Invasive aspergillosis in developing countries

Impact of an institutional antifungal stewardship program on antifungal usage and outcomes in patients with invasive fungal infections

Therapeutic and prophylactic use of antifungals is rising continuously. However, inadequate awareness of diagnostic and treatment guidelines and limited laboratory modalities lead to inappropriate use. This study assessed the impact of an institutional antifungal stewardship program on antifungal use practices and patient outcomes. In the pre-intervention phase, data was collected regarding antifungal therapy among patients with invasive fungal infections. Appropriateness of antifungal prescription was assessed. In the intervention phase, simple algorithms for diagnosis and management of fungal infections were prepared from international guidelines and incorporated into a booklet for distribution. Monthly training sessions were conducted. New serological and molecular tests and therapeutic drug monitoring were introduced. In the post-intervention phase, an antifungal stewardship team was constituted for clinical advisory on demand and ongoing training. Data regarding antifungal therapy was collected and compared with pre-intervention data. Untreated patients decreased from 25% to 18.9% post-intervention (P = .28). Appropriate antifungal use increased from 72.6% to 77.9% (P = .4) among patients with a single fungal infection, and from 57.1% to 88.5% (P = .04) for at least one infection among those with dual fungal infections. 49 incidents of inappropriate use in various categories were seen among 75 patients receiving antifungals pre-intervention, decreasing to 42 incidents among 94 patients post-intervention (P = .06), particularly evident among patients with dual infections (P = .002). Mortality increased from 51% to 75.86% post-intervention (P = .0001). Overall, the small improvement noticed in antifungal usage pattern can still be considered significant, given the limited study period.

Aspergillus-related immune reconstitution inflammatory syndrome in pediatric cancer patients, clinical characteristics, imaging findings, and survival

Aspergillus-related immune reconstitution inflammatory syndrome (IRIS) is a challenge to diagnose in immunocompromised pediatric cancer patients with Invasive Pulmonary Aspergillosis (IPA). If not recognized, it can mimic disease progression and lead to overtreatment. Studies on Aspergillus-related IRIS in the pediatric population are scarce. We prospectively identified four pediatric cancer patients diagnosed with IPA who developed paradoxical worsening of pulmonary symptoms following neutrophil recovery. The clinical course, imaging findings, and response to corticosteroids were also reviewed. All patients had refractory respiratory symptoms, including cough, breathing difficulties (dyspnea), and chest pain, despite antifungal therapy. Serial imaging revealed new or enlarging pulmonary infiltrates. Symptoms improved dramatically with corticosteroids without antifungal escalation, confirming Aspergillus-related IRIS diagnosis. Aspergillus-related IRIS can occur in immunocompromised children with cancer and IPA, mimicking disease progression. Recognition is important for avoiding overtreatment. This is the first report highlighting the features of Aspergillus-related IRIS in pediatric cancer patients.

Invasive Fungal Infections in Immunocompromised Conditions: Emphasis on COVID-19

The COVID-19 pandemic caused death of 6 million lives globally, primarily from respiratory failure, but also a significant number from invasive fungal co-infections in these patients, owing to the immune dysfunction in hospitalized patients. Such complications occurred more often in critically ill, hospitalized patients particularly those admitted in intensive care units and were reported as the major reason associated with a high mortality rate worldwide. Fungal pathogens most commonly associated with COVID-19 patients comprise members of the Mucorales (such as Rhizopus, Mucor, and Lichtheimia), as well as genera Aspergillus and Candida. In India, the prevalence rate of mucormycosis is relatively high than aspergillosis and candidiasis, and the predisposing risk factors associated with such infections included uncontrolled diabetes, underlying lung disease, leukopenia, neutropenia, malignancies and prolonged steroid therapy. However, co-infection with other fungi, including Alternaria and Scedosporium was also sporadically reported. These devastating invasive fungal infections are associated with differential mortality (high-low) and morbidity rates even after active management. The diagnosis of such infections is often challenging due to lack of sensitivity in contemporary diagnostic methods and poses an enormous challenge to healthcare experts. Thus, the role of early and accurate diagnosis, and management of such fungal infections, is vital in preventing life-threatening situations. Hence, this review focusses primarily on the epidemiology, predisposing risk factors, host environment, diagnosis and treatment of the most common medically important invasive fungal infections in immunocompromised conditions associated with COVID-19.

A single-source nosocomial outbreak of Aspergillus flavus uncovered by genotyping

During construction work (2017-2019), an increase in Aspergillus flavus infections was noted among pediatric patients, the majority of whom were receiving amphotericin B prophylaxis. Microsatellite genotyping was used to characterize the outbreak. A total of 153 A. flavus isolates of clinical and environmental origin were included. Clinical isolates included 140 from 119 patients. Eight patients were outbreak-related patients, whereas 111 were outbreak-unrelated patients from Danish hospitals (1994-2023). We further included four control strains. Nine A. flavus isolates were from subsequent air sampling in the outbreak ward (2022-2023). Typing followed Rudramurthy et al.(S. M. Rudramurthy, H. A. de Valk, A. Chakrabarti, J. Meis, and C. H. W. Klaassen, PLoS One 6:e16086, 2011, https://doi.org/10.1371/journal.pone.0016086). Minimum spanning tree (MST) and discriminant analysis of principal components (DAPC) were used for cluster analysis. DAPC analysis placed all 153 isolates in five clusters. Microsatellite marker pattern was clearly distinct for one cluster compared to the others. The same cluster was observed in an MST. This cluster included all outbreak isolates, air-sample isolates, and additional patient isolates from the outbreak hospital, previously undisclosed as outbreak related. The highest air prevalence of A. flavus was found in two technical risers of the outbreak ward, which were then sealed. Follow-up air samples were negative for A. flavus. Microsatellite typing defined the outbreak as nosocomial and facilitated the identification of an in-hospital source. Six months of follow-up air sampling was without A. flavus. Outbreak-related/non-related isolates were easily distinguished with DAPC and MST, as the outbreak clone's distinct marker pattern was delineated in both statistical analyses. Thus, it could be a variant of A. flavus, with a niche ability to thrive in the outbreak-hospital environment.

IMPORTANCE

Aspergillus flavus can cause severe infections and hospital outbreaks in immunocompromised individuals. Although lack of isogeneity does not preclude an outbreak, our study underlines the value of microsatellite genotyping in the setting of potential A. flavus outbreaks. Microsatellite genotyping documented an isogenic hospital outbreak with an internal source. This provided the "smoking gun" that prompted the rapid allocation of resources for thorough environmental sampling, the results of which guided immediate and relevant cleaning and source control measures. Consequently, we advise that vulnerable patients should be protected from exposure and that genotyping be included early in potential A. flavus outbreak investigations. Inspection and sampling are recommended at any site where airborne spores might disperse from. This includes rarely accessed areas where air communication to the hospital ward cannot be disregarded.

Evaluation of Primers OPF-01, P54, and 1253 to Identify A. fumigatus, A. flavus, and A. niger from Polymorphic Patterns Obtained by RAPD-PCR

We evaluated the specificity of the primers OPF-01, P54, and 1253 to identify A. fumigatus, A. flavus, and A. niger, respectively, with the RAPD-PCR method. Eighty-two isolates belonging to the sections Fumigati, Flavi, and Nigri were used. The isolates were identified by phenotypic (macro- and micromorphology) and genotypic (partial sequences of the BenA gene) methods. The RAPD-PCR method was used to obtain polymorphic patterns with the primers OPF-01, P54, and 1253. The specificity of the polymorphic patterns of the isolates of each species was evaluated through the UPGMA clustering method and logistic regression model. All isolates of the genus Aspergillus were identified at the section level by macro- and micromorphology showing the typical morphology of the sections Fumigati, Flavi, and Nigri, and the species were identified by the construction of the phylogeny of the partial sequence of the BenA gene. The patterns' polymorphic strains obtained with the primers OPF-01, P54, and 1253 for the isolates of A. fumigatus, A. flavus, and A niger, respectively, showed the same polymorphic pattern as the reference strains for each species. To verify the specificity of the primers, they were tested with other species from the sections Fumigati, Flavi and Nigri. The results support that the primers OPF-01, P54, and 1253 generate polymorphic patterns by RAPD-PCR species specific to A. fumigatus, A. flavus, and A. niger, respectively.

Fatal co-infection by multiple pathogens in an indigenous woman with autoimmune hemolytic anemia and tuberculosis: a case report

BACKGROUND

Tuberculosis (TB), one of the leading causes of death worldwide, has a higher incidence among indigenous people. Albeit uncommon, autoimmune hemolytic anemia (AIHA) has been deemed a risk condition to develop mycobacterial infection, as a result of the immunosuppressive treatments. TB, in turn, can be a predisposing factor for secondary infections.

CASE PRESENTATION

Here we present a case of a 28-year-old indigenous woman from Colombia, previously diagnosed with AIHA and pulmonary TB. Despite various treatments, therapies and medical interventions, the patient died after severe medullary aplasia of multiple causes, including secondary myelotoxicity by immunosuppressive therapy and secondary disseminated infections, underlining infection by Staphylococcus aureus, Klebsiella pneumoniae and Candida glabrata, which were identified as drug-resistant microorganisms. Together, this led to significant clinical complications. Invasive aspergillosis was diagnosed at autopsy.

CONCLUSIONS

This report presents a rarely finding of AIHA followed by TB, and highlights the great challenges of dealing with co-infections, particularly by drug resistant pathogens. It also aims to spur governments and public health authorities to focus attention in the prevention, screening and management of TB, especially among vulnerable communities, such as indigenous people.

Systems-wide analysis of A. fumigatus using kinetic modeling of metabolic pathways to identify putative drug targets

Aspergillosis is a major causative factor for morbidity in those with impaired immune systems, often caused by Aspergillus fumigatus. The diagnosis and treatment are difficult due to the diversity of individuals and risk factors and still pose a challenge for medical professionals. To understand the pathogenicity of any organism, it is critical to identify the significant metabolic pathways that are involved. Our work focused on developing kinetic models of critical pathways crucial for the survival of A. fumigatus using COPASI. While focusing on the folate biosynthesis, ergosterol biosynthesis and glycolytic pathway; sensitivity, time-course and steady-state analysis were performed to find the proteins/enzymes that are essential in the pathway and can be considered as potential drug targets. For further analysis of the interaction of drug targets identified, a protein-protein interaction (PPI) network was built, and hub nodes were identified using the Cytohubba package from Cytoscape. Based on the findings, dihydropteroate-synthase, dihydrofolate-reductase, 4-amino-4-deoxychorismate synthase, HMG-CoA-reductase, PG-isomerase and hexokinase could act as potential drug targets. Further, molecular docking and MM-GBSA analysis were performed with ligands chosen from DrugBank, and PubChem, and validated by experimental evidence and existing literature based on results from kinetic modeling and PPI network analysis. Based on docking scores and MM-GBSA results, molecular simulations were carried out for 1AJ2-dapsone, 1DIS-sulfamethazine, 1T02-lovastatin and 70YL-3-bromopyruvic acid complexes, which validated our findings. Our study provides a deeper insight into the mechanisms of A. fumigatus's metabolism to reveal dapsone, sulfamethazine, lovastatin and 3-bromopyruvic acid as potential drugs for the treatment of Aspergillosis.

Implications of CD45RA and CD45RO T cell subsets in patients of chronic rhinosinusitis with nasal polyposis infected with Aspergillus flavus

T cell subsets (CD4 and CD8) play a prominent role in the development of chronic rhinosinusitis with nasal polyposis (CRSwNP). Colonization with Aspergillus flavus is recognized as a trigger for the growth of nasal polyps. The fungal proteins initiate the recruitment of T cells into the nasal mucosa, which contributes to the progression of nasal polyps. The study included 50 cases of CRSwNP and 50 healthy controls. Biopsies were subjected to KOH and culture for mycological investigation. We examined the changes in T helper (CD4+) and T cytotoxic (CD8+) in total T cells (CD3+) and expression of naive (CD45RA) and memory (CD45RO) cell markers in T cell subsets in peripheral blood mononuclear cells (PBMCs) challenged by A. flavus antigens in cases before and after treatment and in healthy controls by flow cytometry. Predominantly, A. flavus (86%) identified in nasal polyp biopsies of patients. An increased percentage of CD3+CD4+ T cells observed after A. flavus stimulation in patients when compared with healthy controls. The expression of CD4+CD45RA+ cells was significantly (P < .05) reduced in patients and increased CD4+CD45RO+ was observed upon stimulation with A. flavus in patients when compared with healthy control. Continuous exposure to inhaled fungal spores may induce aberrant immune responses to A. flavus spores, causing an allergic immunological reaction with high CD4+T cell responses, resulting in an unfavourable outcome. Elevated CD4+CD45RO+ T cells may transform the pathogenic response and highlight the chances of A. flavus reactive T cells involvement in prompting inflammation in CRSwNP.

Invasive Pulmonary Aspergillosis in Coronavirus Disease 2019 Patients Lights and Shadows in the Current Landscape

Invasive pulmonary aspergillosis (IPA) presents a known risk to critically ill patients with SARS-CoV-2; quantifying the global burden of IPA in SARS-CoV-2 is extremely challenging. The true incidence of COVID-19-associated pulmonary aspergillosis (CAPA) and the impact on mortality is difficult to define because of indiscriminate clinical signs, low culture sensitivity and specificity and variability in clinical practice between centers. While positive cultures of upper airway samples are considered indicative for the diagnosis of probable CAPA, conventional microscopic examination and qualitative culture of respiratory tract samples have quite low sensitivity and specificity. Thus, the diagnosis should be confirmed with serum and BAL GM test or positive BAL culture to mitigate the risk of overdiagnosis and over-treatment. Bronchoscopy has a limited role in these patients and should only be considered when diagnosis confirmation would significantly change clinical management. Varying diagnostic performance, availability, and time-to-results turnaround time are important limitations of currently approved biomarkers and molecular assays for the diagnosis of IA. The use of CT scans for diagnostic purposes is controversial due to practical concerns and the complex character of lesions presented in SARS-CoV-2 patients. The key objective of management is to improve survival by avoiding misdiagnosis and by initiating early, targeted antifungal treatment. The main factors that should be considered upon selection of treatment options include the severity of the infection, concomitant renal or hepatic injury, possible drug interactions, requirement for therapeutic drug monitoring, and cost of therapy. The optimal duration of antifungal therapy for CAPA is still under debate.

Aspergillosis: an Update on Clinical Spectrum, Diagnostic Schemes, and Management

Purpose of Review

This review gives an overview of the diseases caused by Aspergillus, including a description of the species involved and the infected clinical systems. We provide insight into the various diagnostic methods available for diagnosing aspergillosis, particularly invasive aspergillosis (IA), including the role of radiology, bronchoscopy, culture, and non-culture-based microbiological methods. We also discuss the available diagnostic algorithms for the different disease conditions. This review also summarizes the main aspects of managing infections due to Aspergillus spp., such as antifungal resistance, choice of antifungals, therapeutic drug monitoring, and new antifungal alternatives.

Recent Findings

The risk factors for this infection continue to evolve with the development of many biological agents that target the immune system and the increase of viral illnesses such as coronavirus disease. Due to the limitations of present mycological test methods, establishing a fast diagnosis is frequently difficult, and reports of developing antifungal resistance further complicate the management of aspergillosis. Many commercial assays, like AsperGenius®, MycAssay Aspergillus®, and MycoGENIE®, have the advantage of better species-level identification and concomitant resistance-associated mutations. Fosmanogepix, ibrexafungerp, rezafungin, and olorofim are newer antifungal agents in the pipeline exhibiting remarkable activity against Aspergillus spp.

Summary

The fungus Aspergillus is found ubiquitously around the world and can cause various infections, from harmless saprophytic colonization to severe IA. Understanding the diagnostic criteria to be used in different patient groups and the local epidemiological data and antifungal susceptibility profile is critical for optimal patient management.

Diagnosis and Treatment of Invasive Aspergillosis Caused by Non-fumigatus Aspergillus spp

With increasing frequency, clinical and laboratory-based mycologists are consulted on invasive fungal diseases caused by rare fungal species. This review aims to give an overview of the management of invasive aspergillosis (IA) caused by non-fumigatus Aspergillus spp.-namely A. flavus, A. terreus, A. niger and A. nidulans-including diagnostic and therapeutic differences and similarities to A. fumigatus. A. flavus is the second most common Aspergillus spp. isolated in patients with IA and the predominant species in subtropical regions. Treatment is complicated by its intrinsic resistance against amphotericin B (AmB) and high minimum inhibitory concentrations (MIC) for voriconazole. A. nidulans has been frequently isolated in patients with long-term immunosuppression, mostly in patients with primary immunodeficiencies such as chronic granulomatous disease. It has been reported to disseminate more often than other Aspergillus spp. Innate resistance against AmB has been suggested but not yet proven, while MICs seem to be elevated. A. niger is more frequently reported in less severe infections such as otomycosis. Triazoles exhibit varying MICs and are therefore not strictly recommended as first-line treatment for IA caused by A. niger, while patient outcome seems to be more favorable when compared to IA due to other Aspergillus species. A. terreus-related infections have been reported increasingly as the cause of acute and chronic aspergillosis. A recent prospective international multicenter surveillance study showed Spain, Austria, and Israel to be the countries with the highest density of A. terreus species complex isolates collected. This species complex seems to cause dissemination more often and is intrinsically resistant to AmB. Non-fumigatus aspergillosis is difficult to manage due to complex patient histories, varying infection sites and potential intrinsic resistances to antifungals. Future investigational efforts should aim at amplifying the knowledge on specific diagnostic measures and their on-site availability, as well as defining optimal treatment strategies and outcomes of non-fumigatus aspergillosis.

Cervico-Dorsal Intramedullary Spinal Cord Abscess with Aspergillus fumigates following Pulmonary Infection in an Immunocompetent Patient

Invasive forms of aspergillosis of the nervous system are relatively rare and are usually diagnosed in immunocompromised patients. We present the case of a young female patient, treated in the last two months with corticosteroids and antifungal drug for pulmonary aspergillosis, who developed progressive paraparesis. An intramedullary abscess at the C7-D1 level was identified and the lesion was treated with a combination of surgery and antifungal therapy. Histopathologic findings of surgical specimens showed myelomalacia with Aspergillus hyphae and a peripheral rim of neutrophils. We consider that the use of multiple drugs and corticosteroids for our patient's initial community pneumonia could be the factor that transformed her into a mildly immunocompromised individual and permitted the Aspergillus spp. to disseminate through the blood and into the spinal cord. Moreover, we highlight the fact that more attention should be paid to living and working conditions of the patients, as a simple colonization of the lung with Aspergillus spp. could develop, in a short time, into an invasive disease with a high risk of mortality.

Secondary cutaneous aspergillosis in a child with Behçet’s disease: a case-based update

Background

Invasive aspergillosis (IA) is one of the rarest opportunistic fungal infections and has increased in frequency worldwide in recent years. It is a life-threatening infection associated with high mortality rates. Invasive pulmonary aspergillosis (IPA) is the most severe form of the disease. Extrapulmonary forms can develop as a primary infection or occur as part of a disseminated infection from the lung in severely immunocompromised patients. The major limitation in the management of these infections is the challenge of early diagnosis.

Case presentation

Here we report a case of secondary cutaneous aspergillosis that developed from extensive pulmonary aspergillosis in a 3-year-old female who underwent immunosuppressive therapy for a diagnosed Behçet disease (BD). Aspergillus hyphae were identified on skin biopsies. Cultures grew Aspergillus fumigatus. The diagnosis of cutaneous aspergillosis enabled us to diagnose IPA, although there was no mycopathological proof of lung infection. The patient was successfully treated with voriconazole (8 mg/kg/day) and surgical debridement of the skin lesion.

Conclusions

Although cutaneous involvement in aspergillosis is extremely uncommon, it may be the presenting feature in some cases, allowing for an accurate and timely diagnosis of deeply infected sites. Accordingly, when evaluating skin lesions in immunocompromised individuals, especially debilitated children with underlying diseases requiring long-term immunosuppressive agents, cutaneous aspergillosis should be vigilantly considered.

Sphenoid Sinus Aspergilloma in an Immunocompetent and an Immunocompromised Patient: A Case Report

Sellar, supra-sellar aspergilloma are rare differentials for a sellar mass. CNS aspergilloma occurs due to intracranial extension of invasive fungal sinusitis, and often first manifests with symptoms of headache and visual disturbance. This complication is much more common in immunocompromised patients, but proliferation of fungal pathogens and low index for suspicion has led to more severe breakthrough cases in the immunocompetent. If treated timely, these CNS lesions can have a relatively good prognosis. Conversely, delays in diagnosis can confer very high rates of mortality among patients with invasive fungal disease. Originally from India, in this case report, we describe two patients presenting with sellar, supra-sellar tumors, who eventually were diagnosed with confirmed cases of invasive intracranial aspergilloma. We describe the clinical presentation, imaging techniques, and treatment modalities for this relatively rare disease in both the immunocompromised and the immunocompetent.

Invasive Pulmonary Aspergillosis

Invasive pulmonary aspergillosis is growing in incidence, as patients at risk are growing in diversity. Outside the classical context of neutropenia, new risk factors are emerging or newly identified, such as new anticancer drugs, viral pneumonias and hepatic dysfunctions. Clinical signs remain unspecific in these populations and the diagnostic work-up has considerably expanded. Computed tomography is key to assess the pulmonary lesions of aspergillosis, whose various features must be acknowledged. Positron-emission tomography can bring additional information for diagnosis and follow-up. The mycological argument for diagnosis is rarely fully conclusive, as biopsy from a sterile site is challenging in most clinical contexts. In patients with a risk and suggestive radiological findings, probable invasive aspergillosis is diagnosed through blood and bronchoalveolar lavage fluid samples by detecting galactomannan or DNA, or by direct microscopy and culture for the latter. Diagnosis is considered possible with mold infection in lack of mycological criterion. Nevertheless, the therapeutic decision should not be hindered by these research-oriented categories, that have been completed by better adapted ones in specific settings. Survival has been improved over the past decades with the development of relevant antifungals, including lipid formulations of amphotericin B and new azoles. New antifungals, including first-in-class molecules, are awaited.

Screening of Phyllanthus niruri Root Phytoconstituents for Antibacterial, Antifungal, Anticancer, and Antiviral Activities by Molecular Docking Studies

The systematic exploitation of the structural variety of natural products is made possible by docking studies, which have been shown to be a crucial technique. This study's goal was to evaluate various activities for the chemicals in the root portion of Phyllanthus niruri. This plant's constituents are active in a variety of ways. In order to develop drugs, molecules with such a framework have been utilized as the lead. Schrodinger Maestro (v13.0) software was used to conduct a molecular docking analysis of root components with certain proteins linked to the illnesses. In comparison to commercially available conventional medications, molecular docking data also demonstrated greater scores. For additional docking investigations with distinct proteins, the root chemicals are assessed, that is, crystal structure of serine protease hepsin in complex with inhibitor [PDB ID:5 CE1] for antiviral activity, human topoisomerase II beta in complex with DNA and etoposide [PDB ID:3QX3], and crystal structure of E. coli GyraseB 24 kDa in complex with 4-(4-bromo-1H-pyrazol-1-yl)-6-[(ethylcarbamoyl)amino]-N-(pyridin-3-yl) pyridine-3-carboxamide [PDB ID: 6F86] for antibacterial activity, Cytochrome P450 14 alpha-sterol demethylase (CYP51) from Mycobacterium tuberculosis in complex with fluconazole [PDB ID:1EA1], and structure of yeast Sec14p with a picolinamide compound [PDB ID:6F0E] for antifungal activity and synthesis and biological evaluation of novel selective androgen receptor modulators (SARMs). Part II: Optimization of 4-(pyrrolidin-1-yl) benzonitrile derivatives [PDB ID: 5T8E] and Human Cytochrome P450 CYP17A1 in complex with Abiraterone [PD B ID:3RUK] for anticancer activity have been selected. Ritonavir's antiviral activity, ampicillin's ability to treat bacterial infections, fluconazole's ability to treat fungi, and dacarbazine's ability to treat cancer were utilized as benchmarks to assess the in silico outcomes and grading of virtual screening or molecular docking.

Aspergillus Endophthalmitis: Epidemiology, Pathobiology, and Current Treatments

Fungal endophthalmitis is one of the leading causes of vision loss worldwide. Post-operative and traumatic injuries are major contributing factors resulting in ocular fungal infections in healthy and, more importantly, immunocompromised individuals. Among the fungal pathogens, the Aspergillus species, Aspergillus fumigatus, continues to be more prevalent in fungal endophthalmitis patients. However, due to overlapping clinical symptoms with other endophthalmitis etiology, fungal endophthalmitis pose a challenge in its diagnosis and treatment. Hence, it is critical to understand its pathobiology to develop and deploy proper therapeutic interventions for combating Aspergillus infections. This review highlights the different modes of Aspergillus transmission and the host immune response during endophthalmitis. Additionally, we discuss recent advancements in the diagnosis of fungal endophthalmitis. Finally, we comprehensively summarize various antifungal regimens and surgical options for the treatment of Aspergillus endophthalmitis.

Intracranial aspergillosis in immunocompetent adult patients without risk factors: a systematic review

The clinical features and prognostic factors of intracranial aspergillosis in immunocompetent patients without risk factors are not well known. PubMed, Scopus, Google Scholar, and Web of Science were searched for all relevant case reports/series on adult patient (≥ 18 years) with aspergillosis published from 1976 to 2018. One hundred eighty-two patients (median age, 40 years; range, 18-83 years; male:female, 115:67) were identified. Types of intracranial aspergillosis included intracranial mass from the skull base (54.9%), pure intraparenchymal disease (23.6%), meningoencephalitis (13.2%), and dural-based mass (8.2%). Vascular complications occurred in 44 patients (26.3%). Eighty-one patients (44.5%) had favourable final clinical outcomes without any deficits, whereas 58 (31.9%) died. Disease-related mortality improved significantly over time (43.1% [28/65] before 2000, 25.9% [30/116] after 2001; p = 0.021). Patients with meningoencephalitis demonstrated the highest mortality rate (79.2%, 19/24). Medical non-responders (patients whose disease course worsened after receiving the initial medication regimen) and vascular complications (the presentation of subarachnoid haemorrhage, intracerebral haemorrhage, or infarction related to the rupture or occlusion of intracranial vessels) were significantly associated with mortality (p < 0.001). Findings from the current review may help predict patient prognosis at the initial assessment and determine potential prognostic factors.

A post-COVID-19 Aspergillus fumigatus posterior mediastinitis: Case report

Invasive aspergillosis is a life-threatening condition of the immunocompromised, with a low occurrence reported in the immunocompetent. Although usually made by invasive methods, its early diagnosis is the cornerstone of a better prognosis as it yields a timely management and thus a lower mortality risk. Mediastinal invasion by Aspergillus is, like any fungal mediastinitis, uncommon and usually results from a hematogeneous or a contiguous spread, a postoperative fungal infection, a complication of a descending necrotizing fasciitis, or from an esophageal perforation. We report a case of a diabetic patient with a previous history of hospitalization 2 months earlier for a COVID-19 infection, otherwise healthy, presenting with an unresolving dorsal pain. A malignancy was expected but further work-up showed in fine a posterior mediastinitis due to Aspergillus fumigatus. Thus, fungal etiologies are to be included as a differential while diagnosing a posterior mediastinitis even in a relatively immunocompetent patient and with no evident route of entry.

Clinical and Epidemiological Profile of Patients with Invasive Aspergillosis from a Fourth Level Hospital in Bogota, Colombia: A Retrospective Study

Invasive aspergillosis (IA) is a severe mycosis caused by Aspergillus species. The infection mainly affects immunocompromised patients with a significant clinical burden. This study aimed to determine the clinical and epidemiological characteristics of patients diagnosed with IA in a fourth level hospital in Colombia, as these data are scarce in the country. A retrospective, observational study, from a single center was conducted with 34 male and 32 female patients, between 1 month- and 90-year-old, diagnosed with proven (18.2%), probable (74.2%) and possible (7.6%) IA, during a 21-year period. The most frequent underlying conditions for IA were chemotherapy (39.4%) and corticosteroid use (34.8%). The lung was the most common affected organ (92.4%). Computed tomography (CT) imaging findings were mainly nodules (57.6%) and consolidation (31.8%). A low positive correlation was found between serum galactomannan and hospitalization length. Aspergillus fumigatus prevailed (73.3%) in sputum and bronchoalveolar lavage cultures. Most patients were hospitalized in general wards (63.6%) and treated with voriconazole (80.3%). Mortality rate was 15.2%. Common risk factors for IA were identified in the Colombian cohort, including medications and underlying diseases. However, their frequency differs from other countries, reinforcing the idea that local surveillance is essential and at-risk patients should be carefully monitored.

Exogenous Iron Induces NADPH Oxidases-Dependent Ferroptosis in the Conidia of Aspergillus flavus

Aspergillus flavus is saprophytic soil fungus that contaminates seed crops with the carcinogenic secondary metabolite aflatoxin, posing a significant threat to humans and animals. Ferrous sulfate is a common iron supplement that is used to the treatment of iron-deficiency anemia. Here, we identified an unexpected inhibitory role of ferrous sulfate on A. flavus. With specific fluorescent dyes, we detected several conidial ferroptosis hallmarks in conidia under the treatment of 1 mM Fe²⁺, including nonapoptosis necrosis, iron-dependent, lipid peroxide accumulation, and ROS burst. However, unlike traditional ferroptosis in mammals, Fe²⁺ triggered conidial ferroptosis in A. flavus was regulated by NADPH oxidase (NOXs) activation instead of Fenton reaction. Transcriptomic and some other bioinformatics analyses showed that NoxA in A. flavus might be a potential target of Fe²⁺, and thus led to the occurrence of conidial ferroptosis. Furthermore, noxA deletion mutant was constructed, and both ROS generation and conidial ferroptosis in ΔnoxA was reduced when exposed to Fe²⁺. Taken together, our study revealed an exogenous Fe²⁺-triggered conidial ferroptosis pathway mediated by NoxA of A. flavus, which greatly contributes to the development of an alternative strategy to control this pathogen.

Differentiation of Aspergillus flavus from Aspergillus oryzae Targeting the cyp51A Gene

Aspergillus flavus is one of the most important agents of invasive and non-invasive aspergillosis, especially in tropical and subtropical regions of the world, including Iran. Aspergillus oryzae is closely related to A. flavus, and it is known for its economic importance in traditional fermentation industries. Reports of infection due to A. oryzae are scarce. Several studies reported that differentiating these two species in clinical laboratories is not possible using MALDI-TOF or by targeting fungal barcode genes, such as Internal Transcribed Spacer (ITS) and β-tubulin (benA). The species-level identification of causative agents and the determination of antifungal susceptibility patterns can play significant roles in the outcome of aspergillosis. Here, we aimed to investigate the discriminatory potential of cyp51A PCR-sequencing versus that of the ITS, benA and calmodulin (CaM) genes for the differentiation of A. flavus from A. oryzae. In a prospective study investigating the molecular epidemiology of A. flavus in Iran between 2008 and 2018, out of 200 clinical isolates of A. flavus, 10 isolates showed >99% similarity to both A. flavus and A. oryzae. Overall, the ITS, β-tubulin and CaM genes did not fulfil the criteria for differentiating these 10 isolates. However, the cyp51A gene showed promising results, which warrants further studies using a larger set of isolates from more diverse epidemiological regions of the world.

A simple high-volume culture technique-Good substitute for polymerase chain reaction for the detection of Aspergillus species in bronchoalveolar lavage samples

BACKGROUND

Aspergillus species is the most common agent of invasive pulmonary fungal disease. Culture-based diagnosis considered as gold standard is limited by the fungal load in samples. Detection of Aspergillus by polymerase chain reaction (PCR) has been included as a diagnostic criterion by European Organisation for Research and Treatment of Cancer (EORTC). Most routine laboratories lack facilities for molecular diagnosis. Better yield using high-volume culture (HVC) technique has been reported. Studies have not compared HVC and PCR for detection of Aspergillus species in respiratory samples from patients with suspected invasive pulmonary Aspergillosis (IPA) not on antifungal therapy.

OBJECTIVE

This pilot study compared HVC and PCR for the detection of Aspergillus species in respiratory samples from treatment naïve patients.

METHODS

Bronchoalveolar lavage (BAL) samples from 30 patients with clinical suspicion of IPA were evaluated. Direct microscopy, culture both conventional (CC) and HVC and qualitative Pan Aspergillus PCR were performed. Latent class model was used for statistical analysis.

RESULTS

Sensitivity of HVC (100%) was better compared with CC (60%) and comparable to that of PCR (100%). Specificities of CC, HVC and PCR were 100%, 100% and 25%, respectively.

CONCLUSION

High-volume culture is a simple cost-effective technique with a high sensitivity and specificity. It can be easily introduced in routine microbiology laboratories. In centres with the availability of infrastructure for molecular analysis, Aspergillus PCR with other mycological techniques can be used for better diagnosis and management of patients with IPA.

Fungal abscess after intra-orbital steroid injection: a case report

A 28-year-old male presented with gradually progressive swelling of the right lower eyelid along with a prominence of the eye for 6 months. He had received oral steroids and intraorbital triamcinolone acetonide injection in the inferior quadrant for active thyroid eye disease. External examination revealed right eye proptosis and swelling along the inferior orbital region. Magnetic resonance imaging showed an ill-defined soft tissue lesion in the inferior extraconal space and a bulky right inferior rectus. Histopathology of the biopsied material revealed inflammation with septate fungal filaments, identified as Aspergillus flavus on culture. He responded well to oral voriconazole despite a recurrence during the course of treatment. Intraorbital steroids are given for idiopathic and thyroid-associated orbital inflammation. This is a report of a rare complication of fungal orbital abscess following intraorbital corticosteroid injection in an immunocompetent young patient.

A Prospective Multicenter Cohort Surveillance Study of Invasive Aspergillosis in Patients with Hematologic Malignancies in Greece: Impact of the Revised EORTC/MSGERC 2020 Criteria

Data concerning the incidence of invasive aspergillosis (IA) in high-risk patients in Greece are scarce, while the impact of the revised 2020 EORTC/MSGERC consensus criteria definitions on the reported incidence rate of IA remains unknown. A total of 93 adult hematology patients were screened for IA for six months in four tertiary care Greek hospitals. Serial serum specimens (n = 240) the sample was considered negative by PCR were collected twice-weekly and tested for galactomannan (GM) and Aspergillus DNA (PCR) detection. IA was defined according to both the 2008 EORTC/MSG and the 2020 EORTC/MSGERC consensus criteria. Based on the 2008 EORTC/MSG criteria, the incidence rates of probable and possible IA was 9/93 (10%) and 24/93 (26%), respectively, while no proven IA was documented. Acute myeloid leukemia was the most (67%) common underlying disease with most (82%) patients being on antifungal prophylaxis/treatment. Based on the new 2020 EORTC/MSGERC criteria, 2/9 (22%) of probable and 1/24 (4%) of possible cases should be reclassified as possible and probable, respectively. The episodes of probable IA were reduced by 33% when GM alone and 11% when GM + PCR were used as mycological criterion. The incidence rate of IA in hematology patients was 10%. Application of the 2020 EORTC/MSGERC updated criteria results in a reduction in the classification of probable IA particularly when PCR is not available.

The global impact of Aspergillus infection on COPD

Background

Advanced chronic obstructive pulmonary disease (COPD) often leads to hospitalisation and invasive aspergillosis (IA) is a serious complication. Aspergillus sensitisation may worsen symptoms in COPD.

Methods

We identified published papers between January 2000 and May 2019 with > 50 subjects and GOLD criteria for grade II, III or IV (FEV1/FVC < 70% and FEV1 < 80%) using standardised criteria in multiple countries, to re-estimate the prevalence of COPD. Hospitalised COPD patients develop IA in 1.3–3.9%, based on positive cultures of Aspergillus spp. and radiological findings. Given limited data on per-patient annual hospitalisation rates, we assumed a conservative 10.5% estimate. Annual IA mortality in COPD was estimated using the literature rates of 43–72%. A separate literature search assessed the impact of Aspergillus sensitisation on severity of COPD (by FEV1).

Results

We re-estimated the global prevalence of COPD GOLD stages II-IV at 552,300,599 people (7.39% of the population) with 339,206,893 (8.58%) in Asia, 85,278,783 (8.52%) in the Americas, 64,298,051 (5.37%) in Africa, 59,484,329 (7.77%) in Europe and 4,032,543 (10.86%) in Oceania. An estimated 57,991,563 (10.5%) people with COPD are admitted to hospital annually and of these 753,073 (1.3%) – 2,272,322 (3.9%) develop IA and 540,451–977,082 deaths are predicted annually. Aspergillus sensitisation prevalence in COPD was 13.6% (7.0–18.3%) and not related to lower predicted FEV1% (P > 0.05).

Conclusions

The prevalence of COPD is much higher than previously estimated. Overall COPD mortality may be higher than estimated and IA probably contributes to many deaths. Improved rapid diagnosis of IA using culture and non-culture based techniques is required in COPD hospital admissions to reduce mortality.

The Inhibitory Effect of Validamycin A on Aspergillus flavus

Aspergillus flavus is one of the most common isolates from patients with fungal infections. Aspergillus infection is usually treated with antifungal agents, but side effects of these agents are common. Trehalase is an essential enzyme involved in fungal metabolism, and the trehalase inhibitor, validamycin A, has been used to prevent fungal infections in agricultural products. In this study, we observed that validamycin A significantly increased trehalose levels in A. flavus conidia and delayed germination, including decreased fungal adherence. In addition, validamycin A and amphotericin B showed a combinatorial effect on A. flavus ATCC204304 and clinical isolates with high minimum inhibitory concentrations (MICs) of amphotericin B using checkerboard assays. We observed that validamycin A and amphotericin B had a synergistic effect on A. flavus strains resistant to amphotericin B. The MICs in the combination of validamycin A and amphotericin B were at 0.125 μg/mL and 2 μg/mL, respectively. The FICI of validamycin A and amphotericin B of these clinical isolates was about 0.25-0.28 with synergistic effects. No drug cytotoxicity was observed in human bronchial epithelial cells treated with validamycin A using LDH-cytotoxicity assays. In conclusion, this study demonstrated that validamycin A inhibited the growth of A. flavus and delayed conidial germination. Furthermore, the combined effect of validamycin A with amphotericin B increased A. flavus killing, without significant cytotoxicity to human bronchial epithelial cells. We propose that validamycin A could potentially be used in vivo as an alternative treatment for A. flavus infections.

Successful treatment of disseminated granulomatous aspergillosis in an apparently immunocompetent host

A young Indian man presented elsewhere with a short history of haematuria and cough. Investigations revealed renal and pulmonary lesions. Histopathology of these lesions was reported as mucormycosis. He consulted us two months after onset of symptoms, asymptomatic and clinically well, having received no treatment. In view of clinico-histopathological discordance, a review of the biopsy slides was advised but the patient refused further work-up at that time. One week later, however, he was admitted with left hemiparesis. Brain imaging showed an abscess. He underwent surgical excision of the brain abscess and nephrectomy. Review of previous slides showed septate fungal filaments with granulomatous inflammation. Intraoperative cultures grew Aspergillus flavus. He received voriconazole for one year and is well at his two-year follow-up. His immunological work-up was negative for immunodeficiency. This case illustrates that granulomatous aspergillosis may be an indolent infection in apparently normal individuals and reiterates the importance of interpreting diagnostic reports in conjunction with clinical features.

Crystallography, in Silico Studies, and In Vitro Antifungal Studies of 2,4,5 Trisubstituted 1,2,3-Triazole Analogues

A series of 2,4,5 trisubstituted-1,2,3-triazole analogues have been screened for their antifungal activity against five fungal strains, Candida parapsilosis, Candida albicans, Candida tropicalis, Aspergillus niger, and Trichophyton rubrum, via a 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) microdilution assay. Compounds GKV10, GKV11, and GKV15 emerged as promising antifungal agents against all the fungal strains used in the current study. One of the highly active antifungal compounds, GKV10, was selected for a single-crystal X-ray diffraction analysis to unequivocally establish its molecular structure, conformation, and to understand the presence of different intermolecular interactions in its crystal lattice. A cooperative synergy of the C-H···O, C-H···N, C-H···S, C-H···π, and π···π intermolecular interactions was present in the crystal structure, which contributed towards the overall stabilization of the lattice. A molecular docking study was conducted for all the test compounds against Candida albicans lanosterol-14α-demethylase (pdb = 5 tzl). The binding stability of the highly promising antifungal test compound, GKV15, from the series was then evaluated by molecular dynamics studies.

The Pathogenesis of Fungal-Related Diseases and Allergies in the African Population: The State of the Evidence and Knowledge Gaps

The prevalence of allergic diseases in the African continent has received limited attention with the allergic diseases due to fungal allergens being among the least studied. This lead to the opinion being that the prevalence of allergic disease is low in Africa. Recent reports from different African countries indicate that this is not the case as allergic conditions are common and some; particularly those due to fungal allergens are increasing in prevalence. Thus, there is need to understand both the aetiology and pathogenies of these diseases, particularly the neglected fungal allergic diseases. This review addresses currently available knowledge of fungal-induced allergy, disease pathogenesis comparing findings from human versus experimental mouse studies of fungal allergy. The review discusses the potential role of the gut mycobiome and the extent to which this is relevant to fungal allergy, diagnosis and human health.

Diagnostic and Management Strategies of Aspergillus Endophthalmitis: Current Insights

Fungal endophthalmitis is subsequent to endogenous or exogenous infection and represents an important complication of ocular surgery which may lead to significant visual loss and blindness. The prognosis is poor because of delayed diagnosis and limited availability of effective antifungal drugs with good ocular penetration. Furthermore, the critical issue in diagnosing fungal infection of the eye is microbiological identification of the etiologic agent in clinical samples. Aspergillus is among the most frequent isolated organisms in fungal endophthalmitis. Early diagnosis is essential to prevent severe complications and blindness. Treatments include local, systemic and surgical therapeutic strategies. The purpose of the present review is the analysis of the current procedures adopted to promptly diagnose and treat Aspergillus endophthalmitis.

Treatment of immunocompromised patients with suspected invasive fungal infections: economic analysis of diagnostic-driven versus empirical strategies in Algeria and Egypt

Background: Invasive fungal infections (IFIs) in immunocompromised patients are associated with high mortality and treatment costs. Identifying appropriate, cost-effective treatment strategies is crucial to reduce the burden of IFIs. This economic assessment compared strategies for treating immunocompromised patients in Algeria and Egypt.Methods: We developed a decision analytic model incorporating clinical and cost inputs associated with a diagnostic-driven (DD) and standard empirical (SE) strategy. Costs and clinical outcomes were used to calculate incremental cost-effectiveness ratios (ICERs) per death avoided.Results: In both countries, 73.8 (DD) and 125.3 (SE) hypothetical patients per 1,000 received antifungal therapy; 73.8 (DD) and 32.7 (SE) had diagnosed IFIs. Survival at 180 days was similar between DD and SE strategies in Algeria (92.0% vs 91.6%) and Egypt (90.2% vs 90.0%). Total costs per patient were lower with the DD than SE strategy (Algeria: $839 vs $1,591; Egypt: $4,077 vs $4,717). ICERs indicated that the DD compared with SE strategy was associated with better clinical outcomes at a lower overall cost in both countries.Conclusion: Diagnostic-driven compared to empirical therapy may be cost-saving in Algeria and Egypt for the management of immunocompromised patients with persistent neutropenic fever, with no increase in mortality.

Treatment with etanercept and low monocyte concentration contribute to the risk of invasive aspergillosis in patients post allogeneic stem cell transplantation

Invasive aspergillosis (IA) is a life-threatening complication among allogeneic hematopoietic stem cell transplant (alloSCT) recipients. Despite well known risk factors and different available assays, diagnosis of invasive aspergillosis remains challenging. 103 clinical variables from patients with hematological malignancies and subsequent alloSCT were collected. Associations between collected variables and patients with (n = 36) and without IA (n = 36) were investigated by applying univariate and multivariable logistic regression. The predictive power of the final model was tested in an independent patient cohort (23 IA cases and 25 control patients). Findings were investigated further by in vitro studies, which analysed the effect of etanercept on A. fumigatus-stimulated macrophages at the gene expression and cytokine secretion. Additionally, the release of C-X-C motif chemokine ligand 10 (CXCL10) in patient sera was studied. Low monocyte concentration (p = 4.8 × 10⁻⁰⁶), severe GvHD of the gut (grade 2–4) (p = 1.08 × 10⁻⁰²) and etanercept treatment of GvHD (p = 3.5 × 10⁻⁰³) were significantly associated with IA. Our studies showed that etanercept lowers CXCL10 concentrations in vitro and ex vivo and down-regulates genes involved in immune responses and TNF-alpha signaling. Our study offers clinicians new information regarding risk factors for IA including low monocyte counts and administration of etanercept. After necessary validation, such information may be used for decision making regarding antifungal prophylaxis or closely monitoring patients at risk.

Empyema necessitans due to aspergillus in a 3-year-old paediatric patient at a referral hospital in Nairobi, Kenya

We present a case of empyema necessitans due to aspergillus in a young child. The incidence of deep fungal mycoses in children, especially in developing countries is not known. There is paucity of data and access to diagnostics is usually limited. Our patient had received treatment for pulmonary tuberculosis which is endemic in Kenya for four months before diagnosis was made. We present this case to highlight the importance of considering alternative diagnosis when there is non-response to anti-tuberculous therapy.

Development of a nano-gold immunodiagnostic assay for rapid on-site detection of invasive aspergillosis

Introduction. Timely detection of invasive aspergillosis (IA) caused by fungal pathogens, i.e. Aspergillus fumigatus and Aspergillus flavus, in immunocompromised patients is crucial in preventing high mortality.Aim. To develop a simple immunoassay for the detection of galactomannan (GM), an IA biomarker.Methodology. GM from A. fumigatus and A. flavus clinical strains was purified and characterized by X-ray diffraction, IR spectroscopy and ¹³C/¹H nuclear magnetic resonance (NMR) for polyclonal antibody (pAb) production in rabbits. An enzyme-linked immunosorbent assay (ELISA) was standardized using concanavalin A to capture Aspergillus GM and pAbs to detect it. Gold nanoparticles (AuNPs) were synthesized and conjugated to pAbs for the development of a dot-blot immunoassay. The developed dot-blot was evaluated with 109 clinical serum and bronchoalveolar lavage samples.Results. Spectroscopy studies characterized the d-galactofuranosyl groups of GM responsible for the immune response and generation of pAbs. The ELISA employing pAbs showed a sensitivity of 1 ng ml^-1 for Aspergillus GM. Furthermore, a sensitive, visual, rapid dot-blot assay developed by the conjugation of pAbs to AuNPs (~24±5 nm size, -36±2 mV zeta potential) had a detection limit of 1 pg ml^-1 in serum. The pAbs interacted with Aspergillus spp. but did not cross-react with other fungal pathogen genera such as Penicillium and Candida. Evaluation of the dot-blot with 109 clinical samples showed high sensitivity (80 %) and specificity (93.2 %), with an overall assay accuracy of 89%.Conclusion. The developed nano-gold immunodiagnostic assay has immense potential for practical use in rapid, specific and sensitive on-site diagnosis of IA, even under resource-limited settings.

National trends in incidence, prevalence and disability-adjusted life years of invasive aspergillosis in Iran: a systematic review and meta-analysis

Objectives: We aimed to study the epidemiology, prevalence, incidence, clinical manifestations, underlying diseases, treatments, outcomes, and societal impact through disability-adjusted life years (DALYs) of IA in Iran. Methods: A random-effect meta-analytic model was fitted to estimate the prevalence and incidence of IA in Iran. We also calculated DALYs. Results: Out of 79 published studies during the past 25 years from Iran, 23 met the inclusion criteria. A total of 2947 patients were included, of whom 396 (13.4%) patients were diagnosed with IA according to EORTC/MSG and ICU criteria. The main underlying condition for IA was hematologic disorders (39.4%). A. flavus 86 (43%) was the most common isolate. The pooled prevalence and incidence rates were 20.5 (95% CI 12.5 to 29.9) and 4.8 (95% CI 2.3-8.2) per 100,000 population, respectively. Total DALYs was estimated 164.13 per 100,000 population. YLLs constitute the majority of IA burden compared to YLDs (162.80 YLLs/100,000 population vs 1.33 YLDs per 100,000 population). The highest YLL rates were found in people aged 45-49 (62.9 YLLs/100,000 population) and 30-34 years (45.2 YLLs/100,000 population), respectively. Conclusion: This study indicates an increasing burden of IA in Iran, despite the extensive use of prophylaxis, challenging the public health, especially immunocompromised patients.

Invasive Aspergillosis by Aspergillus flavus: Epidemiology, Diagnosis, Antifungal Resistance, and Management

Aspergillus flavus is the second most common etiological agent of invasive aspergillosis (IA) after A. fumigatus. However, most literature describes IA in relation to A. fumigatus or together with other Aspergillus species. Certain differences exist in IA caused by A. flavus and A. fumigatus and studies on A. flavus infections are increasing. Hence, we performed a comprehensive updated review on IA due to A. flavus. A. flavus is the cause of a broad spectrum of human diseases predominantly in Asia, the Middle East, and Africa possibly due to its ability to survive better in hot and arid climatic conditions compared to other Aspergillus spp. Worldwide, ~10% of cases of bronchopulmonary aspergillosis are caused by A. flavus. Outbreaks have usually been associated with construction activities as invasive pulmonary aspergillosis in immunocompromised patients and cutaneous, subcutaneous, and mucosal forms in immunocompetent individuals. Multilocus microsatellite typing is well standardized to differentiate A. flavus isolates into different clades. A. flavus is intrinsically resistant to polyenes. In contrast to A. fumigatus, triazole resistance infrequently occurs in A. flavus and is associated with mutations in the cyp51C gene. Overexpression of efflux pumps in non-wildtype strains lacking mutations in the cyp51 gene can also lead to high voriconazole minimum inhibitory concentrations. Voriconazole remains the drug of choice for treatment, and amphotericin B should be avoided. Primary therapy with echinocandins is not the first choice but the combination with voriconazole or as monotherapy may be used when the azoles and amphotericin B are contraindicated.

Epidemiology and burden of invasive fungal infections in the countries of the Arab League

The burden of invasive fungal infections is alarming worldwide. The aim of this paper is to review the published literature and evaluate the knowledge gap pertaining to studies on invasive fungal infections in the countries of the Arab League. Few countries from this region have published reports. The most commonly studied invasive fungal infections is invasive candidiasis. Candida albicans remains overall the most common causative pathogen (33.8-60%), however, non-albicans Candida species are increasing. Antifungal susceptibility testing is non-standardized across the published studies. Data on aspergillosis and other fungal infections is scarce. This sheds light on the need for standardized surveillance in the region encompassing more countries of the Arab League to guide diagnostic approach and empiric therapy.

Special scenarios in the management of central nervous system aspergillosis: a case series and review of literature

Aspergillus is a rare but important opportunistic pathogen to invade the central nervous system (CNS). It is a significant pathogen of not only immunocompromised but also immunocompetent patients. Its manifestations are pleiotropic, reflecting multiple mechanisms of pathogenesis and host interactions. Despite significant advances in diagnostic methods and therapeutic options, the mortality remains high. Several advances have been made in medications and surgical management, yet, current treatment practices lack uniformity. Patient woes are further heightened by the high costs of treatment and prolonged duration of therapy. In view of the challenging aspects of this disease, we present a short review of four challenging cases touching on the varied aspects of management of CNS aspergillosis covering pathogenesis, diagnostic pitfalls, surgical and medical options and evidence-based guidelines for the management of the same.

Aspergillus fumigatus enhances human NK cell activity by regulating M1 macrophage polarization

The progression of disease caused by fungal infection is closely associated with the human immune system. Macrophages and natural killer cells (NK cells) are two important types of innate immune cells that serve an important role in anti-infection immunity. There has been limited research into the interactions between fungi and macrophages. In the present in vitro study, reverse transcription-quantitative PCR, ELISA and flow cytometry were performed to reveal that the interaction between macrophages and NK cells, regulated by Aspergillus fumigatus conidia, induced macrophages to polarize into M1 macrophages by secreting large quantities of tumor necrosis factor-α, interleukin-18 and Galectin-9. In addition, when NK cells were co-cultured with the conidia of A. fumigatus-stimulated M1 macrophages, they exhibited increased activation levels and secretion of interferon-γ (IFN-γ). It was further demonstrated via antibody neutralization and gene silencing experiments that galectin-9 served an important role in the interaction between macrophages and NK cells regulated by A. fumigatus. In conclusion, it was demonstrated that A. fumigatus induced the polarization of macrophages into M1 macrophages by secreting Galectin-9, which then promoted NK cell activity and IFN-γ secretion. The results provided improved understanding of the role of innate immune cells in invasive fungal infections. The present study also provided novel insight into the study of macrophages and NK cells in inflammatory infections caused by A. fumigatus and potential strategies to control the progression of inflammation.

Invasive aspergillosis causing gastric necrosis and perforation: A case report

Aspergillosis is an opportunistic infection commonly seen in immunocompromised patients. Patients with hematological malignancies, postorgan transplantation, or those with comorbid conditions are susceptible to the development of invasive aspergillosis. Lungs are the main portal of entry and are thus most commonly involved. Aspergillosis can involve the gut, causing vascular thrombosis leading to ischemia and necrosis of the gut wall, resulting in perforation. Primary gastric involvement has been rarely seen, with few case reports in the literature. We report a rare case of primary invasive gastric aspergillosis in a 60‐year‐old diabetic and cirrhotic woman, who presented with clinical features of perforation peritonitis. Exploratory laparotomy was performed, and a 6 cm × 6 cm perforation with necrotizing inflammation was found in the distal stomach, pylorus, and duodenum. Distal gastrectomy with Billroth II reconstruction was performed. Pathology demonstrated septate fungal hyphae invading the gastric wall transmurally. The morphology was compatible with those of Aspergillus spp. Liposomal amphotericin B was started immediately after surgery based on the presence of unusually large areas of necrosis and perforation with blackish exudate covering the ulcer base. Unfortunately, the patient succumbed to rapidly progressive fungal septicemia despite early surgical intervention and critical care management. We recommend that any large confluent areas of gastric ulceration and necrosis with blackish exudates in an appropriate setting should evoke suspicion of invasive fungal infection. These patients should be started on prophylactic broadspectrum antifungal therapy immediately, which may be switched over to specific therapy once the diagnosis is confirmed.

Epidemiology and clinical outcomes of invasive mould infections in Indian intensive care units (FISF study)

BACKGROUND AND AIM

Due to limited data on invasive mould infections (IMIs) in the intensive care units (ICUs) of developing countries, we ascertain epidemiology and management of IMIs at 11 ICUs across India.

METHODS

Consecutive patients with proven or probable/putative IMIs were enrolled during the study period. Subjects were categorized into classical (neutropenia, malignancy, transplant recipients on immunosuppression) and non-classical (chronic obstructive pulmonary disease, diabetes, liver disease and glucocorticoids) risk groups. We analyzed the demographic, laboratory variables and outcomes of these patients.

RESULTS

398 patients with IMIs (96 proven, 302 probable) were identified, amounting to a prevalence of 9.5 cases/1000 ICU admissions. The mean ± SD age of the participants was 45.6 ± 21.9 years. The mean ± SD APACHE II score was 14.3 ± 11.4. The IMIs were diagnosed at a median of 4 days after ICU admission. There were 145 and 253 subjects with classical and non-classical risk groups, respectively. Although Aspergillus spp. were the commonest (82.1%) isolates, Mucorales were detected in 14.4% subjects. A high APACHE II score and IMI due to mucormycosis were significant predictors of mortality.

CONCLUSIONS

The study highlights the distinct epidemiology of IMIs in India ICUs with high burden, new susceptible patient groups and considerable number of non-Aspergillus mould infections. [clinicaltrials.gov: NCT02683642].

A novel diagnosis scoring model to predict invasive pulmonary aspergillosis in the intensive care unit

OBJECTIVES

To improve the quality of invasive pulmonary aspergillosis (IPA) management for intensive care unit (ICU) patients using a practical diagnostic scoring model.

METHODS

This nested case-control study aimed to determine the incidence of IPA in 405 ICU patients, between July 2012 and June 2014, at 6 hospitals in Jakarta, Indonesia. Phenotypic identifications and galactomannan (GM) tests of sera and lung excreta were performed in mycology laboratory, Parasitology Department, Faculty of Medicine, Universitas Indonesia in Jakarta, Indonesia.

RESULTS

The incidence of IPA in the ICUs was 7.7% (31 of 405 patients). A scoring model used for IPA diagnosis showed 4 variables as the most potential risk factors: lung excreta GM index (score 2), solid organ malignancy (score 2), pulmonary tuberculosis (score 2), and systemic corticosteroids (score 1). Patients were included in a high-risk group if their score was greater than 2, and in a low-risk group if their score was less than 2.

CONCLUSION

This study provides a novel diagnosis scoring model to predict IPA in ICU patients. Using this model, a more rapid diagnosis and treatment of IPA may be possible. The application of the diagnosis scoring should be preceded by specified pre-requisites.