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

Trichosporon asahii co-infection with Pneumocystis jiroveci in a renal transplant patient

Trichosporon asahii is considered an opportunistic pathogen, capable of causing superficial infections in humans and invasive deep-seated infections in immunocompromised hosts. Pneumocystis jirovecii can cause life-threatening pneumonia in immunosuppressed patients. Both Trichosporon and Pneumocystis jirovecii are highly lethal in immunocompromised individuals. Here we present a case of invasive Trichosporon asahii co-infection with Pneumocystis jiroveci in a renal transplant patient.

Fungemia due to opportunistic fungi in patients with cancer

BACKGROUND

Fungemia due to uncommon fungi and secondary to multiple risk factors has become an emergent health problem, particularly in oncology patients.

AIMS

This study shows the following data collected during an 11-year period in a tertiary care oncologic center from patients with fungemia: demographic data, clinical characteristics, and outcome.

METHODS

A retrospective study was performed at Instituto Nacional de Cancerología, a 135-bed referral cancer center in Mexico City, from July 2012 to June 2023. All episodes of non-Candida fungemia were included.

RESULTS

Sixteen cases with uncommon fungemia were found in the database, representing 0.3% from all the blood cultures positive during the study period, and 8.5% from all the fungi isolated. The most common pathogens identified in our series were Histoplasma capsulatum, Acremonium spp., Trichosporon asahii, and Saccharomyces cerevisiae. Eight patients had hematologic malignancies, and five had severe neutropenia. In eight cases fungemia was considered catheter-related, in four cases was classified as primary, and in the last four it was diagnosed as disseminated fungal diseases. Mortality at 30 days was 43.8%.

CONCLUSIONS

The improved diagnostic tools have led to a better diagnosis of uncommon fungal infections. More aggressive therapeutic approaches, particularly in patients with malignancies, would increase survival rates in these potentially fatal diseases.

Differences of clinical characteristics and outcome in proven invasive Trichosporon infections caused by asahii and non-asahii species

BACKGROUND

Trichosporon is an emerging yeast that causes invasive infections in immunocompromised patients experiencing prolonged hospitalisation, indwelling venous catheters and neutropenia.

METHODS

This retrospective observational cohort study analysed invasive Trichosporon infections (ITIs) occurring between January 2005 and December 2022 at three tertiary hospitals and compared the clinical characteristics and prognostic factors of ITIs caused by Trichosporon asahii and non-T. asahii spp. After evaluating 1067 clinical isolates, we identified 46 patients with proven ITIs, defined as cases in which Trichosporon was isolated from blood, cerebrospinal fluid, or sterile tissues.

RESULTS

The patients were separated into T. asahii and non-T. asahii groups containing 25 and 21 patients, respectively, all of which except one were immunocompromised. During this period, both the number of clinical isolates and patients with ITIs (mainly T. asahii) increased; whereas, cases involving non-T. asahii spp. decreased. Compared with the non-T. asahii group, the T. asahii group had more patients with multiple catheters (84% vs. 33%, p = .001) and those receiving renal replacement therapy (48% vs. 14%, p = .005). The all-cause 28-day mortality rate after ITI in the T. asahii group (44%) was significantly higher than in the non-T. asahii group (10%, Log-rank p = .014). The multivariate Cox regression model revealed that T. asahii (reference, non-T. asahii spp.; aHR = 4.3; 95% CI = 1.2-15.2, p = .024) and neutropenia for 5 days or more (aHR = 2.2, 95% CI = 1.5-3.6, p = .035) were independent factors in the 28-day mortality after ITI.

CONCLUSION

The proven ITIs due to T. asahii produced more unfavourable outcomes compared with ITIs caused by non-T. asahii spp.

Case report: Diagnostic and therapeutic challenges of fungal endocarditis by Trichosporon asahii in a child with congenital heart defects

Background

patients with congenital cardiopathies are the main group at risk for infective endocarditis (IE) in the pediatric population. Fungal etiology is responsible for 2%-4% of all IEs, and the Trichosporon genus is an increasingly prevalent cause of infections in human beings.

Case presentation

We describe a 9-year-old male with multiple surgical procedures to correct congenital cardiopathy defects, including insertion of RV-PA conduit, who was admitted due to suspicion of pneumonia and needed a surgical approach after being diagnosed with a mycotic pseudoaneurysm in the right ventricle's outflow tract, with dilation of the RV-PA conduit. The conduit was removed and antifungal treatment was started with Voriconazole after the agent was identified (T. asahii), with satisfactory therapeutic response. Approximately 4 years later, the patient was readmitted, presenting with intermittent fever, associated with nocturnal diaphoresis, dry cough, anxiety and chest pain. Vegetations consistent with T. asahii were evidenced in the RV-PA conduit, and a surgical approach was once again necessary.

Discussion

diagnostic methods and treatment of T. asahii endocarditis aren't yet standardized, and recurrent surgical approaches are needed due to the inefficacy of antifungal treatment.

Intergenic spacer (IGS-1) region sequence-based identification, genotypic analysis, and antifungal susceptibility of clinical Trichosporon species

OBJECTIVES

Molecular genotyping of Trichosporon species using intergenic spacer region (IGS-1) sequencing and antifungal drug susceptibility testing of T. asahii clinical isolates from Indian patients.

MATERIALS AND METHODS

Fifty-five Trichosporon strains were characterized using IGS-1 sequencing from 2006 to 2018 and tested against 5 antifungals using CLSI M27-A3 guidelines.

RESULTS

In this study, broad-spectrum antibiotics with steroids, catheters, and ICU stays were major underlying risk factors. These cases were most commonly associated with diabetes (type-2), chronic obstructive pulmonary disease, and hypertension. Out of fifty-five isolates, 47 (85%) were identified as T. asahii, and the remaining 6 were T. inkin (11%) and 2 were Cutaneotrichosporon dermatis (3.6%). The most common genotype of T. asahii was G3 (22; 49%) subsequently G4 (12; 23%), G1 (8; 17%), and G7 (2; 4%). One new genotype of T asahii was found in addition to the fifteen already known genotypes. Indian T. asahii isolates showed a low level of amphotericin B (range 0.06-4 ​mg/l) resistance but relatively higher in fluconazole (range 0.25-64 ​mg/l). Although, comparatively low MIC ranges were found in the case of voriconazole (0.03-1 ​mg/l), posaconazole (0.06-1 ​mg/l) and itraconazole (0.06-1 ​mg/l). Voriconazole appeared to be the most active drug in T. asahii isolates. The MICs for all the drugs were comparatively lower in the case of non-Trichosporon asahii strains.

CONCLUSION

T. asahii was the most common Trichosporon isolate. Speciation is necessary for optimal antifungal therapy. Voriconazole-based treatment, Steroids, removal of catheters and control of underlying conditions results in positive outcomes.

Metagenomic Next-Generation Sequencing for Pathogens in Bronchoalveolar Lavage Fluid Improves the Survival of Patients with Pulmonary Complications After Allogeneic Hematopoietic Stem Cell Transplantation

INTRODUCTION

Unbiased metagenomic next-generation sequencing (mNGS) has been used for infection diagnosis. In this study, we explored the clinical diagnosis value of mNGS for pulmonary complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT).

METHODS

From August 2019 to June 2021, a prospective study was performed to comparatively analyze the pathogenic results of mNGS and conventional tests for bronchoalveolar lavage fluid (BALF) from 134 cases involving 101 patients with pulmonary complications after allo-HSCT.

RESULTS

More pathogens were identified by mNGS than with conventional tests (226 vs 120). For bacteria, the diagnostic sensitivity (P = 0.144) and specificity (P = 0.687) were similar between the two methods. For fungus except Pneumocystis jirovecii (PJ), conventional tests had a significantly higher sensitivity (P = 0.013) with a similarly high specificity (P = 0.109). The sensitivities for bacteria and fungi could be increased with the combination of the two methods. As for PJ, both the sensitivity (100%) and specificity (99.12%) of mNGS were very high. For viruses, the sensitivity of mNGS was significantly higher (P = 0.021) and the negative predictive value (NPV) was 95.74% (84.27-99.26%). Pulmonary infection complications accounted for 90.30% and bacterium was the most common pathogen whether in single infection (63.43%) or mixed infection (81.08%). The 6-month overall survival (OS) of 88.89% in the early group (mNGS ≤ 7 days) was significantly higher than that of 65.52% (HR 0.287, 95% CI 0.101-0.819, P = 0.006) in the late group (mNGS > 7 days).

CONCLUSIONS

mNGS for BALF could facilitate accurate and fast diagnosis for pulmonary complications. Early mNGS could improve the prognosis of patients with pulmonary complications after allo-HSCT.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT04051372.

A Comprehensive Review of Identification Methods for Pathogenic Yeasts: Challenges and Approaches

Given the increasing incidence of yeast infections and the presence of drug-resistant isolates, accurate identification of the pathogenic yeasts is essential for the management of yeast infections. In this review, we tried to introduce the routine and novel techniques applied for yeast identification. Laboratory identification methods of pathogenic yeast are classified into three categories; I. conventional methods, including microscopical and culture-base methods II. biochemical/physiological-processes methods III. molecular methods. While conventional and biochemical methods require more precautions and are not specific in some cases, molecular diagnostic methods are the optimum tools for diagnosing pathogenic yeasts in a short time with high accuracy and specificity, and having various methods that cover different purposes, and affordable costs for researchers. Nucleotide sequencing is a reference or gold standard for identifying pathogenic yeasts. Since it is an expensive method, it is not widely used in developing countries. However, novel identification techniques are constantly updated, and we recommend further studies in this field. The results of this study will guide researchers in finding more accurate diagnostic method(s) for their studies in a short period of time.

Mycotic aneurysms due to Trichosporon asahii in a patient with ulcerative colitis under immunosuppression

Yeast fungi of the genus Trichosporon spp. can colonize the gastrointestinal tract in humans. In recent decades, the pathogenic role of Trichosporon asahii has been increasingly acknowledged especially in the setting of neutropenic patients with hematological malignancies. However, non-neutropenic patients who are immunosuppressed for other reasons are also at risk of developing invasive forms of this mycosis. We present the case of a 62-year-old male, with a history of ulcerative colitis under immunosuppressive treatment and previous exposure to antibiotics for various bacterial infections, who was admitted to the emergency department with a mycotic aneurysm of the abdominal aorta and left common iliac secondary to T. asahii infection. A multidisciplinary approach of the case (both early medical and surgical interventions) allowed the patient's favorable outcome. The patient was followed for more than two years with no evidence of relapse. We postulate that the diagnosis of invasive Trichosporonosis should be considered in patients with inflammatory bowel disease (IBD) under immunosuppressive treatment and with prior exposure to antibiotics.

The first case of clade I Candida auris candidemia in a patient with COVID-19 in Japan

Candida auris is a health hazard because of its antifungal resistance and the potential to cause healthcare-associated outbreaks. To our knowledge, no previous cases of candidemia caused by C. auris have been reported in Japan. Herein, we report the first known case of clade I C. auris candidemia in a Japanese man with coronavirus disease 2019 (COVID-19) infection who was medically evacuated from the Philippines. A 71-year-old Japanese man traveled to Cebu Island in the Philippines 5 months before admission to our hospital. He contracted severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the Philippines and was admitted to the intensive care unit (ICU) in a local hospital. During his medical evacuation, we implemented precautions given his history of COVID-19 and pneumonia caused by multi-drug-resistant Acinetobacter baumannii complex. His blood culture revealed that C. auris infection was treated with antifungal agents but he did not survive. No evidence of nosocomial transmission was found among other patients in the ICU. This case study determines that accurate detection of C. auris, appropriate antifungal agent selection, precautions, and patient isolation are crucial to prevent nosocomial outbreaks, especially in patients with a history of multidrug-resistant organism (MDRO) colonization or international hospitalization. Medical professionals should recognize the risk of MDROs in international medical evacuation settings, considering the recent resumption of cross-border travel after the COVID-19 pandemic.

A Case of Fatal Invasive Trichosporonosis in the Setting of Immunosuppression and Post-COVID-19 Pneumonia

Trichosporon asahii is an opportunistic fungus that forms septate hyphae and pseudohyphae, resembling Candida albicans, and causes fungemia in susceptible individuals. Risk factors for T. asahii infection include immunosuppression, IV catheters, and malignancy. In the present case, a 67-year-old male with a history of renal transplant on immunosuppressive therapy was hospitalized for coronavirus disease 2019 (COVID-19) pneumonia. Despite treatment with steroids and broad initial antibiotic coverage with cefepime, doxycycline, and vancomycin, the patient underwent continual respiratory decline. His sputum culture on hospital day 10 was positive for non-candidal yeast, and despite subsequent appropriate empiric coverage with micafungin and amphotericin B, the patient continued to decline and ultimately died due to the resistance of T. asahii to these antifungals. This case highlights the importance of suspecting T. asahii as an infectious cause in patients whose cultures show non-candidal yeast and initiating appropriate antifungal treatment early in their treatment course.

Orthopedic infections due to Trichosporon species: Case series and literature review

Reports of orthopedic fungal infections caused by Trichosporon species are extremely scarce, thus we aimed to describe a case series and review the cases published in the literature. Patients were retrospectively included if a previous culture of bone, joint, or soft tissues had resulted positive for Trichosporon species along with a clinical diagnosis of an orthopedic infection. Eight patients were included with diverse orthopedic conditions, most of them cases of osteomyelitis. The main isolated species was Trichosporon asahii. All patients were treated with antifungals, mainly voriconazole, and surgical management, resulting in high rates of clinical improvement and low associated mortality.

Metabolic and phenotypic plasticity may contribute for the higher virulence of Trichosporon asahii over other Trichosporonaceae members

BACKGROUND

The Trichosporonaceae family comprises a large number of basidiomycetes widely distributed in nature. Some of its members, especially Trichosporon asahii, have the ability to cause human infections. This ability is related to a series of virulence factors, which include lytic enzymes production, biofilm formation, resistance to oxidising agents, melanin and glucuronoxylomannan in the cell wall, metabolic plasticity and phenotypic switching. The last two are poorly addressed within human pathogenic Trichosporonaceae.

OBJECTIVE

These factors were herein studied to contribute with the knowledge of these emerging pathogens and to uncover mechanisms that would explain the higher frequency of T. asahii in human infections.

METHODS

We included 79 clinical isolates phenotypically identified as Trichosporon spp. and performed their molecular identification. Lactate and N-acetyl glucosamine were the carbon sources of metabolic plasticity studies. Morphologically altered colonies after subcultures and incubation at 37°C indicated phenotypic switching.

RESULTS AND CONCLUSION

The predominant species was T. asahii (n = 65), followed by Trichosporon inkin (n = 4), Apiotrichum montevideense (n = 3), Trichosporon japonicum (n = 2), Trichosporon faecale (n = 2), Cutaneotrichosporon debeurmannianum (n = 1), Trichosporon ovoides (n = 1) and Cutaneotrichosporon arboriforme (n = 1). T. asahii isolates had statistically higher growth on lactate and N-acetylglucosamine and on glucose during the first 72 h of culture. T. asahii, T. inkin and T. japonicum isolates were able to perform phenotypic switching. These results expand the virulence knowledge of Trichosporonaceae members and point for a role for metabolic plasticity and phenotypic switching on the trichosporonosis pathogenesis.

ERG11 Analysis among Clinical Isolates of Trichosporon asahii with Different Azole Susceptibility Profiles

We analyzed a cohort of Trichosporon asahii strains with different MICs of fluconazole and voriconazole and evaluated the presence of ERG11 mutations. ERG11 mutation conferring an amino acid change was found and its resistance potential was evaluated by cloning into Saccharomyces cerevisiae susceptible host strain. Transformants were not resistant to either fluconazole nor voriconazole. Our results suggest that ERG11 variants exist among T. asahii isolates, but are not responsible for resistance phenotypes.

JMM Profile: Trichosporon yeasts: from superficial pathogen to threat for haematological-neutropenic patients

Trichosporon yeasts are classical agents of superficial mycoses, and they are ranked as the first to second predominant basidiomycetous yeast able to cause invasive infections. The clinical presentation of Trichosporon infections varies with the affected anatomical site, with fungaemia present in the majority of invasive trichosporonosis cases. Only a limited number of antifungal compounds can be used to treat Trichosporon infections. Azoles are the first choice due to their intrinsic resistance to echinocandins. Better laboratory methods and up-to-date databases of commercial platforms are required to improve identification, susceptibility testing and surveillance of this potentially threating infection.

Spectrum of signs, symptoms, and treatment in amphotericin B-resistant Trichosporon endophthalmitis: A series of ten cases of post-cataract surgery cluster endophthalmitis

Purpose

The aim of this study was to present the signs, symptoms, management, and outcome of a series of cases of cluster endophthalmitis caused by a multi-drug resistant fungus, Trichosporon.

Methods

This was a retrospective, non-randomized, consecutive interventional case series. Ten cases of postoperative endophthalmitis operated by a surgeon on three consecutive operation theater (OT) days presented 3-5 months after their surgery. All cases were microbiologically confirmed. The pathogen was found to be resistant to most antifungals, including amphotericin B. The cases had a latent period of around 45 days. Management of endophthalmitis included intravitreal injections, anterior chamber (AC) lavage, Pars Plana vitrectomy (PPV), posterior capsulotomy, IOL, and capsular bag removal. Multiple intravitreal injections were required due to recurrence of infections after initial improvement with voriconazole injections.

Results

Structural integrity was maintained and infection-free status was achieved in all the eyes. The presenting vision ranged from 6/60 to PL (perception of light). Seven out of 10 had improvement in their final vision over the presenting vision. Final outcome of four patients had vision of 6/24 or better, 4 patients had vision in the range of 2/60 to 6/36 and 2 patients had PL.

Conclusion

Trichosporon can cause devasting infections even in the immunocompetent, especially in association with implants and catheters. Triazoles form the mainstay of treatment of Trichosporon infection due to the high susceptibility of the organism in vitro. A regimen including voriconazole and amphotericin B may prove to be the most effective. This is the first report of an outbreak of cluster endophthalmitis caused by Trichosporon.

Fungal Bloodstream Co-infection by Trichosporon asahii in a COVID-19 Critical Patient: Case Report and Literature Review

Opportunistic infections are serious complications in critically ill COVID-19 patients, especially co-infections with bacterial and fungal agents. Here we report a rare case of bloodstream co-infection by Trichosporon asahii, an emerging yeast, and Acinetobacterbaumannii, an opportunistic nosocomial pathogen, both multidrug resistant, in a tertiary hospital from southern Brazil. A review of the literature regarding similar cases is also included. Treatment with multiple antimicrobials failed, and the patient progressed to death four days after the diagnosis of bacteremia and fungemia.

A joint PCR-based gene-targeting method using electroporation in the pathogenic fungus Trichosporon asahii

Trichosporon asahii is a pathogenic fungus that causes deep-seated fungal infections in immunocompromised patients. Established methods for generating gene-deficient T. asahii mutants exist, but the frequency of obtaining transformants by electroporation remains low. In the present study, we optimized the conditions for gene transfer by electroporation using a ku70 gene-deficient mutant with high recombination efficiency. Introducing a DNA fragment by electroporation into T. asahii cells on Sabouraud dextrose agar to generate a cnb1 gene-deficient mutant and incubating for 1 day led to the growth of approximately 100 transformants. When the incubation period was extended to 2 days or 5 days, however, only 2 or no transformants, respectively, were grown. The highest number of transformants was grown by electroporation when a square wave at 1.8 kV (9 kV/cm) was applied for 5 ms. In addition, the number of transformants increased with an increase in the length of the homologous region, and transformants did not grow when the homologous region was less than 500 base pairs. A DNA fragment was produced for deletion of the cnb1 gene by joint PCR, and the cnb1 gene-deficient mutant was obtained by introducing the DNA fragment by electroporation. These results indicate that DNA fragments produced by joint PCR can be used to generate gene-deficient mutants of T. asahii through gene transfer by electroporation.

Role of lizards as reservoirs of pathogenic yeasts of zoonotic concern

Reptiles have become popular exotic pets and in some parts of the world, they are used as important source of food, medicines, and materials. Synanthropic lizards are recognized as reservoirs of viruses, bacteria, and parasites but their role in dissemination of zoonotic pathogenic yeasts in the environment was never investigated. Therefore, fecal samples (n=177) from Podarcis siculus (Italian wall lizard), Chalcides ocellatus (Ocellated skink) and Tarentola mauritanica (Moorish gecko) were collected and yeasts were isolated and identified biochemically and molecularly by sequencing the rDNA internal transcribed spacer region (ITS). The phylogenetical relationship of isolated yeast species and their antifungal susceptibility profiles to ten antifungal agents were also assessed. Sixty samples (n=60/177; 33.9%) scored positive for yeasts, with the highest occurrence in C. ocellatus (n=11/17; 64.7%) and the highest variety of species in P. siculus (n=11/12; 91.6%). A total of 364 isolates belonging to Candida, Trichosporon, Saccharomyces and Geotrichum genera were molecularly identified. In particular, Candida albicans (n=160; 44%) followed by Trichosporon coremiiforme (n=44; 12.1%), Pichia kudriavzevii (n=32; 8.8%) and Trichosporon asahii (n=28; 7.7%) were the most frequently isolated species. The phylogenetic tree grouped all representative sequence types within the clade including Candida spp. strains from different geographical areas and from animal species, including human. All tested strains showed high susceptibility to the assayed antifungal drugs. This study suggests the role of lizards as reservoirs and spreaders of zoonotic pathogenic yeasts in the environment. The absence of resistance phenomena in the isolated yeasts might reflect an environment free of azole antifungal pollution or chemicals, suggesting the usefulness of these animals as bio indicators of environment quality.

de la Pedrosa E, López-Campos JL, Máiz L, del Campo R, Martínez-García MÁ. The Human Mycobiome in Chronic Respiratory Diseases: Current Situation and Future Perspectives

Microbes play an important role in the pathogenesis of chronic lung diseases, such as chronic obstructive pulmonary disease, cystic fibrosis, non-cystic fibrosis bronchiectasis, and asthma. While the role of bacterial pathogens has been extensively studied, the contribution of fungal species to the pathogenesis of chronic lung diseases is much less understood. The recent introduction of next-generation sequencing techniques has revealed the existence of complex microbial lung communities in healthy individuals and patients with chronic respiratory disorders, with fungi being an important part of these communities' structure (mycobiome). There is growing evidence that the components of the lung mycobiome influence the clinical course of chronic respiratory diseases, not only by direct pathogenesis but also by interacting with bacterial species and with the host's physiology. In this article, we review the current knowledge on the role of fungi in chronic respiratory diseases, which was obtained by conventional culture and next-generation sequencing, highlighting the limitations of both techniques and exploring future research areas.

Breakthrough Trichosporon asahii in a Patient With New Diagnosis B-ALL on Echinocandin Prophylaxis: A Case Report

Invasive fungal disease is a difficult to diagnose complication of therapy in patients with hematologic malignancy. Antifungal prophylaxis is recommended in high-risk populations, but its use in other populations is less clear. This brief report describes a patient with Trisomy 21 on caspofungin prophylaxis who died of disseminated Trichosporon asahii during induction therapy for new diagnosis low-risk B-cell acute lymphoblastic leukemia, accompanied by a review of similar cases in the literature. Her case highlights the utility of relatively novel diagnostic modalities and reinforces the need for caution in placing patients on antifungal prophylaxis.

Invasive Trichosporonosis in Neonates and Pediatric Patients with Malignancies or Hematologic Disorders

(1) Background: Trichosporon species have emerged as important opportunistic fungal pathogens, with Trichosporon asahii being the leading and most frequent cause of invasive disease. (2) Methods: We performed a global review focused on invasive trichosporonosis in neonates and pediatric patients with malignancies or hematologic disorders. We reviewed case reports and case series of trichosporonosis due to T. asahii published since 1994, the year of the revised taxonomic classification. (3) Results: Twenty-four cases of invasive trichosporonosis were identified in neonates with the presence of central venous catheter and use of broad-spectrum antibiotics recognized as the main predisposing factors. Thirty-two cases were identified in children with malignancies or hematologic disorders, predominantly with severe neutropenia. Trichosporon asahii was isolated from blood in 24/32 (75%) pediatric cases. Cutaneous involvement was frequently observed in invasive trichosporonosis. Micafungin was the most commonly used prophylactic agent (9/22; 41%). Ten patients receiving prophylactic echinocandins were identified with breakthrough infections. A favorable outcome was reported in 12/16 (75%) pediatric patients receiving targeted monotherapy with voriconazole or combined with liposomal amphotericin B. Overall mortality in neonates and children with malignancy was 67% and 60%, respectively. (4) Conclusions: Voriconazole is advocated for the treatment of invasive trichosporonosis given the intrinsic resistance to echinocandins and poor susceptibility to polyenes.

Factors associated with breakthrough fungemia caused by Candida, Trichosporon, or Fusarium species when the breakthrough fungemia developed in patients with hematological disorders

Limited data are available on breakthrough fungemia, defined as fungemia that develops on administration of antifungal agents, in patients with hematological disorders. We reviewed the medical and microbiological records of adult patients with hematological diseases who had breakthrough fungemia between January 2008 and July 2019 at Toranomon Hospital and Toranomon Hospital Kajigaya in Japan. A total of 121 cases of breakthrough fungemia were identified. Of the 121 cases, 83, 11, 5, and 22 were receiving micafungin, voriconazole, itraconazole, and liposomal amphotericin B, respectively, when the breakthrough occurred. Of the 121 causative breakthrough fungal strains, 96 were Candida species, and the rest were 13 cases of Trichosporon species, 7 of Fusarium species, 2 of Rhodotorula mucilaginosa, and 1 each of Cryptococcus neoformans, Exophiala dermatitidis, and Magnusiomyces capitatus. The crude 14-day mortality rate of breakthrough fungemia was 36%. Significant independent factors associated with the crude 14-day mortality were age ≥60 years (P=0.011), chronic renal failure (P=0.0087), septic shock (P<0.0001), steroid administration (P=0.0085), and liposomal amphotericin B breakthrough fungemia (P=0.0011). An absolute neutrophil count >500/μL was significantly more common in candidemia in the multivariate analysis(P＝0.0065), neutropenia and non-allogeneic hematopoietic stem cell transplant recipients were significantly more common in Trichosporon fungemia (P=0.036 and P=0.033, respectively), and voriconazole breakthrough fungemia and neutropenia were significantly more common in Fusarium fungemia (P=0.016 and P=0.016, respectively). The epidemiological and clinical characteristics of breakthrough fungemia of patients with hematological disorders were demonstrated. Some useful factors to predict candidemia, Trichosporon fungemia, and Fusarium fungemia were identified.

A 71-Year-Old Man From Ecuador With a History of Type 2 Diabetes Mellitus and Severe COVID-19 Pneumonia and Lung Cavitation Associated With Triple Infection With Trichosporon Asahii, Klebsiella Pneumoniae, and Pseudomonas Aeruginosa

Unvaccinated patients with comorbidities that impair the immune function, such as type 2 diabetes mellitus, are more likely to develop severe COVID-19. The COVID-19-associated acute respiratory distress syndrome has raised new concerns in intensive care units globally owing to the presence of secondary fungal infections. We report the case of a 71-year-old man from Ecuador with a history of type 2 diabetes mellitus, severe COVID-19 pneumonia, and lung cavitation associated with triple infections with Trichosporon asahii, Klebsiella pneumoniae, and Pseudomonas aeruginosa. The patient with a history of high blood pressure and type 2 diabetes was admitted to our hospital from a private care center with a diagnosis of COVID-19-associated acute respiratory distress syndrome. On arrival, the patient presented with signs of hypoxemic respiratory failure. During his stay at another hospital, he had received tocilizumab and corticosteroid therapy. Therefore, intubation was performed and mechanical ventilation was initiated. The patient developed a septic shock and renal failure with a glomerular filtration rate of 27.5 mL/min/1.73 m2; therefore, two hemodiafiltration sessions were started. The bronchoalveolar lavage revealed erythematous lesions in the bronchial tree and abundant purulent secretions and erosions in the bronchial mucosa, with a cavitary lesion in the right bronchial tree. The bronchoalveolar lavage samples were used to isolate Trichosporon asahii, Klebsiella pneumoniae, and Pseudomonas aeruginosa carbapenemase class A. Matrix-assisted laser desorption/ionization–time of flight (MALDI-TOF) Biotyper mass spectrometry and polymerase chain reaction (PCR) molecular identification were performed. This case report suggested that patients with severe COVID-19 pneumonia, with or without comorbidities, are more susceptible to opportunistic infections.

OUP accepted manuscript

Background

Invasive infections due to Trichosporon spp. are life-threatening opportunistic fungal infections that require complex clinical management. Guidelines assist clinicians but can be challenging to comply with.

Objectives

To develop a scoring tool to facilitate and quantify adherence to current guideline recommendations for invasive trichosporonosis.

Methods

We reviewed the current guideline for managing rare yeast infections (ECMM, ISHAM and ASM). The most important recommendations for diagnosis, treatment and follow-up were assembled and weighted according to their strength of recommendation and level of evidence. Additional items considered highly relevant for clinical management were also included.

Results

The resulting EQUAL Trichosporon Score 2022 comprises 18 items, with a maximum score of 39 points. For diagnostics, seven or eight items, depending on whether organ involvement is present or not, apply, resulting in a maximum of 18 or 21 points. Recommendations on diagnostics include imaging, infectious diseases expert consultation, culture, microscopy, molecular techniques, histopathology, and susceptibility testing. For treatment, six recommendations with a maximum of ten points were identified, with two additional points for organ involvement and one point for second-line treatment in uncontrolled disease. Treatment recommendations include immediate initiation, source control, pharmacological treatment, therapeutic drug monitoring, treatment duration and surgical intervention. Follow-up comprises two items with five points maximum, covering follow-up blood cultures and imaging.

Conclusions

The EQUAL Trichosporon Score weighs and aggregates factors recommended for optimal management of Trichosporon infections. It provides a tool for antifungal stewardship as well as for measuring guideline adherence, but remains to be correlated with patient outcomes.

Case Report: Trichosporon japonicum Fungemia in a Pediatric Patient With Refractory Acute B Cell Lymphoblastic Leukemia

Trichosporon japonicum is a very rare opportunistic yeast causing fungal disease in humans, especially in immunocompromised hosts. Here, we describe a new case of T. japonicum isolated from the blood of a pyrexial pediatric patient with refractory acute B cell lymphoblastic leukemia and acute respiratory distress. Prompt diagnosis through early clinical suspicion and appropriate molecular microbiology analysis allowed the yeast to be accurately identified at species level. Subsequent drug susceptibility testing and focused antifungal treatment with voriconazole and amphotericin B led to a complete clinical and mycological resolution of the infection, which represents the second successful case of T. japonicum bloodstream infection described in literature to date.

COVID-19-associated brain abscess caused by Trichosporon dohaense: A case report and review of literature

We report the first case of Coronavirus Disease 2019 (COVID-19)-associated brain abscess caused by a rare Trichosporon species, T. dohaense. The patient was a known diabetic and had received systemic corticosteroids for the treatment of COVID-19. He underwent craniotomy and evacuation of abscess. The pus aspirate grew a basidiomycetous yeast, morphologically resembling Trichosporon species. The isolate was initially misidentified by VITEK® MS due to lack of mass spectral database of T. dohaense. Accurate identification was achieved by internal transcribed spacer-directed panfungal polymerase chain reaction. The patient had a favorable outcome following surgical intervention and antifungal therapy.

Complicated Trichosporon asahii mastoiditis in immunocompetent child

Background

Trichosporon asahii is an opportunistic fungus that causes infections in immunosuppressed patients. It is rarely seen in children and immunocompetent hosts. The mortality rates are still high despite early treatment with proper antifungal drugs. Trichosporon asahii mastoiditis in an immunocompetent child makes this case challenging.

Case presentation

This report presents a case of Trichosporon asahii mastoiditis which was complicated by transverse sinus thrombosis, in an otherwise healthy 21-month-old girl, and successfully treated with voriconazole. Trichosporon asahii was isolated, in three different occasions, from ear discharge of an immunocompetent healthy child, who presented with prolonged history of fever and received appropriate dosages of multiple types of antimicrobials as an outpatient but without improvement. After 48 h of starting the Voriconzole; post auricular swelling and ear discharge improved significantly.

Conclusion

A high index of clinical and microbiological suspicion is needed for optimal diagnosis of Trichosporon infection. Trichosporon asahii can also cause infection in immunocompetent individual even without previous history of hospitalization or intervention. We emphasize the importance of early pediatric infectious evaluation and intervention.

Comparing the phenotypic, genotypic, and proteomic identification of Trichosporon species: A globally emerging yeast of medical importance

Trichosporon spp. are widely distributed in the nature, comprising species that inhabit different ecological niches and can be found in the water, soil, and body surface of animals and humans. Such microorganisms have been classically associated with superficial infections; however, in the last decades, they have also been related to disseminated infections in immunocompromised patients, behaving as opportunistic agents, which demands rapid and accurate species identification for efficient therapy. Concordance level between the traditional phenotypic method and the molecular technique (gold standard) in the identification of all 59 Trichosporon samples was 59.3%. Identification concordance between MALDI-TOF spectrometry and the molecular technique was 71.2%. No isolate of environmental origin was identifiable by MALDI-TOF mass spectrometry (MS), and 100% of such environmental isolates were discordant for IGS region sequencing and phenotypic characterization. Both comparisons evidenced greatest concordance in the identification of T. asahii. The species T. debeurmannianum, T. dermatis, T. venhuisii and T. insectorum were not properly identified by both MALDI-TOF MS and the phenotypic technique. MALDI-TOF MS, in particular, seems to be appropriate to investigate yeasts of the genus Trichosporon; however, database updates are still necessary, especially for species that are not common in the clinical routine. With the aim of helping understand the aspects involved in early and accurate diagnosis of infections caused by this opportunistic agent, the present study compared the phenotypic, molecular (IGS region) and mass-spectrometry (MALDI-TOF) identification of 59 yeasts of the genus Trichosporon which had clinical and environmental origin and were kept in a mycology collection.

Identification microbial glycans substructure associate with disease and species

The microbial glycans mediate many significant biological acts, such as pathogen survival, host-microbe interactions, and immune evasion. The systematic study of microbial glycans structure remains challenging because of its high complexity and variability. In this study, we screened all the microbial glycans structures in the CSDB (Carbohydrate Structure Database), disassembled them into substructures, and calculated all the substructures' numbers. The results showed that a large number of glycan substructures are shared among different microorganisms. Further analysis showed that the glycan substructures appeared in specific bacterial groups may be related to the species and pathogenicity of microorganisms. Broadly, these findings provided an alternative approach or clue to discover the hidden information and the biological functions of glycans. The results can be used to detect broad-scope pathogen or prepare broad-spectrum vaccines.

Bloodstream infections due to Trichosporon species in paediatric patients: Results from the first national study from Turkey

BACKGROUND

Invasive Trichosporon infections are rarely seen opportunistic fungal infections in children and mainly affect immunocompromised patients. This multicenter retrospective study has rewieved the characteristics, risk factors, treatment modalities and outcomes of bloodstream infections caused by Trichosporon species in children diagnosed over the past ten years in Turkey.

METHODS

The study was performed with the participation of 12 of 55 hospitals invited from Turkey. In each center, the patients with bloodstream infections caused by Trichosporon spp. between January 2010 and December 2020 were retrospectively ascertained and the results were reported to the study coordinator by means of a simple case report. Data were collected on patient demographics, underlying condition(s), treatment of.infections caused by Trichosporon spp, and 7 and 30- day mortality rates.

RESULTS

A total of 28 cases with fungemia caused by Trichosporon spp. were included in the study. The most common underlying disease was paediatric cancers (39.3%). T. asahii infections were detected in 78.5 % (n=22) of patients. A various spectrum of antifungal treatment regimens were used including intravenous amphotericin B monotherapy in 35.7%, intravenous amphotericin B and voriconazole combination in 32.1% and intravenous voriconazole monotherapy in 28.6% of the patients. The overall mortality rate was 28.5 %. The mortality rates were 12.5% in the voricanozole, 30% in the amphotericin B and 33.3% in combined voriconazole -amphotericin B arms CONCLUSIONS: Invasive Trichosporon infections with an important impact of patients quality of life are almost related to underlying diseases with an overall mortality rate of 28.5%. Voriconazole was found to be associated with lower mortality rates when compared with other treatment regimens.

Insight into the antifungals used to address human infection due to Trichosporon spp.: a scoping review

Trichosporonosis infections have been increasing worldwide. Providing adequate treatment for these infections remains a challenge. This scoping review contains information about potential antifungals to treat this pathology. Using online databases, we found 76 articles published between 2010 and 2020 related to this topic. Classic antifungals, molecules and biomolecules, repositioned drugs and natural products have been tested against species of Trichosporon. Experimental research has lacked depth or was limited to in vitro and in vivo tests, so there are no promising new candidates for the clinical treatment of patients with trichosporonosis. Furthermore, most studies did not present appropriate scientific criteria for drug tests, compromising their quality.

Epidemiological profile and antifungal susceptibility pattern of Trichosporon species in a tertiary care hospital in Chandigarh, India

Background and Purpose

Trichosporon species are ubiquitous in nature which are associated with fatal opportunistic invasive infections, especially in immunocompromised patients. The present study aimed to evaluate the epidemiological and clinical details, as well as the antifungal susceptibility pattern of the patients with Trichosporon infections.

Materials and Methods

In total, 50 clinical isolates of Trichosporon species from various samples were included in this study. The samples were isolated over a period of 18 months from patients in a tertiary hospital in North India. The isolates were characterised phenotypically with Vitek MS (bioMérieux, France). Trichosporon spp. were isolated from urine (30%), nail (30%), tissue (16%), pleural fluid (14%), and sputum (5%). In total, majority of the isolates were of Trichosporon asahii (92%), followed by Trichosporon mucoides (6%), and Trichosporon ovoides (2%). It is noteworthy that most of the reported cases were from intensive care unit (34%).

Results

Intravenous catheters, antibiotics, and antifungal uptake were significantly associated risk factors with Trichosporon infection. All invasive isolates were observed to be resistant in vitro to caspofungin and exhibited high minimum inhibitory concentration (MIC) values against amphotericin B, fluconazole, and 5-flucytosine. The MICs for voriconazole and posaconazole were low.

Conclusion

Trichosporonosis is being increasingly reported all around the world, including India. The results of this study highlighted the importance of early detection and treatment for this emerging yeast and also added to the ongoing surveillance for the antifungal susuceptibility pattern for this fungus.

Fatal fungemia by biofilm-producing Trichosporon asahii in a liver transplant candidate

Acute-on-chronic liver failure (ACLF) is often associated with a dismal outcome. Infections might preclude access to liver transplantation (LT) for these patients, further reducing their chance of survival. We report the case of a patient with ACLF who died before LT for biofilm-producing Trichosporon asahii fungemia. The patient early started antifungal therapy with anidulafungin, but T. asahii was not susceptible to echinocandins, delaying the start of active antifungal therapy. Although rare, invasive infections by Trichosporon spp. are associated with high mortality rates due to low antimicrobial susceptibility and production of biofilms on indwelling devices. Early diagnosis and treatment are crucial to reduce mortality and enhance patient survival.

Prognostic correlations with the microbiome of breast cancer subtypes

Alterations to the natural microbiome are linked to different diseases, and the presence or absence of specific microbes is directly related to disease outcomes. We performed a comprehensive analysis with unique cohorts of the four subtypes of breast cancer (BC) characterized by their microbial signatures, using a pan-pathogen microarray strategy. The signature (includes viruses, bacteria, fungi, and parasites) of each tumor subtype was correlated with clinical data to identify microbes with prognostic potential. The subtypes of BC had specific viromes and microbiomes, with ER+ and TN tumors showing the most and least diverse microbiome, respectively. The specific microbial signatures allowed discrimination between different BC subtypes. Furthermore, we demonstrated correlations between the presence and absence of specific microbes in BC subtypes with the clinical outcomes. This study provides a comprehensive map of the oncobiome of BC subtypes, with insights into disease prognosis that can be critical for precision therapeutic intervention strategies.

Comparison of the characteristics of patients with invasive infections and noninvasive infections caused by Trichosporon asahii

We performed retrospective study to identify the characteristics of invasive Trichosporon asahii infection. A total of 102 patients with T. asahii were identified including 18 (18%) with invasive infection. Invasive infection was associated with indwelling central venous catheter (94% vs 54%, P = .001), prior antifungal agent use (50% vs 18%, P = .01), hematologic malignancy (33% vs 7%, P = .006), and end-stage renal disease (28% vs 7%, P = .02). Patients with invasive infections had higher in-hospital mortality than patients with noninvasive infections (61% vs 27%, P = .006). Those with the above risk factors should be monitored for the development of invasive T. asahii infection.

LAY SUMMARY

Patients with indwelling central venous catheter, prior antifungal agent use, hematologic malignancy, and end-stage renal disease were associated with invasive Trichosporon asahii infection. Patients with invasive infections had higher in-hospital mortality than patients without invasive infection.

All You Need To Know and More about the Diagnosis and Management of Rare Yeast Infections

Invasive infections with emerging yeasts such as Geotrichum, Saprochaete/Magnusiomyces, Trichosporon, and other species are associated with high morbidity and mortality rates. Due to the rarity and heterogeneity of these yeasts, medical mycology has lacked guidance in critical areas affecting patient management. Now, physicians and life scientists from multiple disciplines and all world regions have united their expertise to create the "Global guideline for the diagnosis and management of rare yeast infections: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology and the American Society for Microbiology." Recommendations are stratified for high- and low-resource settings and are therefore applicable worldwide. The advantages and disadvantages of various diagnostic methods and treatment options are outlined. This guideline reflects the current best-practice management for invasive rare yeast infections in a range of settings, with the intent of establishing a global standard of care for laboratorians and clinicians alike.

fuPCR as diagnostic method for the detection of rare fungal pathogens, such as Trichosporon, Cryptococcus and Fusarium

Fungal respiratory tract colonisation is a common finding in patients with hematologic neoplasms due to immunosuppression inherent in the diseases and exacerbated by therapy. This greatly increases the risk of fungal infections of the lungs, which is associated with significant mortality. Therefore, reliable diagnostic methods with rapidly available results are needed to administer adequate antifungal therapy.We have established an improved method for fungal DNA extraction and amplification that allows simultaneous detection of fungal families based on a set of multiplexed real time PCR reactions (fuPCR). We analysed respiratory rinses and blood of 94 patients with haematological systemic diseases by fuPCR and compared it with the results of culture and serological diagnostic methods. 40 healthy subjects served as controls.Regarding Candida species, the highest prevalence resulted from microbiological culture of respiratory rinses and from detection of antibodies in blood serum in patients (61% and 47%, respectively) and in the control group (29% and 51%, respectively). Detection of other pathogenic yeasts, such as Cryptococcus and Trichosporon, and moulds, such as Fusarium, was only possible in patients by fuPCR from both respiratory rinses and whole blood and serum. These fungal species were found statistically significantly more frequent in respiratory rinses collected from patients after myeloablative therapy for stem cell transplantation compared to samples collected before treatment (p<<0.05i>).The results show that fuPCR is a valuable complement to culturing and its inclusion in routine mycological diagnostics might be helpful for early detection of pathophysiologically relevant respiratory colonisation for patients with hematologic neoplasms.

LAY ABSTRACT

We validated a set of PCR reactions (fuPCR) for use in routine diagnostic. In contrast to culture and serological methods, only by fuPCR pathogenic yeasts (Cryptococcus and Trichosporon) and moulds (Aspergillus and Fusarium) were detected in respiratory rinses and blood of haematological patients.

Mycosands: Fungal diversity and abundance in beach sand and recreational waters - Relevance to human health

The goal of most studies published on sand contaminants is to gather and discuss knowledge to avoid faecal contamination of water by run-offs and tide-retractions. Other life forms in the sand, however, are seldom studied but always pointed out as relevant. The Mycosands initiative was created to generate data on fungi in beach sands and waters, of both coastal and freshwater inland bathing sites. A team of medical mycologists and water quality specialists explored the sand culturable mycobiota of 91 bathing sites, and water of 67 of these, spanning from the Atlantic to the Eastern Mediterranean coasts, including the Italian lakes and the Adriatic, Baltic, and Black Seas. Sydney (Australia) was also included in the study. Thirteen countries took part in the initiative. The present study considered several fungal parameters (all fungi, several species of the genus Aspergillus and Candida and the genera themselves, plus other yeasts, allergenic fungi, dematiaceous fungi and dermatophytes). The study considered four variables that the team expected would influence the results of the analytical parameters, such as coast or inland location, urban and non-urban sites, period of the year, geographical proximity and type of sediment. The genera most frequently found were Aspergillus spp., Candida spp., Fusarium spp. and Cryptococcus spp. both in sand and in water. A site-blind median was found to be 89 Colony-Forming Units (CFU) of fungi per gram of sand in coastal and inland freshwaters, with variability between 0 and 6400 CFU/g. For freshwater sites, that number was 201.7 CFU/g (0, 6400 CFU/g (p = 0.01)) and for coastal sites was 76.7 CFU/g (0, 3497.5 CFU/g). For coastal waters and all waters, the median was 0 CFU/ml (0, 1592 CFU/ml) and for freshwaters 6.7 (0, 310.0) CFU/ml (p < 0.001). The results advocate that beaches should be monitored for fungi for safer use and better management.

Trichosporon asahii fungemia and COVID-19 co-infection: An emerging fungal pathogen; case report and review of the literature

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Trichosporon asahii fungemia is an emerging invasive pathogen in critically ill Coronavirus disease 2019 patients.

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Judicious use of immunosuppressant medications is advisable in critically ill Coronavirus disease 2019.

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Periodically fungal surveillance program is recommended in critically ill COVID-19 patients.

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Voriconazole is the first option of therapy for Trichosporon asahii infection.

With the evolving COVID-19 pandemic, increasing concerns about invasive fungal infections have been reported particularly with the use of potent immunosuppressant medications to treat the immunological storms in patients with severe COVID-19 illnesses. Trichosporon asahii (T. asahii) is an emerging highly resistant pathogen with considerable mortality particularly in critically ill patients and immunocompromised individuals. We describe a case of a 58-year-old patient who developed T. asahii fungemia after using immunosuppressant agents for his severe COVID-19 related cytokines release syndrome. Pseudohyphae, arthroconidia, and lateral blastoconidia were seen in the stain, and later confirmed to be T. asahii. Voriconazole successfully treated this multi-drug-resistant fungal infection. The clinical presentation, assessment, and management are reviewed to raise awareness of the circumstances leading to coinfection with this emerging resistant yeast.

Epidemiology, clinical aspects, outcomes and prognostic factors associated with Trichosporon fungaemia: results of an international multicentre study carried out at 23 medical centres

BACKGROUND

Trichosporon fungaemia (TF) episodes have increased in recent years and mortality rates remain high despite the advances in the management of sepsis. New concepts about its clinical course, treatment and microbiology need to be investigated for the better management of this infection.

OBJECTIVES

To describe the aetiology, natural history, clinical management and prognostic factors of TF.

METHODS

TF episodes documented between 2005 and 2018 in 23 South American centres were retrospectively investigated by using a standard clinical form. Molecular identification, antifungal susceptibility testing and biofilm production were also performed.

RESULTS

Eighty-eight TF episodes were studied. Patients had several underlying conditions, including haematological diseases (47.7%), post-operative status (34%), solid organ transplants (n = 7, 7.9%), among others. Seventy-three (82.9%) patients had a central venous catheter (CVC) at TF diagnosis. The 30 day mortality rate was 51.1%. Voriconazole-based therapy was given to 34 patients (38.6%), with a 30 day mortality rate of 38.2%. Multivariate predictors of 30 day mortality were age (OR 1.036), mechanical ventilation (OR 8.25) and persistent neutropenia (OR 9.299). CVC removal was associated with over 75% decreased risk of 30 day mortality (OR 0.241). Microbiological analyses revealed that 77.7% of the strains were identified as Trichosporon asahii, and voriconazole showed the strongest in vitro activity against Trichosporon spp. Most of the strains (63%) were considered medium or high biofilm producers.

CONCLUSIONS

Older age, mechanical ventilation and persistent neutropenia were associated with poor prognosis. CVC may play a role in the pathogenicity of TF and its removal was associated with a better prognosis.

Disseminated Trichosporon asahii infection presenting as eosinophilia in an immunocompetent patient: A case report

Trichosporon are naturally found in external environments and are a part of the normal flora of the human skin, respiratory tract, and gastrointestinal tract. Disseminated Trichosporon infection occurs sporadically in patients with immunodeficiency, and is mainly manifested as blood, urine, catheter, and thorax/peritoneum infections, rarely as lymphatic, liver and spleen infections. Elevated blood eosinophil granulocyte from Trichosporon infection have rarely been reported. Here, we report a rare Case of eosinophilia associated with lymphatic and liver and spleen infections due to Trichosporon asahii in an immunocompetent patient. No reports of eosinophilia from Trichosporon infections other than lung, to our knowledge, have been published.

Trichosporon asahii superinfections in critically ill COVID-19 patients overexposed to antimicrobials and corticosteroids

Objectives

To investigate the occurrence of Trichosporon asahii fungemia among critically ill COVID‐19 patients.

Methods

From 1 July to 30 September 2020, cases of T asahii fungemia (TAF) in a Brazilian COVID‐19 referral centre were investigated. The epidemiology and clinical courses were detailed, along with a mycological investigation that included molecular species identification, haplotype diversity analysis and antifungal susceptibility testing.

Results

Five critically ill COVID‐19 patients developed TAF in the period. All five patients had common risk conditions for TAF: central venous catheter at fungemia, previous exposure to broad‐spectrum antibiotics, prior echinocandin therapy and previous prolonged corticosteroid therapy. The average time of intensive care unit hospitalisation previous to the TAF episode was 23 days. All but one patient had voriconazole therapy, and TAF 30‐day mortality was 80%. The five T asahii strains from the COVID‐19 patients belonged to 4 different haplotypes, mitigating the possibility of skin origin and cross‐transmission linking the 5 reported episodes. The antifungal susceptibility testing revealed low minimal inhibitory concentrations for azole derivatives.

Conclusions

Judicious prescription of antibiotics, corticosteroids and antifungals needs to be discussed in critically ill COVID‐19 patients to prevent infections by hard‐to‐treat fungi like T asahii.

Recent developments in less known and multi-resistant fungal opportunists

Fungal infections have increased in recent years due to host factors, such as oncohaematological and transplant-related disorders, immunosuppressive therapy, and AIDS. Additionally, molecular and proteomic facilities have become available to identify previously unrecognizable opportunists. For these reasons, reports on less-known and recalcitrant mycoses, such as those caused by black fungi, hyaline filamentous fungi, coelomycetes, Mucorales, and non-Candida yeasts have emerged. In this review, novel taxonomy in these groups, which often are multi-resistant to one or several classes of antifungals, is discussed. Clinical presentations, diagnosis and current treatment of some major groups are summarised.

Emerging Fungal Infections

Various uncommon fungal pathogens have been increasingly identified as causes of disseminated and invasive fungal disease (IFD) worldwide. Growing recognition and clinical knowledge of these emerging fungal pathogens has occurred through improved molecular diagnostics, nucleic sequence databases, and taxonomic reclassification of medically significant fungi. However, emerging fungal diseases carry significant morbidity and mortality and, due to a paucity of published literature, the collective clinical experience with these fungi is often limited. In this review, we focus on unusual emerging fungal pathogens not extensively covered elsewhere in this issue of Infectious Diseases Clinics of North America.