Endophthalmitis due to Trichosporon beigelii in acute leukemia

Trichosporon Endophthalmitis Following Cataract Surgery: A Case Report

Fungal infections always pose a predicament to management and prognosis. The saprophytic fungus, Trichosporon inkin commonly causes endogenous infection in immunocompromised individuals. We report a case of exogenous T. inkin endophthalmitis successfully treated with voriconazole, pars plana vitrectomy, and removal of the source of infection. A 51-year-old gentleman with suboptimal control of diabetes presented with a right painful red eye for a week after undergoing an uneventful phacoemulsification with a posterior chamber intraocular lens implant more than a month prior. He presented with intense inflammation in the right anterior chamber that did not respond to steroid challenge. Ultrasound B scan showed vitreous opacities with no loculations. The culture of vitreous humor was negative. Systemic investigations were also normal. Despite being given multiple intravitreal antibiotics, his right eye got worse. He then underwent vitrectomy and intraocular lens explantation, in which the culture of the lens grew Trichosporon Inkin. He was subsequently started on the appropriate antifungals (topical, intravitreal, and systemic) based on the minimum inhibitory concentration of the antifungal sensitivity test. The patient eventually showed significant clinical improvement, and intraocular inflammation was subsiding after six months of treatment. His best corrected visual acuity improved to 6/12 with Snellen's visual acuity chart.

An Overview of the Management of the Most Important Invasive Fungal Infections in Patients with Blood Malignancies

In patients with hematologic malignancies due to immune system disorders, especially persistent febrile neutropenia, invasive fungal infections (IFI) occur with high mortality. Aspergillosis, candidiasis, fusariosis, mucormycosis, cryptococcosis and trichosporonosis are the most important infections reported in patients with hematologic malignancies that undergo hematopoietic stem cell transplantation. These infections are caused by opportunistic fungal pathogens that do not cause severe issues in healthy individuals, but in patients with hematologic malignancies lead to disseminated infection with different clinical manifestations. Prophylaxis and creating a safe environment with proper filters and air pressure for patients to avoid contact with the pathogens in the surrounding environment can prevent IFI. Furthermore, due to the absence of specific symptoms in IFI, rapid and accurate diagnosis reduces the mortality rate of these infections and using molecular techniques along with standard mycological methods will improve the diagnosis of disseminated fungal infection in patients with hematologic disorders. Amphotericin B products, extended-spectrum azoles, and echinocandins are the essential drugs to control invasive fungal infections in patients with hematologic malignancies, and according to various conditions of patients, different results of treatment with these drugs have been reported in different studies. On the other hand, drug resistance in recent years has led to therapeutic failures and deaths in patients with blood malignancies, which indicates the need for antifungal susceptibility tests to use appropriate therapies. Life-threatening fungal infections have become more prevalent in patients with hematologic malignancies in recent years due to the emergence of new risk factors, new species, and increased drug resistance. Therefore, in this review, we discuss the different dimensions of the most critical invasive fungal infections in patients with hematologic malignancies and present a list of these infections with different clinical manifestations, treatment, and outcomes.

Ophthalmology Consultation to Detect Endogenous Endophthalmitis: Clinical Characteristics in Consulted Versus Diagnosed Cases Among At-Risk Inpatients

BACKGROUND AND OBJECTIVE

Predisposing factors for ophthalmology consultations and endogenous endophthalmitis were compared among inpatients with systemic infection.

PATIENTS AND METHODS

This was a retrospective cohort study in a tertiary care hospital between January 1, 2010, and December 31, 2014. Multivariable logistic regression was utilized.

RESULTS

There were 9,527 encounters identified with systemic infection. The 5-year incidence rate was 8.4% (803/9,527) for consultations and 0.3% (25/9,527) for endophthalmitis. Factors most associated with consultations included positive fungal blood cultures and HIV. Factors most associated with endophthalmitis included positive blood fungal cultures and endocarditis. Four of 25 endophthalmitis patients lacked positive blood cultures; six of 20 endophthalmitis patients with adequate mentation were asymptomatic.

CONCLUSIONS

Positive blood fungal cultures were strongly associated with both endophthalmitis and consultations. Endocarditis was strongly associated with endophthalmitis but less associated with consultation and may warrant increased attention. Neither presence of symptoms nor positive cultures may be sufficiently accurate to determine need for consultation. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:159-169.].

Invasive Trichosporon Infection: a Systematic Review on a Re-emerging Fungal Pathogen

Objectives: This review aimed to better depict the clinical features and address the issue of therapeutic management of Trichosporon deep-seated infections.

Methods: We comprehensively reviewed the cases of invasive Trichosporon infection reported in the literature from 1994 (date of taxonomic modification) to 2015. Data from antifungal susceptibility testing (AST) studies were also analyzed.

Results: Two hundred and three cases were retained and split into four groups: homeopathy (n = 79), other immunodeficiency conditions (n = 41), miscellaneous (n = 58) and newborns (n = 25). Trichosporon asahii was the main causative species (46.7%) and may exhibit cross-resistance to different antifungal classes. The unfavorable outcome rate was at 44.3%. By multivariate analysis, breakthrough infection (OR 2.45) was associated with unfavorable outcome, whilst the use of an azole-based therapy improved the prognosis (OR 0.16). Voriconazole-based treatment was associated with favorable outcome in hematological patients (73.6 vs. 41.8%; p = 0.016). Compiled data from AST demonstrated that (i) T. asahii exhibits the highest MICs to amphotericin B and (ii) voriconazole has the best in vitro efficacy against clinical isolates of Trichosporon spp.

Conclusions:Trichosporon infection is not only restricted to hematological patients. Analysis of compiled data from AST and clinical outcome support the use of voriconazole as first line therapy.

Current knowledge of Trichosporon spp. and Trichosporonosis

Trichosporon spp. are basidiomycetous yeast-like fungi found widely in nature. Clinical isolates are generally related to superficial infections. However, this fungus has been recognized as an opportunistic agent of invasive infections, mostly in cancer patients and those exposed to invasive medical procedures. It is possible that the ability of Trichosporon strains to form biofilms on implanted devices, the presence of glucuronoxylomannan in their cell walls, and the ability to produce proteases and lipases are all factors likely related to the virulence of this genus and therefore may account for the progress of invasive trichosporonosis. Disseminated trichosporonosis has been increasingly reported worldwide and represents a challenge for both diagnosis and species identification. Phenotypic identification methods are useful for Trichosporon sp. screening, but only molecular methods, such as IGS region sequencing, allow the complete identification of Trichosporon isolates at the species level. Methods for the diagnosis of invasive trichosporonosis include PCR-based methods, Luminex xMAP technology, and, more recently, proteomics. Treating patients with trichosporonosis remains a challenge because of limited data on the in vitro and in vivo activities of antifungal drugs against clinically relevant species of the genus. Despite the mentioned limitations, the use of antifungal regimens containing triazoles appears to be the best therapeutic approach.

Primary antifungal prophylaxis in hematopoietic stem cell transplant recipients: clinical implications of recent studies

PURPOSE OF REVIEW

Infectious complications after hematopoietic stem cell transplant, especially those caused by fungi, contribute to poor outcomes. Availability of new antifungal drugs has led to creative attempts to prevent infections caused by both yeasts and molds with new antifungal prophylaxis strategies; these studies will be reviewed.

RECENT FINDINGS

Trials evaluating mold-active azoles, posaconazole and voriconazole, demonstrate that invasive aspergillosis infections can be prevented by prophylactic therapy in patients with hematologic malignancies and after allogeneic hematopoietic stem cell transplant. However, issues arise regarding appropriate dosing and levels, drug interactions, and the importance of breakthrough infections caused by organisms that demonstrate microbiologic resistance. Other recent studies evaluating efficacy and safety of aerosolized lipid formulations of amphotericin B demonstrate promise with directed delivery to the lungs; more long-term follow-up safety information is needed to be assured that this strategy is safe late after allogeneic hematopoietic stem cell transplant, in the setting of acute and chronic graft vs. host disease.

SUMMARY

Clinicians should consider using new mold-active azole drugs for prophylaxis instead of fluconazole in allogeneic hematopoietic stem cell transplant recipients that have high risks due to prolonged neutropenia and severe graft vs. host disease. More investigations are needed to support other preventive strategies that utilize diagnostic tests and aerosolized delivery of amphotericin B formulations.