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Bonagiri PR, Raman A, Hassan S, Ramsey A. CNS Aspergillosis: A Downside of Corticosteroid Use. Cureus 2024; 16:e62018. [PMID: 38984001 PMCID: PMC11233157 DOI: 10.7759/cureus.62018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2024] [Indexed: 07/11/2024] Open
Abstract
Glucocorticoids are ubiquitously used by physicians for a myriad of diseases. Though powerful and potentially lifesaving, sometimes the dangerous side effects are not at the forefront of our medical decision-making. By immunosuppressing patients, glucocorticoids can place patients at increased risk for not only the metabolic effects of chronic glucocorticoid use but also increased risk for opportunistic infections. Patients at increased risk include those on prolonged courses or those that require high doses. We report a case of a 34-year-old man who was initiated on glucocorticoids for an unknown rheumatologic disease and presented with generalized weakness, fatigue, nausea, and vomiting. The patient experienced a seizure, which prompted head imaging. A mass was found and eventually biopsied, which was notable for Aspergillus fumigatus. The patient was initiated on antifungals for CNS aspergillosis and recovered.
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Affiliation(s)
| | - Anjalee Raman
- Internal Medicine, Touro University California, Vallejo, USA
| | | | - Andrea Ramsey
- Infectious Disease, Scripps Mercy Hospital, San Diego, USA
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Amanati A, Lotfi M, Abdolkarimi B, Karimi Rouzbahani A, Mahmoudvand G. Evolution of neuroimaging findings in angioinvasive cerebral aspergillosis in a pediatric patient with leukemia during long-term observation. BMC Infect Dis 2023; 23:811. [PMID: 37978456 PMCID: PMC10657136 DOI: 10.1186/s12879-023-08483-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/25/2023] [Indexed: 11/19/2023] Open
Abstract
The central nervous system is one of the most common sites of aspergillosis involvement in immunocompromised people, just after sinopulmonary infections. Neuroimaging modalities are crucial for the diagnosis of cerebral aspergillosis (CA). Here, we describe a rare case of concurrent mixed aspergillosis infection with Aspergillus fumigatus and Aspergillus niger in a 2-year-old leukemic boy. The first neuroimaging finding, which was followed by focal seizures, was recognized as extensive cerebral hemorrhage in the absence of thrombocytopenia and coagulopathy. As the patient survived for more than 4 months after diagnosis, we were able to perform a neuroimaging evaluation during long-term observation. In serial neuroimaging studies, a secondary fungal abscess was observed at the site of hemorrhagic infarctions. Finally, the patient died from bacterial sepsis. In this case study, we try to categorize the neuroimaging findings of CA into distinct phases to better understand how CA changes over time.
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Affiliation(s)
- Ali Amanati
- Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Infection Control Unit, Amir Oncology Hospital, Shiraz, Iran
| | - Mehrzad Lotfi
- Medical Imaging Research Center, Department of Radiology, Shiraz University of Medical Sciences, Nemazee Hospital, Nemazee Sq., Zand St., Shiraz, 7193613311, Iran.
| | - Babak Abdolkarimi
- Pediatric Hematology-Oncology, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Arian Karimi Rouzbahani
- Student Research Committee, Lorestan University of Medical Sciences, Anooshirvan Rezaei Sq., Khorramabad, 6814713115, Lorestan, Iran.
- USERN Office, Lorestan University of Medical Sciences, Khorramabad, Iran.
| | - Golnaz Mahmoudvand
- Student Research Committee, Lorestan University of Medical Sciences, Anooshirvan Rezaei Sq., Khorramabad, 6814713115, Lorestan, Iran
- USERN Office, Lorestan University of Medical Sciences, Khorramabad, Iran
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3
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Sousa C, Pasini RA, Pasqualotto A, Marchiori E, Altmayer S, Irion K, Mançano A, Hochhegger B. Imaging Findings in Aspergillosis: From Head to Toe. Mycopathologia 2023; 188:623-641. [PMID: 37380874 DOI: 10.1007/s11046-023-00766-6] [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: 04/11/2023] [Accepted: 06/16/2023] [Indexed: 06/30/2023]
Abstract
Aspergillosis is a mycotic infection induced by airborne fungi that are ubiquitous. Inhalation of Aspergillus conidia results in transmission through the respiratory tract. The clinical presentation is dependent on organism and host specifics, with immunodeficiency, allergies, and preexisting pulmonary disease constituting the most important risk factors. In recent decades, the incidence of fungal infections has increased dramatically, due in part to the increased number of transplants and the pervasive use of chemotherapy and immunosuppressive drugs. The spectrum of clinical manifestations can range from an asymptomatic or mild infection to a swiftly progressive, life-threatening illness. Additionally, invasive infections can migrate to extrapulmonary sites, causing infections in distant organs. Recognition and familiarity with the various radiological findings in the appropriate clinical context are essential for patient management and the prompt initiation of life-saving treatment. We discuss the radiological characteristics of chronic and invasive pulmonary aspergillosis, as well as some of the typically unexpected extrapulmonary manifestations of disseminated disease.
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Affiliation(s)
- Célia Sousa
- Radiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | | | - Alessandro Pasqualotto
- Radiology Department, Universidade Federal de Ciências da Saúde de Porto Alegre, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Edson Marchiori
- Radiology Department, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | | | - Klaus Irion
- Radiology Department, University of Florida, Gainesville, FL, USA
| | | | - Bruno Hochhegger
- Radiology Department, University of Florida, Gainesville, FL, USA.
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Senoner T, Breitkopf R, Treml B, Rajsic S. Invasive Fungal Infections after Liver Transplantation. J Clin Med 2023; 12:jcm12093238. [PMID: 37176678 PMCID: PMC10179452 DOI: 10.3390/jcm12093238] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/25/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Invasive fungal infections represent a major challenge in patients who underwent organ transplantation. Overall, the most common fungal infections in these patients are candidiasis, followed by aspergillosis and cryptococcosis, except in lung transplant recipients, where aspergillosis is most common. Several risk factors have been identified, which increase the likelihood of an invasive fungal infection developing after transplantation. Liver transplant recipients constitute a high-risk category for invasive candidiasis and aspergillosis, and therefore targeted prophylaxis is favored in this patient population. Furthermore, a timely implemented therapy is crucial for achieving optimal outcomes in transplanted patients. In this article, we describe the epidemiology, risk factors, prophylaxis, and treatment strategies of the most common fungal infections in organ transplantation, with a focus on liver transplantation.
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Affiliation(s)
- Thomas Senoner
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Sasa Rajsic
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
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Pérez MA, Martínez L, Bravo J, Rodríguez B, Quintero P, Moncada P. Infection due to Aspergillus flavus and Rhizopus oryzae complex in a patient with diabetes mellitus. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2023; 43:27-36. [PMID: 37167471 PMCID: PMC10470490 DOI: 10.7705/biomedica.6358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 03/04/2023] [Indexed: 05/13/2023]
Abstract
Fungal sinusitis is a pathology that can occur in patients with diabetes mellitus and be associated with a hyperglycemic crisis. It is an aggressive entity with local complications that include involvement of the orbit or the central nervous system, and vascular involvement. Despite surgical and antifungal treatment, mortality raises up to 75%. We report the case of a female patient with a diagnosis of diabetic ketoacidosis and signs of unilateral ophthalmoplegia, which led to the study with magnetic resonance imaging of the central nervous system, finding signs of sinusitis, meningitis, and cerebritis. Initial microbiological studies were negative, and biomarkers such as serum galactomannan and Cryptococcus antigen were also negative. After surgical management and the identification of Aspergillus flavus and Rhizopus spp. in sinus tissue, the patient received treatment with posaconazole and after two months of follow-up she presented clinical improvement. Dual fungal infection and infection by A. flavus are uncommon and clinically relevant entities, with no cases previously reported in our country, therefore this corresponds to a case of clinical interest.
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Affiliation(s)
| | - Luisa Martínez
- Departamento de Microbiología, Fundación Valle del Lili, Cali, Colombia.
| | - Juan Bravo
- Departamento de Patología, Fundación Valle del Lili, Cali, Colombia.
| | - Brenda Rodríguez
- Departamento de Medicina Interna, Fundación Valle del Lili, Cali, Colombia.
| | - Paola Quintero
- Departamento de Medicina Interna, Fundación Valle del Lili, Cali, Colombia.
| | - Pablo Moncada
- Departamento de Infectología, Fundación Valle del Lili, Cali, Colombia.
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Feys S, Dedeurwaerdere F, Lagrou K, Van Lerbeirghe J, Deeren D. Successful Multimodal Therapy with Intracerebral Liposomal Amphotericin B and Systemic High-Dose Isavuconazole in Proven Disseminated Aspergillosis. J Fungi (Basel) 2023; 9:jof9030327. [PMID: 36983495 PMCID: PMC10054323 DOI: 10.3390/jof9030327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/30/2023] Open
Abstract
We report the case of a 32-year-old man receiving chemotherapeutics for an acute B-lymphoblastic leukemia who developed proven cerebral and pulmonary aspergillosis with Aspergillus flavus. Because of progressive fungal disease with neurological deterioration despite adequate systemic antifungal therapy and surgical debridement, intracerebral administration of liposomal amphotericin B was initiated at 5 mg twice weekly. This led to improvement of the cerebral infection. Surgical debridement of a pleural Aspergillus empyema was necessary, and pleural trough level of isavuconazole was found to be subtherapeutic despite adequate blood trough levels, which led us to increase the dose of isavuconazole. We conclude that intralesional amphotericin B might be beneficial at 5 mg twice weekly in cerebral aspergillosis if systemic antifungals and surgical debridement fail. In Aspergillus empyema, measurement of pleural isavuconazole trough levels should be considered.
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Affiliation(s)
- Simon Feys
- Medical Intensive Care Unit, UZ Leuven, 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | | | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
- Department of Laboratory Medicine and National Reference Center of Mycoses, UZ Leuven, 3000 Leuven, Belgium
| | | | - Dries Deeren
- Department of Hematology, AZ Delta, 8800 Roeselare, Belgium
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Samantaray S, Kumar D, Meena DS, Bohra GK, Akshatha R, Jain V, Tiwari S, Balamurugan T, Midha N, Garg MK. Invasive Cerebral Aspergillosis in Non-Neutropenic Patients: A Case Series from Western India. J Mycol Med 2023; 33:101380. [PMID: 37031499 DOI: 10.1016/j.mycmed.2023.101380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 03/01/2023] [Accepted: 03/27/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE Invasive cerebral aspergillosis (ICA) is a rare but fatal infection affecting neutropenic immunocompromised patients. Recently cases have been reported in non-neutropenic settings also. We hereby present a series of ICA cases in non-neutropenic patients diagnosed at our tertiary care centre in Western India between March to October 2021. METHODS All patients with clinico-radiological suspicion of CNS infections were analysed. Data regarding Clinico-radiological features, diagnosis, treatment and outcome were collected. After ruling out bacterial, viral and mycobacterial causes, appropriate samples were sent for KOH (potassium hydroxide) wet mount, fungal culture, histopathology and serum/CSF galactomannan. RESULTS A total of four patients were diagnosed with ICA with a mean age of 43.5 years. Three patients had significant comorbidities; Diabetes mellitus, chronic liver disease and COVID-19 pneumonia treated with dexamethasone, respectively. One patient had no known predisposing factor. Radiologically, one patient presented with a frontal brain abscess and two patients had multiple subcortical hyperintensities. Three patients were diagnosed based on CSF galactomannan (Platelia™ Aspergillus antigen, Bio-Rad, France) with OD >1 and one patient had high serum galactomannan (OD >2). CSF culture grew Aspergillus species in two patients. All patients were treated with Voriconazole. One patient recovered, and the remaining three succumbed due to delayed presentation and extensive cerebral involvement. CONCLUSION Even in non-neutropenic patients, a high index of suspicion is warranted for cerebral aspergillosis. CSF galactomannan can be considered a reliable marker for diagnosing ICA in non-neutropenic settings. Early diagnosis allows timely antifungal therapy, which could be a key to improving the outcomes.
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Affiliation(s)
- Subhashree Samantaray
- Department of General Medicine (Infectious diseases), All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Deepak Kumar
- Department of General Medicine (Infectious diseases), All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
| | - Durga Shankar Meena
- Department of General Medicine (Infectious diseases), All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Gopal Krishana Bohra
- Department of General Medicine (Infectious diseases), All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - R Akshatha
- Department of General Medicine (Infectious diseases), All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Vidhi Jain
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - T Balamurugan
- Department of Pathology and lab medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Naresh Midha
- Department of General Medicine (Infectious diseases), All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mahendra Kumar Garg
- Department of General Medicine (Infectious diseases), All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Imaging of Uncommon Bacterial, Rickettsia, Spirochete, and Fungal Infections. Neuroimaging Clin N Am 2023; 33:83-103. [DOI: 10.1016/j.nic.2022.07.005] [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]
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9
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Rayón-López G, Carapia-Minero N, Medina-Canales MG, García-Pérez BE, Reséndiz-Sánchez J, Pérez NO, Rodríguez-Tovar AV, Ramírez-Granillo A. Lipid-Like Biofilm from a Clinical Brain Isolate of Aspergillus terreus: Quantification, Structural Characterization and Stages of the Formation Cycle. Mycopathologia 2022; 188:35-49. [PMID: 36515766 DOI: 10.1007/s11046-022-00692-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/07/2022] [Indexed: 12/15/2022]
Abstract
Invasive infections caused by filamentous fungi have increased considerably due to the alteration of the host's immune response. Aspergillus terreus is considered an emerging pathogen and has shown resistance to amphotericin B treatment, resulting in high mortality. The development of fungal biofilm is a virulence factor, and it has been described in some cases of invasive aspergillosis. In addition, although the general composition of fungal biofilms is known, findings related to biofilms of a lipid nature are rarely reported. In this study, we present the identification of a clinical strain of A. terreus by microbiological and molecular tools, also its in vitro biofilm development capacity: (i) Biofilm formation was quantified by Crystal Violet and reduction of tetrazolium salts assays, and simultaneously the stages of biofilm development were described by Scanning Electron Microscopy in High Resolution (SEM-HR). (ii) Characterization of the organizational structure of the biofilm was performed by SEM-HR. The hyphal networks developed on the surface, the abundant air channels created between the ECM (extracellular matrix) and the hyphae fused in anastomosis were described. Also, the presence of microhyphae is reported. (iii) The chemical composition of the ECM was analyzed by SEM-HR and CLSM (Confocal Laser Scanning Microscopy). Proteins, carbohydrates, nucleic acids and a relevant presence of lipid components were identified. Some structures of apparent waxy appearance were highlighted by SEM-HR and backscatter-electron diffraction, for which CLSM was previously performed. To our knowledge, this work is the first description of a lipid-type biofilm in filamentous fungi, specifically of the species A. terreus from a clinical isolate.
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Affiliation(s)
- Gerardo Rayón-López
- Medical Mycology Laboratory, Microbiology Department, Escuela Nacional de Ciencias Biológicas (ENCB), Instituto Politécnico Nacional (IPN), Mexico City, Mexico
| | - Natalee Carapia-Minero
- Medical Mycology Laboratory, Microbiology Department, Escuela Nacional de Ciencias Biológicas (ENCB), Instituto Politécnico Nacional (IPN), Mexico City, Mexico
| | | | | | - Jesús Reséndiz-Sánchez
- Mycology Laboratory, Hospital Infantil de México "Dr. Federico Gómez", Mexico City, Mexico
| | - Néstor O Pérez
- Research and Development Department Probiomed SA de CV, Tenancingo Edo. de Mex., Mexico
| | - Aída Verónica Rodríguez-Tovar
- Medical Mycology Laboratory, Microbiology Department, Escuela Nacional de Ciencias Biológicas (ENCB), Instituto Politécnico Nacional (IPN), Mexico City, Mexico.
- Laboratorio de Micología Médica, Departamento de Microbiología, Prolongación de Carpio y Plan de Ayala s/n, ENCB-Instituto Politécnico Nacional, 11340, México, CDMX, México.
| | - Adrián Ramírez-Granillo
- Medical Mycology Laboratory, Microbiology Department, Escuela Nacional de Ciencias Biológicas (ENCB), Instituto Politécnico Nacional (IPN), Mexico City, Mexico.
- Clinical Laboratory Technician Academy, Centro de Estudios Científicos y Tecnológicos No. 6 "Miguel Othón de Mendizábal", IPN, Mexico City, Mexico.
- Laboratorio de Micología Médica, Departamento de Microbiología, Prolongación de Carpio y Plan de Ayala s/n, ENCB-Instituto Politécnico Nacional, 11340, México, CDMX, México.
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Galanaud D, Gupta R. MR Imaging for Acute Central Nervous System Pathologies and Presentations in Emergency Department. Magn Reson Imaging Clin N Am 2022; 30:371-381. [PMID: 35995468 DOI: 10.1016/j.mric.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Although evaluation of suspected stroke is a major driver of MRI use in the emergency department (ED), the exquisite contrast resolution and flexibility provided by MRI are valuable in the workup of a broad variety of acute neurologic complaints. This article provides an overview, focused primarily on "non-stroke" neurologic emergencies encountered in ED brain MRI that emergency radiologists should be familiar with.
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Affiliation(s)
- Damien Galanaud
- Department of Neuroradiology, Pitié Salpêtrière Hospital, 47 Boulevard de l'hopital, Paris 75013, France
| | - Rajiv Gupta
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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11
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The Evolving Landscape of Diagnostics for Invasive Fungal Infections in Lung Transplant Recipients. CURRENT FUNGAL INFECTION REPORTS 2022. [DOI: 10.1007/s12281-022-00433-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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12
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Murala S, Nagarajan E, Bollu PC. Infectious Causes of Stroke. J Stroke Cerebrovasc Dis 2022; 31:106274. [PMID: 35093633 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 12/11/2021] [Accepted: 12/13/2021] [Indexed: 12/15/2022] Open
Abstract
Stroke is one of the primary causes of mortality and morbidity worldwide. It can be ischemic or hemorrhagic, and the former can be due to an in-situ thrombus or a distant embolus. Despite being a rare cause, stroke can also be caused in the setting of infection. Bacterial agents are the most common cause of stroke, among other infectious agents. Until the antibiotic era, rheumatic heart disease was a predisposing risk factor of infective endocarditis. VZV is the most common cause of strokes in pediatric and adult populations. Cryptococcus and Candida spp are the most common yeasts involved in CNS infections, especially in immunocompromised patients. In COVID-19 patients, ischemic strokes are more common than hemorrhagic strokes. In this review, we will discuss the most common infectious agents, with particular emphasis on COVID-19.
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Affiliation(s)
- Sireesha Murala
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States.
| | - Elanagan Nagarajan
- Department of Neurology, Erlanger Health System, University of Tennessee School of Medicine, Chattanooga, TN, United States
| | - Pradeep C Bollu
- Department of Neurology, Prisma Health, Midlands/University of South Carolina School of Medicine, Columbia, SC, United States
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13
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Serris A, Benzakoun J, Danion F, Porcher R, Sonneville R, Wolff M, Kremer S, Letscher-Bru V, Fekkar A, Hekimian G, Pourcher V, Bougnoux ME, Poirée S, Ader F, Persat F, Cotton F, Tattevin P, Gangneux JP, Lelièvre L, Cassaing S, Bonneville F, Houze S, Bretagne S, Herbrecht R, Lortholary O, Naggara O, Lanternier F. Cerebral aspergillosis in the era of new antifungals: The CEREALS national cohort study Nationwide CEREbral Aspergillosis Lesional study (CEREALS). J Infect 2021; 84:227-236. [PMID: 34838593 DOI: 10.1016/j.jinf.2021.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/28/2021] [Accepted: 11/21/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Cerebral aspergillosis (CA) is a life-threatening disease for which diagnosis and management remain challenging. Detailed analyses from large cohorts are lacking. METHODS We included 119 cases of proven (n = 54) or probable (n = 65) CA diagnosed between 2006 and 2018 at 20 French hospitals. Data were collected at baseline and during follow-up. Cerebral imaging was reviewed centrally by two neuroradiologists. RESULTS The most frequent underlying conditions were hematological malignancy (40%) and solid organ transplantation (29%). Galactomannan was detected in the serum of 64% of patients. In 75% of cases, at least one of galactomannan, Aspergillus PCR, and β-d-glucan was positive in the cerebrospinal fluid. Six-week mortality was 45%. Two distinct patterns of disease were identified according to presumed route of dissemination. Presumed haematogenous dissemination (n = 88) was associated with a higher frequency of impaired consciousness (64%), shorter time to diagnosis, the presence of multiple abscesses (70%), microangiopathy (52%), detection of serum galactomannan (69%) and Aspergillus PCR (68%), and higher six-week mortality (54%). By contrast, contiguous dissemination from the paranasal sinuses (n = 31) was associated with a higher frequency of cranial nerve palsy (65%), evidence of meningitis on cerebral imaging (83%), macrovascular lesions (61%), delayed diagnosis, and lower six-week mortality (30%). In multivariate analysis and in a risk prediction model, haematogenous dissemination, hematological malignancy and the detection of serum galactomannan were associated with higher six-week mortality. CONCLUSION Distinguishing between hematogenous and contiguous dissemination patterns appears to be critical in the workup for CA, as they are associated with significant differences in clinical presentation and outcome.
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Affiliation(s)
- A Serris
- Centre for Infectious Diseases and Tropical Medicine, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France
| | - J Benzakoun
- Department of Neuroradiology, Université de Paris, INSERM UMR 1266, GHU Paris, Hôpital Sainte-Anne, DHU Neurovasc Paris Sorbonne, Paris, France
| | - F Danion
- Department of Infectious Diseases, Hôpital Universitaire de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - R Porcher
- Clinical Epidemiology Centre, Hôpital Hôtel-Dieu, Assistance Publique Hôpitaux de Paris, and Centre of Research in Epidemiology and Statistics (CRESS), Institut National de la Santé et de la Recherche Médicale U1153; Université de Paris, Paris, France
| | - R Sonneville
- Intensive Care Medicine and Infectious Diseases, Hôpital Bichat, Assistance Publique Hôpitaux de Paris, and UMR1148, LVTS, Sorbonne Paris Cité, INSERM, France
| | - M Wolff
- Neurological Intensive Care Unit, Hôpital Sainte-Anne, GHU Paris Psychiatrie et NeuroSciences, Paris, France
| | - S Kremer
- Department of Neuroradiology, Hôpital Universitaire de Strasbourg, Engineering science, computer science and imaging laboratory (ICube), UMR 7357, University of Strasbourg-CNRS, Strasbourg, France
| | - V Letscher-Bru
- Parasitology-Mycology Laboratory, Hôpital Universitaire de Strasbourg, Strasbourg, France
| | - A Fekkar
- Parasitology Mycology, hôpital Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris, Paris, France
| | - G Hekimian
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, France
| | - V Pourcher
- Infectious Diseases Department, , hôpital Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris, France
| | - M-E Bougnoux
- Parasitology-Mycology Laboratory, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - S Poirée
- Department of adult radiology, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - F Ader
- Infectious Diseases department, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - F Persat
- Parasitology-Mycology Laboratory, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Francois Cotton
- Department of Radiology, Lyon Sud Hospital, Hospices Civils de Lyon, Lyon, France; CREATIS, CNRS UMR 5220 & Inserm U1044, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, hôpital universitaire Pontchaillou, Rennes, France
| | - J-P Gangneux
- Department of Mycology, Rennes University Hospital, Rennes, France
| | - L Lelièvre
- Department of Infectious and Tropical Diseases, hôpital universitaire de Toulouse, France
| | - S Cassaing
- Department of Parasitology Mycology, hôpital universitaire de Toulouse, Toulouse, France
| | - Fabrice Bonneville
- Department of Neuroradiology, hôpital universitaire de Toulouse, Toulouse, France
| | - S Houze
- Mycology Parasitology Department, hôpital Bichat, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Stephane Bretagne
- Molecular Mycology Unit, National Reference Centre for Invasive Mycoses and Antifungals, UMR 2000, Institut Pasteur, CNRS, Université de Paris, Paris, France; Parasitology-Mycology Laboratory, Lariboisière, Saint-Louis, Fernand Widal Hospitals, Assistance Publique-Hôpitaux de Paris (AP-HP), Université de Paris, Paris, France
| | - R Herbrecht
- Department of Haematology, Institut de Cancérologie de Strasbourg (ICANS), Strasbourg, France
| | - O Lortholary
- Centre for Infectious Diseases and Tropical Medicine, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France; Molecular Mycology Unit, National Reference Centre for Invasive Mycoses and Antifungals, UMR 2000, Institut Pasteur, CNRS, Université de Paris, Paris, France
| | - O Naggara
- Department of Neuroradiology, Université de Paris, INSERM UMR 1266, GHU Paris, Hôpital Sainte-Anne, DHU Neurovasc Paris Sorbonne, Paris, France
| | - F Lanternier
- Centre for Infectious Diseases and Tropical Medicine, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France; Molecular Mycology Unit, National Reference Centre for Invasive Mycoses and Antifungals, UMR 2000, Institut Pasteur, CNRS, Université de Paris, Paris, France.
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14
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Kim BJH, Garcia Redmond J, Donaldson AD, Aspoas AR. Aspergillus fumigatus cerebral abscess and sphenoid sinus osteomyelitis in an immunocompetent patient following previous nasopharyngeal carcinoma and radiotherapy. J Surg Case Rep 2021; 2021:rjab402. [PMID: 34567519 PMCID: PMC8460270 DOI: 10.1093/jscr/rjab402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 08/19/2021] [Indexed: 11/05/2022] Open
Abstract
Cerebral mycosis is extremely rare in immunocompetent patients. A 61-year-old male presented with a 3-month history of worsening left-sided headaches and 3-week history of left-sided upper lip paraesthesia. Magnetic resonance imaging revealed an enhancing lesion in the left temporal lobe. Histopathology of this lesion revealed what initially resembled a zygomycete but additional cultures obtained on further surgical debridement revealed the infection to be Aspergillus fumigatus with associated sphenoid sinus osteomyelitis. We postulate that the presentation was related to the patient’s previous radiotherapy for nasopharyngeal carcinoma. To the best of our knowledge, this is the only report of such a case.
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Affiliation(s)
- Bernard J H Kim
- Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | | | | | - A Robert Aspoas
- Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
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15
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Chaussade H, Cazals X, Desoubeaux G, Jouvion G, Bougnoux ME, Lefort A, Rivoisy C, Desnos-Ollivier M, Chretien F, Chouaki T, Gruson B, Bernard L, Lortholary O, Lanternier F. Central nervous system candidiasis beyond neonates: Lessons from a nationwide study. Med Mycol 2021; 59:266-277. [PMID: 32577733 DOI: 10.1093/mmy/myaa051] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/27/2020] [Accepted: 06/05/2020] [Indexed: 12/12/2022] Open
Abstract
Though candidiasis is the most frequent invasive fungal infection, Candida spp. central nervous system (CNS) infections are rare but severe. To further describe clinico-patho-radiological presentations of this entity, we report a retrospective study from January 2005 to December 2018 including patients aged ≥ 28 days with proven or probable CNS candidiasis in France. Twenty-four patients were included. Seventeen patients (70%) had CNS localization secondary to disseminated candidiasis (10 with hematologic malignancies [HM]; the seven other patients had infective endocarditis [IE]). Among patients with HM, seven previously had lumbar puncture for intrathecal chemotherapy, the three others had IE. Among patients with disseminated infection, magnetic resonance imaging (MRI) evidenced meningitis (17%), micro-abscesses (58%), or vascular complications (67%). Seven patients (30%) had isolated CNS involvement related to neurosurgery (n = 2), CARD9 deficiency (n = 2), intravenous drug use, diabetes mellitus, or no identified predisposing condition (n = 1 each). All evaluated patients with isolated CNS involvement had meningitis on cerebrospinal fluid (CSF) and intracranial hypertension. For the latter patients, MRI evidenced meningitis (71%) or abscesses (57%). Among all patients, cerebrospinal fluid (CSF) culture grew Candida spp. in 31% of cases. CSF βDGlucan or mannan Ag were positive in respectively 86% and 80% of cases. Mortality attributed to CNS candidiasis was 42%: 53% in case of disseminated infection (70% for HM) and 14% in case of localized infection. CNS candidiasis are isolated or occur during disseminated infection in patients with HM and lumbar puncture for intrathecal chemotherapy or during IE. Clinical, radiological finding and outcome highly vary according to CNS localized versus disseminated candidiasis. LAY SUMMARY Candida is a yeast and is the most common cause of fungal infections worldwide. Candida central nervous system (CNS) infections are rare, severe, and poorly described. We report a retrospective study from January 2005 to December 2018 including patients aged ≥ 28 days with proven or probable CNS candidiasis in France. Twenty-four patients were included (14 men, median age 51 years). Seventeen patients had CNS localization secondary to disseminated candidiasis from blood to CNS (10 with hematologic malignancies [HM], the seven other patients had infective endocarditis [IE]). Seven patients had isolated CNS involvement related to neurosurgery (n = 2), CARD9 deficiency (n = 2), intravenous drug use (n = 1), diabetes mellitus (n = 1), or no identified risk factor (n = 1).During Candida CNS infections, brain lesions were meningitis abscesses or vascular complications. Cerebrospinal fluid (CSF) culture grew Candida spp. in 31% of cases. Forty-two percent of patients died from infection: 53% in case of disseminated infection (70% for HM) and 14% in case of localized infection.
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Affiliation(s)
- Hélène Chaussade
- Université de Paris, Service de maladies infectieuses, hôpital Universitaire Necker-Enfants malades, Assistance Publique - Hôpitaux de Paris, IHU Imagine, Paris, France.,Service de médecine interne et maladies infectieuses, Tours, France
| | | | | | - Gregory Jouvion
- Unité histopathologie humaine et modèles animaux, Institut Pasteur, Paris, France.,Université de la Sorbonne, INSERM, Maladies génétiques d'expression pédiatrique, Assistance Publique-Hôpitaux de Paris, Hôpital Armand-Trousseau, UF Génétique moléculaire, Paris, France
| | | | - Agnes Lefort
- Service de médecine interne, Hôpital Beaujon, Clichy, France
| | - Claire Rivoisy
- Université de Paris, Service de maladies infectieuses, hôpital Universitaire Necker-Enfants malades, Assistance Publique - Hôpitaux de Paris, IHU Imagine, Paris, France
| | - Marie Desnos-Ollivier
- Institut Pasteur, Unité de Mycologie Moléculaire, UMR 2000, CNR des Mycoses Invasives et antifongiques, Paris, France
| | - Fabrice Chretien
- Unité histopathologie humaine et modèles animaux, Institut Pasteur, Paris, France
| | - Taieb Chouaki
- Laboratoire de mycologie et parasitologie, Amiens, France
| | | | - Louis Bernard
- Service de médecine interne et maladies infectieuses, Tours, France
| | - Olivier Lortholary
- Université de Paris, Service de maladies infectieuses, hôpital Universitaire Necker-Enfants malades, Assistance Publique - Hôpitaux de Paris, IHU Imagine, Paris, France.,Institut Pasteur, Unité de Mycologie Moléculaire, UMR 2000, CNR des Mycoses Invasives et antifongiques, Paris, France
| | - Fanny Lanternier
- Université de Paris, Service de maladies infectieuses, hôpital Universitaire Necker-Enfants malades, Assistance Publique - Hôpitaux de Paris, IHU Imagine, Paris, France.,Institut Pasteur, Unité de Mycologie Moléculaire, UMR 2000, CNR des Mycoses Invasives et antifongiques, Paris, France
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16
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Invasive sinus aspergillosis with mycotic aneurysm of the vertebral artery and subarachnoid hemorrhage - Case report. Radiol Case Rep 2021; 16:2651-2657. [PMID: 34336072 PMCID: PMC8318899 DOI: 10.1016/j.radcr.2021.06.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 11/21/2022] Open
Abstract
Invasive sinus aspergillosis is a rare life-threatening condition usually found in immunocompromised patients. The fungus spreads from paranasal sinuses into the central nervous system by direct extension or through blood vessels. Perineural spread is an uncommon mechanism of spread in invasive aspergillosis. A mycotic aneurysm is a dangerous complication of invasive sinus aspergillosis because of its insidious development and is often diagnosed only post-mortem after causing fatal intracranial hemorrhage. Intracranial vascular complications of invasive sinus aspergillosis require prompt recognition and treatment and should always be considered when a diagnosis of CNS aspergillosis is made. We present a case of invasive sinus aspergillosis in an apparently immunocompetent patient that manifested with a brain abscess, perineural spread of the infection, and mycotic aneurysm of the vertebral artery with subsequent rupture and fatal subarachnoid hemorrhage. This case highlights the possibility of perineural spread and hemorrhagic complications in invasive cerebral aspergillosis.
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17
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Lersy F, Royer-Leblond J, Lhermitte B, Chammas A, Schneider F, Hansmann Y, Lefebvre N, Denis J, Sabou M, Lafitte F, Cotton F, Boncoeur-Martel MP, Tourdias T, Pruvo JP, Cottier JP, Herbrecht R, Kremer S. Cerebral mucormycosis: neuroimaging findings and histopathological correlation. J Neurol 2021; 269:1386-1395. [PMID: 34240320 DOI: 10.1007/s00415-021-10701-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/04/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Mucormycosis are infections caused by molds of the order Mucorales. These opportunistic infections are rare, difficult to diagnose, and have a poor prognosis. We aimed to describe common radiographic patterns that may help to diagnose cerebral mucormycosis and search for histopathological correlations with imaging data. METHODS We studied the radiological findings (CT and MRI) of 18 patients with cerebral mucormycosis and four patients' histopathological findings. RESULTS All patients were immunocompromised and/or diabetic. The type of lesions depended on the infection's dissemination pathway. Hematogenous dissemination lesions were most frequently abscesses (59 lesions), cortical, cortical-subcortical, or in the basal ganglia, with a halo aspect on DWI for lesions larger than 1.6 cm. Only seven lesions were enhanced after contrast injection, with different presentations depending on patients' immune status. Ischemia and hemorrhagic areas were also seen. Vascular lesions were represented by stenosis and thrombosis. Direct posterior extension lesions were bi-fronto basal hypodensities on CT and restricted diffusion without enhancement on MRI. A particular extension, perineural spread, was seen along the trigeminal nerve. Histopathological analysis found endovascular lesions with destruction of vessel walls by Mucorales, microbleeds around vessels, as well as acute and chronic inflammation. CONCLUSIONS MRI is the critical exam for cerebral mucormycosis. Weak ring enhancement and reduced halo diffusion suggest the diagnosis of fungal infections. Involvement of the frontal lobes should raise suspicion of mucormycosis (along with aspergillosis). The perineural spread can be considered a more specific extension pathway of mucormycosis.
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Affiliation(s)
- François Lersy
- Service d'imagerie 2, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière 67200, Strasbourg, France
| | | | - Benoit Lhermitte
- Department of Pathology, Hautepierre University Hospital, 1 avenue Molière, 67200, Strasbourg, France
| | - Agathe Chammas
- Service d'imagerie 2, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière 67200, Strasbourg, France
| | - Francis Schneider
- Service de Médecine-Intensive-Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Yves Hansmann
- Service de Maladies Infectieuses, NHC, CHU de Strasbourg, Strasbourg, France
| | - Nicolas Lefebvre
- Service de Maladies Infectieuses, NHC, CHU de Strasbourg, Strasbourg, France
| | - Julie Denis
- CHU de Strasbourg, Laboratoire de Parasitologie Et de Mycologie Médicale, Plateau Technique de Microbiologie, 1 rue Koeberlé, 67000, Strasbourg, France
| | - Marcela Sabou
- CHU de Strasbourg, Laboratoire de Parasitologie Et de Mycologie Médicale, Plateau Technique de Microbiologie, 1 rue Koeberlé, 67000, Strasbourg, France.,Université de Strasbourg, Institut de Parasitologie Et de Pathologie Tropicale, DIHP-UR 7292, Fédération de Médecine Translationnelle, 3 rue Koeberlé, 67000, Strasbourg, France
| | - François Lafitte
- Radiology Department, Rothschild Foundation in Paris, Paris, France
| | - François Cotton
- Service de Radiologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Pierre-Bénite, F-69495, Lyon, France
| | - Marie-Paule Boncoeur-Martel
- INSERM, U1094, Neuroépidémiologie Tropicale, Limoges, France.,Univ. Limoges, U1094, Neuroépidémiologie Tropicale, Institut D'Epidémiologie Et de Neurologie Tropicale, GEIST, Limoges, France.,IRD, Unité Associée, Neuroépidémiologie Tropicale, Limoges, France.,Service de Neuroradiologie, CHU Limoges, Limoges, France
| | - Thomas Tourdias
- CHU de Bordeaux, Neuro imagerie diagnostique et thérapeutique, 33000, Bordeaux, France.,Univ. Bordeaux, INSERM U1215, Neurocentre Magendie, 33000, Bordeaux, France
| | - Jean-Pierre Pruvo
- Inserm U 1172, CHU de Lille, University of Lille, Lille, France.,Department of Neuroradiology, CHU de Lille, University of Lille, Lille, France
| | | | - Raoul Herbrecht
- Department of Hematology, Institut de Cancérologie Strasbourg.Europe (ICANS) and Université de Strasbourg, Inserm UMR-S1113/IRFAC, Strasbourg, France
| | - Stéphane Kremer
- Service d'imagerie 2, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière 67200, Strasbourg, France. .,Engineering Science, Computer Science and Imaging Laboratory (ICube), Integrative Multimodal Imaging in Healthcare, UMR 7357, University of Strasbourg-CNRS, Strasbourg, France.
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18
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Hakamifard A, Hashemi M, Fakhim H, Aboutalebian S, Hajiahmadi S, Mohammadi R. Fatal disseminated aspergillosis in an immunocompetent patient with COVID-19 due to Aspergillus ochraceus. J Mycol Med 2021; 31:101124. [PMID: 33684835 PMCID: PMC7901383 DOI: 10.1016/j.mycmed.2021.101124] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/07/2021] [Accepted: 02/18/2021] [Indexed: 11/28/2022]
Abstract
Aspergillus infection is a well-known complication of severe influenza and severe acute respiratory syndrome coronavirus (SARS-CoV), and these infections have been related with significant morbidity and mortality even when appropriately diagnosed and treated. Recent studies have indicated that SARS-CoV-2 might increase the risk of invasive pulmonary aspergillosis (IPA). Here, we report the first case of Aspergillus ochraceus in a SARS-CoV-2 positive immunocompetent patient, which is complicated by pulmonary and brain infections. Proven IPA is supported by the positive Galactomannan test, culture-positive, and histopathological evidence. The patient did not respond to voriconazole, and liposomal amphotericin B was added to his anti-fungal regimen. Further studies are needed to evaluate the prevalence of IPA in immunocompetent patients infected with SARS-CoV-2. Consequently, testing for the incidence of Aspergillus species in lower respiratory secretions and Galactomannan test of COVID-19 patients with appropriate therapy and targeted anti-fungal therapy based on the primary clinical suspicion of IPA are highly recommended.
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Affiliation(s)
- Atousa Hakamifard
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Marzieh Hashemi
- Department of Pulmonology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamed Fakhim
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shima Aboutalebian
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Somayeh Hajiahmadi
- Department of Radiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasoul Mohammadi
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran; Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
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19
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Mascitti H. Infections de l’immunodéprimé (hors VIH). Med Mal Infect 2020; 50:8S6-8S11. [PMID: 33357973 DOI: 10.1016/s0399-077x(20)30777-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- H Mascitti
- Service d'infectiologie, CHU Raymond-Poincaré (AP-HP), Université Paris-Saclay, 104, boulevard Raymond-Poincaré, 92380 Garches, France..
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20
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Amer EM, Youssef AF, Romeih MA, Youssef AA, Khater HM. Role of magnetic resonance imaging in characterization of central nervous system lesions in pediatric patients with leukemia and post-treatment complications. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00337-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Leukemia is one of the most common fatal diseases in pediatric oncology. Recently, advances in drug therapy have improved the prognosis of acute leukemia with event-free survival of up to 60%; however, complications and adverse effects of the disease and anti-leukemic treatment have also increased. The CNS complications of leukemia can be classified into those that developed directly or indirectly from the underlying leukemic process and those that can be related to antileukemic therapy. MRI had improved early detection of CNS complications and proper management. The study aims to characterize the MRI findings caused by the leukemic involvement of CNS structures and treatment-associated CNS complications and assess its value in early management and avoidance of long-term side effects.
Results
The patient’s age ranged from 2 to 18 years with different types of leukemia classified regarding the time of presentation as pretreatment, during treatment phases, and post-treatment. Different MRI abnormalities were recorded and clinically correlated.
Conclusion
The neurological complications of leukemia have common presenting symptoms but varying imaging abnormalities. To reach the correct diagnosis, the presenting signs, symptoms, and laboratory data must be considered along with the radiologic findings. A diagnostic algorithm using conventional, post-contrast MRI, MR venography, along with diffusion-weighted MRI was of great value in early detection and differentiation of different CNS lesions detected in pediatric patients with leukemia and post-treatment CNS complications.
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21
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Ma Y, Li W, Ao R, Lan X, Li Y, Zhang J, Yu S. Central nervous system aspergillosis in immunocompetent patients: Case series and literature review. Medicine (Baltimore) 2020; 99:e22911. [PMID: 33126348 PMCID: PMC7598844 DOI: 10.1097/md.0000000000022911] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The aim of this study was to investigate the clinical characteristics of central nervous system (CNS) aspergillosis in immunocompetent patients.This study enrolled six immunocompetent patients diagnosed with CNS aspergillosis. Additionally, we reviewed the clinical profiles for 28 cases reported in the literature. The age, gender, etiology of Aspergillus infection, clinical manifestations, location of the lesion, treatment, and prognosis were analyzed.There were 19 men (average age, 54.6 ± 14.3 years) and 15 women (average age, 47.0 ± 19.4 years). The clinical manifestations included headache (55.9%; n = 19), visual impairment (32.4%; n = 11), diplopia (32.4%; n = 11), hemiplegia (20.6%; n = 7), fever (17.6%; n = 6), and epilepsy (8.8%; n = 3). According to the radiological features, CNS aspergillosis lesions were divided into two subtypes: parenchymal lesions in the cerebral lobes (n = 11), and meningeal lesions in the meninges (n = 23). The patients with meningeal lesions are easy to be complicated with more serious cerebrovascular diseases, such as subarachnoid hemorrhage and massive infarction. Most of the lesions in brain parenchyma were abscess formation, and magnetic resonance imaging showed ring enhancement. The clinical diagnosis of Aspergillus infection was mainly based on brain biopsy (n = 14), autopsy (n = 8), pathological examination of adjacent brain tissues (n = 7), cerebrospinal fluid (CSF) or tissue culture (n = 3), and second-generation sequencing analysis of the CSF (n = 3). Clinical improvement was achieved in 23 cases, and 11 patients succumbed to the disease. Voriconazole treatment was effective in 24 (70.6%) cases.Immunocompetent subjects are also at risk for Aspergillus infections. Concomitant cerebrovascular diseases are common in patients with CNS aspergillosis, especially in patients with meningeal aspergillosis. Parenchymal aspergillosis lesions are usually localized and manifest as brain abscesses with annular enhancement on magnetic resonance imaging. Biopsy, CSF culture, and next-generation sequencing are mainstream diagnostic modalities. Voriconazole is an effective treatment for Aspergillus infection, and early diagnosis and treatment should be highlighted.
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22
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Porto L, You SJ, Attarbaschi A, Cario G, Döring M, Moser O, Mücke U, Poyer F, Temme C, Voigt S, Groll AH, Lauten M, Hattingen E, Lehrnbecher T. Invasive Mold Infection of the Central Nervous System in Immunocompromised Children. J Fungi (Basel) 2020; 6:jof6040226. [PMID: 33081142 PMCID: PMC7711511 DOI: 10.3390/jof6040226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 11/30/2022] Open
Abstract
Background: Due to the difficulties in the definite diagnosis, data on brain imaging in pediatric patients with central nervous system (CNS)-invasive mold infection (IMD) are scarce. Our aim was to describe brain imaging abnormalities seen in immunocompromised children with CNS-IMD, and to analyze retrospectively whether specific imaging findings and sequences have a prognostic value. Methods: In a retrospective study of 19 pediatric patients with proven or probable CNS-IMD, magnetic resonance imaging (MRI)-findings were described and analyzed. The results were correlated with outcome, namely death, severe sequelae, or no neurological sequelae. Results: 11 children and 8 adolescents (11/8 with proven/probable CNS-IMD) were included. Seven of the patients died and 12/19 children survived (63%): seven without major neurological sequelae and five with major neurological sequelae. Multifocal ring enhancement and diffusion restriction were the most common brain MRI changes. Diffusion restriction was mostly seen at the core of the lesion. No patient with disease limited to one lobe died. Perivascular microbleeding seen on susceptibility weighted imaging (SWI) and/or gradient-echo/T2* images, as well as infarction, were associated with poor prognosis. Conclusions: The presence of infarction was related to poor outcome. As early microbleeding seems to be associated with poor prognosis, we suggest including SWI in routine diagnostic evaluation of immunocompromised children with suspected CNS-IMD.
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Affiliation(s)
- Luciana Porto
- Department of Neuroradiology, University of Frankfurt, 60528 Frankfurt, Germany; (S.-J.Y.); (E.H.)
- Correspondence: ; Tel.: +49-696-301-5462; Fax: 49-696-301-7176
| | - Se-Jong You
- Department of Neuroradiology, University of Frankfurt, 60528 Frankfurt, Germany; (S.-J.Y.); (E.H.)
| | - Andishe Attarbaschi
- Department of Pediatrics and Adolescent Medicine, St. Anna Children’s Hospital, Medical University of Vienna, Pediatric Hematology and Oncology, 1090 Vienna, Austria; (A.A.); (F.P.)
| | - Gunnar Cario
- Department of Paediatrics, Pediatric Hematology and Oncology, Christian Albrechts University Kiel, 24118 Kiel, Germany;
| | - Michaela Döring
- Department of Paediatric Haematology and Oncology, University Children’s Hospital Tübingen, 53424 Tübingen, Germany;
| | - Olga Moser
- Department of Paediatrics, University Hospital Aachen, 52056 Aachen, Germany;
| | - Urs Mücke
- Department of Paediatric Haematology and Oncology, Hannover Medical School, 30625 Hannover, Germany;
| | - Fiona Poyer
- Department of Pediatrics and Adolescent Medicine, St. Anna Children’s Hospital, Medical University of Vienna, Pediatric Hematology and Oncology, 1090 Vienna, Austria; (A.A.); (F.P.)
| | - Christian Temme
- Department of Paediatric Haematology and Oncology, University Hospital Essen, 45147 Essen, Germany;
| | - Sebastian Voigt
- Department of Paediatric Haematology and Oncology, University Hospital Charité Berlin, 10117 Berlin, Germany;
| | - Andreas H. Groll
- Department of Infectious Disease Research, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, University Children’s Hospital Münster, 53424 Münster, Germany;
| | - Melchior Lauten
- Department of Paediatrics, Paediatric Haematology and Oncology, University of Lübeck, 23562 Lübeck, Germany;
| | - Elke Hattingen
- Department of Neuroradiology, University of Frankfurt, 60528 Frankfurt, Germany; (S.-J.Y.); (E.H.)
| | - Thomas Lehrnbecher
- Department of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University of Frankfurt, 60528 Frankfurt, Germany;
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23
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Finelli PF. MR Target Sign in Cerebral Aspergillosis. Neurohospitalist 2020; 10:287-290. [PMID: 32983348 DOI: 10.1177/1941874420929191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Magnetic resonance (MR) is an effective imaging modality in the evaluation of infectious brain disease, yet findings are often nonspecific. The presence of a diagnostic feature can facilitate early treatment, particularly where mortality is high. We highlight MR apparent diffusion coefficient/T2-weighted target sign in the diagnosis of cerebral aspergillosis.
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Affiliation(s)
- Pasquale F Finelli
- Department of Neurology, Hartford Hospital and University of Connecticut School of Medicine, Hartford, CT, USA
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Role of Voriconazole in the Management of Invasive Central Nervous System Aspergillosis: A Case Series from a Tertiary Care Centre in India. J Fungi (Basel) 2020; 6:jof6030139. [PMID: 32824829 PMCID: PMC7558272 DOI: 10.3390/jof6030139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 11/17/2022] Open
Abstract
Invasive central nervous system (CNS) aspergillosis is acquired by either hematogenous dissemination or direct spread from a sinus infection. We describe a series of nine patients with CNS aspergillosis from a tertiary care teaching institute in North India who were treated with voriconazole alone or in combination with surgery. All patients who had clinical and radiological features consistent with fungal CNS infection, showed the presence of septate hyphae on histopathology/microscopy and were either culture positive for Aspergillus spp. or had serum galactomannan positivity were diagnosed as CNS aspergillosis. Clinical features, risk factors, diagnostic modalities, treatment details and outcome at last follow-up were recorded for all patients diagnosed with CNS aspergillosis. A total of nine patients were diagnosed with CNS aspergillosis. The median duration of presentation at our hospital was six months (IQR-2-9 months). Six patients had concomitant sinus involvement, while two patients had skull-base involvement as well. All patients were treated with voriconazole therapy, and three of these patients underwent surgery. All but one patient survived at the last follow-up (median duration was 14 months (IQR- 8-21.5). Two patients had complete resolution, and voriconazole was stopped at the last follow-up, and the rest of the patients were continued on voriconazole. Of the six patients who were continued on voriconazole, all but one had more than 50% radiological resolution on follow-up imaging. Invasive CNS aspergillosis is an important cause of CNS fungal infection that is often diagnosed late and requires long-term voriconazole-based therapy.
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Isavuconazole Treatment of Cerebral and Pulmonary Aspergillosis in a Pediatric Patient With Acute Lymphoblastic Leukemia: Case Report and Review of Literature. J Pediatr Hematol Oncol 2020; 42:e469-e471. [PMID: 31094909 DOI: 10.1097/mph.0000000000001508] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Invasive aspergillosis in hematologic pediatric patients is an opportunistic infection that is difficult to treat, with a high mortality rate when localized in the central nervous system. We are describing a 3-year-old girl who was affected by acute lymphoblastic leukemia who developed cerebral and pulmonary aspergillosis during induction chemotherapy. The patient failed first-line voriconazole treatment because of being a CYP2C19 ultrarapid metabolizer and received effective isavuconazole therapy with no notable side effects.
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Cerebral and pulmonary aspergillosis, treatment and diagnostic challenges of mixed breakthrough invasive fungal infections: case report study. BMC Infect Dis 2020; 20:535. [PMID: 32703183 PMCID: PMC7376672 DOI: 10.1186/s12879-020-05162-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 06/17/2020] [Indexed: 02/08/2023] Open
Abstract
Background Breakthrough invasive fungal infections (bIFIs) are an area of concern in the scarcity of new antifungals. The mixed form of bIFIs is a rare phenomenon but could be potentially a troublesome challenge when caused by azole-resistant strains or non-Aspergillus fumigatus. To raise awareness and emphasize diagnostic challenges, we present a case of mixed bIFIs in a child with acute lymphoblastic leukemia. Case presentation A newly diagnosed 18-month-old boy with acute lymphoblastic leukemia was complicated with prolonged severe neutropenia after induction chemotherapy. He experienced repeated episodes of fever due to extended-spectrum beta-lactamase-producing Escherichia coli bloodstream infection and pulmonary invasive fungal infection with Aspergillus fumigatus (early-type bIFIs) while receiving antifungal prophylaxis. Shortly after pulmonary involvement, his condition aggravated by abnormal focal movement, loss of consciousness and seizure. Cerebral aspergillosis with Aspergillus niger diagnosed after brain tissue biopsy. The patient finally died despite 108-day antifungal therapy. Conclusions Mixed bIFIs is a rare condition with high morbidity and mortality in the patients receiving immunosuppressants for hematological malignancies. This case highlights the clinical importance of Aspergillus identification at the species level in invasive fungal infections with multiple site involvement in the patients on antifungal prophylaxis.
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Sanguinetti M, Posteraro B, Beigelman-Aubry C, Lamoth F, Dunet V, Slavin M, Richardson MD. Diagnosis and treatment of invasive fungal infections: looking ahead. J Antimicrob Chemother 2020; 74:ii27-ii37. [PMID: 31222314 DOI: 10.1093/jac/dkz041] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Improved standards of care depend on the development of new laboratory diagnostic and imaging procedures and the development of new antifungal compounds. Immunochromatography technologies have led to the development of lateral flow devices for the diagnosis of cryptococcal meningitis and invasive aspergillosis (IA). Similar devices are being developed for the detection of histoplasmosis that meet the requirements for speed (∼15 min assay time) and ease of use for point-of-care diagnostics. The evolution of molecular tools for the detection of fungal pathogens has been slow but the introduction of new nucleic acid amplification techniques appears to be helpful, for example T2Candida. An Aspergillus proximity ligation assay has been developed for a rapid near-patient bedside diagnosis of IA. CT remains the cornerstone for radiological diagnosis of invasive pulmonary fungal infections. MRI of the lungs may be performed to avoid radiation exposure. MRI with T2-weighted turbo-spin-echo sequences exhibits sensitivity and specificity approaching that of CT for the diagnosis of invasive pulmonary aspergillosis. The final part of this review looks at new approaches to drug discovery that have yielded new classes with novel mechanisms of action. There are currently two new classes of antifungal drugs in Phase 2 study for systemic invasive fungal disease and one in Phase 1. These new antifungal drugs show promise in meeting unmet needs with oral and intravenous formulations available and some with decreased potential for drug-drug interactions. Novel mechanisms of action mean these agents are not susceptible to the common resistance mechanisms seen in Candida or Aspergillus. Modification of existing antifungal susceptibility testing techniques may be required to incorporate these new compounds.
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Affiliation(s)
- Maurizio Sanguinetti
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Istituto di Microbiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Brunella Posteraro
- Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Istituto di Patologia Medica e Semeiotica Medica, Università Cattolica del Sacro Cuore Rome, Italy
| | - Catherine Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Frederic Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Institute of Microbiology, Department of Laboratory Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Vincent Dunet
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Monica Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Malcolm D Richardson
- Mycology Reference Centre Manchester, ECMM Excellence Centre of Medical Mycology, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Schauwvlieghe AFAD, Bredius RGM, Verdijk RM, Smiers FJW, van der Beek MT, Goemans BF, Zwaan CM, Brüggemann RJ, Rijnders BJA. Management of cerebral azole-resistant Aspergillus fumigatus infection: A role for intraventricular liposomal-amphotericin B. J Glob Antimicrob Resist 2020; 22:354-357. [PMID: 32251868 DOI: 10.1016/j.jgar.2020.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/17/2020] [Accepted: 03/20/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES In the pre-azole era, central nervous system (CNS) infections with Aspergillus had a dismal outcome. Survival improved with voriconazole but CNS infections caused by azole-resistant Aspergillus fumigatus preclude its use. Intravenous liposomal-amphotericin B (L-AmB) is the preferred treatment option for azole-resistant CNS infections but has suboptimal brain concentrations. METHODS We describe three patients with biopsy-proven CNS aspergillosis where intraventricular L-AmB was added to systemic therapy. Two patients with azole-resistant aspergillosis and one patient with azole-susceptible CNS aspergillosis were treated with intraventricular L-AmB at a dose of 1mg weekly. RESULTS We describe three patients successfully treated with a combination of intravenous and intraventricular L-AmB. All three patients survived but one patient developed serious headaches, most likely not related to this treatment. CONCLUSIONS Intraventricular L-AmB may have a role in the treatment of therapy-refractory CNS aspergillosis when added to systemic therapy.
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Affiliation(s)
- A F A D Schauwvlieghe
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, Netherlands.
| | - R G M Bredius
- Department of Paediatric Immunology, Section of Infections, Haematology, and Stem Cell Transplantation, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands
| | - R M Verdijk
- Department of Pathology, Erasmus Medical Center, Rotterdam, Netherlands
| | - F J W Smiers
- Department of Paediatric Immunology, Section of Infections, Haematology, and Stem Cell Transplantation, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands
| | - M T van der Beek
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands
| | - B F Goemans
- Department of Haemato-oncology, Princess Máxima Centre for Paediatric Oncology, Utrecht, Netherlands
| | - C M Zwaan
- Department of Haemato-oncology, Princess Máxima Centre for Paediatric Oncology, Utrecht, Netherlands; Department of Paediatric Oncology/Haematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - R J Brüggemann
- Department of Pharmacy, Radboud Institute of Health Science, Radboud University Medical Center, Nijmegen, Netherlands; Center of Expertise in Mycology, Radboudumc, Nijmegen, Netherlands
| | - B J A Rijnders
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, Netherlands
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Infections causing stroke or stroke-like syndromes. Infection 2020; 48:323-332. [PMID: 32239441 DOI: 10.1007/s15010-020-01415-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/20/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Stroke has relevant morbidity and mortality despite appropriate treatments and early diagnosis. Beside common risk factors such as diabetes and atrial fibrillation, infections can be involved in stroke pathogenesis, probably causing a systemic release of cytokines and other inflammatory mediators, triggering a latent pro-thrombotic state or damaging the vascular endothelium. In other cases, infections can occur as stroke-like syndromes, requiring a high grade of suspicion to avoid a delay in establishing a correct diagnosis. RESULTS Treatment of stroke or stroke-like syndromes of infectious origin can be difficult. When a previous infective event triggers stroke, Alteplase administration can be associated with a higher incidence of bleeding and the extension of the ischaemic area can be major than expected. On the other hand, when stroke is part of some infectious diseases' presentation as in endocarditis, bacterial or tuberculous meningitis and meningo-vascular syphilis, a correct diagnosis can be difficult. The management of these stroke-like syndromes is not standardised because common treatments proven to be effective for patients with stroke of vascular origin can worsen the prognosis, as it can be demonstrated after to be incorrect Alteplase administration to patients with endocarditis with septic embolism to the brain is associated with an increase of the risk of haemorrhage. CONCLUSIONS Stroke or stroke-like syndrome of infectious origin can be observed in an important proportion of case presenting with sensory-motor deficit of unknown origin; their accurate diagnosis has a considerable impact in terms of treatment choices and outcome.
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Thakkar K, Ramteke-Jadhav S, Kasaliwal R, Memon SS, Patil V, Thadani P, Lomte N, Sankhe S, Goel A, Epari S, Goel N, Lila A, Shah NS, Bandgar T. Sellar surprises: a single-centre experience of unusual sellar masses. Endocr Connect 2020; 9:111-121. [PMID: 31910151 PMCID: PMC6993267 DOI: 10.1530/ec-19-0497] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 01/07/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Most common incidentally detected sellar-suprasellar region (SSR) masses are pituitary adenomas, followed by craniopharyngioma, rathke's cleft cyst, hypophysitis, and meningioma. Besides these, certain unusual SSR lesions can sometimes present as diagnostic challenges, where diagnosis is often made post-operatively on histopathology, the pre-operative suspicion of which might have influenced the management strategies. Series describing such masses are few. OBJECTIVE To present clinical, biochemical, and radiological characteristics and management outcomes of rare SSR lesions other than pituitary adenomas, craniopharyngioma, rathke's cleft cyst, hypophysitis, and meningioma. DESIGN, SETTING, PATIENTS Retrospective case record analysis of patients with uncommon SSR masses (from January 2006 to December 2016). RESULTS Our series consisted of ten patients, five with neoplastic and five with non-neoplastic lesions. Neoplastic masses included granular cell tumor (n = 2), astrocytoma (n = 1), malignant peripheral nerve sheath tumor (MPNST, n = 1), and metastasis from occult papillary carcinoma of thyroid (n = 1), while non-neoplastic masses were aspergillus abscess (n = 1), sterile abscess (n = 1), and tubercular abscess (n = 1), aneurysm of left internal carotid artery (n = 1), and ruptured dermoid cyst (n = 1). All patients (except one) presented with headache and/or visual disturbance. Only one patient had acromegaly while most others had hypopituitarism. We describe detailed MRI characteristics of each of the lesion. Seven patients underwent trans-sphenoidal surgery. Post-operatively, five patients had permanent diabetes insipidus, while two patients died in early post-operative period. CONCLUSION Our series expand the differential diagnostic considerations of SSR lesions. Most of the rare SSR masses present with symptoms of mass effects and hypopituitarism. Except for some non-neoplastic lesions like sellar abscesses, aneurysms, and dermoid cysts which can have some specific imaging characteristics that can provide clue to pre-operative diagnosis, most of the other neoplastic masses have overlapping radiological features, and pre-operative suspicion remains difficult.
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Affiliation(s)
- Kunal Thakkar
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Swati Ramteke-Jadhav
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Rajeev Kasaliwal
- Department of Endocrinology, Mahatma Gandhi Medical College & Hospital, Jaipur, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Virendra Patil
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
- Correspondence should be addressed to V Patil:
| | - Puja Thadani
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Nilesh Lomte
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Shilpa Sankhe
- Department of Radiology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Atul Goel
- Department of Neurosurgery, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Sridhar Epari
- Department of Pathology, Tata Memorial Centre, Mumbai, India
| | - Naina Goel
- Department of Neuropathology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Anurag Lila
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Nalini S Shah
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
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Salomone G, Pavone P, Greco F, Smilari P, Fiumara A, Praticò AD. Neuroaspergillosis as the Presenting Sign of a Chronic Granulomatous Disease. Pediatr Neurol 2020; 102:79-80. [PMID: 31570298 DOI: 10.1016/j.pediatrneurol.2019.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 08/14/2019] [Accepted: 08/17/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Giulia Salomone
- Residency Program in Pediatrics, University of Catania, Catania, Italy
| | - Piero Pavone
- Unit of Pediatrics, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Filippo Greco
- Unit of Pediatrics, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Pierluigi Smilari
- Unit of Pediatrics, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Agata Fiumara
- Unit of Pediatrics, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Andrea D Praticò
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.
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Lebeaux D, Klein I, Garcia G, Bruneel F, Pico F, Lortholary O. Teaching NeuroImages: Aspergillosis-induced vasculitis presenting as ischemic stroke in an immunocompetent patient. Neurology 2019; 92:e2618-e2619. [PMID: 31133570 DOI: 10.1212/wnl.0000000000007575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- David Lebeaux
- From Centre d'Infectiologie Necker-Pasteur and Institut Imagine (D.L., O.L.), Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Sorbonne Paris Cité, Université Paris Descartes; Neuroimaging Department (I.K.), Clinic Alleray-Labrouste, Paris; Department of Diagnostic Radiology (G.G.), Gustave Roussy, Villejuif; and Critical Care Unit, Department of Neurology, and Stroke Center (F.P.), Versailles Saint Quentin en Yvelines University, Versailles Hospital, France. D.L. is currently affiliated with the Hôpital Européen Georges Pompidou, Unité Mobile de Microbiologie Clinique, Service de Microbiologie, AP-HP, Sorbonne Paris Cité, Université Paris Descartes, France.
| | - Isabelle Klein
- From Centre d'Infectiologie Necker-Pasteur and Institut Imagine (D.L., O.L.), Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Sorbonne Paris Cité, Université Paris Descartes; Neuroimaging Department (I.K.), Clinic Alleray-Labrouste, Paris; Department of Diagnostic Radiology (G.G.), Gustave Roussy, Villejuif; and Critical Care Unit, Department of Neurology, and Stroke Center (F.P.), Versailles Saint Quentin en Yvelines University, Versailles Hospital, France. D.L. is currently affiliated with the Hôpital Européen Georges Pompidou, Unité Mobile de Microbiologie Clinique, Service de Microbiologie, AP-HP, Sorbonne Paris Cité, Université Paris Descartes, France
| | - Gabriel Garcia
- From Centre d'Infectiologie Necker-Pasteur and Institut Imagine (D.L., O.L.), Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Sorbonne Paris Cité, Université Paris Descartes; Neuroimaging Department (I.K.), Clinic Alleray-Labrouste, Paris; Department of Diagnostic Radiology (G.G.), Gustave Roussy, Villejuif; and Critical Care Unit, Department of Neurology, and Stroke Center (F.P.), Versailles Saint Quentin en Yvelines University, Versailles Hospital, France. D.L. is currently affiliated with the Hôpital Européen Georges Pompidou, Unité Mobile de Microbiologie Clinique, Service de Microbiologie, AP-HP, Sorbonne Paris Cité, Université Paris Descartes, France
| | - Fabrice Bruneel
- From Centre d'Infectiologie Necker-Pasteur and Institut Imagine (D.L., O.L.), Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Sorbonne Paris Cité, Université Paris Descartes; Neuroimaging Department (I.K.), Clinic Alleray-Labrouste, Paris; Department of Diagnostic Radiology (G.G.), Gustave Roussy, Villejuif; and Critical Care Unit, Department of Neurology, and Stroke Center (F.P.), Versailles Saint Quentin en Yvelines University, Versailles Hospital, France. D.L. is currently affiliated with the Hôpital Européen Georges Pompidou, Unité Mobile de Microbiologie Clinique, Service de Microbiologie, AP-HP, Sorbonne Paris Cité, Université Paris Descartes, France
| | - Fernando Pico
- From Centre d'Infectiologie Necker-Pasteur and Institut Imagine (D.L., O.L.), Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Sorbonne Paris Cité, Université Paris Descartes; Neuroimaging Department (I.K.), Clinic Alleray-Labrouste, Paris; Department of Diagnostic Radiology (G.G.), Gustave Roussy, Villejuif; and Critical Care Unit, Department of Neurology, and Stroke Center (F.P.), Versailles Saint Quentin en Yvelines University, Versailles Hospital, France. D.L. is currently affiliated with the Hôpital Européen Georges Pompidou, Unité Mobile de Microbiologie Clinique, Service de Microbiologie, AP-HP, Sorbonne Paris Cité, Université Paris Descartes, France
| | - Olivier Lortholary
- From Centre d'Infectiologie Necker-Pasteur and Institut Imagine (D.L., O.L.), Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Sorbonne Paris Cité, Université Paris Descartes; Neuroimaging Department (I.K.), Clinic Alleray-Labrouste, Paris; Department of Diagnostic Radiology (G.G.), Gustave Roussy, Villejuif; and Critical Care Unit, Department of Neurology, and Stroke Center (F.P.), Versailles Saint Quentin en Yvelines University, Versailles Hospital, France. D.L. is currently affiliated with the Hôpital Européen Georges Pompidou, Unité Mobile de Microbiologie Clinique, Service de Microbiologie, AP-HP, Sorbonne Paris Cité, Université Paris Descartes, France
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Thornton CR. Detection of the 'Big Five' mold killers of humans: Aspergillus, Fusarium, Lomentospora, Scedosporium and Mucormycetes. ADVANCES IN APPLIED MICROBIOLOGY 2019; 110:1-61. [PMID: 32386603 DOI: 10.1016/bs.aambs.2019.10.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Fungi are an important but frequently overlooked cause of morbidity and mortality in humans. Life-threatening fungal infections mainly occur in immunocompromised patients, and are typically caused by environmental opportunists that take advantage of a weakened immune system. The filamentous fungus Aspergillus fumigatus is the most important and well-documented mold pathogen of humans, causing a number of complex respiratory diseases, including invasive pulmonary aspergillosis, an often fatal disease in patients with acute leukemia or in immunosuppressed bone marrow or solid organ transplant recipients. However, non-Aspergillus molds are increasingly reported as agents of disseminated diseases, with Fusarium, Scedosporium, Lomentospora and mucormycete species now firmly established as pathogens of immunosuppressed and immunocompetent individuals. Despite well-documented risk factors for invasive fungal diseases, and increased awareness of the risk factors for life-threatening infections, the number of deaths attributable to molds is likely to be severely underestimated driven, to a large extent, by the lack of readily accessible, cheap, and accurate tests that allow detection and differentiation of infecting species. Early diagnosis is critical to patient survival but, unlike Aspergillus diseases, where a number of CE-marked or FDA-approved biomarker tests are now available for clinical diagnosis, similar tests for fusariosis, scedosporiosis and mucormycosis remain experimental, with detection reliant on insensitive and slow culture of pathogens from invasive bronchoalveolar lavage fluid, tissue biopsy, or from blood. This review examines the ecology, epidemiology, and contemporary methods of detection of these mold pathogens, and the obstacles to diagnostic test development and translation of novel biomarkers to the clinical setting.
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Weidauer S, Wagner M, Enkirch SJ, Hattingen E. CNS Infections in Immunoincompetent Patients : Neuroradiological and Clinical Features. Clin Neuroradiol 2019; 30:9-25. [PMID: 31538219 DOI: 10.1007/s00062-019-00837-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/28/2019] [Indexed: 12/15/2022]
Abstract
In patients with immunodeficiency the pathogen spectrum of central nervous system (CNS) infections is broader and different from that of immunocompetent patients. Numerous opportunistic infections are characterized by a high prevalence of viral, bacterial and parasitic pathogens, and depend on the type of impaired immune defense, for example impaired T‑cell or monocyte function, monoclonal antibody treatment, and impaired granulocyte function. Neuroradiological features as well as laboratory findings are often different and versatile in comparison to immunocompetent individuals and pathognomonic imaging findings do not exist; however, knowledge of possible pathways of pathogens in the CNS and preferred tissue affection may help in narrowing down differential diagnoses. Therefore, knowledge of the type of patient and the performed immunomodulatory therapy is essential for the neuroradiological assessment and the differential diagnostic considerations. Moreover, parenchymal reactions in the sense of an immune reconstitution inflammatory syndrome (IRIS) can occur when immunocompetence is restored. This review focus on the most common pathologies in immunocompromised patients, and an overview of imaging features but also of pathology and clinical aspects is given. The synopsis of anamnestic information, clinical findings and structured analysis of the lesion pattern, its spread and short-term follow-up may increase the correct diagnostic classification; however, the gold standard is still determination of the pathogen in the cerebrospinal fluid (CSF), blood cultures or biopsies.
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Affiliation(s)
- Stefan Weidauer
- Department of Neurology, Sankt Katharinen Hospital, Teaching Hospital, Goethe University, Seckbacher Landstraße 65, 60389, Frankfurt/Main, Germany.
| | - Marlies Wagner
- Institute of Neuroradiology, Goethe University, Frankfurt am Main, Germany
| | | | - Elke Hattingen
- Institute of Neuroradiology, Goethe University, Frankfurt am Main, Germany
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El Hasbani G, Chirayil J, Nithisoontorn S, Antezana AA, El Husseini I, Landaeta M, Saeed Y, Assaker R. Cerebral aspergillosis presenting as a space occupying lesion in an immunocompetent individual. Med Mycol Case Rep 2019; 25:45-48. [PMID: 31453078 PMCID: PMC6700407 DOI: 10.1016/j.mmcr.2019.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/06/2019] [Accepted: 07/31/2019] [Indexed: 11/11/2022] Open
Abstract
Cerebral aspergillosis has the tendency to occur in immunocompromised patients. Less commonly, immunocompetent individuals can be affected, with neuroimaging findings being difficult to interpret. The diagnosis necessitates imaging of the brain as well as the sinuses with biopsy and pathological confirmation. A surgical excision with aggressive antifungal agents are required for a proper management. This case report describes an immunocompetent patient with cerebral aspergillosis that presented radiologically as a suspicious mass to be diagnosed pathologically and excised surgically.
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Affiliation(s)
| | - Joseph Chirayil
- Lincoln Medical and Mental Health Center, Bronx, New York, USA
| | | | | | | | - Maria Landaeta
- Lincoln Medical and Mental Health Center, Bronx, New York, USA
| | - Yasir Saeed
- Lincoln Medical and Mental Health Center, Bronx, New York, USA
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Danion F, Rouzaud C, Duréault A, Poirée S, Bougnoux ME, Alanio A, Lanternier F, Lortholary O. Why are so many cases of invasive aspergillosis missed? Med Mycol 2019; 57:S94-S103. [PMID: 30816963 DOI: 10.1093/mmy/myy081] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/10/2018] [Indexed: 12/20/2022] Open
Abstract
Invasive aspergillosis (IA) incidence is increasing in several countries like France, and numerous cases are indeed missed and still only diagnosed at autopsy as evidenced by recently published data. Such missed diagnoses are obviously encountered when appropriate diagnostic tools are not available especially in low resource areas or when biologists have not been trained enough in medical mycology (i.e., microscopic examination and culture in most of those areas). Besides logistical issues, which are indeed critical, IA may not be recognized because clinicians failed to consider that risk factors are evolving with the IA burden now observed among patients with chronic lymphoid malignancies or receiving new biotherapies, with diabetes mellitus or liver cirrhosis and/or acute alcoholic hepatitis, with patients from the intensive care unit (ICU) and among patients with some predisposing primary immune deficiencies now reaching the adult's age. This is also the case for human immunodeficiency virus (HIV)-infected patients who failed to meet the classical definitions of IA. From the radiology perspective, new entities of IA have also emerged which absolutely need to be recognized especially bronchial-based-IA among allogeneic stem cell transplant recipients. Finally, from the laboratory side, contribution and limits of indirect blood biomarkers should be integrated to the clinical life in order not to miss IA cases. To conclude, several diagnostic tools should be combined and a constant dialog between laboratory and clinics is crucial to appropriately diagnose IA.
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Affiliation(s)
- François Danion
- Department of Infectious Diseases and Tropical Medicine, Necker-Pasteur Infectious Diseases Center, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Imagine, Paris Descartes University, Paris, France.,Aspergillus Unit, Institut Pasteur, Paris, France
| | - Claire Rouzaud
- Department of Infectious Diseases and Tropical Medicine, Necker-Pasteur Infectious Diseases Center, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Imagine, Paris Descartes University, Paris, France
| | - Amélie Duréault
- Department of Infectious Diseases and Tropical Medicine, Necker-Pasteur Infectious Diseases Center, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Imagine, Paris Descartes University, Paris, France
| | - Sylvain Poirée
- Department of Radiology, Necker-Enfants Malades University Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Marie-Elisabeth Bougnoux
- Department of Mycology, Necker-Enfants Malades University Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Alexandre Alanio
- National Reference Center for Invasive Mycoses and Antifungals, Molecular Mycology Unit, Institut Pasteur, Paris, France.,Department of Mycology, Saint-Louis Hospital, AP-HP, Paris, France
| | - Fanny Lanternier
- Department of Infectious Diseases and Tropical Medicine, Necker-Pasteur Infectious Diseases Center, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Imagine, Paris Descartes University, Paris, France.,National Reference Center for Invasive Mycoses and Antifungals, Molecular Mycology Unit, Institut Pasteur, Paris, France
| | - Olivier Lortholary
- Department of Infectious Diseases and Tropical Medicine, Necker-Pasteur Infectious Diseases Center, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Imagine, Paris Descartes University, Paris, France.,National Reference Center for Invasive Mycoses and Antifungals, Molecular Mycology Unit, Institut Pasteur, Paris, France
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Diagnostic and therapeutic approach to infectious diseases in solid organ transplant recipients. Intensive Care Med 2019; 45:573-591. [PMID: 30911807 PMCID: PMC7079836 DOI: 10.1007/s00134-019-05597-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 03/06/2019] [Indexed: 12/18/2022]
Abstract
Purpose Prognosis of solid organ transplant (SOT) recipients has improved, mainly because of better prevention of rejection by immunosuppressive therapies. However, SOT recipients are highly susceptible to conventional and opportunistic infections, which represent a major cause of morbidity, graft dysfunction and mortality. Methods Narrative review. Results We cover the current epidemiology and main aspects of infections in SOT recipients including risk factors such as postoperative risks and specific risks for different transplant recipients, key points on anti-infective prophylaxis as well as diagnostic and therapeutic approaches. We provide an up-to-date guide for management of the main syndromes that can be encountered in SOT recipients including acute respiratory failure, sepsis or septic shock, and central nervous system infections as well as bacterial infections with multidrug-resistant strains, invasive fungal diseases, viral infections and less common pathogens that may impact this patient population. Conclusion We provide state-of the art review of available knowledge of critically ill SOT patients with infections.
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Neyaz Z, Singh V, Mehrotra A, Jain M. Cerebral Aspergillosis Mimicking a Neoplasm in an Immunocompetent Patient. Int J Appl Basic Med Res 2019; 8:269-271. [PMID: 30598919 PMCID: PMC6259295 DOI: 10.4103/ijabmr.ijabmr_393_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cerebral aspergillosis mostly presents as single or multiple abscesses with vascular invasion in immunocompromised patients. A rare mass like or tumoral form of cerebral aspergillosis has been described mostly in immunocompetent patients. A 22-year-old-male presented with recurrent attacks of complex partial seizures with secondary generalization, headache, and blurring of vision. Preoperative diagnosis of a cerebral neoplasm was considered in view of solid mass-like enhancement. However, histopathological examination was suggestive of central nervous system aspergillosis. The presence of imaging findings such as T2 hypointensity, irregular frond-like margins, and absence of choline peak may be the clues, which suggest a fungal etiology.
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Affiliation(s)
- Zafar Neyaz
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vivek Singh
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Manoj Jain
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Caceres A, Avila ML, Herrera ML. Fungal infections in pediatric neurosurgery. Childs Nerv Syst 2018; 34:1973-1988. [PMID: 30121829 DOI: 10.1007/s00381-018-3942-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Invasive mycosis of the central nervous system represent a diverse group of diseases that have gradually emerged as not only opportunistic infections in patients with immune susceptibility due to congenital and acquired deficiency, immunomodulation, solid organ and stem cell transplantation, hematological malignancies, and chronic steroid use but also in selected risk populations such as low weight preterm infants, patients with shunted hydrocephalus and external ventricular drainages, skull base surgery, and head injury. OBJECTIVES The purpose of this review is to familiarize the pediatric neurosurgeon with the most common mycosis and their clinical scenarios which can be encountered in the clinical practice, with special emphasis on clinical, radiological, and laboratory diagnosis beyond classical microorganism cultures as well as options in medical and surgical treatment given the high incidence of morbidity and mortality associated with these challenging entities. METHODS We conducted an online database review (Ovid, PubMed) gathering relevant English language literature published in the last 20 years with special emphasis on recent breakthroughs in the diagnosis and treatment of invasive mycosis of the CNS as well as reported cases within the pediatric neurosurgical literature and their surgical management. RESULTS Fungal agents capable of invading the CNS can behave as aggressive entities with rapid progression manifesting as overwhelming meningoencephalitis with vascular compromise or can lead to space-occupying lesions with abscess formation which require prompt diagnosis by either laboratory identification of the components of these biological agents and their host response or by obtaining tissue specimens for microbiological identification which may not be straightforward due to prolonged culture time. CONCLUSION Following a high degree of suspicion with prompt initiation of antifungal agents and reversal of potential immunosuppressant therapies along with neurosurgical evacuation of intracranial collections or removal of infected hardware (CSF shunts) can lead to more optimistic outcomes of these complex clinical scenarios.
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Affiliation(s)
- Adrian Caceres
- Neurosurgery Department, National Children's Hospital of Costa Rica, Paseo Colón y Calle 20 sur, San José, 10103, Costa Rica.
| | - Maria Luisa Avila
- Infectious Diseases Department, National Children's Hospital of Costa Rica, San José, Costa Rica
| | - Marco Luis Herrera
- Microbiology Division, Clinical Laboratory, National Children's Hospital of Costa Rica, San José, Costa Rica
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Kumar D, Nepal P, Singh S, Ramanathan S, Khanna M, Sheoran R, Bansal SK, Patil S. CNS aspergilloma mimicking tumors: Review of CNS aspergillus infection imaging characteristics in the immunocompetent population. J Neuroradiol 2018; 45:169-176. [DOI: 10.1016/j.neurad.2017.11.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 09/24/2017] [Accepted: 11/28/2017] [Indexed: 11/29/2022]
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Ullmann AJ, Aguado JM, Arikan-Akdagli S, Denning DW, Groll AH, Lagrou K, Lass-Flörl C, Lewis RE, Munoz P, Verweij PE, Warris A, Ader F, Akova M, Arendrup MC, Barnes RA, Beigelman-Aubry C, Blot S, Bouza E, Brüggemann RJM, Buchheidt D, Cadranel J, Castagnola E, Chakrabarti A, Cuenca-Estrella M, Dimopoulos G, Fortun J, Gangneux JP, Garbino J, Heinz WJ, Herbrecht R, Heussel CP, Kibbler CC, Klimko N, Kullberg BJ, Lange C, Lehrnbecher T, Löffler J, Lortholary O, Maertens J, Marchetti O, Meis JF, Pagano L, Ribaud P, Richardson M, Roilides E, Ruhnke M, Sanguinetti M, Sheppard DC, Sinkó J, Skiada A, Vehreschild MJGT, Viscoli C, Cornely OA. Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline. Clin Microbiol Infect 2018; 24 Suppl 1:e1-e38. [PMID: 29544767 DOI: 10.1016/j.cmi.2018.01.002] [Citation(s) in RCA: 823] [Impact Index Per Article: 137.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 02/06/2023]
Abstract
The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.
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Affiliation(s)
- A J Ullmann
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J M Aguado
- Infectious Diseases Unit, University Hospital Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - S Arikan-Akdagli
- Department of Medical Microbiology, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D W Denning
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; European Confederation of Medical Mycology (ECMM)
| | - A H Groll
- Department of Paediatric Haematology/Oncology, Centre for Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - K Lagrou
- Department of Microbiology and Immunology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lass-Flörl
- Institute of Hygiene, Microbiology and Social Medicine, ECMM Excellence Centre of Medical Mycology, Medical University Innsbruck, Innsbruck, Austria; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R E Lewis
- Infectious Diseases Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - P Munoz
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - P E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - F Ader
- Department of Infectious Diseases, Hospices Civils de Lyon, Lyon, France; Inserm 1111, French International Centre for Infectious Diseases Research (CIRI), Université Claude Bernard Lyon 1, Lyon, France; European Respiratory Society (ERS)
| | - M Akova
- Department of Medicine, Section of Infectious Diseases, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M C Arendrup
- Department Microbiological Surveillance and Research, Statens Serum Institute, Copenhagen, Denmark; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R A Barnes
- Department of Medical Microbiology and Infectious Diseases, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK; European Confederation of Medical Mycology (ECMM)
| | - C Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland; European Respiratory Society (ERS)
| | - S Blot
- Department of Internal Medicine, Ghent University, Ghent, Belgium; Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia; European Respiratory Society (ERS)
| | - E Bouza
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R J M Brüggemann
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG)
| | - D Buchheidt
- Medical Clinic III, University Hospital Mannheim, Mannheim, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Cadranel
- Department of Pneumology, University Hospital of Tenon and Sorbonne, University of Paris, Paris, France; European Respiratory Society (ERS)
| | - E Castagnola
- Infectious Diseases Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - A Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India; European Confederation of Medical Mycology (ECMM)
| | - M Cuenca-Estrella
- Instituto de Salud Carlos III, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - G Dimopoulos
- Department of Critical Care Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece; European Respiratory Society (ERS)
| | - J Fortun
- Infectious Diseases Service, Ramón y Cajal Hospital, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J-P Gangneux
- Univ Rennes, CHU Rennes, Inserm, Irset (Institut de Recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Garbino
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - W J Heinz
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R Herbrecht
- Department of Haematology and Oncology, University Hospital of Strasbourg, Strasbourg, France; ESCMID Fungal Infection Study Group (EFISG)
| | - C P Heussel
- Diagnostic and Interventional Radiology, Thoracic Clinic, University Hospital Heidelberg, Heidelberg, Germany; European Confederation of Medical Mycology (ECMM)
| | - C C Kibbler
- Centre for Medical Microbiology, University College London, London, UK; European Confederation of Medical Mycology (ECMM)
| | - N Klimko
- Department of Clinical Mycology, Allergy and Immunology, North Western State Medical University, St Petersburg, Russia; European Confederation of Medical Mycology (ECMM)
| | - B J Kullberg
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lange
- International Health and Infectious Diseases, University of Lübeck, Lübeck, Germany; Clinical Infectious Diseases, Research Centre Borstel, Leibniz Center for Medicine & Biosciences, Borstel, Germany; German Centre for Infection Research (DZIF), Tuberculosis Unit, Hamburg-Lübeck-Borstel-Riems Site, Lübeck, Germany; European Respiratory Society (ERS)
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Confederation of Medical Mycology (ECMM)
| | - J Löffler
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Lortholary
- Department of Infectious and Tropical Diseases, Children's Hospital, University of Paris, Paris, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Maertens
- Department of Haematology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Marchetti
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland; Department of Medicine, Ensemble Hospitalier de la Côte, Morges, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - L Pagano
- Department of Haematology, Universita Cattolica del Sacro Cuore, Roma, Italy; European Confederation of Medical Mycology (ECMM)
| | - P Ribaud
- Quality Unit, Pôle Prébloc, Saint-Louis and Lariboisière Hospital Group, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M Richardson
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece; Hippokration General Hospital, Thessaloniki, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Ruhnke
- Department of Haematology and Oncology, Paracelsus Hospital, Osnabrück, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Sanguinetti
- Institute of Microbiology, Fondazione Policlinico Universitario A. Gemelli - Università Cattolica del Sacro Cuore, Rome, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D C Sheppard
- Division of Infectious Diseases, Department of Medicine, Microbiology and Immunology, McGill University, Montreal, Canada; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Sinkó
- Department of Haematology and Stem Cell Transplantation, Szent István and Szent László Hospital, Budapest, Hungary; ESCMID Fungal Infection Study Group (EFISG)
| | - A Skiada
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M J G T Vehreschild
- Department I of Internal Medicine, ECMM Excellence Centre of Medical Mycology, University Hospital of Cologne, Cologne, Germany; Centre for Integrated Oncology, Cologne-Bonn, University of Cologne, Cologne, Germany; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; European Confederation of Medical Mycology (ECMM)
| | - C Viscoli
- Ospedale Policlinico San Martino and University of Genova (DISSAL), Genova, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O A Cornely
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; CECAD Cluster of Excellence, University of Cologne, Cologne, Germany; Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM); ESCMID European Study Group for Infections in Compromised Hosts (ESGICH).
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Thornton CR. Molecular Imaging of Invasive Pulmonary Aspergillosis Using ImmunoPET/MRI: The Future Looks Bright. Front Microbiol 2018; 9:691. [PMID: 29686661 PMCID: PMC5900000 DOI: 10.3389/fmicb.2018.00691] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 03/23/2018] [Indexed: 12/19/2022] Open
Abstract
Invasive pulmonary aspergillosis (IPA) is a life-threatening lung disease of immuno-compromised humans caused by the ubiquitous environmental mold Aspergillus. Biomarker tests for the disease lack sensitivity and specificity, and culture of the fungus from invasive lung biopsy is slow, insensitive, and undesirable in critically ill patients. A computed tomogram (CT) of the chest offers a simple non-intrusive diagnostic procedure for rapid decision making, and so is used in many hematology units to drive antifungal treatment. However, radiological indicators that raise the suspicion of IPA are either transient signs in the early stages of the disease or not specific for Aspergillus infection, with other angio-invasive molds or bacterial pathogens producing comparable radiological manifestations in a chest CT. Improvements to the specificity of radiographic imaging of IPA have been attempted by coupling CT and positron emission tomography (PET) with [18F]fluorodeoxyglucose ([18F]FDG), a marker of metabolic activity well suited to cancer imaging, but with limited use in invasive fungal disease diagnostics due to its inability to differentiate between infectious etiologies, cancer, and inflammation. Bioluminescence imaging using single genetically modified strains of Aspergillus fumigatus has enabled in vivo monitoring of IPA in animal models of disease. For in vivo detection of Aspergillus lung infections in humans, radiolabeled Aspergillus-specific monoclonal antibodies, and iron siderophores, hold enormous potential for clinical diagnosis. This review examines the different experimental technologies used to image IPA, and recent advances in state-of-the-art molecular imaging of IPA using antibody-guided PET/magnetic resonance imaging (immunoPET/MRI).
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Affiliation(s)
- Christopher R Thornton
- Department of Biosciences, College of Life and Environmental Sciences, University of Exeter, Exeter, United Kingdom.,ISCA Diagnostics Ltd., Exeter, United Kingdom
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Schwartz S, Kontoyiannis DP, Harrison T, Ruhnke M. Advances in the diagnosis and treatment of fungal infections of the CNS. Lancet Neurol 2018; 17:362-372. [PMID: 29477506 DOI: 10.1016/s1474-4422(18)30030-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 12/16/2022]
Abstract
Fungal infections of the CNS are challenging to treat and their optimal management requires knowledge of their epidemiology, host characteristics, diagnostic criteria, and therapeutic options. Aspergillus and Cryptococcus species predominate among fungal infections of the CNS. Most of these fungi are ubiquitous, but some have restricted geographical distribution. Fungal infections of the CNS usually originate from primary sites outside the CNS (eg, fungal pneumonia) or occur after inoculation (eg, invasive procedures). Most patients with these infections have immunodeficiencies, but immunocompetent individuals can also be infected through heavy exposure. The infecting fungi can be grouped into moulds, yeasts, and dimorphic fungi. Substantial progress has been made with new diagnostic approaches and the introduction of novel antifungal drugs, but fungal infections of the CNS are frequently lethal because of diagnostic delays, impaired drug penetration, resistance to antifungal treatments, and inadequate restoration of immune function. To improve outcomes, future research should advance diagnostic methods (eg, molecular detection and fungus identification), develop antifungal compounds with enhanced CNS-directed efficacy, and further investigate crucial host defence mechanisms.
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Affiliation(s)
- Stefan Schwartz
- Medical Department, Division of Haematology, Oncology and Tumour Immunology, Charité, Berlin, Germany.
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas Harrison
- Institute of Infection and Immunity, St George's University of London, London, UK
| | - Markus Ruhnke
- Department of Haematology and Oncology, Paracelsus-Hospital, Osnabrück, Germany
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Chavez JA, Brat DJ, Hunter SB, Velazquez Vega J, Guarner J. Practical Diagnostic Approach to the Presence of Hyphae in Neuropathology Specimens With Three Illustrative Cases. Am J Clin Pathol 2018; 149:98-104. [PMID: 29365030 DOI: 10.1093/ajcp/aqx144] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Early and accurate diagnosis remains crucial in the therapeutic management of invasive central nervous system fungal infections. Different molds have intrinsic resistance to antifungal agents; thus, morphologic differentiation is helpful to clinicians. METHODS Using three examples, we present a guide on how to approach neuropathology specimens where hyphae are identified on initial histologic examination. RESULTS Hyphae can be classified into three basic groups: hyaline pauciseptated, hyaline septated, and pigmented or dematiaceous. The hyaline pauciseptated group includes the order of the Mucorales (previously Zygomyces) and is frequent in patients with decompensated diabetes and severe neutropenia. Aspergillus species constitutes the most frequently isolated mold in the hyaline septated group. However, other invasive hyaline septated molds include Fusarium species, which is frequently resistant to multiple antifungals, and Candida species Last, dematiaceous molds, although infrequent, can be found in neuropathology specimens, as happened during the outbreak of Exserohilum associated with manufacturing practices in a compound pharmacy. CONCLUSIONS Categorizing hyphae into the three groups described allows pathologists to provide information that is useful for infectious disease treatment with an inclusive differential diagnosis of diverse fungal genera that share the same morphological features.
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Affiliation(s)
- Jesus A Chavez
- Department of Pathology and Laboratory Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - Daniel J Brat
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Steven B Hunter
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jose Velazquez Vega
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jeannette Guarner
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
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Economides MP, Ballester LY, Kumar VA, Jiang Y, Tarrand J, Prieto V, Torres HA, Kontoyiannis DP. Invasive mold infections of the central nervous system in patients with hematologic cancer or stem cell transplantation (2000–2016): Uncommon, with improved survival but still deadly often. J Infect 2017; 75:572-580. [DOI: 10.1016/j.jinf.2017.09.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 09/04/2017] [Accepted: 09/11/2017] [Indexed: 11/25/2022]
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Imbert S, Brossas JY, Palous M, Joly I, Meyer I, Fekkar A. Performance of Aspergillus PCR in cerebrospinal fluid for the diagnosis of cerebral aspergillosis. Clin Microbiol Infect 2017. [DOI: 10.1016/j.cmi.2017.06.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Successful treatment of pituitary sella Aspergillus abscess in a renal transplant recipient. J Clin Neurosci 2017; 45:138-140. [PMID: 28760653 DOI: 10.1016/j.jocn.2017.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/30/2017] [Accepted: 07/11/2017] [Indexed: 11/23/2022]
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Warris A, Lehrnbecher T. Progress in the Diagnosis of Invasive Fungal Disease in Children. CURRENT FUNGAL INFECTION REPORTS 2017; 11:35-44. [PMID: 28680525 PMCID: PMC5487864 DOI: 10.1007/s12281-017-0274-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the fungal diagnostic measures currently available for use in paediatric patients at high risk for developing invasive fungal disease (IFD) and those suspected of having an IFD. The clinical utility of each test is described based on reported performances of individual tests in specific paediatric populations. RECENT FINDINGS Available studies in the paediatric population are scarce and are characterized by a huge heterogeneity in underlying diseases (e.g. different risk for IFD), different study objectives and management strategies (screening versus diagnostic) used. SUMMARY A final valuation of paediatric studies on fungal diagnostic tools is limited. While the galactomannan and fungal PCR assays are useful to exclude the presence of IFD, it is unclear if mannan, mannan antibodies and β-D-glucan are of benefit due to a lack of studies or validation of the cut-off, respectively. Well-designed multicentre paediatric studies are urgently needed to improve the outcome of IFD.
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Affiliation(s)
- Adilia Warris
- Aberdeen Fungal Group, MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Thomas Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
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Simmonds L, Mitchell S, White B, Crusz SA, Denning D. Aspergillus niger infection in an immunosuppressed patient confined solely to the brain. BMJ Case Rep 2017; 2017:bcr-2016-218658. [PMID: 28331021 DOI: 10.1136/bcr-2016-218658] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 68-year-old woman with a background of hypertension, stroke and rheumatoid arthritis presented to her local hospital after a 4-week history of gradual deterioration and increasing confusion with new onset right-sided weakness. Her initial CT scan revealed a rim enhancing mass lesion with surrounding oedema in the left parietal lobe for which she underwent CT stealth-guided biopsy. Microbiology culture of the 2 biopsy samples yielded Aspergillus niger and she was started on the antifungal agent voriconazole. MRI 2 weeks after the procedure also demonstrated radiological findings consistent with intracranial aspergillosis. She later developed leucopenia with neutrophils of 1.5×109/L and her methotrexate and voriconazole were stopped. Voriconazole was changed to oral posaconazole. She did not undergo surgical resection and has continued to improve clinically on posaconazole, with recovery in her white cell count.
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Affiliation(s)
- Lucy Simmonds
- Department of Neurosurgery, Queen's Medical Centre, Nottingham, UK
| | - Sian Mitchell
- Department of Neurosurgery, Queen's Medical Centre, Nottingham, UK
| | - Barrie White
- Department of Neurosurgery, Queen's Medical Centre, Nottingham, UK
| | - Shanika A Crusz
- Department of Microbiology, Queen's Medical Centre, Nottingham, UK
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