Treatment of systemic mycoses with ketoconazole: emphasis on toxicity and clinical response in 52 patients. National Institute of Allergy and Infectious Diseases collaborative antifungal study

Male animal sterilization: history, current practices, and potential methods for replacing castration

Sterilization and castration have been synonyms for thousands of years. Making an animal sterile meant to render them incapable of producing offspring. Castration or the physical removal of the testes was discovered to be the most simple but reliable method for managing reproduction and sexual behavior in the male. Today, there continues to be global utilization of castration in domestic animals. More than six hundred million pigs are castrated every year, and surgical removal of testes in dogs and cats is a routine practice in veterinary medicine. However, modern biological research has extended the meaning of sterilization to include methods that spare testis removal and involve a variety of options, from chemical castration and immunocastration to various methods of vasectomy. This review begins with the history of sterilization, showing a direct link between its practice in man and animals. Then, it traces the evolution of concepts for inducing sterility, where research has overlapped with basic studies of reproductive hormones and the discovery of testicular toxicants, some of which serve as sterilizing agents in rodent pests. Finally, the most recent efforts to use the immune system and gene editing to block hormonal stimulation of testis function are discussed. As we respond to the crisis of animal overpopulation and strive for better animal welfare, these novel methods provide optimism for replacing surgical castration in some species.

Antifungal efficacy of imidazo[1,2-a]pyrazine-based thiosemicarbazones and thiazolidinediones against Sporothrix species

Aim: To evaluate antifungal potential of 5,6,7,8-tetrahydroimidazo[1,2-a]pyrazine hybrids based on thiosemicarbazones and thiazolidinediones against pathogenic Sporothrix species. Methods: Antifungal activity of nine compounds were assessed by broth microdilution. Interactions between active compounds and itraconazole were evaluated by the checkerboard assay using non-wild-type isolates. Cytotoxicity of the compounds was determined. Results: Four C-3 substituted analogs showed antifungal activity, unrelated to thiosemicarbazone or thiazolidinedione functions. Synergistic interactions between the four compounds and itraconazole, and low toxicity on mouse fibroblast cells were observed. Activity of 5,6,7,8-tetrahydroimidazo[1,2-a]pyrazine hybrids against Sporothrix depended on the substitution on the imidazopyrazine ring. Conclusion: Antifungal potential, overcoming itraconazole resistance and low toxicity indicate the possible use of that series of compounds in a therapeutic alternative for treatment of sporotrichosis.

Enhancing Solubility and Dissolution Rate of Antifungal Drug Ketoconazole through Crystal Engineering

To improve the solubility and dissolution rate of the BCS class II drug ketoconazole, five novel solid forms in 1:1 stoichiometry were obtained upon liquid-assisted grinding, slurry, and slow evaporation methods in the presence of coformers, namely, glutaric, vanillic, 2,6-dihydroxybenzoic, protocatechuic, and 3,5-dinitrobenzoic acids. Single-crystal X-ray diffraction analysis revealed that the hydroxyl/carboxylic acid. . .N-imidazole motif acts as the dominant supramolecular interaction in the obtained solid forms. The solubility of ketoconazole in distilled water significantly increased from 1.2 to 2165.6, 321.6, 139.1, 386.3, and 191.7 μg mL-1 in the synthesized multi-component forms with glutaric, vanillic, 2,6-dihydroxybenzoic, protocatechuic, and 3,5-dinitrobenzoic acid, respectively. In particular, the cocrystal form with glutaric acid showed an 1800-fold solubility increase in water concerning ketoconazole. Our study provides an alternative approach to improve the solubility and modify the release profile of poorly water-soluble drugs such as ketoconazole.

Augmenting Azoles with Drug Synergy to Expand the Antifungal Toolbox

Fungal infections impact the lives of at least 12 million people every year, killing over 1.5 million. Wide-spread use of fungicides and prophylactic antifungal therapy have driven resistance in many serious fungal pathogens, and there is an urgent need to expand the current antifungal arsenal. Recent research has focused on improving azoles, our most successful class of antifungals, by looking for synergistic interactions with secondary compounds. Synergists can co-operate with azoles by targeting steps in related pathways, or they may act on mechanisms related to resistance such as active efflux or on totally disparate pathways or processes. A variety of sources of potential synergists have been explored, including pre-existing antimicrobials, pharmaceuticals approved for other uses, bioactive natural compounds and phytochemicals, and novel synthetic compounds. Synergy can successfully widen the antifungal spectrum, decrease inhibitory dosages, reduce toxicity, and prevent the development of resistance. This review highlights the diversity of mechanisms that have been exploited for the purposes of azole synergy and demonstrates that synergy remains a promising approach for meeting the urgent need for novel antifungal strategies.

In silico analysis of cytochrome P450 monooxygenases in chronic granulomatous infectious fungus Sporothrix schenckii: Special focus on CYP51

Sporotrichosis is an emerging chronic, granulomatous, subcutaneous, mycotic infection caused by Sporothrix species. Sporotrichosis is treated with the azole drug itraconazole as ketoconazole is ineffective. It is a well-known fact that azole drugs act by inhibiting cytochrome P450 monooxygenases (P450s), heme-thiolate proteins. To date, nothing is known about P450s in Sporothrix schenckii and the molecular basis of its resistance to ketoconazole. Here we present genome-wide identification, annotation, phylogenetic analysis and comprehensive P450 family-level comparative analysis of S. schenckii P450s with pathogenic fungi P450s, along with a rationale for ketoconazole resistance by S. schenckii based on in silico structural analysis of CYP51. Genome data-mining of S. schenckii revealed 40 P450s in its genome that can be grouped into 32 P450 families and 39 P450 subfamilies. Comprehensive comparative analysis of P450s revealed that S. schenckii shares 11 P450 families with plant pathogenic fungi and has three unique P450 families: CYP5077, CYP5386 and CYP5696 (novel family). Among P450s, CYP51, the main target of azole drugs was also found in S. schenckii. 3D modeling of S. schenckii CYP51 revealed the presence of characteristic P450 motifs with exceptionally large reductase interaction site 2. In silico analysis revealed number of mutations that can be associated with ketoconazole resistance, especially at the channel entrance to the active site. One of possible reason for better stabilization of itraconazole, compared to ketoconazole, is that the more extended molecule of itraconazole may form a hydrogen bond with ASN-230. This in turn may explain its effectiveness against S. schenckii vis-a-vis resistant to ketoconazole. This article is part of a Special Issue entitled: Cytochrome P450 biodiversity and biotechnology, edited by Erika Plettner, Gianfranco Gilardi, Luet Wong, Vlada Urlacher, Jared Goldstone.

Multicenter, International Study of MIC/MEC Distributions for Definition of Epidemiological Cutoff Values for Sporothrix Species Identified by Molecular Methods

Clinical and Laboratory Standards Institute (CLSI) conditions for testing the susceptibilities of pathogenic Sporothrix species to antifungal agents are based on a collaborative study that evaluated five clinically relevant isolates of Sporothrixschenckii sensu lato and some antifungal agents. With the advent of molecular identification, there are two basic needs: to confirm the suitability of these testing conditions for all agents and Sporothrix species and to establish species-specific epidemiologic cutoff values (ECVs) or breakpoints (BPs) for the species. We collected available CLSI MICs/minimal effective concentrations (MECs) of amphotericin B, five triazoles, terbinafine, flucytosine, and caspofungin for 301 Sporothrix schenckii sensu stricto, 486 S. brasiliensis, 75 S. globosa, and 13 S. mexicana molecularly identified isolates. Data were obtained in 17 independent laboratories (Australia, Europe, India, South Africa, and South and North America) using conidial inoculum suspensions and 48 to 72 h of incubation at 35°C. Sufficient and suitable data (modal MICs within 2-fold concentrations) allowed the proposal of the following ECVs for S. schenckii and S. brasiliensis, respectively: amphotericin B, 4 and 4 μg/ml; itraconazole, 2 and 2 μg/ml; posaconazole, 2 and 2 μg/ml; and voriconazole, 64 and 32 μg/ml. Ketoconazole and terbinafine ECVs for S. brasiliensis were 2 and 0.12 μg/ml, respectively. Insufficient or unsuitable data precluded the calculation of ketoconazole and terbinafine (or any other antifungal agent) ECVs for S. schenckii, as well as ECVs for S. globosa and S. mexicana These ECVs could aid the clinician in identifying potentially resistant isolates (non-wild type) less likely to respond to therapy.

Sporotrichosis: an overview and therapeutic options

Sporotrichosis is a chronic granulomatous mycotic infection caused by Sporothrix schenckii, a common saprophyte of soil, decaying wood, hay, and sphagnum moss, that is endemic in tropical/subtropical areas. The recent phylogenetic studies have delineated the geographic distribution of multiple distinct Sporothrix species causing sporotrichosis. It characteristically involves the skin and subcutaneous tissue following traumatic inoculation of the pathogen. After a variable incubation period, progressively enlarging papulo-nodule at the inoculation site develops that may ulcerate (fixed cutaneous sporotrichosis) or multiple nodules appear proximally along lymphatics (lymphocutaneous sporotrichosis). Osteoarticular sporotrichosis or primary pulmonary sporotrichosis are rare and occur from direct inoculation or inhalation of conidia, respectively. Disseminated cutaneous sporotrichosis or involvement of multiple visceral organs, particularly the central nervous system, occurs most commonly in persons with immunosuppression. Saturated solution of potassium iodide remains a first line treatment choice for uncomplicated cutaneous sporotrichosis in resource poor countries but itraconazole is currently used/recommended for the treatment of all forms of sporotrichosis. Terbinafine has been observed to be effective in the treatment of cutaneous sporotrichosis. Amphotericin B is used initially for the treatment of severe, systemic disease, during pregnancy and in immunosuppressed patients until recovery, then followed by itraconazole for the rest of the therapy.

Antifungal clinical trials and guidelines: what we know and do not know

For over the last three decades, extensive testing of antifungal compounds in clinical trials has been essential to the development of treatment guidelines for the most common invasive fungal infections, including cryptococcosis, candidiasis, aspergillosis, and the endemic fungi. These guidelines have greatly helped guide clinicians in the management of these complicated diseases. The data on which most of these guidelines are based are among the most widely recognized and cited clinical trials comparing antimicrobial agents. Unfortunately, there are many unanswered questions with respect to the diagnosis and treatment of these emerging disorders. Regarding treatment, there is a need for more clinically effective and less toxic agents. The current armamentarium of antifungal agents represents important progress over gold standard agents such as amphotericin B, but there is much progress to be made. With respect to diagnostics, mycology has generally lagged behind other disciplines in microbiology, as there are very few rapid, sensitive, specific, and point-of-care diagnostics. The ability to implement therapies for at-risk patients based on positive early diagnostic signals would greatly enhance the ability to intervene with appropriate antifungal therapy in a more targeted and specific manner. This article will review some of the major advances, as well as significant challenges that remain in the management of invasive mycoses.

Sporotrichosis: a forgotten disease in the drug research agenda

Potassium iodide was discovered in the 19th century and still remains as one of the more effective and most prescribed treatments for sporotrichosis. No new drugs have been evaluated in large randomized clinical trials in comparison with standard or alternative treatments for sporotrichosis during the last decades. The emergence of disseminated sporotrichosis in AIDS patients has uncovered the need for more effective treatments. Sporotrichosis is only a public health problem in a few geographical areas, mostly located in developing countries; and its usually harmless history could explain the limited investment in sporotrichosis treatment research. Better understanding of the virulence factors, such as the melanization process, could reveal new potential drug targets.

Endocrine and metabolic manifestations of invasive fungal infections and systemic antifungal treatment

Systemic fungal infections are increasingly reported in immunocompromised patients with hematological malignancies, recipients of bone marrow and solid organ allografts, and patients with AIDS. Mycoses may infiltrate endocrine organs and adversely affect their function or produce metabolic complications, such as hypopituitarism, hyperthyroidism or hypothyroidism, pancreatitis, hypoadrenalism, hypogonadism, hypernatremia or hyponatremia, and hypercalcemia. Antifungal agents used for prophylaxis and/or treatment of mycoses also have adverse endocrine and metabolic effects, including hypoadrenalism, hypogonadism, hypoglycemia, dyslipidemia, hypernatremia, hypocalcemia, hyperphosphatemia, hyperkalemia or hypokalemia, and hypomagnesemia. Herein, we review how mycoses and conventional systemic antifungal treatment can affect the endocrine system and cause metabolic abnormalities. If clinicians are equipped with better knowledge of the endocrine and metabolic complications of fungal infections and antifungal therapy, they can more readily recognize them and favorably affect outcome.

Clinical practice guidelines for the management of sporotrichosis: 2007 update by the Infectious Diseases Society of America

Guidelines for the management of patients with sporotrichosis were prepared by an Expert Panel of the Infectious Diseases Society of America and replace the guidelines published in 2000. The guidelines are intended for use by internists, pediatricians, family practitioners, and dermatologists. They include evidence-based recommendations for the management of patients with lymphocutaneous, cutaneous, pulmonary, osteoarticular, meningeal, and disseminated sporotrichosis. Recommendations are also provided for the treatment of sporotrichosis in pregnant women and in children.

Epidemiology of sporotrichosis: A study of 304 cases in Brazil

BACKGROUND

Sporotrichosis is an infection caused by Sporothrix schenckii . It primarily involves the skin and lymphatic channels, but dissemination may occur.

OBJECTIVE

We sought to describe clinical and epidemiologic features of cases of sporotrichosis observed in southern Brazil, and to review the literature. Methods We conducted a retrospective analysis of medical records over a 35-year period, from 1967 to 2002.

RESULTS

In all, 304 cases of sporotrichosis confirmed by fungal culture, histopathologic examination, and/or remission of lesions with potassium iodide were reviewed. No statistical difference was found between the number of patients with fixed cutaneous sporotrichosis and those with the lymphangitic type. Multifocal and extracutaneous involvement was verified. The upper extremity was the most affected site. Unusual sites, such as the penis and pubic region, were also involved.

CONCLUSION

Sporotrichosis is endemic in the study area. There is much to be learned about S schenckii . More studies and therapeutic options are still needed.

Cutaneous sporotrichosis in Himachal Pradesh, India

During the period 1990-2002 in Himachal Pradesh, India, 103 new patients with cutaneous sporotrichosis were detected. Lymphocutaneous and fixed cutaneous varieties were the most common and seen in 49% and 43% respectively. Chronic non-specific inflammation without granuloma formation was seen in 46% skin biopsy specimens, 29% showed acute or chronic inflammation and tuberculoid granuloma formation was seen in 25%. In 32% of cases Sporothrix schenckii growth was seen on Sabouraud glucose agar. A saturated solution of potassium iodide was used as first-line treatment and in 93% patients healing of lesions occurred in 4-32 weeks (average 8.7 weeks) without significant side-effects. Itraconazole, used in 12 patients, was highly effective in recommended doses. Rapid healing was seen with higher than previously used doses of fluconazole in one patient who also had unusual exacerbation of lesional inflammation with saturated solution of potassium iodide.

Liver cirrhosis developed after ketoconazole-induced acute hepatic injury

We describe a previously healthy woman who developed liver cirrhosis as a sequela of acute hepatic injury that was induced by ketoconazole administration to treat onychomycosis. The initial presentation of the disease was of a typical acute hepatitis, characterized by nausea, anorexia, fatigue, and jaundice that developed during the administration of ketoconazole. Many other causes of hepatitis were absent in the patient. Even though the hepatic injury was gradually resolved for several months after cessation of the drug, the liver function was not completely restored. Six months after the onset of illness, a follow-up abdominal computed tomography and peritoneoscopic liver biopsy were performed. They revealed a marked reduction in the liver volume and a definite cirrhotic change, which persisted for more than 5 years. The case suggests that the administration of ketoconazole can cause liver cirrhosis through acute hepatic injury within a short time under certain circumstances.

Pulmonary Cryptococcosis in Nonimmunocompromised Patients

BACKGROUND

Cryptococcus neoformans can cause serious systemic infections requiring systemic antifungal therapy in immunocompromised hosts. However, isolated pulmonary cryptococcosis in nonimmunocompromised hosts has been reported to resolve spontaneously without treatment.

STUDY OBJECTIVE

s: To determine the role of antifungal therapy in the management of isolated pulmonary cryptococcosis in nonimmunocompromised hosts.

DESIGN

Retrospective study.

SETTING

Tertiary care, referral medical center

PATIENTS

Thirty-six nonimmunocompromised subjects with isolated pulmonary cryptococcosis who received diagnoses at the Mayo Clinic (Rochester, MN) from 1976 to 2001.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Of 42 nonimmunocompromised subjects with cryptococcal infections, 36 (86%) had isolated pulmonary cryptococcosis. The mean (+/- SD) age of these 36 patients was 61 +/- 15 years (range, 14 to 88 years), and the groups included 17 men (47%) and 19 women (53%). Twenty-four patients (67%) were symptomatic, and 12 patients (33%) were asymptomatic. The most common presenting symptoms were cough, dyspnea, and fever. Cultures of sputum and bronchial washings most commonly yielded the diagnosis. Cerebrospinal fluid examination was performed in 11 patients (31%) and was negative in all of them. Follow-up information was available on 25 patients (69%) with a median duration of 19 months (range, 1 to 330 months). Twenty-three of these patients (92%) had resolution of their disease (no treatment, 8 patients; surgical resection only, 6 patients; and antifungal therapy, 9 patients). The condition of the two remaining patients had improved. There was no documented treatment failure, relapse, dissemination, or death in any of these 25 patients.

CONCLUSIONS

Our findings suggest that an initial period of observation without the administration of antifungal therapy is a reasonable option for nonimmunocompromised subjects with pulmonary cryptococcosis in the absence of systemic symptoms or evidence of dissemination, as well as after surgical resection for focal cryptococcal pneumonia.

Cutaneous sporotrichosis: an unusual clinico-pathologic and therapeutic presentation

This report presents a number of unusual clinico-histopathologic and therapeutic features in a culture proven case of cutaneous sporotrichosis. These include lymphocutaneous sporotrichosis involving face; its dissemination in an otherwise healthy patient; its histology mimicking cutaneous cryptococcosis; two episodes of severe purulent inflammatory reaction bordering the lesion during therapy with saturated solution of potassium iodide; no therapeutic response to potassium iodide therapy and rapid healing of lesion with high-dose of fluconazole.

Subcutaneous mycoses

Subcutaneous mycoses include a heterogeneous group of fungal infections that develop at the site of transcutaneous trauma. Infection slowly evolves as the etiologic agent survives and adapts to the adverse host tissue environment. Diagnosis rests on clinical presentation, histopathology, and culture of the etiologic agents. This article considers sporotrichosis, chromoblastomycosis, and mycetoma.

Cryptococcosis

Cryptococcus neoformans has risen to a worldwide highly recognizable major opportunistic pathogen with deadly consequences. It has become a model fungus to study a variety of paradigms in the host-fungus relationships. Genomic studies are advancing knowledge on its evolution and dissecting its virulence composite. Studies designed to understand host immunology to this fungus are leading to development of active and passive prevention and therapeutic strategies. This article collates and analyzes both new and old knowledge about the pathogen to help frame the meaning of human cryptococcosis as it starts to evolve in the new millennium.

Ketoconazole potentiates the antitumor effects of nocodazole: In vivo therapy for human tumor xenografts in nude mice

Our previous studies demonstrated that the oral antifungal agent ketoconazole (KT) induces apoptosis and G0/G1 phase cell cycle arrest in human cancer cell lines. In this study, we first demonstrated that KT (1 microM) potentiated the apoptotic effects of nocodazole (ND, 1 nM) in COLO 205 cancer cells. We further demonstrated the therapeutic efficacy of a combined treatment of KT (50 mg/kg/three times per week) and ND (5 mg/kg/three times per week) in vivo by treating athymic mice bearing COLO 205 tumor xenografts. The antitumor effects of ND were significantly potentiated by KT in mice after 6 wk of treatment. No gross signs of toxicity were observed in mice receiving these treatment regimens. The apoptotic cells were detected in a microscopic view of the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling staining and by observation of DNA fragmentation in KT + ND-treated tumor tissues. The levels of cell cycle regulatory proteins were determined by Western blot analysis. Treatment with KT inhibits tumor growth through elevation of p53, p21/CIP1, and p27/KIP1 as well as inhibition of cyclin D3 and cyclin-dependent kinase 4 protein expression. Immunohistochemical staining analysis showed that p53, p21/CIP1, and p27/KIP1 immunoreactivity were induced in the tumor tissues. To clarify the roles of the p21/CIP1 and p27/KIP1 protein expression involved in G(0)/G(1) arrest and/or apoptosis induced by a combined treatment with KT and ND, antisense oligodeoxynucleotides (ODNs) specific to p21/CIP1 and p27/KIP1 were used. Our results demonstrated that apoptotic phenomena, including BAX induction and cytochrome C released from mitochondria induced by KT + ND, were significantly attenuated by pretreatment the cells with the p27/KIP1-specific antisense ODNs. These results indicate that p27/KIP1 protein does indeed play a critical role in the KT + ND-induced apoptosis. Our study revealed the molecular mechanism of KT + ND in regression of the tumor growth. The apoptotic effects of KT in a great variety of cancer cells make it a very attractive agent for cancer chemotherapy.

Ketoconazole induces G0/G1 arrest in human colorectal and hepatocellular carcinoma cell lines

Ketoconazole is an oral-antifungal agent that has been used worldwide in the treatment of some hormone-dependent human cancer. In this study, we demonstrated that ketoconazole (20 microM) induced various types of human cancer cell growth arrest in the G0/G1 phase. Our results revealed that ketoconazole-induced growth arrest was more profound in COLO 205 and Hep G2 (with wild-type p53) than in HT 29 (p53 His(273) mutant) and Hep 3B (with deleted p53) cells. The protein levels of p53, p21/Cip1, and p27/Kip1 were significantly elevated by ketoconazole (10 microM) treatment in COLO 205 but not in HT 29 cells. The ketoconazole-induced G0/G1 phase arrest in COLO 205 cells was attenuated by p53-specific antisense oligodeoxynucleotides (20 microM) treatment. These results suggested that the p53-associated signaling pathway is involved in the regulation of ketoconazole-induced cancer cell growth arrest. By Western blot analysis, we demonstrated that cyclin D3 and CDK4 protein but not other G0/G1 phase regulatory protein levels were decreased by ketoconazole-treatment in both COLO 205 and HT 29 cells. Our study provides the basis of molecular mechanisms for ketoconazole in growth inhibition of human cancer cells and such results may have significant applications for cancer chemotherapy.

Drug resistance in Cryptococcus neoformans

Cryptococcus neoformans has become a major opportunistic fungal pathogen worldwide. Successful treatment of invasive disease with this fungus has used amphotericin B, flucytosine and various azoles. However, treatment failures continue to occur for a variety of reasons including direct antifungal drug resistance. Issues and mechanisms for antifungal drug resistance in Cryptococcus neoformans are reviewed. Furthermore, approaches and strategies for prevention and treatment of antifungal drug resistance are identified and these include host immune modulation, dose optimization, prophylaxis/empirical regimens, improved drug delivery systems such as lipid preparations of amphotericin B, surgery, combination antifungal treatments and development of new antifungal agents. Copyright 1999 Harcourt Publishers Ltd.

Antifungal agents. Part II. The azoles

Before 1978, amphotericin B and flucytosine were the only drugs available for the treatment of systemic fungal infections. The imidazoles, miconazole and ketoconazole, were introduced during the next 3 years. Intravenously administered miconazole served a limited therapeutic role and is no longer available. Orally administered ketoconazole, an inexpensive, effective, and convenient option for treating mucosal candidiasis, was widely used for a decade because it was the only available oral therapy for systemic fungal infections. During the 1990s, use of ketoconazole diminished because of the release of the triazoles--fluconazole and itraconazole. Fluconazole is less toxic and has several pharmacologic advantages over ketoconazole, including penetration into the cerebrospinal fluid. In addition, it has superior efficacy against systemic candidiasis, cryptococcosis, and coccidioidomycosis. Despite a myriad of drug interactions and less favorable pharmacologic and toxicity profiles in comparison with fluconazole, itraconazole has become a valuable addition to the antifungal armamentarium. It has excellent activity against sporotrichosis and seems promising in the treatment of aspergillosis. Itraconazole has replaced ketoconazole as the therapy of choice for nonmeningeal, non-life-threatening cases of histoplasmosis, blastomycosis, and paracoccidioidomycosis and is effective in patients with cryptococcosis and coccidioidomycosis, including those with meningitis. Further investigation into the development of new antifungal agents is ongoing.

Intracranial fungal granuloma

BACKGROUND

Intracranial fungal granulomas are uncommon and their pathogenesis, clinical picture, and effectiveness of therapy remains unclear.

METHODS

Thirty-two cases were studied retrospectively in two groups: (1) Rhinocerebral group (22 cases) had a chronic paranasal sinus (PNS) disease with secondary involvement of skull base, cranial nerves, and/or brain. The granulomas were adherent to dura, firm, avascular, and tough, requiring a knife to cut. (2) Primary intracranial group (10 cases) had no detectable PNS lesion at initial presentation. The granulomas were soft, suckable, and contained pus or necrotic material.

RESULTS

Postoperative and overall mortality were 37.5% and 50%, respectively. Meningoencephalitis was the most common cause of death. Altered sensorium, pus in the granuloma, and/or severe brain edema were poor prognostic factors. All survivors except four have symptomatic residual or recurrent lesions.

CONCLUSION

Early diagnosis with MRI or stereotactic biopsy, radical surgery, and high dose and chronic suppressive chemotherapy may improve overall results in these cases.

Drug treatment of HIV-related opportunistic infections

The AIDS epidemic has led to the emergence of several disease entities which in the pre-AIDS era were rare or seemingly innocuous. Experience of treating these diseases varies. In some instances, such as Pneumocystis carinii pneumonia, there is an abundance of published literature to direct our course of action. However, for many of these newly recognised diseases our treatment experience is limited. Furthermore, in many instances, well controlled trials evaluating treatment modalities in the AIDS population are lacking. We have identified 13 disease entities (P. carinii pneumonia, toxoplasmosis, cryptococcosis, histoplasmosis, Mycobacterium tuberculosis, Mycobacterium avium complex, cytomegalovirus, coccidioidomycosis, isosporiasis, candidosis, Kaposi's sarcoma, herpes simplex virus, and varicella zoster virus) and have reviewed the current literature with regard to their treatment.

A study of physiological responses during match play in Indian national kabaddi players

OBJECTIVE

To determine the physical and physiological profile of kabaddi players and the physiological demands of playing a kabaddi match.

METHODS

Maximum aerobic capacity (VO2max), maximum ventilation (VEmax), O2 pulse, respiratory equivalent (RE), maximum heart rate, and O2 debt were assessed on 16 players. The somatotype of the players was calculated by the Health and Carter method. Heart rate was monitored during a selection trial match on eight players who represented India in the Asian Games, 1994. From the playing heart rate, oxygen consumption (VO2) was computed through a heart rate v VO2 regression equation. Maximum lactate was evaluated from the blood samples collected at the end of the match.

RESULTS

The average heart rate and oxygen consumption during the match were 146.5 (SD 9.25) beats min-1 and 2.25(0.59) litre min-1 respectively. During raiding the maximum heart rate attained varied from 162.4(11.3) to 177.4(4.2) beats min-1. Out of 40 min of match play a raider raided on average on 8.13(2.03) occasions. The average time per raid was 20.8(6.26) s. The match heart rate and oxygen consumption was 72.3-83.3% of the maximum heart rate, and 43.5-70.5% of VO2max respectively. Maximum lactate at the end of the match was 6.13(2.53) mmol litre-1. Kabaddi players had the somatotype of 2.68-4.71-1.83, with absolute back strength of 175.0 kg. VO2max and O2 debt were 3.59(0.36) litre min-1 [47.82(3.68) ml kg-1 min-1] and 5.3(1.85) litres (70 ml kg-1) respectively.

CONCLUSIONS

Kabaddi is an intermittent sport. The rest pause during the game is sufficient for recovery. During raiding the main source of energy is anaerobic.

Cryptococcosis in the era of AIDS--100 years after the discovery of Cryptococcus neoformans

Although Cryptococcus neoformans and cryptococcosis have existed for several millennia, a century has passed since the discovery of this encapsulated yeast and its devastating disease. With the advent of the AIDS pandemic, cryptococcal meningitis has emerged as a leading cause of infectious morbidity and mortality and a frequently life-threatening opportunistic mycosis among patients with AIDS. Both basic and clinical research have accelerated in the 1990s, and this review attempts to highlight some of these advances. The discussion covers recent findings, current concepts, controversies, and unresolved issues related to the ecology and genetics of C. neoformans; the surface structure of the yeast; and the mechanisms of host defense. Regarding cell-mediated immunity, CD4+ T cells are crucial for successful resistance, but CD8+ T cells may also participate significantly in the cytokine-mediated activation of anticryptococcal effector cells. In addition to cell-mediated immunity, monoclonal antibodies to the major capsular polysaccharide, the glucuronoxylomannan, offer some protection in murine models of cryptococcosis. Clinical concepts are presented that relate to the distinctive features of cryptococcosis in patients with AIDS and the diagnosis, treatment, and prevention of cryptococcosis in AIDS patients.

Liposomal amphotericin B therapy of murine histoplasmosis

Liposomal amphotericin B (AmBisome) was compared with amphotericin B deoxycholate for the treatment of disseminated murine histoplasmosis. Liposomal amphotericin B was well tolerated and, milligram for milligram, was as potent as amphotericin B deoxycholate.

Sporotrichosis of the hand: an urban experience

Sporotrichosis is uncommon in Canadian urban centers. Lymphocutaneous and fixed cutaneous are the most common cutaneous forms of the disease, typically seen in the upper extremity in adult patients. History usually reveals a puncture injury contaminated with soil. Lesions are refractory to commonly used antibiotics. Cultures of biopsy specimens reliably grow the fungus Sporothrix schenkii. First line treatment is oral potassium iodide. We have reviewed a series of 7 cases from various Toronto teaching hospitals and compared them to the world literature.

Fungal pneumonia

Fungal pneumonias are rare but important. Sometimes the clinical presentation is identical to more common bacterial or atypical pneumonias. In such cases, the diagnosis is either not made or is made accidentally from diagnostic specimens obtained to determine the likely bacterial pathogen. Other cases look like routine bacterial or atypical pneumonia at presentation but do not improve or even progress as they are being treated with appropriate antibacterial agents. In such cases, it is important not to give a series of treatment courses with different antibacterial antibiotics that all cover essentially the same range of pathogens. Rather the diagnostic efforts must be escalated, progressing to more aggressive measures (fiberoptic bronchoscopy, fine needle aspiration, and rarely thoracoscopic or traditional open lung biopsy) until a specific diagnosis is reached. In some cases, there are clinical clues that point to a fungal cause. Attention to these clues can lead to early initiation of appropriate diagnostic sequences, faster diagnosis, and earlier initiation of specific therapy. A review of some of these clinical clues is provided in Table 1.

Neonatal renal candidiasis

A case is presented of renal candidiasis complicated by obstructive uropathy in a 4 month old infant. Management was successful with surgical decompression combined with peri-operative amphotericin B, followed by 3 weeks of oral ketoconazole and subsequently 6 weeks of oral fluconazole. Fluconazole was substituted for ketoconazole owing to persistent candiduria, and achieved rapid urinary sterilization. Fluconazole is an effective and less toxic alternative to prolonged courses of amphotericin B in the treatment of neonatal renal candidiasis.

Efficacy of oral amphotericin B in AIDS patients with thrush clinically resistant to fluconazole

Reports of thrush clinically refractory to azoles in AIDS patients are increasing with the more widespread use of these agents. We studied our own oral preparation of amphotericin B in the treatment of two AIDS patients who developed oral thrush due to Candida glabrata after prolonged fluconazole use. Improvement occurred in both in less than 1 week, with eventual clearing and absence of side effects. Oral amphotericin B may have advantages over alternatives for this increasing problem.

Treatment of sporotrichosis with itraconazole. NIAID Mycoses Study Group

PURPOSE

To describe the clinical presentation and outcomes of treatment with itraconazole in patients with sporotrichosis.

METHODS

A culture for Sporothrix schenckii or compatible histopathology was required for inclusion in the study. Patients with both cutaneous and systemic sporotrichosis were treated. Patients received from 100 to 600 mg of itraconazole daily for 3 to 18 months. Patients were classified as responders or nonresponders. Responders were further classified as remaining on treatment, relapsed, or free of disease. Nonresponders included patients who failed to respond or progressed during treatment with itraconazole.

RESULTS

Twenty-seven patients (mean age: 53 years) were treated with 30 courses of itraconazole. Diabetes mellitus and alcoholism were present in eight and seven patients, respectively. Sites of involvement included lymphocutaneous alone in 9 patients, articular/osseous in 15 (multifocal in 3), and lung in 3. Prior therapy was unsuccessful in 11 patients. Among the 30 courses, there were 25 responders and 5 nonresponders. All 5 nonresponders received at least 200 mg daily of itraconazole for durations that ranged from 6 to 18 months. Of the 25 responders, 7 relapsed 1 to 7 months after treatment durations of 6 to 18 months. Of the 7 who relapsed, 2 are responding to a second course. One responder was lost to follow-up after 10 months of treatment with itraconazole. Of the remaining 17 responders, 3 remain on treatment, and 14 are free of disease over follow-up durations of 6 to 42 months (mean: 17.6 months). Itraconazole was well tolerated with few side effects noted.

CONCLUSIONS

These results document the efficacy of itraconazole in the treatment of cutaneous and systemic sporotrichosis.

Sporotrichosis presenting as arthritis and subcutaneous nodules

Arthritis is a rare manifestation of systemic sporotrichosis. A patient who had sporotrichal arthritis of both wrists and elbows is described. Predisposing factors included alcoholism, rose gardening, and antecedent trauma. The onset of the arthritis was insidious, and the diagnosis was made 2 1/2 years after his first symptoms were noted. Treatment with surgical debridement and a 23-week course of ketoconazole was unsuccessful. A review of the literature suggests that some combination of intravenous or intraarticular amphotericin B and potassium iodide, ketoconazole, or surgery is necessary for effective treatment.

Orofacial manifestations of the systemic mycoses

Aspergillosis, cryptococcosis and zygomycosis (mucormycosis) are overall the most common systemic mycoses but histoplasmosis is particularly endemic in parts of central USA and other areas worldwide. Orofacial lesions caused by systemic mycoses have rarely been reported in the past though they have been recorded particularly in outdoor workers from geographic areas with a high prevalence of infection and occasionally in immunocompromised individuals. Increasing world-wide travel, and the dramatic increase in numbers of immunocompromised persons, especially those with human immunodeficiency virus (HIV) disease, have been responsible for an increase in reports and other studies of orofacial disease in systemic mycoses and new opportunists are now being recognized. Those in Oral Medicine and Pathology must now be aware of the possibility of a systemic mycosis as the cause of chronic oral ulceration, chronic maxillary sinus infection, or bizarre mouth lesions, especially in patients with HIV disease, lymphoproliferative disorders, or diabetes mellitus, or in those who have been in endemic areas. Diagnosis and management should be undertaken in consultation with a physician with appropriate expertise, as pulmonary and other systemic infection may well be present. This paper reviews the eight main systemic mycoses.

Case report: treatment of blastomycosis with fluconazole

The authors present two cases of systemic blastomycosis successfully treated with fluconazole. In one case, the disease involved the respiratory tract, and the central nervous system was presumed to be involved. The second case consisted only of pulmonary blastomycosis. Both patients were treated with oral fluconazole 200 mg twice per day for 9 and 6 months, respectively. Treatment with this new triazole antifungal agent resulted in the complete resolution of the disease in both patients. They have remained asymptomatic for more than 6 months after the completion of therapy.

Antifungal agents used for deep-seated mycotic infections

The increased use of immunosuppressive regimens in organ transplantation and in the treatment of malignant lesions and the epidemic of acquired immunodeficiency syndrome (AIDS) are major reasons for the greater prevalence of fungal infections seen in clinical practice during the past decade. The traditional cornerstone of antifungal treatment, amphotericin B, continues to play a major role in deep-seated mycotic infections. The indications for intravenously administered miconazole have become limited. Orally administered flucytosine remains useful in certain infections, particularly cryptococcal meningitis. The new orally administered antifungal agents ketoconazole and fluconazole have been approved for clinical use and have supplanted amphotericin B in certain situations. Investigational antifungal agents, including liposomal amphotericin B, itraconazole, and saperconazole, hold promise for the future. Active investigation in the development of new antifungal agents is expected to continue.