Polymicrobial candidaemia revealed by peripheral blood smear and chromogenic medium

Peripheral Blood Smear: Hematologist Buddy to Catch Dangerous Budding: A Report of Two Cases

The incidence of nosocomial infections has been reported as 12%-18% in various studies from India, with bloodstream infections amounting 15%. Fungal pathogens have become a major cause of nosocomial bloodstream infections. Detection of fungemia by blood culture often requires 2 or 3 days of incubation. Few studies have reported the detection of Candida species (Candida albicans, Candida glabrata, and Candida parapsilosis) by review of routinely stained blood smears, often days earlier than diagnosis being possible by culture. These can be seen as round-oval extracellular as well as intracellular budding yeast organisms which show pink-magenta staining with periodic acid Schiff stain. We report here the detection of Candida spp. in the peripheral blood smear.

Laboratory diagnosis of community-acquired bloodstream infection in therapeutic pathology

Community-acquired bloodstream infections (CBSIs) occur in the out-of-hospital setting (44%) and increase the overall mortality from bloodstream infections (BSIs) by 7.2% per year. The development of CBSIs depends on both comorbid and polymorbid diseases and the patients' age. The causes of CBSIs are: respiratory, hepatobiliary gastrointestinal and urogenital tracts and dental interventions. The etiology of CBSIs is characterized by the isolation of coagulase-negative staphylococci (CNS) (32%), E. coli (27%). To investigate community-acquired bloodstream infection in therapeutic patients. The study included out-of-hospital patients (n=382). 4.5 ml of blood were taken intravenously into a closed vacuum system in order to obtain a buffy coat of blood, which was put on glasses for microscopy and Petri dishes with blood agar for cultivating under aerobic and anaerobic conditions. Microorganisms were identified by mass spectrometry. Microscopy of blood smears was used for rapid diagnosis of infection in the bloodstream. BSI was diagnosed in 183 (48.0%) out of 382 out-of-hospital patients. The etiology of CBSIs was studied on 297 isolated strains of microorganisms. CBSIs rather often complicated the underlying disease in women and young people. The spectrum of CBSI pathogens included aerobic and anaerobic bacteria and fungi. Gram-positive cocci with the leadership of S.epidermidis (25.7%) were more often isolated among bacteria. 70% of all isolated pathogens grew under anaerobic conditions. CBSIs were characterized by polymicrobiality (33.5%) of two to four different microorganisms in one blood culture; the species of associates of polymicrobial blood cultures are shown. Microscopic examination of blood smears revealed microorganisms in 97.1% of cases, including associations of bacteria with fungi (66.9%). CBSIs occurred after contour plastic, in diseases of the respiratory system, genitourinary system, oral cavity, skin and subcutaneous tissue. Microbiological examination of the buffy coat is an alternative microbiological method of CBSIs diagnosis, which includes microscopy and blood cultivating and has a high diagnostic efficiency (97.1% and 48% respectively). It can become an option for replacing imported blood culture automated systems.

Anesthesia and perioperative management for giant adrenal Ewing’s sarcoma with inferior vena cava and right atrium tumor thrombus: A case report

BACKGROUND

Ewing’s sarcoma of the adrenal gland with inferior vena cava (IVC) and right atrium thrombus is extremely rare. Here, we report a case of giant adrenal Ewing’s sarcoma with IVC and right atrium tumor thrombus and summarize the anesthesia and perioperative management.

CASE SUMMARY

A young female was admitted to the Department of Urology with intermittent pain under the right costal arch for four months. Enhanced abdominal computed tomography revealed a large retroperitoneal mass (22 cm in diameter), which may have originated from the right adrenal gland and was closely related to the liver. Transthoracic echocardiography showed a strong echogenic filling measuring 70 mm extended from the IVC into the right atrium and ventricle. After preoperative preparation with cardiopulmonary bypass, sufficient blood products, transesophageal echocardiography and multiple monitoring, tumor and thrombus resection by IVC exploration and right atriotomy were successfully performed by a multidisciplinary team. Intraoperative hemodynamic stability was the major concern of anesthesiologists and the status of tumor thrombus and pulmonary embolism were monitored continuously. During transfer of the patient to the intensive care unit (ICU), cardiac arrest occurred without external stimulus. Cardiopulmonary resuscitation was performed immediately and cardiac function was restored after 1 min. In the ICU, extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) were provided to maintain cardiac, liver and kidney function. Histopathologic examination confirmed the diagnosis of Ewing’s sarcoma. After postoperative treatments and rehabilitation, the patient was discharged from the urology ward.

CONCLUSION

An adrenal Ewing’s sarcoma with IVC and right atrium thrombus is extremely rare, and its anesthesia and perioperative management have not been reported. Thus, this report provides significant insights in the perioperative management of patients with adrenal Ewing’s sarcoma and IVC tumor thrombus. Intraoperative circulation fluctuations and sudden cardiovascular events are the major challenges during surgery. In addition, postoperative treatments including ECMO and CRRT provide essential support in critically ill patients. Moreover, this case report also highlights the importance of multidisciplinary cooperation during treatment of the disease.

Susceptibility of Fluconazole-Resistant Candida albicans to Thyme Essential Oil

Candida spp. is the most common microbial pathogen in fungal infections. There has been a tremendous increase in cases of candidiasis, especially among critically ill non-neutropenic patients. Candida albicans’ isolates were procured from the Prince Sultan Military Hospital, Riyadh, KSA. The isolates were characterized for their identification using CHROMagar, carbohydrate metabolism, germ tube formation, and RAPD-PCR techniques. The essential oil of Thymus vulgaris was obtained by hydro-distillation and characterized to decipher the major bioactive phytoconstituents. The antifungal activity of the thyme essential oil (TEO) was evaluated against fluconazole-resistant C. albicans isolates. The major phytocomponents identified by GC/MS were thymol (68.1%) followed by γ-terpinene (8.9%), cymol (7.7%), caryophyllene (1.1%), linalool (1.4%). The TEO successfully reduced the growth of C. albicans isolates. At very low doses, the TEO proved to be fungi static and fungicidal. TEO also effectively inhibited the germ tube formation and budging of fungal pathogens. The time kill assays have shown that TEO was more effective against drug resistant clinical isolates than fluconazole. This study provides an array of experimental evidence regarding the therapeutic efficacy of TEO against the drug-resistant clinical isolates of C. albicans. The findings may be used in the development of a new antifungal agent accordingly.

Mixed fungaemia: an 18-year report from a tertiary-care university hospital and a systematic review

BACKGROUND

While fungaemia caused by two or more different species of yeasts (mixed fungaemia, MF) is infrequent, it might be underestimated.

AIMS

This study aimed to determine the incidence of MF, clinical characteristics of the patients, and antifungal susceptibility profiles of the isolates with a systematic review of the literature.

SOURCES

Data sources were PubMed and Scopus.

STUDY ELIGIBILITY CRITERIA

Studies reporting ten or more mixed fungaemia episodes.

CONTENT

Study included MF episodes in adults between January 2000 and August 2018 in Hacettepe University Hospitals, Turkey. The isolation, identification and antifungal susceptibility testing (AFST) of the isolates were by standard mycological methods. Patient data were obtained retrospectively. Literature search was performed using relevant keywords according to PRISMA systematic review guidelines. A total of 32 patients with 33 MF episodes were identified. Among all fungaemia episodes, MF incidence was 3.7% (33/883). All patients had one or more underlying disorders among which solid-organ cancer (50.0%, 16/32) was the most common. Overall mortality was 51.5% (17/33). The most preferred antifungal agents for initial treatment were fluconazole (48.5%, 16/33) and echinocandins (39.4%, 13/33). Fluconazole susceptible-dose-dependent (S-DD) or -resistant Candida species were detected in 15 episodes, and an isolate of C. parapsilosis was classified as S-DD by AFST. All Candida isolates were susceptible to echinocandins. Non-candida yeasts with intrinsic resistance/reduced susceptibility to both echinocandins and fluconazole were detected in two episodes. Systematic review of the literature revealed 24 studies that reported more than ten MF episodes. Methodology was variable. Improvement of detection rates was reported when chromogenic agars were used. Most studies underlined detection of isolates with reduced susceptibility.

IMPLICATIONS

Although rare, the MF rate is affected by the detection methods, which have improved in recent years. Fluconazole and echinocandins were used for initial treatment in accordance with the current guideline recommendations; however, isolates non-susceptible to both were detected. Detection of a mixed infection offers an opportunity for optimum treatment.

A Fatal Case of Candida auris and Candida tropicalis Candidemia in Neutropenic Patient

We report a fatal case of Candida auris that was involved in mixed candidemia with Candida tropicalis, isolated from the blood of a neutropenic patient. Identification of both isolates was confirmed by amplification and sequencing of internal transcribed spacer and D1/D2 domain of large subunit in rRNA gene. Antifungal susceptibility test by E-test method revealed that C. auris was resistant to amphotericin B, anidulafungin, caspofungin, fluconazole, itraconazole and voriconazole. On the other hand, C. tropicalis was sensitive to all antifungal tested. The use of chromogenic agar as isolation media is vital in detecting mixed candidemia.

[Study of the infectivity of Candida on peripheral vascular catheters collected from the University Hospital of Tlemcen]

Yeasts can adhere to medical implants and cause infections responsible for high morbidity and mortality among hospitalized patients. The objective of this study is to investigate the infectivity on peripheral vascular catheters collected from general surgery and cardiology in University Hospital of Tlemcen. The results showed that from 29 samples altered by yeast, 35 Candida sp. strains were isolated. However, Candida albicans is the most isolated species in an infectious context. Risk factors that accompanied the infections are the duration of implantation, male gender, and bacterial presence.

Fungal Profile of Vulvovaginal Candidiasis in a Tertiary Care Hospital

INTRODUCTION

Vulvovaginal Candidiasis (VVC) is a common medical health problem of adult women. It is most commonly caused by Candida albicans. But there is a change in fungal profile. Sabouraud's Dextrose Agar (SDA) is the most common culture medium used where mixed fungal infection may be missed. It can be detected easily by using chromogenic culture medium.

AIM

To know the fungal profile of vulvovaginal candidiasis using Candida CHROMagar and antifungal susceptibility pattern in patients attending tertiary care hospital.

MATERIALS AND METHODS

Culture confirmed cases of VVC presented at Department of Obstetrics and Gynaecology of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India, from July 2015 to December 2015 were included in the cross-sectional study. Two high vaginal swabs were collected and inoculated on SDA and Candida CHROMagar (Hi-Media, Mumbai, India). After overnight incubation the colonies were counted and colour of the colonies were recorded from Candida CHROMagar. Candida spp. were identified by sugar fermentation and assimilation tests and other conventional tests. Antifungal susceptibility tests were performed by the disc diffusion method using fluconazole (25 μg) and voriconazole (1μg) as per the Clinical and Laboratory Standards Institute (CLSI - M44-A2) guidelines.

RESULTS

A total of 50 culture confirmed (23.7%) cases were detected from 211 clinically suspected VVC cases. Candida glabrata (45.1%) was the most common isolate, followed by Candidatropicalis (23.5%), Candida albicans (17.6%), Candida krusei (9.8%) and Candida parapsilosis (3.9%). One mixed infection of C. glabrata and C. albicans was identified on Candida CHROMagar. Mixed fungal infection was observed in 2% of positive culture and 0.5% of VVC cases. The antifungal susceptibility testing revealed that 15.7% and 9.8% isolates of Candida spp. were resistant and Susceptible Dose Dependent (S-DD) respectively to fluconazole. The increase resistant against fluconazole was because of increased isolation of C. glabrata strains. All strains of Candida spp. were susceptible to voriconazole.

CONCLUSION

C. glabrata was the most common causative agent of VVC in a tertiary care hospital. Chromogenic culture medium facilitates detection of mixed fungal infection. In vitro susceptibility testing should be used to guide the treatment especially in cases of non-albicans Candidiasis.

Candidemia Diagnosed from Peripheral Blood Smear: Case Report and Review of Literature 1954-2013

BACKGROUND

Yeast with pseudohyphae or those that have been phagocytized by white blood cells are coincidentally found in peripheral blood smears. The clinical diagnostic value and outcome of candidaemia diagnosed from peripheral blood smears (CPBSs) are unclear.

CASE PRESENTATION

A 45-year-old man with diabetes and panhypopituitarism for 20 years received 10 mg of hydrocortisone and 100 μg of levothyroxine sodium hydrate daily. He has been admitted seven times because of adrenal failure triggered by infections and was admitted for pneumonia. On day 56, some budding yeast was found microscopically in a peripheral blood smear with May-Giemsa staining. Some of them were phagocytized by white blood cells. The two blood cultures yielded Candida parapsilosis. Despite antifungal treatment and removal of an intravenous catheter, on day 98 (42 days after the candidaemia diagnosis), the patient died.

CONCLUSION

We analysed 36 cases including the present case. Almost all CPBS patients (96.5 %, n = 29) were using an intravenous catheter. The most frequently isolated species was C. parapsilosis (35.1 %), followed by C. albicans (29.7 %). The overall mortality rate was 53.6 % (n = 28). The time from the discovery of yeast-like pathogens using peripheral blood smears to death ranged from a few hours to 93 days (median 19 days). The present results suggest that intravenous catheter use and the underlying conditions of patients are responsible for CPBSs. The detection of yeast in peripheral blood smears suggests advanced infections with uncontrollable complications, which means a poor prognosis. Rapid detection methods besides blood culture are needed.

[Double fungemia. Report of four Tunisian cases]

Fungemia is classically caused by a single species and the detection of more than one species in blood samples is uncommon. We report four cases of mixed fungemia (MF) diagnosed in the parasitology-mycology laboratory of Farhat-Hached hospital in Sousse, Tunisia. The MF episodes occurred in two neonates and two adults suffering from acute myeloid leukemia. Two fungal species were detected concomitantly within the same blood culture in all cases. Species combination was detected by the subculture of the blood culture on Candida ID(®) chromogenic medium in three cases and on Sabouraud agar in one case. Predisposing factors were: indwelling catheters (4/4), broad-spectrum antibiotics (3/4), neutropenia (2/4), exclusive parenteral nutrition (2/4) and Candida colonization (1/4). Patients presented febrile sepsis with no response to broad-spectrum antibiotic therapy in all cases. Outcome under antifungal treatment was favorable in two cases and the two other patients died.

CONCLUSION

MF appears similar to the more common monomicrobial fungemia. The use of chromogenic media in routine can improve the detection of MF episodes allowing appropriate antifungal therapy.

Multiple OralCandidaInfections in Patients with Sjögren’s Syndrome — Prevalence and Clinical and Drug Susceptibility Profiles

Objective.

To determine the prevalence of oral candidiasis and multiple oralCandidainfections in patients with primary Sjögren’s syndrome (SS), and the clinical and drug susceptibility profile.

Methods.

Thirty patients with primary SS were enrolled in our study. The diagnosis of oral candidiasis was based on the clinical manifestation, and confirmed by a concentrated rinse culture.Candidaspp. assessment was accomplished using standard methods: Sabouraud dextrose agar with 50 mg/l chloramphenicol and CHROMagar were used for the rapid screening of clinical species, followed by the API 20C system for further species identification.In vitroantifungal drug susceptibility ofCandidaisolates was determined by the minimal inhibitory concentrations.

Results.

In our study, 87% (26/30) of subjects had oral candidiasis, in which 42% (11/26) had multipleCandidaspp. infection. AlthoughC. albicansremains the predominant isolate, other rare species such asC. tropicalis,C. glabrata,C. parapsilosis, andC. kruseiwere present, alone or in combination. Chronic atrophic candidiasis is the most common clinical type of oral candidiasis in patients with SS. The susceptibilities of the 44Candidaisolates to 7 antifungal agents varied dramatically. The resistance to azoles was remarkable, and the phenomenon of cross-resistance between itraconazole and fluconazole was observed.

Conclusion.

Patients with primary SS carry a high risk of oral candidiasis and a high frequency of multipleCandidainfections. The azole resistance patterns ofCandidaspp. support the necessity for drug susceptibility testing as a routine procedure for patients with oralCandidainfections.

Mixed Fungemia: Incidence, Risk Factors, and Mortality in a General Hospital

BACKGROUND

Fungemia has been historically considered to be a disease caused by a single Candida species; the detection of >1 species of yeast in circulating blood was distinctly uncommon using traditional microbiological procedures. We describe episodes of mixed fungemia (MF), detected between 1985 and 2006, in a large teaching hospital.

METHODS

The study was divided into 2 periods that were separated by the introduction, in January 2005, of the CHROmagar Candida medium (CHROMagar) for the routine subculturing of blood cultures in which yeast has been identified. Overall, we documented 747 cases of fungemia. During the first period (1985-1994), we identified 217 episodes of fungemia and no single episode of MF; during the second period (1995-2006), 15 episodes of MF were detected among 530 episodes of fungemia (2.8%). Candida albicans was isolated in 13 patients, non-albicans species of Candida in 16 patients, and Saccharomyces cerevisiae in 1 patient. Each episode of MF was compared with 2 control episodes of monomicrobial fungemia.

RESULTS

Patients with MF had more frequently experienced organ transplantation (13% vs. 0%) and surgery (60% vs. 27%), had less frequently received parenteral nutrition (40% vs. 70%) or had intravenous lines (80% vs. 100%), and had a lower incidence of shock (6% vs. 37%) and a lower mortality (20% vs. 53%).

CONCLUSIONS

Despite the introduction of chromogenic agar, MF is still an uncommon disease and has a less severe outcome than does monomicrobial candidemia.