Human Hyalohyphomycoses: A Review of Human Infections Due toAcremoniumspp.,Paecilomycesspp.,Penicilliumspp., andScopulariopsisspp

Acremonium keratitis: Risk factors, clinical characteristics, management, and outcome in 65 cases

Purpose

To study the risk factors, clinical presentation, management options, and outcomes in cases of culture-proven Acremonium keratitis.

Methods

Medical and microbiology records of culture-proven Acremonium keratitis from Jan 2007 to Dec 2019 at a tertiary eye care center were reviewed. Details of clinical findings on each visit and operating notes were reviewed from the medical records. All cases were subjected to corneal scraping at the first visit for microbiological investigation consisting of direct smear examination and culture. Topical natamycin 5% was the mainstay of medical treatment. Surgical treatment was considered for nonresponding patients.

Results

During the 13-year study period, 65 cases of culture-proven Acremonium keratitis were identified out of 1605 cases of fungal keratitis. Trauma was the most common predisposing factor in 32 cases (49.2%). The average area of the corneal stromal infiltrate was 24.8 mm² at the initial presentation. Hypopyon at the time of presentation was evident in 28 (43.1%) cases. Staphylococcus spp. was the most common (n = 22, 33.8%) organism coexistent with Acremonium. Direct microscopy of corneal scraping was positive for fungal filaments in 57/65 (87.6%) cases. Medical management alone was given in 44 patients (67.6%). Age (>50 years) and treatment delay (>15 days) were found to be independent risk factors for the poor final visual outcome (VA <20/60).

Conclusion

When treated early, Acremonium keratitis responds well to medical therapy with currently available topical antifungals. However, advanced and nonresponding cases require surgical intervention for resolution of the infection.

Blowing in the wind: Bacteria and fungi are spreading from public restroom hand dryers

This study aimed to identify and quantify fungi and bacteria in the airflow of restroom hand dryers in public areas. Airflow from restroom hand dryers in 8 retail locations was tested using three types of culture media, followed by PCR and sequence analysis to identify microbial species. Both bacterial and fungal colonies were detected in all locations. The number of colonies did not vary significantly across different locations, suggesting a similar level of microbial spread by hand dryers between different types of commercial stores. Molecular analysis revealed 24 bacterial species and 40 fungal species. Of these species, 48% (31/64) have been reported to be implicated in various infections in humans, primarily those with underlying medical conditions. This study is the first to demonstrate the spread of fungi by the airflow of restroom hand dryers, and the first to show the prevalence of different fungal and bacterial species spread by restroom hand dryers in common public areas.

Paecilomyces in an immune competent host

Paecilomyces species was first recognized to cause human disease in 1963. It is a rare cause of invasive fungal infection, with cases sporadically reported in immunocompromised patients. Here we report the first case of pulmonary Paecilomyces in an immunocompetent patient that was successfully treated with amphotericin B and posaconazole.

Diversity, Co-occurrence and Implications of Fungal Communities in Wastewater Treatment Plants

Three wastewater treatment plants (WWTPs) located in Gauteng province in South Africa were investigated to determine the diversity, co-occurrence and implications of their fungal communities using illumina sequencing platform and network analysis. Phylogenetic taxonomy revealed that members of the fungal communities were assigned to 6 phyla and 361 genera. Basidiomycota and Ascomycota were the most abundant phyla, dominated by the genera Naumovozyma, Pseudotomentella, Derxomyces, Ophiocordyceps, Pulchromyces and Paecilomyces. Phylogenetic analysis revealed the existence of fungal OTUs related to class lineages such as Agaricomycetes, Eurotiomycetes and Sordariomycetes indicating new fungal diversity in WWTPs. Dominant and rare fungal genera that can potentially be used in bioremediation such as Trichoderma, Acremonium, Talaromyces, Paecilomyces, cladophialophora and Saccharomyces were detected. Conversely, genera whose members are known to be pathogenic to human and plant such as Olpidium, Paecilomyces, Aspergillus, Rhodotorula, Penicillium, Candida, Synchytrium, Phyllosticta and Mucor were also detected in all WWTPs. Phylotype analysis confirmed that some fungal phylotypes were highly similar to the reported fungal pathogens of concern. Co-occurrence network analysis revealed that the fungal genera such as Minimedusa, Glomus, Circinella, Coltricia, Caloplaca, Phylosticta, Peziza, Candida, and Hydnobolites were the major networking hub in the WWTPs. The overall results in this study highlighted that WWTPs represent a potential source of beneficial fungi for bioremediation of pollutants in the ecosystem and the need to consider human and plant fungal pathogens during safety evaluation of treated wastewater for reuse.

Diversity of phenotypically non-dermatophyte, non-Aspergillus filamentous fungi causing nail infections: importance of accurate identification and antifungal susceptibility testing

Onychomycosis is most commonly caused by dermatophytes. In this study, we examined the spectrum of phenotypically non-dermatophyte and non-Aspergillus fungal isolates recovered over a 10-year period from nails of patients with onychomycosis in Hong Kong. A total of 24 non-duplicated isolates recovered from 24 patients were included. The median age of the patients was 51 years, and two-thirds of them were males. One-third and two-thirds had finger and toe nail infections respectively. Among these 24 nail isolates, 17 were confidently identified as 13 different known fungal species, using a polyphasic approach. These 13 species belonged to 11 genera and ≥9 families. For the remaining seven isolates, multilocus sequencing did not reveal their definite species identities. These seven potentially novel species belonged to four different known and three potentially novel genera of seven families. 33.3%, 41.7% and 95.8% of the 24 fungal isolates possessed minimum inhibitory concentrations of >1 µg/mL to terbinafine, itraconazole and fluconazole, respectively, the first line treatment of onychomycosis. A high diversity of moulds was associated with onychomycosis. A significant proportion of the isolates were potentially novel fungal species. To guide proper treatment, molecular identification and antifungal susceptibility testing should be performed for these uncommonly isolated fungal species.

Skin infection on both legs caused by Acremonium strictum (case report)

Acremonium species are saprophytic molds widely distributed in nature, existing in soil and decaying vegetation. Penetrating wounds, intravascular catheters and immunosuppression are risk factors for invasive infections of Acremonium. The fungus can also cause cutaneous infections and mycetoma in the immunocompetent; such infections occur in extremities open to trauma. In this paper, a female patient with skin infection due to Acremonium strictum in both legs is described.

Clinical experiences in fungal keratitis caused by Acremonium

Purpose

To report the predisposing risk factors, clinical presentation, management, and therapeutic outcomes of fungal keratitis caused by Acremonium.

Methods

This is a retrospective study of cases with Acremonium fungal keratitis that presented to our tertiary referral center between January 2006 and August 2012. Patient demographic and clinical details were determined and reported.

Results

Five cases of fungal keratitis from Acremonium species were identified in five patients (three males, two females). The mean age of the patients was of 73.4±5.46 years, with a mean follow-up time of 124±72 days. All patients had a history of corneal trauma with vegetable matter. Four cases were unresponsive to initial treatment (0.2% fluconazole, 0.15% amphotericin B) and required topical 5% natamycin, and, in two out of five cases, topical 1% voriconazole.

Conclusion

The most common risk factors for Acremonium fungal keratitis was ocular trauma. When a corneal lesion is found to be unresponsive to the initial treatment, we should consider adding or substituting topical natamycin or voriconazole for treatment.

Uncommon mold infections in hematological patients: epidemiology, diagnosis and treatment

Invasive fungal diseases continue to be an important cause of morbidity and mortality in immunosuppressed patients. This is of particular interest, since the progress we made in the treatment of underlying malignancies has led to an increase of the number of persons 'at high risk'. During the last few years, several changes in clinical practice in hematology (new immunosuppressants, hematopoietic stem cell transplants) have influenced the epidemiology of invasive fungal diseases; in particular, cases due to some uncommon etiologic agents are being increasingly reported, making it even more urgent to reconsider differential diagnoses in high-risk patients. A better understanding of epidemiology, risk factors and prognosis appears to be crucial to analyze prevention and diagnostic strategies, as well as to guarantee an early and adequate treatment.

Pediatric invasive sinonasal Scopulariopsis brevicaulis--a case report and literature review

OBJECTIVE

Acute invasive fungal sinusitis (AIFS) appears mainly in immunocompromized patients and may be caused by various pathogens. We describe a teenager with invasive sinonasal Scopulariopsis brevicaulis and review all the reports on this rare pathogen.

METHODS

A literature search on Scopulariopsis sinonasal invasive infections was performed and clinical data including age, gender, co-morbidities, treatment and prognosis was collected on all the patients.

RESULTS

A 17 years old boy with acute myelocytic leukemia and Scopulariopsis brevicaulis sinonasal infection was successfully treated at our department with a combination of extensive surgical debridement and antifungal antibiotics. We found six articled describing six patients with AIFS due to Scopulariopsis species. Four patients were adults and two were children, 3 males and 3 females. Two had an infection with Scopulariopsis acremoium, one with Scopulariopsis candida and for 3 patients no data was given on the specific Scopulariopsis species. All the patients except one were immunocompromized. One patient was treated with antifungal drugs, 2 with surgery and 4 patients received antifungals and were operated. One patient died due to the fungal infection and two patients died due to other causes.

CONCLUSIONS

Scopulariopsis AIFS is a life threatening disease affecting mainly immunocompromized patients, both children and adults. No clear treatment regimen has been established yet. We describe the first case of a teenager with Scopulariopsis brevicaulis sinonasal infection treated successfully with a combination of wide local excision and antifungal therapy.

[Update: invasive fungal infections: Diagnosis and treatment in surgical intensive care medicine]

Fungal infections are of great relevance in surgical intensive care and Candida species represent the predominant part of fungal pathogens. Invasive aspergillosis is also relevant especially in patients with chronic pulmonary diseases. It is crucial for therapy success to begin adequate antifungal treatment at an early stage of the disease. Risk stratification of individual patient symptoms is essential for therapy timing. In case of suspected or proven candida infection, fluconazole is the agent of choice when the patient is clinically stable and no azoles have been administrated in advance and the local epidemiology makes azol resistance unlikely. For clinically instable patients with organ dysfunction the echinocandins serve as primary therapy because of their broad spectrum and reasonable safety profile. Due to a relevant proportion of azole resistant Candida species, susceptibility testing should be done routinely. Depending on the species detected de-escalating to an azole is feasible if organ dysfunctions have resolved. An invasive aspergillosis is primarily treated with voriconazole.

Acremonium strictum fungaemia in a paediatric immunocompromised patient: diagnosis and treatment difficulties

During the past two decades, an increasing number of unusual moulds has been reported as responsible for septicaemia and systemic or disseminated infections in immunocompromised patients. Investigation of fever in a 10-year-old boy with acute myeloblastic leukaemia, including blood cultures on selective media, allowed the diagnosis of a fungaemia due to the slow-growing fungus Acremonium strictum. The patient recovered with liposomal amphotericin B (AmB) and voriconazole, followed by voriconazole alone due to AmB resistance. Facing a neutropenic patient with fever, clinicians usually suspect bacterial or viral aetiologies. This case, however, illustrates the need for mycological analysis of blood samples in febrile neutropenic patients and for antifungal susceptibility testing.

Pharmacokinetics of fluoroquinolones in critical care patients: A bio-analytical HPLC method for the simultaneous quantification of ofloxacin, ciprofloxacin and moxifloxacin in human plasma

A high-performance liquid chromatographic (HPLC) method with fluorescence detection was developed and validated for the simultaneous quantification of ofloxacin, ciprofloxacin and moxifloxacin in human plasma. Sarafloxacin was used as internal standard. Chromatography was carried out using a Waters XBridge C(18) HPLC column and a gradient mobile phase consisting of CH(3)CN/MeOH/0.025M TBA.Cl/TFA (eluent A at 75/25/899/1 (v/v); eluent B at 150/50/799/1 (v/v); both at pH 3.5). Excitation/emission wavelengths were 279/442nm for ciprofloxacin and 290/500nm for ofloxacin, moxifloxacin and internal standard. Prior to chromatography, plasma samples were treated with acetonitrile for protein precipitation, followed by evaporation of the liquid layer and reconstitution in eluent A. The method was validated for the three fluoroquinolones over the clinically relevant concentration range from 0.02 to 7.50mug/ml. The method showed acceptable linearity with correlation coefficients, r(2)>0.995, as well as high precision (RSD% <7% in each case), accuracy (90.4-105.4%) and selectivity. The limit of quantification for the three fluoroquinolones was established at 0.02mug/ml. Ofloxacin, ciprofloxacin and moxifloxacin were extracted from plasma with a mean recovery of 95%, 86.4% and 94.2%, respectively. During validation, the concentration of the three fluoroquinolones was found to be stable after 3 freeze-thaw cycles and for at least 15h after extraction. This bio-analytical method was finally applied to the analysis of samples which have been obtained from patients, participating in a pharmacokinetic study on moxifloxacin.

In vitro activities of 10 combinations of antifungal agents against the multiresistant pathogen Scopulariopsis brevicaulis

The activities of 10 combinations of antifungal agents against 25 clinical isolates of Scopulariopsis brevicaulis were tested by the checkerboard technique. An average indifferent effect was detected for all combinations. Synergy was observed for some isolates and combinations, particularly with posaconazole-terbinafine (68% of strains), amphotericin B-caspofungin (60%), and posaconazole-caspofungin (48%).

Tratamiento de las infecciones fúngicas invasoras

Invasive fungal infections have increased progressively in the last decades, producing elevated morbidity and mortality. In recent years, there have been numerous advances in the treatment of these diseases, with the introduction of new drugs in clinical practice and the information derived from several types of studies. This has improved the prognosis of some invasive fungal infections and increased the therapeutic options in various clinical situations. This new knowledge must be assessed to determine its application in clinical practice, taking into account available scientific evidence and clinical experience. With this aim, the Andalusian Society of Infectious Diseases has developed this consensus document containing recommendations for the treatment of the invasive fungal infections.

Fatal Scopulariopsis Infection in a Lung Transplant Recipient: A Case Report

A case of a fatal Scopulariopsis infection is reported in a 63-year-old lung transplantation patient with a 7-week history of dyspnea that presented initially with pericardial and pleural fluid. Because of a respiratory arrest, the patient was intubated and received positive pressure ventilation. Later, obstructive shock developed due to a pericardial tamponade requiring pericardectomy and then urgent extracorporal membrane oxygenation. The working hypothesis was of disseminated cytomegalovirus infection because cultures from bronchoalveolar lavage and transbronchial biopsy specimens were positive. The pericardial biopsy specimen showed fungal hyphae. After the patient died from the infection, the fungus was identified as Scopulariopsis acremonium. This case report describes the first case, to our knowledge, of an insidious Scopulariopsis acremonium infection in an immunocompromised lung transplant patient, underscoring the importance of a direct, invasive approach and early treatment with anti-fungal therapy in immunocompromised patients.

Voriconazole-resistant disseminated Paecilomyces variotii infection in a neutropenic patient with leukaemia on voriconazole prophylaxis

Paecilomyces variotii, an emerging hyalohyphomycetes, has been reported to be susceptible in vitro to voriconazole. We describe a case of disseminated P. variotii infection in a neutropenic child with relapsed leukaemia who was on voriconazole prophylaxis. The P. variotii isolate was resistant to voriconazole in vitro. The patient responded to liposomal amphotericin B.

Successful treatment of antifungal- and cryotherapy-resistant subcutaneous hyalohyphomycosis in an immunocompetent case with topical 5% imiquimod cream

Hyalohyphomycosis is an unusual opportunistic mycotic infection where the tissue morphology of the causative organism is mycelial. Etiological agents, which are not responsible for the otherwise-named infections like aspergillosis, are the species of non-dematiaceous hyaline hyphomycetes including Penicillium, Paecilomyces, Acremonium (formerly known Cephalosporium), Beauveria, Fusarium, and Scopulariopsis. Several cases of Acremonium infection have been described in immunocompromised patients; however it can cause invasive disease in an immunocompetent person very rarely. Optimum therapy of Acremonium infection is unclear because of the limited number of reported cases and conflicting results of therapies. Imiquimod, an imidazoquinoline with potent antiviral, antitumor and immunoregulatory properties, is currently approved for the topical treatment of external anogenital warts and actinic keratosis. Imiquimod has also been found to be effective for other virus-associated dermatologic lesions, including common and flat warts, molluscum contagiosum, and herpes simplex virus type-2 as well as for some cases of cutaneous leishmaniasis. We report herein, for the first time, a case of unusually recalcitrant hyalohyphomycosis of the face due to Acremonium strictum successfully treated with topical 5% imiquimod in an immunocompetent patient, who had failed to respond to various antifungals, including itraconazole, and cryotherapy.