Subcutaneous mycosis caused by filamentous basidiomycete Megasporoporia setulosa-first report of human infection

Filamentous basidiomycetes are an emerging cause of human infection in tropical and subtropical regions. We report a case of subcutaneous infection caused by the shelf fungus, Megasporoporia setulosa, in an immunocompetent male. This is also the first report of human infection caused by this filamentous basidiomycete. Identification of the fungus could only be achieved by sequencing the ITS and LSU regions of rDNA. The patient recovered following surgery and treatment with amphotericin B and oral itraconazole. This report underscores the cross-kingdom pathogenicity of plant fungi and the importance of molecular tools for definitive identification of nonsporulating fungal species.

First report of human infection caused by Curvularia warraberensis, manifesting as invasive sinusitis with intracranial involvement

Curvularia species are saprophytic dematiaceous fungi commonly isolated from environmental sources. Most often, they are responsible for allergic fungal rhinosinusitis, an intense, allergic inflammatory sinus disease in immunocompetent individuals. Though invasive infections are rare and more commonly observed in immunocompromised patients, recent reports indicate an increasing trend of invasive sinusitis caused by Curvularia species in immunocompetent hosts. Over the past few years, new species of the genus Curvularia are increasingly being recognized as human pathogens. Here, we report the first human infection caused by Curvularia warraberensis, a cryptic species of Curvularia primarily described as an endophyte in Australian grasses. The 33-year-old female presented with chronic invasive sinusitis of the sphenoid and ethmoid sinuses that progressed to involve the pituitary gland, mid-brain, the facial-vestibulocochlear nerve complex, and basilar artery. The patient underwent endoscopic sinus surgery. Histopathology, microscopic examination and culture of biopsy tissues revealed a dematiaceous fungus that was identified as C. warraberensis, based on sequencing the internal transcribed spacer (ITS) and large subunit (LSU) regions of ribosomal DNA. Antifungal susceptibility testing (AFST) showed low minimum inhibitory concentrations (MICs) for amphotericin B (1 µg/mL), itraconazole (0.25 µg/mL) and posaconazole (0.125 µg/mL). Accurate identification and AFST are crucial for making treatment decisions as some Curvularia species demonstrate variable susceptibility to antifungal agents. The patient died despite combined surgical and medical intervention owing to late presentation and delay in initiating antifungal therapy. A high index of suspicion together with an early diagnosis and aggressive treatment may improve the outcome in such cases.

Mucormycosis caused by Apophysomyces species: An experience from a tertiary care hospital in Western India and systematic review of global cases

Apophysomyces species are an emerging cause of mucormycosis in several regions of the world, primarily affecting immunocompetent individuals. The present study addresses the global epidemiology, clinical presentation, management and outcome of mucormycosis caused by Apophysomyces spp. The study included patients diagnosed with Apophysomyces infection at our hospital between March 2019 and August 2020. In addition, cases published in PubMed and Google Scholar from inception to July 2022 were systematically searched and analysed. Only proven and probable cases that meet the eligibility criteria were included. The Indian cases were compared with those from other countries, and the results were analysed by descriptive statistics. In total, six cases of mucormycosis due to Apophysomyces spp. were diagnosed at our hospital, with additional 250 cases identified through literature search. The main underlying diseases were diabetes mellitus (24%), malignancy (3.2%) and chronic kidney disease (2.8%). The major predisposing factor was trauma (55.6%). Necrotizing fasciitis was the most common (63.2%) clinical presentation. Healthcare-associated mucormycosis accounted for 10.4% of the cases. Globally, A. elegans was the most common species (48.8%), whereas A. variabilis was predominant (86.2%) in India. Surgery was performed in 83.5% of patients. Among those treated with antifungal agents, 98% received amphotericin B and 8.1% received posaconazole. Inappropriate antifungal usage was observed in 12.7%. The overall mortality was 42.3%. A combined medical and surgical management was associated with higher survival. Our study highlights the knowledge gap among physicians regarding this infection. A timely diagnosis and aggressive management can improve the outcomes in such cases.

First case of neonatal fungemia caused by Aureobasidium melanogenum

Aureobasidium melanogenum is a saprophytic, dematiaceous, yeast-like fungus rarely implicated in human infections. Here, we report the first case of A. melanogenum fungemia in a 30-week-old preterm, very low birth weight neonate born to a primigravida with history of gestational diabetes, pregnancy induced hypertension and oligohydramnios. The baby developed respiratory distress, hypotension, bradycardia, coagulopathy and septic shock shortly after birth, and eventually succumbed to multiple organ dysfunction syndrome on day 9 of life. Paired blood culture showed growth of a dematiaceous yeast-like fungus which was identified as A. melanogenum by rDNA internal transcribed spacer (ITS) sequencing. Antifungal susceptibility testing of the isolate showed high minimum inhibitory concentration of fluconazole (32 µg/mL), indicating resistance. Diagnosis of A. melanogenum fungemia is difficult as it is easily confused with Candida species in Gram stained smears and similar colony morphology during the initial stages of growth. Also, the conventional diagnostic methods, such as VITEK 2 and MALDI-TOF MS are unreliable for identification of this pathogen. Accurate identification using molecular techniques is crucial for making treatment decisions as A. melanogenum shows substantial antifungal resistance. Clinicians should be aware that yeast-like cells in blood culture are not only indicative of Candida species, but also rare pathogens like A. melanogenum and should exercise caution while starting fluconazole therapy. At present, there are no established susceptibility breakpoints for Aureobasidium spp. Further studies are needed to determine the optimal treatment for such infections.

P272 Fungal brain abscess in the era of COVID 19: an experience from a tertiary care Neurosciences Institute in South India

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is ruling the world for more than 2 years since 2020. In 2021, the second wave of COVID-19 attributed to the ‘delta variant’ swept across India, causing significant morbidity and mortality. In addition, the epidemic of COVID-19-associated mucormycosis affected the Indian subcontinent specifically, with a whopping 41 512 cases and 3554 deaths attributed to this dreadful disease.

Methods

The single-center retrospective cross-sectional study was aimed to determine the impact of COVID-19 on fungal brain abscess cases at a non-COVID tertiary care Neurosciences Institute in South India. The study included all cases diagnosed with fungal brain abscess microbiologically (microscopy and/or fungal culture), supported by radiological findings or by histopathological examination. Cases of brain abscess which were negative for fungal elements by microscopy, culture, and imaging were excluded from the study. Fungal culture was done on routine mycological media as per standard procedures. Fungal identification was done by microscopic morphology, MALDI-TOF MS, and ITS sequencing.

Results

A total of 406 cases of brain abscess were recorded between January 2020 and April 2022. Out of these, 26 (6.4%) were cases of fungal brain abscess. In 2020, three out of 153 (2%) cases had a fungal etiology, while it was 10.4% (22/211) in 2021 and 0.24% (1/42) till April 2022. Overall, a male preponderance was observed (20/26, 77% were males). The cases had an even distribution from 6 to 62 years, with no predilection in any particular age group. The most common underlying comorbidity was type 2 diabetes mellitus (13/26, 50%). Four cases had a past history of COVID-19. Radiological suspicion of fungal infection was present in all the cases. Mycological examination (wet mount and 20% KOH mount) of brain abscess pus from all the cases revealed fungal elements. Out of 26 cases, 23 cases showed hyaline, broad aseptate hyphae, 2 showed melanized septate hyphae and 1 showed budding yeast cells with pseudohyphae and arthroconidia on direct microscopy. Culture positivity was observed in 15 cases (57.7%). Out of 23 suspected cases of rhinocerebral mucormycosis based on clinical, radiological, and direct microscopic findings, fungal culture was positive in 13 cases, all of which were identified as Rhizopus arrhizus. Out of two cases that showed melanized hyphae in direct microscopy, one grew a dematiaceous mold that was identified as Cladophialophora bantiana. The other melanized fungus failed to grow in culture. The single case of brain abscess caused by a yeast-like fungus was attributed to Trichosporon dohaense, identified by ITS sequencing. It was initially misidentified as T. ovoides/T. mucoides by VITEK MS due to lack of mass spectral database for T. dohaense.

Conclusions

A significant increase in the incidence of fungal brain abscess has been observed in the COVID-19 era, particularly with each new wave of infection. Clinical features along with imaging and mycological findings are crucial in making an early diagnosis and decision regarding antifungal therapy. Accurate identification to the species level is necessary to guide optimal antifungal therapy as several species exhibit emerging resistance to antifungal drugs.

P231 The first case of neonatal fungemia caused by Aureobasidium melanogenum

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Background

Aureobasidium melanogenum is a ubiquitous, saprophytic, dematiaceous fungus commonly isolated from environmental sources. It has the highest virulence potential among all Aureobasidium species and is implicated in catheter-related infections, particularly in immunocompromised hosts.

Case Report

A 6-day-old female child was admitted to the neonatal intensive care unit (NICU), AIIMS, Jodhpur with respiratory distress, hypotension, bradycardia, and sepsis. The baby was preterm with a very low birth weight (1140 g) and was born to a 34-year-old G3P1A2 mother at 30 weeks gestation by elective caesarian section at a private hospital. The mother had a primary ovarian failure and had a history of spontaneous abortions for two consecutive times following in vitro fertilization. She also had a history of gestational diabetes mellitus and pregnancy-induced hypertension, for which she was on medication. At birth, the baby had respiratory distress (Apgar scores were 6 and 7 at 1 and 5 minutes of life, respectively), for which she was shifted to NICU and intubated. On day 2, she developed hypotension, bradycardia, hypocalcemia, and sepsis with deranged coagulation profile, for which she received inotropes, broad-spectrum antibiotics, fluconazole, and fresh frozen plasma. On day 3, the baby developed chest retractions and seizure-like episodes with intermittent myoclonic jerks and was started on anti-epileptics. She had persistently raised serum urea, creatinine, and C-reactive protein from day 3 of life. Due to clinical deterioration, she was shifted to AIIMS NICU for further management where she was continued on inotropes, broad-spectrum antibiotics, and fluconazole. After 46 h of admission at AIIMS NICU, the baby developed hypotension with cold extremities, feeble pulses, and increased ventilatory requirements. Chest X-ray showed bilateral diffuse infiltrates suggestive of acute respiratory distress syndrome. Culture of tracheal aspirate yielded Klebsiella pneumoniae, sensitive to piperacillin/tazobactam, amikacin, and carbapenems. The patient was started on intravenous meropenem and colistin. Blood culture showed growth of Gram-positive budding yeast cells after 48 h of incubation (Fig. 1). Subculture on Sabouraud dextrose agar revealed yeast-like colonies, initially cream-colored, becoming dark-brown with an olive-green feathery margin (Fig. 2a). Microscopically, the isolate had septate pigmented hyphae with ellipsoidal hyaline conidia (Fig. 2b). The morphologic features were consistent with Aureobasidium species. Sequencing the internal transcribed spacer region of rDNA confirmed the identity of the isolate as A. melanogenum. Antifungal susceptibility testing revealed the following MICs: amphotericin B, 0.5 μg/ml, itraconazole, 0.25 μg/ml, voriconazole, 0.125 μg/ml, fluconazole, 16 μg/ml, and caspofungin, 0.25 μg/ml. Despite maximum inotropic and ventilatory support, the baby had persistent desaturations and hypoxia and developed multiple organ dysfunction syndrome, following which she succumbed to death on day 3 of admission to AIIMS.

Conclusion

This is the first documented case of neonatal fungemia caused by the emerging yeast A. melanogenum. The patient had multiple arterial and intravenous catheters and this could be the portal of entry of the pathogen. Accurate identification is crucial for initiating appropriate antifungal therapy. Physicians should be mindful of possible A. melanogenum infection in patients with risk factors, and provide appropriate antifungal therapy with the removal of indwelling catheters whenever possible.

P337 Species distribution and biofilm profile of Candida isolated from clinical specimens at a tertiary care hospital in India

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM

 

Introduction

The epidemiology of invasive candidiasis (IC) is dynamically changing, given the increasing population of susceptible hosts, use of indwelling medical devices (IMD), and environmental factors. The presence of an IMD is one of the most important risk factors for persistent infection due to the possibility of biofilm formation. The biofilm cells are significantly less susceptible to antifungal drugs and are able to evade the host immune system, serving as a nidus for reinfections.

Objectives

Methods

A total of 100 Candida isolates from patients with suspected invasive candidiasis were tested for the production of biofilm. Based on clinical history, 62% of the isolates were found to be clinically significant, while 38% represented commensals or colonizers. Species identification was done on the basis of germ tube test, CHROMagar, Dalmau plate technique, and carbohydrate fermentation and assimilation tests, and VITEK 2. Four isolates that failed to be identified by conventional methods were subjected to MALDI-TOF MS. Biofilm production was detected and graded by visual (test tube) and spectrophotometric (microtiter plate) methods.

Results

Non-albicans Candida (NAC) were the predominant clinically relevant isolates recovered from cases of IC (71%), while C. albicans was most commonly associated with colonization (68.4%). Among the NAC isolates, C. tropicalis was the most common isolate (23%) followed by C. glabrata (11%), C. krusei (8%), C. parapsilosis (6%), C. lusitaniae (2%), C. kefyr (2%), C. rugosa (2%), C. guilliermondii (1%), and C. famata (1%) (Fig. 1). A total of 55% of the Candida isolates produced biofilm. Biofilm positivity in clinically relevant isolates was found to be significantly higher than commensals/colonizers (P <.05). Biofilm positive Candida spp. were most commonly isolated from urine (84.6%) followed by blood (67.8%). Biofilm production by NAC (69%) was found to be significantly higher than C. albicans (31%) (P <.05). Majority of the biofilm positive isolates produced Grade 2 (moderate) biofilm (36.4%). C. tropicalis accounted for maximum biofilm production comprising 20% of Grade 4, 53.8% of Grade 3, and 50% of Grade 2 biofilm (Fig. 2). There was 72.7% concordance between the two methods in grading of biofilm. Spectrophotometric method was found to be more sensitive than a visual method for the detection of biofilm.

Conclusion

Our study demonstrated a paradigm shift from C. albicans to NAC with the isolation of C. tropicalis from a large number of cases, highlighting the growing importance of this pathogen. The knowledge about local epidemiological trends of Candida spp. is important to guide therapeutic choices. Moreover, clinically relevant Candida spp. were found to possess a greater ability to produce biofilms than commensals or colonizers. These findings are unique as previous studies haven't differentiated between biofilms formed by commensal Candida populations and those related to infections. This study highlights that biofilm production should be considered a relevant biologic variable while treating patients with invasive candidiasis, particularly those who fail to respond to antifungal therapy.

WITHDRAWN: Pulmonary Nocardiosis Caused by Nocardia otitidiscaviarum in an Immunocompromised Patient and Its Review of Literature

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Analysis of Blood Culture Data Influences Future Epidemiology of Bloodstream Infections: A 5-year Retrospective Study at a Tertiary Care Hospital in India

Background

Blood cultures are the most significant samples received in a microbiology laboratory. Good quality control of pre-analytic, analytic, and post-analytic stages can have a significant impact on patient outcomes. Here, we present the improvements brought about by reviewing blood culture data with clinicians at a tertiary care institute in India.

Methods

Four-year blood culture data (phase I—February 2014–February 2018) were shared with clinicians in the clinical grand round. Several take-home messages were discussed in a quiz format, and a number of holistic quality control measures were implemented at different levels. Based on observable changes in blood culture reports, another dataset was analyzed and compared in phase II (April 2018–April 2019).

Results

In phase II, the blood culture contamination rate improved from 6 to 2% along with four times reduction in ICU isolates and three times increased isolation of salmonellae and pneumococci. The development of resistance in Klebsiella pneumoniae to carbapenems and piperacillin–tazobactam was reduced. Colistin resistance in ICU isolates hovered around 15%. Vaccine-preventable pneumococcal serotypes were predominant in the under-five age-group. Typhoidal salmonellae were more commonly isolated from adults with 50% showing sensitivity to pefloxacin and 97% to ampicillin, chloramphenicol, and cotrimoxazole. Candida parapsilosis was the leading non-albicans Candida (NAC). Fluconazole resistance was observed in 50% of NAC.

Conclusion

Reviewing blood culture data with clinicians mutually helped us to improve the overall quality of blood culture reports. It had a major impact on epidemiological trends and thus, found to be superior to just sharing an antibiogram with the clinicians.

How to cite this article

Sharma A, Samaddar A, Maurya A, Hada V, Narula H, Shrimali T, et al. Analysis of Blood Culture Data Influences Future Epidemiology of Bloodstream Infections: A 5-year Retrospective Study at a Tertiary Care Hospital in India. Indian J Crit Care Med 2021;25(11):1258–1262.

Fatal cerebral phaeohyphomycosis caused by Cladophialophora bantiana mimicking tuberculous brain abscess

INTRODUCTION

Cladophialophora bantiana, a neurotropic phaeoid fungus, is the primary agent of cerebral phaeohyphomycosis. The disease more commonly affects immunocompetent males and is associated with a high mortality rate.

CASE REPORT

We report a case of brain abscess caused by Cladophialophora bantiana in a 50-year-old immunocompetent male who presented with headache for two months, weakness of both lower limbs for 15 days, and altered sensorium and aphasia for one day. Contrast-enhanced MRI of the brain showed multiple coalescent abscesses in the right basal ganglia and corpus callosum. Based on clinical and radiological suspicion of tuberculoma, treatment with antitubercular drugs was initiated. A month after discharge, the patient was re-admitted with history of loss of consciousness, altered sensorium, respiratory distress and aphasia. Brain CECT revealed multiple ring-enhancing lesions in the right basal ganglia with mass effect and a leftward midline shift. The patient underwent craniotomy and evacuation of abscess. Direct microscopy of pus aspirated from the lesions showed pigmented septate fungal hyphae, which was identified as C. bantiana in fungal culture. The patient was administered intravenous liposomal amphotericin B and voriconazole. However, he died due to multiple organ failure on day 19 after surgery.

CONCLUSIONS

Fungal etiology should be considered in the differential diagnosis of intracranial space occupying lesions, regardless of the host immune status. An early diagnosis, together with aggressive medical and neurosurgical interventions are imperative for improving the survival in such patients.

First report of COVID-19-associated rhino-orbito-cerebral mucormycosis in pediatric patients with type 1 diabetes mellitus

Coronavirus disease 2019 (COVID-19) is a major public health problem worldwide. These patients are at increased risk of developing secondary infections due to a combination of virus- and drug-induced immunosuppression. Recently, several countries have reported an emergence of COVID-19 associated mucormycosis (CAM), particularly among patients with uncontrolled diabetes, with India reporting an alarming increase in rhino-orbito-cerebral mucormycosis (ROCM) in post-COVID cases. Hyperglycemia and diabetic ketoacidosis (DKA) are the major underlying risk factors. So far, case reports and review articles have reported CAM only in adult patients. Here, we describe the first cases of COVID-19-associated ROCM in two pediatric patients with Type 1 diabetes mellitus (DM). Both the cases had asymptomatic infection with SARS-CoV-2 and developed ROCM during the course of treatment of DKA. None of them had exposure to systemic steroids. Imaging findings in both cases revealed involvement of orbit, paranasal sinuses, and brain with cavernous sinus thrombosis. The patients underwent craniotomy with evacuation of abscess. Microbiological and histopathological findings were consistent with the diagnosis of mycormycosis, with fungal culture growing Rhizopus arrhizus. Post-operatively, the patients received liposomal amphotericin B (LAMB) and systemic antibiotics. Retrobulbar injection of LAMB was given in an attempt to halt orbital disease progression. However, it wasn't successful and both of them had to undergo orbital exenteration eventually. ROCM is a rapidly progressive disease and prompt diagnosis with aggressive surgery and timely initiation of antifungal therapy can be life-saving. Physicians should have a high index of suspicion, so as to avoid a delayed diagnosis, particularly in post-COVID patients with uncontrolled diabetes.

Vaccination of cancer patients against COVID-19: towards the end of a dilemma

With the emergence of second wave of COVID-19 infection globally, particularly in India in March-April 2021, protection by massive vaccination drive has become the need of the hour. Vaccines have been proved to reduce the risk of developing severe illness and are emerging as vital tools in the battle against COVID-19. As per the GLOBOCAN database, nearly 19.3 million new cancer cases have been reported in 2020 globally, which posed a significant challenge to health care providers to protect such large number of 'vulnerable' patients from COVID-19. Nevertheless, a considerable degree of doubt, hesitancy and misconceptions are noted regarding the administration of vaccines particularly during active immuno-suppressant treatment. This review article highlights the added vulnerability of cancer patients to the COVID-19 infection and has explored the immunological challenges associated with malignancy, anticancer treatment and COVID-19 vaccination.

Emergomycosis, an Emerging Systemic Mycosis in Immunocompromised Patients: Current Trends and Future Prospects

Recently, the global emergence of emergomycosis, a systemic fungal infection caused by a novel dimorphic fungus Emergomyces species has been observed among immunocompromised individuals. Though initially classified under the genus Emmonsia, a taxonomic revision in 2017 based on DNA sequence analyses placed five Emmonsia-like fungi under a separate genus Emergomyces. These include Emergomyces pasteurianus, Emergomyces africanus, Emergomyces canadensis, Emergomyces orientalis, and Emergomyces europaeus. Emmonsia parva was renamed as Blastomyces parvus, while Emmonsia crescens and Emmonsia sola remained within the genus Emmonsia until a taxonomic revision in 2020 placed both the species under the genus Emergomyces. However, unlike other members of the genus, Emergomyces crescens and Emergomyces sola do not cause disseminated disease. The former causes adiaspiromycosis, a granulomatous pulmonary disease, while the latter has not been associated with human disease. So far, emergomycosis has been mapped across four continents: Asia, Europe, Africa and North America. However, considering the increasing prevalence of HIV/AIDS, it is presumed that the disease must have a worldwide distribution with many cases going undetected. Diagnosis of emergomycosis remains challenging. It should be considered in the differential diagnosis of histoplasmosis as there is considerable clinical and histopathological overlap between the two entities. Sequencing the internal transcribed spacer region of ribosomal DNA is considered as the gold standard for identification, but its application is compromised in resource limited settings. Serological tests are non-specific and demonstrate cross-reactivity with Histoplasma galactomannan antigen. Therefore, an affordable, accessible, and reliable diagnostic test is the need of the hour to enable its diagnosis in endemic regions and also for epidemiological surveillance. Currently, there are no consensus guidelines for the treatment of emergomycosis. The recommended regimen consists of amphotericin B (deoxycholate or liposomal formulation) for 1–2 weeks, followed by oral itraconazole for at least 12 months. This review elaborates the taxonomic, clinical, diagnostic, and therapeutic aspects of emergomycosis. It also enumerates several novel antifungal drugs which might hold promise in the treatment of this condition and therefore, can be potential areas of future studies.

Viral Ribonucleic Acid Shedding and Transmission Potential of Asymptomatic and Paucisymptomatic Coronavirus Disease 2019 Patients

We studied the pattern and duration of viral ribonucleic acid (RNA) shedding in 32 asymptomatic and 11 paucisymptomatic coronavirus disease 2019 cases. Viral RNA shedding in exhaled breath progressively diminished and became negative after 6 days of a positive reverse-transcription polymerase chain reaction test. Therefore, the duration of isolation can be minimized to 6 days.

Indian agriculture, air pollution, and public health in the age of COVID

Emerging evidence supports the intuitive link between chronic health conditions associated with air pollution and the vulnerability of individuals and communities to COVID-19. Poor air quality already imposes a highly significant public health burden in Northwest India, with pollution levels spiking to hazardous levels in November and early December when rice crop residues are burned. The urgency of curtailing the COVID-19 pandemic and mitigating a potential resurgence later in the year provides even more justification for accelerating efforts to dramatically reduce open agricultural burning in India.

Mycobacterium chelonae bacteraemia in a patient with myasthenia gravis receiving long-term steroid therapy

Non-tuberculous mycobacteria (NTM) are ubiquitous environmental organisms found in soil and water. Infections caused by NTM are increasing with conditions ranging from harmless colonization to invasive infections, the latter being more common in immunocompromised hosts. In this report, we present a case of bacteraemia caused by Mycobacterium chelonae, a rapidly growing NTM belonging to Class IV in the Runyon classification, in a 71-year-old male with ocular myasthenia gravis undergoing treatment with oral prednisolone. Gram staining of these organisms from blood culture can be easily overlooked or confused with diptheroids. Detection of Gram-positive bacilli should prompt Ziehl–Neelsen staining to distinguish diphtheroids from rapidly growing mycobacteria in immunosuppressed patients. In addition, speciation and antimicrobial susceptibility testing are of paramount importance in such cases as there is considerable variation in the resistance patterns between different species of NTM. Line probe assay provides a rapid and reliable method for identification of NTM to the species level, which can guide treatment with appropriate antibiotics. This case report highlights the importance of early detection of such cases so as to optimize management and improve patient outcomes.

Pathophysiology and Potential Therapeutic Candidates for COVID-19: A Poorly Understood Arena

Coronavirus disease 2019 (COVID-19), an acute onset pneumonia caused by a novel Betacoronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in the Wuhan City of China in December 2019 and evolved into a global pandemic. To date, there are no proven drugs or vaccines against this virus. Hence, the situation demands an urgent need to explore all potential therapeutic strategies that can be made available to prevent the disease progression and improve patient outcomes. In absence of clinically proven treatment guidelines, several repurposed drugs and investigational agents are currently being evaluated in clinical trials for their probable benefits in the treatment of COVID-19. These include antivirals (remdesivir, lopinavir/ritonavir, umifenovir, and favipiravir), interferon, antimalarials (chloroquine/hydroxychloroquine), antiparasitic drugs (ivermectin and nitazoxanide), biologics (monoclonal antibodies and interleukin receptor antagonist), cellular therapies (mesenchymal stem cells and natural killer cells), convalescent plasma, and cytokine adsorber. Though several observational studies have claimed many of these agents to be effective based on their in vitro activities and extrapolated evidence from SARS and Middle East respiratory syndrome (MERS) epidemics, the currently available data remains inconclusive because of ill-defined patient selection criteria, small sample size, lack of concurrent controls, and use of intermediary outcomes instead of patient-relevant outcomes. Moreover, there is a need to clearly define the patient populations who warrant therapy and also the timing of initiation of treatment. Understanding the disease pathology responsible for the clinical manifestations of COVID-19 is imperative to identify the potential targets for drug development. This review explains the pathophysiology of COVID-19 and summarizes the potential treatment candidates, which can provide guidance in developing effective therapeutic strategies.

An injection abscess due to M. fortuitum: A rare case report

An iatrogenic injection abscess is usually easy to treat if caused by aerobic bacteria but some rapidly growing mycobacteria (RGM), namely, Mycobacterium fortuitum, M. chelonae, and M. abscessus are associated with postinjection abscess and may cause delayed wound healing. RGM can cause mild localized cellulitis or abscess to osteomyelitis following penetration injuries or unsafe injection practices. A 7-year-old girl was presented to pediatric surgery OPD with abscess formation over the right buttock. Incision and drainage from abscess were performed in OPD and pus sample was sent for aerobic bacterial culture and sensitivity. On gram stain plenty of pus cells with no microorganism were seen and growth on blood agar after 48 h of aerobic incubation at 37°C showed small off-white pinpoint, smooth butyrous waxy colonies. Smear prepared from blood agar showed uniformly stained short, slender, faintly stained gram-positive bacilli, for which acid-fast staining (1% and 20% H₂SO₄) was performed that showed acid-fast bacilli. The isolate was further identified by the molecular method and was confirmed to be Mycobacterium fortuitum by genotype Mycobacterium CM VER 1.0 (HAIN LIFESCIENCE, BioMerieux India Pvt. Ltd.).

The Enigma of Low COVID-19 Fatality Rate in India

Coronavirus disease 2019 (COVID-19), an acute onset pneumonia caused by a novel Betacoronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has rapidly evolved into a pandemic. Though its origin has been linked to the Wuhan City of China's Hubei Province in December 2019, recent reports claim that the original animal-to-human transmission of the virus probably happened sometime between September and October 2019 in Guangdong Province, rather than Hubei. As of July 3, 2020, India has reported a case positivity rate of 6.5% and a fatality rate of 2.8%, which are among the lowest in the world. Also, the severity of the disease is much less among Indians as evidenced by the low rate of ICU admission (15.3%) and the need for mechanical ventilation (4.16%). As per the World Health Organization (WHO) situation report 165 on July 3, 2020, India has one of the lowest deaths per 100,000 population (1.32 deaths against a global average of 6.04). Several factors related to the pathogen, host and environment might have some role in reducing the susceptibility of Indians to COVID-19. These include some ongoing mutations that can alter the virulence of the circulating SARS-CoV-2 strains, host factors like innate immunity, genetic diversity in immune responses, epigenetic factors, genetic polymorphisms of ACE2 receptors, micro RNAs and universal BCG vaccination, and environmental factors like high temperature and humidity which may alter the viability and transmissibility of the strain. This perspective -highlights the potential factors that might be responsible for the observed low COVID-19 fatality rate in Indian population. It puts forward several hypotheses which can be a ground for future studies determining individual and population susceptibility to COVID-19 and thus, may offer a new dimension to our current understanding of the disease.

Pulmonary infection due to Acrophialophora fusispora in a patient with underlying mixed connective tissue disease and chronic pulmonary aspergillosis: A case report and review of literature

Acrophialophora fusispora is a soil-borne fungus rarely implicated in human infections. Here, we report a case of pulmonary infection due to A. fusispora in a 59-year-old male who presented with productive cough and gradually progressive dyspnoea for 20 days. He had a past history of pulmonary tuberculosis and was a known case of chronic obstructive pulmonary disease for past five years. He was diagnosed with mixed connective tissue disease and had been receiving oral azathioprine and prednisolone for three months. CECT thorax revealed an aspergilloma and serum Aspergillus fumigatus-specific IgG levels were raised, suggestive of chronic pulmonary aspergillosis. He was also tested positive for influenza A (H1N1) and received treatment with oral oseltamivir without any clinical benefit. Culture of sputum and bronchoalveolar lavage fluid showed growth of a fungus which was identified as Acrophialophora fusispora based on characteristic microscopic morphology and internal transcribed spacer sequencing of the ribosomal DNA. Antifungal susceptibility testing for six antifungal drugs showed itraconazole to have the most potent in vitro activity (MIC=0.25μg/mL) against A. fusispora in comparison to the other drugs tested. Treatment with itraconazole capsule 200mg twice daily was initiated and favourable clinical response was observed after 10 days of therapy. Follow-up visit after three months showed marked clinical and radiological improvement. A. fusispora is an emerging opportunistic fungus capable of causing invasive infections in immunocompromised hosts. Lack of knowledge about this fungus and confusion with morphologically similar opportunistic fungi have led to its misidentification and hence its prevalence remains largely underestimated. Accurate identification is crucial as it can help initiate early effective antifungal therapy and improve patient outcomes. To our knowledge, this is the first case of pulmonary infection due to A. fusispora reported from India.

Necrotizing fasciitis caused by Apophysomyces variabilis in a burn patient

The genus Apophysomyces belonging to the order Mucorales is increasingly being reported as a cause of mucormycosis in immunocompetent patients. We report a case of necrotizing fasciitis caused by Apophysomyces variabilis in a 52-year-old immunocompetent male who sustained thermal burn in his right leg following a road-traffic accident. There was rapidly progressive necrosis of skin, soft tissues and underlying muscles which required extensive surgical debridement. Microscopic examination of excised tissues revealed broad aseptate fungal hyphae. Fungal culture on Sabouraud dextrose agar (SDA) showed growth of a mucoraceous mould which was identified as A. variabilis based on characteristic microscopic morphology and internal transcribed spacer sequencing of the ribosomal DNA. The isolate was found to sporulate on SDA, a finding that was unique as Apophysomyces spp. does not usually sporulate on primary isolation medium used in mycology laboratories. The disease progressed as there was an initial assumption of bacterial infection and the fungus was isolated late in the course of the disease because of which no antifungal drug was added to the regime. The patient left against medical advice and eventually underwent below-knee amputation at another city hospital a week later. Infection due to A. variabilis should be considered as a differential diagnosis of rapidly progressive necrosis of skin and soft tissues in immunocompetent individuals as early diagnosis and management will prevent the disease progression and a possible amputation.

Disseminated histoplasmosis in immunocompetent patients from an arid zone in Western India: A case series

Histoplasmosis is a systemic fungal disease caused by dimorphic fungus Histoplasma capsulatum and is more common in immunocompromised patients. We report two cases of disseminated histoplasmosis in immunocompetent individuals from a non-endemic zone in Western India. Rapid diagnostic tests like urinary antigen detection and molecular assays comprise the need of the hour as early initiation of antifungal therapy can be life-saving. Clinicians need to be aware of this entity to prevent misdiagnosis and initiate prompt effective management.

Infectious hepatitis: A 3-year retrospective study at a tertiary care hospital in India

Context

Acute viral hepatitis (AVH) is predominantly caused by hepatitis A virus (HAV) and hepatitis E virus (HEV), the prevalence of which varies in different geographical regions.

Aims

This study aimed to determine the prevalence of HAV and HEV infections in patients with AVH, the rate of HAV-HEV co-infection and the prevalence of HEV infection among pregnant women with hepatitis.

Settings and Design

It was a retrospective observational study conducted over 3 years from January 2015 to December 2017, after obtaining clearance from the institutional ethics committee.

Subjects and Methods

A total of 675 serum samples were collected from patients with a clinical diagnosis of AVH, between January 2015 and December 2017. The study population included outdoor and hospitalised patients between 3 and 70 years of age who presented with signs and symptoms of hepatitis. The presence of IgM anti-HAV and IgM anti-HEV antibodies in serum were assessed by enzyme-linked immunosorbent assay.

Statistical Analysis Used

Chi-square test.

Results

The prevalence of HAV, HEV and HAV-HEV co-infection was found to be 6.96%, 9.63% and 2.07%, respectively. Among males, this was 7.3%, 8.8% and 2.6%, respectively and in females 6.7%, 10.2% and 1.7%, respectively. However, these differences in the prevalence rates were of no statistical significance. The prevalence of HEV infection in pregnant women with hepatitis was 9.4%. HAV and HEV infections showed a seasonal trend with predominance during summer and rainy seasons (May to September).

Conclusions

A higher seroprevalence of HEV as compared to HAV together with a co-infection rate of 2.07% mandates screening for HEV in all suspected cases of acute hepatitis, particularly pregnant women in whom the outcomes of HEV infection are poor. Health and civic authorities should make necessary efforts to counter epidemic or outbreak situations, thus reducing morbidity, mortality and economic burden.