DNA extraction procedure and broad-range and E. rostratum-specific PCR assays and confirmed the presence of fungal DNA in 28% of the case patients. Here, we report the development and validation of a TaqMan real-time PCR assay for the detection of E. rostratum in body fluids, which we used to confirm infections in 57 additional case patients, bringing the total number of case patients with PCR results positive for E. rostratum to 171 (37% of the 461 case patients with available specimens). Compared to fungal culture and the previous PCR assays, this real-time PCR assay was more sensitive. Of the 139 identical specimens from case patients tested by all three methods, 19 (14%) were positive by culture, 41 (29%) were positive by the conventional PCR assay, and 65 (47%) were positive by the real-time PCR assay. We also compared the utility of the real-time PCR assay with that of the previously described beta-d-glucan (BDG) detection assay for monitoring response to treatment in case patients with serially collected CSF. Only the incident CSF specimens from most of the case patients were positive by real-time PCR, while most of the subsequently collected specimens were negative, confirming our previous observations that the BDG assay was more appropriate than the real-time PCR assay for monitoring the response to treatment. Our results also demonstrate that the real-time PCR assay is extremely susceptible to contamination and its results should be used only in conjunction with clinical and epidemiological data.
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Outbreak of fungal infections associated with contaminated methylprednisolone acetate: an update. Curr Infect Dis Rep 2014; 17:441. [PMID: 25416847 DOI: 10.1007/s11908-014-0441-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In September 2012, an unprecedented outbreak of fungal infections due to preservative-free, injectable methylprednisolone acetate (MPA) was identified. Exserohilum rostratum was quickly identified as the predominant organism involved in disease cases. Prior to this outbreak, little was known about the pathogenesis, treatment, and prognosis of infections due to this unusual brown-black mold. Almost 2 years after the onset of this outbreak, numerous epidemiologic and basic science studies have provided some guidance in understanding the epidemiology, clinical findings, diagnosis, and treatment of patients exposed to the contaminated medication. Additionally, this outbreak has directly led to the passage of legislation supporting increased regulation in the industry of pharmaceutical compounding. Many unanswered questions, particularly surrounding the long-term prognosis and outcomes for affected patients remain. However, it is clear that a strong relationship between clinicians caring for patients and public health as well as a rapid, effective public health response was critical in preventing additional cases of disease.
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Mikulska M, Furfaro E, Viscoli C. Non-cultural methods for the diagnosis of invasive fungal disease. Expert Rev Anti Infect Ther 2014; 13:103-17. [PMID: 25385534 DOI: 10.1586/14787210.2015.979788] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Invasive fungal diseases carry a high mortality risk which can be reduced by early treatment. Diagnosing invasive fungal diseases is challenging, because invasive methods for obtaining histological samples are frequently not feasible in thrombocytopenic immunocompromised patients, while fungal cultures have low sensitivity and a long turn-around time. Non-cultural methods are fundamental for a rapid diagnosis of invasive fungal diseases and they include assays based on the detection of fungal antigens (galactomannan, Aspergillus-lateral flow device, [1,3]-β-D-glucan, mannan), antibodies, such as anti-mannan, and molecular tests. With the exception of some molecular methods for rare fungi, the non-cultural assays are usually applied to the diagnosis of invasive aspergillosis, invasive candidiasis and pneumocystosis. The performance of a single test or a combination of tests will be discussed, with particular focus on choosing the most appropriate marker(s) for every specific patient population. Reasons for potential false-positive or false-negative results will be discussed.
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Affiliation(s)
- Małgorzata Mikulska
- Division of Infectious Diseases, IRCCS San Martino University Hospital - IST, L.go R. Benzi, 10 - 16132, Genoa, Italy
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23
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Chowdhary A, Perfect J, de Hoog GS. Black Molds and Melanized Yeasts Pathogenic to Humans. Cold Spring Harb Perspect Med 2014; 5:a019570. [PMID: 25384772 DOI: 10.1101/cshperspect.a019570] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A review is given of melanized fungi involved in human infection, including species forming budding cells and strictly filamentous representatives. Classically, they are known as "phaeoid" or "dematiaceous" fungi, and, today, agents are recognized to belong to seven orders of fungi, of which the Chaetothyriales and Pleosporales are the most important. Infections range from cutaneous or pulmonary colonization to systemic or disseminated invasion. Subcutaneous involvement, either primary or after dissemination, may lead to host tissue proliferation of dermis or epidermis. Particularly in the Chaetothyriales, subcutaneous and systemic infections may occur in otherwise apparently healthy individuals. Infections are mostly chronic and require extended antifungal therapy and/or surgery.
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Affiliation(s)
- Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi 110 007, India
| | - John Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center Durham, North Carolina 27710
| | - G Sybren de Hoog
- CBS-KNAW Fungal Biodiversity Centre, 3508 AD Utrecht, The Netherlands
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24
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Fungi associated with drug recalls and rare disease outbreaks. ACTA ACUST UNITED AC 2014; 41:1591-7. [DOI: 10.1007/s10295-014-1503-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
Abstract
Abstract
Fungi rarely cause disease outbreaks associated with use of microbe-contaminated drugs. These rare episodes typically involve a restricted spectrum of common environmental species with relatively low virulence, rather than classical pathogens. Review of data involving over-the-counter contact lens solutions and prescription drug-related recalls revealed six episodes during the past decade with significant adverse health and financial impact (including loss of vision and death). Contaminations involved fungi mostly identified with the genera Aspergillus, Exserohilum, Fusarium, Paecilomyces, and Rhizopus. These organisms are noted for their capacity to produce resistant morphotypes (chlamydoconidia, ascospores) under various adverse conditions, generally with temperature survival/tolerances markedly in excess of maximal growth temperatures. High constituent levels of melanin, trehalose and heat-shock proteins facilitate differential survival of morphotypes following exposures to toxic chemicals and temperatures above 80 °C. Adverse environmental factors that induce resistant morphotypes are suggested to occur more readily in situ than during in vitro testing. Rare unexplained, sporadic drug contamination episodes with select thermotolerant fungi may relate, in part, to resistant dormant stages.
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Abstract
The recent outbreak of exserohilum rostratum meningitis linked to epidural injections of methylprednisolone acetate has brought renewed attention to mold infections of the central nervous system (CNS). Although uncommon, these infections are often devastating and difficult to treat. This focused review of the epidemiologic aspects, clinical characteristics, and treatment of mold infections of the CNS covers a group of common pathogens: aspergillus, fusarium, and scedosporium species, molds in the order Mucorales, and dematiaceous molds. Infections caused by these pathogen groups have distinctive epidemiologic profiles, clinical manifestations, microbiologic characteristics, and therapeutic implications, all of which clinicians should understand.
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Affiliation(s)
- Matthew McCarthy
- From the Transplantation-Oncology Infectious Diseases Program, Departments of Medicine, Pediatrics, and Microbiology and Immunology (M.M., T.J.W.), and the Departments of Neurology, Neuroscience, and Neurosurgery (A.R.) and Pathology and Laboratory Medicine (A.N.S.), Weill Cornell Medical Center of Cornell University, New York; and the Infectious Diseases Department and Division of Internal Medicine, University of Texas M.D. Anderson Cancer Center, Houston (D.P.K.)
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26
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Whole-genome analysis of Exserohilum rostratum from an outbreak of fungal meningitis and other infections. J Clin Microbiol 2014; 52:3216-22. [PMID: 24951807 DOI: 10.1128/jcm.00936-14] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Exserohilum rostratum was the cause of most cases of fungal meningitis and other infections associated with the injection of contaminated methylprednisolone acetate produced by the New England Compounding Center (NECC). Until this outbreak, very few human cases of Exserohilum infection had been reported, and very little was known about this dematiaceous fungus, which usually infects plants. Here, we report using whole-genome sequencing (WGS) for the detection of single nucleotide polymorphisms (SNPs) and phylogenetic analysis to investigate the molecular origin of the outbreak using 22 isolates of E. rostratum retrieved from 19 case patients with meningitis or epidural/spinal abscesses, 6 isolates from contaminated NECC vials, and 7 isolates unrelated to the outbreak. Our analysis indicates that all 28 isolates associated with the outbreak had nearly identical genomes of 33.8 Mb. A total of 8 SNPs were detected among the outbreak genomes, with no more than 2 SNPs separating any 2 of the 28 genomes. The outbreak genomes were separated from the next most closely related control strain by ∼136,000 SNPs. We also observed significant genomic variability among strains unrelated to the outbreak, which may suggest the possibility of cryptic speciation in E. rostratum.
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Nelson G, Fermo O, Thakur K, Felton E, Bang J, Wilson L, Rhee S, Llinas R, Johnson K, Sullivan D. Resolution of a fungal mycotic aneurysm after a contaminated steroid injection: a case report. BMC Res Notes 2014; 7:327. [PMID: 24885172 PMCID: PMC4057927 DOI: 10.1186/1756-0500-7-327] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 05/28/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In the past ten years there have been three separate outbreaks of fungal contaminated steroid injections from compounding pharmacies. The 2012 outbreak of central nervous system fungal infections associated with contaminated methylprednisolone produced by a United States compounding pharmacy has led to 750 infections (151 with meningitis and paraspinal infections and 325 cases with paraspinal infections without meningitis) and 64 deaths as of October 23, 2013. Exserohilum rostratum has been the predominant pathogen identified by culture, polymerase chain reaction or antibody tests. According to previous reports, cerebral involvement with phaeohyphomycosis has a high risk of morbidity and mortality. CASE PRESENTATION We report a 41 year-old Caucasian woman who received a lumbar methylprednisolone injection from a contaminated lot in August 2012. She was diagnosed with fungal meningitis by cerebrospinal fluid pleocytosis and positive (1, 3) beta-D-glucan after cultures and polymerase chain reaction were negative. Two weeks after onset of therapy, she developed a 4.1 mm superior cerebellar artery mycotic aneurysm associated with new stroke symptoms, which resolved with thirty-two weeks of antifungal treatment. CONCLUSIONS This is the rare case report of successful medical management of a cerebral mycotic aneurysm with stroke symptoms related to a presumed phaeohyphomycosis in an immunocompetent individual. Further studies are needed to determine the utility of cerebrospinal fluid (1, 3) beta-D-glucan in diagnosing and monitoring patients with meningitis thought to be related to fungal infection.
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Affiliation(s)
- George Nelson
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olga Fermo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kiran Thakur
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Felton
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jee Bang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lucy Wilson
- Maryland Department of Health and Mental Hygiene, Baltimore, Maryland, USA
| | - Susan Rhee
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael Llinas
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kristine Johnson
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Sullivan
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- W. Harry Feinstone Department of Microbiology and Immunology, Room E5628, The Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe St, Baltimore, Maryland 21205, USA
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Moudgal V, Singal B, Kauffman CA, Brodkey JA, Malani AN, Olmsted RN, Kasotakis MJ, Koch SR, Kaakaji R, Nyaku M, Neelakanta A, Valenstein P, Winter S, Otto M, Jagarlamudi R, Kerr L, Czerwinski J, Vandenberg D, Sutton SR, Murphy H, Halasyamani LK. Spinal and paraspinal fungal infections associated with contaminated methylprednisolone injections. Open Forum Infect Dis 2014; 1:ofu022. [PMID: 25734095 PMCID: PMC4324199 DOI: 10.1093/ofid/ofu022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND A nationwide outbreak of fungal infections was traced to injection of Exserohilum-contaminated methylprednisolone. We describe our experience with patients who developed spinal or paraspinal infection after injection of contaminated methylprednisolone. METHODS Data were assembled from the Michigan Department of Community Health, electronic medical records, and magnetic resonance imaging (MRI) reports. RESULTS Of 544 patients who received an epidural injection from a contaminated lot of methylprednisolone at a pain clinic in southeastern Michigan, 153 (28%) were diagnosed at our institution with probable or confirmed spinal or paraspinal fungal infection at the injection site. Forty-one patients had both meningitis and spinal or paraspinal infection, and 112 had only spinal or paraspinal infection. Magnetic resonance imaging abnormalities included abscess, phlegmon, arachnoiditis, and osteomyelitis. Surgical debridement in 116 patients revealed epidural phlegmon and epidural abscess most often. Among 26 patients with an abnormal MRI but with no increase or change in chronic pain, 19 (73%) had infection identified at surgery. Fungal infection was confirmed in 78 patients (51%) by finding hyphae in tissues, positive polymerase chain reaction, or culture. Initial therapy was voriconazole plus liposomal amphotericin B in 115 patients (75%) and voriconazole alone in 38 patients (25%). As of January 31, 2014, 20 patients remained on an azole agent. Five patients died of infection. CONCLUSIONS We report on 153 patients who had spinal or paraspinal fungal infection at the site of epidural injection of contaminated methylprednisolone. One hundred sixteen (76%) underwent operative debridement in addition to treatment with antifungal agents.
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Affiliation(s)
| | | | - Carol A Kauffman
- Veterans Affairs Ann Arbor Healthcare System and the University of Michigan Medical School , Ann Arbor, Michigan
| | | | | | | | | | | | - Rami Kaakaji
- Saint Joseph Mercy Hospital , Ann Arbor, Michigan
| | - Mawuli Nyaku
- Centers for Disease Control and Prevention , Atlanta, Georgia
| | | | | | | | - Michael Otto
- Saint Joseph Mercy Hospital , Ann Arbor, Michigan
| | | | - Lisa Kerr
- Saint Joseph Mercy Hospital , Ann Arbor, Michigan
| | | | | | | | - Holly Murphy
- Saint Joseph Mercy Hospital , Ann Arbor, Michigan
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Abstract
PURPOSE OF REVIEW The recent outbreak of fungal meningitis related to contaminated methylprednisolone acetate injections represents an important cause of morbidity and continues to be a significant public health problem in the United States. RECENT FINDINGS As of August 2013, there have been 749 cases and 63 deaths in 20 states associated with epidemic fungal meningitis, most of these because of Exserohilum rostratum. Clinical experience in managing these cases has grown dramatically in the last several months; most patients require at least 6 months of antifungal therapy for complicated disease. Most patients are treated with voriconazole, with or without liposomal amphotericin B, for central nervous system and paraspinal complications of the disease. For disease involving the sacroiliac and peripheral joints, voriconazole alone has been preferred. MRI spine imaging has identified several cases of asymptomatic disease, suggesting an aggressive diagnostic approach to exposed asymptomatic patients. Mortality remains low (<10%), but morbidity relating to persistent symptoms and treatment-associated toxicity is high. SUMMARY The ongoing fungal meningitis epidemic demonstrates an important achievement for the public health community. Important questions remain relating to the diagnosis, management, and long-term outcomes of these patients. Important research questions pertaining to specific risks influencing disease manifestations remain unanswered.
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Chowdhary A, Meis J, Guarro J, de Hoog G, Kathuria S, Arendrup M, Arikan-Akdagli S, Akova M, Boekhout T, Caira M, Guinea J, Chakrabarti A, Dannaoui E, van Diepeningen A, Freiberger T, Groll A, Hope W, Johnson E, Lackner M, Lagrou K, Lanternier F, Lass-Flörl C, Lortholary O, Meletiadis J, Muñoz P, Pagano L, Petrikkos G, Richardson M, Roilides E, Skiada A, Tortorano A, Ullmann A, Verweij P, Cornely O, Cuenca-Estrella M. ESCMID and ECMM joint clinical guidelines for the diagnosis and management of systemic phaeohyphomycosis: diseases caused by black fungi. Clin Microbiol Infect 2014; 20 Suppl 3:47-75. [DOI: 10.1111/1469-0691.12515] [Citation(s) in RCA: 216] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 12/13/2013] [Accepted: 12/16/2013] [Indexed: 11/28/2022]
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Katragkou A, Pana ZD, Perlin DS, Kontoyiannis DP, Walsh TJ, Roilides E. Exserohilum infections: review of 48 cases before the 2012 United States outbreak. Med Mycol 2014; 52:376-86. [PMID: 24682112 DOI: 10.1093/mmy/myt030] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Exserohilum species are soilborne fungi that have been uncommon causes of human disease. The ongoing outbreak in the United States warrants improved understanding of this pathogen. We systematically reviewed all cases of Exserohilum spp. infections published before the outbreak in 2012 in order to provide a better understanding of the organism and its wider spectrum of human disease. Cases of Exserohilum infections were retrieved by searching PubMed. Demographic data, underlying conditions, microbiology, clinical manifestations, therapy, and outcome were recorded and analyzed. Forty-eight evaluable cases were identified from 1975 to 2012. The number of reported cases increased more than twofold during the study period (P < 0.01). Most cases occurred in the southern United States, India, and Israel. Median age of patients was 25 years, with a male predominance. Most infections were due to E. rostratum (60.4%), followed by E. longirostratum (6.3%) and E. mcginnisii (2%), while 31.3% were unidentified species. The most frequent underlying conditions were immunosuppression (27.2%), trauma (16.6%), and atopy (12.5%). Exserohilum disease manifested as systemic (73%), cutaneous (25%), corneal (16.7%), and subcutaneous (10.4%) infection. Antifungal therapy consisted mainly of amphotericin B (44%) alone or combined with a triazole. Surgery was used in 48% of cases and was combined with antifungal therapy in 31%. The all-cause mortality was 23%, which was higher in patients with preexisting immunosuppression (56.2%; odds ratio 15.4; 95% confidence interval, 2.7-88.6). This review of the pre-outbreak reported cases highlights several aspects of epidemiology, clinical presentation, risk factors, and management of this unusual pathogen.
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Affiliation(s)
- Aspasia Katragkou
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University School of Medicine, Hippokration Hospital, Thessaloniki, Greece
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Kourbeti IS, Mylonakis E. Fungal central nervous system infections: prevalence and diagnosis. Expert Rev Anti Infect Ther 2014; 12:265-73. [PMID: 24392732 DOI: 10.1586/14787210.2014.874282] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fungal infections of the central nervous system (CNS) are rare but they pose a significant challenge. Their prevalence spans a wide array of hosts including immunosuppressed and immunocompetent individuals, patients undergoing neurosurgical procedures and those carrying implantable CNS devices. Cryptococcus neoformans and Aspergillus spp. remain the most common pathogens. Magnetic resonance imaging can help localize the lesions, but diagnosis is challenging since invasive procedures may be needed for the retrieval of tissue, especially in cases of fungal abscesses. Antigen and antibody tests are available and approved for use in the cerebrospinal fluid (CSF). PCR-based techniques are promising but they are not validated for use in the CSF. This review provides an overview on the differential diagnosis of the fungal CNS disease based on the host and the clinical syndrome and suggests the optimal use of diagnostic techniques. It also summarizes the emergence of Cryptococcus gatti and an unanticipated outbreak caused by Exserohilum rostratum.
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Affiliation(s)
- Irene S Kourbeti
- Infectious Disease Division, Alpert Medical School and Brown University, Rhode Island Hospital, RI, USA
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33
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The Exserohilum rostratum Incident. Emerg Infect Dis 2014. [DOI: 10.1016/b978-0-12-416975-3.00022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Litvintseva AP, Lindsley MD, Gade L, Smith R, Chiller T, Lyons JL, Thakur KT, Zhang SX, Grgurich DE, Kerkering TM, Brandt ME, Park BJ. Utility of (1-3)-β-D-glucan testing for diagnostics and monitoring response to treatment during the multistate outbreak of fungal meningitis and other infections. Clin Infect Dis 2013; 58:622-30. [PMID: 24336827 DOI: 10.1093/cid/cit808] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The 2012 outbreak of fungal meningitis associated with contaminated methylprednisolone produced by a compounding pharmacy has resulted in >750 infections. An important question facing patients and clinicians is the duration of antifungal therapy. We evaluated (1-3)-β-d-glucan (BDG) as a marker for monitoring response to treatment. METHODS We determined sensitivity and specificity of BDG testing using the Fungitell assay, by testing 41 cerebrospinal fluid (CSF) specimens from confirmed cases of fungal meningitis and 66 negative control CSF specimens. We also assessed whether BDG levels correlate with clinical status by using incident samples from 108 case patients with meningitis and 20 patients with serially collected CSF. RESULTS A cutoff value of 138 pg/mL provided 100% sensitivity and 98% specificity for diagnosis of fungal meningitis in this outbreak. Patients with serially collected CSF were divided into 2 groups: those in whom BDG levels declined with treatment and those in whom BDG remained elevated. Whereas most patients with a decline in CSF BDG had clinical improvement, all 3 patients with continually elevated BDG had poor clinical outcomes (stroke, meningitis relapse, or development of new disease). CONCLUSIONS Our data suggest that measuring BDG in CSF is a highly sensitive test for diagnosis of fungal meningitis in this outbreak. Analysis of BDG levels in serially collected CSF demonstrated that BDG may correlate with clinical response. Routine measurement of BDG in CSF may provide useful adjunctive data for the clinical management of patients with outbreak-associated meningitis.
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Affiliation(s)
- Anastasia P Litvintseva
- Mycotic Diseases Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Ohno H, Miyazaki Y. [Genetic diagnosis against fungal cerebromeningitis]. Rinsho Shinkeigaku 2013; 53:1191-3. [PMID: 24291925 DOI: 10.5692/clinicalneurol.53.1191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Fungal cerebromeningitis is one of deep seated mycoses and also a fatal fungal infectious disease. Regarding to causative pathogen of fungal cerebromeningitis in Japan, Cryptococcus spp., Candida spp., Aspergillus spp., are popular fungi. In general, the diagnosis of deep seated mycosis is sometime difficult. The genetic diagnosis method such as PCR against deep seated mycosis has been developing and it has been also reported as one of useful diagnostic tests. However, PCR for fungal detection is still a research test that has not been cleared or approved officially, therefore it should not be used for diagnosis, or patient management routinely. The PCR which detect broad range of fungi or specific fungus is applied for clinical situation, a careful attention should be paid for avoiding contamination because many fungal species are available in living environment.
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Affiliation(s)
- Hideaki Ohno
- Department of Chemotherapy and Mycoses, National Institute of Infectious diseases
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Andes D, Casadevall A. Insights into fungal pathogenesis from the iatrogenic epidemic of Exserohilum rostratum fungal meningitis. Fungal Genet Biol 2013; 61:143-5. [DOI: 10.1016/j.fgb.2013.08.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 08/22/2013] [Accepted: 08/23/2013] [Indexed: 10/26/2022]
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Larone DH, Walsh TJ. Exserohilum rostratum: Anatomy of a national outbreak of fungal meningitis. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.clinmicnews.2013.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Emerging infections affecting the central nervous system often present as encephalitis and can cause substantial morbidity and mortality. Diagnosis requires not only careful history taking, but also the application of newly developed diagnostic tests. These diseases frequently occur in outbreaks stemming from viruses that have mutated from an animal host and gained the ability to infect humans. With globalization, this can translate to the rapid emergence of infectious clusters or the establishment of endemicity in previously naïve locations. Since these infections are often vector borne and effective treatments are almost uniformly lacking, prevention is at least as important as prompt diagnosis and institution of supportive care. In this review, we focus on some of the recent literature addressing emerging and resurging viral encephalitides in the United States and around the world-specifically, West Nile virus, dengue, polio, and cycloviruses. We also discuss new, or "emerging," techniques for the precise and rapid diagnosis of encephalitides.
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Affiliation(s)
- Jennifer Lyons
- Department of Neurology, Division of Neurological Infections, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Smith RM, Schaefer MK, Kainer MA, Wise M, Finks J, Duwve J, Fontaine E, Chu A, Carothers B, Reilly A, Fiedler J, Wiese AD, Feaster C, Gibson L, Griese S, Purfield A, Cleveland AA, Benedict K, Harris JR, Brandt ME, Blau D, Jernigan J, Weber JT, Park BJ. Fungal infections associated with contaminated methylprednisolone injections. N Engl J Med 2013; 369:1598-609. [PMID: 23252499 DOI: 10.1056/nejmoa1213978] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fungal infections are rare complications of injections for treatment of chronic pain. In September 2012, we initiated an investigation into fungal infections associated with injections of preservative-free methylprednisolone acetate that was purchased from a single compounding pharmacy. METHODS Three lots of methylprednisolone acetate were recalled by the pharmacy; examination of unopened vials later revealed fungus. Notification of all persons potentially exposed to implicated methylprednisolone acetate was conducted by federal, state, and local public health officials and by staff at clinical facilities that administered the drug. We collected clinical data on standardized case-report forms, and we tested for the presence of fungi in isolates and specimens by examining cultures and performing polymerase-chain-reaction assays and histopathological and immunohistochemical testing. RESULTS By October 19, 2012, more than 99% of 13,534 potentially exposed persons had been contacted. As of July 1, 2013, there were 749 reported cases of infection in 20 states, with 61 deaths (8%). Laboratory evidence of Exserohilum rostratum was present in specimens from 153 case patients (20%). Additional data were available for 728 case patients (97%); 229 of these patients (31%) had meningitis with no other documented infection. Case patients had received a median of 1 injection (range, 1 to 6) of implicated methylprednisolone acetate. The median age of the patients was 64 years (range, 15 to 97), and the median incubation period (the number of days from the last injection to the date of the first diagnosis) was 47 days (range, 0 to 249); 40 patients (5%) had a stroke. CONCLUSIONS Analysis of data from a large, multistate outbreak of fungal infections showed substantial morbidity and mortality. The infections were associated with injection of a contaminated glucocorticoid medication from a single compounding pharmacy. Rapid public health actions included prompt recall of the implicated product, notification of exposed persons, and early outreach to clinicians.
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Affiliation(s)
- Rachel M Smith
- From the Epidemic Intelligence Service, Scientific Education and Professional Development Program Office (R.M.S., S.G., A.P.), Division of Foodborne, Waterborne, and Environmental Diseases (R.M.S., A.P., A.A.C., K.B., J.R.H., M.E.B., B.J.P.), Division of Healthcare Quality Promotion (M.K.S., M.W., J.J., J.T.W.), and Division of High-Consequence Pathogens and Pathology (D.B.), Centers for Disease Control and Prevention, Atlanta; the Tennessee Department of Health, Nashville (M.A.K., A.D.W.); the Michigan Department of Community Health, Bureau of Epidemiology, Lansing (J. Finks, J. Fiedler); the Indiana State Department of Health, Indianapolis (J.D., C.F.); the Virginia Department of Health, Richmond (E.F., L.G.); the Maryland Department of Health and Mental Hygiene, Baltimore (A.C.); the New Jersey Department of Health, Trenton (B.C.); the Florida Department of Health, Tallahassee (A.R.); and the North Carolina Division of Public Health, Raleigh (S.G.)
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Chiller TM, Roy M, Nguyen D, Guh A, Malani AN, Latham R, Peglow S, Kerkering T, Kaufman D, McFadden J, Collins J, Kainer M, Duwve J, Trump D, Blackmore C, Tan C, Cleveland AA, MacCannell T, Muehlenbachs A, Zaki SR, Brandt ME, Jernigan JA. Clinical findings for fungal infections caused by methylprednisolone injections. N Engl J Med 2013; 369:1610-9. [PMID: 24152260 DOI: 10.1056/nejmoa1304879] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Since September 18, 2012, public health officials have been investigating a large outbreak of fungal meningitis and other infections in patients who received epidural, paraspinal, or joint injections with contaminated lots of methylprednisolone acetate. Little is known about infections caused by Exserohilum rostratum, the predominant outbreak-associated pathogen. We describe the early clinical course of outbreak-associated infections. METHODS We reviewed medical records for outbreak cases reported to the Centers for Disease Control and Prevention before November 19, 2012, from the six states with the most reported cases (Florida, Indiana, Michigan, New Jersey, Tennessee, and Virginia). Polymerase-chain-reaction assays and immunohistochemical testing were performed on clinical isolates and tissue specimens for pathogen identification. RESULTS Of 328 patients without peripheral-joint infection who were included in this investigation, 265 (81%) had central nervous system (CNS) infection and 63 (19%) had non-CNS infections only. Laboratory evidence of E. rostratum was found in 96 of 268 patients (36%) for whom samples were available. Among patients with CNS infections, strokes were associated with an increased severity of abnormalities in cerebrospinal fluid (P<0.001). Non-CNS infections were more frequent later in the course of the outbreak (median interval from last injection to diagnosis, 39 days for epidural abscess and 21 days for stroke; P<0.001), and such infections developed in patients with and in those without meningitis. CONCLUSIONS The initial clinical findings from this outbreak suggest that fungal infections caused by epidural and paraspinal injection of a contaminated glucocorticoid product can result in a broad spectrum of clinical disease, reflecting possible variations in the pathogenic mechanism and in host and exposure risk factors. (Funded by the Centers for Disease Control and Prevention.).
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Affiliation(s)
- Tom M Chiller
- The authors' affiliations are listed in the Appendix
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Lyons JL. CNS Mold Infections. Curr Infect Dis Rep 2013; 15:569-575. [PMID: 24122369 DOI: 10.1007/s11908-013-0376-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Mold infections of the central nervous system (CNS) present as abscesses, infarcts, hemorrhages, and, less commonly, meningitis. These invasive infections are difficult both to identify and to eradicate given low-sensitivity diagnostics and high-toxicity, low-efficacy antifungal therapies, hence resulting in high rates of morbidity and mortality. Herein, the recent literature on CNS mold infections is reviewed, and updates in diagnosis and management are discussed.
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Affiliation(s)
- Jennifer L Lyons
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA,
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Lockhart SR, Pham CD, Gade L, Iqbal N, Scheel CM, Cleveland AA, Whitney AM, Noble-Wang J, Chiller TM, Park BJ, Litvintseva AP, Brandt ME. Preliminary laboratory report of fungal infections associated with contaminated methylprednisolone injections. J Clin Microbiol 2013; 51:2654-61. [PMID: 23761142 PMCID: PMC3719655 DOI: 10.1128/jcm.01000-13] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 06/03/2013] [Indexed: 11/20/2022] Open
Abstract
In September 2012, the Centers for Disease Control and Prevention (CDC) initiated an outbreak investigation of fungal infections linked to injection of contaminated methylprednisolone acetate (MPA). Between 2 October 2012 and 14 February 2013, the CDC laboratory received 799 fungal isolates or human specimens, including cerebrospinal fluid (CSF), synovial fluid, and abscess tissue, from 469 case patients in 19 states. A novel broad-range PCR assay and DNA sequencing were used to evaluate these specimens. Although Aspergillus fumigatus was recovered from the index case, Exserohilum rostratum was the primary pathogen in this outbreak and was also confirmed from unopened MPA vials. Exserohilum rostratum was detected or confirmed in 191 specimens or isolates from 150 case patients, primarily from Michigan (n=67 patients), Tennessee (n=26), Virginia (n=20), and Indiana (n=16). Positive specimens from Michigan were primarily abscess tissues, while positive specimens from Tennessee, Virginia, and Indiana were primarily CSF. E. rostratum antifungal susceptibility MIC50 and MIC90 values were determined for voriconazole (1 and 2 μg/ml, respectively), itraconazole (0.5 and 1 μg/ml), posaconazole (0.5 and 1 μg/ml), isavuconazole (4 and 4 μg/ml), and amphotericin B (0.25 and 0.5 μg/ml). Thirteen other mold species were identified among case patients, and four other fungal genera were isolated from the implicated MPA vials. The clinical significance of these other fungal species remains under investigation. The laboratory response provided significant support to case confirmation, enabled linkage between clinical isolates and injected vials of MPA, and described significant features of the fungal agents involved in this large multistate outbreak.
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Affiliation(s)
- Shawn R Lockhart
- Mycotic Diseases Branch, National Center for Emerging, Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Feldmesser M. Fungal disease following contaminated steroid injections: Exserohilum is ready for its close-up. THE AMERICAN JOURNAL OF PATHOLOGY 2013; 183:661-4. [PMID: 23876717 DOI: 10.1016/j.ajpath.2013.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 06/28/2013] [Accepted: 06/28/2013] [Indexed: 11/25/2022]
Abstract
This Commentary highlights the article by Ritter et al. that reported the pathology associated with the recent fungal outbreak associated with contaminated methylprednisolone acetate injections.
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Affiliation(s)
- Marta Feldmesser
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA.
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Ritter JM, Muehlenbachs A, Blau DM, Paddock CD, Shieh WJ, Drew CP, Batten BC, Bartlett JH, Metcalfe MG, Pham CD, Lockhart SR, Patel M, Liu L, Jones TL, Greer PW, Montague JL, White E, Rollin DC, Seales C, Stewart D, Deming MV, Brandt ME, Zaki SR. Exserohilum infections associated with contaminated steroid injections: a clinicopathologic review of 40 cases. THE AMERICAN JOURNAL OF PATHOLOGY 2013; 183:881-92. [PMID: 23809916 DOI: 10.1016/j.ajpath.2013.05.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 05/16/2013] [Accepted: 05/20/2013] [Indexed: 12/25/2022]
Abstract
September 2012 marked the beginning of the largest reported outbreak of infections associated with epidural and intra-articular injections. Contamination of methylprednisolone acetate with the black mold, Exserohilum rostratum, was the primary cause of the outbreak, with >13,000 persons exposed to the potentially contaminated drug, 741 confirmed drug-related infections, and 55 deaths. Fatal meningitis and localized epidural, paraspinal, and peripheral joint infections occurred. Tissues from 40 laboratory-confirmed cases representing these various clinical entities were evaluated by histopathological analysis, special stains, and IHC to characterize the pathological features and investigate the pathogenesis of infection, and to evaluate methods for detection of Exserohilum in formalin-fixed, paraffin-embedded (FFPE) tissues. Fatal cases had necrosuppurative to granulomatous meningitis and vasculitis, with thrombi and abundant angioinvasive fungi, with extensive involvement of the basilar arterial circulation of the brain. IHC was a highly sensitive method for detection of fungus in FFPE tissues, demonstrating both hyphal forms and granular fungal antigens, and PCR identified Exserohilum in FFPE and fresh tissues. Our findings suggest a pathogenesis for meningitis involving fungal penetration into the cerebrospinal fluid at the injection site, with transport through cerebrospinal fluid to the basal cisterns and subsequent invasion of the basilar arteries. Further studies are needed to characterize Exserohilum and investigate the potential effects of underlying host factors and steroid administration on the pathogenesis of infection.
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Affiliation(s)
- Jana M Ritter
- Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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