Candida parapsilosis bone marrow infection in an immunocompetent patient

Background

We discuss a case of an immunocompetent patient who presented with fever and tachypnoea, found to have Candida parapsilosis bone marrow infection, cultured on bone marrow aspirate sample. Candida parapsilosis is an opportunistic yeast pathogen that typically affects immunocompromised individuals, or occurs in patients with apparent introduced source; neither of these factors were present for this case. Bone marrow aspirates and trephines are not regular investigations for fever; however they can be useful diagnostic aids as evidenced in this case.

Case report

An 83-year-old woman presenting with fevers and tachypnoea was being treated for a systemic bacterial infection, however was unresponsive to empirical antibiotic therapy. To exclude an occult malignancy, an 18-fluorodeoxyglucose positron emission tomography scan was conducted. Significant bone marrow uptake was noted, prompting a bone marrow aspirate and trephine to investigate for a hematological malignancy. While the trephine biopsy was benign, a culture of the aspirate grew Candida parapsilosis. Intravenous antifungal therapy was initiated; however, the patient did not improve despite targeted therapy likely due to delays in diagnosis, and was palliated.

Conclusion

Our case seeks to demonstrate a novel case whereby a bone marrow aspirate culture provided a conclusive diagnosis of invasive Candida parapsilosis bone marrow infection, and guided treatment in an immunocompetent patient. It is important for clinicians to consider invasive fungal infections in febrile patients regardless of immune status. Additionally, when performing a bone marrow aspirate and trephine on a febrile patient, we recommend including aspirate fungal cultures to investigate for an invasive fungal infection.

Revealing the hidden interplay: the unexplored relationship between fungi and viruses beyond HIV, SARS-CoV-2 and influenza

The complex interaction between viruses and fungi has profound implications, especially given the significant impact of these microorganisms on human health. While well-known examples such as HIV, influenza and SARS-CoV-2 are recognized as risk factors for invasive fungal diseases (IFD), the relationship between viruses and fungi remains largely underexplored outside of these cases. Fungi and viruses can engage in symbiotic or synergistic interactions. Remarkably, some viruses, known as mycoviruses, can directly infect fungi, may influencing their phenotype and potentially their virulence. In addition, viruses and fungi can coexist within the human microbiome, a complex ecosystem of microorganisms. Under certain conditions, viral infection might predispose the host to an invasive fungal infection, as observed with Influenza-associated pulmonary aspergillosis or COVID-19 associated pulmonary aspergillosis. We aim in this review to highlight potential connections between fungi and viruses (CMV and other herpesviruses, HTLV-1 and respiratory viruses), excluding SARS-CoV-2 and influenza.

[Impact of the first year of the COVID-19 pandemic on the epidemiology of invasive infections (bacteremia) in the hospitals of the Assistance Publique-Hôpitaux de Paris]

Introduction

The COVID-19 pandemic has led to a massive influx of patients suffering from severe forms of the disease into hospitals, often requiring intensive care (vascular catheters, ventilation, etc.) which exposes them to high risks of nosocomial infections, particularly invasive infections (bacteremia).

Method

The impact of the COVID-19 pandemic on the epidemiology of bacteremia in 2020 was analysed in 25 hospitals of the Assistance Publique-Hôpitaux de Paris (AP-HP, approximately 14,000 beds, covering the Île-de-France region). Up to a quarter of patients admitted to AP-HP during the March-April period (peak of the 1st wave) were infected with COVID-19. The incidence over 100 admissions of bacteraemia increased overall compared to previous years: by 24% in March 2020 and by 115% in April.

Results

The evolution of the incidence of bacteremia was not the same for 2 groups of microorganisms with very different ecologies. For the "hospital" type microorganisms classically responsible for nosocomial infections, the incidence increased significantly in March-April 2020: Klebsiella pneumoniae (×2.3), Pseudomonas aeruginosa (×2.4), Staphylococcus aureus (×2.4), enterococci (×3.4), yeasts (×2.7). Two thirds of the bacteremias caused by these microorganisms were considered as acquired during hospitalization. Importantly, there was also a sharp increase in the incidence of bacteremia caused by antibiotic-resistant strains. The antibiotics used as indicators were the 3rd generation cephalosporins (3GCs), major antibiotics in the treatment of serious infections used for monitoring bacterial resistance in Europe. For example, the incidence of bacteremia with 3GC-resistant strains increased threefold in April 2020 for K. pneumoniae. During the same period, the consumption of 3GC increased sharply in the same hospitals (+131% in March and +148% in April). For Streptococcus pneumoniae (pneumococcus) and Streptococcus pyogenes (group A hemolytic streptococcus), two pathogens responsible for mainly community and respiratory-transmitted infections, the pandemic had the opposite effect. There was a decrease in incidence in 2020 by 34% and 28% respectively for these two species, particularly in the spring when strict containment, physical distancing and mask-wearing measures were in place. A slight re-emergence of infections with these two species occurred in the summer of 2020 after the relaxation of prevention measures. In contrast to what was seen above, 4/5 of the bacteremias caused by these two species were considered as community-acquired.

Conclusion

The COVID-19 pandemic which had a strong impact on hospital management and social organization in the general population, had opposite impacts on the incidence of bacteremia depending on the pathogens and their mode of transmission.

Global epidemiological burden of fungal infections in cirrhosis patients: a systematic review with meta-analysis

BACKGROUND & AIMS

 Fungal infections (FIs) have serious implications, yet understated in cirrhosis. Therefore, we reviewed the epidemiology and trends of FIs among cirrhotics.

METHODS

Four electronic-databases were searched for full-text articles describing prevalence of FIs in cirrhosis. Studies from post-transplant, malignancy and classical-immuno-deficiency patients were excluded. A random-effects meta-analysis was done to pool estimates of FIs (overall, and by type and infection-site), and their variation(I² ) was explored on moderator-analysis and meta-regression. Risk of bias and asymmetry in estimates was assessed by a checklist and Eggers-regression, respectively.(CRD42019142782) RESULTS:  Thirty-four low-risk and four moderate-risk studies (31984 cirrhotics) were included. Pooled-estimates of overall-FIs (17 studies), invasive fungal infections (IFIs; 17 studies), invasive-candidiasis (23 studies), and invasive-aspergillosis (16 studies) in cirrhosis were 10.2%(6.0-16.9), 9.5%(5.4-16.2), 4.0%(2.0-8.0) and 2.8%(1.5-5.3); respectively (I² >90%;each). Site of FIs in decreasing order of pooled-prevalence was pulmonary, urinary-tract, bloodstream, peritoneal, esophageal, and cerebral. Geographic differences in these estimates were remarkable, with highest burden of overall-FIs from Belgium, USA, and India. Non-albicans-Candida and Aspergillus infections have increased over the last-decade in cirrhosis. Intensive-care-unit (ICU)-admitted and acute-on-chronic liver failure (ACLF) patients had the highest prevalence of IFIs. MELD-score(cases), bias-score, and sample size across studies were the predictors of variance in overall-FI-estimates. Diabetes, steroid and broad-spectrum antibiotic-exposure, and multiple organ failures were the common predispositions reported in patients with FIs.

CONCLUSIONS

 FIs impose a substantial burden in cirrhosis. ACLF and ICU-admission should be considered as a host factor for defining IFIs. Epidemiology of FIs can guide interpretation of biomarkers and antifungal treatment in cirrhosis.

Disseminated mycosis in a patient with yellow fever

Disseminated mycosis (DM)—with cardiac involvement and shock—is an unexpected and severe opportunistic infection in patients with yellow fever. DM can mimic bacterial sepsis and should be considered in the differential diagnosis of causes of systemic inflammatory response syndrome in this group of patients, especially in areas where an outbreak of yellow fever is ongoing. We report the case of a 53-year-old male patient who presented to the emergency department with fever, myalgia, headache, and low back pain. The laboratory investigation revealed a positive molecular test for yellow fever, hepatic injury, and renal failure. During hospitalization, the patient developed hepatic encephalopathy, ascending leukocytosis, and ascites, with signs consistent with peritonitis. On the 11th day of hospitalization, the patient developed atrioventricular block, shock and died. At autopsy, angioinvasive mycosis was evidenced mainly in the heart, lungs, kidneys, and adrenals.

Non-Invasive Methods to Diagnose Fungal Infections in Pediatric Patients with Hematologic Disorders

Background

Invasive fungal infection (IFIs) is a major infectious complication in immunocompromised patients. Early diagnosis and initiation of antifungal therapy is important to achieve the best outcome.

Objectives

The current study aimed to investigate the incidence of IFIs and evaluate the diagnostic performance of non-invasive laboratory tests: serologic (β-D-glucan, galactomannan) and molecular (nested polymerase chain reaction) tests to diagnose fungal infections in hematologic pediatric patients.

Patients and Methods

In a cross-sectional study from October 2014 to January 2015, 321 blood samples of 62 pediatric patients with hematologic disorders and at high risk for fungal infections were analyzed. Non-invasive tests including the Platelia Aspergillus enzyme immunoassay (EIA) to detect galactomannan antigen, Glucatell for β–D–glucan and nested PCR to detect Candida and Aspergillus species-specific DNA were used in a weekly screening strategy.

Results

Twenty six patients (42%) were considered as proven and probable IFIs, including 3 (5%) proven and 23 (37%) probable cases. Eighteen patients (29%) were considered as possible cases. The sensitivity, specificity, positive and negative predictive values for galactomannan test in 26 patients with proven and probable fungal infections were 94.4%, 100%, 100% and 94.7%; for β-D-glucan test 92.3%, 77.7%, 85%, 87.5% and for nested-PCR were 84.6%, 88.8%, 91.7% and 80%, respectively.

Conclusions

The rate of IFIs in pediatric patients with hematologic disorders is high, and sample collection from the sterile sites cannot be performed in immunocompromised patients. Detection of circulating fungal cell wall components and DNA in the blood using non-invasive methods can offer diagnostic help in patients with suspected IFIs. Their results should be interpreted in combination with clinical, radiological and microbiological findings.